Treatment for PCOS
Multicomponent lifestyle intervention combining diet, exercise, 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 requires management independent of BMI. 1, 2
Understanding the Critical Foundation
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 This is why lifestyle intervention cannot be dismissed even in normal-weight patients—the metabolic dysfunction requires active management regardless of body habitus. 1
Dietary Management
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, body weight, and physical activity levels. 1, 3
For all women with PCOS: No specific diet type has proven superior; any balanced dietary approach creating an energy deficit is acceptable. 1, 3 Focus on patient preferences and cultural needs while following general healthy eating principles. 1, 3 Recent 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, 4
Achievable weight loss goals: Target 5-10% weight loss in those with excess weight, as this yields significant clinical improvements in metabolic and reproductive abnormalities. 1, 2, 3
Physical Activity Prescription
Minimum for health maintenance: At least 150 minutes/week of moderate-intensity physical activity (brisk walking, cycling 8-15 km/h, low-impact aerobics, yoga) OR 75 minutes/week of vigorous-intensity activity (jogging/running, high-impact aerobics, competitive sports) or equivalent combination. 1, 2, 3
For weight loss and greater metabolic benefits: At least 250 minutes/week of moderate-intensity activities OR 150 minutes/week of vigorous-intensity activities or equivalent combination. 1, 3
Muscle strengthening: Include resistance training activities involving major muscle groups on 2 non-consecutive days per week. 1, 2, 3 Both aerobic and resistance exercises improve insulin sensitivity and metabolic outcomes in PCOS. 1, 3
Practical implementation: Perform activity in at least 10-minute bouts, aiming for at least 30 minutes daily on most days, targeting 10,000 steps daily. 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 for step count and exercise intensity. 1, 2, 3
Include behavioral change techniques: goal-setting, self-monitoring, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention. 1, 2, 3
Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence. 1
Address psychological factors: Screen for and actively manage anxiety, depression, body image concerns, and disordered eating, as these dramatically reduce adherence to lifestyle interventions. 1 Refer patients with moderately severe depression to psychiatry or behavioral health for evaluation and potential pharmacotherapy. 1
Medical Management
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 A typical regimen is drospirenone 3 mg/ethinyl estradiol 20 μg in a 24-active/4-inert pill regimen, taken daily. 1
Metformin 500-2000 mg daily for patients with insulin resistance or glucose intolerance, starting at 500 mg daily and titrating 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
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
For hirsutism: Combined medical interventions (antiandrogen plus ovarian suppression agent) may be most effective. 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, 5 Weight control and regular exercise programs should be started before medication. 1
If clomiphene fails: Low-dose gonadotropin therapy should be used, which induces a high rate of monofollicular development with lower risk of ovarian hyperstimulation. 1
Pregestational metformin: Consider metformin 1 g twice daily for 12 weeks or until pregnancy in the pregestational stage. 1
Critical Pitfalls 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
Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma which negatively impacts treatment engagement. 1, 3
Monitor for ovarian hyperstimulation syndrome (OHSS) in patients receiving clomiphene citrate, especially those with polycystic ovary syndrome who may be unusually sensitive to gonadotropin and have an exaggerated response to usual doses. 6 Start with the lowest recommended dose and shortest treatment duration for the first course. 6 Early warning signs include abdominal pain and distention, nausea, vomiting, diarrhea, and weight gain. 6
Visual symptoms with clomiphene: Patients with any visual symptoms (blurring, scotomata, phosphenes) should discontinue treatment immediately and have complete ophthalmological evaluation. 6
Monitoring and Follow-Up
Regular monitoring of weight and waist circumference is essential during weight loss and maintenance. 1, 3 Use ethnic-specific BMI and waist circumference categories for Asian, Hispanic, and South Asian populations, who require lower thresholds and greater consideration for lifestyle intervention. 1, 3
Fortnightly review for the first 3 months with structured dietary and physical activity plans, and regular review for the first 12 months to ensure adherence and adjust interventions. 1
Special Population Considerations
Adolescents: Prevention of weight gain and monitoring should begin from adolescence, as weight gain escalates from this period. 1, 3 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
Ethnic populations at high cardiometabolic risk: Asian, Hispanic, and South Asian populations require greater consideration for lifestyle intervention with lower BMI and waist circumference thresholds. 1, 3