What are the management guidelines for Polycystic Ovary Syndrome (PCOS)?

Management of PCOS: Indian Guidelines

Lifestyle modification with multicomponent intervention (diet, exercise, and behavioral strategies) should be the first-line treatment for all women with PCOS, regardless of weight status, to improve hormonal outcomes, metabolic health, and quality of life. 1

First-Line Management: Lifestyle Intervention

Weight Management Goals

• Target 5-10% weight loss in women with excess weight within 6 months, as this yields significant clinical improvements in hormonal, metabolic, and reproductive outcomes 1
• Use ethnic-specific BMI and waist circumference categories for Indian women, as South Asian populations have higher cardiometabolic risk at lower BMI thresholds 1
• Healthy lifestyle interventions provide benefits even without weight loss, improving quality of life and metabolic parameters 1, 2

Dietary Recommendations

• Implement a balanced diet with energy deficit of 500-750 kcal/day (total 1,200-1,500 kcal/day) for women seeking weight loss 1, 2
• No specific diet type (low-carb, Mediterranean, low-GI) is superior to others—choose based on individual food preferences and cultural considerations to maximize adherence 1, 2
• Follow general healthy eating principles across the lifespan, avoiding restrictive or nutritionally unbalanced diets 1, 2
• Consider low glycemic index foods, high-fiber diets, and anti-inflammatory dietary patterns as they improve insulin sensitivity 3

Exercise Prescription

• Recommend at least 150 minutes/week of moderate-intensity aerobic activity OR 75 minutes/week of vigorous-intensity activity (or equivalent combination) 2
• Include muscle-strengthening activities on 2 non-consecutive days per week 2
• For greater weight loss benefits, increase to 250 minutes/week of moderate-intensity or 150 minutes/week of vigorous-intensity exercise 2
• Both aerobic and resistance training show benefits; the choice depends on patient preference and accessibility 2, 3
• Activities should be performed in bouts of at least 10 minutes, minimizing sedentary time 2

Behavioral Strategies

• Implement SMART goal-setting (Specific, Measurable, Achievable, Realistic, Timely) with self-monitoring to enhance adherence 1
• Include behavioral techniques: goal-setting, stimulus control, problem-solving, slower eating, and relapse prevention strategies 1
• Consider comprehensive cognitive behavioral therapy to increase engagement and long-term maintenance of lifestyle changes 1

Critical Considerations for Indian Population

Ethnic-Specific Factors

• Indian women with PCOS have higher cardiometabolic risk and require more intensive lifestyle intervention compared to other ethnic groups 1
• Apply lower BMI cutoffs for defining overweight (≥23 kg/m²) and obesity (≥25 kg/m²) in South Asian populations 1
• Tailor dietary recommendations to Indian food preferences and cultural practices to improve adherence 1

Addressing Insulin Resistance

• Insulin resistance affects ALL women with PCOS regardless of BMI, including lean patients 1, 2
• Common pitfall: Do not dismiss lifestyle intervention in normal-weight Indian women—they still require management for insulin resistance and metabolic dysfunction 2

Psychological Management

• Screen and address anxiety, depression, body image concerns, and disordered eating, as these affect adherence to lifestyle interventions 1
• Ensure health professional interactions are respectful, patient-centered, and avoid weight-related stigma 1
• Consider referral to mental health professionals when psychological barriers impede lifestyle changes 1

Pharmacological Management (When Lifestyle Alone is Insufficient)

For Menstrual Irregularity and Hyperandrogenism

• Combined oral contraceptives serve as first-line pharmacological treatment for women not attempting conception 4

For Metabolic Features

• Consider metformin for women with cardiometabolic features including abdominal obesity and insulin resistance 4
• Metformin should complement, not replace, lifestyle interventions 5

For Infertility

• Clomiphene citrate 50 mg daily for 5 days is indicated for ovulatory dysfunction in women with PCOS desiring pregnancy 6
• Start on day 5 of the cycle; if no ovulation occurs, increase to 100 mg daily for 5 days in subsequent cycles 6
• Use lowest effective dose in PCOS patients due to increased sensitivity to gonadotropins and risk of ovarian hyperstimulation syndrome 6
• Limit treatment to 6 total cycles (including 3 ovulatory cycles) 6

Monitoring and Follow-Up

• Assess BMI and waist circumference regularly to track progress 4, 2
• Monitor for improvements in menstrual regularity, which indicates successful treatment 4
• Screen for metabolic complications: fasting glucose with 75-gram oral glucose tolerance test for diabetes risk 4
• Check fasting lipid profile (total cholesterol, LDL, HDL, triglycerides) for cardiovascular risk assessment 4
• Ongoing assessment during weight loss and maintenance phases is essential 1

Implementation Strategy

• Lifestyle intervention is the joint responsibility of all healthcare professionals partnering with women with PCOS 1
• Refer to dietitians, exercise physiologists, and behavioral health specialists when complex issues arise 1
• Emphasize realistic, achievable goals to increase long-term sustainability of lifestyle changes 7
• Combine dietary changes with exercise for greatest improvements in clinical outcomes 7

Important Clinical Pitfalls

• Never neglect lifestyle interventions in normal-weight PCOS patients—metabolic benefits occur regardless of weight status 4, 2
• Avoid overly restrictive diets that compromise adherence and nutritional balance 1, 2
• Do not prescribe exercise and dietary interventions without coordination, as poorly planned combinations may reduce effectiveness 7
• Remember that Indian women require lower BMI thresholds for intervention due to higher metabolic risk 1