What is the treatment for Polycystic Ovary Syndrome (PCOS)?

Treatment of 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 drives the core pathophysiology of the syndrome. 1, 2

Why Lifestyle Intervention Works for All PCOS Patients

Insulin resistance is present in PCOS irrespective of BMI and affects both lean and overweight women, contributing to hyperandrogenism through effects on the pituitary, liver, and ovaries. 1, 2 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 (approximately 1,200-1,500 kcal/day total), considering individual energy requirements, body weight, and physical activity levels. 1, 2
• Aim for 5-10% weight loss, as this yields significant clinical improvements in metabolic and reproductive abnormalities. 2, 3

For All Women (Including Normal Weight)

• No specific diet type has proven superior; focus on balanced dietary approaches that match individual preferences and cultural needs while maintaining nutritional balance. 1, 3
• Follow general healthy eating principles across the life course. 1
• Avoid unduly restrictive or nutritionally unbalanced diets. 1

Evidence on Specific Diets

The evidence shows that regardless of diet type (high protein vs. high carbohydrate, DASH diet vs. control), the overall finding is that any diet aimed at reducing weight benefits women with PCOS. 4 Recent research supports low glycemic index foods, high-fiber diets, omega-3 fatty acid-rich diets, ketogenic diets, Mediterranean diets, and anti-inflammatory diets for improving insulin sensitivity and hormonal balance. 5

Exercise Prescription

Minimum Requirements for Health Maintenance

• Prescribe at least 150 minutes/week of moderate-intensity physical activity OR 75 minutes/week of vigorous-intensity activity (or equivalent combination). 1, 2
• Include muscle-strengthening activities on 2 non-consecutive days per week. 1, 2
• 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

• Recommend at least 250 minutes/week of moderate-intensity activities OR 150 minutes/week of vigorous-intensity activity (or equivalent combination). 1, 3
• Both aerobic and resistance exercises improve insulin sensitivity and metabolic outcomes in PCOS. 1, 3
• Minimize sedentary, screen, or sitting time. 1

Specific Exercise Examples

• Moderate-intensity activities: brisk walking, cycling (8-15 km/h), low-impact aerobics, yoga. 3
• Vigorous-intensity activities: jogging/running, high-impact aerobics, competitive sports. 3

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
• 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, 2 Address psychological factors such as anxiety, depression, body image concerns, and disordered eating, as these require active management to optimize engagement with treatment. 1, 2

Medical Management

For Menstrual Cycle Regulation and Hyperandrogenism

• Combined oral contraceptives (COCs) are recommended for menstrual cycle regulation and hyperandrogenism in women not attempting conception. 2
• Menstrual cycle control is necessary to prevent endometrial hyperplasia. 6

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, including metformin or a thiazolidinedione, may have a positive impact on risk factors for diabetes and cardiovascular disease. 1

For Fertility Treatment

• Clomiphene citrate is recommended as first-line ovulation induction, with about 80% of women ovulating and half of those conceiving. 1
• Commonly used ovulation induction therapies include weight loss, clomiphene citrate, and/or metformin. 6

Critical caveat: Patients with polycystic ovary syndrome who are unusually sensitive to gonadotropin may have an exaggerated response to usual doses of clomiphene citrate and should be started on the lowest recommended dose and shortest treatment duration for the first course of therapy. 7 Visual symptoms during clomiphene citrate therapy require immediate discontinuation and complete ophthalmological evaluation. 7

For Hirsutism

• Combined medical interventions, such as an antiandrogen and an ovarian suppression agent, may be the most effective treatment approach to hirsutism. 1
• Treatment options include estrogen-containing hormonal contraceptive agents, antiandrogens, and topical agents. 6

Monitoring and Follow-Up

• Regular monitoring of weight and waist circumference is essential during weight loss and maintenance. 1, 3
• Calculate BMI and measure waist circumference to assess central obesity, using ethnic-specific cutoffs for populations at high cardiometabolic risk (Asian, Hispanic, South Asian populations require lower thresholds). 1
• Evaluate metabolic complications including risk assessment for diabetes, dyslipidemia, hypertension, and nonalcoholic fatty liver disease. 6
• Screen for sleep apnea, as this occurs more commonly in women with PCOS. 6

Special Considerations

Ethnic and Cultural Factors

• Use ethnic-specific BMI and waist circumference categories when optimizing lifestyle and weight. 1, 3
• Ethnic groups with PCOS who are at high cardiometabolic risk require greater consideration for lifestyle intervention. 1, 3
• Ensure health professional interactions are respectful, patient-centered, and considerate of individual preferences and cultural differences. 1

Benefits Beyond Weight Loss

• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss. 1, 3
• Exercise improves insulin sensitivity in PCOS with benefits occurring independently of significant weight loss. 1

Common Pitfalls to Avoid

• Do not delay lifestyle intervention in normal-weight PCOS patients—insulin resistance requires management regardless of BMI. 1, 2
• Avoid weight-related stigma in health professional interactions, as this negatively impacts engagement with treatment. 1, 3
• Do not pursue unproven complementary therapies (such as evening primrose oil or other herbal supplements) as primary therapy while delaying evidence-based treatment. 1
• Recognize that weight gain over time is significantly greater in women with PCOS than in unaffected women, making early intervention crucial. 3