Management Options for Polycystic Ovary Syndrome (PCOS)
The management of PCOS should follow a stepwise approach with lifestyle modifications as first-line therapy, followed by pharmacological interventions tailored to specific symptoms, with clomiphene citrate for ovulation induction in women desiring pregnancy and combined oral contraceptives for menstrual irregularities and hyperandrogenism. 1
Lifestyle Modifications
Dietary Management
- Implement a balanced dietary approach focusing on:
- Low glycemic index foods
- Energy deficit of 500-750 kcal/day
- Daily caloric intake of 1,200-1,500 kcal/day
- Limiting fat to 25-30% of calories
- Adequate magnesium and zinc intake 1
- The DASH Diet (rich in fruits, vegetables, whole grains, lean proteins) is recommended for improved insulin sensitivity 1
- Goal: Achieve modest weight reduction of 5-10% to improve metabolic parameters and ovulatory function 1, 2
Physical Activity
- Recommend at least 60 minutes of moderate to vigorous activity daily 1
- Combine both aerobic and resistance exercises:
- Weight training 3 times per week
- Longer duration exercise programs (24 weeks) yield greater metabolic benefits than shorter ones 1
- Exercise enhances insulin sensitivity and improves metabolic and reproductive outcomes even without significant weight loss 2, 3
Behavioral Strategies
- Set SMART goals (specific, measurable, achievable, realistic, timely)
- Implement self-monitoring techniques
- Address psychological factors (anxiety, depression, body image concerns) 1, 3
Pharmacological Management
For Women Desiring Pregnancy
- Clomiphene citrate is first-line medication for ovulation induction:
- Approximately 80% of PCOS patients will ovulate with clomiphene
- About half of those ovulating will conceive 1, 4
- Start on day 5 of the menstrual cycle
- Limit to a total of about six cycles (including three ovulatory cycles) 4
- Caution: Monitor for ovarian hyperstimulation syndrome (OHSS), which may progress rapidly and become serious 4
For Menstrual Irregularities and Hyperandrogenism
- Combined oral contraceptives (COCs) are first-line treatment:
For Insulin Resistance
- Metformin can be added to:
For Persistent Hirsutism
- Anti-androgens (e.g., spironolactone) for those resistant to first-line treatments
- Topical treatments (e.g., eflornithine cream) for facial hirsutism 1
Monitoring and Assessment
Regular Evaluation
- Body mass index (BMI) and waist-hip ratio to assess central obesity
- Menstrual cycles every 3-6 months
- Metabolic parameters annually 1
Screening
- Cardiovascular risk factors, including dyslipidemia
- Glucose tolerance (2-hour 75g oral glucose tolerance test) for women with BMI >25 kg/m² or other risk factors 1, 6
- Anxiety and depression 1
Important Considerations and Pitfalls
Clomiphene Citrate Precautions
- Do not use in patients with:
- Pregnancy
- Ovarian cysts (except in PCOS)
- Abnormal vaginal bleeding
- Liver dysfunction 4
- Monitor for visual symptoms (blurring, scotomata) and discontinue immediately if they occur 4
- Watch for signs of OHSS: abdominal pain/distention, nausea, vomiting, diarrhea, weight gain 4
Combined Oral Contraceptive Considerations
- Increased relative risk of venous thrombosis with different formulations
- Perform risk stratification before prescribing:
- Age
- Smoking status
- Obesity
- Glucose tolerance
- Hypertension
- Dyslipidemia
- Thrombophilia history
- Personal/family history of venous thromboembolism 5
- OC use might increase diabetes risk in morbidly obese women with severe insulin resistance 5