What is the recommended treatment plan for a patient with Polycystic Ovary Syndrome (PCOS)?

Treatment Plan for Polycystic Ovary Syndrome (PCOS)

All women with PCOS, regardless of body weight, must begin with multicomponent lifestyle intervention as mandatory first-line treatment, combining dietary modification (500-750 kcal/day deficit), structured physical activity (at least 150 minutes/week moderate-intensity or 75 minutes/week vigorous-intensity), and behavioral strategies, because insulin resistance affects both lean and overweight patients independent of BMI. 1, 2

Initial Assessment and Metabolic Screening

Before initiating treatment, perform comprehensive metabolic surveillance:

• Measure fasting glucose and lipid profile to screen for type 2 diabetes and cardiovascular risk 1
• Calculate BMI and waist-hip ratio using ethnic-specific cutoffs (lower thresholds for Asian, Hispanic, and South Asian populations who have higher cardiometabolic risk) 1, 2
• Check androgen levels (total/free testosterone) and gonadotropins (LH, FSH) for diagnostic confirmation 1
• Screen for depression, anxiety, eating disorders (binge eating disorder, night eating syndrome), and body image concerns, as these dramatically reduce treatment adherence and require active management 1

Lifestyle Intervention Protocol (First-Line for ALL Patients)

Dietary Management

• Target 1,200-1,500 kcal/day with 500-750 kcal/day deficit adjusted for individual energy requirements 1, 2, 3
• Any balanced dietary approach creating energy deficit is acceptable—no specific diet type (low glycemic index, Mediterranean, ketogenic, high-fiber, omega-3 rich) has proven superior 1, 2, 4
• Focus on patient preferences and cultural needs while following general healthy eating principles, avoiding overly restrictive or nutritionally unbalanced diets 1, 2

Physical Activity Prescription

• For weight maintenance: minimum 150 minutes/week moderate-intensity (brisk walking, cycling 8-15 km/h, low-impact aerobics) OR 75 minutes/week vigorous-intensity (jogging, high-impact aerobics, competitive sports) 1, 2, 3
• For weight loss: minimum 250 minutes/week moderate-intensity OR 150 minutes/week vigorous-intensity 1, 2, 3
• Include muscle-strengthening activities on 2 non-consecutive days/week involving major muscle groups 1, 2
• Perform activity in at least 10-minute bouts, progressively increasing by 5% weekly, targeting 10,000 steps daily including 30 minutes structured activity 1, 2
• Minimize sedentary, screen, and sitting time throughout the day 1, 2
• Both aerobic and resistance exercise improve insulin sensitivity independent of significant weight loss 1, 3

Behavioral Strategies

• Implement SMART goal-setting with self-monitoring using fitness tracking devices for step count and exercise intensity 1, 2
• Include stimulus control, problem-solving, assertiveness training, slower eating, reinforcement of changes, and relapse prevention 1, 2
• Target 5-10% weight loss in those with excess weight—this yields significant clinical improvements in hormonal, metabolic, and reproductive outcomes 1, 2, 3

Monitoring Schedule

• Fortnightly review for first 3 months, then regular review for first 12 months to ensure adherence and adjust interventions 1
• Monitor weight and waist circumference regularly during weight loss and maintenance 1, 3

Pharmacological Management: Based on Reproductive Goals

For Women NOT Attempting to Conceive

Combined oral contraceptives (COCs) are first-line hormonal therapy because they suppress ovarian androgen secretion, increase sex hormone-binding globulin, regulate menstrual cycles, prevent endometrial hyperplasia, and reduce hirsutism and acne 1, 2:

• Typical regimen: drospirenone 3 mg/ethinyl estradiol 20 μg in 24-active/4-inert pill regimen, taken daily 1
• COCs reduce endometrial cancer risk but increase circulating triglycerides and HDL cholesterol 1

Add metformin 500-2000 mg daily when insulin resistance or glucose intolerance is documented, lifestyle modifications alone are insufficient, or patient has obesity or elevated cardiovascular risk 1:

• Start 500 mg daily, titrate up to 1000-2000 mg daily in divided doses to improve glucose tolerance and reduce diabetes/cardiovascular disease risk 1, 5
• Metformin benefits weight reduction and metabolic outcomes, particularly in those with BMI >25 kg/m² 5

For hirsutism and acne resistant to COCs alone, combine antiandrogen plus ovarian suppression agent as most effective approach 1

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, 6, 7:

• Start with 50 mg daily for 5 days beginning on cycle day 5 6
• If no ovulation after first course, increase to 100 mg daily for 5 days (may start as early as 30 days after previous course after excluding pregnancy) 6
• Do NOT exceed 100 mg/day for 5 days—increasing dosage or duration beyond this is not recommended 6
• Discontinue after 3 ovulatory cycles without pregnancy, or after 6 total cycles—further treatment not recommended 6
• CRITICAL PITFALL: Patients with PCOS are unusually sensitive to gonadotropins and may have exaggerated response—use lowest dose and shortest duration for first course 6
• Monitor for ovarian hyperstimulation syndrome (OHSS): early warning signs include abdominal pain/distention, nausea, vomiting, diarrhea, weight gain 6
• If clomiphene fails, use low-dose gonadotropin therapy which has lower risk of ovarian hyperstimulation 1

Consider metformin 1 g twice daily for 12 weeks or until pregnancy in pregestational stage to improve fertility outcomes 1

Emerging Anti-Obesity Pharmacotherapy

GLP-1 receptor agonists show promise for weight reduction and metabolic improvement when combined with lifestyle interventions 1:

• Liraglutide 1.8-3 mg daily, semaglutide 1-2 mg weekly, or exenatide 5-10 μg twice daily or 2 mg weekly 1
• These agents appear superior to placebo for anthropometric and metabolic outcomes 1

Orlistat 120 mg three times daily plus lifestyle intervention is an alternative option for weight loss 1

Long-Term Surveillance and Prevention

• Screen for type 2 diabetes, dyslipidemia, hypertension at least annually regardless of weight, as metabolic risk is present even in lean PCOS 1, 8
• Screen for sleep apnea, which occurs more commonly in PCOS 9
• Begin prevention and monitoring from adolescence (girls should aim for 60 minutes moderate-to-vigorous activity daily, including muscle/bone strengthening 3 times weekly), as weight gain escalates from this period 1
• Central obesity increases progressively with waist-to-hip ratio rising between ages 20-45 years—early vigilance is essential 1

Critical Pitfalls to Avoid

• DO NOT dismiss lifestyle intervention in lean PCOS patients—insulin resistance requires management regardless of BMI 1, 2
• DO NOT neglect metabolic screening in normal-weight patients—insulin resistance affects all PCOS phenotypes 1
• DO NOT exceed clomiphene 100 mg/day for 5 days or continue beyond 6 cycles total 6
• DO NOT use herbal supplements (evening primrose oil) as primary therapy—these lack evidence and delay proven treatments 1
• Ensure health professional interactions avoid weight-related stigma, which negatively impacts treatment engagement 1, 2
• Address psychological factors (depression, anxiety, eating disorders, body image concerns) actively—refer to psychiatry/behavioral health for moderately severe depression, as these dramatically reduce adherence 1