What is the best way to manage my polycystic ovary syndrome (PCOS) and metabolic syndrome, given my height of 5'7" and weight of 138 lbs?

Management of PCOS and Metabolic Syndrome at Normal BMI

At your height (5'7") and weight (138 lbs), corresponding to a BMI of approximately 21.6, you still require comprehensive lifestyle intervention as first-line management for PCOS and metabolic syndrome, because insulin resistance affects all PCOS patients regardless of body weight. 1

Understanding Your Condition

Insulin Resistance Occurs Independent of Weight

• Insulin resistance is present in nearly all PCOS patients irrespective of BMI, affecting both lean and overweight women 1, 2
• Hyperinsulinemia resulting from insulin resistance contributes to hyperandrogenism through effects on the pituitary, liver, and ovaries in all women with PCOS, regardless of weight 1
• The metabolic syndrome occurs in approximately 43-47% of PCOS patients, raising cardiovascular risk up to seven-fold 2, 3
• Visceral fat accumulation and insulin resistance create a vicious cycle with androgen excess, even in normal-weight women 4

Critical Pitfall to Avoid

Do not dismiss lifestyle intervention simply because you have normal BMI—insulin resistance requires active management through diet, exercise, and behavioral strategies regardless of weight. 1

First-Line Treatment: Multicomponent Lifestyle Intervention

Dietary Management

• Follow any balanced dietary approach that emphasizes diet quality rather than caloric restriction, focusing on your individual preferences and cultural needs 5, 1
• No specific diet type (low-fat, low-carb, high-protein, DASH) has proven superior; all produce comparable outcomes when followed consistently 5
• Implement general healthy eating principles: reduce sugar-sweetened beverages, fruit juices, and soft drinks 6
• Consider low glycemic index foods, high-fiber diets, omega-3 fatty acid-rich foods, Mediterranean diet patterns, or anti-inflammatory diets for improving insulin sensitivity 1

Exercise Prescription (Essential Regardless of Weight)

• Perform at least 150 minutes per week of moderate-intensity physical activity OR 75 minutes per week of vigorous-intensity activity (or equivalent combination) 1
• Include muscle-strengthening activities involving major muscle groups on 2 non-consecutive days per week 1
• Structure activity in at least 10-minute bouts, aiming for 30 minutes daily on most days 1
• Target 10,000 steps daily using fitness tracking devices for self-monitoring 1
• Both aerobic and resistance exercises show metabolic benefits in PCOS, with improvements occurring independent of weight loss 5, 1
• 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, 6
• Include goal-setting, stimulus control, problem-solving, assertiveness training, slower eating rate, reinforcing changes, and relapse prevention 5, 1
• Start with realistic 10-minute activity bouts, progressively increasing physical activity by 5% weekly 1

Medical Management

Metabolic Screening (Required for All PCOS Patients)

• Obtain 2-hour oral glucose tolerance test with 75-gram glucose load to detect type 2 diabetes and glucose intolerance 6
• Check fasting lipid profile (total cholesterol, LDL, HDL, triglycerides) as insulin resistance drives atherogenic dyslipidemia 6
• Measure TSH to exclude thyroid disease 6
• Check prolactin to exclude hyperprolactinemia 6
• Monitor blood pressure regularly due to increased cardiovascular disease risk 6
• Examine for acanthosis nigricans, indicating underlying insulin resistance 6

Pharmacological Options (If Not Seeking Pregnancy)

• Metformin 500-2000 mg daily improves glucose tolerance, decreases circulating androgens (including those of adrenal origin), and tends to decrease weight 1, 6
• Start metformin at 500 mg daily and titrate up to 1000-2000 mg daily in divided doses 1
• Consider GLP-1 receptor agonists (semaglutide, liraglutide) if lifestyle modifications plus metformin prove insufficient after 3-6 months 6
• Combined oral contraceptives regulate menstrual cycles, provide endometrial protection, and suppress ovarian androgen secretion 1, 6

Psychological Considerations

Mental Health Screening and Support

• Screen for anxiety, depression, body image concerns, and disordered eating, which are highly prevalent in PCOS and dramatically reduce adherence to lifestyle interventions 5, 1
• Eating disorders including binge eating disorder and night eating syndrome are exacerbated with PCOS, creating a vicious cycle that aggravates both metabolic disturbances and hormonal imbalances 5
• Refer to psychiatry or behavioral health for evaluation if moderately severe depression is present 1
• Address psychological distress related to PCOS symptoms, as these significantly impact treatment adherence 1

Monitoring and Follow-Up

• Schedule fortnightly review for the first 3 months with structured dietary and physical activity plans 1
• Continue regular review for the first 12 months to ensure adherence and adjust interventions 1
• Monitor weight and waist circumference regularly, even though weight loss is not your primary goal 1
• Healthy lifestyle may contribute to health and quality of life benefits even in the absence of weight loss 1

Special Considerations for Normal-Weight PCOS

• Women with all three PCOS components (oligo/anovulation + hyperandrogenism + polycystic ovaries) show the highest level of metabolic disturbances, indicating that metabolic screening is necessary regardless of BMI 7
• Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma which negatively impacts treatment engagement 1
• Prevention and monitoring should continue across the life course, as central obesity increases progressively with waist-to-hip ratio rising between ages 20-45 years 1