From the Guidelines
Polycystic ovary syndrome (PCOS) treatment should prioritize lifestyle modifications, including a 5-10% weight loss through a balanced diet and regular exercise, as the foundation of treatment, as evidenced by the most recent study in 2024 1.
Treatment Overview
PCOS is a chronic condition that affects multiple body systems through insulin resistance and hormonal disruption. The primary goal of treatment is to manage symptoms and address underlying hormonal imbalances.
Lifestyle Modifications
Lifestyle modifications form the foundation of treatment, including weight loss of 5-10% of body weight through a balanced diet and regular exercise (150 minutes weekly of moderate activity), which can significantly improve symptoms and restore ovulation.
Medications
Medications commonly prescribed include:
- Combined hormonal contraceptives (like Yasmin or Diane-35) to regulate periods and reduce excess hair growth
- Metformin (500-2000mg daily) to improve insulin sensitivity
- Anti-androgens such as spironolactone (50-200mg daily) for hirsutism and acne
- Clomiphene citrate or letrozole for women seeking pregnancy
Additional Treatments
For specific symptoms, additional treatments include:
- Topical eflornithine for facial hair
- Inositol supplements (2-4g daily) which may help with metabolic and reproductive aspects of PCOS
Individualized Treatment
Treatment should be individualized based on symptoms, whether fertility is desired, and metabolic risk factors, as recommended by the American College of Obstetricians and Gynecologists (ACOG) in 2003 1.
Bariatric Surgery
Bariatric surgery is emerging as a potential adjunct therapy for PCOS for patients with excess weight, as it has been shown to improve anthropometric, reproductive, hormonal, and metabolic outcomes among women with PCOS, according to a systematic review and meta-analysis in 2024 1.
Key Considerations
PCOS is a complex condition that requires ongoing management, and treatment should prioritize the individual's specific needs and symptoms. With proper treatment, most symptoms can be effectively controlled, and quality of life can be significantly improved.
From the FDA Drug Label
Clomiphene citrate is indicated for the treatment of ovulatory dysfunction in women desiring pregnancy. Those patients most likely to achieve success with clomiphene therapy include patients with polycystic ovary syndrome (see WARNINGS: Ovarian Hyperstimulation Syndrome)
PCOS Treatment: Clomiphene citrate is indicated for the treatment of ovulatory dysfunction in women with polycystic ovary syndrome (PCOS) who desire pregnancy.
- The treatment should be started on or about the 5th day of the cycle, and each course of clomiphene citrate should not exceed six cycles (including three ovulatory cycles) 2.
- Patients with PCOS should be started on the lowest recommended dose and shortest treatment duration for the first course of therapy to minimize the risk of ovarian hyperstimulation syndrome (OHSS) 2.
From the Research
PCOS Treatment Options
- Lifestyle modifications, such as dietary changes and physical activity, are suggested as first-line interventions in managing PCOS 3, 4
- Dietary interventions, including foods with low glycemic index scores, caloric restrictions, and high-fiber diets, can improve insulin sensitivity and hormonal balance in women with PCOS 3
- Physical activity, such as aerobic and resistance exercise, can enhance insulin sensitivity, help with weight loss, and improve metabolic and reproductive outcomes in women with PCOS 3
Medical Treatment Options
- Gonadotropins, such as follicle-stimulating hormone (FSH), can be used as a second-line treatment for ovulation induction in women with PCOS who do not ovulate or conceive on clomiphene citrate or letrozole 5
- Recombinant FSH (rFSH) may have little or no difference in birth rate compared to urinary-derived gonadotropins, but may result in more clinical pregnancies and miscarriages 5
- Letrozole, an aromatase inhibitor, can induce ovulation without anti-estrogenic effects and may be more effective than clomiphene citrate in achieving full-term pregnancies in clomiphene-resistant PCOS patients 6
Combination Therapies
- Combining metformin with letrozole or clomiphene citrate may be more effective than using either medication alone, depending on the patient's BMI and CC sensitivity 6, 7
- Clomiphene citrate and metformin are both effective for increasing ovulation and pregnancy rates in PCOS patients, but CC is more effective than metformin for ovulation, pregnancy, and live-birth rates in patients with BMI >30 7