What is the initial treatment approach for patients with PCOS (Polycystic Ovary Syndrome) or PCOD (Polycystic Ovary Disorder)?

PCOS and PCOD: Clarifying Terminology and Initial Treatment

PCOS (Polycystic Ovary Syndrome) and PCOD (Polycystic Ovary Disorder) refer to the same condition—the internationally recognized term is PCOS, and multicomponent lifestyle intervention including diet, exercise, and behavioral strategies is the first-line treatment for all patients regardless of body weight. 1

Understanding the Terminology

• PCOS is the correct medical terminology used in international evidence-based guidelines and medical literature 2, 1
• PCOD is an outdated or regional term that refers to the same condition but is not used in current clinical practice guidelines 1
• The condition affects 8-13% of reproductive-aged women and is characterized by hyperandrogenism, ovulatory dysfunction, and metabolic disturbances 3, 4

Critical Understanding: Insulin Resistance Affects All Body Types

• 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
• Do not dismiss lifestyle intervention in normal-weight PCOS patients—insulin resistance requires management regardless of weight 1, 5

First-Line Treatment: Multicomponent Lifestyle Intervention

Dietary Modifications

• Create an energy deficit of 500-750 kcal/day (targeting 1,200-1,500 kcal/day total) for patients with overweight or obesity, adjusted to individual energy requirements 1, 6
• For normal-weight patients, focus on diet quality rather than caloric restriction, emphasizing low glycemic index foods, high-fiber intake, and omega-3 fatty acids to improve insulin sensitivity 1, 4
• No specific diet type has proven superior—balanced dietary approaches should consider individual preferences and cultural needs while avoiding overly restrictive or nutritionally unbalanced diets 1, 6
• Even modest weight loss of 5-10% yields significant clinical improvements in metabolic, reproductive, and psychological outcomes 2, 6

Physical Activity Requirements

• Prescribe at least 150 minutes/week of moderate-intensity exercise or 75 minutes/week of vigorous-intensity activity for prevention of weight gain and health maintenance 1, 6
• For weight loss and greater health benefits, prescribe at least 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous-intensity activity 1, 6
• Include muscle-strengthening activities on 2 non-consecutive days per week 1, 6
• Both aerobic and resistance exercise improve insulin sensitivity and metabolic outcomes in PCOS 1, 6
• Activities should be performed in at least 10-minute bouts, aiming for at least 30 minutes daily on most days 1

Behavioral Strategies

• Implement SMART goal setting (specific, measurable, achievable, realistic, timely) with self-monitoring to enable achievement of realistic lifestyle goals 1, 6
• Include behavioral strategies such as stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 1, 6
• 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, 5

Medical Management (When Indicated)

For Fertility Treatment

• Clomiphene citrate is first-line ovulation induction for patients desiring pregnancy, with approximately 80% of women ovulating and 50% of those conceiving 1, 7
• Start with 50 mg daily for 5 days, beginning on or about the 5th day of the cycle 7
• If ovulation does not occur after the first course, increase to 100 mg daily for 5 days 7
• If ovulation does not occur after three courses of therapy, further treatment with clomiphene citrate is not recommended and the patient should be reevaluated 7
• Long-term cyclic therapy is not recommended beyond a total of about six cycles (including three ovulatory cycles) 7

Insulin-Sensitizing Agents

• Metformin or thiazolidinediones may improve insulin sensitivity and have a positive impact on risk factors for diabetes and cardiovascular disease 1
• These interventions improve ovulation frequency and may positively impact metabolic outcomes 5

Monitoring and Follow-Up

• Monitor weight and waist circumference regularly, using ethnic-specific cutoffs for populations at high cardiometabolic risk 1, 6
• Target 5-10% weight loss within 6 months as an achievable and clinically meaningful goal for patients with excess weight 5, 6
• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1, 6
• Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma which can negatively impact engagement with treatment 1, 5

Common Pitfalls to Avoid

• Do not recommend herbal supplements (including evening primrose oil) as primary therapy instead of evidence-based interventions 1
• Do not delay evidence-based treatment while pursuing unproven complementary therapies 1
• Recognize that weight gain accelerates over time in PCOS, making early intervention crucial 5, 6
• Do not use overly restrictive or nutritionally unbalanced diets 1

Special Considerations

• Ethnic groups with PCOS who are at high cardiometabolic risk (Asian, Hispanic, South Asian populations) require lower BMI and waist circumference thresholds and greater consideration for lifestyle intervention 1, 6
• Lifestyle intervention was superior to minimal treatment for reducing total testosterone, hirsutism, weight, waist circumference, waist-hip ratio, and fasting insulin in clinical trials 2