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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

Lifestyle management is the first-line treatment for PCOS, with multicomponent interventions including diet, exercise, and behavioral strategies being most effective for improving symptoms and reducing long-term health risks. 1

First-Line Treatment: Lifestyle Modifications

Dietary Approaches

• No specific diet has proven superior; focus should be on creating an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day) for those with excess weight 2, 3
• Dietary interventions that may be beneficial include low glycemic index foods, high-fiber diets, and anti-inflammatory diets which improve insulin sensitivity and hormonal balance 4
• Set achievable weight loss goals of 5-10% in those with excess weight, which can yield significant clinical improvements in PCOS symptoms 3

Physical Activity Recommendations

• Recommend at least 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous-intensity activity for prevention of weight gain 2, 3
• For weight loss and greater health benefits, aim for 250 minutes/week of moderate-intensity activities 3
• Include muscle-strengthening activities on 2 non-consecutive days/week 2

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring 2, 3
• Address psychological factors such as anxiety, depression, and body image concerns, which are common in PCOS 2
• Regular monitoring of weight and waist circumference is essential during weight loss and maintenance 3

Pharmacological Management

For Menstrual Irregularity and Anovulation

• Hormonal contraceptives are first-line therapy for menstrual cycle regulation and prevention of endometrial hyperplasia 5, 6
• For women desiring pregnancy, clomiphene citrate is indicated for treatment of ovulatory dysfunction 7, 6
  • Should be started on or about the 5th day of the cycle once ovulation has been established 7
  • Not recommended beyond a total of about six cycles (including three ovulatory cycles) 7
  • Caution: Ovarian hyperstimulation syndrome (OHSS) may occur, with symptoms including abdominal pain, distention, nausea, vomiting, and weight gain 7

For Metabolic Manifestations

• Metformin is the first-line medication for metabolic manifestations such as hyperglycemia and insulin resistance 6
• Metformin in addition to lifestyle modification can improve menstrual cyclicity and hyperandrogenism, particularly in patients with PCOS and type 2 diabetes 2

For Dermatologic Manifestations

• Estrogen-containing hormonal contraceptives and antiandrogens are first-line therapy for hirsutism, acne, and male-pattern hair loss 5, 6
• More permanent hair reduction can be achieved with electrolysis and laser therapy 5

Multidisciplinary Approach

• A team including dietitian, health psychologist, gynecologist, and endocrinologist has shown enhanced outcomes in PCOS management 2
• Health professional interactions should be respectful, patient-centered, and considerate of individual preferences and cultural differences 2

Important Considerations and Pitfalls

• Avoid focusing solely on weight loss without addressing psychological aspects of PCOS 2
• Be aware that ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention 2, 3
• Central obesity increases over time in PCOS, with a progressive increase in waist-to-hip ratio between ages 20-45 years, making early intervention crucial 3
• Patients with clomiphene therapy should be monitored for visual symptoms (blurring, scotomata), which warrant immediate discontinuation and ophthalmological evaluation 7
• Before initiating clomiphene, ensure patient is not pregnant, does not have ovarian cysts (except in PCOS), and has normal liver function 7