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

Treatment of Polycystic Ovary Syndrome (PCOS)

Multicomponent lifestyle intervention including diet, exercise, and behavioral strategies is the first-line treatment for all women with PCOS, regardless of weight or reproductive goals. 1

First-Line Treatment: Lifestyle Modification

Lifestyle management sits at the top of the intervention hierarchy for PCOS and must be implemented before or alongside any pharmacological therapy. 1, 2

Weight Management

• Target a 30% energy deficit or 500-750 kcal/day reduction for women who are overweight or obese. 2, 3
• Even modest weight loss of just 5% of initial body weight significantly improves both metabolic and reproductive abnormalities, including ovulation and pregnancy rates. 3
• Weight loss improves insulin resistance, which is present in PCOS regardless of BMI and drives hyperandrogenism through effects on the pituitary, liver, and ovaries. 1

Exercise

• Exercise programs show positive effects even without weight loss, improving insulin sensitivity and metabolic outcomes. 3, 4
• Both aerobic and resistance exercise enhance insulin sensitivity and improve reproductive outcomes. 4

Dietary Approach

• No specific diet is recommended over others, but evidence supports low glycemic index foods, high-fiber diets, omega-3 fatty acids, Mediterranean diet, and anti-inflammatory diets. 1, 4
• The key is adherence to a sustainable dietary pattern that achieves the caloric deficit. 1

Behavioral Strategies

• Behavioral interventions improve awareness, adherence to treatment, and help manage mental health issues related to PCOS. 1, 4

Treatment Based on Reproductive Goals

For Women NOT Attempting to Conceive

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

• Oral contraceptives suppress ovarian androgen secretion and increase sex hormone binding globulin, addressing both menstrual irregularity and hyperandrogenism. 2
• They are the first-line therapy for irregular menses and dermatologic manifestations (hirsutism, acne). 5

For Women Attempting to Conceive

Clomiphene citrate is the first-line pharmacological treatment for ovulation induction. 2, 3, 6

• Approximately 80% of PCOS patients ovulate on clomiphene, and half of those who ovulate conceive. 2, 3
• Clomiphene should be started on or about the 5th day of the cycle, with properly timed coitus in relationship to ovulation. 6
• Do not exceed 6 total cycles (including 3 ovulatory cycles) of clomiphene therapy. 6
• If clomiphene fails, low-dose gonadotropin therapy is the next step due to lower risk of ovarian hyperstimulation compared to higher doses. 2

Preconception Requirements

• All women with PCOS attempting pregnancy require preconception counseling about increased pregnancy risks. 3
• Screen for metabolic abnormalities before conception: fasting glucose, 2-hour glucose tolerance test, and lipid profile. 3

Metabolic Management

Metformin

Metformin is first-line medication for metabolic manifestations such as insulin resistance and hyperglycemia. 2, 5

• Metformin improves insulin sensitivity, reduces ovarian androgen production, and reduces risk factors for diabetes and cardiovascular disease. 2, 3
• Metformin improves ovulation frequency and appears safe during pregnancy, though effects on early pregnancy outcomes are not fully established. 3
• Metformin improves or maintains glucose tolerance over time in PCOS patients. 3

Metabolic Screening

Screen all PCOS patients for metabolic abnormalities at diagnosis and regularly thereafter, including fasting glucose, oral glucose tolerance test, and lipid profile. 2

• This applies even to normal-weight PCOS patients, as insulin resistance occurs regardless of BMI. 1, 2
• Women with PCOS have increased risk for type 2 diabetes (4 times higher than general population) and metabolic syndrome (2 times higher). 5

Long-Term Monitoring

Regular screening for metabolic abnormalities and mental health assessment is essential. 2

• Women with PCOS have higher rates of depression, anxiety, and eating disorders. 2
• Monitor for cardiovascular disease risk factors throughout life. 2

Pregnancy Management

Women with PCOS who become pregnant require closer monitoring throughout pregnancy. 3

• Monitor blood pressure, kidney function, and proteinuria regularly. 3
• Prescribe low-dose aspirin from week 12 to week 36 to reduce preeclampsia risk. 3

Critical Pitfalls to Avoid

• Do not neglect metabolic screening in normal-weight PCOS patients—insulin resistance occurs regardless of BMI. 2
• Do not exceed recommended clomiphene dosage and duration (6 total cycles maximum). 2, 6
• Do not skip lifestyle modification—it is not optional and should be implemented even when pharmacological therapy is used. 1, 2
• Do not use clomiphene in patients with ovarian enlargement except those with polycystic ovary syndrome. 6
• Pelvic examination is necessary prior to the first and each subsequent course of clomiphene treatment. 6