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

Treatment of Polycystic Ovary Syndrome (PCOD/PCOS)

First-Line Treatment: Lifestyle Modification

All women with PCOS should begin with lifestyle interventions including diet, exercise, and behavioral strategies, regardless of whether they are attempting to conceive or their current weight status. 1, 2

Dietary Management

• Reduce energy intake by 30% or 500-750 kcal/day (targeting 1,200-1,500 kcal/day total) for women with excess weight 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, 3
• Avoid overly restrictive or nutritionally unbalanced diets 2
• Target 5-10% weight loss within 6 months, which yields significant clinical improvements in both metabolic and reproductive outcomes 1, 2

Exercise Prescription

• Minimum: 150 minutes/week of moderate-intensity activity OR 75 minutes/week of vigorous-intensity activity 2
• For weight loss: Increase to at least 250 minutes/week of moderate-intensity OR 150 minutes/week of vigorous-intensity activity 2
• Include muscle-strengthening activities on 2 non-consecutive days per week 2
• Perform activity in bouts of at least 10 minutes (approximately 1,000 steps), aiming for 30 minutes daily on most days 2
• Both aerobic and resistance exercises show benefits in PCOS 2, 3
• Minimize sedentary and screen time 2

Behavioral Strategies

• Implement SMART goal setting (specific, measurable, achievable, realistic, timely) and self-monitoring 1, 2
• Use behavioral techniques including stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 1, 2
• Address psychological factors including anxiety, depression, body image concerns, and disordered eating before or during treatment 1, 2

Critical Pitfall: Do not dismiss lifestyle interventions in lean PCOS patients—insulin resistance affects all PCOS phenotypes regardless of BMI and requires management even in normal-weight women 2

Medical Management for Women NOT Attempting Pregnancy

Hormonal Contraception (Primary Medical Treatment)

Combination oral contraceptive pills are the cornerstone of long-term PCOS management for women not seeking pregnancy. 1

• Suppress ovarian androgen secretion 1
• Increase sex hormone-binding globulin levels 1
• Reduce endometrial cancer risk (though extent of protection in PCOS specifically is unknown) 1
• Monitor lipid profiles, as oral contraceptives may increase triglycerides and HDL cholesterol in PCOS patients 1

Progestin Therapy (Alternative)

• Medroxyprogesterone acetate (depot or intermittent oral) suppresses circulating androgens and pituitary gonadotropins 1
• Optimal progestin type, duration, and frequency for endometrial cancer prevention in PCOS remains unknown 1

Insulin-Sensitizing Agents

Metformin and thiazolidinediones improve insulin sensitivity, decrease androgens, and improve glucose tolerance, though FDA has not labeled these for PCOS treatment. 1

• Metformin: Tends to decrease weight; improves or maintains glucose tolerance over time; appears safe with good documentation 1
• Thiazolidinediones (pioglitazone, rosiglitazone): Tend to increase weight; troglitazone removed from market due to hepatotoxicity 1
• These agents improve ovulation frequency and may positively impact cardiovascular and diabetes risk factors, though role in primary/secondary prevention remains unknown 1

Metabolic Screening and Management

• Screen all PCOS patients for dyslipidemia with fasting lipoprotein profile (total cholesterol, LDL, HDL, triglycerides) 1
• Calculate BMI and waist-hip ratio 1
• Attempt regular exercise and weight control before initiating drug therapy for metabolic abnormalities 1

Medical Management for Women ATTEMPTING Pregnancy

Treatment Algorithm

1. Start with weight control and regular exercise program 1

2. First-line ovulation induction: Clomiphene citrate 1, 4

   • Approximately 80% of PCOS patients ovulate with clomiphene 1
   • About 50% of those who ovulate will conceive 1
   • Start on day 5 of cycle 4
   • Limit to 6 total cycles (including 3 ovulatory cycles) 4
   • Requires proper timing of intercourse with ovulation 4
   • Monitor for ovarian hyperstimulation syndrome, especially in polycystic ovary syndrome patients who may have exaggerated response 4

3. Second-line: Low-dose gonadotropin therapy (if clomiphene fails) 1

   • Use low-dose rather than high-dose protocols 1
   • Low-dose induces high rate of monofollicular development with lower ovarian hyperstimulation risk 1

4. Insulin-sensitizing agents as adjuncts 1

   • Metformin and thiazolidinediones improve ovulation frequency 1
   • Effects on early pregnancy are not well known 1
   • Metformin appears safe during pregnancy, though documentation is limited 1, 5

Critical Pitfall: Exclude or adequately treat all impediments to pregnancy before starting clomiphene, including thyroid disorders, adrenal disorders, hyperprolactinemia, male factor infertility, and uterine abnormalities 4

Long-Term Health Considerations

• PCOS increases risk for type 2 diabetes, metabolic syndrome, hepatic steatosis, cardiovascular disease, endometrial cancer, and mood disorders 6, 7
• Lifestyle modifications reduce long-term metabolic and cardiovascular disease risks 3
• Healthy lifestyle may provide health and quality of life benefits even without weight loss 1, 2
• Regular monitoring of weight, waist circumference, and metabolic parameters is essential 2
• Consider ethnic-specific BMI and waist circumference categories, as certain ethnic groups face higher cardiometabolic risk 1, 2