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

Treatment Recommendations for Polycystic Ovary Syndrome (PCOS)

The first-line treatment for PCOS should be lifestyle modifications focusing on a balanced diet with low glycemic index foods, caloric restriction (1,200-1,500 kcal/day with 500-750 kcal/day deficit), and regular physical activity combining both aerobic and resistance exercises. 1

Dietary Management

• Recommended dietary approach:

  • Energy deficit: 30% or 500-750 kcal/day
  • Daily caloric intake: 1,200-1,500 kcal/day
  • Focus on low glycemic index foods
  • Anti-inflammatory diet pattern
  • Adequate magnesium and zinc intake
  • Limit fat to 25-30% of calories 1

• Effective diet patterns:

  • DASH Diet (emphasizing fruits, vegetables, whole grains, lean proteins)
  • No specific macronutrient composition has selective long-term advantages 1
  • Mediterranean diet and anti-inflammatory diets may improve insulin sensitivity 2

Exercise Recommendations

• At least 60 minutes of moderate to vigorous activity daily 1
• Combine both aerobic and resistance exercises for optimal results
• Weight training recommended 3 times per week 1
• Exercise programs of longer duration (24 weeks vs. 12 weeks) show greater metabolic benefits 1
• Benefits include improved insulin sensitivity even without significant weight loss 1, 3

Pharmacological Interventions

1. For ovulation induction:

   • Clomiphene citrate is first-line medication (80% of PCOS patients ovulate, half conceive) 1
   • Start with low dose: 50 mg daily for 5 days 4
   • If no ovulation, increase to 100 mg daily for 5 days 4
   • Do not exceed 100 mg/day for 5 days 4
   • Discontinue after three unsuccessful courses 4
   • Monitor for visual symptoms (blurring, scotomata) and ovarian hyperstimulation syndrome 4

2. For insulin resistance:

   • Metformin can improve insulin sensitivity and increase ovulation frequency 1

3. For menstrual irregularities and acne:

   • Combined oral contraceptives (COCs) as first-line treatment 1
   • Not contraindicated in patients with type 2 diabetes 1

4. For hirsutism:

   • Anti-androgens (e.g., spironolactone) for those resistant to first-line treatments 1
   • Topical treatments (e.g., eflornithine cream) for facial hirsutism 1

Monitoring and Assessment

• Regular assessment of:
  • Body mass index (BMI) and waist-hip ratio to evaluate central obesity 1
  • Menstrual cycles (every 3-6 months) 1
  • Metabolic parameters (annually) 1
  • Cardiovascular risk factors including dyslipidemia 1
  • Screening for anxiety and depression 1

Important Considerations and Pitfalls

• PCOS patients with polycystic ovary syndrome may be unusually sensitive to gonadotropin and should start with the lowest recommended dose of clomiphene citrate 4

• Ovarian Hyperstimulation Syndrome (OHSS) risk:

  • Monitor for early warning signs: abdominal pain/distention, nausea, vomiting, diarrhea, weight gain 4
  • Can progress rapidly (within 24 hours to several days) to a serious medical disorder 4
  • Discontinue clomiphene if ovarian enlargement occurs and wait until ovaries return to pretreatment size 4

• Long-term cyclic therapy with clomiphene citrate is not recommended beyond a total of about six cycles 4

• Set SMART goals (specific, measurable, achievable, realistic, timely) and implement self-monitoring techniques 1

• Inadequate support for weight management is a common issue in PCOS treatment, despite its critical importance 5

• Combining dietary changes with exercise yields the greatest improvements in clinical outcomes 3