What is the recommended treatment approach for patients with Polycystic Ovary Syndrome (PCOS)?

Treatment Approach for Polycystic Ovary Syndrome (PCOS)

Lifestyle modification should be the first-line treatment for all patients with PCOS, regardless of fertility status, with a focus on weight loss and regular exercise. 1

Treatment Based on Reproductive Goals

For Women Not Seeking Pregnancy:

• Combined oral contraceptives (COCs) are the first-line medication treatment for long-term management of PCOS 2
• COCs suppress androgen secretion by the ovaries, increase circulating sex hormone binding globulin, and reduce the risk of endometrial cancer 1
• Medroxyprogesterone acetate is an alternative that suppresses circulating androgen levels and pituitary gonadotropin levels 1

For Women Seeking Pregnancy:

1. Start with lifestyle modifications:

   • Weight loss (even 5% of initial weight) improves metabolic and reproductive abnormalities 1
   • Regular exercise program is beneficial even without weight loss 1, 2

2. If lifestyle modifications are insufficient:

   • Clomiphene citrate is the first-line medication for ovulation induction 1, 2, 3
   • Approximately 80% of PCOS patients ovulate with clomiphene, and half of these conceive 1, 2
   • Start with 50mg daily for 5 days, beginning on day 5 of the cycle 3
   • If ovulation doesn't occur, increase to 100mg daily for 5 days 3
   • Do not exceed 100mg/day or continue beyond three unsuccessful ovulatory cycles 3

3. For clomiphene-resistant cases:

   • Low-dose gonadotropin therapy is preferred over high-dose therapy 1, 2
   • Metformin may be considered to improve ovulation frequency 1, 4

Management of Metabolic Aspects

• All women with PCOS should be screened for:

  • Type 2 diabetes with fasting glucose and 2-hour glucose tolerance test 1, 2
  • Dyslipidemia with fasting lipoprotein profile 1, 2

• Metformin can be considered for:

  • Improving insulin sensitivity 1
  • Reducing weight 2
  • Improving glucose tolerance 1

Hirsutism Management

• Combined approach with antiandrogens and COCs is most effective 1, 2
• Options include:
  • Spironolactone, flutamide, or finasteride combined with COCs 1, 2
  • Topical eflornithine hydrochloride cream (FDA-approved for hirsutism) 1
  • Mechanical hair removal methods (shaving, waxing) or electrolysis/laser treatments as adjuncts 1

Important Considerations and Cautions

• Monitor for ovarian hyperstimulation syndrome (OHSS) when using clomiphene, especially in women with PCOS who may be unusually sensitive to gonadotropin 3
• Warning signs of OHSS include abdominal pain, distention, nausea, vomiting, diarrhea, and weight gain 3
• Visual symptoms during clomiphene therapy require immediate discontinuation and ophthalmological evaluation 3
• Women with PCOS have increased risk of cardiovascular disease and type 2 diabetes, requiring regular monitoring 1, 5, 6

Treatment Algorithm

1. All patients: Begin with lifestyle modifications (diet, exercise, weight loss) 1, 7
2. Assess reproductive goals:
   • If not seeking pregnancy → COCs 2
   • If seeking pregnancy → Continue to step 3
3. For fertility treatment:
   • First-line: Clomiphene citrate 1, 2, 3
   • Second-line: Low-dose gonadotropins or metformin 1, 4
   • Third-line: Consider laparoscopic ovarian drilling or assisted reproductive technology 5, 6
4. For metabolic management: Consider metformin 1, 8
5. For hirsutism: Combined antiandrogens with COCs 1, 2

By following this structured approach, clinicians can effectively manage the various manifestations of PCOS while prioritizing interventions that improve morbidity, mortality, and quality of life.