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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

Lifestyle interventions should be the first-line treatment for all patients with PCOS, with multicomponent approaches including diet, exercise, and behavioral strategies being most effective, particularly for those with excess weight. 1, 2

Lifestyle Management

Dietary Recommendations

• No specific diet type has proven superior for PCOS management; focus on individual preferences and cultural needs while maintaining nutritional balance 1
• 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 1
• Various dietary approaches may be beneficial, including low glycemic index foods, Mediterranean diets, and anti-inflammatory diets that improve insulin sensitivity 3

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 a minimum of 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
• Examples of moderate-intensity activities include brisk walking, cycling (8-15 km/h), and yoga, while vigorous-intensity activities include jogging/running and high-impact aerobics 1

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring to achieve realistic lifestyle goals 1, 2
• Include behavioral techniques such as stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 1
• Address psychological factors such as anxiety, depression, and body image concerns that may impact treatment adherence 2

Weight Management Goals

• Set achievable weight loss goals of 5-10% in those with excess weight, which can yield significant clinical improvements in metabolic and reproductive parameters 1, 4
• Regular monitoring of weight and waist circumference is essential during weight loss and maintenance 1
• Recognize that healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1

Pharmacological Management

• Metformin may be considered in addition to lifestyle modification to improve menstrual cyclicity and hyperandrogenism, particularly in patients with type 2 diabetes or metabolic syndrome 2
• Anti-obesity medications may be considered for patients who fail to achieve adequate weight loss with lifestyle interventions alone, though data specific to PCOS is limited 5

Multidisciplinary Approach

• A multidisciplinary model of care involving dietitians, health psychologists, gynecologists, and endocrinologists has shown enhanced outcomes in PCOS management 2
• Health professional interactions should be respectful, patient-centered, and avoid weight-related stigma, which can negatively impact engagement with treatment 1

Important Considerations and Pitfalls

• Women with PCOS experience greater weight gain over time compared to unaffected women, making early intervention crucial 1
• Central obesity increases over time in PCOS, with a progressive increase in waist-to-hip ratio between ages 20-45 years 1
• Despite the importance of weight management in PCOS, many patients report inadequate support and guidance for implementing lifestyle changes 6
• Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention 1, 2
• Lifestyle interventions may improve free androgen index (FAI), weight, and BMI, but evidence for improvements in glucose tolerance remains uncertain 4