What is the best treatment for Polycystic Ovary Syndrome (PCOS)?

Best Treatment for Polycystic Ovary Syndrome (PCOS)

Lifestyle interventions focusing on weight management through diet, exercise, and behavioral strategies should be the first-line treatment for PCOS, particularly for patients with excess weight, as even a modest 5% weight reduction can significantly improve metabolic, reproductive, and psychological outcomes. 1

Lifestyle Interventions: The Foundation of PCOS Treatment

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 to achieve weight loss, considering individual energy requirements 1
• No specific diet type has proven superior for women with PCOS; focus should be on individual preferences while maintaining nutritional balance 1, 2
• Low glycemic index foods, high-fiber diets, and anti-inflammatory diets can improve insulin sensitivity and hormonal balance 2

Physical Activity Guidelines

• Adults 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 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
• Both aerobic and resistance exercise improve insulin sensitivity and metabolic outcomes in PCOS 1, 2

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring to achieve realistic lifestyle goals 1
• Include behavioral strategies such as stimulus control, problem-solving, slower eating, and relapse prevention 1

Pharmacological Interventions

Insulin-Sensitizing Agents

• Metformin improves menstrual regularity and features of metabolic syndrome in premenopausal PCOS women 3
• Newer insulin sensitizers like inositols, GLP-1 agonists, and DPP-4 inhibitors show promise in PCOS management 4

Hormonal Therapy

• Oral contraceptives regulate menstrual cycles and protect the endometrium against dysplasia and carcinoma 5
• Progestins, either alone or in combination with estrogen, are the mainstay of treatment for oligomenorrhea 5
• Antiandrogens can be used to target androgen excess symptoms like hirsutism and acne 5, 3

Treatment Algorithm Based on Primary Symptoms

For Patients with Irregular Menstrual Cycles

1. Start with lifestyle modifications (diet, exercise, behavioral strategies) 1
2. If no improvement after 3-6 months, add hormonal therapy (oral contraceptives) 5
3. Consider adding metformin, particularly if insulin resistance is present 3

For Patients with Hyperandrogenism (Hirsutism, Acne)

1. Implement lifestyle modifications 1
2. Add oral contraceptives with or without antiandrogens 5
3. For hirsutism, consider cosmetic approaches like laser hair removal as adjunctive therapy 6

For Patients Seeking Fertility

1. Weight loss through lifestyle intervention is the primary therapy 3
2. If anovulation persists, treatment should begin with an oral agent such as clomiphene citrate or letrozole 3, 7
3. Screen and treat for hypertension and diabetes prior to conception 3

Monitoring and Follow-up

• Set achievable goals of 5-10% weight loss within 6 months for those with excess weight 1
• Regular monitoring of weight and waist circumference is essential 1
• Perform oral glucose tolerance tests every 1-2 years based on family history of T2DM and BMI, yearly in women with impaired glucose tolerance 3

Important Caveats and Pitfalls

• Recognize that central obesity increases over time in PCOS, with progressive increase in waist-to-hip ratio between ages 20-45 years 1
• Avoid weight-related stigma during health professional interactions, as this can negatively impact treatment engagement 1
• Be aware that PCOS women have a 1.5-times higher baseline risk of venous thromboembolic disease and a 3.7-fold greater risk with oral contraceptive use compared to non-PCOS subjects 3
• Persistent bleeding should always be investigated for pregnancy and/or uterine pathology in women with PCOS 3