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

Treatment of Polycystic Ovary Syndrome (PCOS)

Lifestyle modification incorporating diet, exercise, and behavioral strategies is the first-line treatment for all women with PCOS, regardless of weight status, as it improves reproductive, metabolic, and psychological outcomes. 1, 2

Dietary Management

Target an energy deficit of 500-750 kcal/day (total intake 1,200-1,500 kcal/day) to achieve clinically meaningful weight loss. 1, 2

• No single diet type (low-carb, Mediterranean, ketogenic, low-glycemic index) has proven superior to others in PCOS, so select based on patient preference and cultural needs while maintaining nutritional balance 2, 3
• Avoid overly restrictive or nutritionally unbalanced diets that compromise long-term adherence 2
• Focus on foods with low glycemic index, high fiber content, omega-3 fatty acids, and anti-inflammatory properties, as these improve insulin sensitivity and hormonal balance 3

A 5-10% reduction in body weight within 6 months yields significant clinical improvements in metabolic, reproductive, and psychological parameters. 1, 2

Exercise Prescription

For weight maintenance and prevention of weight gain: prescribe a minimum of 150 minutes/week of moderate-intensity activity OR 75 minutes/week of vigorous-intensity activity. 1, 2

For weight loss and greater metabolic benefit: prescribe a minimum of 250 minutes/week of moderate-intensity activity OR 150 minutes/week of vigorous-intensity activity. 1, 2

• 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) and resistance training improve insulin sensitivity and metabolic outcomes in PCOS 1, 2
• Structure activity in bouts of at least 10 minutes (approximately 1,000 steps), aiming for at least 30 minutes daily on most days 2
• Minimize sedentary time, screen time, and prolonged sitting 2

Behavioral Strategies

Implement SMART goal-setting (Specific, Measurable, Achievable, Realistic, Timely) with self-monitoring to enable achievement of realistic lifestyle goals. 1, 2

• Incorporate behavioral techniques including goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcement of changes, and relapse prevention strategies 1, 2
• Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence 2
• Address psychological comorbidities including anxiety, depression, body image concerns, and disordered eating, as these are common in PCOS and affect treatment adherence 2

Monitoring and Follow-Up

Regularly monitor weight and waist circumference during both weight loss and maintenance phases. 1

• Use ethnic-specific BMI and waist circumference categories when optimizing lifestyle interventions, as cardiometabolic risk thresholds vary by ethnicity 2
• Recognize that weight gain over time is significantly greater in women with PCOS compared to unaffected women, making early intervention crucial 1
• Central obesity increases progressively in PCOS, with waist-to-hip ratio rising between ages 20-45 years 1

Critical Considerations for All PCOS Patients

Insulin resistance is present in PCOS regardless of BMI and affects both lean and overweight women, requiring lifestyle intervention even in normal-weight patients. 2

• Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight 2
• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1, 2
• Ensure health professional interactions avoid weight-related stigma, which negatively impacts engagement with treatment 1

Evidence Supporting Lifestyle Intervention

Lifestyle intervention improves the free androgen index (FAI) (MD -1.11,95% CI -1.96 to -0.26), reduces total testosterone, decreases hirsutism scores, lowers fasting insulin, and improves waist circumference and waist-hip ratio compared to minimal treatment 4, 5

Common Pitfall: Many women with PCOS receive inadequate support for weight management despite its critical importance—only a minority are referred to dieticians or receive structured exercise guidance, yet all recognize weight control as vital to their condition 6