From the Guidelines
Treatment for Polycystic Ovary Syndrome (PCOS) should prioritize lifestyle modifications, including a balanced diet, regular exercise, and weight management, as the first-line approach, as recommended by the most recent and highest quality study 1. Key recommendations:
- Lifestyle modifications:
- Aim for 5-10% weight loss if overweight
- Regular exercise (150 minutes/week of moderate intensity)
- Balanced diet rich in whole grains, fruits, vegetables, and lean proteins
- Medications:
- For irregular periods: Combined oral contraceptive pills (e.g., Yaz, Yasmin) or cyclic progestin (e.g., medroxyprogesterone 10mg daily for 10-14 days each month)
- For excess hair growth: Spironolactone (start at 50mg daily, increase to 100-200mg daily as needed)
- For insulin resistance: Metformin (start at 500mg daily, increase to 1500-2000mg daily in divided doses)
- Additional treatments:
- Hair removal methods: laser hair removal, electrolysis
- Fertility treatments if trying to conceive: Clomiphene citrate or letrozole for ovulation induction
- Consideration of anti-obesity pharmacological agents, such as glucagon-like peptide 1 receptor agonists (GLP-1 RAs), as an adjunct to lifestyle management for weight loss and improvement of metabolic outcomes, as suggested by recent studies 1
- Bariatric surgery may be considered for patients with PCOS and clinically severe obesity, as it has been shown to improve anthropometric, reproductive, hormonal, and metabolic outcomes, according to a recent systematic review and meta-analysis 1 These treatments address the hormonal imbalances in PCOS, and lifestyle changes improve insulin sensitivity, which helps regulate hormone levels. Some key points to consider:
- The association between obesity and PCOS is complex and bidirectional, and weight loss is recommended as part of management in individuals with PCOS with higher body mass index (BMI) 1
- Pharmacotherapy, including anti-obesity agents, may be recommended as an adjunct to lifestyle approaches to optimize weight loss success and efficacy in obesity 1
- Bariatric surgery has been shown to be effective in improving outcomes in women with PCOS and clinically severe obesity, but its efficacy and safety compared to existing strategies for weight reduction in PCOS are not well described 1
From the FDA Drug Label
Clomiphene citrate is indicated for the treatment of ovulatory dysfunction in women desiring pregnancy. Impediments to achieving pregnancy must be excluded or adequately treated before beginning clomiphene citrate therapy Those patients most likely to achieve success with clomiphene therapy include patients with polycystic ovary syndrome
- Treatment options for PCOS include clomiphene citrate therapy, which is indicated for the treatment of ovulatory dysfunction in women desiring pregnancy, including those with polycystic ovary syndrome (PCOS) 2.
- Clomiphene citrate should only be used in patients with demonstrated ovulatory dysfunction who meet specific conditions, including patients without ovarian cysts, except those with PCOS.
From the Research
Treatment Options for PCOS
The treatment options for Polycystic Ovary Syndrome (PCOS) vary depending on the symptoms and the patient's desire for fertility. The following are some of the treatment options:
- Lifestyle modification (LSM) is considered the first-line treatment, regardless of fertility status, without the addition of metformin 3
- Oral contraceptive (OC) pills should be used as a first-line treatment for long-term management for patients with no reproductive requirements 3
- For patients with fertility requirements, ovulation therapy is an effective treatment 3, 4, 5, 6
- Medications such as clomiphene citrate, tamoxifen, aromatase inhibitors, metformin, glucocorticoids, or gonadotropins can be used to treat anovulation 4, 5, 6
- Laparoscopic ovarian drilling is a surgical option for treating anovulation 4, 5, 6
- In vitro fertilization (IVF) is a third-line treatment option for patients who have not responded to other treatments 5, 6
- Weight loss and exercise can improve menstrual disturbances, infertility, insulin resistance, and metabolic consequences 7, 4, 5
- Dietary interventions such as foods with low glycemic index scores, caloric restrictions, high-fiber, omega three fatty acid-rich diets, ketogenic diets, Mediterranean diets, antioxidant-rich food, and anti-inflammatory diets can improve insulin sensitivity and hormonal balance in women with PCOS 7
- Behavioral and education modules can be used to improve awareness, adherence, and the effectiveness of conventional treatment and to manage mental health issues related to PCOS 7
Fertility Treatment
For patients with PCOS who wish to become pregnant, the following fertility treatments are available:
- Clomiphene citrate is recommended as first-line treatment for induction of ovulation in patients with PCOS 4
- Gonadotrophin therapy is an alternative for clomiphene-resistant patients 4
- Laparoscopic ovarian diathermy is a surgical option for treating ovulation disorders 4
- Recombinant FSH (rFSH) has been introduced in clinical practice and seems more effective than urinary FSH 4
- In vitro fertilization (IVF) represents a third-line treatment option for patients who have not responded to other treatments 5, 6
Management of Androgen-Related Symptoms
For patients with PCOS who experience androgen-related symptoms such as hirsutism, acne, and/or alopecia, the following treatments are available: