What are the guidelines for managing Polycystic Ovary Syndrome (PCOS)?

PCOS Management Guidelines

First-Line Treatment: Multicomponent Lifestyle Intervention

All women with PCOS, regardless of body weight, should receive multicomponent lifestyle intervention as first-line management, combining dietary modification, structured physical activity, and behavioral strategies, because insulin resistance affects all PCOS patients independent of BMI. 1, 2

Dietary Management

• Create an energy deficit of 500-750 kcal/day, targeting 1,200-1,500 kcal/day total intake for overweight or obese patients, adjusted to individual energy requirements and physical activity levels. 3, 2, 4

• Focus on diet quality rather than strict caloric restriction, emphasizing low glycemic index foods, high-fiber intake, and omega-3 fatty acids to improve insulin sensitivity and hormonal balance. 3, 2, 5

• No specific diet type (Mediterranean, ketogenic, anti-inflammatory) has proven superior—select based on patient preferences and cultural needs while maintaining nutritional balance. 2, 4, 5

• Avoid unduly restrictive or nutritionally unbalanced diets, as these reduce adherence and may worsen metabolic outcomes. 2

Physical Activity Prescription

• Prescribe at least 150 minutes/week of moderate-intensity exercise (brisk walking, cycling 8-15 km/h, low-impact aerobics) OR 75 minutes/week of vigorous-intensity activity (jogging, high-impact aerobics, competitive sports), performed in at least 10-minute bouts. 1, 2, 4

• For weight loss and greater metabolic benefits, increase to at least 250 minutes/week of moderate-intensity OR 150 minutes/week of vigorous-intensity activity. 2, 4

• Include muscle-strengthening activities involving major muscle groups on 2 non-consecutive days per week. 1, 2

• Target 10,000 steps daily, including 30 minutes (approximately 3,000 steps) of structured physical activity, considering women's family routines and cultural preferences. 1

• Both aerobic and resistance exercise improve insulin sensitivity and metabolic outcomes in PCOS, with benefits occurring independently of significant weight loss. 2, 4, 5

• Minimize sedentary, screen, and sitting time throughout the day. 1, 2

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting with self-monitoring using fitness tracking devices for step count and exercise intensity. 1, 3, 2, 4

• Include behavioral change techniques: goal-setting, stimulus control, problem-solving, assertiveness training, slowing the rate of eating, reinforcing changes, and relapse prevention. 1, 3, 2, 4

• Start with realistic 10-minute activity bouts, progressively increasing physical activity by 5% weekly up to and above recommendations. 1, 3

• Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence, as these techniques combined with diet and exercise increase weight loss over diet or physical activity alone. 1, 2

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

Weight Management and Monitoring

• Target 5-10% weight loss within 6 months for overweight or obese patients, as even modest weight loss yields significant clinical improvements in menstrual regularity, metabolic parameters, and reproductive outcomes. 3, 2, 4

• Monitor weight and waist circumference regularly using ethnic-specific cutoffs (lower thresholds for Asian, Hispanic, and South Asian populations who are at higher cardiometabolic risk). 3, 2, 4

• Conduct weight assessment respectfully and considerately, explaining the purpose beforehand, seeking permission, and providing support if results impact emotional well-being. 1

• Recognize that weight gain accelerates over time in PCOS (significantly greater than unaffected women), with progressive increase in waist-to-hip ratio between ages 20-45 years, making early intervention crucial. 3, 4

• Healthy lifestyle contributes to quality of life benefits even without weight loss, particularly regarding insulin sensitivity and hormonal balance. 2, 4

Medical Management for Specific Symptoms

Menstrual Irregularity and Fertility

• For patients seeking pregnancy, start with clomiphene citrate 50 mg daily for 5 days starting on cycle day 3-5, which achieves 80% ovulation rate with 50% of those conceiving. 3, 6, 7

• If clomiphene fails after 3-6 cycles, use low-dose gonadotropin therapy rather than high-dose to induce monofollicular development with lower risk of ovarian hyperstimulation syndrome (OHSS). 3

• Patients with PCOS are unusually sensitive to gonadotropins and should be started on the lowest recommended clomiphene dose (50 mg) and shortest treatment duration for the first course. 6

• Discontinue clomiphene immediately if visual symptoms (blurring, scotomata, phosphenes) occur, as these may progress to severe visual impairment; complete ophthalmological evaluation is required. 6

• Monitor for early warning signs of OHSS: abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain; if ovarian enlargement occurs, withhold additional clomiphene until ovaries return to pretreatment size. 6

Insulin Resistance Management

• Metformin and thiazolidinediones improve ovulation frequency and may positively impact diabetes and cardiovascular risk factors, though lifestyle modification remains first-line. 3, 7

• Insulin resistance is present irrespective of BMI and affects both lean and overweight women with PCOS, contributing to hyperandrogenism through effects on the pituitary, liver, and ovaries. 2

Critical Pitfalls to Avoid

• Do not dismiss lifestyle intervention in normal-weight PCOS patients simply because they have normal BMI—insulin resistance requires management through diet, exercise, and behavioral strategies regardless of weight. 3, 2

• Do not recommend herbal supplements (including evening primrose oil) as primary therapy instead of evidence-based interventions, as international guidelines do not support these as standard management. 2

• Do not delay evidence-based treatment while pursuing unproven complementary therapies. 2

• Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma which negatively impacts treatment engagement. 1, 2, 4

• Do not perform aggressive abdominal or pelvic examination in patients with suspected ovarian enlargement, as enlarged ovaries are fragile and prone to torsion or hemorrhage. 6

Special Population Considerations

• Prevention of weight gain and monitoring should begin from adolescence, with encouragement of evidence-based and socio-culturally appropriate healthy lifestyle. 1

• Ethnic groups with PCOS at high cardiometabolic risk (Asian, Hispanic, South Asian) require greater consideration for lifestyle intervention with lower BMI and waist circumference thresholds. 2, 4

• Family support improves outcomes; structure recommended activities considering women's and family routines as well as cultural preferences. 1