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

Management of Polycystic Ovary Syndrome (PCOS)

All women with PCOS, regardless of body weight or fertility goals, should begin with multicomponent lifestyle intervention as first-line treatment, combining structured physical activity (at least 150 minutes/week moderate-intensity or 75 minutes/week vigorous-intensity), dietary modification creating a 500-750 kcal/day deficit if overweight, and behavioral strategies, because insulin resistance affects all PCOS patients independent of BMI and drives both metabolic and reproductive complications. 1

Initial Assessment and Risk Stratification

Metabolic Screening (Required for All PCOS Patients)

• Screen for type 2 diabetes with fasting glucose followed by 2-hour glucose level after 75-gram oral glucose load, repeating annually or every 1-2 years based on BMI and family history 2, 3
• Obtain comprehensive fasting lipid profile including total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides at baseline 2, 3
• Calculate BMI and waist-hip ratio at each visit, using ethnic-specific cutoffs (lower thresholds for Asian, Hispanic, and South Asian populations who have higher cardiometabolic risk) 1, 3
• Screen for depression, anxiety, eating disorders (particularly binge eating and night eating syndrome), and body image concerns, as these dramatically reduce treatment adherence 1

First-Line Treatment: Lifestyle Intervention (For ALL Patients)

Physical Activity Prescription

• Prescribe at least 150 minutes/week of moderate-intensity exercise OR 75 minutes/week of vigorous-intensity activity, performed in at least 10-minute bouts 1
• Include muscle-strengthening activities involving major muscle groups on 2 non-consecutive days per week 1
• For patients needing weight loss, increase to at least 250 minutes/week of moderate-intensity OR 150 minutes/week of vigorous-intensity activity 1
• Target 10,000 steps daily, including 30 minutes of structured physical activity 1
• Start with realistic 10-minute activity bouts, progressively increasing by 5% weekly 1
• Both aerobic and resistance exercises show benefits in PCOS 1

Dietary Management

• For overweight/obese patients: create energy deficit of 500-750 kcal/day (typically 1,200-1,500 kcal/day total), considering individual energy requirements 1
• No specific diet type is superior—any balanced approach creating energy deficit is acceptable, focusing on patient preferences and cultural needs 1
• Emphasize low glycemic index foods, high-fiber diets, omega-3 fatty acids, and anti-inflammatory dietary patterns 1
• For normal-weight patients: focus on diet quality rather than caloric restriction 1
• Avoid unduly restrictive or nutritionally unbalanced diets 1

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting with self-monitoring using fitness tracking devices 1
• Include goal-setting, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 1
• Target achievable weight loss of 5-10% in those with excess weight, which yields significant clinical improvements 1
• Address psychological factors (anxiety, depression, body image concerns, disordered eating) to optimize engagement and adherence 1
• Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma 1

Monitoring Schedule

• Fortnightly review for first 3 months with structured dietary and physical activity plans 1
• Regular review for first 12 months to ensure adherence and adjust interventions 1
• Regular monitoring of weight and waist circumference during weight loss and maintenance 1

Medical Management: Based on Primary Concern

For Women NOT Attempting to Conceive

Menstrual Regulation and Hyperandrogenism (First-Line)

• Prescribe combined oral contraceptive pills (COCs) as 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 2, 1
• Typical regimen: drospirenone 3 mg/ethinyl estradiol 20 μg in 24-active/4-inert pill regimen, taken daily 1
• COCs reduce risk of endometrial cancer, though they increase triglycerides and HDL cholesterol 2
• Alternative: medroxyprogesterone acetate (depot or intermittent oral) suppresses androgens and gonadotropins, though optimal dosing for endometrial protection is unknown 2

Insulin Resistance and Metabolic Management

• Prescribe metformin 500-2000 mg daily for patients with insulin resistance, glucose intolerance, or high metabolic risk (BMI >25 kg/m²) 2, 1, 4
• Start with 500 mg daily and titrate up to 1000-2000 mg daily in divided doses 1
• Metformin improves glucose tolerance over time and reduces risk of diabetes and cardiovascular disease 2, 3
• Consider GLP-1 receptor agonists (liraglutide 1.8-3 mg daily, semaglutide 1-2 mg weekly, or exenatide 5-10 μg twice daily or 2 mg weekly) in combination with lifestyle interventions for weight loss and metabolic control 1, 3

Persistent Hirsutism (After COC Trial)

• For bothersome hirsutism despite COCs, add antiandrogen therapy with spironolactone (50-200 mg daily) or finasteride, combined with mechanical hair removal methods 3
• Topical eflornithine hydrochloride cream is FDA-approved for hirsutism and can be used adjunctively 3
• Combined medical interventions (antiandrogen plus ovarian suppression agent) may be most effective 2

For Women ATTEMPTING to Conceive

Ovulation Induction (Sequential Approach)

1. First-line: Clomiphene citrate as initial pharmacological treatment, with approximately 80% of patients ovulating and 50% conceiving 2, 1

   • Start with lowest recommended dose and shortest treatment duration, especially in polycystic ovary syndrome patients who may have exaggerated response 5
   • If ovarian enlargement occurs, do not give additional clomiphene until ovaries return to pretreatment size 5
   • Monitor for visual symptoms (blurring, scotomata, phosphenes) and discontinue immediately if they occur 5
   • Watch for ovarian hyperstimulation syndrome (OHSS): early warning signs include abdominal pain/distention, nausea, vomiting, diarrhea, and weight gain 5

2. Second-line: Low-dose gonadotropin therapy if clomiphene fails, which induces high rate of monofollicular development with lower risk of ovarian hyperstimulation 1

3. Adjunctive: Metformin 1 g twice daily for 12 weeks or until pregnancy in pregestational stage to improve fertility outcomes 1

Critical Pitfall to Avoid

• Weight control and regular exercise programs should be started BEFORE medication, as lifestyle intervention improves ovulation rates independent of pharmacotherapy 2, 1

Special Population Considerations

Adolescents with PCOS

• 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 muscle and bone strengthening activities at least 3 times weekly 1
• Family support improves outcomes—structure activities considering family routines and cultural preferences 1

Lean PCOS Patients (Normal BMI)

• Do not dismiss lifestyle intervention in lean PCOS patients simply because they have normal BMI—insulin resistance requires management regardless of weight 1
• Insulin resistance is present irrespective of BMI and affects both lean and overweight women, contributing to hyperandrogenism through effects on pituitary, liver, and ovaries 1
• Focus on diet quality, regular physical activity, and behavioral strategies rather than caloric restriction 1
• Healthy lifestyle contributes to health and quality of life benefits even in absence of weight loss 1

High Cardiometabolic Risk Populations

• Ethnic groups (Asian, Hispanic, South Asian) with PCOS require lower BMI and waist circumference thresholds and greater consideration for lifestyle intervention 1, 3
• Use ethnic-specific cutoffs when assessing central obesity 1, 3

Postmenopausal Women with PCOS

• Continue annual diabetes screening with fasting glucose and 2-hour glucose tolerance test 3
• Monitor comprehensive fasting lipid profile regularly 3
• Continue multicomponent lifestyle intervention targeting cardiovascular risk reduction 3
• For persistent hirsutism, use spironolactone (50-200 mg daily) or finasteride with mechanical hair removal 3
• Standard menopausal hormone therapy guidelines apply—transdermal 17-β estradiol preferred over oral formulations to minimize thrombotic risk 3
• Continue screening for depression, anxiety, and body image concerns 3

Psychological Management Integration

When to Refer to Mental Health

• 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 for eating disorders (binge eating disorder, night eating syndrome), which are highly prevalent in PCOS and create vicious cycle worsening both obesity and hormonal disturbances 1
• Address body image concerns and psychological distress related to hair loss and PCOS symptoms, as these significantly impact treatment adherence 1