What are the management options for Polycystic Ovary Disorder (PCOD)?

Management of Polycystic Ovary Disorder (PCOD)

Multicomponent lifestyle intervention—combining diet, exercise, and behavioral strategies—is the mandatory first-line treatment for all women with PCOS, regardless of body weight, because insulin resistance affects both lean and overweight patients equally. 1

Initial Assessment and Mandatory Screening

Before initiating any treatment, perform these specific evaluations:

• Calculate BMI and measure waist circumference using ethnic-specific cutoffs (lower thresholds for Asian, Hispanic, and South Asian populations who face higher cardiometabolic risk) 1
• Screen for psychological conditions: anxiety, depression, body image concerns, and disordered eating at initial presentation, as these directly impair treatment adherence 2
• Assess insulin resistance markers in all patients, including those with normal BMI, since hyperinsulinemia drives hyperandrogenism through pituitary, liver, and ovarian effects regardless of weight 1

First-Line Treatment: Lifestyle Modification (All Patients)

Dietary Management

Target an energy deficit of 500-750 kcal/day (total intake 1,200-1,500 kcal/day) for weight loss, adjusted to individual energy requirements. 3

• No specific diet type (low-carb, Mediterranean, ketogenic) has proven superior; prioritize patient preferences and cultural needs while maintaining nutritional balance 1, 4
• Focus on low glycemic index foods, high-fiber intake, omega-3 fatty acids, and anti-inflammatory foods to improve insulin sensitivity 4
• Avoid unduly restrictive or nutritionally unbalanced diets that may trigger disordered eating patterns 2
• For lean women with PCOS, emphasize diet quality over caloric restriction 1

Exercise Prescription

Prescribe at least 150 minutes/week of moderate-intensity activity OR 75 minutes/week of vigorous-intensity activity for weight maintenance and health. 1

• For weight loss and greater metabolic benefit, increase to at least 250 minutes/week of moderate-intensity OR 150 minutes/week of vigorous-intensity activity 3
• Include muscle-strengthening activities on 2 non-consecutive days per week 1
• Both aerobic exercise (brisk walking, cycling 8-15 km/h, low-impact aerobics) and resistance training improve insulin sensitivity and metabolic outcomes 3, 5
• Structure activity in at least 10-minute bouts, aiming for 30 minutes daily on most days 1
• Exercise improves ovulation and reduces insulin resistance by 9-30% independent of weight loss 5

Behavioral Strategies (Mandatory Component)

Implement comprehensive behavioral or cognitive behavioral interventions simultaneously with diet and exercise, as mental health issues directly undermine adherence. 2

• Use SMART goal setting (specific, measurable, achievable, realistic, timely) with self-monitoring 1, 3
• Include stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 1
• Address psychological barriers before initiating aggressive lifestyle interventions—starting treatment without managing underlying anxiety, depression, or eating disorders leads to treatment failure 2
• Ensure all interactions are respectful, patient-centered, and avoid weight-related stigma 2

Realistic Goals and Monitoring

• Target 5-10% weight loss in patients with excess weight—this achievable goal yields significant clinical improvements within 6 months 3
• Monitor weight and waist circumference regularly during the first 12 months 2, 3
• Healthy lifestyle contributes to health and quality of life benefits even without weight loss 1, 3
• Continued contact after initial treatment improves long-term weight maintenance 2

Medical Management for Specific Indications

For Menstrual Irregularity and Hyperandrogenism

• Combined oral contraceptives (COCs) regulate menstrual cycles and manage hirsutism/acne 6
• Progesterone therapy prevents endometrial hyperplasia in women not desiring pregnancy 6
• Combined antiandrogen plus ovarian suppression may be most effective for hirsutism 1

For Fertility (Ovulation Induction)

Clomiphene citrate is first-line ovulation induction therapy, with approximately 80% of women ovulating and 50% of those conceiving. 1, 7

• Start clomiphene on day 5 of the cycle after confirming no pregnancy, no ovarian cysts (except polycystic ovaries), normal liver function, and adequate estrogen levels 7
• Use the lowest effective dose in PCOS patients, as they may have exaggerated responses to usual doses due to gonadotropin sensitivity 7
• Limit to 6 total cycles (including 3 ovulatory cycles) 7
• Monitor for ovarian hyperstimulation syndrome (OHSS): abdominal pain/distention, nausea, vomiting, weight gain—this can progress rapidly and become life-threatening 7

For Insulin Resistance and Metabolic Risk

• Metformin or thiazolidinediones improve insulin sensitivity and may reduce diabetes and cardiovascular disease risk 1
• These agents benefit both lean and overweight women since insulin resistance is present regardless of BMI 1

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
• Do not initiate aggressive lifestyle changes without first addressing mental health conditions (anxiety, depression, eating disorders), as this guarantees poor adherence 2
• Avoid weight-focused language that increases stigma; frame discussions around health improvements and metabolic benefits 2
• Do not delay evidence-based treatment while pursuing unproven complementary therapies like evening primrose oil or herbal supplements 1
• Perform pelvic examination before each clomiphene course to detect ovarian enlargement 7
• If visual symptoms occur during clomiphene therapy (blurring, scotomata, phosphenes), discontinue immediately and obtain ophthalmologic evaluation 7

Special Population Considerations

• Ethnic groups at high cardiometabolic risk (Asian, Hispanic, South Asian) require lower BMI/waist circumference thresholds and greater consideration for intensive lifestyle intervention 1, 3
• Women with PCOS experience greater weight gain over time than unaffected women, making early intervention crucial 3
• Screen for sleep apnea, as it occurs more commonly in PCOS 6
• Evaluate for nonalcoholic fatty liver disease, dyslipidemia, hypertension, and diabetes risk 6