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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

Lifestyle modifications should be the first-line treatment for PCOS, with specific interventions including a 500-750 kcal/day caloric deficit diet low in glycemic index, rich in fiber and omega-3 fatty acids, and at least 250 minutes of moderate-intensity physical activity per week. 1

Lifestyle Interventions

Dietary Recommendations

• Implement a caloric deficit of 500-750 kcal/day 1
• Focus on low glycemic index foods, high fiber, and omega-3 fatty acids 1, 2
• Consider Mediterranean diet, anti-inflammatory foods, and antioxidant-rich options 2
• Even modest weight loss of 5-10% can restore ovulation and improve fertility 1

Physical Activity Guidelines

• Aim for at least 250 minutes of moderate-intensity physical activity per week 1
• Include strength training 2-3 times weekly 1
• Daily goal of 10,000 steps including 30 minutes of structured activity (approximately 3,000 steps) 3
• Set realistic SMART goals with progressive 5% weekly increases in physical activity 3
• Consider fitness tracking devices to monitor progress and minimize sedentary behavior 3

Behavioral Strategies

• Implement self-monitoring techniques 3
• Incorporate family support to improve outcomes 3
• Use goal-setting, stimulus control, problem-solving, and relapse prevention strategies 3

Pharmacological Interventions

For Metabolic Abnormalities

• Metformin:
  • First-line medication for PCOS with metabolic features 1
  • Starting dose: 500 mg/day with meals, gradually increasing to 1000-1500 mg/day in divided doses 1
  • Benefits: improved insulin resistance, regularized menstrual cycles, reduced cardiometabolic risks 1

For Menstrual Irregularity and Hyperandrogenism

• Combined Oral Contraceptives (COCs):

  • First-line therapy for menstrual regulation and reducing hyperandrogenism 1
  • Provides endometrial protection 1
  • Note: Increases venous thromboembolism risk three to fourfold (up to 4 per 10,000 woman-years) 1

• Oral Micronized Progesterone:

  • 200-300 mg daily for 12-14 days monthly 1
  • Provides endometrial protection and improves menstrual regularity 1
  • Better safety profile than synthetic progestins 1

• Levonorgestrel-releasing Intrauterine Device (LNG-IUD):

  • First-line non-oral contraceptive option 1
  • Effective for endometrial protection and menstrual regulation 1
  • Minimal impact on metabolic parameters 1

• Spironolactone:

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

For Fertility

• Clomiphene Citrate:
  • First-line medication for ovulation induction 1, 4
  • Start on approximately day 5 of the cycle 1, 4
  • 80% ovulation rate and 50% conception rate 1
  • Should not be used in patients with ovarian cysts (except PCOS), abnormal vaginal bleeding, or liver dysfunction 4
  • Monitor for visual symptoms (rare but serious side effect) 4
  • Risk of Ovarian Hyperstimulation Syndrome (OHSS) - monitor for abdominal pain, distention, nausea, vomiting 4
  • Not recommended for long-term cyclic therapy beyond six cycles (including three ovulatory cycles) 4

Monitoring and Follow-up

• Regular consultations every 6 months to monitor:

  • Blood pressure
  • Lipid profile
  • Menstrual cycles
  • Weight changes
  • Metabolic parameters 1

• Screen for gestational diabetes and pre-eclampsia during pregnancy 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

Special Considerations

• Women with PCOS have higher prevalence of weight gain and obesity 3
• Both lean and overweight women with PCOS may have insulin resistance, but obesity exacerbates this condition 1
• Increased risk of eating disorders such as bulimic hyperphagia 1
• Higher risk of pregnancy complications including gestational diabetes, preeclampsia, and preterm birth 1

By implementing these evidence-based interventions in a structured manner, PCOS symptoms can be effectively managed while reducing long-term health risks associated with the condition.