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

Management of Polycystic Ovary Syndrome (PCOS)

Multicomponent lifestyle intervention—combining 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 drives hyperandrogenism through effects on the pituitary, liver, and ovaries. 1, 2

Why Lifestyle Management is Essential for ALL PCOS Patients

• Insulin resistance is present in PCOS irrespective of BMI and contributes to hyperandrogenism in both lean and overweight women 1, 2
• Hyperinsulinemia worsens all PCOS symptoms, making lifestyle intervention essential even in normal-weight patients 2
• Critical pitfall to avoid: Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight 1

Dietary Management Algorithm

For women with excess weight:

• Create an energy deficit of 30% or 500-750 kcal/day (targeting 1,200-1,500 kcal/day total), adjusted for individual energy requirements, body weight, and physical activity levels 2, 3
• Target 5-10% weight loss, as this yields significant clinical improvements in metabolic and reproductive abnormalities 2, 3

For all women with PCOS (including normal weight):

• No specific diet type has proven superior; focus on balanced dietary approaches that match individual preferences and cultural needs 1, 3
• Avoid unduly restrictive or nutritionally unbalanced diets 1
• Low-glycemic index nutrients associated with high fiber intake should be preferred in hyperinsulinemic patients 4
• Follow general healthy eating principles across the life course 1

Exercise Prescription

Minimum requirements for weight maintenance and health:

• At least 150 minutes/week of moderate-intensity physical activity OR 75 minutes/week of vigorous-intensity activity (or equivalent combination) 1, 2, 3
• Include muscle-strengthening activities involving major muscle groups on 2 non-consecutive days/week 5, 2, 3
• Activity should be performed in at least 10-minute bouts, aiming for at least 30 minutes daily on most days 3

For weight loss and greater health benefits:

• At least 250 minutes/week of moderate-intensity activities OR 150 minutes/week of vigorous-intensity activity (or equivalent combination) 3
• Both aerobic and resistance exercises improve insulin sensitivity and metabolic outcomes in PCOS 3

Practical implementation:

• Daily goal of 10,000 steps is ideal, including activities of daily living and 30 minutes of structured physical activity (around 3,000 steps) 5
• Moderate-intensity activities include brisk walking, cycling (8-15 km/h), low-impact aerobics, and yoga 3
• Vigorous-intensity activities include jogging/running, high-impact aerobics, and competitive sports 3
• Minimize sedentary, screen, or sitting time 5, 1

Behavioral Strategies for Long-Term Success

Essential behavioral components:

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring 2, 3
• Realistic physical activity SMART goals could include 10-minute bouts, progressively increasing physical activity 5% weekly, up to and above recommendations 5
• Use self-monitoring including fitness tracking devices and technologies for step count and exercise intensity as an adjunct to support active lifestyles 5

Comprehensive behavioral techniques:

• Goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 5, 2, 3
• Behavioral change techniques in combination with diet and exercise interventions increase weight loss over diet and/or physical activity alone 5
• Self-management has positive impacts, and family support improves outcomes 5
• Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence 1

Medical Management

For menstrual cycle regulation and hyperandrogenism:

• Combined oral contraceptives are recommended for women not attempting conception 2

For cardiometabolic features:

• Metformin should be considered for women with PCOS who have cardiometabolic features such as abdominal obesity and insulin resistance 2

For ovulation induction in women desiring pregnancy:

• Clomiphene citrate is indicated for treatment of ovulatory dysfunction in women desiring pregnancy, with patients with polycystic ovary syndrome most likely to achieve success 6
• Patients with polycystic ovary syndrome should be started on the lowest recommended dose and shortest treatment duration for the first course of therapy due to unusual sensitivity to gonadotropin and potential for exaggerated response 6
• Long-term cyclic therapy is not recommended beyond a total of about six cycles (including three ovulatory cycles) 6

Monitoring and Follow-Up

• Regular monitoring of weight and waist circumference is essential during weight loss and maintenance 3
• All those with PCOS should be offered regular monitoring for weight changes and excess weight 5
• Use ethnic-specific BMI and waist circumference categories when optimizing lifestyle and weight 1, 3
• Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention 1, 3

Addressing Psychological Factors

• Address psychological factors such as anxiety, depression, body image concerns, and disordered eating 1
• When assessing weight, related stigma, negative body image, and/or low self-esteem need to be considered, and assessment needs to be respectful and considerate 5
• Health professional interactions should be respectful, patient-centered, and considerate of individual preferences and cultural differences 1
• Ensure that health professional interactions avoid weight-related stigma, which can negatively impact engagement with treatment 3

Special Considerations

• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1, 3
• Prevention of weight gain, monitoring of weight, and encouraging evidence-based and socio-culturally appropriate healthy lifestyle is important in PCOS, particularly from adolescence 5
• Weight gain over time is significantly greater in women with PCOS than in unaffected women, making early intervention crucial 3