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

Management of 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 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
• 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 1

Dietary Management

For women with excess weight:

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

For all women with PCOS (including normal weight):

• No specific diet type has proven superior; focus on individual preferences and cultural needs while maintaining a healthy balanced diet 1
• Avoid unduly restrictive or nutritionally unbalanced diets 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

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
• Activity should be performed in at least 10-minute bouts, aiming for at least 30 minutes daily on most days 1

For greater benefits:

• 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 have shown benefits in PCOS 1
• Minimize sedentary, screen, or sitting time 1

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring 1, 2
• Include behavioral strategies: 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
• Address psychological factors such as anxiety, depression, body image concerns, and disordered eating, as these require active management to optimize engagement with treatment 1, 3

Medical Management

For menstrual cycle regulation and hyperandrogenism (in women not attempting conception):

• Combined oral contraceptives are recommended for menstrual cycle regulation and hyperandrogenism 2
• Menstrual cycle control is necessary to prevent endometrial hyperplasia 5

For insulin resistance and cardiometabolic features:

• Metformin should be considered for women with PCOS who have cardiometabolic features such as abdominal obesity and insulin resistance 2
• Interventions that improve insulin sensitivity may have a positive impact on risk factors for diabetes and cardiovascular disease 1

For fertility treatment:

• Clomiphene citrate is indicated as first-line ovulation induction for treatment of ovulatory dysfunction in women with PCOS desiring pregnancy 6
• About 80% of women ovulate with clomiphene citrate, and half of those conceiving 1
• Each course 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 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 and shortest treatment duration for the first course 6

For hirsutism:

• Combined medical interventions, such as an antiandrogen and an ovarian suppression agent, may be the most effective treatment approach 1

Monitoring and Follow-Up

Initial assessment:

• Calculate BMI and measure waist circumference to assess central obesity 3
• Use ethnic-specific BMI and waist circumference cutoffs for populations at high cardiometabolic risk (Asian, Hispanic, South Asian populations require lower thresholds) 1, 3

Ongoing monitoring:

• Regular monitoring of weight and waist circumference 1
• Screen for metabolic complications including diabetes risk, dyslipidemia, hypertension, and nonalcoholic fatty liver disease 5
• Screen for sleep apnea, as this occurs more commonly in women with PCOS 5

Special Considerations

• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1, 3
• Ensure health professional interactions are respectful, patient-centered, and considerate of individual preferences, avoiding weight-related stigma 1
• Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention 1
• Do not recommend herbal supplements, including evening primrose oil, as primary therapy; instead advocate for evidence-based lifestyle and medical interventions with proven efficacy 1
• Patients should not delay evidence-based treatment while pursuing unproven complementary therapies 1