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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

Lifestyle modification combining diet, exercise, and behavioral strategies is the first-line treatment for all women with PCOS, particularly those with excess weight, as even 5-10% weight loss significantly improves reproductive, metabolic, and psychological outcomes. 1, 2

First-Line Treatment: Multicomponent Lifestyle Intervention

Dietary Management

• Implement a caloric deficit of 500-750 kcal/day (targeting 1,200-1,500 kcal/day total) to achieve weight loss, adjusting for individual energy requirements, body weight, and physical activity levels 1
• No single diet type (low glycemic index, Mediterranean, ketogenic, high-fiber) has proven superior to others for PCOS—select based on patient preferences and cultural needs while maintaining nutritional balance 1, 3
• Low glycemic index foods, omega-3 fatty acids, antioxidant-rich foods, and anti-inflammatory diets all improve insulin sensitivity and hormonal balance 3

Exercise Prescription

• For weight maintenance and prevention of weight gain: minimum 150 minutes/week of moderate-intensity activity OR 75 minutes/week of vigorous-intensity activity 1, 2
• For active weight loss and greater health benefits: minimum 250 minutes/week of moderate-intensity activity OR 150 minutes/week of vigorous-intensity activity 1
• Include muscle-strengthening activities on 2 non-consecutive days per week 2
• Both aerobic exercise (brisk walking, cycling 8-15 km/h, low-impact aerobics, yoga) and resistance training improve insulin sensitivity and metabolic outcomes 1
• Vigorous activities include jogging/running, high-impact aerobics, and competitive sports 1

Behavioral Strategies

• Implement SMART goal setting (Specific, Measurable, Achievable, Realistic, Timely) with self-monitoring as the foundation of behavioral change 1, 2
• Include stimulus control, problem-solving, assertiveness training, slower eating patterns, reinforcement of positive changes, and relapse prevention strategies 1
• Address psychological comorbidities including anxiety, depression, body image concerns, and disordered eating, which are common in PCOS 2

Weight Loss Goals and Monitoring

• Target 5-10% weight loss within 6 months for those with excess weight—this achieves significant clinical improvements in reproductive function, metabolic parameters, and quality of life 1, 2
• The evidence shows lifestyle interventions reduce total testosterone (mean difference −0.27 nmol/L), hirsutism scores (mean difference −1.19), weight (mean difference −3.47 kg), waist circumference (mean difference −1.95 cm), and fasting insulin (mean difference −2.02 μU/mL) 4
• Monitor weight and waist circumference regularly during both weight loss and maintenance phases 1
• Use ethnic-specific BMI and waist circumference categories when setting targets 2

Pharmacological Adjuncts

For Adolescents

• Metformin combined with lifestyle modification improves menstrual cyclicity and hyperandrogenism in adolescent girls with PCOS and type 2 diabetes 2

For Adults with Obesity

• Orlistat combined with lifestyle changes produces greater weight loss and metabolic benefits than lifestyle changes alone in overweight/obese patients, though data specific to PCOS remain limited 5
• Note that sibutramine and rimonabant have been withdrawn from the market due to adverse effects 5

Multidisciplinary Care Model

• A team approach involving dietitian, health psychologist, gynecologist, and endocrinologist enhances weight loss outcomes, particularly in adolescents 2
• Ensure health professional interactions avoid weight-related stigma, which negatively impacts treatment engagement 1, 2
• Interactions should be respectful, patient-centered, and considerate of individual preferences and cultural differences 2

Critical Pitfalls to Avoid

• Do not delay lifestyle intervention—weight gain accelerates significantly faster in women with PCOS than unaffected women, and central obesity progressively increases between ages 20-45 years 1
• Recognize that healthy lifestyle changes provide health and quality of life benefits even without weight loss 1
• Ethnic groups with PCOS at high cardiometabolic risk require more intensive lifestyle intervention 1, 2
• Do not focus solely on weight loss without addressing the psychological aspects of PCOS 2
• Be aware that drop-out rates from lifestyle programs range from 12-47%, necessitating ongoing support and realistic goal-setting 6
• Most overweight women with PCOS receive inadequate support for weight management—only a minority are referred to dietitians despite the critical importance of weight control 7

Evidence Quality Considerations

The lifestyle intervention recommendations are based on systematic reviews of RCTs showing moderate-quality evidence, though individual studies have methodological limitations including small sample sizes, variable outcomes, and inconsistent intervention components 4. Despite these limitations, the consistency of benefits across reproductive, metabolic, and psychological outcomes supports the strong recommendation for lifestyle modification as first-line therapy 4, 1.