Management of Polycystic Ovary Syndrome (PCOS)
All women with PCOS, regardless of body weight, should receive multicomponent lifestyle intervention as first-line treatment, combining dietary modification, structured physical activity, and behavioral strategies, because insulin resistance affects all PCOS patients independent of BMI. 1, 2
Understanding the Critical Pathophysiology
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 pitfall to avoid: do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight. 1
First-Line Treatment: Multicomponent Lifestyle Intervention
Dietary Management
For women with excess weight, target an energy deficit of 500-750 kcal/day (approximately 1,200-1,500 kcal/day total), considering individual energy requirements. 1, 2 The goal is 5-10% weight loss, which yields significant clinical improvements in both metabolic and reproductive abnormalities. 2, 3
For normal-weight women, focus on diet quality rather than caloric restriction, emphasizing low glycemic index foods, high-fiber diets, omega-3 fatty acid-rich diets, and anti-inflammatory dietary patterns to improve insulin sensitivity and hormonal balance. 1
No specific diet type has proven superior; the approach should align with individual preferences and cultural needs while maintaining nutritional balance. 1
Exercise Prescription
Prescribe at least 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous-intensity activity (or equivalent combination). 1, 2 For women with excess weight seeking weight loss, increase to at least 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous-intensity activities. 1
Include muscle-strengthening activities involving major muscle groups on 2 non-consecutive days per week, as both aerobic and resistance exercises show benefits in PCOS. 1, 2
Activity should be performed in at least 10-minute bouts, aiming for at least 30 minutes daily on most days, targeting approximately 10,000 steps daily. 1
Start with realistic 10-minute activity bouts and progressively increase physical activity by 5% weekly up to and above recommendations. 1
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, 2
Include behavioral change techniques: 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 support and adherence to healthy lifestyle. 1
Psychological Assessment and Management
Screen all patients immediately for anxiety, depression, body image concerns, and disordered eating, as these conditions are highly prevalent in PCOS and directly impair engagement with treatment. 1, 3 Address psychological barriers simultaneously with lifestyle modifications, not sequentially. 3
Refer patients with moderately severe depression to psychiatry or behavioral health for evaluation and potential pharmacotherapy, as depression dramatically reduces adherence to lifestyle interventions. 1
Screen specifically for eating disorders, such as binge eating disorder and night eating syndrome, which are highly prevalent in PCOS and create a vicious cycle worsening both obesity and hormonal disturbances. 1
Medical Management for Women NOT Attempting to Conceive
Combined oral contraceptive pills 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. 1, 2
A typical regimen is drospirenone 3 mg/ethinyl estradiol 20 μg in a 24-active/4-inert pill regimen, taken daily. 1
Combined oral contraceptives reduce the risk of endometrial cancer, though they are associated with increases in circulating triglyceride and HDL cholesterol levels. 1
Metformin for Insulin Resistance
Metformin 500-2000 mg daily should be considered for women with PCOS who have cardiometabolic features such as abdominal obesity and insulin resistance. 1, 2 Start with 500 mg once or twice daily with meals and titrate gradually to 1500-2000 mg daily over 2-4 weeks as tolerated. 1, 3
Metformin improves glucose tolerance over time and may have a positive impact on risk factors for diabetes and cardiovascular disease. 1
For patients with very high-risk prediabetes (HbA1c ≥6.4%, PCOS with insulin resistance, BMI >25), initiate metformin immediately alongside lifestyle intervention. 3
GLP-1 Receptor Agonists
GLP-1 receptor agonists, such as liraglutide, semaglutide, and exenatide, can be used in combination with lifestyle interventions for weight loss and metabolic control in patients with PCOS. 1
Antiandrogen Therapy for Hirsutism
Combined medical interventions, such as an antiandrogen (spironolactone or cyproterone) plus an ovarian suppression agent (combined oral contraceptive), may be most effective for hirsutism. 1
Medical Management 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. 1, 4
Clomiphene Citrate Dosing Protocol
Start with 50 mg daily for 5 days, beginning on or about the 5th day of the cycle. 4 A low dosage is particularly recommended if unusual sensitivity to pituitary gonadotropin is suspected, such as in patients with polycystic ovary syndrome. 4
If ovulation does not occur after the first course, increase to 100 mg daily for 5 days, starting as early as 30 days after the previous course after excluding pregnancy. 4
Increasing the dosage or duration beyond 100 mg/day for 5 days is not recommended. 4 The majority of patients who will ovulate do so after the first course of therapy. 4
If ovulation does not occur after three courses of therapy, further treatment with clomiphene citrate is not recommended and the patient should be reevaluated. 4 If three ovulatory responses occur but pregnancy has not been achieved, further treatment is not recommended. 4
Long-term cyclic therapy is not recommended beyond a total of about six cycles (including three ovulatory cycles). 4
Critical Warning: Ovarian Hyperstimulation Syndrome
Patients with polycystic ovary syndrome who are unusually sensitive to gonadotropin may have an exaggerated response to usual doses of clomiphene citrate and should be started on the lowest recommended dose and shortest treatment duration. 4
The early warning signs of ovarian hyperstimulation syndrome (OHSS) are abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain. 4 If enlargement of the ovary occurs, additional clomiphene citrate therapy should not be given until the ovaries have returned to pretreatment size. 4
Alternative Fertility Treatments
Metformin 1 g twice daily for 12 weeks or until pregnancy can be used in the pregestational stage. 1
If clomiphene treatment fails, low-dose gonadotropin therapy should be used, which induces a high rate of monofollicular development with a lower risk of ovarian hyperstimulation. 1
Monitoring and Follow-Up
Assess adherence to lifestyle modifications and metformin tolerance at 2-4 weeks, and monitor weight and waist circumference monthly during active weight loss. 1, 3
For patients on metformin with prediabetes, repeat HbA1c at 3 months to assess glycemic response. 3
Regular monitoring of weight and waist circumference is essential during weight loss and maintenance phases. 1
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. 1
Fortnightly review for the first 3 months with structured dietary and physical activity plans, and regular review for the first 12 months to ensure adherence and adjust interventions. 1
Special Considerations for Adolescents
Prevention of weight gain and monitoring should begin from adolescence, as weight gain escalates from this period. 1
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. 1
Family support improves outcomes, and structure recommended activities considering women's and family routines as well as cultural preferences. 1
Critical Pitfalls to Avoid
Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma which negatively impacts treatment engagement. 1
Do not delay evidence-based treatment while pursuing unproven complementary therapies such as evening primrose oil or other herbal supplements, which are not part of standard management. 1
Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss, so do not withhold lifestyle intervention from patients who struggle with weight loss. 1, 2