What are the best practices for managing Polycystic Ovary Syndrome (PCOS)?

Best Practices for Managing 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

Critical Understanding: Why Lifestyle Matters for ALL PCOS Patients

• Insulin resistance is present irrespective of BMI in PCOS and requires management through diet, exercise, and behavioral strategies even in normal-weight women 1, 2
• Hyperinsulinemia worsens all PCOS symptoms by contributing to hyperandrogenism through effects on the pituitary, liver, and ovaries in all women with PCOS, regardless of weight 1, 2
• 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

For Women with Excess Weight

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

General Dietary Principles for All PCOS Patients

• No specific diet type has proven superior; focus on individual preferences and cultural needs while maintaining a healthy balanced diet 1, 2, 3
• Follow general healthy eating principles across the life course 1
• Avoid unduly restrictive or nutritionally unbalanced diets 1
• Women with PCOS have lower magnesium and zinc intake, higher cholesterol intake, and lower total adherence to healthy eating patterns compared to controls 4

Physical Activity Prescription

Minimum Requirements for Health Maintenance

• Prescribe 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 per week 4, 1, 2
• 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

• Increase to at least 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous intensity (or equivalent combination) 3
• Both aerobic and resistance exercise improve insulin sensitivity and metabolic outcomes in PCOS 3
• 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

Additional Activity Recommendations

• Aim for 10,000 steps daily, including activities of daily living and 30 minutes of structured physical activity (approximately 3,000 steps) 4
• Minimize sedentary, screen, or sitting time 4, 1, 3
• Women with PCOS have significantly lower total physical activity compared to controls 4

Behavioral Strategies

Goal Setting and Self-Monitoring

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring to enable achievement of realistic lifestyle goals 1, 2, 3
• Realistic physical activity SMART goals could include 10-minute bouts, progressively increasing physical activity 5% weekly, up to and above recommendations 4
• Self-monitoring including fitness tracking devices and technologies for step count and exercise intensity can support and promote active lifestyles 4

Comprehensive Behavioral Interventions

• Include behavioral strategies such as goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 4, 1, 2, 3
• Behavioral change techniques in combination with diet and exercise interventions increase weight loss over diet and/or physical activity alone 4
• Self-management has positive impacts, and family support improves outcomes 4
• More intensive behavioral interventions induce greater weight loss 4

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 4
• Calculate BMI and measure waist circumference to assess central obesity, using ethnic-specific cutoffs for populations at high cardiometabolic risk (Asian, Hispanic, South Asian populations require lower thresholds) 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 4

Medical Management Considerations

Hormonal Management

• Combined oral contraceptives are recommended for menstrual cycle regulation and hyperandrogenism in women not attempting conception 2

Insulin Sensitizers

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

Ovulation Induction (When Fertility is the Goal)

• Start clomiphene citrate at 50 mg daily for 5 days as the initial dose 5
• If ovulation does not occur after the first course, increase to 100 mg daily for 5 days 5
• Increasing the dosage or duration beyond 100 mg/day for 5 days is not recommended 5
• Patients with PCOS are unusually sensitive to gonadotropin and may have an exaggerated response to usual doses of clomiphene citrate; therefore, start with the lowest recommended dose and shortest treatment duration 5
• Long-term cyclic therapy is not recommended beyond a total of about six cycles 5

Critical Pitfalls and Caveats

Ovarian Hyperstimulation Risk

• Ovarian hyperstimulation syndrome (OHSS) can occur in PCOS patients receiving clomiphene citrate, and may progress rapidly (within 24 hours to several days) to become a serious medical disorder 5
• Early warning signs include abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain 5
• To minimize risks, use the lowest dose consistent with expected clinical results, especially in PCOS patients who are unusually sensitive to gonadotropin 5
• If ovarian enlargement occurs, additional clomiphene citrate therapy should not be given until the ovaries have returned to pretreatment size 5

Weight-Related Considerations

• Weight gain over time is significantly greater in women with PCOS than in unaffected women, making early intervention crucial 3
• Central obesity increases over time in PCOS, with a progressive increase in waist-to-hip ratio between ages 20-45 years 3
• Ensure that health professional interactions avoid weight-related stigma, which can negatively impact engagement with treatment 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 4

Benefits Beyond Weight Loss

• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1, 3
• Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention 1, 3