What is the recommended management for a woman with polycystic ovary syndrome, including lifestyle modification, combined oral contraceptives, metformin, and fertility‑inducing agents?

PCOS Treatment

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 both lean and overweight patients and drives hyperandrogenism through effects on the pituitary, liver, and ovaries. 1, 2, 3

First-Line Treatment: Lifestyle Modification

Dietary Management

• Create an energy deficit of 500-750 kcal/day, targeting 1,200-1,500 kcal/day total intake for women with overweight or obesity, adjusted to individual energy requirements 1, 2
• Focus on diet quality rather than strict caloric restriction, as insulin resistance affects all patients regardless of BMI 1
• Prioritize low glycemic index foods, high-fiber intake, and omega-3 fatty acid-rich diets to improve insulin sensitivity and hormonal balance 1, 4
• No specific diet type (Mediterranean, ketogenic, anti-inflammatory) has proven superior—choose based on patient preferences and cultural needs while maintaining balanced nutrition 2, 4
• Target 5-10% weight loss within 6 months for those with excess weight, which yields significant clinical improvements in menstrual regularity, ovulation, and metabolic parameters 1, 2

Physical Activity Prescription

• Prescribe at least 150 minutes/week of moderate-intensity exercise OR 75 minutes/week of vigorous-intensity activity, performed in bouts of at least 10 minutes 1, 2
• Include muscle-strengthening activities involving major muscle groups on 2 non-consecutive days per week 1, 2
• For weight loss specifically, increase to at least 250 minutes/week of moderate-intensity OR 150 minutes/week of vigorous-intensity activity 2
• Target 10,000 steps daily, including at least 30 minutes of structured physical activity 2
• Minimize sedentary, screen, and sitting time throughout the day 2
• Both aerobic and resistance exercises improve insulin sensitivity independent of weight loss 2, 4

Behavioral Strategies

• Implement SMART goal setting (Specific, Measurable, Achievable, Realistic, Timely) with self-monitoring using fitness tracking devices 1, 2
• Start with realistic 10-minute activity bouts and progressively increase by 5% weekly 2
• Include stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention 1, 2
• Address psychological factors including anxiety, depression, body image concerns, and disordered eating, as these dramatically reduce adherence to lifestyle interventions 2, 3
• Screen for eating disorders (binge eating disorder, night eating syndrome), which are highly prevalent in PCOS and worsen both obesity and hormonal disturbances 2

Medical Management for Women NOT Attempting Conception

Hormonal Therapy

• Use combined oral contraceptives (COCs) as first-line hormonal therapy for menstrual cycle regulation and hyperandrogenism, as they suppress ovarian androgen secretion, increase sex hormone-binding globulin, regulate menstrual cycles, prevent endometrial hyperplasia, and reduce hirsutism and acne 1, 2
• Consider drospirenone 3 mg/ethinyl estradiol 20 μg in a 24-active/4-inert pill regimen as an effective COCP option 2
• Medroxyprogesterone acetate can be used to suppress circulating androgen and pituitary gonadotropin levels, though optimal dosing for endometrial protection is not established 2

Insulin-Sensitizing Agents

• Prescribe metformin 500-2000 mg daily for patients with insulin resistance or glucose intolerance, starting at 500 mg daily and titrating to 1000-2000 mg daily in divided doses 2, 3
• Metformin improves glucose tolerance over time and may positively impact diabetes and cardiovascular risk factors 1, 2
• Consider GLP-1 receptor agonists (liraglutide 1.8-3 mg daily, semaglutide 1-2 mg weekly, or exenatide 5-10 μg twice daily) in combination with lifestyle interventions for weight loss and metabolic control 2

Antiandrogen Therapy

• Combined medical interventions (antiandrogen plus ovarian suppression agent) may be most effective for hirsutism 1, 2

Medical Management for Women ATTEMPTING Conception

Ovulation Induction

• Use clomiphene citrate as first-line pharmacological treatment for ovulation induction, which achieves 80% ovulation rate with 50% of those conceiving 1, 2
• If clomiphene fails, use low-dose gonadotropin therapy to induce monofollicular development with lower risk of ovarian hyperstimulation 1
• Metformin 1 g twice daily for 12 weeks or until pregnancy can be used in the pregestational stage, though it should not be used as first-line therapy alone since clomiphene or letrozole are much more effective 2, 5
• Metformin alone increases ovulation rate compared to placebo but is inferior to oral ovulation induction agents for pregnancy and live-birth rates 5

Monitoring and Follow-Up

• Monitor weight and waist circumference regularly using ethnic-specific cutoffs (lower thresholds for Asian, Hispanic, and South Asian populations) 1, 2
• Conduct fortnightly review for the first 3 months with structured dietary and physical activity plans, then regular review for the first 12 months 2
• Begin prevention of weight gain and monitoring from adolescence, as weight gain escalates from this period 2
• Refer patients with moderately severe depression to psychiatry or behavioral health for evaluation and potential pharmacotherapy 2

Critical Pitfalls to Avoid

• Do not dismiss lifestyle intervention in normal-weight PCOS patients—insulin resistance requires management regardless of BMI 1, 2, 3
• Do not recommend overly restrictive or nutritionally unbalanced diets 1, 2
• Do not use herbal supplements (including evening primrose oil) as primary therapy instead of evidence-based interventions 2
• Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma which negatively impacts treatment engagement 2
• Recognize that weight gain accelerates over time in PCOS, making early intervention crucial 1

Special Population Considerations

• For adolescents with PCOS, prescribe at least 60 minutes of moderate to vigorous intensity physical activity daily, including muscle and bone strengthening activities at least 3 times weekly 2
• Ethnic groups at high cardiometabolic risk require greater consideration for lifestyle intervention with lower BMI and waist circumference thresholds 2
• Structure activities considering women's family routines and cultural preferences, as family support improves outcomes 2
• Central obesity increases progressively with waist-to-hip ratio rising between ages 20-45 years, requiring early vigilance 2