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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

The management of PCOS should prioritize lifestyle modifications as first-line treatment, followed by targeted pharmacological interventions based on the patient's specific symptoms and metabolic profile. 1

Lifestyle Modifications (First-Line Treatment)

Weight Management

• Weight loss of just 5-10% can restore ovulation and improve fertility in women with PCOS 1
• Recommended approach:
  • Caloric deficit of 500-750 kcal/day 1
  • Diet low in glycemic index, rich in fiber and omega-3 fatty acids 1
  • Prevention of weight gain is crucial, as women with PCOS have higher prevalence of weight gain and obesity 2
  • Regular monitoring of weight changes is essential 2

Physical Activity

• Minimum recommendations:
  • 150 minutes of moderate-intensity physical activity weekly 1
  • Ideally 250 minutes per week with strength training 2-3 times weekly 1
  • Daily goal of 10,000 steps, including 30 minutes of structured activity (approximately 3,000 steps) 2
  • Consider 10-minute exercise bouts, progressively increasing by 5% weekly 2
  • Self-monitoring with fitness tracking devices can support adherence 2

Behavioral Strategies

• Combine behavioral change techniques with diet and exercise for improved outcomes 2
• Incorporate self-management, self-monitoring, and family support 2
• Consider e-health resources to supplement face-to-face support 2
• Implement goal-setting, stimulus control, problem-solving, and relapse prevention strategies 2

Pharmacological Management

For Metabolic Abnormalities

• Metformin:
  • First-line for PCOS with metabolic characteristics 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 Endometrial Protection

• Combined Oral Contraceptives (COCs):

  • First-line therapy for menstrual regulation and endometrial protection 1
  • Also reduces hyperandrogenism 1
  • Caution: Increases venous thromboembolism risk (up to 4 per 10,000 woman-years) 1

• Levonorgestrel-releasing intrauterine device (LNG-IUD):

  • First-line non-oral contraceptive option 1
  • Provides endometrial protection and regulates menstrual cycles with minimal metabolic impact 1

• Oral Micronized Progesterone:

  • 200-300 mg daily for 12-14 days monthly 1
  • Protects against endometrial hyperplasia 1
  • Better safety profile than synthetic progestins 1

For Fertility Treatment

• Clomiphene Citrate:
  • First-line medication for ovulation induction 1, 3
  • Starting on day 5 of the cycle 1
  • 80% ovulation rate and 50% conception rate 1
  • Most effective in PCOS patients with ovulatory dysfunction 3
  • Not recommended for long-term cyclic therapy beyond six cycles (including three ovulatory cycles) 3
  • Contraindicated in patients with ovarian cysts (except PCOS), abnormal vaginal bleeding, or liver dysfunction 3

For Hirsutism and Hyperandrogenism

• Spironolactone:
  • 100 mg daily to improve hirsutism 1
  • Visible improvement typically takes 6 months 1

Monitoring and Follow-up

• Regular consultations every 6 months to monitor:

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

Ovarian Hyperstimulation Syndrome (OHSS)

• Potential complication of clomiphene citrate therapy 3
• Warning signs: abdominal pain/distention, nausea, vomiting, diarrhea, weight gain 3
• Can progress rapidly (within 24 hours) to a serious medical condition 3
• Use lowest effective dose of clomiphene citrate to minimize risk 3
• PCOS patients may be unusually sensitive to gonadotropins and require lower starting doses 3

Visual Symptoms with Clomiphene

• Discontinue treatment and obtain prompt ophthalmological evaluation if visual symptoms develop 3
• Visual symptoms typically resolve after discontinuation of medication 3

Psychological Support

• Address negative body image, low self-esteem, and weight-related stigma 2
• Depression prevalence can reach up to 30% in conditions with similar hormonal imbalances 1
• Provide supportive, respectful assessment and communication 2

PCOS management requires a comprehensive approach targeting the specific symptoms and metabolic profile of each patient, with lifestyle modifications forming the foundation of treatment and pharmacological interventions addressing specific manifestations of the syndrome.