What are the preventative treatments to decrease progression in Polycystic Ovary Syndrome (PCOS)?

Preventative Treatment and Progression Management in PCOS

Multicomponent lifestyle intervention—including diet, exercise, and behavioral strategies—is the first-line preventative treatment for all women with PCOS regardless of body weight, as insulin resistance affects both lean and overweight women and drives disease progression. 1, 2

Why Lifestyle Intervention Works for Prevention

Insulin resistance is present in PCOS irrespective of BMI and contributes to hyperandrogenism through effects on the pituitary, liver, and ovaries in all women with PCOS, regardless of weight 1, 2. Hyperinsulinemia resulting from insulin resistance worsens all PCOS symptoms and drives metabolic and reproductive complications over time 2. Women with PCOS experience significantly greater weight gain over time compared to unaffected women, with progressive increases in central obesity between ages 20-45 years, making early intervention crucial 3.

Dietary Approach to Prevent Progression

For Women with Excess Weight:

• Target an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day total), considering individual energy requirements, body weight, and physical activity levels 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):

• Follow general healthy eating principles across the life course, focusing on diet quality rather than caloric restriction for thin women 1
• 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
• Consider low glycemic index foods, high-fiber diets, omega-3 fatty acid-rich diets, Mediterranean diets, and anti-inflammatory diets, which improve insulin sensitivity and hormonal balance 4

Exercise Prescription to Halt Progression

Minimum Requirements for Health Maintenance:

• 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
• 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 Weight Loss and Greater Health Benefits:

• Recommend at least 250 minutes/week of moderate-intensity activities OR 150 minutes/week of vigorous-intensity activity (or equivalent combination) 1, 3
• Both aerobic and resistance exercise improve insulin sensitivity and metabolic outcomes in PCOS 3, 4
• Moderate-intensity activities include brisk walking, cycling (8-15 km/h), low-impact aerobics, and yoga 3
• Vigorous-intensity activities include jogging/running, high-impact aerobics, and competitive sports 3

Additional Activity Recommendations:

• Minimize sedentary, screen, or sitting time 1

Behavioral Strategies for Long-Term Prevention

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring 1, 2, 3
• Include behavioral strategies such as 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, as these require active management to optimize engagement with treatment 1, 2

Medical Management for Prevention

For Metabolic Risk Reduction:

• 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, including metformin or thiazolidinediones, may have a positive impact on risk factors for diabetes and cardiovascular disease 1, 5

For Menstrual Regulation (Non-Fertility Seeking):

• Combined oral contraceptives are recommended for menstrual cycle regulation and hyperandrogenism in women not attempting conception 2, 5

Monitoring and Risk Stratification

• Calculate BMI and measure waist circumference to assess central obesity, using ethnic-specific cutoffs for populations at high cardiometabolic risk (Asian, Hispanic, South Asian populations require lower thresholds) 1
• Regular monitoring of weight and waist circumference is essential 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 requires management regardless of weight 1. Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1, 3. Ensure health professional interactions avoid weight-related stigma, which can negatively impact engagement with treatment 1, 3. Do not recommend herbal supplements like evening primrose oil as primary therapy; instead advocate for evidence-based lifestyle and medical interventions with proven efficacy 1.