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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

The first-line treatment for PCOS includes lifestyle modifications combined with specific medications tailored to symptoms, with clomiphene citrate being the primary medication for women seeking pregnancy. 1

Lifestyle Modifications - First-Line Treatment

Lifestyle changes form the cornerstone of PCOS management:

• Weight reduction: Even a modest 5-10% weight loss can significantly improve ovulation, pregnancy rates, and hormonal profiles 1, 2
• Dietary recommendations:
  • Energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day)
  • Focus on low glycemic index foods and anti-inflammatory diet patterns
  • Limit calories from fat to 25-30% and saturated fat to <7%
  • Avoid trans fats
  • Ensure adequate magnesium and zinc intake 1
• Physical activity:
  • At least 60 minutes of moderate to vigorous activity daily
  • Combine both aerobic and resistance exercises (weight training 3 times weekly)
  • Regular exercise improves insulin sensitivity independent of weight loss 1, 2

Medication Options Based on Treatment Goals

For Women Seeking Pregnancy:

1. Ovulation Induction:

   • Clomiphene citrate: First-line medication with approximately 80% of PCOS patients ovulating and 50% conceiving 1, 3
   • Important precautions: Must exclude pregnancy, ovarian cysts, abnormal vaginal bleeding, and liver dysfunction before starting treatment 3
   • Monitoring: Regular evaluation of menstrual cycles and ovulation using basal body temperature charts 1, 3
   • Risk awareness: Monitor for ovarian hyperstimulation syndrome (OHSS), which can progress rapidly and become serious 3

2. Additional options:

   • Metformin: Can be added to improve insulin sensitivity and increase ovulation frequency 1
   • Gonadotropins: Consider if clomiphene citrate fails 1
   • Laparoscopic ovarian drilling: Surgical option for clomiphene-resistant cases 4
   • In vitro fertilization: Last option when other treatments fail 4

For Menstrual Irregularities and Hyperandrogenism:

1. Combined oral contraceptives (COCs):

   • First-line for menstrual irregularities and acne
   • Prevents endometrial hyperplasia 1, 5

2. Anti-androgens:

   • Spironolactone: For hirsutism and acne resistant to first-line treatments
   • Topical treatments: Eflornithine cream for facial hirsutism 1

3. Metformin:

   • Starting dose of 500 mg/day with gradual increase as tolerated
   • Improves insulin sensitivity and reduces hyperandrogenism 1

Monitoring and Follow-up

• Regular evaluation of menstrual cycles every 3-6 months
• Annual assessment of metabolic parameters
• Screening for cardiovascular risk factors, including dyslipidemia
• Assessment of BMI and waist-hip ratio to evaluate central obesity
• Screening for anxiety and depression 1

Important Cautions and Considerations

• Endometrial protection: Chronic anovulation increases risk of endometrial hyperplasia and carcinoma, requiring appropriate treatment 4
• OHSS risk: Patients with PCOS may be unusually sensitive to ovulation induction medications; start with lowest doses 3
• Visual symptoms: Discontinue clomiphene citrate immediately if visual disturbances occur 3
• Long-term health: PCOS patients should be monitored for metabolic complications including diabetes, dyslipidemia, hypertension, and non-alcoholic fatty liver disease 5
• Sleep apnea: Screen for this condition as it occurs more commonly in women with PCOS 5

Treatment Algorithm

1. Start with lifestyle modifications for all patients
2. Add medication based on primary goal:
   • For pregnancy: Clomiphene citrate ± metformin
   • For menstrual regulation/hyperandrogenism: COCs or metformin
3. Monitor response and adjust treatment accordingly
4. Progress to second-line options if initial treatment fails

Remember that PCOS is a spectrum of disorders requiring a comprehensive approach addressing reproductive, metabolic, and psychological aspects of the condition.