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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

The first-line treatment for PCOS should be lifestyle interventions focusing on a balanced dietary approach with an energy deficit of 30% or 500-750 kcal/day, combined with regular physical activity of at least 60 minutes daily. 1

Lifestyle Interventions

Lifestyle modifications form the cornerstone of PCOS management, particularly for patients who are overweight or obese:

• Dietary Recommendations:

  • Low glycemic index foods
  • Anti-inflammatory diet patterns
  • Adequate magnesium and zinc intake
  • Limit calories from fat to 25-30%
  • Limit saturated fat to <7%
  • Avoid trans fats 1
  • Target caloric intake: 1,200-1,500 kcal/day

• Exercise Recommendations:

  • 60 minutes of moderate to vigorous activity daily
  • Weight training 3 times per week
  • Set SMART goals (specific, measurable, achievable, realistic, timely)
  • Implement self-monitoring techniques 1

A modest weight reduction of 5-10% can yield significant clinical improvements in metabolic parameters, menstrual regularity, and fertility outcomes. Health benefits can occur even without significant weight loss. 1, 2

Pharmacological Interventions

When lifestyle interventions alone are insufficient, medication may be necessary:

1. Insulin Sensitizers:

   • Metformin: Start at 500 mg/day and gradually increase as tolerated
   • Improves insulin sensitivity and reduces hyperandrogenism 1

2. Hormonal Therapy:

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

3. Anti-androgens:

   • Spironolactone: Consider for patients resistant to first-line treatments
   • Topical treatments: Eflornithine cream for facial hirsutism 1

4. Ovulation Induction (for fertility):

   • Clomiphene citrate: Indicated for ovulatory dysfunction in women desiring pregnancy
   • Most effective in PCOS patients with anovulation
   • Should be started on or about the 5th day of the cycle
   • Not recommended beyond a total of six cycles (including three ovulatory cycles) 3
   • Contraindicated in patients with ovarian cysts (except PCOS), abnormal vaginal bleeding, or liver dysfunction 3

Monitoring and Screening

Regular monitoring is essential for PCOS management:

• Evaluate menstrual cycles every 3-6 months
• Screen for cardiovascular risk factors, including dyslipidemia
• Screen for anxiety and depression
• Monitor metabolic parameters annually
• Assess BMI and waist-hip ratio to evaluate central obesity 1

Important Considerations and Pitfalls

1. Ovarian Hyperstimulation Syndrome (OHSS):

   • A serious potential complication of clomiphene citrate therapy
   • Early warning signs: abdominal pain, distention, nausea, vomiting, diarrhea, weight gain
   • Can progress rapidly within 24 hours to several days
   • Use the lowest effective dose of clomiphene citrate to minimize risk
   • PCOS patients may be unusually sensitive to clomiphene citrate 3

2. Visual Disturbances with Clomiphene:

   • Visual blurring, scotomata, and other visual symptoms have been reported
   • Discontinue treatment and seek prompt ophthalmological evaluation if visual symptoms occur 3

3. Adherence Challenges:

   • Lifestyle interventions often have high dropout rates (12-47%)
   • Consider psychological factors, cultural differences, and socioeconomic barriers 1, 4

4. Long-term Risks:

   • PCOS increases risk for cardiovascular disease, type 2 diabetes, and endometrial hyperplasia
   • Regular screening and early intervention are crucial 2, 5

By following this comprehensive approach to PCOS management, focusing first on lifestyle modifications and adding pharmacological interventions when necessary, patients can experience significant improvements in both short-term symptoms and long-term health outcomes.