What is the first line treatment for a patient with Polycystic Ovary Syndrome (PCOS)?

First-Line Treatment for PCOS

Multicomponent lifestyle intervention—combining dietary modification, structured physical activity, and behavioral strategies—is the first-line treatment for all women with PCOS, regardless of body weight, because insulin resistance affects both lean and overweight patients and drives the pathophysiology of this condition. 1, 2

Why Lifestyle Intervention is Universal First-Line Therapy

• 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
• Hyperinsulinemia resulting from insulin resistance worsens all PCOS symptoms, creating a metabolic vicious cycle that requires management even in normal-weight patients 1, 2
• 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

Dietary Management Component

For women with excess weight:

• Target an energy deficit of 30% or 500-750 kcal/day (approximately 1,200-1,500 kcal/day), considering individual energy requirements 1, 2
• Aim for 5-10% weight loss, which yields significant clinical improvements in metabolic and reproductive abnormalities 1, 2

For all women with PCOS (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, 3
• Avoid unduly restrictive or nutritionally unbalanced diets 1

Physical Activity Prescription

Aerobic exercise 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
• Activity should be performed in at least 10-minute bouts, aiming for at least 30 minutes daily on most days 1
• For modest weight loss and greater health benefits, recommend at least 250 minutes/week of moderate-intensity activities 1

Resistance training:

• Include muscle-strengthening activities on 2 non-consecutive days per week 1, 2
• Both aerobic and resistance exercises have shown benefits in PCOS 1, 2

Additional recommendations:

• Minimize sedentary, screen, or sitting time 1
• Target 10,000 steps daily when possible 1

Behavioral Strategies Component

Essential behavioral interventions:

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting with self-monitoring 1, 2
• Include goal-setting, 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

Psychological considerations:

• Address psychological factors such as anxiety, depression, body image concerns, and disordered eating, as these dramatically reduce adherence to lifestyle interventions 1
• Screen for eating disorders (binge eating disorder, night eating syndrome), which are highly prevalent in PCOS 1
• Refer patients with moderately severe depression to psychiatry or behavioral health for evaluation 1

When to Add Pharmacological Management

After initiating lifestyle intervention, add pharmacological therapy based on patient goals:

For Women NOT Attempting to Conceive:

• Combined oral contraceptives (COCs) are first-line hormonal therapy as they suppress ovarian androgen secretion, increase sex hormone-binding globulin, regulate menstrual cycles, prevent endometrial hyperplasia, and reduce hirsutism and acne 1, 2, 4
• Typical dosing: drospirenone 3 mg/ethinyl estradiol 20 μg in a 24-active/4-inert pill regimen, taken daily 1
• Metformin 500-2000 mg daily should be added for patients with insulin resistance or glucose intolerance, starting at 500 mg daily and titrating to 1000-2000 mg daily in divided doses 1, 2

For Women Attempting to Conceive:

• Clomiphene citrate is first-line pharmacological treatment for ovulation induction, with approximately 80% of patients ovulating and 50% conceiving 1, 5, 4
• Start clomiphene on or about the 5th day of the cycle 5
• Long-term cyclic therapy is not recommended beyond a total of about six cycles (including three ovulatory cycles) 5
• Metformin 1 g twice daily for 12 weeks or until pregnancy can be used in the pregestational stage 1

Monitoring and Follow-Up

• Regular monitoring of weight and waist circumference is recommended 1, 2
• Use ethnic-specific BMI and waist circumference categories for Asian, Hispanic, and South Asian populations, who require lower thresholds 1
• Screen for metabolic complications including type 2 diabetes with fasting glucose followed by 75-gram oral glucose tolerance test 6
• Screen for dyslipidemia with fasting lipoprotein profile 6

Special Population Considerations

Adolescents:

• Prevention of weight gain and monitoring should begin from adolescence, as weight gain escalates from this period 1
• Adolescents 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
• Hormonal contraceptives and metformin are the treatment options in adolescents with PCOS 7

Ethnic groups at high cardiometabolic risk:

• Asian, Hispanic, and South Asian populations require lower BMI and waist circumference thresholds and greater consideration for lifestyle intervention 1, 6

Critical Implementation Points

• Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma which negatively impacts treatment engagement 1
• Family support improves outcomes; structure recommended activities considering women's and family routines as well as cultural preferences 1
• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1, 2