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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

The first-line treatment for PCOS should be lifestyle modifications including a 500-750 kcal/day caloric deficit, 250+ minutes/week of moderate physical activity, and behavioral strategies, with pharmacological interventions tailored to specific symptoms. 1

Lifestyle Modifications: The Foundation of PCOS Management

Dietary Interventions

• Create a 30% energy deficit or reduce daily caloric intake by 500-750 kcal/day
• Target daily caloric intake of 1,200-1,500 kcal/day
• Focus on low glycemic index foods and anti-inflammatory diet patterns
• Ensure adequate magnesium and zinc intake 1

Physical Activity

• For general health: 150+ minutes/week of moderate activity or 75+ minutes/week of vigorous activity
• For weight loss: 250+ minutes/week of moderate activity or 150+ minutes/week of vigorous activity
• Include muscle-strengthening activities 2 days/week
• Target 10,000 steps daily and minimize sedentary time 1

Behavioral Strategies

• Set SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound)
• Use stimulus control and problem-solving approaches
• Develop relapse prevention strategies
• Implement self-monitoring techniques 1

Even a modest weight loss of 5% of initial body weight can significantly improve metabolic and reproductive abnormalities in PCOS 1, 2. Prevention of weight gain is as important as weight loss itself.

Pharmacological Interventions

For Menstrual Irregularities and Hyperandrogenism

• First-line: Combined oral contraceptives (COCs) for menstrual irregularities and acne 1
• Second-line: Anti-androgens (spironolactone, flutamide, finasteride) for hirsutism resistant to first-line treatments 1

For Insulin Resistance

• Metformin is a first-line pharmacological intervention, particularly beneficial for:
  • Adolescents with PCOS
  • Women with type 2 diabetes
  • Those with significant insulin resistance 1

For Fertility and Ovulation Induction

• First-line: Clomiphene citrate - approximately 80% of PCOS patients ovulate with this treatment, and half of these conceive 1, 3
• Second-line: Low-dose gonadotropin therapy if clomiphene fails 1

Important Monitoring and Prevention Strategies

Regular monitoring should include:

• Weight and waist circumference
• Menstrual cycles
• Metabolic parameters
• Annual assessment of insulin resistance markers, lipid profile, and blood pressure 1

Psychological health assessment:

• Screen for anxiety and depression
• Consider the psychological impact of weight management
• Provide patient-centered care considering cultural, socio-economic, and ethnic differences 1

Cautions and Potential Complications

Ovarian Hyperstimulation Syndrome (OHSS)

When using clomiphene citrate, be vigilant for signs of OHSS, which can progress rapidly:

• Early warning signs: abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain
• Use the lowest effective dose and monitor closely
• Patients with PCOS are particularly susceptible 1, 3

Visual Disturbances with Clomiphene

• Monitor for visual blurring, scotomata, and other visual symptoms
• Discontinue treatment and perform ophthalmological evaluation if visual symptoms occur 3

Other Considerations

• Consider ethnic-specific BMI and waist circumference categories
• Pay attention to ethnic groups with PCOS at high cardiometabolic risk
• Avoid focusing solely on weight loss rather than overall health improvements 1

Treatment Algorithm

1. Start with lifestyle modifications for all patients with PCOS
2. Add symptom-specific pharmacological therapy as needed:
   • For menstrual irregularities/hyperandrogenism: COCs → anti-androgens
   • For insulin resistance: Metformin
   • For fertility: Clomiphene citrate → gonadotropins
3. Monitor regularly for metabolic parameters, treatment response, and complications
4. Adjust therapy based on response and development of any side effects

Despite the importance of lifestyle modifications in PCOS management, implementation remains challenging, with high dropout rates in intervention programs 4, 5. Providing adequate support systems and regular follow-up can improve adherence to lifestyle changes.