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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

First-Line Treatment: Multicomponent Lifestyle Intervention

All women with PCOS, regardless of body weight, should begin with multicomponent lifestyle intervention including diet, exercise, and behavioral strategies, as insulin resistance affects both lean and overweight women and drives hyperandrogenism through effects on the pituitary, liver, and ovaries. 1, 2

Critical Understanding

• Insulin resistance is present in PCOS irrespective of BMI and contributes to hyperandrogenism in all phenotypes 1, 2
• Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight 1
• Hyperinsulinemia worsens all PCOS symptoms, making lifestyle intervention essential even in normal-weight patients 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), considering individual energy requirements 1, 2, 3
• Aim for 5-10% weight loss, which yields significant clinical improvements in metabolic and reproductive abnormalities 2, 3

For All Women (Including Normal Weight)

• No specific diet type has proven superior; focus on individual preferences and cultural needs while maintaining nutritional balance 1, 3
• Avoid unduly restrictive or nutritionally unbalanced diets 1
• Follow general healthy eating principles across the life course 1
• Consider low glycemic index foods, high-fiber diets, omega-3 fatty acid-rich diets, Mediterranean diets, and anti-inflammatory diets to improve insulin sensitivity and hormonal balance 4

Exercise Prescription

Prescribe at least 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous-intensity activity (or equivalent combination). 1, 2, 3

Specific Exercise Guidelines

• Include muscle-strengthening activities on 2 non-consecutive days per week 1, 2, 3
• Activity should be performed in at least 10-minute bouts, aiming for at least 30 minutes daily on most days 1
• For weight loss and greater health benefits, increase to at least 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous intensity 1, 3
• Both aerobic and resistance exercise improve insulin sensitivity and metabolic outcomes 3, 4
• Minimize sedentary, screen, or sitting time 1

Behavioral Strategies

Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring to enable achievement of realistic lifestyle goals. 1, 2, 3

• Include 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, 2
• Address psychological factors such as anxiety, depression, body image concerns, and disordered eating 1, 2

Medical Management

For Menstrual Irregularities and Hyperandrogenism (Not Attempting Conception)

Combined oral contraceptives are the first-line medical management for menstrual cycle regulation and treatment of hirsutism/acne. 2, 5

• Hormonal contraceptives are also appropriate for adolescents with PCOS 5
• Combined medical interventions (antiandrogen plus ovarian suppression agent) may be most effective for hirsutism 1

For Metabolic/Glycemic Abnormalities

Metformin should be considered for women with PCOS who have cardiometabolic features such as abdominal obesity and insulin resistance. 2, 5

• Metformin improves menstrual irregularities and metabolic/glycemic abnormalities 1, 5
• Metformin has limited or no benefit in treating hirsutism, acne, or infertility 5
• Interventions that improve insulin sensitivity may have positive impact on risk factors for diabetes and cardiovascular disease 1

For Infertility/Ovulation Induction

Clomiphene citrate is the first-line ovulation induction therapy, with approximately 80% of women ovulating and half of those conceiving. 1, 6, 5

Clomiphene Citrate Prescribing Details

• Indicated for ovulatory dysfunction in women desiring pregnancy, particularly those with PCOS 6
• Each course should be started on or about the 5th day of the cycle 6
• Long-term cyclic therapy is not recommended beyond approximately 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 due to unusual sensitivity to gonadotropin 6

Critical Warnings for Clomiphene

• Ovarian hyperstimulation syndrome (OHSS) can occur and may progress rapidly to become a serious medical disorder 6
• Early warning signs of OHSS include abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain 6
• Visual symptoms (blurring, scotomata, phosphenes) require immediate discontinuation and complete ophthalmological evaluation 6
• If ovarian enlargement occurs, do not give additional clomiphene until ovaries return to pretreatment size 6
• Pelvic examination is necessary prior to the first and each subsequent course 6

Monitoring and Follow-Up

• Regular monitoring of weight and waist circumference is recommended 1, 3
• Use ethnic-specific BMI and waist circumference categories when optimizing lifestyle and weight 1, 3
• Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention 1, 3
• Screen for risk factors for endometrial cancer, mood disorders, obstructive sleep apnea, diabetes, and cardiovascular disease 5

Special Considerations

• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1, 2, 3
• Ensure health professional interactions are respectful, patient-centered, and avoid weight-related stigma 1, 3
• Weight gain over time is significantly greater in women with PCOS than in unaffected women, making early intervention crucial 3
• Do not delay evidence-based treatment while pursuing unproven complementary therapies such as evening primrose oil or other herbal supplements 1