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

PCOS Treatment

Multicomponent lifestyle intervention—combining diet, exercise, and behavioral strategies—is the first-line treatment for all women with PCOS, regardless of body weight, because insulin resistance affects both lean and overweight women and drives the core pathophysiology of this condition. 1, 2, 3

Why Lifestyle Intervention Works for All PCOS Patients

Insulin resistance is present in PCOS irrespective of BMI and contributes to hyperandrogenism through effects on the pituitary, liver, and ovaries in all women with PCOS, regardless of weight. 1, 3 This is a critical concept: do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight. 1

Dietary Management

For Women with Excess Weight

• Target an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day), considering individual energy requirements, body weight, and physical activity levels. 1, 2, 3
• Aim for 5-10% weight loss, as this yields significant clinical improvements in metabolic and reproductive abnormalities within 6 months. 2, 3

For All Women (Including Normal Weight)

• No specific diet type has proven superior; focus on individual preferences and cultural needs while maintaining nutritional balance. 1, 2
• Avoid unduly restrictive or nutritionally unbalanced diets. 1
• Foods with low glycemic index, high-fiber content, omega-3 fatty acids, Mediterranean diet patterns, and anti-inflammatory diets improve insulin sensitivity and hormonal balance. 4
• For thin women with PCOS, focus on diet quality rather than caloric restriction. 1

Ethnic Considerations

Use ethnic-specific BMI and waist circumference categories when optimizing lifestyle interventions, as Asian, Hispanic, and South Asian populations require lower thresholds for cardiometabolic risk assessment. 1, 2

Exercise Prescription

Minimum Requirements for Health Maintenance

• Prescribe at least 150 minutes/week of moderate-intensity physical activity (brisk walking, cycling 8-15 km/h, low-impact aerobics, yoga) OR 75 minutes/week of vigorous-intensity activity (jogging/running, high-impact aerobics, competitive sports) or equivalent combination. 1, 2, 3
• Include muscle-strengthening activities on 2 non-consecutive days per week. 1, 3
• Activity should be performed in at least 10-minute bouts or around 1,000 steps, aiming for at least 30 minutes daily on most days. 1

For Weight Loss and Greater Health Benefits

• Increase to at least 250 minutes/week of moderate-intensity activities OR 150 minutes/week of vigorous-intensity activity or equivalent combination. 1, 2
• Both aerobic and resistance exercise improve insulin sensitivity and metabolic outcomes in PCOS, with benefits occurring independently of significant weight loss. 1, 2

Key Point

Minimize sedentary, screen, or sitting time. 1

Behavioral Strategies

Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring to enable achievement of realistic lifestyle goals. 1, 2, 3

Include these specific behavioral strategies:

• Goal-setting and self-monitoring 1, 2, 3
• Stimulus control 1, 2
• Problem-solving 1, 2
• Assertiveness training 1, 2
• Slower eating 1, 2
• Reinforcing changes 1, 2
• Relapse prevention 1, 2

Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence. 1

Psychological Management

Address psychological factors such as anxiety, depression, body image concerns, and disordered eating, as these require active management to optimize engagement with treatment. 1 Ensure health professional interactions are respectful, patient-centered, and avoid weight-related stigma, which can negatively impact engagement. 1, 2

Medical Management

For Menstrual Irregularity and Hyperandrogenism (Not Seeking Pregnancy)

• Combined oral contraceptives are recommended for menstrual cycle regulation and hyperandrogenism. 3
• With severe hyperandrogenism, a pure antiandrogen should be added. 5

For Metabolic Management

• Metformin should be considered for women with PCOS who have cardiometabolic features such as abdominal obesity and insulin resistance. 3
• Interventions that improve insulin sensitivity, including metformin or a thiazolidinedione, may have a positive impact on risk factors for diabetes and cardiovascular disease. 1

For Fertility Treatment

• Letrozole (an aromatase inhibitor) appears to be more successful than clomiphene citrate for treating infertility caused by PCOS. 6
• Clomiphene citrate is recommended as first-line ovulation induction when letrozole is not available, with about 80% of women ovulating and half of those conceiving. 1

Critical Pitfalls and Caveats

Clomiphene Citrate Safety

If using clomiphene citrate, patients with any visual symptoms (blurring, scotomata, phosphenes) should discontinue treatment immediately and have a complete ophthalmological evaluation. 7 The ovarian hyperstimulation syndrome (OHSS) can progress rapidly (within 24 hours to several days) and become a serious medical disorder; early warning signs include abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain. 7

Ovarian Enlargement Management

Patients with polycystic ovary syndrome who are unusually sensitive to gonadotropin may have an exaggerated response to usual doses of clomiphene citrate; therefore, start on the lowest recommended dose and shortest treatment duration for the first course of therapy. 7 If ovarian enlargement occurs, do not give additional clomiphene citrate therapy until the ovaries have returned to pretreatment size. 7

Avoid Unproven Therapies

Do not recommend evening primrose oil or other herbal supplements as part of standard management, as these are not supported by international evidence-based guidelines. 1 Patients should not delay evidence-based treatment while pursuing unproven complementary therapies. 1

Monitoring and Follow-Up

• Regular monitoring of weight and waist circumference is essential during weight loss and maintenance. 1, 2
• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss. 1, 2, 3
• Weight gain over time is significantly greater in women with PCOS than in unaffected women, with progressive increase in waist-to-hip ratio between ages 20-45 years, making early intervention crucial. 2