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

Treatment Options for Polycystic Ovary Syndrome (PCOS)

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 requires management even in normal-weight patients. 1, 2

First-Line Treatment: Lifestyle Intervention

Dietary Management

• Implement an energy deficit of 500-750 kcal/day (targeting 1,200-1,500 kcal/day total) for women with excess weight, adjusting based on individual energy requirements and physical activity levels 1, 3
• No specific diet type (low-carb, Mediterranean, ketogenic) has proven superior to others; select based on patient preferences and cultural needs while maintaining nutritional balance 1, 4
• Follow general healthy eating principles: 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 compromise long-term adherence 1

Exercise Prescription

• Prescribe at least 150 minutes per week of moderate-intensity physical activity OR 75 minutes per week of vigorous-intensity activity for prevention of weight gain and health maintenance 1, 2
• For weight loss and greater metabolic benefits, increase to at least 250 minutes per week of moderate-intensity OR 150 minutes per week of vigorous-intensity activity 1, 3
• Include muscle-strengthening activities on 2 non-consecutive days per week 1, 2
• Perform activity in at least 10-minute bouts, aiming for at least 30 minutes daily on most days 1
• Both aerobic exercise (brisk walking, cycling 8-15 km/h, low-impact aerobics) and resistance training improve insulin sensitivity and metabolic outcomes 3, 4
• Minimize sedentary, screen, and sitting time 1

Behavioral Strategies

• Implement SMART goal setting (specific, measurable, achievable, realistic, timely) with self-monitoring to enable achievement of realistic lifestyle goals 1, 3, 2
• 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 and adherence 1
• Address psychological factors including anxiety, depression, body image concerns, and disordered eating, as these require active management to optimize engagement with treatment 1, 5

Weight Loss Targets and Monitoring

• Target 5-10% weight loss in women with excess weight, as this yields significant clinical improvements in metabolic, reproductive, and hormonal outcomes within 6 months 1, 3, 2
• Weight loss as little as 5% of total body weight improves testosterone levels, hirsutism, waist circumference, waist-hip ratio, and fasting insulin 6
• Regular monitoring of weight and waist circumference is essential during weight loss and maintenance 1, 3
• Use ethnic-specific BMI and waist circumference categories for populations at high cardiometabolic risk (Asian, Hispanic, South Asian populations require lower thresholds) 1, 3

Medical Management Options

For Menstrual Irregularity and Hyperandrogenism

• Combined oral contraceptives (COCs) regulate menstrual cycles and treat hyperandrogenism in women not attempting conception 2, 5
• Progesterone therapy prevents endometrial hyperplasia in women with chronic anovulation 7, 5
• Combined medical interventions (antiandrogen plus ovarian suppression agent) are most effective for hirsutism 1, 5
• Topical agents, electrolysis, and laser therapy provide more permanent hair reduction 5

For Insulin Resistance and Metabolic Features

• Metformin should be considered for women with PCOS who have cardiometabolic features such as abdominal obesity and insulin resistance 2
• Interventions that improve insulin sensitivity (metformin or thiazolidinediones) may positively impact risk factors for diabetes and cardiovascular disease 1, 7

For Infertility

• Clomiphene citrate is first-line ovulation induction, with approximately 80% of women ovulating and half of those conceiving 1, 7
• Alternative ovulation induction options include tamoxifen, aromatase inhibitors, metformin, glucocorticoids, or gonadotropins 7
• Laparoscopic ovarian drilling is a surgical option for ovulation induction 7
• In vitro fertilization remains the last option when other treatments fail 7

Critical Pitfalls to Avoid

• Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance is present irrespective of BMI and requires management through diet, exercise, and behavioral strategies even in normal-weight women 1, 2
• Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma that can negatively impact engagement with treatment 1, 3
• Do not delay evidence-based treatment while pursuing unproven complementary therapies such as evening primrose oil or other herbal supplements, which are not supported by international evidence-based guidelines 1

Metabolic Screening and Long-Term Management

• Screen for diabetes risk, dyslipidemia, hypertension, and nonalcoholic fatty liver disease 5
• Screen for sleep apnea, which occurs more commonly in women with PCOS 5
• Investigate and treat chronic anovulation to prevent endometrial hyperplasia and carcinoma 7, 5
• Recognize that 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 3

Benefits Beyond Weight Loss

• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1, 3, 2
• Exercise improves insulin sensitivity in the short term with benefits occurring independently of significant weight loss 1
• Lifestyle interventions improve reproductive, metabolic, anthropometric, and psychological outcomes collectively 6, 4