What is the first-line management of polycystic ovary syndrome in a reproductive-age woman?

First-Line Management of PCOS in Reproductive-Age Women

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 requires management independent of BMI. 1, 2

Why Lifestyle Intervention is Universal First-Line Therapy

The critical understanding here is that 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 means even normal-weight women with PCOS require lifestyle intervention—a common pitfall is dismissing lifestyle modification in lean patients simply because they have normal BMI. 1

Dietary Management

For Women with Elevated BMI:

• Create a daily energy deficit of 500-750 kcal (target total intake approximately 1,200-1,500 kcal/day), considering individual energy requirements. 1, 2
• Target 5-10% weight loss, which yields significant clinical improvements in insulin resistance, ovulation frequency, fertility potential, and circulating androgen concentrations. 1, 2

For All Women (Including Normal Weight):

• No specific diet type has proven superior; focus on patient preferences and cultural needs while maintaining a healthy balanced diet. 1
• 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, 3
• Avoid unduly restrictive or nutritionally unbalanced diets. 1

Physical Activity Prescription

Minimum Requirements:

• Prescribe at least 150 minutes/week of moderate-intensity physical activity OR 75 minutes/week of vigorous-intensity activity (or equivalent combination). 1, 2
• Include muscle-strengthening activities involving major muscle groups on 2 non-consecutive days per week. 1, 2
• Structure activity in bouts of at least 10 minutes (approximately 1,000 steps per bout), aiming for at least 30 minutes daily on most days. 1

For Weight Loss:

• Increase to at least 250 minutes/week of moderate-intensity activities OR 150 minutes/week of vigorous-intensity activity. 1

Additional Guidance:

• Both aerobic and resistance exercises show benefits in PCOS, improving insulin sensitivity independent of weight loss. 1, 3
• Minimize sedentary, screen, and sitting time throughout the day. 1
• Start with realistic 10-minute activity bouts and progressively increase physical activity by 5% weekly. 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
• Include behavioral change techniques: goal-setting, stimulus control, problem-solving, assertiveness training, slower eating, reinforcing changes, and relapse prevention. 1, 2
• Consider comprehensive behavioral or cognitive behavioral interventions to increase engagement and adherence. 1

Addressing Psychological Barriers

This is critical and often overlooked: Screen for and address anxiety, depression, body image concerns, and disordered eating (particularly binge eating disorder and night eating syndrome), 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 (Adjunctive to Lifestyle)

For Women NOT Attempting to Conceive:

• Combined oral contraceptives 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, 4
• A typical regimen is drospirenone 3 mg/ethinyl estradiol 20 μg in a 24-active/4-inert pill regimen, taken daily. 1

For Metabolic Management:

• Metformin 500-2000 mg daily (starting at 500 mg daily and titrating up to 1000-2000 mg daily in divided doses) for patients with insulin resistance or glucose intolerance. 1, 2
• GLP-1 receptor agonists (liraglutide, semaglutide, exenatide) in combination with lifestyle interventions for weight loss and metabolic control. 1, 5

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, 4
• Weight control and regular exercise programs should be started before medication. 1

Monitoring and Follow-Up

• Regular monitoring of weight and waist circumference during both weight loss and maintenance phases. 1
• Use ethnic-specific BMI and waist circumference categories (lower thresholds for Asian, Hispanic, and South Asian populations who are at higher cardiometabolic risk). 1
• Fortnightly review for the first 3 months with structured dietary and physical activity plans, and regular review for the first 12 months. 1

Critical Pitfall to Avoid

Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma, which negatively impacts treatment engagement and adherence. 1 Structure recommended activities considering women's family routines and cultural preferences, as family support improves outcomes. 1