What is the latest approach to managing Polycystic Ovary Syndrome (PCOS)?

Latest Guideline in Polycystic Ovarian Syndrome Management

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, 3

Critical Understanding: Why Lifestyle Matters for Everyone

Insulin resistance is present in PCOS irrespective of BMI and contributes to hyperandrogenism in all phenotypes, making lifestyle intervention essential even in normal-weight patients 1, 2. The resulting hyperinsulinemia worsens all PCOS symptoms through multiple pathways 2. Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—this is a critical pitfall to avoid. 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 and physical activity levels 1, 2, 3
• Target 5-10% weight loss, which yields significant clinical improvements in metabolic and reproductive abnormalities 2, 3

For All Women (Any Weight):

• No specific diet type has proven superior—focus on individual preferences and cultural needs while maintaining a healthy balanced diet 1
• Follow general healthy eating principles across the life course 1, 3
• Avoid unduly restrictive or nutritionally unbalanced diets 1
• Address common nutritional deficiencies: women with PCOS tend to have higher cholesterol intake and lower magnesium and zinc intake 3

Evidence-Based Dietary Approaches:

Low glycemic index foods, high-fiber diets, omega-3 fatty acid-rich diets, ketogenic diets, Mediterranean diets, antioxidant-rich foods, and anti-inflammatory diets all improve insulin sensitivity and hormonal balance 4.

Exercise Prescription

Minimum for Health Maintenance:

• 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 on 2 non-consecutive days per week 1, 2, 3
• Perform activity in at least 10-minute bouts or around 1,000 steps, aiming for at least 30 minutes daily on most days 1

For Weight Loss and Greater Benefits:

• At least 250 minutes/week of moderate-intensity activities OR 150 minutes/week of vigorous-intensity (or equivalent combination) 1, 3
• Minimize sedentary, screen, or sitting time 1

Exercise Type:

Both aerobic and resistance exercises show benefits in PCOS, with combination therapy superior to monotherapy 1, 5. Women with PCOS have lower total physical activity levels than women without PCOS, making exercise interventions particularly important 3.

Behavioral Strategies

Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring 1, 2. Include comprehensive behavioral strategies: goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 1, 2, 3. Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence 1. Address psychological factors such as anxiety, depression, body image concerns, and disordered eating, as women with PCOS have higher rates of these conditions 1, 3.

Pharmacological Management

For Menstrual Regulation and Hyperandrogenism (Not Attempting Conception):

Combined oral contraceptives are first-line pharmacological treatment to suppress ovarian androgen secretion and increase sex hormone binding globulin 2, 3, 6. However, individual cardiometabolic risk assessment is mandatory before initiating COCs: evaluate age, smoking, obesity, glucose intolerance or diabetes, hypertension, dyslipidemia, thrombophilia, and family history of venous thromboembolism 6.

For Hirsutism:

Consider oral contraceptives, antiandrogen drugs, or topical eflornithine hydrochloride cream 3.

For Cardiometabolic Features:

Metformin should be considered for women with PCOS who have cardiometabolic features such as abdominal obesity and insulin resistance 2. Insulin-sensitizing agents like metformin may improve insulin sensitivity and reduce risk factors for diabetes and cardiovascular disease 3. Emerging therapies include newer insulin sensitizers (inositols, GLP-1 agonists, DPP-4 inhibitors, SGLT2 inhibitors), vitamin D, and statins 7.

For Infertility:

Letrozole (an aromatase inhibitor) appears more successful than clomiphene citrate for treating infertility caused by PCOS 8.

For Weight Management:

Anti-obesity medications may be considered for appropriate candidates with BMI ≥25 kg/m² 3.

Monitoring and Follow-Up

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) 1, 2. Regular screening for metabolic abnormalities including type 2 diabetes and cardiovascular disease is essential 3. Assess mental health regularly 3. Re-assess patients at consecutive visits, more closely if any baseline cardiometabolic risk factor is present when using COCs 6.

Special Population Considerations

Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention 1, 3. Health professional interactions should be respectful, patient-centered, and considerate of individual preferences and cultural differences 1. Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1. Combination therapy with diet and exercise results in improved fasting insulin levels compared to monotherapy 5.