Treatment Options for Polycystic Ovary Disorder (PCOD)
Multicomponent lifestyle intervention including diet, exercise, and behavioral strategies is the first-line treatment for PCOS, regardless of body weight, and should be implemented before or alongside any pharmacological therapy. 1, 2
First-Line Treatment: Lifestyle Management
Dietary Interventions
Implement a balanced diet with an energy deficit of 500-750 kcal/day (targeting 1,200-1,500 kcal/day total) for women with overweight or obesity. 2, 3
No specific diet type (low-carb, Mediterranean, ketogenic, etc.) has proven superior—select based on patient preference and cultural needs while maintaining nutritional balance. 2, 4
Avoid unduly restrictive or nutritionally unbalanced diets that compromise long-term adherence. 2
For lean PCOS patients (normal BMI), focus on healthy eating principles across the life course rather than caloric restriction, as insulin resistance affects all PCOS phenotypes regardless of weight. 2
Exercise Prescription
Prescribe at least 150 minutes/week of moderate-intensity activity (brisk walking, cycling 8-15 km/h, low-impact aerobics) OR 75 minutes/week of vigorous-intensity activity (jogging, high-impact aerobics, competitive sports) for weight maintenance and health. 2, 3
For weight loss and greater metabolic benefit, increase to at least 250 minutes/week of moderate-intensity OR 150 minutes/week of vigorous-intensity activity. 2, 3
Include muscle-strengthening activities on 2 non-consecutive days per week, as both aerobic and resistance exercise improve insulin sensitivity and metabolic outcomes. 2, 3
Structure activity in at least 10-minute bouts (approximately 1,000 steps), aiming for at least 30 minutes daily on most days. 2
Minimize sedentary, screen, and sitting time throughout the day. 2
Behavioral Strategies
Implement SMART goal setting (specific, measurable, achievable, realistic, timely) with self-monitoring to enable achievement of realistic lifestyle goals. 2, 3
Incorporate behavioral techniques including goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention. 2, 3
Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence, particularly for patients with anxiety, depression, body image concerns, or disordered eating. 2
Realistic Weight Loss Goals
Target 5-10% weight loss in patients with excess weight within 6 months, as this yields significant clinical improvements in insulin sensitivity, hormonal balance, and ovulation. 2, 3, 4
Monitor weight and waist circumference regularly during weight loss and maintenance phases. 2, 3
Recognize that healthy lifestyle contributes to health and quality of life benefits even without weight loss, particularly important for lean PCOS patients. 2, 3
Pharmacological Treatment for Ovulation Induction
Clomiphene Citrate
Clomiphene citrate is FDA-indicated for treatment of ovulatory dysfunction in women with PCOS desiring pregnancy, making it the primary pharmacological option for fertility. 5
Start clomiphene citrate on or about day 5 of the menstrual cycle after confirming the patient is not pregnant, has no ovarian cysts (except polycystic ovaries), has no abnormal vaginal bleeding, and has normal liver function. 5
Perform pelvic examination prior to the first and each subsequent course of treatment to exclude ovarian enlargement. 5
Limit long-term cyclic therapy to approximately six cycles total (including three ovulatory cycles maximum). 5
Use the lowest effective dose, as patients with PCOS may have exaggerated response to usual doses due to unusual sensitivity to gonadotropin stimulation. 5
Critical Safety Considerations with Clomiphene
Discontinue treatment immediately if visual symptoms develop (blurring, scotomata, phosphenes) and perform complete ophthalmological evaluation. 5
Monitor for ovarian hyperstimulation syndrome (OHSS), which can progress rapidly within 24 hours to several days and become life-threatening with symptoms including abdominal pain/distention, nausea, vomiting, diarrhea, and weight gain. 5
If ovarian enlargement occurs, withhold additional clomiphene therapy until ovaries return to pretreatment size and reduce dosage or duration for the next course. 5
Perform abdominal and pelvic examination very cautiously in suspected OHSS due to fragility of enlarged ovaries. 5
Long-Term Management Considerations
Monitoring for Metabolic Complications
Implement long-term standardized individualized management to reduce risk of type 2 diabetes mellitus, as insulin resistance predisposes PCOS patients to metabolic dysfunction. 6
Monitor for cardiovascular disease risk, as approximately 70% of PCOS cases present with insulin resistance and increased cardiovascular risk. 7
Screen for endometrial cancer risk, which is increased in PCOS patients due to chronic anovulation and unopposed estrogen exposure. 6
Addressing Barriers to Treatment
Provide adequate support for weight management through dietician referral and regular follow-up, as studies show only 26% of overweight PCOS patients receive dietician referral despite weight control being vital to treatment. 8
Ensure health professional interactions avoid weight-related stigma and are respectful, patient-centered, and considerate of individual preferences and cultural differences. 3
Consider ethnic-specific BMI and waist circumference categories when optimizing lifestyle interventions, as ethnic groups with PCOS at high cardiometabolic risk require greater consideration. 2, 3
Common Pitfalls to Avoid
Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight status. 2
Do not delay lifestyle intervention while waiting for pharmacological therapy—lifestyle management should be implemented first or concurrently. 1
Do not prescribe clomiphene citrate for male infertility, as there are no adequate studies demonstrating effectiveness and testicular tumors have been reported. 5
Do not use clomiphene citrate in combination regimens for in vitro fertilization programs, as there is no universally accepted standard regimen and it is not recommended for these uses. 5
Do not continue clomiphene citrate if ovarian cysts develop—wait for resolution and reduce subsequent dosing. 5