From the Guidelines
Management of Polycystic Ovary Syndrome (PCOS) should prioritize lifestyle modifications, including a weight loss of 5-10% through caloric restriction and regular exercise, as the first-line treatment to improve symptoms and restore ovulation. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of lifestyle changes in managing PCOS 1. Key aspects of PCOS management include:
- Lifestyle modifications with weight loss and regular exercise to improve symptoms and restore ovulation
- Combined hormonal contraceptives for contraception and menstrual regulation, which also reduce androgen levels and improve acne and hirsutism
- Ovulation induction with letrozole for patients seeking pregnancy, due to its higher live birth rates compared to clomiphene citrate
- Metformin for improving insulin sensitivity, weight management, and ovulation, particularly in women with glucose intolerance
- Spironolactone for hirsutism, with the requirement of contraception due to potential fetal risks
- Regular screening for metabolic complications, including glucose tolerance testing and lipid profiles Treatment should be individualized based on the patient's primary concerns, whether they be fertility, menstrual irregularity, hirsutism, or metabolic issues, as PCOS manifests differently among affected individuals 1. Bariatric surgery is also emerging as a potentially effective weight loss strategy for women with PCOS, with significant improvements in anthropometric, metabolic, and reproductive outcomes, although more research is needed to fully understand its effects and to inform clinical recommendations 1. The correlation between PCOS and the environment is complex, with environmental factors potentially influencing the development and severity of PCOS, but the current evidence is limited, and more research is needed to fully understand this relationship. In terms of pharmacological treatments, anti-obesity agents such as glucagon-like peptide 1 receptor agonists, orlistat, phentermine, and topiramate may be considered as adjuncts to lifestyle modifications for weight loss and metabolic improvement in PCOS, although their use in PCOS is still being studied and not yet widely approved for this indication 1.
From the FDA Drug Label
The cause and effect relationship between reports of testicular tumors and the administration of clomiphene citrate is not known. A causal relationship between ovarian hyperstimulation and ovarian cancer has not been determined However, because a correlation between ovarian cancer and nulliparity, infertility, and age has been suggested, if ovarian cysts do not regress spontaneously, a thorough evaluation should be performed to rule out the presence of ovarian neoplasia. The FDA drug label does not answer the question about the correlation of PCOS and environment.
From the Research
Management and Treatment Options for PCOS
The management and treatment options for patients with Polycystic Ovary Syndrome (PCOS) are multifaceted and depend on various factors, including the patient's symptoms, medical history, and reproductive goals.
- First-line treatment for ovulation induction: Letrozole is recommended as the preferred first-line treatment for women with PCOS and infertility, as it improves live birth and clinical pregnancy rates and reduces time-to-pregnancy compared to clomiphene citrate (CC) 2.
- Clomiphene citrate (CC) plus metformin: CC plus metformin may increase clinical pregnancy and reduce time-to-pregnancy compared to CC alone, although there is insufficient evidence of a difference on live birth rates 2.
- Gonadotropins: Gonadotropins, such as follicle-stimulating hormone (FSH), are a second-line treatment for ovulation induction in women with PCOS who do not ovulate or conceive on CC or letrozole 3.
- Weight loss: Initial treatment for reproductive disorders in overweight and obese women with PCOS is weight loss, which helps menstrual disturbances, shortens the time to conception, and reduces adverse obstetric risks 4.
- Aromatase inhibitors or laparoscopic ovarian surgery: Clomiphene citrate-resistant women may be offered aromatase inhibitors or laparoscopic ovarian surgery 4.
Environmental Factors and PCOS
Environmental factors, particularly endocrine-disrupting chemicals (EDCs), may influence the development and severity of PCOS.
- Bisphenol A (BPA) and phthalates: There is a positive association between BPA, phthalates, and PCOS, suggesting that exposure to these chemicals may contribute to the development of PCOS 5.
- Octocrylene: Octocrylene has also been linked to an increased risk of PCOS 5.
- Triclosan and parabens: The data concerning triclosan and PCOS are inconclusive, and no link between parabens and PCOS has been observed 5.
- Prenatal exposure to EDCs: Prenatal exposure to EDCs, such as BPA and phthalates, may contribute to the altered fetal programming and increase the risk of PCOS and other adverse health effects 6.