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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

Lifestyle modification with multicomponent intervention (diet, exercise, and behavioral strategies) is the first-line treatment for all women with PCOS, regardless of weight or reproductive goals, followed by targeted pharmacotherapy based on whether pregnancy is desired. 1, 2

First-Line Treatment: Lifestyle Modification

All women with PCOS should begin with comprehensive lifestyle intervention before or alongside pharmacological treatment. 1

Weight Management

• Target a 30% energy deficit or 500-750 kcal/day reduction for weight loss 2, 3
• Even modest weight loss of just 5% of initial body weight significantly improves metabolic and reproductive abnormalities, including ovulation and pregnancy rates 3, 4
• Weight loss improves insulin resistance, hyperandrogenism (measured by free androgen index), and BMI 5
• Exercise shows positive effects even without weight loss, so physical activity should be emphasized regardless of weight changes 3

Exercise Recommendations

• Both aerobic and resistance exercise enhance insulin sensitivity, promote weight loss, and improve metabolic and reproductive outcomes 4
• Exercise improves the free androgen index independent of weight changes 5

Dietary Approaches

• No specific diet is superior; focus on caloric restriction and healthy eating patterns 1
• Evidence supports: low glycemic index foods, high-fiber diets, omega-3 fatty acid-rich diets, ketogenic diets, Mediterranean diets, and anti-inflammatory diets 4
• All dietary approaches work primarily through improving insulin sensitivity and hormonal balance 4

Behavioral Strategies

• Include education modules, adherence support, and mental health management 1
• Address depression, anxiety, and eating disorders, which occur at higher rates in PCOS patients 2

Treatment Based on Reproductive Goals

For Women NOT Attempting Pregnancy

Combined oral contraceptives (COCs) are first-line pharmacological treatment for women with PCOS not seeking pregnancy 2

• COCs suppress ovarian androgen secretion and increase sex hormone binding globulin 2
• Address menstrual irregularity, hirsutism, and acne
• Continue lifestyle modifications alongside hormonal therapy 1

Metformin as adjunctive therapy:

• Improves insulin sensitivity and reduces risk factors for diabetes and cardiovascular disease 2
• Reduces insulin levels, which decreases ovarian androgen production 3
• Maintains or improves glucose tolerance over time 3

For Women Attempting Pregnancy

Step 1: Optimize lifestyle first - Weight loss and exercise must be implemented before pharmacological ovulation induction 3

Step 2: Clomiphene citrate is first-line pharmacological treatment for ovulation induction 2, 3, 6

• Approximately 80% of patients ovulate and half of those who ovulate conceive 2, 3
• FDA-approved specifically for ovulatory dysfunction in women with PCOS 6
• Start on or about the 5th day of the cycle 6
• Limit to about six cycles total (including three ovulatory cycles) 6
• Use the lowest effective dose to minimize risk of ovarian hyperstimulation syndrome, particularly in PCOS patients who are unusually sensitive to gonadotropin stimulation 6

Step 3: If clomiphene fails, use low-dose gonadotropin therapy due to lower risk of ovarian hyperstimulation compared to higher doses 2

Metformin role in fertility:

• Improves ovulation frequency and appears safe during pregnancy 3
• Effects on early pregnancy outcomes not fully established 3
• Can be used as adjunct to clomiphene 3

Preconception and Pregnancy Management

Before attempting pregnancy:

• Screen for metabolic abnormalities: fasting glucose, 2-hour glucose tolerance test, and lipid profile 3
• Provide preconception counseling about increased pregnancy risks 3

During pregnancy:

• Closer monitoring throughout pregnancy with regular assessment of blood pressure, kidney function, and proteinuria 3
• Prescribe low-dose aspirin from week 12 to week 36 to reduce preeclampsia risk 3

Long-Term Metabolic Screening and Monitoring

Regular screening for metabolic complications is essential regardless of weight or symptom severity 2

• Screen for type 2 diabetes mellitus and cardiovascular disease risk factors 2
• Calculate BMI and waist-hip ratio to assess metabolic risk 2
• Monitor fasting glucose and lipid profiles 2
• Assess mental health regularly for depression, anxiety, and eating disorders 2

Critical Pitfalls to Avoid

• Do not neglect metabolic screening in normal-weight PCOS patients - insulin resistance occurs regardless of BMI 1, 2
• Do not exceed recommended clomiphene dosage and duration - risk of ovarian hyperstimulation syndrome increases, especially in PCOS patients 2, 6
• Do not skip pelvic examination before each clomiphene course - must rule out ovarian cysts before treatment 6
• Do not use clomiphene in patients with ovarian enlargement except those with polycystic ovary syndrome 6
• Do not delay lifestyle intervention - it must be first-line, not an afterthought 1, 3
• Watch for visual symptoms with clomiphene - discontinue immediately and perform complete ophthalmological evaluation if visual changes occur 6