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

Treatment Options for Managing Polycystic Ovary Syndrome (PCOS) Symptoms

Multicomponent lifestyle intervention including diet, exercise, and behavioral strategies should be recommended as first-line treatment for all women with PCOS, with particular focus on those with excess weight. 1

Lifestyle Management

Dietary Interventions

• No specific diet type has proven superior for PCOS; 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, 3
• Avoid unduly restrictive or nutritionally unbalanced diets 2
• A 5-10% weight reduction in those with excess weight can yield significant clinical improvements in PCOS symptoms 1
• General healthy eating principles should be followed across the life course, even for normal-weight women with PCOS 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 and maintenance of health 2
• For weight loss and greater health benefits, increase to at least 250 minutes/week of moderate intensity or 150 minutes/week of vigorous intensity activity 2, 3
• Include muscle-strengthening activities on 2 non-consecutive days/week 2
• Both aerobic and resistance exercises have shown benefits in improving insulin sensitivity in PCOS 2, 4
• Minimize sedentary, screen, or sitting time 2

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring to increase adherence 1, 2
• Include behavioral strategies such as stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 2, 3
• Address psychological factors such as anxiety, depression, body image concerns, and disordered eating, which are common in PCOS 2, 3

Pharmacological Management

For Menstrual Irregularity and Hyperandrogenism

• Combined oral contraceptives (COCs) are first-line pharmacological treatment to regulate menstrual cycles and reduce hyperandrogenism in women not attempting conception 3
• For hirsutism management, consider oral contraceptives, antiandrogen drugs, or topical treatments 3

For Insulin Resistance

• Metformin may improve insulin sensitivity and reduce risk factors for diabetes and cardiovascular disease in women with PCOS 3

For Fertility

• Clomiphene citrate is indicated for treatment of ovulatory dysfunction in women with PCOS desiring pregnancy 5
• Proper timing of treatment is important - each course should be started on or about the 5th day of the menstrual cycle 5
• Long-term cyclic therapy with clomiphene is not recommended beyond a total of about six cycles 5

Monitoring and Follow-up

• Regular monitoring of weight and waist circumference is recommended 2
• Screen for metabolic abnormalities including type 2 diabetes and cardiovascular disease 3
• Assess mental health regularly, as women with PCOS have higher rates of depression, anxiety, and eating disorders 3

Special Considerations

• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1, 2
• Ethnic-specific BMI and waist circumference categories need to be considered when optimizing lifestyle and weight 1, 2
• Health professional interactions should be respectful, patient-centered, and considerate of individual preferences and cultural differences 1
• Women with PCOS should be monitored for ovarian hyperstimulation syndrome during fertility treatments, especially when using gonadotropins 3, 5

Treatment Algorithm

1. Start with comprehensive lifestyle intervention (diet, exercise, behavioral strategies) for all women with PCOS 1
2. For women with menstrual irregularity and hyperandrogenism not seeking pregnancy: Add combined oral contraceptives 3
3. For women with insulin resistance: Consider adding metformin 3
4. For women seeking pregnancy with anovulation: Consider clomiphene citrate after excluding other impediments to pregnancy 5
5. For women with hirsutism: Add antiandrogens (with contraception) or topical treatments 3