What is the treatment for Polycystic Ovary Syndrome (PCOS)?

Treatment for 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 body weight, because insulin resistance affects both lean and overweight women and requires management even in normal-weight patients. 1, 2, 3

Understanding the Core Pathophysiology

• Insulin resistance is present irrespective of BMI and affects both lean and overweight women with PCOS 1, 2, 3
• Hyperinsulinemia resulting from insulin resistance contributes to hyperandrogenism through effects on the pituitary, liver, and ovaries in all women with PCOS, regardless of weight 1, 2, 3

Critical Pitfall: Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight 2

First-Line Treatment: Lifestyle Management

Dietary Intervention

• Aim for an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day) for weight loss, considering individual energy requirements, body weight, and physical activity levels 2, 3, 4
• Target 5-10% weight loss in those with excess weight, as this yields significant clinical improvements in metabolic and reproductive abnormalities 3, 4
• No specific diet type has proven superior; focus on individual preferences and cultural needs while maintaining a healthy balanced diet 2, 3, 4
• Avoid unduly restrictive or nutritionally unbalanced diets 2
• Follow general healthy eating principles across the life course 2

Exercise Prescription

• Prescribe at least 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous-intensity activity (or equivalent combination) for prevention of weight gain and health maintenance 2, 3, 4
• For modest weight loss and greater health benefits, prescribe at least 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous-intensity (or equivalent combination) 2, 4
• Include muscle-strengthening activities on 2 non-consecutive days per week 2, 3
• Activity should be performed in at least 10-minute bouts or around 1,000 steps, aiming for at least 30 minutes daily on most days 2
• Both aerobic and resistance exercises have shown benefits in PCOS 2, 4
• Minimize sedentary, screen, or sitting time 2

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring 2, 3, 4
• Include behavioral strategies such as goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 2, 3, 4
• Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence 2
• Address psychological factors such as anxiety, depression, body image concerns, and disordered eating 2

Medical Management (Second-Line)

For Menstrual Irregularity and Hyperandrogenism (Not Attempting Conception)

• Combined oral contraceptives (COCs) are recommended for menstrual cycle regulation and hyperandrogenism in women not attempting conception 3, 5
• COCs restore menstrual cyclicity, improve hyperandrogenism, and reduce the risk of endometrial cancer 5

Critical Caveat: All patients must be carefully evaluated for cardiometabolic risk factors before initiating COCs, including age, smoking, obesity, glucose intolerance or diabetes, hypertension, dyslipidemia, thrombophilia, and family history of venous thromboembolism 5

For Metabolic Management

• Metformin should be considered for women with PCOS who have cardiometabolic features such as abdominal obesity and insulin resistance 3, 6
• Metformin is of benefit for reducing excess body weight and improving hormonal and metabolic outcomes in those with high metabolic risk (e.g., BMI greater than 25 kg/m²) 6

For Ovulation Induction (Attempting Conception)

• Clomiphene citrate is indicated for treatment of ovulatory dysfunction in women with PCOS desiring pregnancy 7
• Patients most likely to achieve success with clomiphene therapy include those with polycystic ovary syndrome 7
• Long-term cyclic therapy is not recommended beyond a total of about six cycles (including three ovulatory cycles) 7

Critical Warning: Patients with polycystic ovary syndrome who are unusually sensitive to gonadotropin may have an exaggerated response to usual doses of clomiphene citrate and should be started on the lowest recommended dose and shortest treatment duration 7

Monitoring and Follow-Up

• Regular monitoring of weight and waist circumference is recommended 2, 4
• Use ethnic-specific BMI and waist circumference categories when optimizing lifestyle and weight 2, 4
• Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention 2, 4

Special Considerations

• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 2, 4
• Health professional interactions should be respectful, patient-centered, and considerate of individual preferences and cultural differences to avoid weight-related stigma 2, 4
• Weight gain over time is significantly greater in women with PCOS than in unaffected women, making early intervention crucial 4