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

Treatment of 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

Critical Understanding: Why Lifestyle Matters for ALL PCOS Patients

• Insulin resistance is present irrespective of BMI and affects both lean and overweight women with PCOS, contributing to hyperandrogenism through effects on the pituitary, liver, and ovaries 1, 2, 3
• Hyperinsulinemia resulting from insulin resistance worsens all PCOS symptoms, making lifestyle intervention essential even in normal-weight patients 2
• Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight 3

First-Line Treatment: Multicomponent Lifestyle Intervention

Dietary Management

• For women with excess weight, prescribe 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 2, 4, 3
• Target 5-10% weight loss in those with excess weight within 6 months, as this yields significant clinical improvements in metabolic, reproductive, and psychological outcomes 1, 2, 4
• No specific diet type (low-carbohydrate, Mediterranean, ketogenic, etc.) has proven superior to others; focus on balanced dietary approaches that the patient can sustain long-term 4, 3, 5
• For lean women with PCOS, focus on diet quality rather than caloric restriction, emphasizing low glycemic index foods, high fiber, omega-3 fatty acids, and anti-inflammatory foods 3, 5
• Avoid unduly restrictive or nutritionally unbalanced diets 3

Exercise Prescription

• Prescribe at least 150 minutes/week of moderate-intensity physical activity (brisk walking, cycling 8-15 km/h, low-impact aerobics, yoga) or 75 minutes/week of vigorous-intensity activity (jogging/running, high-impact aerobics, competitive sports) or equivalent combination 2, 4, 3
• For modest weight loss and greater health benefits, increase to at least 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous-intensity 4, 3
• Include muscle-strengthening activities on 2 non-consecutive days per week 2, 3
• Activity should be performed in at least 10-minute bouts, aiming for at least 30 minutes daily on most days 3
• Both aerobic and resistance exercise improve insulin sensitivity and metabolic outcomes in PCOS 4, 3, 5
• Minimize sedentary, screen, or sitting time 3

Behavioral Strategies

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

Medical Management

For Menstrual Irregularity and Hyperandrogenism (Not Attempting Conception)

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

For Metabolic Features

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

For Fertility Treatment

• Clomiphene citrate is indicated as first-line ovulation induction for women with PCOS desiring pregnancy, with approximately 80% of women ovulating 3, 6
• Properly timed coitus in relationship to ovulation is important; basal body temperature graphs or other appropriate tests should be used to determine if ovulation occurred 6
• Each course of clomiphene citrate should be started on or about the 5th day of the cycle 6
• Long-term cyclic therapy is not recommended beyond a total of about six cycles (including three ovulatory cycles) 6
• Patients with polycystic ovary syndrome should be started on the lowest recommended dose and shortest treatment duration for the first course of therapy, as they may have an exaggerated response to usual doses 6

Monitoring and Follow-Up

• Regular monitoring of weight and waist circumference is essential during weight loss and maintenance 4, 3
• Use ethnic-specific BMI and waist circumference categories when optimizing lifestyle interventions, as Asian, Hispanic, and South Asian populations require lower thresholds 4, 3
• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 4, 3

Common Pitfalls and Caveats

• The most critical pitfall is dismissing lifestyle intervention in lean PCOS patients—insulin resistance requires management regardless of weight 2, 3
• Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma, which can negatively impact engagement with treatment 4, 3
• Recognize that weight gain over time is significantly greater in women with PCOS than in unaffected women, with progressive increase in waist-to-hip ratio between ages 20-45 years, making early intervention crucial 4
• Be aware of ovarian hyperstimulation syndrome (OHSS) risk when using clomiphene citrate, particularly in patients with polycystic ovary syndrome who may be unusually sensitive to gonadotropin 6
• If ovarian enlargement occurs during clomiphene citrate therapy, additional treatment should not be given until the ovaries have returned to pretreatment size 6
• Visual symptoms (blurring, scotomata, phosphenes) can occur with clomiphene citrate; patients should discontinue treatment and have complete ophthalmological evaluation if these develop 6