From the Guidelines
Polycystic ovary syndrome (PCOS) treatment should prioritize lifestyle modifications, including a balanced diet and regular exercise, as the foundation of therapy, as evidenced by a systematic review and meta-analysis of 39,471 women 1.
Key Components of PCOS Treatment
- Lifestyle modifications: weight loss of 5-10% can significantly improve symptoms, with a focus on a balanced diet low in refined carbohydrates and regular exercise (150 minutes weekly of moderate activity) 1.
- For menstrual irregularity and ovulation issues: combined hormonal contraceptives like ethinyl estradiol with progestins (e.g., Yaz, Yasmin) are recommended as first-line medications.
- Metformin (starting at 500mg daily, increasing to 1500-2000mg daily in divided doses) can help improve insulin sensitivity and may regulate periods.
- For hirsutism: spironolactone (50-200mg daily) can reduce excess hair growth, though results take 6-12 months, and topical eflornithine (Vaniqa) can slow facial hair growth.
- For acne: topical retinoids, benzoyl peroxide, or oral antibiotics may be prescribed alongside hormonal treatments.
Considerations for Women Seeking Pregnancy
- Ovulation induction using clomiphene citrate (50-150mg on cycle days 3-7) or letrozole (2.5-7.5mg on cycle days 3-7) may be beneficial for women seeking pregnancy.
Emerging Therapies
- Bariatric surgery is emerging as a potential adjunct therapy for PCOS in patients with excess weight, with a systematic review and meta-analysis showing improvements in hirsutism, menstrual regularity, and fertility 1.
Monitoring and Individualization
- Regular monitoring is essential as PCOS increases risks for diabetes, cardiovascular disease, and endometrial cancer.
- Treatment should be individualized based on specific symptoms, reproductive goals, and metabolic concerns, with consideration of the latest evidence from high-quality studies like the 2022 systematic review and meta-analysis 1 and the 2024 systematic review and meta-analysis on bariatric surgery 1.
From the FDA Drug Label
Clomiphene citrate is indicated for the treatment of ovulatory dysfunction in women desiring pregnancy. Those patients most likely to achieve success with clomiphene therapy include patients with polycystic ovary syndrome (see WARNINGS: Ovarian Hyperstimulation Syndrome), amenorrhea-galactorrhea syndrome, psychogenic amenorrhea, post-oral-contraceptive amenorrhea, and certain cases of secondary amenorrhea of undetermined etiology.
PCOS Treatment with Clomiphene Citrate
- Clomiphene citrate is indicated for the treatment of ovulatory dysfunction in women with PCOS who desire pregnancy.
- The medication should be used with caution in patients with PCOS due to the risk of Ovarian Hyperstimulation Syndrome (OHSS).
- Patients with PCOS should be started on the lowest recommended dose and shortest treatment duration for the first course of therapy.
- The potential benefit of subsequent clomiphene citrate therapy in patients with PCOS should exceed the risk, and the dosage or duration of the next course should be reduced if ovarian enlargement occurs 2.
From the Research
PCOS Treatment Options
- Lifestyle modifications, such as dietary changes and physical activity, are suggested as first-line interventions in managing PCOS 3, 4
- Dietary interventions, including foods with low glycemic index scores, caloric restrictions, and high-fiber diets, can improve insulin sensitivity and hormonal balance in women with PCOS 3
- Physical activity, such as aerobic and resistance exercise, can enhance insulin sensitivity, help with weight loss, and improve metabolic and reproductive outcomes in women with PCOS 3
Medical Treatment Options
- Gonadotropins, such as follicle-stimulating hormone (FSH), can be used as a second-line treatment for ovulation induction in women with PCOS who do not ovulate or conceive on clomiphene citrate or letrozole 5
- Letrozole, an aromatase inhibitor, can induce ovulation without anti-estrogenic effects and may be a viable alternative to clomiphene citrate 6, 7
- Metformin can be used in combination with letrozole or clomiphene citrate to improve ovulatory response and pregnancy rates in women with PCOS 6, 7
Comparison of Treatment Options
- There may be little or no difference in live birth rates between recombinant FSH (rFSH) and urinary-derived gonadotropins in women with PCOS 5
- Letrozole may be associated with higher full-term pregnancy rates compared to clomiphene citrate in women with PCOS 6
- Clomiphene citrate may still be recommended as the first-line therapy for ovulation induction in women with PCOS, despite similar efficacy to letrozole 7