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

Treatment for Weight Loss in PCOS

Multicomponent lifestyle intervention combining diet, exercise, and behavioral strategies is the first-line treatment for weight loss in all women with PCOS who have excess weight, with a target of 5-10% weight loss achievable within 6 months. 1

Dietary Approach

Create an energy deficit of 500-750 kcal/day (total intake 1,200-1,500 kcal/day) adjusted for individual energy requirements, body weight, and physical activity levels. 2, 3

• No specific diet composition (low-carb, high-protein, DASH) has proven superior to others for weight loss in PCOS 1, 2
• The key is caloric restriction rather than macronutrient manipulation 1
• Focus on general healthy eating principles that respect individual preferences and cultural needs 1, 2
• Avoid unduly restrictive or nutritionally unbalanced diets 2

Common pitfall: Many clinicians recommend specific "PCOS diets" (ketogenic, low-carb), but evidence shows any balanced diet with appropriate caloric deficit works equally well. 1

Physical Activity Prescription

For weight loss: prescribe at least 250 minutes per week of moderate-intensity activity OR 150 minutes per week of vigorous-intensity activity (or equivalent combination). 2, 3

• Include muscle-strengthening activities on 2 non-consecutive days per week 2
• Activity should be performed in bouts of at least 10 minutes (approximately 1,000 steps) 2
• Both aerobic and resistance exercise improve outcomes in PCOS 2, 3
• Minimize sedentary and screen time 2

For weight maintenance only: 150 minutes per week of moderate-intensity OR 75 minutes per week of vigorous-intensity activity is sufficient. 2

Behavioral Strategies (Critical Component)

Implement structured behavioral interventions using SMART goal-setting (specific, measurable, achievable, realistic, timely) combined with self-monitoring. 1, 2, 3

The evidence is clear that behavioral change techniques combined with diet and exercise produce greater weight loss than diet or exercise alone. 1

Essential behavioral components to include: 1, 2, 3

• Goal-setting and self-monitoring
• Stimulus control
• Problem-solving skills
• Assertiveness training
• Slowing rate of eating
• Reinforcing changes
• Relapse prevention strategies

Continued contact after initial treatment (face-to-face or telephone) improves weight-loss maintenance. 1

Realistic Weight Loss Targets

Target 5-10% weight loss within 6 months—this yields significant clinical improvements in hormonal, metabolic, and reproductive outcomes. 1, 3, 4

• Regular monitoring of weight and waist circumference is essential during weight loss and maintenance phases 1, 3
• Use ethnic-specific BMI and waist circumference cutoffs for Asian, Hispanic, and South Asian populations 2, 4

Adjunctive Pharmacotherapy

Metformin combined with low-calorie diet has only subtle additive effect on weight loss compared to diet alone. 5

• Consider metformin as adjunctive therapy, but recognize its weight loss benefit is modest 5
• For higher BMI categories with comorbidities, refer to general population obesity algorithms that may include very low-calorie diets, anti-obesity medications, or bariatric surgery 1

Psychological Considerations (Often Overlooked)

Address anxiety, depression, body image concerns, and disordered eating before or concurrent with weight loss interventions. 1, 2, 4

• Women with PCOS have high prevalence of low self-esteem, poor body image, anxiety, and depression 1
• Health professional interactions must be respectful, patient-centered, and avoid weight-related stigma 1, 3
• Family support improves outcomes 1

Critical pitfall: Approaching weight management insensitively can cause disengagement from treatment. 1

Implementation Strategy

Provide fortnightly review for the first 3 months, then regular review for the first 12 months with structured dietary and physical activity plans. 1

• Self-management and self-monitoring have positive impacts 1
• E-health tools can supplement face-to-face support 1
• More intensive behavioral interventions induce greater weight loss 1
• Refer to allied health professionals (dietitians, exercise physiologists, psychologists) when time constraints or expertise limitations exist 1

Special Population Considerations

Do not dismiss lifestyle intervention in lean PCOS patients—insulin resistance requires management regardless of BMI. 2

• Insulin resistance affects both lean and overweight women with PCOS 2
• Healthy lifestyle may contribute to health and quality of life benefits even without weight loss 1, 3
• Ethnic groups with high cardiometabolic risk require greater consideration for lifestyle intervention 1, 3