What is the recommended treatment for Polycystic Ovarian Disease (PCOD)?

Treatment of PCOD (Polycystic Ovarian Disease)

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 the core pathophysiology of hyperandrogenism, anovulation, and metabolic dysfunction. 1, 2

Why Lifestyle Intervention Works for All Body Types

Insulin resistance is present in PCOS irrespective of BMI and affects both lean and overweight women, contributing to hyperandrogenism through effects on the pituitary (increasing LH secretion), liver (reducing sex hormone-binding globulin), and ovaries (stimulating androgen production). 1, 2 Hyperinsulinemia resulting from insulin resistance worsens all PCOS symptoms, making lifestyle intervention essential even in normal-weight patients. 2

Critical pitfall 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

Dietary Management

For Women with Excess Weight (BMI ≥25 kg/m²)

• Create a daily energy deficit of 500-750 kcal, targeting total intake of 1,200-1,500 kcal/day, adjusted for individual energy requirements, body weight, and physical activity levels. 1, 2, 3
• Aim for 5-10% weight loss within 6 months, which produces clinically meaningful improvements in insulin resistance, ovulation frequency, fertility potential, and circulating androgen concentrations. 1, 3

For All Women (Including Normal Weight)

• No specific diet type is superior; any balanced dietary approach creating an energy deficit is acceptable, with focus on patient preferences and cultural needs while following general healthy eating principles. 1, 3
• Reduce intake of sugar-sweetened beverages, fruit juice, and refined carbohydrates; prefer foods with lower glycemic index. 3, 4
• Incorporate legumes, whole grains, nuts, and seeds—food sources rich in myo-inositol—to aid in managing both cardiometabolic disturbances and reproductive dysfunction. 1
• Increase fish intake (4 times/week) or take omega-3 fatty acid supplements to address the omega-6/omega-3 PUFA ratio imbalance common in PCOS. 5, 4
• Divide food intake into small, frequent meals with high caloric intake at breakfast. 5

Micronutrient Optimization

• Routinely assess and supplement magnesium, folic acid, zinc, and B-vitamin complex, as women with PCOS commonly have suboptimal intake of these micronutrients. 1
• Take vitamin D supplementation if serum levels are low. 5
• Consider chromium supplementation if serum levels are low. 5

Physical Activity Prescription

Minimum Requirements for Weight Maintenance and Health

• Perform at least 150 minutes/week of moderate-intensity aerobic 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
• Include muscle-strengthening activities involving major muscle groups on 2 non-consecutive days per week. 1, 2, 3

Enhanced Requirements for Weight Loss

• Increase to at least 250 minutes/week of moderate-intensity activities OR 150 minutes/week of vigorous-intensity activities, or equivalent combination. 1, 3

Activity Structure

• Perform activity in bouts of at least 10 minutes (approximately 1,000 steps per bout), aiming for 10,000 steps daily, including at least 30 minutes of structured physical activity. 1
• Minimize sedentary, screen, and sitting time throughout the day. 1, 3
• Both aerobic and resistance exercises improve insulin sensitivity independent of weight loss. 1, 3, 4

Special Considerations for Adolescents

• Encourage at least 60 minutes/day of moderate-to-vigorous intensity physical activity, incorporating muscle- and bone-strengthening exercises at least 3 times weekly. 1
• Begin weight-gain prevention and monitoring from early adolescence, as weight gain escalates from this period. 1, 3

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
• Start with realistic 10-minute activity bouts and progressively increase total physical activity by 5% weekly up to and above recommendations. 1
• Include comprehensive behavioral change techniques: goal-setting, stimulus control, problem-solving, assertiveness training, slower eating, positive reinforcement, and relapse prevention planning. 1, 2, 3

Psychological Screening and Management

Screen for eating-disorder phenotypes (binge-eating disorder, night-eating syndrome) because these conditions are highly prevalent in PCOS and exacerbate obesity and hormonal imbalance. 1

• Address anxiety, depression, body-image concerns, and emotional-eating patterns, as these psychosocial factors markedly diminish adherence to lifestyle interventions. 1
• 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

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
• Typical COCP dosing: drospirenone 3 mg/ethinyl estradiol 20 μg in a 24-active/4-inert pill regimen, taken daily. 1
• Metformin 500-2000 mg daily improves glucose tolerance and may have a positive impact on risk factors for diabetes and cardiovascular disease; start with 500 mg daily and titrate up 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 can improve weight loss and metabolic control. 1
• Combined medical interventions (antiandrogen plus ovarian suppression agent) may be most effective for hirsutism. 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, 6
• Start with 50 mg daily for 5 days beginning on cycle day 5; if ovulation does not occur, increase to 100 mg daily for 5 days in the next cycle. 6
• If ovulation does not occur after three courses of therapy, further treatment with clomiphene citrate is not recommended and the patient should be reevaluated. 6
• Metformin 1 g twice daily for 12 weeks or until pregnancy can be used in the pregestational stage to improve fertility outcomes. 1

Monitoring and Follow-Up

• Conduct 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
• Regularly monitor weight and waist circumference throughout both weight-loss and maintenance phases. 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

Expected Outcomes

Achieving 5-10% weight loss in overweight/obese patients leads to significant improvements in metabolic parameters, ovulatory frequency, fertility, and reduces long-term endometrial cancer risk. 1, 3 Even without measurable weight loss, lifestyle modification enhances quality of life and overall health. 1, 3

Ensure health professional interactions are respectful and patient-centered, avoiding weight-related stigma which negatively impacts treatment engagement. 1, 3