What are the next steps in managing a patient with Polycystic Ovary Syndrome (PCOS)?

Management of Polycystic Ovary Syndrome (PCOS)

The first-line management for PCOS should be lifestyle modification, including dietary changes and physical activity, followed by targeted pharmacological interventions based on the patient's specific symptoms and goals. 1

Initial Assessment and Screening

After confirming PCOS diagnosis, comprehensive screening should include:

• Metabolic screening:

  • Two-hour oral glucose tolerance test (75g glucose load) 2
  • Fasting lipid profile (total cholesterol, LDL, HDL, triglycerides) 2
  • Blood pressure measurement
  • BMI calculation and waist-hip ratio measurement 2

• Hormonal assessment:

  • Total testosterone or bioavailable/free testosterone levels 2
  • Thyroid-stimulating hormone (TSH) 2
  • Prolactin level 2

• Mental health screening:

  • Assessment for anxiety and depression 1

Treatment Algorithm

Step 1: Lifestyle Modifications (First-line for all patients)

• Dietary recommendations:

  • 30% energy deficit or 500-750 kcal/day reduction
  • Target 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 recommendations:

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

Step 2: Pharmacological Management (Based on primary symptoms)

For women not attempting to conceive:

• Menstrual irregularities and hyperandrogenism:

  • First-line: Combined oral contraceptive pills (COCs) 2, 1
    • Benefits: Suppresses ovarian androgen secretion, increases sex hormone binding globulin, reduces endometrial cancer risk

• Persistent hirsutism despite COCs:

  • Add anti-androgens: spironolactone, flutamide, or finasteride 1

• Insulin resistance:

  • Metformin - particularly beneficial for adolescents and women with type 2 diabetes 1
  • Consider GLP-1 receptor agonists (liraglutide, semaglutide) for patients with obesity 1

For women attempting to conceive:

• Ovulation induction:
  • First-line: Clomiphene citrate (approximately 80% ovulation rate) 1
  • Second-line: Low-dose gonadotropin therapy if clomiphene fails 1
  • Consider metformin to improve insulin sensitivity and ovulation rates 2, 1

Ongoing Monitoring

• Regular assessment of weight, waist circumference, and menstrual cycles
• Annual metabolic screening (glucose tolerance, lipid profile, blood pressure)
• Monitor for endometrial hyperplasia in women with irregular cycles 2
• Psychological support as needed 1

Important Considerations

• Even modest weight loss (5% of initial body weight) can significantly improve metabolic and reproductive outcomes 1
• Prevention of weight gain is as important as weight loss 1
• Obese women require more frequent glucose tolerance testing due to risk of rapid progression to diabetes 3
• Monitor for potential side effects of medications (e.g., venous thrombosis risk with COCs, OHSS with clomiphene) 1, 4

By following this structured approach, PCOS management can effectively address both immediate symptoms and reduce long-term health risks associated with the condition.