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

PCOD Management

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 and requires management through these evidence-based approaches. 1

Initial Assessment and Psychological Screening

Screen every PCOS patient for anxiety, depression, body image concerns, and disordered eating at initial presentation and throughout treatment, as these psychological factors directly impair adherence to all therapies. 2

• 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
• Address psychological barriers before initiating aggressive lifestyle interventions, as untreated mental health conditions lead to treatment failure 2
• Ensure all interactions are respectful, patient-centered, and avoid weight-related stigma 2

Dietary Management

Aim for an energy deficit of 500-750 kcal/day (total intake 1,200-1,500 kcal/day) for weight loss, but no specific diet type is superior—choose based on patient preferences and cultural needs. 1, 3

• Follow general healthy eating principles across the life course 1
• Consider low glycemic index foods, high-fiber diets, omega-3 fatty acids, Mediterranean diet, or anti-inflammatory approaches 4
• Avoid unduly restrictive or nutritionally unbalanced diets that may trigger disordered eating 1, 2
• Set achievable weight loss goals of 5-10% in those with excess weight, as this yields significant clinical improvements 1, 3

Exercise Prescription

Prescribe at least 150 minutes/week of moderate-intensity activity OR 75 minutes/week of vigorous-intensity activity for weight maintenance; increase to 250 minutes/week moderate OR 150 minutes/week vigorous for weight loss. 1, 3

• Include muscle-strengthening activities on 2 non-consecutive days per week 1
• Perform activity in at least 10-minute bouts, aiming for 30 minutes daily on most days 1
• Both aerobic exercise (brisk walking, cycling 8-15 km/h, low-impact aerobics, yoga) and resistance training improve insulin sensitivity and metabolic outcomes 3, 5
• Exercise benefits occur independently of significant weight loss 1, 5
• Minimize sedentary, screen, and sitting time 1

Behavioral Strategies

Implement SMART goal setting (specific, measurable, achievable, realistic, timely) with self-monitoring to enable realistic lifestyle goals. 1, 3

• Include 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, retention, and adherence 2
• Provide ongoing assessment and monitoring during weight loss and maintenance phases, with regular review for the first 12 months 2
• Continued contact after initial treatment improves weight-loss maintenance 2

Medical Management

Combined oral contraceptives regulate menstrual cycles and manage hyperandrogenism, while metformin or thiazolidinediones improve insulin sensitivity and reduce diabetes/cardiovascular risk. 1, 6

• For fertility: clomiphene citrate is first-line ovulation induction (80% ovulation rate, 50% conception rate among ovulators) 1
• For hirsutism: combined antiandrogen plus ovarian suppression agent is most effective 1
• Menstrual cycle control prevents endometrial hyperplasia through hormonal contraception, progesterone therapy, or weight loss 6

Monitoring and Follow-Up

• Regular monitoring of weight and waist circumference is essential 1, 3
• Healthy lifestyle contributes to health and quality of life benefits even without weight loss 1, 3
• Ethnic groups at high cardiometabolic risk require greater consideration for lifestyle intervention 1, 3
• Screen for sleep apnea, as it occurs more commonly in PCOS 6
• Evaluate metabolic complications including diabetes risk, dyslipidemia, hypertension, and nonalcoholic fatty liver disease 6

Critical Pitfalls to Avoid

• Never dismiss lifestyle intervention in lean PCOS patients—insulin resistance requires management regardless of BMI 1
• Do not initiate aggressive lifestyle changes without first addressing underlying anxiety, depression, or eating disorders 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