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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

Treatment of PCOS should be comprehensive, addressing lifestyle modifications, hormonal regulation, metabolic features, and cosmetic concerns, with individualized therapy based on the patient's primary symptoms and goals. 1

First-Line Interventions

Lifestyle Modifications

• Weight management:
  • Calorie deficit of 500-750 kcal/day for overweight patients 1
  • At least 250 minutes of moderate-intensity physical activity weekly 1
  • Low-glycemic diet rich in fiber and omega-3 fatty acids 1, 2
  • Strength training 2-3 times per week 1

Hormonal Management

• For menstrual regulation and endometrial protection:
  • Combined oral contraceptives (COCs) - first-line therapy for menstrual regulation and reducing hyperandrogenism 1
    • Caution: Increases VTE risk three to fourfold (up to 4 per 10,000 woman-years) 1
  • Levonorgestrel-releasing intrauterine device (LNG-IUD) - recommended as first-line non-oral contraceptive option 1
    • Minimal systemic metabolic effects
    • Provides endometrial protection
    • Can improve lipid profile
  • Oral micronized progesterone (200-300 mg daily for 12-14 days monthly) 1
    • Better safety profile than synthetic progestins

Metabolic Management

• Metformin: First-line medication for PCOS with metabolic features 1
  • Starting dose: 500mg daily with meals
  • Gradually increase to 1000-1500mg daily in divided doses
  • Addresses insulin resistance, menstrual irregularities, and cardiometabolic risks
• GLP-1 receptor agonists (liraglutide, semaglutide):
  • More effective for weight loss than metformin
  • Liraglutide: 0.3-3.38 kg weight reduction
  • Semaglutide: 3.47-6.5 kg weight reduction 1

Symptom-Specific Treatments

For Hirsutism and Androgen Excess

• Spironolactone: 100 mg daily 1
  • Visible improvement typically takes 6 months
  • Often combined with COCs for better effect

For Fertility/Ovulation Induction

• Clomiphene citrate: First-line medication for ovulation induction 1, 3
  • Start on day 5 of the cycle
  • 80% ovulation rate and 50% conception rate
  • Important: Should not be used in patients with ovarian cysts (except PCOS) 3
  • Warning: Risk of ovarian hyperstimulation syndrome (OHSS) 3
  • Maximum treatment duration: about six cycles (including three ovulatory cycles) 3

Monitoring and Follow-up

Regular Assessment (Every 6 Months)

• Weight and waist circumference
• Blood pressure
• Lipid levels
• Menstrual cyclicity
• Metabolic parameters 1

Red Flags Requiring Prompt Evaluation

• Persistent abnormal uterine bleeding despite treatment
• Signs of significant virilization
• Rapid development of symptoms
• Significant weight gain or worsening insulin resistance despite treatment 1

Important Considerations and Pitfalls

• For clomiphene therapy: Monitor for visual symptoms (blurring, scotomata) - discontinue if they occur 3
• OHSS warning signs: Abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain 3
• Contraceptive selection: Requires individualized risk stratification based on cardiometabolic risk factors 4
• Endometrial protection: Essential in all PCOS patients with irregular cycles to prevent hyperplasia 1, 5

Emerging Treatments

• Inositol supplements: Similar efficacy to metformin with fewer side effects 6
• Statins and natural statins (monakolin): May reduce hyperandrogenism 6

The comprehensive approach to PCOS management should address the patient's primary concerns while considering the long-term health implications, including increased risks of metabolic syndrome, cardiovascular disease, and endometrial cancer.