How to manage a patient with Polycystic Ovary Syndrome (PCOS)?

Management of Polycystic Ovary Syndrome (PCOS)

First-Line Treatment: Multicomponent Lifestyle Intervention for ALL Patients

Lifestyle modification including diet, exercise, and behavioral strategies is the mandatory first-line treatment for every PCOS patient, regardless of body weight or BMI, because insulin resistance is present in all women with PCOS and drives the pathophysiology of hyperandrogenism through effects on the pituitary, liver, and ovaries. 1, 2

Critical Understanding to Avoid Common Pitfalls

• Do not dismiss lifestyle intervention in lean or normal-weight PCOS patients—insulin resistance affects both lean and overweight women with PCOS irrespective of BMI and requires active management through diet, exercise, and behavioral strategies even when weight loss is not needed 1, 2
• Hyperinsulinemia resulting from insulin resistance contributes to hyperandrogenism and worsens all PCOS symptoms, creating a metabolic vicious cycle that must be broken with lifestyle intervention 1, 2

Dietary Management Algorithm

For Patients with Overweight or Obesity:

• Prescribe an energy deficit of 500-750 kcal/day (targeting 1,200-1,500 kcal/day total) to achieve weight loss, adjusting for individual energy requirements, body weight, and physical activity levels 1, 3, 2
• Set achievable weight loss goals of 5-10% body weight within 6 months, as this yields significant clinical improvements in metabolic and reproductive abnormalities 3, 2
• No specific diet type has proven superior; choose based on patient preferences and cultural needs while maintaining nutritional balance 1, 3

For All Patients (Including Normal Weight):

• Emphasize diet quality over caloric restriction for lean women, focusing on low glycemic index foods, high-fiber diets, omega-3 fatty acid-rich diets, Mediterranean diets, and anti-inflammatory diets to improve insulin sensitivity and hormonal balance 1, 4
• Follow general healthy eating principles across the life course and avoid unduly restrictive or nutritionally unbalanced diets 1
• Use ethnic-specific BMI and waist circumference categories when optimizing dietary interventions, as Asian, Hispanic, and South Asian populations require lower thresholds for cardiometabolic risk assessment 1

Exercise Prescription

Minimum Requirements for All Patients:

• 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, 3, 2
• Include muscle-strengthening activities on 2 non-consecutive days per week 1, 2
• Activity should be performed in bouts of at least 10 minutes or around 1,000 steps, aiming for at least 30 minutes daily on most days 1

For Weight Loss and Greater Metabolic Benefits:

• Increase to 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 exercise improve insulin sensitivity and metabolic outcomes in PCOS, with benefits occurring independently of significant weight loss 1, 4
• Minimize sedentary, screen, and 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, 3, 2
• Include behavioral strategies: goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 1, 3, 2
• Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence to lifestyle changes 1
• Address psychological factors including 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 treatment engagement 1, 3

Medical Management

For Menstrual Irregularity and Hyperandrogenism (Not Seeking Pregnancy):

• Combined oral contraceptives are the preferred therapy for menstrual cycle regulation and hyperandrogenism in women not attempting conception 2
• Combined medical interventions (antiandrogen plus ovarian suppression agent) may be the most effective treatment approach for hirsutism 1

For Cardiometabolic Features:

• Consider metformin for women with PCOS who have cardiometabolic features such as abdominal obesity and insulin resistance, as interventions that improve insulin sensitivity may have positive impact on risk factors for diabetes and cardiovascular disease 1, 2

For Infertility and Ovulation Induction:

• Letrozole (an aromatase inhibitor) appears more successful than clomiphene citrate for treating infertility caused by PCOS 5
• Clomiphene citrate is FDA-indicated for ovulatory dysfunction in women with PCOS desiring pregnancy, with approximately 80% of women ovulating and half of those conceiving 1, 6
• Start clomiphene citrate at 50 mg daily for 5 days, beginning on or about the 5th day of the cycle 6
• A low dosage or duration is particularly recommended if unusual sensitivity to pituitary gonadotropin is suspected in patients with PCOS due to risk of ovarian hyperstimulation syndrome 6
• If ovulation does not occur after the first course, increase to 100 mg daily for 5 days; increasing beyond this is not recommended 6
• Discontinue clomiphene citrate if ovulation does not occur after three courses of therapy, or if three ovulatory responses occur without pregnancy 6
• Long-term cyclic therapy is not recommended beyond a total of about six cycles (including three ovulatory cycles) 6

Critical Safety Considerations for Clomiphene Citrate:

• Patients with any visual symptoms (blurring, scotomata, phosphenes) must discontinue treatment immediately and undergo complete ophthalmological evaluation 6
• Monitor for ovarian hyperstimulation syndrome (OHSS), which can progress rapidly and become serious, with signs including abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain 6
• Patients with PCOS who are unusually sensitive to gonadotropin may have exaggerated response to usual doses, requiring the lowest recommended dose and shortest treatment duration for the first course 6
• If ovarian enlargement occurs, do not give additional clomiphene citrate until ovaries return to pretreatment size 6

Monitoring and Follow-Up

• Regularly monitor weight and waist circumference during treatment and maintenance phases 1, 3
• Recognize that healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1, 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 3
• Time coitus to coincide with expected ovulation (5-10 days after clomiphene citrate course); use basal body temperature graphs or other appropriate tests to determine if ovulation occurred 6