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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

Treatment for PCOS should be comprehensive, addressing specific symptoms with lifestyle modifications as first-line therapy, followed by targeted pharmacological interventions for metabolic features, menstrual irregularities, hyperandrogenism, and fertility concerns. 1

First-Line Approach: Lifestyle Modifications

Lifestyle modifications form the foundation of PCOS management:

• Weight management:

  • Calorie deficit of 500-750 kcal/day for weight loss 1
  • At least 250 minutes of moderate-intensity physical activity weekly 1
  • Strength training 2-3 times weekly 1

• Dietary recommendations:

  • Low-glycemic diet rich in fiber and omega-3 fatty acids 1
  • Portion control for weight management 1
  • Anti-inflammatory and antioxidant-rich foods improve insulin sensitivity 2

Pharmacological Management by Symptom

For Menstrual Irregularity & Endometrial Protection:

1. First-line options:

   • Combined oral contraceptives (COCs) - regulate cycles and reduce hyperandrogenism 1
   • Levonorgestrel-releasing intrauterine device (LNG-IUD) - provides endometrial protection with minimal metabolic impact 1
   • Oral micronized progesterone (200-300 mg daily for 12-14 days monthly) - protects against endometrial hyperplasia 1

2. Monitoring:

   • Regular assessment of blood pressure, lipid levels, and menstrual cyclicity every 6 months 1
   • Periodic assessment of endometrial thickness by transvaginal ultrasound 1

For Metabolic Features:

1. Metformin:

   • Start at 500mg daily with meals
   • Gradually increase to 1000-1500mg daily in divided doses
   • Addresses insulin resistance, menstrual irregularities, and cardiometabolic risks 1

2. GLP-1 receptor agonists:

   • Consider for weight loss (liraglutide, semaglutide)
   • More effective than metformin for weight reduction in PCOS 1
   • Semaglutide shows greater weight loss (3.47-6.5 kg) compared to liraglutide (0.3-3.38 kg) 1

For Hyperandrogenism (Hirsutism, Acne, Hair Loss):

1. Spironolactone:

   • 100 mg daily for hirsutism
   • Visible improvement typically takes 6 months 1

2. Combined oral contraceptives:

   • First-line for reducing hyperandrogenism 1
   • Caution: Increases VTE risk three to fourfold (up to 4 per 10,000 woman-years) 1

For Fertility:

1. Clomiphene citrate:

   • First-line for ovulation induction 1, 3
   • Start on day 5 of cycle
   • 80% ovulation rate and 50% conception rate 1
   • Contraindicated in patients with ovarian cysts (except PCOS), abnormal vaginal bleeding, or liver dysfunction 3

2. Monitoring during treatment:

   • Watch for ovarian hyperstimulation syndrome (OHSS) - abdominal pain, distention, nausea, vomiting 3
   • Start with lowest recommended dose in PCOS patients due to sensitivity 3
   • Limit to about six cycles (including three ovulatory cycles) 3

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

1. Contraceptive selection: Consider metabolic impact when selecting contraceptives. LNG-IUD has minimal systemic metabolic effects compared to combined hormonal methods 1.

2. Clomiphene citrate cautions:

   • Visual symptoms (blurring, scotomata) require immediate discontinuation and ophthalmological evaluation 3
   • Risk of OHSS, particularly in PCOS patients who are unusually sensitive to gonadotropins 3

3. Long-term monitoring: Regular follow-up every 6 months is essential to monitor metabolic parameters, blood pressure, and treatment efficacy 1.

4. Pregnancy complications: Women with PCOS have increased risk of gestational diabetes, preeclampsia, and preterm birth, requiring close monitoring during pregnancy 1.

5. Mental health: Consider screening for depression and eating disorders, which may be more prevalent in PCOS patients 4.

By addressing both the reproductive and metabolic aspects of PCOS with this comprehensive approach, treatment can effectively manage symptoms while reducing long-term health risks.