What are the guidelines for managing Polycystic Ovary Disorder (PCOD)?

PCOS Management Guidelines

First-Line Treatment: Multicomponent Lifestyle Intervention for ALL Patients

All women with PCOS, regardless of body weight or BMI, 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 weight status. 1, 2

Critical Understanding: Why Lifestyle Matters Even in Lean Women

• 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 1, 2
• Hyperinsulinemia resulting from insulin resistance worsens all PCOS symptoms, making lifestyle intervention essential even in normal-weight patients 2
• 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

• Aim for an energy deficit of 30% or 500-750 kcal/day (targeting 1,200-1,500 kcal/day), considering individual energy requirements, body weight, and physical activity levels 1, 2
• Target 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 individual preferences and cultural needs while maintaining a healthy balanced diet 1
• 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 OR 75 minutes/week of vigorous-intensity activity (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 Greater Benefits

• Recommend at least 250 minutes/week of moderate-intensity activities OR 150 minutes/week of vigorous-intensity activity for modest weight loss and greater health benefits 1
• Target 10,000 steps daily, including 30 minutes of structured physical activity 1
• Both aerobic and resistance exercises have shown benefits, with improvements in insulin resistance (9-30%) and weight loss (4.5-10%) 1, 5
• Minimize sedentary, screen, and sitting time throughout the day 1

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting with self-monitoring using fitness tracking devices 1, 2
• Include behavioral strategies: goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 1, 2
• 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

Medical Management

For Menstrual Regulation and Hyperandrogenism

• Combined oral contraceptives (COCs) are recommended as first-line pharmacological treatment for women with PCOS who are not attempting conception 2, 3
• Combined medical interventions (antiandrogen plus ovarian suppression agent) may be the most effective treatment approach for 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, 3
• Interventions that improve insulin sensitivity, including metformin or thiazolidinediones, may positively impact risk factors for diabetes and cardiovascular disease 1

For Fertility Treatment

• Clomiphene citrate is recommended as first-line ovulation induction, starting with 50 mg daily for 5 days 6
• About 80% of women ovulate with clomiphene, and half of those conceive 1
• If ovulation does not occur after the first course, increase to 100 mg daily for 5 days 6
• If ovulation does not occur after three courses of therapy, further treatment with clomiphene citrate is not recommended 6
• If three ovulatory responses occur but pregnancy has not been achieved, further treatment is not recommended 6

Critical Warnings for Clomiphene Use

• Use low dosage or short duration particularly in patients with polycystic ovary syndrome due to unusual sensitivity to pituitary gonadotropin 6
• Ovarian hyperstimulation syndrome (OHSS) can occur and may progress rapidly within 24 hours to several days, becoming a serious medical disorder 6
• Early warning signs of OHSS include abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain 6
• Visual symptoms (blurring, scotomata, phosphenes) require immediate discontinuation and complete ophthalmological evaluation 6

Monitoring and Follow-Up

Regular Assessments

• Monitor weight and waist circumference regularly, using ethnic-specific BMI and waist circumference categories 1, 3
• Calculate BMI and measure waist circumference to assess central obesity, using ethnic-specific cutoffs for Asian, Hispanic, and South Asian populations (lower thresholds required) 1, 3
• Screen for type 2 diabetes with fasting glucose followed by 75-gram oral glucose tolerance test 3
• Screen for dyslipidemia with fasting lipoprotein profile including total cholesterol, LDL, HDL, and triglycerides 3
• Monitor for improvements in menstrual regularity with successful treatment 3

Special Population Considerations

Adolescents

• Prevention of weight gain and monitoring should begin from adolescence 1
• Encourage evidence-based and socio-culturally appropriate healthy lifestyle for girls with PCOS 1

High Cardiometabolic Risk Groups

• 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 1, 3

Family and Cultural Considerations

• Family support improves outcomes; structure recommended activities considering women's and family routines as well as cultural preferences 1
• Ensure health professional interactions are respectful and patient-centered, valuing women's individualized preferences and avoiding weight-related stigma 1, 2

Critical Pitfalls to Avoid

• Never neglect lifestyle interventions in normal-weight PCOS patients—overall health benefits of lifestyle changes are important regardless of weight status 1, 3
• Do not delay evidence-based treatment while pursuing unproven complementary therapies (e.g., evening primrose oil or herbal supplements are not part of standard management) 1
• Weight-related stigma negatively impacts treatment engagement; maintain respectful, patient-centered communication 1
• Before initiating drug therapy, regular exercise and weight control measures should be tried 3