What is the management of 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

First-Line Treatment: Lifestyle Modification

Dietary Management

For women with excess weight, target an energy deficit of 500-750 kcal/day (total intake 1,200-1,500 kcal/day), aiming for 5-10% weight loss within 6 months, which yields significant clinical improvements in metabolic and reproductive abnormalities. 1, 3

• No specific diet type (low-carb, Mediterranean, ketogenic) has proven superior; select based on patient preferences and cultural needs while maintaining nutritional balance 1, 4
• Avoid unduly restrictive or nutritionally unbalanced diets 1
• For lean women with PCOS, focus on diet quality rather than caloric restriction, emphasizing low glycemic index foods, high fiber, omega-3 fatty acids, and anti-inflammatory foods 1, 4
• General healthy eating principles should be followed across the life course 1

Exercise Prescription

Prescribe at least 150 minutes/week of moderate-intensity physical activity (brisk walking, cycling 8-15 km/h, low-impact aerobics) or 75 minutes/week of vigorous-intensity activity (jogging, high-impact aerobics, competitive sports). 1, 3

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

• Include behavioral strategies: goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 1, 3
• Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence 1
• Address psychological factors including anxiety, depression, body image concerns, and disordered eating, as these require active management to optimize engagement with treatment 1, 2

Medical Management

For Menstrual Irregularities and Hyperandrogenism (Not Seeking Pregnancy)

Combined oral contraceptives (COCs) are first-line medical therapy for menstrual cycle regulation and treatment of hirsutism/acne. 5

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

For Metabolic Management

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

• Metformin is beneficial for metabolic/glycemic abnormalities and improving menstrual irregularities 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 Fertility Treatment

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

• Clomiphene citrate is indicated for treatment of ovulatory dysfunction in women desiring pregnancy, with patients with PCOS most likely to achieve success 6
• Start clomiphene citrate on or about the 5th day of the cycle once ovulation has been established 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 should be started on the lowest recommended dose and shortest treatment duration for the first course due to unusual sensitivity to gonadotropin and risk of ovarian hyperstimulation syndrome 6
• Pelvic examination is necessary prior to the first and each subsequent course of clomiphene citrate treatment 6

Monitoring and Follow-Up

Regular monitoring of weight and waist circumference is essential during treatment and maintenance. 1, 3

• Use ethnic-specific BMI and waist circumference categories when optimizing lifestyle interventions, as Asian, Hispanic, and South Asian populations require lower thresholds 1
• Achievable goals of 5-10% weight loss in those with excess weight are considered successful weight reduction within 6 months 1, 3
• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1, 3
• Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention 1, 3

Critical Pitfalls to Avoid

Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance is present irrespective of BMI and requires management through diet, exercise, and behavioral strategies even in normal-weight women. 1, 2

• Hyperinsulinemia resulting from insulin resistance contributes to hyperandrogenism through effects on the pituitary, liver, and ovaries in all women with PCOS, regardless of weight 1, 2
• Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma, which can negatively impact engagement with treatment 1, 3
• Weight gain over time is significantly greater in women with PCOS than in unaffected women, with progressive increase in waist-to-hip ratio between ages 20-45 years, making early intervention crucial 3
• Do not use 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

Special Populations

Adolescents

Hyperandrogenism is central to the presentation in adolescents, and hormonal contraceptives and metformin are the treatment options. 5

• Establishing a diagnosis of PCOS is problematic in adolescents 5

Postmenopausal Women

There is no consistent phenotype in postmenopausal women, making diagnosis and management challenging. 5

Long-Term Considerations

Evaluation of women with PCOS should exclude alternate androgen-excess disorders and screen for risk factors including endometrial cancer, mood disorders, obstructive sleep apnea, diabetes, and cardiovascular disease. 5

• The role of weight loss in improving PCOS status per se is uncertain, but lifestyle intervention is beneficial in overweight/obese patients for other health benefits 5
• Long-term standardized individualized management is needed to achieve fertility and reduce the risk of metabolic-related diseases 7