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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

The most effective treatment approach for PCOS involves a combination of lifestyle modifications, dietary management, and pharmacological interventions tailored to specific symptoms, with lifestyle changes being the first-line treatment for most patients. 1

Lifestyle and Dietary Management (First-Line Treatment)

Dietary Recommendations

• Energy deficit approach: 30% or 500-750 kcal/day reduction with daily caloric intake of 1,200-1,500 kcal/day 1
• Diet quality: Focus on low glycemic index foods, anti-inflammatory diet pattern, with adequate magnesium and zinc intake 1
• Fat intake: Limited to 25-30% of total calories 1
• Specific diets: The DASH Diet (rich in fruits, vegetables, whole grains, lean proteins) has shown benefits for PCOS management 1

Physical Activity

• Duration: At least 60 minutes of moderate to vigorous activity daily 1
• Type: Combination of aerobic and resistance exercises (weight training 3 times per week) 1
• Benefits: Improved insulin sensitivity even without significant weight loss 1
• Program length: Longer durations (24 weeks vs. 12 weeks) yield greater metabolic benefits 1

Implementation Strategies

• Set SMART goals (specific, measurable, achievable, realistic, timely) 1
• Implement self-monitoring techniques 1
• Address psychological factors (anxiety, depression, body image concerns) 1
• Even modest weight loss of 5% can normalize menstrual cycles and improve ovulation 2

Pharmacological Interventions (Symptom-Specific)

For Menstrual Irregularities and Hyperandrogenism

• Combined oral contraceptives (COCs): First-line treatment for menstrual irregularities and acne 1, 3
  • Safe even in patients with type 2 diabetes 1
  • Reduces androgen and LH levels, improves acne and hirsutism 4

For Infertility/Anovulation

• Clomiphene citrate: First-line medication for ovulation induction 1

  • Approximately 80% of PCOS patients ovulate and half conceive with this treatment 1
  • Caution: Monitor for visual symptoms (blurring, scotomata) which require discontinuation 5
  • Caution: Risk of Ovarian Hyperstimulation Syndrome (OHSS), especially in PCOS patients 5

• Metformin: Can be added to improve insulin sensitivity and increase ovulation frequency 1

  • Particularly beneficial for patients with metabolic/glycemic abnormalities 3
  • Increases SHBG, decreases androgen levels 4

• Laparoscopic ovarian drilling: Surgical option when medications fail 2

• In vitro fertilization: Last option when other treatments fail 2

For Hirsutism and Acne

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

Monitoring and Assessment

Regular Evaluation

• Anthropometric measures: BMI and waist-hip ratio every 3-6 months 1
• Menstrual cycles: Every 3-6 months 1
• Metabolic parameters: Annual screening 1
• Cardiovascular risk factors: Regular screening for dyslipidemia 1
• Mental health: Screen for anxiety and depression 1

Warning Signs for OHSS (with clomiphene)

• Early warning signs: abdominal pain and distention, nausea, vomiting, diarrhea, weight gain 5
• Severe signs: gross ovarian enlargement, ascites, dyspnea, oliguria, pleural effusion 5
• Management: Discontinue treatment, conservative management unless surgical indication exists 5

Special Considerations

PCOS in Adolescents

• Diagnostic features: menstrual irregularity, clinical hyperandrogenism, and/or hyperandrogenemia 6
• Treatment options similar to adults: lifestyle interventions, hormonal contraceptives, and metformin 3
• Regular follow-up and planned transition to adult care providers is essential 6

Patients with Polycystic Ovaries

• May be unusually sensitive to ovulation induction medications 5
• Should start with lowest recommended dose of clomiphene citrate 5
• Monitor for ovarian enlargement before continuing treatment 5

Treatment Algorithm

1. All patients: Implement lifestyle modifications (dietary changes + physical activity)
2. For menstrual irregularities/hyperandrogenism: Add combined oral contraceptives
3. For infertility:
   • Start with clomiphene citrate at lowest effective dose
   • Consider adding metformin if insulin resistance present
   • Progress to laparoscopic ovarian drilling if needed
   • Consider IVF as last resort
4. For hirsutism/acne not responding to COCs: Add anti-androgens or topical treatments
5. For metabolic abnormalities: Add metformin

The key to successful PCOS management is addressing both the immediate symptoms and the underlying metabolic dysfunction through a comprehensive approach that begins with lifestyle modifications and adds pharmacological interventions as needed based on specific symptoms.