What is the treatment for Polycystic Ovary Syndrome (PCOS)?

Treatment of Polycystic Ovary Syndrome (PCOS)

Lifestyle interventions should be the first-line treatment for all patients with PCOS, with particular emphasis on multicomponent approaches including diet, exercise, and behavioral strategies to achieve weight reduction and improve metabolic and hormonal outcomes. 1

Comprehensive Management Approach

Lifestyle Interventions

1. Weight Management

   • Target 5-10% weight reduction, which yields significant clinical improvements 1, 2
   • Create an energy deficit of 500-750 kcal/day (1,200-1,500 kcal/day) 2
   • Set SMART (specific, measurable, achievable, realistic, timely) goals 1

2. Physical Activity

   • Perform at least 150 minutes/week of moderate-intensity OR 75 minutes/week of vigorous-intensity exercise 2
   • Include muscle-strengthening activities on 2 non-consecutive days/week 2
   • For weight loss, aim for 300+ minutes/week of moderate activity 2

3. Dietary Recommendations

   • Follow a balanced diet, such as the Mediterranean diet 2
   • Consider low glycemic index foods to improve insulin sensitivity 3
   • Reduce sodium intake to minimize fluid retention 2
   • Consider increasing magnesium and zinc intake 2

4. Behavioral Strategies

   • Implement goal-setting, self-monitoring, stimulus control, problem-solving, and relapse prevention techniques 1
   • Address psychological factors such as anxiety, depression, and body image concerns 1

Pharmacological Interventions

1. For Menstrual Irregularity and Hyperandrogenism

   • Combined oral contraceptive pills (OCPs) to regulate menstrual cycles and reduce androgen-related symptoms 2

2. For Ovulatory Dysfunction in Women Seeking Pregnancy

   • Clomiphene citrate is indicated for treatment of ovulatory dysfunction in women desiring pregnancy 4
   • Start on or about the 5th day of the cycle once ovulation has been established 4
   • Not recommended beyond a total of about six cycles (including three ovulatory cycles) 4
   • Contraindicated in patients with ovarian cysts (except those with PCOS), abnormal vaginal bleeding, pregnancy, or abnormal liver function 4

3. For Insulin Resistance

   • Metformin to improve insulin sensitivity, which may help reduce fluid retention and improve ovulatory function 2

Monitoring and Follow-up

1. Regular Assessment

   • Monitor weight and waist circumference 2
   • Screen for cardiovascular risk factors, including dyslipidemia with fasting lipoprotein profile 2
   • Evaluate for signs of insulin resistance 2

2. Psychological Support

   • Screen for anxiety and depression, which are common in PCOS 2
   • Provide supportive counseling and resources 2

3. Metabolic Screening

   • Monitor for development of type 2 diabetes with fasting glucose and HbA1c 2
   • Assess cardiovascular risk factors, including lipid profile 2

Important Considerations and Pitfalls

1. Ovarian Hyperstimulation Syndrome (OHSS)

   • Monitor for signs of OHSS when using clomiphene citrate, including abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain 4
   • OHSS may progress rapidly (within 24 hours to several days) and become a serious medical disorder 4
   • Use the lowest effective dose of clomiphene citrate to minimize risk 4

2. Visual Symptoms with Clomiphene

   • Discontinue clomiphene citrate if visual symptoms occur and arrange prompt ophthalmological evaluation 4

3. Common Treatment Pitfalls

   • Failing to provide adequate support for long-term lifestyle modifications 2
   • Focusing solely on weight loss rather than overall health benefits 2
   • Implementing overly restrictive diets that are not sustainable 2
   • Neglecting psychological aspects of PCOS management 2
   • Not recognizing that healthy lifestyle may contribute to health benefits even in the absence of weight loss 1

4. Cultural Considerations

   • Health professional interactions need to be respectful and patient-centered 1
   • Consider cultural, socio-economic, and ethnic differences 1
   • Be sensitive to personal sensitivities, marginalization, and potential weight-related stigma 1
   • Ethnic-specific BMI and waist circumference categories need consideration 1

The evidence strongly supports a comprehensive approach to PCOS management, with lifestyle interventions forming the foundation of treatment. Pharmacological interventions should be added based on specific symptoms and patient goals, particularly for those seeking pregnancy or needing management of specific metabolic or hormonal abnormalities.