Treatment Options for Polycystic Ovary Syndrome (PCOS)
Multicomponent lifestyle intervention including diet, exercise, and behavioral strategies is the first-line treatment for PCOS, particularly for patients with excess weight. 1, 2
Lifestyle Management
Dietary Recommendations
- A balanced dietary approach with an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day) is recommended for weight loss, considering individual energy requirements and activity levels 3, 1
- No specific diet type has proven superior for women with PCOS; focus should be on reducing energy intake while maintaining nutritional balance 3, 1
- General healthy eating principles should be followed for all women with PCOS across the life course 3
Physical Activity Recommendations
- Adults (18-64 years) should engage in a minimum of 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous intensity (or equivalent combination) 3, 1
- For weight loss and greater health benefits, increase to 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous intensity 1
- Adolescents should engage in at least 60 minutes of moderate to vigorous intensity physical activity daily, including muscle-strengthening activities 3
Behavioral Strategies
- Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring to achieve realistic lifestyle goals 3, 1
- Include behavioral techniques such as goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 3, 1
- Consider psychological factors such as anxiety, depression, body image concerns, and disordered eating when developing lifestyle interventions 3, 2
Pharmacological Management
For Menstrual Irregularity and Hyperandrogenism
- Hormonal contraceptives are effective for managing menstrual irregularity and hyperandrogenic symptoms like hirsutism and acne 4
- Antiandrogens may be added for persistent hirsutism and other androgenic symptoms 5
For Ovulation Induction in Women Seeking Pregnancy
- Clomiphene citrate is indicated for ovulatory dysfunction in women with PCOS desiring pregnancy 6
- Treatment should be started on or about the 5th day of the cycle once ovulation has been established 6
- Long-term cyclic therapy is not recommended beyond a total of about six cycles (including three ovulatory cycles) 6
- Patients must not be pregnant, should not have ovarian cysts (except those with PCOS), and should have normal liver function before starting clomiphene 6
Monitoring and Goals
- Achievable weight loss goals of 5-10% in those with excess weight can yield significant clinical improvements within 6 months 3, 1
- Regular monitoring of weight and waist circumference is essential during weight loss and maintenance 1
- Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 3, 1
Special Considerations
- Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention 3, 1
- Weight gain over time is significantly greater in women with PCOS than in unaffected women, making early intervention crucial 1
- For women with PCOS seeking fertility treatment, weight loss (if overweight), clomiphene citrate, and/or metformin are commonly used 4
Common Pitfalls and Caveats
- Avoid unduly restrictive and nutritionally unbalanced diets 3
- Health professional interactions should be respectful and patient-centered, avoiding weight-related stigma 3, 1
- Central obesity increases over time in PCOS, with progressive increase in waist-to-hip ratio between ages 20-45 years 1
- Comprehensive metabolic evaluation is crucial for women with obesity 2
- Alternative treatments such as dietary supplements, herbs, myo-inositol, and acupuncture have been explored but require more research 5, 7