What is the treatment approach for individuals with polycystic ovary syndrome (PCOS)?

Treatment Approach 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 drives the pathophysiology of the syndrome. 1, 2

Why Lifestyle Management is First-Line for ALL 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 Hyperinsulinemia resulting from this insulin resistance worsens all PCOS symptoms, making lifestyle intervention essential even in normal-weight patients. 3

Critical Pitfall: Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight. 2

Dietary Management

For Women with Excess Weight

• Target an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day total), considering individual energy requirements, body weight, and physical activity levels. 2, 4
• Aim for 5-10% weight loss, as this yields significant clinical improvements in metabolic and reproductive abnormalities. 3, 4

For All Women (Including Normal Weight)

• No specific diet type has proven superior; focus on individual preferences and cultural needs while maintaining a healthy balanced diet. 2, 4
• Follow general healthy eating principles across the life course. 2
• Avoid unduly restrictive or nutritionally unbalanced diets. 2
• For lean women, focus on diet quality rather than caloric restriction. 2

Evidence-Based Dietary Approaches

Dietary interventions such as low glycemic index foods, high-fiber diets, omega-3 fatty acid-rich diets, ketogenic diets, Mediterranean diets, antioxidant-rich foods, and anti-inflammatory diets improve insulin sensitivity and hormonal balance in women with PCOS. 5

Exercise 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). 2, 3
• Include muscle-strengthening activities on 2 non-consecutive days per week. 2, 3
• Activity should be performed in at least 10-minute bouts or around 1,000 steps, aiming for at least 30 minutes daily on most days. 2

For Weight Loss and Greater Health Benefits

• Recommend at least 250 minutes/week of moderate-intensity activities OR 150 minutes/week of vigorous-intensity activity (or equivalent combination). 2, 4

Types of Exercise

• Both aerobic and resistance exercise improve insulin sensitivity and metabolic outcomes in PCOS. 4, 5
• Moderate-intensity activities include brisk walking, cycling (8-15 km/h), low-impact aerobics, and yoga. 4
• Vigorous-intensity activities include jogging/running, high-impact aerobics, and competitive sports. 4
• Minimize sedentary, screen, or sitting time. 2

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring to enable achievement of realistic lifestyle goals. 2, 3, 4
• Include behavioral strategies such as goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention. 2, 3, 4
• 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, as these require active management to optimize engagement with treatment. 2

Medical Management

For Menstrual Irregularity and Hyperandrogenism

Combined oral contraceptives are recommended for menstrual cycle regulation and hyperandrogenism in women not attempting conception. 3

For Metabolic Features

Metformin should be considered for women with PCOS who have cardiometabolic features such as abdominal obesity and insulin resistance. 3

For Fertility Treatment

• Clomiphene citrate is recommended as first-line ovulation induction, with about 80% of women ovulating and half of those conceiving. 2
• Start with 50 mg daily for 5 days, beginning on or about the 5th day of the cycle. 6
• If ovulation does not occur after the first course, increase to 100 mg daily for 5 days. 6
• The majority of patients who will ovulate do so after the first course of therapy. 6
• If ovulation does not occur after three courses of therapy, further treatment with clomiphene citrate is not recommended. 6

Critical Warning for Clomiphene: 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 (50 mg) and shortest treatment duration for the first course. 6 If ovarian enlargement occurs, additional clomiphene therapy should not be given until the ovaries have returned to pretreatment size. 6

Monitoring and Follow-Up

• Regular monitoring of weight and waist circumference is essential during weight loss and maintenance. 2, 4
• Use ethnic-specific BMI and waist circumference categories when optimizing lifestyle and weight, as Asian, Hispanic, and South Asian populations require lower thresholds. 2, 4
• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss. 2, 4

Evidence Supporting Lifestyle as First-Line

Lifestyle intervention provides significant benefits compared to minimal treatment for total testosterone (MD -0.27 nmol/L, P = 0.004), hirsutism by Ferriman-Gallwey score (MD -1.19, P = 0.04), weight (MD -3.47 kg, P < 0.00001), waist circumference (MD -1.95 cm, P = 0.006), waist-hip ratio (MD -0.04, P = 0.02), fasting insulin (MD -2.02 µU/mL, P = 0.002), and oral glucose tolerance test insulin. 1, 7

Combination therapy with diet and exercise results in improved fasting insulin levels compared to monotherapy with diet or exercise alone. 8 Moderate weight loss (minimum of 5%) results in improved metabolic index. 8

Special Considerations

• Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention. 2, 4
• Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma, which can negatively impact engagement with treatment. 2, 4
• Weight gain over time is significantly greater in women with PCOS than in unaffected women, making early intervention crucial. 4