What are the primary management goals and treatment options for a patient with Polycystic Ovary Syndrome (PCOS)?

PCOS Management

First-Line Treatment: Multicomponent Lifestyle Intervention for ALL Patients

Lifestyle modification is the foundational first-line treatment for all women with PCOS, regardless of body weight, because insulin resistance affects both lean and overweight patients and requires management through diet, exercise, and behavioral strategies. 1, 2

Critical Understanding: Why Lifestyle Matters Even in Lean PCOS

• 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

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Dietary Management

General Principles

• No specific diet type has proven superior; focus on individual preferences and cultural needs while maintaining a healthy balanced diet 1
• Any balanced dietary approach creating an energy deficit is acceptable for weight management 1
• Avoid unduly restrictive or nutritionally unbalanced diets 1

Specific Dietary Approaches with Evidence

• Low glycemic index foods, high-fiber diets, omega-3 fatty acid-rich diets, ketogenic diets, Mediterranean diets, and anti-inflammatory diets all improve insulin sensitivity and hormonal balance 1, 3

Weight Loss Targets (for those with excess weight)

• For weight loss, aim for an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day), considering individual energy requirements 1, 2
• Target 5-10% weight loss in those with excess weight, as this yields significant clinical improvements in metabolic and reproductive abnormalities 1, 2

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Physical Activity Prescription

Minimum Requirements for Weight Maintenance

• Prescribe at least 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous-intensity activity (or equivalent combination) 1, 2
• Include muscle-strengthening activities on 2 non-consecutive days per week 1, 2
• Activity should be performed in at least 10-minute bouts or around 1,000 steps, aiming for at least 30 minutes daily on most days 1

Enhanced Targets for Weight Loss

• For modest weight loss and greater health benefits, recommend at least 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous-intensity (or equivalent combination) 1

Exercise Types and Intensity

• Both aerobic and resistance exercises have shown benefits in PCOS 1, 3
• Minimize sedentary, screen, or sitting time 1
• Start with realistic 10-minute activity bouts, progressively increasing physical activity by 5% weekly up to and above recommendations 1

Adolescent-Specific Recommendations

• Adolescents with PCOS should aim for at least 60 minutes of moderate to vigorous intensity physical activity/day, including activities that strengthen muscle and bone at least 3 times weekly 1

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Behavioral Strategies

Goal Setting and Self-Monitoring

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

Comprehensive Behavioral Techniques

• Include behavioral strategies such as 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

Addressing Psychological Factors

• Address psychological factors such as anxiety, depression, body image concerns, and disordered eating—these dramatically reduce adherence to lifestyle interventions 1
• Screen patients with PCOS 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
• Refer patients with PCOS and moderately severe depression to psychiatry or behavioral health for evaluation and potential pharmacotherapy 1

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Medical Management

For Women NOT Attempting to Conceive

Hormonal Therapy

• 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 1, 2
• A typical COCP dosing regimen is drospirenone 3 mg/ethinyl estradiol 20 μg in a 24-active/4-inert pill regimen, taken daily 1
• Medroxyprogesterone acetate suppresses circulating androgen and pituitary gonadotropin levels, although the optimal progestin, duration, and frequency to prevent endometrial cancer in PCOS is not known 1

Insulin Sensitizers

• Metformin 500-2000 mg daily should be considered for patients with insulin resistance or glucose intolerance, with a starting dose of 500 mg daily and titration up to 1000-2000 mg daily in divided doses 1, 2
• Metformin improves glucose tolerance over time and may have a positive impact on risk factors for diabetes and cardiovascular disease 1

Weight Loss Medications

• GLP-1 receptor agonists, such as liraglutide, semaglutide, and exenatide, in combination with lifestyle interventions for weight loss and metabolic control in patients with PCOS 1

Antiandrogen Therapy

• Combined medical interventions, such as antiandrogen plus ovarian suppression agent, may be most effective for hirsutism 1
• Consider adding spironolactone as antiandrogen therapy for persistent hirsutism or acne 4

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
• Weight control and regular exercise programs should be started before medication 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
• Metformin 1 g twice daily for 12 weeks or until pregnancy in the pregestational stage 1

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Monitoring and Follow-Up

Weight and Metabolic Monitoring

• Regular monitoring of weight and waist circumference is recommended 1
• Use ethnic-specific BMI and waist circumference categories for Asian, Hispanic, and South Asian populations, which require lower thresholds 1
• Fortnightly review for the first 3 months with structured dietary and physical activity plans, and regular review for the first 12 months 1

Cardiometabolic Screening

• Screen annually for type 2 diabetes with fasting glucose and 2-hour oral glucose tolerance test 4
• Monitor fasting lipid panels regularly to assess cardiovascular risk 4

Endometrial Protection

• Ensure regular menstrual cycles through hormonal therapy or spontaneous ovulation, and provide endometrial protection with progestins or COCs to prevent endometrial hyperplasia/cancer 4

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Special Population Considerations

Adolescents

• Prevention of weight gain and monitoring should begin from adolescence, as weight gain escalates from this period 1
• Encourage evidence-based and socio-culturally appropriate healthy lifestyle for girls with PCOS 1
• Family support improves outcomes, and structure recommended activities considering women's and family routines as well as cultural preferences 1

High Cardiometabolic Risk Ethnic Groups

• Ethnic groups with PCOS at high cardiometabolic risk (Asian, Hispanic, South Asian populations) require greater consideration for lifestyle intervention with lower BMI and waist circumference thresholds 1

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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 1
• Recognize that psychological factors require active management to optimize engagement with treatment 1
• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1