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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

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

First-Line Interventions

Lifestyle Modifications

1. Dietary Recommendations:

   • Energy deficit of 30% or 500-750 kcal/day
   • Daily caloric intake of 1,200-1,500 kcal/day
   • Low glycemic index foods
   • Anti-inflammatory diet pattern
   • Adequate magnesium and zinc intake 1

2. Physical Activity Guidelines:

   • 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

Even modest weight loss (5% of initial weight) can significantly improve metabolic and reproductive abnormalities in PCOS 1, 2

Pharmacological Interventions

For Menstrual Irregularities and Hyperandrogenism

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

For Insulin Resistance

• Metformin: First-line pharmacological intervention for insulin resistance in PCOS
  • Particularly beneficial for adolescents and women with type 2 diabetes 1
• GLP-1 receptor agonists (liraglutide, semaglutide): May improve anthropometric outcomes in PCOS patients with obesity 1

For Fertility Treatment

• Clomiphene citrate: First-line treatment for ovulation induction
  • Approximately 80% of PCOS patients ovulate with this treatment, and half of these conceive 1
  • Caution: Monitor for Ovarian Hyperstimulation Syndrome (OHSS), especially in PCOS patients who are unusually sensitive to gonadotropins 3
  • Early warning signs of OHSS include abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain 3
  • Use the lowest effective dose and provide close monitoring 3
• Low-dose gonadotropin therapy: Recommended if clomiphene fails 1

Monitoring and Assessment

Initial Evaluation

• Metabolic screening:

  • Two-hour oral glucose tolerance test (75g glucose load)
  • Fasting lipid profile (total cholesterol, LDL, HDL, triglycerides)
  • 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

Ongoing Monitoring

• Annual metabolic screening for women with irregular cycles
• Monitor for endometrial hyperplasia in women with irregular cycles
• Regular assessment of weight, waist circumference, menstrual cycles
• Annual assessment of metabolic parameters, including insulin resistance markers, lipid profile, and blood pressure 1
• Screening for anxiety and depression 1

Special Considerations

Ethnic-Specific Approach

• Consider ethnic-specific BMI and waist circumference categories
• Ethnic groups with PCOS at high cardiometabolic risk require greater attention to lifestyle interventions 1

Potential Complications

• With clomiphene citrate therapy, monitor for visual symptoms (blurring, scotomata)
  • Discontinue treatment and perform ophthalmological evaluation if visual symptoms occur 3
• Monitor for OHSS, which can progress rapidly and become a serious medical disorder
  • Symptoms include ovarian enlargement, gastrointestinal symptoms, ascites, dyspnea, oliguria, and pleural effusion 3

Treatment Algorithm

1. Start with lifestyle modifications for all PCOS patients
2. Add pharmacological therapy based on predominant symptoms:
   • For menstrual irregularities/hyperandrogenism → COCs
   • For insulin resistance → Metformin
   • For fertility → Clomiphene citrate (with careful monitoring)
3. Consider second-line therapies if first-line treatments fail:
   • Anti-androgens for persistent hirsutism
   • Gonadotropins for clomiphene resistance

Remember that PCOS management requires a comprehensive approach addressing both the immediate symptoms and the long-term metabolic and reproductive health risks.