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 benefits, 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
Special Population Considerations
Lean PCOS Patients (Normal BMI)
Do not dismiss lifestyle intervention in lean PCOS patients—insulin resistance requires management regardless of weight, as it is present irrespective of BMI and contributes to hyperandrogenism in all PCOS phenotypes. 2
Focus on weight gain prevention, healthy eating principles, and exercise for insulin sensitivity rather than weight loss in this population. 1, 2
Ethnic Considerations
Apply ethnic-specific BMI and waist circumference categories when optimizing lifestyle and weight interventions. 2, 3
Ethnic groups with PCOS at high cardiometabolic risk require greater consideration for lifestyle intervention. 2, 3
Long-Term Management Rationale
Implement long-term standardized individualized management to achieve fertility goals and reduce risk of type 2 diabetes, cardiovascular disease, and endometrial cancer. 6
Recognize that weight gain over time is significantly greater in women with PCOS than unaffected women, with progressive increase in waist-to-hip ratio between ages 20-45 years, making early intervention crucial. 3
Address insulin resistance proactively, as approximately 70% of PCOS cases present with insulin resistance that predisposes to metabolic dysfunction. 7, 6
Common Pitfalls to Avoid
Avoid weight-related stigma in health professional interactions, as this negatively impacts treatment engagement. 3
Ensure interactions are respectful, patient-centered, and considerate of individual preferences and cultural differences. 2
Do not rely solely on pharmacological interventions without addressing lifestyle factors, as lifestyle modifications improve biochemical, hormonal, and anthropometric parameters while reducing long-term metabolic and cardiovascular disease risks. 4, 6
Recognize that inadequate support for weight management is common—patients require more than biannual consultant visits and should have access to dietitian referrals and structured exercise programs. 8