Treatment Options 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 Critical Foundation
Insulin resistance is present in PCOS irrespective of BMI and affects both lean and overweight women, contributing to hyperandrogenism through effects on the pituitary, liver, and ovaries. 1, 2, 3 This means that even normal-weight women with PCOS require lifestyle intervention—a common pitfall is dismissing lifestyle management in lean PCOS patients simply because they have normal BMI. 2
First-Line Treatment: Lifestyle Management
Dietary Intervention
For women with excess weight: Target an energy deficit of 30% or 500-750 kcal/day (approximately 1,200-1,500 kcal/day), considering individual energy requirements, body weight, and physical activity levels. 2, 3
Weight loss goal: Aim for 5-10% weight loss in those with excess weight, as this yields significant clinical improvements in metabolic and reproductive abnormalities. 1, 3
No specific diet is superior: Use a variety of balanced dietary approaches based on individual preferences and cultural needs while maintaining healthy eating principles. 2 Evidence supports low glycemic index foods, high-fiber diets, omega-3 fatty acid-rich diets, ketogenic diets, Mediterranean diets, and anti-inflammatory diets for improving insulin sensitivity and hormonal balance. 4
Avoid unduly restrictive or nutritionally unbalanced diets. 2
Exercise Prescription
Minimum requirement: At least 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous-intensity activity (or equivalent combination). 2, 3
For greater weight loss: At least 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous-intensity activity. 2
Muscle strengthening: Include activities on 2 non-consecutive days per week. 2, 3
Activity structure: Perform 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 show benefits in PCOS. 2 High-intensity interval training (HIIT) demonstrates particular potential in improving insulin resistance. 5
Minimize sedentary, screen, or sitting time. 2
Behavioral Strategies
Implement SMART goal setting (specific, measurable, achievable, realistic, timely) and self-monitoring. 2, 3
Include specific behavioral techniques: goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention. 2, 3
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
Second-Line Treatment: Pharmacological Management
For Menstrual Irregularity and Hyperandrogenism (Not Seeking Pregnancy)
- Combined oral contraceptives (COCs) are first-line pharmacological treatment for women with PCOS who are not attempting conception, providing menstrual cycle regulation and management of hyperandrogenism. 3, 6, 7
For Metabolic Features and Insulin Resistance
Metformin should be considered for women with PCOS who have cardiometabolic features such as abdominal obesity and insulin resistance. 3, 6, 7
GLP-1 receptor agonists, particularly when combined with metformin, have exhibited notable efficacy in managing hyperandrogenism and menstrual disturbances, with marked weight loss effects. 5
For Infertility (Seeking Pregnancy)
Clomiphene is indicated as first-line medication for treatment of ovulatory dysfunction in women with PCOS desiring pregnancy. 8, 7 Patients with polycystic ovary syndrome are most likely to achieve success with clomiphene therapy. 8
Letrozole is also first-line medication for infertility. 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. 8 Ovarian hyperstimulation syndrome (OHSS) can occur and may progress rapidly to become a serious medical disorder. 8
Advanced Weight Loss Interventions (When First-Line Fails)
Pharmacotherapy
Various pharmacological treatments can result in marked weight loss with some evidence of improved rates of conception including spontaneous and in response to assisted reproduction treatment. 9
Orlistat may help achieve weight loss and improve lipid and glucose metabolism. 10
Bariatric Surgery
Bariatric surgery appears more effective than conventional pharmacologic treatments for PCOS, though data on mechanisms and direct comparisons with GLP-1RAs remain limited. 5
Significant weight loss from bariatric surgery is anticipated to improve fertility, though available data prevents firm conclusions. 9
Monitoring and Long-Term Management
Regular monitoring of weight and waist circumference is recommended, using ethnic-specific BMI and waist circumference categories for populations at high cardiometabolic risk (Asian, Hispanic, South Asian populations require lower thresholds). 2, 6
Screen for metabolic complications: Type 2 diabetes with fasting glucose followed by 75-gram oral glucose tolerance test, as women with PCOS have increased risk. 6
Screen for dyslipidemia with fasting lipoprotein profile including total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride measurements. 6
Long-term standardized individualized management is needed to achieve fertility and reduce the risk of metabolic-related diseases, as PCOS predisposes patients to metabolic dysfunction and increased risk of type 2 diabetes mellitus. 10, 7
The risk of endometrial cancer can be increased, and endometrial biopsy should be performed prior to treatment in older patients. 8, 10
Critical Pitfalls to Avoid
Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight. 2
Do not delay treatment with the most appropriate intervention early in management to avoid unnecessary delays, especially when fertility is desired. 9
Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss. 2