Treatment Options for Polycystic Ovary Syndrome (PCOS)
Multicomponent lifestyle intervention including diet, exercise, and behavioral strategies is the first-line treatment for all patients with PCOS, with a focus on weight management and healthy lifestyle behaviors. 1
First-Line Treatment: Lifestyle Management
Dietary Approaches
- No specific diet type has proven superior; focus should be on individual preferences and cultural needs 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), considering individual energy requirements 2
- Various dietary approaches that may be beneficial include low glycemic index foods, caloric restrictions, high-fiber diets, Mediterranean diets, and anti-inflammatory diets 3
Physical Activity Guidelines
- 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
- Include muscle-strengthening activities on 2 non-consecutive days/week 2
- Both aerobic and resistance exercise enhance insulin sensitivity, promote weight loss, and improve metabolic and reproductive outcomes 3, 4
Behavioral Strategies
- Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring 2
- Address psychological factors such as anxiety, depression, body image concerns, and disordered eating 2, 5
- Educational modules can improve awareness, treatment adherence, and management of mental health issues related to PCOS 3
Weight Management
- Set achievable weight loss goals of 5-10% in those with excess weight, which can yield significant clinical improvements 2, 5
- Even modest weight loss can improve insulin sensitivity, hormonal balance, and reproductive outcomes 6
- Consider ethnic-specific BMI and waist circumference categories when optimizing lifestyle and weight 2, 5
Second-Line Treatments
Pharmacological Management
- Metformin may be added to lifestyle modification to improve menstrual cyclicity and hyperandrogenism, particularly in women with insulin resistance or type 2 diabetes 2
- Hormonal contraceptives (oral contraceptive pills) should be used as first-line pharmacological treatment for long-term management in patients without reproductive requirements 7
- Clomiphene citrate is commonly used for ovulation induction in women desiring pregnancy, but requires careful monitoring due to risk of ovarian hyperstimulation syndrome 8, 9
Ovulation Induction for Fertility
- For women desiring pregnancy, ovulation induction therapies include weight loss (if overweight), clomiphene citrate, and/or metformin 9
- For refractory ovulation disorders, options include bilateral ovarian drilling and assisted reproductive technology 7
- Careful monitoring is essential during ovulation induction, particularly in women with PCOS who may be unusually sensitive to gonadotropins 8
Multidisciplinary Approach
- A multidisciplinary model of care with dietitian, health psychologist, gynecologist, and endocrinologist has shown enhanced outcomes 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, 5
- Monitor for potential side effects of clomiphene citrate, including visual disturbances and ovarian hyperstimulation syndrome 8
- Comprehensive metabolic evaluation is crucial for women with obesity to assess for diabetes, dyslipidemia, hypertension, and nonalcoholic fatty liver disease 5