What is the management approach for Polycystic Ovarian Syndrome (PCOS)?

Management Approach for Polycystic Ovarian Syndrome (PCOS)

The management of PCOS should focus on a multicomponent lifestyle intervention including diet, exercise, and behavioral strategies as the first-line treatment, particularly for patients with excess weight. 1, 2

Lifestyle Management

Dietary Interventions

• Implement a balanced dietary approach with an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day) to achieve weight loss, considering individual energy requirements 1, 2
• No specific diet type has proven superior for women with PCOS; focus on individual preferences while maintaining nutritional balance 1, 2
• Avoid unduly restrictive or nutritionally unbalanced diets 2
• Achievable goals of 5-10% weight loss in those with excess weight can yield significant clinical improvements 1, 2

Physical Activity Recommendations

• Engage in a minimum of 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous intensity (or equivalent combination) for prevention of weight gain 1, 2
• For weight loss and greater health benefits, aim for at least 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous intensity 1, 2
• Include muscle-strengthening activities on 2 non-consecutive days/week 3, 2
• Activity should be performed in at least 10-minute bouts, progressively increasing physical activity 5% weekly 3, 2
• Both aerobic and resistance exercises have shown benefits in PCOS 2, 4
• Minimize sedentary, screen, or sitting time 3, 2

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring 1, 2
• Include behavioral techniques such as goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 1, 2
• Self-monitoring with fitness tracking devices can support active lifestyles 3, 1
• Family support improves outcomes for lifestyle interventions 3

Medical Management for Specific Symptoms

For Ovulatory Dysfunction/Infertility

• For women desiring pregnancy with ovulatory dysfunction, clomiphene citrate is indicated 5
• Start with a low dose of 50 mg daily for 5 days, particularly recommended for patients with PCOS due to potential sensitivity to pituitary gonadotropin 5
• If ovulation does not occur after the first course, a second course of 100 mg daily for 5 days may be given 5
• Monitor for ovarian hyperstimulation syndrome (OHSS), which can progress rapidly and become serious 5
• Treatment should not exceed 100 mg/day for 5 days, and long-term cyclic therapy is not recommended beyond a total of about six cycles 5

Monitoring and Follow-up

• Regular monitoring of weight and waist circumference is essential 1, 2
• When assessing weight, consider related stigma, negative body image, and/or low self-esteem 3
• Prevention of weight gain is particularly important from adolescence 3, 2
• For patients on clomiphene citrate, pelvic examination is necessary prior to the first and each subsequent course of treatment 5

Special Considerations

• Women with PCOS have a higher prevalence of weight gain and obesity 3, 2
• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1, 2
• For ethnic groups with high cardiometabolic risk, consider ethnic-specific BMI and waist circumference categories 1, 6
• Address psychological factors such as anxiety, depression, body image concerns, and disordered eating 2, 7

Common Pitfalls and Caveats

• Recognize that central obesity increases over time in PCOS, with a progressive increase in waist-to-hip ratio between ages 20-45 years 1
• Ensure that health professional interactions avoid weight-related stigma, which can negatively impact engagement with treatment 1, 2
• For patients on clomiphene citrate, be vigilant for visual symptoms which require discontinuation and prompt ophthalmological evaluation 5
• Monitor for OHSS in patients receiving clomiphene citrate, with early warning signs including abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain 5