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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

Lifestyle modification is the first-line therapy for PCOS management, focusing on dietary changes and physical activity to improve metabolic and reproductive outcomes. 1

First-Line Management: Lifestyle Modifications

Dietary Recommendations

• Energy deficit: 30% or 500-750 kcal/day
• Daily caloric intake: 1,200-1,500 kcal/day
• Diet pattern: Low glycemic index, anti-inflammatory
• Nutritional focus: Adequate magnesium and zinc intake 1
• Key dietary approaches: Mediterranean diet, high-fiber, omega-3 rich foods, and anti-inflammatory diets improve insulin sensitivity and hormonal balance 2

Physical Activity Guidelines

• General health maintenance: 150+ minutes/week of moderate activity or 75+ minutes/week of vigorous activity
• Weight loss goals: 250+ minutes/week of moderate activity or 150+ minutes/week of vigorous activity
• Additional recommendations:
  • Muscle-strengthening activities 2 days/week
  • Target 10,000 steps daily
  • Minimize sedentary time 1
  • Both aerobic and resistance exercise enhance insulin sensitivity 2

Even modest weight loss (5% of initial weight) can significantly improve metabolic and reproductive abnormalities 1

Pharmacological Interventions

Menstrual Irregularities and Dermatologic Manifestations

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

Metabolic Management

• First-line for insulin resistance: Metformin, particularly beneficial for:
  • Adolescents with PCOS
  • Women with type 2 diabetes
  • Patients with metabolic syndrome 1
• For obesity: GLP-1 receptor agonists (liraglutide, semaglutide) may improve anthropometric outcomes, though data is limited 1

Fertility Treatment

• First-line for ovulation induction: Clomiphene citrate
  • Approximately 80% of PCOS patients ovulate with clomiphene
  • About half of those ovulating will conceive 1
  • Should be started on or about the 5th day of the cycle 3
  • Not recommended beyond a total of about six cycles 3
• Second-line if clomiphene fails: Low-dose gonadotropin therapy 1

Monitoring and Follow-up

Regular Assessment

• Annual metabolic screening:
  • Two-hour oral glucose tolerance test (75g glucose load)
  • Fasting lipid profile
  • Blood pressure
  • BMI calculation with waist-hip ratio measurement 1

Hormonal Evaluation

• Total testosterone or bioavailable/free testosterone levels
• Thyroid-stimulating hormone (TSH) levels
• Prolactin levels 1

Endometrial Monitoring

• Women with irregular cycles should be monitored for endometrial hyperplasia 1
• Endometrial biopsy should be performed prior to clomiphene citrate therapy in older women 3

Important Precautions and Considerations

Ovarian Hyperstimulation Syndrome (OHSS)

• Warning signs: Abdominal pain and distention, nausea, vomiting, diarrhea, weight gain 3
• Serious complications: Ascites, dyspnea, oliguria, pleural effusion, acute abdomen, thromboembolism 3
• Prevention: Use lowest effective dose of clomiphene citrate and close monitoring 3
• Special caution: Patients with PCOS are unusually sensitive to gonadotropin and may have exaggerated response to clomiphene 3

Visual Symptoms

• Patients experiencing any visual symptoms should discontinue clomiphene treatment immediately and undergo ophthalmological evaluation 3

Ethnic Considerations

• Ethnic-specific BMI and waist circumference categories should be considered in management 1
• Ethnic groups with PCOS at high cardiometabolic risk require greater attention to lifestyle interventions 1

Mental Health

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

Treatment Algorithm

1. Start with lifestyle modifications (dietary changes and physical activity)
2. Add pharmacological therapy based on predominant symptoms:
   • For menstrual irregularities/hirsutism/acne → Combined oral contraceptives
   • For insulin resistance/metabolic issues → Metformin
   • For fertility concerns → Clomiphene citrate
3. Consider second-line therapies if inadequate response:
   • For persistent hirsutism → Add anti-androgens
   • For clomiphene failure → Low-dose gonadotropins
   • For obesity → Consider GLP-1 receptor agonists
4. Monitor regularly for metabolic parameters, menstrual cycles, and potential complications