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, followed by pharmacological interventions tailored to specific symptoms and reproductive goals. 1, 2

First-Line Approach: Lifestyle Interventions

Dietary Recommendations

• Implement a balanced dietary approach with an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day) for women with excess weight 2
• No specific diet type is superior; dietary changes should be tailored to food preferences while focusing on reducing energy intake 1
• Daily physical activity goals should include 10,000 steps, incorporating activities of daily living and 30 minutes of structured physical activity 1
• Set realistic SMART goals that include 10-minute exercise bouts, progressively increasing physical activity by 5% weekly 1

Physical Activity Guidelines

• For prevention of weight gain: at least 150 min/week of moderate intensity or 75 min/week of vigorous intensity physical activity, plus muscle-strengthening activities twice weekly 2
• For weight loss: at least 250 min/week of moderate-intensity or 150 min/week of vigorous-intensity activity plus muscle strengthening twice weekly 2
• Self-monitoring with fitness tracking devices can support active lifestyles and minimize sedentary behaviors 1

Pharmacological Management Based on Symptoms

For Women Not Attempting Conception

• Combined oral contraceptives (COCs) are the first-line medication for long-term management 1, 3
  • Benefits: suppress ovarian androgen secretion, increase sex hormone binding globulin, reduce endometrial cancer risk 1, 3
  • COCs containing norgestimate have a favorable side effect profile 3
• Medroxyprogesterone acetate (depot or intermittent oral therapy) suppresses circulating androgen levels and pituitary gonadotropin levels 1

For Hirsutism Management

• Combination of antiandrogens (spironolactone, flutamide, finasteride) with COCs is more effective than either treatment alone 3
• Topical eflornithine hydrochloride cream can be used for facial hirsutism 2

For Metabolic Management

• Metformin improves insulin sensitivity, decreases weight, and may have positive impacts on risk factors for diabetes and cardiovascular disease 1, 2
• Thiazolidinediones (pioglitazone, rosiglitazone) improve insulin sensitivity but tend to increase weight 1
• Anti-obesity medications may be considered for patients with BMI ≥25 kg/m² 2
  • GLP-1 receptor agonists (liraglutide, semaglutide) appear superior to placebo for weight loss 1
  • Orlistat may help achieve weight loss and improve lipid and glucose metabolism 4

For Women Attempting Conception

• Clomiphene citrate is the first-line ovulation induction treatment 1, 5
  • Approximately 80% of PCOS patients ovulate with clomiphene, and half of these conceive 3
  • Should be started on or about the 5th day of the cycle 5
  • Long-term cyclic therapy is not recommended beyond a total of about six cycles 5
• If clomiphene treatment fails, low-dose gonadotropin therapy is preferred over high-dose therapy 1
• Metformin may improve ovulation rates but is not FDA-approved for PCOS treatment 1

Screening and Monitoring

• All women with PCOS should be screened for:
  • Type 2 diabetes with fasting glucose and 2-hour glucose tolerance test 1, 2
  • Dyslipidemia with fasting lipoprotein profile (total cholesterol, LDL, HDL, triglycerides) 1, 2
  • Mental health issues, as women with PCOS have higher rates of depression, anxiety, and eating disorders 2
• Regular monitoring for weight changes and excess weight is essential 1

Common Pitfalls and Caveats

• Neglecting lifestyle interventions in normal-weight PCOS patients should be avoided, as overall health benefits extend beyond weight loss 2, 6
• Risk of ovarian hyperstimulation syndrome during fertility treatments, especially in PCOS patients who are unusually sensitive to gonadotropins 2, 5
• Baseline risk of venous thromboembolism increases three to fourfold with COC use 3
• Weight loss of even 5% can significantly improve metabolic and reproductive abnormalities 3, 6
• Long-term management is necessary to reduce the risk of endometrial cancer and metabolic-related diseases 4

By implementing this comprehensive approach to PCOS management, focusing first on lifestyle interventions and then adding appropriate pharmacological treatments based on specific symptoms and reproductive goals, patients can experience significant improvements in their quality of life and long-term health outcomes.