Treatment Options for Polycystic Ovary Syndrome (PCOS)
Lifestyle modifications are the first-line treatment for PCOS, with pharmacological therapies targeted to specific symptoms including metformin for metabolic issues, combined oral contraceptives for menstrual irregularity and hyperandrogenism, and clomiphene citrate for ovulation induction in women seeking pregnancy. 1
Lifestyle Interventions
Lifestyle modifications form the cornerstone of PCOS management, particularly important given the higher prevalence of weight gain and obesity in women with PCOS 2:
Diet Recommendations
- Caloric deficit of 500-750 kcal/day 1
- Low glycemic index foods 1
- High fiber content 1
- Rich in omega-3 fatty acids 1
Physical Activity Guidelines
- At least 250 minutes of moderate-intensity physical activity weekly 1
- Strength training 2-3 times weekly 1
- Daily goal of 10,000 steps, including 30 minutes of structured activity 2
- Realistic SMART goals with progressive 5% weekly increases in activity 2
- Self-monitoring with fitness tracking devices can support active lifestyle 2
Behavioral Support
- Behavioral change techniques combined with diet and exercise interventions increase weight loss effectiveness 2
- Self-management and family support improve outcomes 2
- Goal-setting, self-monitoring, stimulus control, and problem-solving are recommended strategies 2
Important Note: Even a modest 5-10% weight loss can restore ovulation and improve fertility in women with PCOS 1
Pharmacological Treatments
For Metabolic Dysfunction
- Metformin: First-line for PCOS with metabolic features 1
- Starting dose: 500 mg/day with meals
- Target dose: 1000-1500 mg/day in divided doses
- Benefits: Improved insulin resistance, regularized menstrual cycles, reduced cardiometabolic risks
For Menstrual Irregularity and Hyperandrogenism
Combined Oral Contraceptives (COCs): First-line therapy 1
- Benefits: Menstrual regulation, reduced hyperandrogenism, endometrial protection
- Caution: Increases VTE risk three to fourfold (up to 4 per 10,000 woman-years)
Oral Micronized Progesterone: 200-300 mg daily for 12-14 days monthly 1
- Benefits: Endometrial protection, improved cycle regularity
- Advantage: Better safety profile than synthetic progestins
Levonorgestrel-releasing IUD (LNG-IUD): First-line non-oral option 1
- Benefits: Endometrial protection, menstrual regulation
- Advantage: Minimal impact on metabolic parameters
For Hirsutism
- Spironolactone: 100 mg daily 1
- Note: Visible improvement typically takes 6 months
For Fertility
- Clomiphene Citrate: First-line for ovulation induction 1
- Dosing: Starts on day 5 of cycle
- Efficacy: 80% ovulation rate, 50% conception rate
Monitoring and Follow-up
Regular monitoring is essential for women with PCOS 1:
- Consultations every 6 months
- Monitor: Blood pressure, lipid profile, menstrual cycles, weight changes, metabolic parameters
- Screen for gestational diabetes and pre-eclampsia during pregnancy
- Watch for red flags: Persistent abnormal bleeding, rapid symptom development, significant virilization, worsening insulin resistance
Special Considerations
- Psychological Impact: PCOS treatment should consider related stigma, negative body image, and self-esteem issues 2
- Eating Disorders: Women with PCOS have increased risk of eating disorders like bulimic hyperphagia 1
- Insulin Resistance: Present in both lean and overweight women with PCOS, but significantly worsened by obesity 1
Treatment Algorithm
- Initial Approach: Lifestyle modifications (diet, exercise, behavioral support)
- If metabolic features present: Add metformin
- For menstrual irregularity/hyperandrogenism: Add COCs, progesterone, or LNG-IUD
- For hirsutism: Add spironolactone (can be combined with COCs)
- For fertility concerns: Clomiphene citrate for ovulation induction
Regular monitoring and adjustment of treatment based on response and changing goals is essential for optimal management of PCOS.