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

Management Options for Polycystic Ovary Syndrome (PCOS)

Lifestyle interventions focused on weight loss, exercise, and behavioral strategies should be the first-line treatment for PCOS, followed by combined oral contraceptives for menstrual irregularities and metformin for insulin resistance. 1

First-Line Management: Lifestyle Interventions

Dietary Recommendations

• Create a caloric deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day) 1
• Focus on:
  • Low glycemic index foods
  • Anti-inflammatory diet patterns
  • Adequate magnesium and zinc intake 1
  • Mediterranean diet, antioxidant-rich foods 2

Physical Activity Guidelines

• Adults: 150+ minutes/week of moderate activity OR 75+ minutes/week of vigorous activity
• For weight loss: Increase to 250+ minutes/week of moderate activity OR 150+ minutes/week of vigorous activity
• Include muscle-strengthening activities on 2 non-consecutive days/week
• Adolescents: At least 60 minutes of moderate to vigorous activity daily 1
• Minimize sedentary and screen time

Behavioral Strategies

• Set SMART goals (specific, measurable, achievable, relevant, and timely)
• Implement self-monitoring, stimulus control, problem-solving, stress management
• Practice slower eating and relapse prevention techniques 1
• Provide psychological support for anxiety, depression, and eating disorders 1

Pharmacological Management

Menstrual Irregularities and Hyperandrogenism

• Combined oral contraceptives (COCs): First-line treatment for menstrual irregularities and acne
  • Not contraindicated in patients with type 2 diabetes 1
  • Helps prevent endometrial hyperplasia 3

Insulin Resistance

• Metformin:
  • Starting dose: 500 mg/day with gradual increase as tolerated
  • Improves insulin sensitivity and reduces hyperandrogenism 1
  • Can be used in combination with lifestyle modifications 4

Hirsutism and Acne

• Anti-androgens (e.g., spironolactone): Consider for patients resistant to first-line treatments
• Topical treatments: Eflornithine cream for facial hirsutism 1
• Permanent hair reduction: Electrolysis and laser therapy for more definitive management 3

Fertility Management

• Clomiphene citrate: Indicated for ovulatory dysfunction in women desiring pregnancy
  • Start on or about the 5th day of the cycle
  • Not recommended beyond a total of about six cycles (including three ovulatory cycles) 5
  • Caution: Monitor for ovarian hyperstimulation syndrome 5
  • Contraindications: Pregnancy, ovarian cysts (except in PCOS), abnormal vaginal bleeding, abnormal liver function 5

Monitoring and Follow-up

Regular Evaluation

• Menstrual cycles: Every 3-6 months
• Metabolic parameters: Annually 1
• Body mass index (BMI) and waist-hip ratio to evaluate central obesity 1

Screening for Comorbidities

• Cardiovascular risk factors, including dyslipidemia 1
• Diabetes and insulin resistance 4
• Sleep apnea 3
• Mental health issues (depression, anxiety, eating disorders) 1, 6
• Non-alcoholic fatty liver disease 3

Important Clinical Considerations

Benefits of Weight Loss

• Even a modest 5-10% weight reduction can:
  • Restore ovulation and fertility
  • Reduce risks of endometrial cancer and cardiovascular disease
  • Improve insulin sensitivity
  • Alleviate hyperandrogenism symptoms 1

Common Pitfalls to Avoid

• Delaying treatment in adolescents with suspected PCOS
• Focusing only on cosmetic treatments without addressing underlying metabolic and endocrine disturbances 7
• Neglecting psychological impact of PCOS
• Failing to screen for associated comorbidities
• Not providing adequate education about long-term health risks

Special Considerations for Adolescents

• Different diagnostic criteria apply for adolescents vs. adults
• Menstrual irregularity, clinical hyperandrogenism, and/or hyperandrogenemia are key diagnostic features
• Pelvic ultrasound findings are not needed for diagnosis in adolescents 6
• Early intervention is crucial to prevent long-term complications 6