What are the current international guidelines for the assessment and management of polycystic ovary syndrome (PCOS)?

Current Guidelines for PCOS Management

Multicomponent lifestyle intervention—combining dietary modification, structured physical activity, and behavioral strategies—is the mandatory first-line treatment for all women with PCOS, regardless of body weight, because insulin resistance affects every PCOS patient independent of BMI. 1, 2

Diagnostic Approach

Essential Diagnostic Criteria

• Use the Rotterdam criteria requiring two of three features: hyperandrogenism, ovulatory dysfunction, or polycystic ovaries 3, 4
• When hyperandrogenism and ovulatory dysfunction are both present, ultrasound is unnecessary for diagnosis in adult women 5, 4
• Anti-Müllerian hormone (AMH) levels can substitute for ultrasound in adults only 4

Initial Laboratory Workup

• Measure TSH, prolactin, total or free testosterone, fasting glucose, and fasting lipid panel to exclude other causes of androgen excess (Cushing's syndrome, androgen-secreting tumors, nonclassic congenital adrenal hyperplasia, thyroid disease, hyperprolactinemia) 2
• Calculate BMI and measure waist circumference using ethnic-specific cutoffs—Asian, Hispanic, and South Asian populations require lower thresholds 1, 2

Critical Diagnostic Pitfall

• In adolescents within 8 years of menarche, diagnosis requires both hyperandrogenism and ovulatory dysfunction; do not perform ultrasound due to overlap with normal ovarian physiology 5, 3

---

First-Line Lifestyle Management

Dietary Prescription

• Create an energy deficit of 500-750 kcal/day (target total intake 1,200-1,500 kcal/day) for those with elevated BMI 6, 1
• No specific diet type is superior—any balanced approach creating energy deficit is acceptable; prioritize patient preferences and cultural needs 1, 2
• Reduce sugar-sweetened beverages, fruit juice, and refined carbohydrates 1
• Incorporate legumes, whole grains, nuts, and seeds (myo-inositol sources) 1
• Avoid unduly restrictive or nutritionally unbalanced diets that may trigger disordered eating 1, 7

Physical Activity Prescription

• For weight maintenance and health: minimum 150 minutes/week of moderate-intensity activity OR 75 minutes/week of vigorous-intensity activity 6, 1
• Include muscle-strengthening activities involving major muscle groups on 2 non-consecutive days/week 6, 1
• For weight loss: minimum 250 minutes/week of moderate-intensity OR 150 minutes/week of vigorous-intensity activity 6, 1
• Perform activity in at least 10-minute bouts (approximately 1,000 steps), targeting 10,000 steps daily including 30 minutes of structured activity 6, 1
• Minimize sedentary, screen, and sitting time throughout the day 6, 1
• Both aerobic and resistance exercises improve insulin sensitivity independent of weight loss 1

Adolescent-Specific Targets

• At least 60 minutes of moderate-to-vigorous intensity physical activity daily 6, 1
• Include muscle and bone strengthening activities at least 3 times weekly 6
• Prevention of weight gain and monitoring should begin from adolescence 6, 1

Behavioral Strategies (Essential Component)

• Implement SMART goal setting (specific, measurable, achievable, realistic, timely) with self-monitoring using fitness tracking devices 6, 1
• Start with realistic 10-minute activity bouts, progressively increasing physical activity by 5% weekly 6, 1
• Include goal-setting, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 6, 1
• Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence 6, 1

Achievable Weight Loss Goals

• Target 5-10% weight loss in those with excess weight—this yields significant clinical improvements in insulin resistance, ovulation frequency, fertility, and androgen levels 1, 2
• Healthy lifestyle contributes to health and quality of life benefits even without weight loss 6, 1

---

Mandatory Psychological Assessment and Management

Screening Requirements

• Screen all women with PCOS at initial presentation and regularly throughout treatment for anxiety, depression, body image concerns, and disordered eating 7, 2
• Screen specifically for binge-eating disorder and night-eating syndrome, which are highly prevalent in PCOS and create a vicious cycle worsening obesity and hormonal disturbances 1, 7

Integration with Treatment

• Address psychological barriers simultaneously when prescribing lifestyle modifications—mental health issues directly undermine adherence to diet and exercise interventions 7
• 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

Critical Communication Approach

• Ensure all interactions are respectful and patient-centered, explicitly avoiding weight-related stigma 1, 7
• Frame discussions around health improvements and metabolic benefits rather than weight-focused language 7
• Provide explanations on assessment purpose, seek permission, and explain implications of results 6

Common Pitfall to Avoid

• Do not initiate aggressive lifestyle interventions without first addressing underlying anxiety, depression, or eating disorders—this leads to poor adherence and treatment failure 7

---

Medical Management

For Women NOT Attempting to Conceive

• Combined oral contraceptive pills 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
• Metformin 500-2000 mg daily improves glucose tolerance and may reduce risk of diabetes and cardiovascular disease; start at 500 mg daily and titrate to 1000-2000 mg daily in divided doses 1, 2
• 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 improve weight loss and metabolic control 1
• Combined medical interventions (antiandrogen plus ovarian suppression agent) may be most effective for hirsutism 1, 2

For Women ATTEMPTING to Conceive

• Letrozole is now first-line treatment for infertility because it improves live birth rates while reducing multiple pregnancies compared with clomiphene citrate 5
• If letrozole unavailable, clomiphene citrate remains an option—approximately 80% of patients ovulate and 50% conceive 1, 2
• Weight control and regular exercise programs should be started before medication 2
• If clomiphene treatment fails, use low-dose gonadotropin therapy 2
• Metformin 1 g twice daily for 12 weeks or until pregnancy can be used in the pregestational stage 1

---

Monitoring and Follow-Up

Weight and Metabolic Monitoring

• Regular monitoring of weight and waist circumference during weight loss and maintenance phases 6, 1
• Fortnightly review for the first 3 months with structured dietary and physical activity plans 1
• Regular review for the first 12 months to ensure adherence and adjust interventions 1
• Assess blood pressure, HbA1c, and lipid status regularly 2

Screening for Complications

• Screen for metabolic syndrome elements, type 2 diabetes risk, and cardiovascular disease risk 2, 8
• Screen for obstructive sleep apnea 9
• Recognize high risk status for adverse outcomes during pregnancy 4

---

Special Population Considerations

Ethnic-Specific Thresholds

• Asian, Hispanic, and South Asian populations require lower BMI and waist circumference thresholds for intervention due to high cardiometabolic risk 1, 2
• Use ethnic-specific categories when optimizing lifestyle and weight interventions 6, 1

Lean PCOS Patients (Critical Concept)

• 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 the pituitary, liver, and ovaries 1
• Focus on diet quality rather than caloric restriction for thin women 1

Family and Cultural Considerations

• Structure recommended activities considering women's and family routines as well as cultural preferences 6, 1
• Family support improves outcomes 6, 1
• Value women's individualized preferences and cultural, socio-economic, and ethnic differences 7

---

Micronutrient Optimization

• Women with PCOS commonly have suboptimal intake of magnesium, folic acid, zinc, and B-vitamin complex; routine assessment and supplementation are recommended 1

---

What NOT to Recommend

• Do not recommend evening primrose oil or other herbal supplements as primary therapy—guidelines support evidence-based lifestyle and medical interventions with proven efficacy instead 1
• Patients should not delay evidence-based treatment while pursuing unproven complementary therapies 1
• Thiazolidinediones have an unfavorable risk-benefit ratio overall 9