What are the treatment options for Polycystic Ovary Disorder (PCOD)?

Treatment of Polycystic Ovary Syndrome (PCOD/PCOS)

Lifestyle modification with diet and exercise is the first-line treatment for all women with PCOS, regardless of weight or fertility goals, followed by targeted medical therapy based on specific symptoms and reproductive intentions. 1, 2

First-Line Management: Lifestyle Intervention

Weight Management and Dietary Approach

• Target 5-10% weight loss in women with excess weight through a 500-750 kcal/day energy deficit (total 1,200-1,500 kcal/day), which yields significant clinical improvements in hormonal, metabolic, and reproductive outcomes within 6 months. 1, 2
• No specific diet type (low-carb, Mediterranean, ketogenic) has proven superior; choose based on patient preference and cultural needs while maintaining nutritional balance. 2
• Emphasize low glycemic index foods, high fiber intake, omega-3 fatty acids, and anti-inflammatory foods to improve insulin sensitivity. 3
• Critical pitfall: Do not dismiss lifestyle intervention in lean PCOS patients—insulin resistance affects all PCOS phenotypes regardless of BMI and requires management even at normal weight. 2

Exercise Prescription

• Prescribe at least 250 minutes/week of moderate-intensity aerobic activity (or 150 minutes/week vigorous intensity) for weight loss and metabolic improvement. 2
• Include resistance training on 2 non-consecutive days per week. 2
• Both aerobic and resistance exercises improve insulin sensitivity and hormonal balance; combining both types yields greatest benefit. 2, 4
• Break activity into 10-minute bouts (approximately 1,000 steps), aiming for at least 30 minutes daily on most days. 2

Behavioral Strategies

• Implement SMART goal-setting (specific, measurable, achievable, realistic, timely) with self-monitoring to optimize adherence. 1, 2
• Include stimulus control, problem-solving, assertiveness training, slower eating, and relapse prevention strategies. 1
• Address psychological factors—anxiety, depression, body image concerns, and disordered eating—as these directly impact treatment adherence and must be managed concurrently. 1, 2

Medical Management for Women NOT Attempting Pregnancy

Hormonal Regulation and Hyperandrogenism

• Combination oral contraceptive pills (OCPs) are the primary medical treatment for menstrual regulation and androgen suppression in women not seeking pregnancy. 1
• OCPs suppress ovarian androgen secretion, increase sex hormone-binding globulin, and reduce endometrial cancer risk. 1
• Medroxyprogesterone acetate (depot or intermittent oral) suppresses androgens and gonadotropins, though optimal dosing for endometrial protection remains undefined. 1
• Important caveat: OCPs increase triglycerides and HDL cholesterol in PCOS patients, though no evidence shows increased cardiovascular events compared to general population. 1

Insulin-Sensitizing Agents

• Metformin improves insulin sensitivity, decreases circulating androgens, enhances glucose tolerance, and improves ovulation frequency based on good and consistent evidence. 1
• Metformin maintains or improves glucose tolerance over time in PCOS patients. 1
• Thiazolidinediones (pioglitazone, rosiglitazone) also improve insulin sensitivity but tend to increase weight, whereas metformin tends to decrease weight. 1
• FDA has not labeled any insulin-sensitizing agent specifically for PCOS treatment, though evidence supports their use for metabolic and reproductive benefits. 1
• These agents may positively impact cardiovascular disease and diabetes risk factors, though their role in primary/secondary prevention remains unknown. 1

Metabolic Screening

• Screen all PCOS patients for dyslipidemia with fasting lipoprotein profile (total cholesterol, LDL, HDL, triglycerides) based on good and consistent evidence. 1
• Calculate BMI and waist-hip ratio at baseline and monitor regularly. 1
• Use ethnic-specific BMI and waist circumference categories for appropriate risk stratification. 1, 2

Medical Management for Women Attempting Pregnancy

Ovulation Induction Algorithm

1. Start with weight control and regular exercise program before medication. 1
2. First-line pharmacologic therapy: Clomiphene citrate 50-100mg daily for 5 days starting on cycle day 5, based on good and consistent evidence showing 80% ovulation rate and 50% conception rate in PCOS. 1, 5
3. If clomiphene fails: Use low-dose gonadotropin therapy (not high-dose) to induce monofollicular development and minimize ovarian hyperstimulation risk. 1
4. Metformin improves ovulation frequency but effects on early pregnancy are not fully known; appears safe during pregnancy though documentation is limited. 1, 6

Critical Safety Warnings for Ovulation Induction

• Discontinue clomiphene immediately if visual symptoms occur (blurring, scotomata, phosphenes)—these can progress to severe visual impairment and require complete ophthalmologic evaluation. 5
• Monitor for ovarian hyperstimulation syndrome (OHSS): early signs include abdominal pain/distention, nausea, vomiting, diarrhea, and weight gain. 5
• Women with PCOS are unusually sensitive to gonadotropins and may have exaggerated response to usual clomiphene doses—start with lowest dose (50mg) and shortest duration for first course. 5
• Perform pelvic examination before each clomiphene course to assess for ovarian enlargement. 5
• Limit clomiphene to approximately 6 total cycles (including 3 ovulatory cycles); long-term cyclic therapy beyond this is not recommended. 5

Long-Term Monitoring and Prevention

Endometrial Protection

• Ensure regular menstrual cycles (at least every 3 months) through OCPs or cyclic progestins to prevent endometrial hyperplasia and reduce endometrial cancer risk. 1
• Perform endometrial biopsy before treatment in women over 35 or with prolonged amenorrhea, as endometrial cancer risk increases with age and anovulation. 5

Cardiometabolic Surveillance

• Regular monitoring of weight, waist circumference, blood pressure, and lipid profiles throughout life course. 1, 2
• Screen for type 2 diabetes development, particularly in high-risk ethnic groups. 1, 2
• Ethnic groups at high cardiometabolic risk require more intensive lifestyle intervention and closer monitoring. 1, 2

Quality of Life Considerations

• Healthy lifestyle contributes to health and quality of life benefits even without weight loss. 1, 2
• Health professional interactions must be respectful, patient-centered, and avoid weight-related stigma. 1
• Consider referral to allied health professionals (dietitians, psychologists, endocrinologists) for complex cases. 1