What is the first line of treatment for Polycystic Ovary Syndrome (PCOS)?

From the Guidelines

Lifestyle modifications are the first-line treatment for Polycystic Ovary Syndrome (PCOS), as they address the underlying metabolic and hormonal imbalances characteristic of the condition. According to the most recent and highest quality study 1, lifestyle management is fundamental in the treatment of PCOS, and it has been recommended as a first-line treatment. The study suggests that a multicomponent lifestyle intervention, including diet, exercise, and behavioral strategies, is central to PCOS management, with a focus on weight and healthy lifestyle behaviors.

The benefits of lifestyle modifications in PCOS management are numerous, including:

• Improving insulin sensitivity and reducing insulin resistance
• Normalizing hormone levels and reducing androgen production
• Regulating ovulation and menstrual cycles
• Reducing the risk of long-term health risks associated with PCOS, such as type 2 diabetes and cardiovascular disease

The study 1 also highlights the importance of lifestyle modifications in PCOS management, stating that lifestyle is fundamental in chronic disease prevention and management, and it has been recommended as a first-line treatment in the Australian PCOS guideline 2011. The international evidence-based guideline on PCOS, developed in 2018, also emphasizes the importance of lifestyle modifications in PCOS management.

In terms of specific lifestyle modifications, the study 1 recommends a weight loss of 5-10% through diet and regular exercise, with at least 150 minutes of moderate activity weekly. The study also suggests that behavioral and cognitive behavioral intervention approaches can be effective in promoting weight loss and improving adherence to lifestyle modifications.

Overall, the evidence suggests that lifestyle modifications are the first-line treatment for PCOS, and they should be combined with other treatments, such as metformin and hormonal contraceptives, to manage the condition effectively. The most effective approach to PCOS management is a multi-faceted one, addressing the metabolic and hormonal imbalances characteristic of the condition, and lifestyle modifications are a critical component of this approach 1.

From the Research

First Line Treatment for PCOS

The first line treatment for Polycystic Ovary Syndrome (PCOS) is a crucial aspect of managing the condition, especially in women of reproductive age.

• Lifestyle modification is considered the first-line treatment and is associated with improved endocrine profile 2.
• Clomiphene citrate (CC) should be considered as the first line pharmacologic therapy for ovulation induction 2.
• Letrozole, an aromatase inhibitor, is headed toward replacing clomiphene, a selective estrogen receptor modulator, as the first-choice option 3.
• Weight loss interventions, lifestyle related, through obesity drugs or through bariatric surgery have shown mixed results on pregnancy outcomes 3.

Medical Ovulation Induction Therapy

First line medical ovulation induction therapy to improve fertility outcomes is letrozole, whilst other less efficacious ovulation induction agents, such as clomiphene citrate, metformin, and metformin combined with clomiphene citrate, may also be considered 4.

• Metformin combined with clomiphene citrate is more effective than clomiphene citrate alone 4.
• In obese women with PCOS, clomiphene citrate could be used in preference to metformin alone whilst clomiphene citrate could be added to metformin alone in order to improve reproductive outcome in all women with PCOS 4.
• Gonadotrophins, which are more effective than clomiphene citrate in therapy naïve women with PCOS, can be considered a first line therapy in the presence of ultrasound monitoring, following counselling on the cost and the potential risk of multiple pregnancy 4.

Effectiveness of Letrozole

Letrozole is used to stimulate the ovaries of the infertile women with PCOS combined with intrauterine insemination is the effective treatment 5.

• The clinical pregnancy rate was 22.5% of the both groups 5.
• These patients had the high risk of insulin resistance 5.

Role of Metformin

Metformin alone compared with placebo increases the ovulation rate in women with polycystic ovary syndrome (PCOS) but should not be used as first-line therapy for anovulation because oral ovulation induction agents such as clomiphene citrate or letrozole alone are much more effective in increasing ovulation, pregnancy, and live-birth rates in women with PCOS 6.

• There is fair evidence that metformin alone does not increase rates of miscarriage when stopped at the initiation of pregnancy and insufficient evidence that metformin in combination with other agents used to induce ovulation increases live-birth rates 6.