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

Management of Polycystic Ovary Syndrome (PCOS)

First-Line Treatment: Multicomponent Lifestyle Intervention for ALL Patients

Lifestyle modification through diet, exercise, and behavioral strategies is the mandatory first-line treatment for every woman with PCOS, regardless of body weight or BMI, because insulin resistance affects both lean and overweight women and drives hyperandrogenism through effects on the pituitary, liver, and ovaries. 1, 2

Critical Pitfall to Avoid

• Do not dismiss lifestyle intervention in normal-weight PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight 1
• Hyperinsulinemia worsens all PCOS symptoms in both lean and overweight women, making lifestyle intervention essential even in thin patients 2

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Dietary Management

For Women with Excess Weight (BMI ≥23 kg/m² for Asian populations, ≥25 kg/m² for others):

• Create an energy deficit of 500-750 kcal/day, targeting 1,200-1,500 kcal/day total intake 1, 2
• Aim for 5-10% weight loss, which yields significant clinical improvements in metabolic and reproductive abnormalities 2

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 1
• Emphasize low glycemic index foods, high-fiber intake, omega-3 fatty acids, Mediterranean diet patterns, and anti-inflammatory foods to improve insulin sensitivity and hormonal balance 3
• Avoid unduly restrictive or nutritionally unbalanced diets 1

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Exercise Prescription

Minimum Requirements:

• At least 150 minutes/week of moderate-intensity physical activity OR 75 minutes/week of vigorous-intensity activity (or equivalent combination) 1, 2
• Include muscle-strengthening activities on 2 non-consecutive days per week 1, 2
• Perform activity in at least 10-minute bouts, aiming for at least 30 minutes daily on most days 1

For Greater Benefits:

• Prescribe at least 250 minutes/week of moderate-intensity activities OR 150 minutes/week of vigorous-intensity (or equivalent combination) for modest weight loss and greater health benefits 1
• Both aerobic and resistance exercises improve insulin sensitivity, aid weight loss, and enhance metabolic and reproductive outcomes 1, 3

Additional Recommendations:

• Minimize sedentary, screen, or sitting time 1

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Behavioral Strategies

Implementation Techniques:

• Use SMART goal setting (specific, measurable, achievable, realistic, timely) and self-monitoring 1, 2
• Include goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 1, 2
• Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence 1

Psychological Management:

• Actively address anxiety, depression, body image concerns, and disordered eating to optimize engagement and adherence to lifestyle interventions 1
• Ensure health professional interactions are respectful, patient-centered, and considerate of individual preferences, avoiding weight-related stigma 1

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Medical Management

For Menstrual Irregularities and Hyperandrogenism (Not Attempting Conception):

• Combined oral contraceptives (COCs) are first-line pharmacological treatment for menstrual cycle regulation, hirsutism, and acne 2, 4
• Combined medical interventions (antiandrogen plus ovarian suppression agent) may be most effective for hirsutism 1

For Metabolic Management:

• Metformin should be considered for women with cardiometabolic features such as abdominal obesity and insulin resistance 2, 4
• Metformin improves metabolic/glycemic abnormalities and menstrual irregularities but has limited benefit for hirsutism, acne, or infertility 5
• Interventions that improve insulin sensitivity may positively impact risk factors for diabetes and cardiovascular disease 1

For Infertility Treatment:

• Clomiphene citrate is first-line ovulation induction therapy, with approximately 80% of women ovulating and half of those conceiving 1
• Clomiphene is indicated for ovulatory dysfunction in women desiring pregnancy, particularly those with PCOS 6
• Start on the lowest recommended dose (especially in polycystic ovary syndrome patients who may have exaggerated response) and shortest treatment duration for the first course 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

Important Clomiphene Safety Considerations:

• Patients must not be pregnant, must not have ovarian cysts (except PCOS), must not have abnormal vaginal bleeding, and must have normal liver function 6
• Pelvic examination is necessary prior to the first and each subsequent course 6
• Monitor for ovarian hyperstimulation syndrome (OHSS), which can progress rapidly and become serious, with symptoms including abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain 6
• Discontinue treatment immediately if visual symptoms occur (blurring, scotomata, phosphenes) and perform complete ophthalmological evaluation 6
• If ovarian enlargement occurs, do not give additional clomiphene until ovaries return to pretreatment size 6

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Monitoring and Follow-Up

Regular Assessments:

• Monitor weight and waist circumference regularly, using ethnic-specific BMI and waist circumference categories 1, 4
• Screen for type 2 diabetes with fasting glucose followed by 75-gram oral glucose tolerance test 4
• Screen for dyslipidemia with fasting lipoprotein profile including total cholesterol, LDL, HDL, and triglycerides 4
• Monitor for improvements in menstrual regularity with successful treatment 4

Special Population Considerations:

• Use ethnic-specific cutoffs for Asian, Hispanic, and South Asian populations, which require lower BMI and waist circumference thresholds for cardiometabolic risk assessment 1
• Ethnic groups with PCOS at high cardiometabolic risk require greater consideration for lifestyle intervention 1

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Evidence-Based Recommendations to Avoid

Not Recommended:

• Do not use herbal supplements (including evening primrose oil) as primary therapy; instead use evidence-based lifestyle and medical interventions with proven efficacy 1
• Patients should not delay evidence-based treatment while pursuing unproven complementary therapies 1
• Thiazolidinediones have an unfavorable risk-benefit ratio overall 5