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

Treatment of Polycystic Ovary Syndrome (PCOD/PCOS)

Lifestyle modification with multicomponent intervention (diet, exercise, and behavioral strategies) is the first-line treatment for all women with PCOS, regardless of body weight or fertility goals. 1, 2

Lifestyle Management: The Foundation for All PCOS Patients

Dietary Interventions

• Target an energy deficit of 500-750 kcal/day (total intake 1,200-1,500 kcal/day) for women with overweight or obesity. 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
• Avoid restrictive or nutritionally unbalanced diets. 2
• Even modest weight loss of 5-10% yields significant clinical improvements in metabolic and reproductive abnormalities. 1, 2

Critical pitfall: Do not dismiss lifestyle intervention in lean PCOS patients—insulin resistance affects both lean and overweight women with PCOS and requires management regardless of BMI. 2

Exercise Prescription

• Prescribe at least 150 minutes/week of moderate-intensity activity OR 75 minutes/week of vigorous-intensity activity. 2
• Include muscle-strengthening activities on 2 non-consecutive days per week. 2
• For weight loss, increase to at least 250 minutes/week of moderate-intensity or 150 minutes/week of vigorous-intensity exercise. 2
• Both aerobic and resistance training show benefits; vigorous aerobic exercise specifically improves insulin sensitivity, while resistance training may improve androgen levels. 3
• Perform activity in at least 10-minute bouts, aiming for 30 minutes daily on most days. 2

Behavioral Strategies

• Implement SMART goal setting (specific, measurable, achievable, realistic, timely) and self-monitoring. 2
• Use stimulus control, problem-solving, assertiveness training, slower eating, and relapse prevention techniques. 2
• Address psychological comorbidities including anxiety, depression, body image concerns, and disordered eating. 2

Medical Management Based on Clinical Goals

For Women NOT Attempting Conception

Combined oral contraceptives (COCs) are the first-line pharmacological treatment. 1

Benefits of COCs:

• Suppress ovarian androgen secretion. 1
• Increase sex hormone-binding globulin levels. 1
• Reduce endometrial cancer risk. 1
• Regulate menstrual cycles and reduce hyperandrogenism symptoms. 1

Important caveat: COCs may increase triglyceride and HDL cholesterol levels in PCOS patients, though no evidence suggests increased cardiovascular events compared to the general population. 1

Alternative Progestin Therapy:

• Medroxyprogesterone acetate (depot or intermittent oral) suppresses circulating androgen and pituitary gonadotropin levels. 1
• Use when COCs are contraindicated, though optimal progestin type, duration, and frequency for endometrial cancer prevention remain unknown. 1

Insulin-Sensitizing Agents:

• Metformin or thiazolidinediones improve ovulation frequency and may positively impact diabetes and cardiovascular disease risk factors. 1
• FDA has not labeled any insulin-sensitizing agent specifically for PCOS treatment. 1
• Metformin tends to decrease weight; thiazolidinediones tend to increase weight. 1
• Metformin improves or maintains glucose tolerance over time. 1

For Women Attempting Conception

Begin with weight control and regular exercise, then add medication if needed. 1

First-Line Ovulation Induction:

• Clomiphene citrate is the recommended first-line medication due to proven effectiveness. 1, 4
• Approximately 80% of PCOS patients ovulate with clomiphene; half of those who ovulate conceive. 1
• Start on day 5 of the cycle; limit to 6 total cycles (including 3 ovulatory cycles). 4

Critical warning: Clomiphene can cause ovarian hyperstimulation syndrome (OHSS), which may progress rapidly to a serious medical disorder with ovarian enlargement, ascites, dyspnea, and thromboembolism. 4 Patients with PCOS are particularly sensitive and should start with the lowest dose and shortest duration. 4

Second-Line Ovulation Induction:

• If clomiphene fails, use low-dose gonadotropin therapy rather than high-dose. 1
• Low-dose treatment induces monofollicular development with lower risk of ovarian hyperstimulation. 1

Role of Metformin in Fertility:

• Metformin improves ovulation frequency, but effects on early pregnancy are not well-established. 1
• Metformin appears safe, though documentation is limited. 1

Surgical option: Laparoscopic ovarian drilling (laser or diathermy) has undetermined benefit and role in PCOS. 1

For Hirsutism Management

No single primary treatment is established; combined medical interventions are most effective. 1

Pharmacological Options:

• Oral contraceptives combined with antiandrogens (spironolactone, flutamide, or finasteride) appear most effective. 1
• Topical eflornithine hydrochloride cream is the only FDA-labeled treatment specifically for hirsutism. 1
• Concomitant medical management to reduce androgen levels is usually necessary with mechanical hair removal. 1

Mechanical Options:

• Plucking, shaving, waxing, electrolysis, or laser vaporization. 1
• Multiple treatments typically required; electrolysis may be impractical for large areas. 1

Metabolic Screening and Disease Prevention

Required Screening:

• Screen all PCOS patients for dyslipidemia with fasting lipoprotein profile (total cholesterol, LDL, HDL, triglycerides). 1
• Calculate BMI and waist-hip ratio. 1
• Screen for type 2 diabetes with fasting glucose followed by 75-gram oral glucose tolerance test. 5

Before Initiating Drug Therapy:

• Always attempt regular exercise and weight control measures first. 1
• Interventions improving insulin sensitivity (weight loss, metformin, thiazolidinediones) may positively impact diabetes and cardiovascular disease risk factors. 1

Monitoring Strategy

• Assess BMI and waist circumference regularly. 2
• Monitor for menstrual regularity improvements with treatment. 5
• Use ethnic-specific BMI and waist circumference categories for optimization. 2
• Recognize that healthy lifestyle contributes to health and quality of life even without weight loss. 2