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

Treatment of PCOS

Multicomponent lifestyle intervention—including 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. 2, 3
• Aim for 5-10% weight loss, which 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 individual preferences and cultural needs while maintaining nutritional balance. 1, 3
• Evidence 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. 1, 4
• Avoid unduly restrictive or nutritionally unbalanced diets. 1

Exercise Prescription

Minimum Requirements

• 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, 2
• Activity should be performed in at least 10-minute bouts, aiming for at least 30 minutes daily on most days. 1

For Weight Loss and Greater Benefits

• Increase to at least 250 minutes/week of moderate-intensity activities OR 150 minutes/week of vigorous intensity or equivalent combination. 1, 3
• Both aerobic and resistance exercises improve insulin sensitivity and metabolic outcomes in PCOS. 1, 3

Additional Guidance

• Minimize sedentary, screen, or sitting time. 1
• Exercise improves insulin sensitivity even in the absence of significant weight loss. 1

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring. 1, 2, 3
• Include goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention. 1, 2, 3
• Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence. 1
• 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 Irregularity and Hyperandrogenism

• Combined oral contraceptives are recommended for menstrual cycle regulation and hyperandrogenism in women not attempting conception. 2
• Combined medical interventions, such as an antiandrogen and an ovarian suppression agent, may be the most effective treatment approach to hirsutism. 1

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
• Patients with polycystic ovary syndrome who are unusually sensitive to gonadotropin should be started on the lowest recommended dose and shortest treatment duration for the first course of therapy. 5
• Monitor for ovarian hyperstimulation syndrome (OHSS), which can progress rapidly and become a serious medical disorder; early warning signs include abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain. 5

Monitoring and Follow-Up

• Regular monitoring of weight and waist circumference is essential. 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
• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss. 1, 3

Critical Pitfalls to Avoid

• Do not delay lifestyle intervention while pursuing unproven complementary therapies (such as evening primrose oil or other herbal supplements, which are not part of evidence-based PCOS management). 1
• Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma, which can negatively impact engagement with treatment. 1, 3
• Recognize that weight gain over time is significantly greater in women with PCOS than in unaffected women, making early intervention crucial. 3