What are the treatment options for Polycystic Ovary Syndrome (PCOS)?

From the Guidelines

Treatment options for Polycystic Ovary Syndrome (PCOS) should prioritize lifestyle modifications, including weight loss through diet and exercise, as the first-line treatment to improve insulin sensitivity and restore ovulation. This approach is supported by the most recent and highest quality study, which emphasizes the importance of lifestyle changes in managing PCOS 1.

Key Treatment Options:

• Lifestyle modifications: weight loss through diet and exercise to improve insulin sensitivity and restore ovulation
• Medications:
  • Combined hormonal contraceptives to regulate menstrual cycles and reduce androgen levels
  • Metformin to improve insulin sensitivity
  • Anti-androgens such as spironolactone to reduce hirsutism and acne
  • Clomiphene citrate or letrozole for ovulation induction in women seeking pregnancy
• Surgery: laparoscopic ovarian drilling for women with severe symptoms not responding to other treatments

Management Considerations:

• Address associated conditions like insulin resistance, dyslipidemia, and mental health concerns
• Regular monitoring is essential as PCOS is a chronic condition requiring ongoing management
• Treatment plans should be adjusted based on changing symptoms, life stages, and reproductive goals
• Consideration of anti-obesity pharmacological agents as an adjunct to lifestyle management for weight loss and improvement of metabolic outcomes, as suggested by recent studies 1

Importance of Recent Guidelines:

The 2023 international evidence-based guideline for the assessment and management of PCOS emphasizes the role of lifestyle management as the first-line treatment, with a focus on weight loss and healthy lifestyle behaviors 1. These guidelines also highlight the importance of addressing associated conditions and adjusting treatment plans according to individual needs and responses to treatment.

Prioritizing Morbidity, Mortality, and Quality of Life:

In managing PCOS, it is crucial to prioritize interventions that improve morbidity, mortality, and quality of life outcomes. This includes not only treating the symptoms of PCOS but also addressing the associated metabolic and psychological risks to prevent long-term complications and improve overall well-being 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 Some patients with polycystic ovary syndrome who are unusually sensitive to gonadotropin may have an exaggerated response to usual doses of clomiphene citrate. Therefore, patients with polycystic ovary syndrome should be started on the lowest recommended dose and shortest treatment duration for the first course of therapy

The treatment options for Polycystic Ovary Syndrome (PCOS) include:

• Clomiphene citrate therapy: Clomiphene citrate is indicated for the treatment of ovulatory dysfunction in women with PCOS who desire pregnancy.
• Lowest recommended dose and shortest treatment duration: Patients with PCOS should be started on the lowest recommended dose and shortest treatment duration for the first course of therapy to minimize the risk of ovarian hyperstimulation syndrome.
• Careful monitoring: Patients with PCOS should be carefully monitored for signs of ovarian hyperstimulation syndrome, such as abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain 2, 2.

From the Research

Treatment Options for Polycystic Ovary Syndrome (PCOS)

The treatment options for PCOS can be categorized into lifestyle modifications and medical interventions.

• Lifestyle Modifications:

  • Dietary changes, 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 3.
  • Physical activity, like aerobic and resistance exercise, enhances insulin sensitivity, helps weight loss, and improves metabolic and reproductive outcomes in women with PCOS 3.
  • Behavioral and education modules can also be used to improve awareness, adherence, and the effectiveness of conventional treatment and to manage mental health issues related to PCOS 3.
  • A balanced diet with 40% energy from carbohydrates, 30% from fats, and 30% from protein with optimum physical activity could reduce severe PCOS symptoms and improve metabolic balance 4.

• Medical Interventions:

  • Insulin-sensitising drugs, such as metformin, may be effective in treating PCOS-related anovulation and improving reproductive and metabolic outcomes 5, 6.
  • Metformin alone may be beneficial over placebo for live birth, although the evidence quality was low 5.
  • Clomiphene citrate is superior to metformin in achieving live birth in infertile women with PCOS, although multiple birth is a complication 7.
  • A combination of metformin with clomifene citrate is more effective than either alone and is a useful option in women with clomifene-resistant PCOS 6.
  • Continuing metformin to the end of the 1st trimester at an effective dose may help to reduce the rate of miscarriages 6.