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

PCOS Treatment

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

First-Line Treatment: Lifestyle Management

Why Lifestyle Matters for ALL Women with PCOS (Including Lean Women)

• 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, 3

Critical Pitfall 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

Dietary Management

• No specific diet type has proven superior; focus on individual preferences and cultural needs while maintaining a healthy balanced diet 1, 2, 4
• For women with excess weight seeking weight loss, aim for an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day), considering individual energy requirements 2, 4, 3
• Target 5-10% weight loss in those with excess weight, as this yields significant clinical improvements in metabolic and reproductive abnormalities 2, 4, 3
• For lean women, focus on diet quality rather than caloric restriction 2
• Avoid unduly restrictive or nutritionally unbalanced diets 1, 2

Exercise Prescription

• Prescribe at least 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous-intensity activity (or equivalent combination) for prevention of weight gain and maintenance of health 2, 4, 3
• Include muscle-strengthening activities on 2 non-consecutive days per week 2, 4, 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 modest weight loss and greater health benefits, recommend at least 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous-intensity (or equivalent combination) 2
• Both aerobic and resistance exercises have shown benefits in PCOS 2
• Minimize sedentary, screen, or sitting time 2

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring 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, 3
• Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence 2, 4
• Address psychological factors such as anxiety, depression, body image concerns, and disordered eating 2, 4

Medical Management (Second-Line)

For Menstrual Irregularities and Hyperandrogenism

• Combined oral contraceptives (COCs) are recommended for menstrual cycle regulation and hyperandrogenism in women not attempting conception 3, 5
• Progesterone therapy can be used to prevent endometrial hyperplasia 6

For Metabolic Features

• Metformin should be considered for women with PCOS who have cardiometabolic features such as abdominal obesity and insulin resistance 3, 5
• Metformin is beneficial for metabolic/glycemic abnormalities and for improving menstrual irregularities, but has limited or no benefit in treating hirsutism, acne, or infertility 5

For Infertility

• Clomiphene citrate is recommended as first-line ovulation induction, with about 80% of women ovulating and half of those conceiving 2, 5

For Hirsutism and Acne

• Combined medical interventions, such as an antiandrogen and an ovarian suppression agent, may be the most effective treatment approach to hirsutism 2
• Hormonal contraceptives are first-line management for hirsutism and acne 5

Monitoring and Follow-Up

• Regular monitoring of weight and waist circumference is recommended 2
• Use ethnic-specific BMI and waist circumference categories when optimizing lifestyle and weight 2, 4
• Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention 2, 4
• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 2, 4

Special Considerations for Adolescents

• Lifestyle interventions should be the first-line treatment for all adolescents with PCOS, with multicomponent approaches including diet, exercise, and behavioral strategies being most effective for those with excess weight 4
• Metformin in addition to lifestyle modification is likely to improve menstrual cyclicity and hyperandrogenism in girls with PCOS and type 2 diabetes 4
• A multidisciplinary model of care with dietitian, health psychologist, gynecologist, and endocrinologist has shown enhanced weight loss outcomes in adolescents with PCOS 4

Patient-Centered Care Principles

• Health professional interactions should be respectful, patient-centered, and considerate of individual preferences and cultural differences 2, 4
• Avoid weight-related stigma 2
• Recognize that psychological factors require active management to optimize engagement with treatment 2