Treatment Options for Polycystic Ovary Syndrome (PCOS)
Multicomponent lifestyle intervention including diet, exercise, and behavioral strategies is the first-line treatment for PCOS management, particularly for patients with excess weight. 1, 2
Lifestyle Management
Dietary Approaches
- A balanced dietary approach with an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day) is recommended to achieve weight loss, considering individual energy requirements and physical activity levels 2
- No specific diet type has proven superior for women with PCOS; the focus should be on creating a caloric deficit while maintaining nutritional balance 1, 2
- Weight loss of 5-10% in those with excess weight can yield significant clinical improvements in PCOS symptoms and is considered successful weight reduction within 6 months 2, 3
Physical Activity Recommendations
- Adults with PCOS should engage in a minimum of 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous intensity for prevention of weight gain 2
- For weight loss and greater health benefits, increase to 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous intensity 2
- Both aerobic and resistance exercise improve insulin sensitivity and metabolic outcomes in PCOS 2
Behavioral Strategies
- Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring to achieve realistic lifestyle goals 2
- Include behavioral techniques such as stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 2
Pharmacological Management
Menstrual Irregularity and Hyperandrogenism
- Hormonal contraceptives are the first-line pharmacological treatment for menstrual abnormalities, hirsutism, and acne in PCOS 4, 5
- For severe hirsutism, antiandrogens may be added to estrogen-progestin therapy for improved results 6
Insulin Resistance and Metabolic Manifestations
- Metformin is the first-line medication for metabolic manifestations such as hyperglycemia and insulin resistance 4, 5
- Insulin-sensitizing drugs improve insulin resistance and ovulatory performance 6
- Natural substances like inositol may have efficacy similar to metformin with fewer side effects 6
Infertility Treatment
- For women desiring pregnancy with anovulatory infertility, clomiphene citrate is the first-line therapy 7, 4, 5
- Letrozole is another first-line medication option for infertility 5
- Clomiphene citrate should be started on or about the 5th day of the cycle once ovulation has been established 7
- Long-term cyclic therapy with clomiphene is not recommended beyond a total of about six cycles 7
- Caution: Ovarian hyperstimulation syndrome (OHSS) may occur with clomiphene citrate therapy, particularly in patients with PCOS who may be unusually sensitive to gonadotropin 7
Special Considerations and Monitoring
- Regular monitoring of weight and waist circumference is essential during weight loss and maintenance 2
- Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 2
- Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention 2, 3
- Psychological factors, such as anxiety, depression, body image concerns, and disordered eating, should be addressed as part of comprehensive management 3
Common Pitfalls and Caveats
- Central obesity increases over time in PCOS, with a progressive increase in waist-to-hip ratio between ages 20-45 years 2
- Avoid weight-related stigma during health professional interactions, as this can negatively impact treatment engagement 2
- When using clomiphene citrate, monitor for visual symptoms (blurring, scotomata) which warrant discontinuation and prompt ophthalmological evaluation 7
- For patients with PCOS using clomiphene, be vigilant for signs of OHSS including abdominal pain, distention, nausea, vomiting, diarrhea, and weight gain 7