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 hormonal outcomes, general health, and quality of life. 1

First-Line Treatment: Lifestyle Interventions

Dietary Approaches

• No specific diet has proven superior; focus should be on individual preferences while maintaining a healthy balanced diet 2
• For weight loss, aim for an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day) 2
• Avoid unduly restrictive or nutritionally unbalanced diets 2
• Achievable goals such as 5-10% weight loss in those with excess weight yield significant clinical improvements within 6 months 1

Physical Activity Recommendations

• Recommend at least 150 minutes/week of moderate intensity physical activity or 75 minutes/week of vigorous intensity activity 2
• Include muscle-strengthening activities on 2 non-consecutive days/week 2
• For greater health benefits, aim for at least 250 minutes/week of moderate intensity activities 2
• Both aerobic and resistance exercises have shown benefits in PCOS 2, 3
• Minimize sedentary, screen, or sitting time 2

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring 1
• Include behavioral strategies such as:
  • Goal-setting and self-monitoring
  • Stimulus control and problem-solving
  • Assertiveness training and slower eating
  • Reinforcing changes and relapse prevention 1
• Address psychological factors such as anxiety, depression, body image concerns, and disordered eating 1

Medical Management Options

For Ovulatory Dysfunction/Infertility

• Clomiphene citrate is indicated for treatment of ovulatory dysfunction in women with PCOS desiring pregnancy 4
  • Should be started on or about the 5th day of the cycle once ovulation has been established
  • Long-term cyclic therapy is not recommended beyond a total of about six cycles
  • Caution: May cause ovarian hyperstimulation syndrome (OHSS), which can progress rapidly and become serious 4

Special Considerations

• Ethnic-specific BMI and waist circumference categories need consideration when optimizing lifestyle and weight 1, 5
• Ethnic groups with PCOS who are at high cardiometabolic risk require greater attention for lifestyle intervention 1, 5
• Healthy lifestyle may contribute to health and quality of life benefits even without weight loss 1
• Regular monitoring of weight and waist circumference is recommended 2

Common Pitfalls and Caveats

• Patients with PCOS often describe significant difficulty losing weight; persistence with lifestyle modifications is essential 6
• Avoid focusing solely on weight loss as the goal; improvements in insulin sensitivity and hormonal balance can occur even with modest lifestyle changes 3
• Be aware of potential ovarian enlargement and cyst formation with clomiphene therapy, which usually regress spontaneously after discontinuing treatment 4
• Visual symptoms during clomiphene therapy require immediate discontinuation and ophthalmological evaluation 4
• Long-term management is necessary to reduce risks of metabolic-related diseases and endometrial cancer 7

The evidence strongly supports multicomponent lifestyle intervention as the cornerstone of PCOS management, with medical therapies like clomiphene added specifically for ovulatory dysfunction when pregnancy is desired.