PCOS Management and Diagnostic Criteria

Diagnostic Criteria and Initial Investigation

PCOS diagnosis requires laboratory evaluation including androgen levels (total/free testosterone), gonadotropins (LH, FSH), and metabolic screening with fasting glucose and lipid profile. 1

Essential Laboratory Workup

Measure androgen levels and gonadotropin panel (LH, FSH) to confirm hyperandrogenism and assess ovarian function 1
Screen for metabolic abnormalities with fasting glucose and complete lipid profile at diagnosis 1
Calculate BMI and measure waist-hip ratio to assess metabolic risk, using ethnic-specific cutoffs for Asian, Hispanic, and South Asian populations who require lower thresholds 2, 1
Repeat metabolic screening at least annually regardless of body weight, as insulin resistance affects all PCOS patients independent of BMI 1

First-Line Management: Multicomponent Lifestyle Intervention

All women with PCOS, regardless of body weight, must receive multicomponent lifestyle intervention as mandatory first-line treatment, combining dietary modification, structured physical activity, and behavioral strategies, because insulin resistance is present irrespective of BMI and affects both lean and overweight women. 2, 3

Critical Understanding

Insulin resistance is present in all PCOS phenotypes regardless of BMI and contributes to hyperandrogenism through effects on the pituitary, liver, and ovaries 2, 3
Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight 2

Dietary Prescription

For women with excess weight, target an energy deficit of 500-750 kcal/day (total intake 1,200-1,500 kcal/day), adjusted for individual energy requirements 2, 3
Target 5-10% weight loss in those with excess weight, as this yields significant clinical improvements in metabolic and reproductive abnormalities 2, 3
Any balanced dietary approach creating an energy deficit is acceptable—no specific diet type has proven superior 2, 4
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 2, 4
Avoid overly restrictive or nutritionally unbalanced diets 2

Exercise Prescription

Prescribe at least 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous-intensity activity for weight maintenance and health 2, 3
For weight loss and prevention of regain, prescribe at least 250 minutes/week of moderate-intensity activity or 150 minutes/week of vigorous-intensity activity 2
Include muscle-strengthening activities on 2 non-consecutive days per week 2, 3
Perform activity in at least 10-minute bouts, aiming for at least 30 minutes daily on most days, targeting 10,000 steps daily 2
Both aerobic and resistance exercise improve insulin sensitivity, aid weight loss, and improve metabolic and reproductive outcomes 2, 4
Start with realistic 10-minute activity bouts, progressively increasing physical activity by 5% weekly 2
Minimize sedentary, screen, and sitting time throughout the day 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 2, 3
Include behavioral change techniques: goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 2, 3
Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence 2

Monitoring Schedule

Conduct fortnightly review for the first 3 months with structured dietary and physical activity plans 2
Perform regular review for the first 12 months to ensure adherence and adjust interventions 2
Monitor weight and waist circumference regularly during weight loss and maintenance 2

Medical Management: Treatment Based on Reproductive Goals

For Women NOT Attempting to Conceive

Combined oral contraceptives (COCs) are first-line hormonal therapy for women with PCOS not attempting to conceive, as they suppress ovarian androgen secretion, increase sex hormone-binding globulin, regulate menstrual cycles, prevent endometrial hyperplasia, and reduce hirsutism and acne. 2, 1

Typical COCP regimen: drospirenone 3 mg/ethinyl estradiol 20 μg in a 24-active/4-inert pill regimen, taken daily 2
COCs reduce the risk of endometrial cancer and are associated with increases in circulating triglyceride and HDL cholesterol levels 2
For hirsutism and acne, COCs are preferred over antiandrogens as monotherapy 5
Combined medical interventions (antiandrogen plus ovarian suppression agent) may be most effective for severe hirsutism 2
Medroxyprogesterone acetate suppresses circulating androgen and pituitary gonadotropin levels, though optimal progestin duration and frequency to prevent endometrial cancer is not established 2

For Women ATTEMPTING to Conceive

Clomiphene citrate is first-line pharmacological treatment for ovulation induction in women with PCOS attempting to conceive, with approximately 80% of patients ovulating and 50% conceiving. 2, 1

Weight control and regular exercise programs should be started before medication 2
Clomiphene citrate is preferred due to its effectiveness, safety, and ease of administration 2
If clomiphene treatment fails, use low-dose gonadotropin therapy, which induces high rates of monofollicular development with lower risk of ovarian hyperstimulation 2, 1
Consider metformin 1 g twice daily for 12 weeks or until pregnancy in the pregestational stage 2

Metabolic Management

Metformin Therapy

Add metformin (500-2000 mg daily) when insulin resistance or glucose intolerance is documented, lifestyle modifications alone are insufficient for metabolic control, or the patient has obesity or elevated cardiovascular risk factors. 1

Start with 500 mg daily and titrate up to 1000-2000 mg daily in divided doses 2
Metformin improves glucose tolerance over time and may have positive impact on risk factors for diabetes and cardiovascular disease 2, 5
Metformin is of benefit for reducing excess body weight and improving hormonal and metabolic outcomes in those with high metabolic risk (BMI >25 kg/m²) 5

Emerging Anti-Obesity Agents

GLP-1 receptor agonists (liraglutide, semaglutide, exenatide) show promise for weight reduction and metabolic improvement when combined with lifestyle interventions 2, 1
Anti-obesity drugs may be considered for weight management in addition to lifestyle interventions 5
Inositol appears to have limited benefits for metabolic outcomes, although it is associated with fewer adverse effects than metformin 5

Psychological Management

Refer patients with PCOS and moderately severe depression to psychiatry or behavioral health for evaluation and potential pharmacotherapy, as depression and psychological factors dramatically reduce adherence to lifestyle interventions. 2

Screen patients with PCOS for eating disorders, such as binge eating disorder and night eating syndrome, which are highly prevalent and create a vicious cycle worsening both obesity and hormonal disturbances 2
Address psychological factors such as anxiety, depression, body image concerns, and disordered eating to optimize engagement and adherence to lifestyle interventions 2, 3
Address body image concerns and psychological distress related to hair loss and PCOS symptoms, as these significantly impact treatment adherence 2
Women with PCOS have higher rates of depression, anxiety, and eating disorders requiring active management 1, 6, 7

Long-Term Monitoring and Screening

Screen for type 2 diabetes mellitus, dyslipidemia, and hypertension at diagnosis and regularly thereafter 1, 6
Perform comprehensive metabolic surveillance for all patients with PCOS, regardless of weight, including screening for type 2 diabetes, fasting lipid profile, BMI calculation, and waist-hip ratio 1
Screen for sleep apnea, as this occurs more commonly in women with PCOS 7
Use ethnic-specific BMI and waist circumference categories for Asian, Hispanic, and South Asian populations, who require lower thresholds and greater consideration for lifestyle intervention 2, 1

Special Population Considerations

Adolescents

Prevention of weight gain and monitoring should begin from adolescence, as weight gain escalates from this period 2
Adolescents with PCOS should aim for at least 60 minutes of moderate to vigorous intensity physical activity daily, including activities that strengthen muscle and bone at least 3 times weekly 2
Encourage evidence-based and socio-culturally appropriate healthy lifestyle for girls with PCOS 2

High Cardiometabolic Risk Populations

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, 1
Central obesity increases progressively with waist-to-hip ratio rising between ages 20-45 years, requiring early vigilance 2

Critical Pitfalls to Avoid

Do not neglect metabolic screening even in normal-weight PCOS patients, as insulin resistance is present regardless of BMI 1
Do not exceed recommended clomiphene dosage and duration 1
Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma which negatively impacts treatment engagement 2
Do not delay evidence-based treatment while pursuing unproven complementary therapies such as evening primrose oil or other herbal supplements 2
Family support improves outcomes—structure recommended activities considering women's and family routines as well as cultural preferences 2

What are the criteria and management options for a patient with Polycystic Ovary Syndrome (PCOS), including investigation and treatment approaches?

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