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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

Multicomponent lifestyle intervention including diet, exercise, and behavioral strategies is the first-line treatment for all women with PCOS, regardless of weight status, with pharmacological therapy reserved for specific symptoms or fertility needs. 1, 2, 3

First-Line Treatment: Lifestyle Modification

Dietary Interventions

All women with PCOS should follow a balanced dietary approach with no specific diet type proven superior to others. 1, 2, 3 The evidence supports multiple dietary patterns including low glycemic index foods, Mediterranean diet, high-fiber diets, and omega-3 fatty acid-rich foods, all of which improve insulin sensitivity and hormonal balance. 4

For women with excess weight requiring weight loss:

• Target an energy deficit of 30% or 500-750 kcal/day (total intake 1,200-1,500 kcal/day), adjusted for individual energy requirements, body weight, and physical activity levels. 2, 3
• Aim for 5-10% weight loss within 6 months, which yields significant clinical improvements in metabolic and reproductive outcomes. 2, 5
• Avoid unduly restrictive or nutritionally unbalanced diets. 3

Physical Activity Requirements

For prevention of weight gain and health maintenance, prescribe a minimum of 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous-intensity activity (or equivalent combination). 2, 3

For weight loss and greater metabolic benefits, prescribe a minimum of 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous-intensity activity (or equivalent combination). 2, 3

• Include muscle-strengthening activities on 2 non-consecutive days per week. 3
• Activity should be performed in at least 10-minute bouts, aiming for at least 30 minutes daily on most days. 3
• Both aerobic exercise (brisk walking, cycling 8-15 km/h, low-impact aerobics, yoga) and resistance training improve insulin sensitivity and metabolic outcomes. 2, 4
• Minimize sedentary, screen, and sitting time. 3

Behavioral Strategies

Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring as core behavioral interventions. 2, 3

Additional behavioral strategies include:

• Goal-setting and self-monitoring 2, 3
• Stimulus control and problem-solving 2, 3
• Assertiveness training and slower eating 2, 3
• Reinforcing changes and relapse prevention 2, 3
• Comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence 3
• Address psychological factors including anxiety, depression, body image concerns, and disordered eating 3, 5

Pharmacological Treatment for Specific Indications

For Ovulatory Dysfunction and Infertility

Clomiphene citrate is the first-line pharmacological therapy for ovulation induction in women with PCOS desiring pregnancy. 6, 7

Key prescribing considerations for clomiphene:

• Indicated specifically for ovulatory dysfunction in women with PCOS desiring pregnancy 6
• Start each course on or about the 5th day of the cycle 6
• Long-term cyclic therapy should not exceed approximately six cycles (including three ovulatory cycles) 6
• Patients must be evaluated to ensure they are not pregnant, have no ovarian cysts (except polycystic ovaries), have no abnormal vaginal bleeding, and have normal liver function 6
• Women with PCOS may have exaggerated response to usual doses; start with the lowest recommended dose and shortest treatment duration for the first course. 6

Critical warning: Ovarian hyperstimulation syndrome (OHSS) can occur with clomiphene therapy, progressing rapidly within 24 hours to several days into a serious medical disorder with gross ovarian enlargement, ascites, dyspnea, oliguria, and pleural effusion. 6 Early warning signs include abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain. 6

For Metabolic Abnormalities

Metformin is beneficial for metabolic and glycemic abnormalities and for improving menstrual irregularities, but has limited or no benefit in treating hirsutism, acne, or infertility. 7

• Metformin is particularly useful in women with insulin resistance and metabolic dysfunction 8, 7
• It can be used as complementary pharmacological support to lifestyle intervention 9

For Menstrual Abnormalities and Hyperandrogenism

Hormonal contraceptives are first-line pharmacological management for menstrual abnormalities, hirsutism, and acne in PCOS. 7

• Hormonal contraceptives are also appropriate treatment options in adolescents with PCOS 7

Monitoring and Follow-Up

Regular monitoring of weight and waist circumference is essential during weight loss and maintenance phases. 2

• Use ethnic-specific BMI and waist circumference categories for ethnic groups at high cardiometabolic risk 3, 5
• Comprehensive metabolic evaluation is crucial for women with obesity 5
• Screen for risk factors including endometrial cancer, mood disorders, obstructive sleep apnea, diabetes, and cardiovascular disease 7

Special Populations and Considerations

Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention with ethnic-specific BMI and waist circumference thresholds. 2, 3, 5

In adolescents with PCOS, hyperandrogenism is central to the diagnosis, and treatment options include hormonal contraceptives and metformin. 7

Healthy lifestyle interventions may contribute to health and quality of life benefits even in the absence of weight loss. 2, 3

Common Pitfalls and Caveats

• Weight gain over time is significantly greater in women with PCOS than in unaffected women, with progressive increase in waist-to-hip ratio between ages 20-45 years, making early intervention crucial. 2
• Avoid weight-related stigma in health professional interactions, as this negatively impacts engagement with treatment. 2
• Thiazolidinediones have an unfavorable risk-benefit ratio overall and are not recommended. 7
• The role of weight loss in improving PCOS status per se remains uncertain, but lifestyle intervention provides clear benefits for overall health in overweight/obese patients. 7
• High-fat diets exacerbate obesity, impair hypothalamic-pituitary-ovarian axis function, and worsen metabolic and reproductive consequences of PCOS. 10