What are the treatment options for Polycystic Ovary Syndrome (PCOS)?

Treatment Options for Polycystic Ovary Syndrome (PCOS)

Lifestyle modification targeting 5-10% weight loss through diet and exercise is the foundational 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 dietary changes, physical activity, and behavioral strategies. 1, 2

Treatment Algorithm Based on Primary Goals

For Women NOT Attempting Pregnancy

Combined oral contraceptives are first-line pharmacological treatment, as they suppress ovarian androgen secretion and increase sex hormone binding globulin, effectively managing menstrual irregularities, hirsutism, and acne. 1

• Start with lifestyle modification first, then add hormonal contraceptives if symptoms persist 1
• COCs address hyperandrogenism, menstrual cycle regulation, and reduce endometrial cancer risk 1, 3

For Women Attempting Pregnancy

Clomiphene citrate is the first-line pharmacological treatment for ovulation induction, with approximately 80% of patients ovulating and half of those who ovulate conceiving. 1, 4, 5

• Begin with lifestyle modification and achieve 5% weight loss before starting clomiphene, as this significantly improves ovulation and pregnancy rates 4
• Start clomiphene on day 5 of the cycle; limit to 6 total cycles (including 3 ovulatory cycles) 5
• If clomiphene fails, use low-dose gonadotropin therapy due to lower risk of ovarian hyperstimulation 1
• Critical pitfall: Women with PCOS are unusually sensitive to gonadotropins and should start with the lowest recommended dose and shortest treatment duration 5

All women attempting pregnancy require preconception counseling about increased pregnancy risks and metabolic screening (fasting glucose, 2-hour glucose tolerance test, lipid profile) before conception. 4

Core Lifestyle Intervention Components (For ALL Patients)

Dietary Approach

• Target an energy deficit of 500-750 kcal/day, with total intake of 1,200-1,500 kcal/day, adjusted for individual requirements 1, 2
• Any balanced dietary approach creating an energy deficit is acceptable—no specific diet type is superior 1, 2
• Focus on low glycemic index foods, high-fiber intake, omega-3 fatty acids, Mediterranean diet patterns, and anti-inflammatory foods 6
• Avoid overly restrictive or nutritionally unbalanced diets 2

Physical Activity Requirements

For weight maintenance and health: Perform at least 150 minutes/week of moderate-intensity activity OR 75 minutes/week of vigorous activity, plus muscle-strengthening activities on 2 non-consecutive days/week 1, 2

For weight loss and prevention of regain: Perform at least 250 minutes/week of moderate-intensity activity OR 150 minutes/week of vigorous activity, plus muscle strengthening on 2 non-consecutive days/week 1, 2

• Both aerobic and resistance exercises show benefits in PCOS, improving insulin sensitivity even without significant weight loss 2, 6
• Activity should be performed in at least 10-minute bouts, aiming for at least 30 minutes daily on most days 2

Behavioral Strategies

Incorporate goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcement of changes, and relapse prevention to optimize weight management and emotional well-being 1, 2

• Address psychological factors including anxiety, depression, body image concerns, and disordered eating, as women with PCOS have higher rates of these conditions 1, 2
• Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence 2

Metabolic Management

Metformin improves insulin sensitivity, reduces insulin levels (which decreases ovarian androgen production), improves ovulation frequency, and reduces risk factors for diabetes and cardiovascular disease. 1, 4

• Metformin is beneficial for metabolic/glycemic abnormalities and menstrual irregularities, but has limited benefit for hirsutism, acne, or infertility 3
• Metformin appears safe during pregnancy, though effects on early pregnancy outcomes are not fully established 4

Emerging option: GLP-1 agonists (semaglutide, liraglutide, exenatide) show promise for weight reduction and metabolic improvement when combined with lifestyle interventions 1

Critical Considerations for Lean/Normal-Weight PCOS Patients

Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance is present irrespective of BMI and affects both lean and overweight women, requiring management through diet, exercise, and behavioral strategies. 2

• Insulin resistance contributes to hyperandrogenism through effects on the pituitary, liver, and ovaries in all women with PCOS, regardless of weight 2
• Focus on diet quality and insulin-sensitizing foods rather than caloric restriction for thin women 2
• Use ethnic-specific BMI and waist circumference categories when optimizing lifestyle interventions 1, 2

Long-Term Monitoring Requirements

• Regular screening for metabolic abnormalities including type 2 diabetes and cardiovascular disease 1
• Mental health assessment for depression, anxiety, and eating disorders 1
• Monitor weight and waist circumference regularly; 5-10% weight loss yields significant clinical improvements 2
• For pregnant patients: Closer monitoring throughout pregnancy with regular blood pressure, kidney function, and proteinuria checks; prescribe low-dose aspirin from week 12 to week 36 to reduce preeclampsia risk 4

Common Pitfalls to Avoid

• Never exceed recommended clomiphene dosage and duration (maximum 6 cycles total) 1, 5
• Do not neglect metabolic screening even in normal-weight PCOS patients—insulin resistance affects all phenotypes 1, 2
• Avoid using clomiphene in patients with ovarian enlargement except those with polycystic ovary syndrome; perform pelvic examination before each course 5
• Watch for ovarian hyperstimulation syndrome (OHSS) in women with PCOS, who are unusually sensitive to gonadotropins—start with lowest doses 5
• Do not delay evidence-based treatment while pursuing unproven complementary therapies like evening primrose oil or herbal supplements 2
• Ethnic groups at high cardiometabolic risk (Asian, Hispanic, South Asian) require lower BMI thresholds and greater consideration for lifestyle intervention 1, 2