From the Guidelines
The best treatment for polycystic ovarian syndrome (PCOS) is a combination approach tailored to each patient's specific symptoms and goals, with lifestyle modification, including dietary changes and physical activity, as the first-line therapy, as recommended by the most recent study in 2022 1.
Key Components of PCOS Treatment
- For women not trying to conceive, combined hormonal contraceptives are typically first-line treatment, regulating periods and reducing androgen levels.
- Metformin helps improve insulin sensitivity and may be particularly beneficial for women with insulin resistance or diabetes risk.
- For those seeking pregnancy, ovulation induction medications like clomiphene citrate or letrozole are recommended.
- Weight management through diet and regular exercise is crucial for all PCOS patients, as even modest weight loss of 5-10% can significantly improve symptoms.
- Anti-androgen medications like spironolactone may be added to address hirsutism and acne.
Importance of Recent Evidence
The most recent study in 2024 1 highlights the impact of bariatric surgery on anthropometric, metabolic, and reproductive outcomes in PCOS, suggesting that it may be a potential adjunct therapy for PCOS patients with excess weight.
Considerations for Treatment
- Treatment should be individualized based on the patient's specific symptoms, goals, and medical history.
- A multi-faceted approach is necessary to address the hormonal imbalances, metabolic dysfunction, and reproductive issues associated with PCOS.
- Lifestyle modification, including dietary changes and physical activity, should be the foundation of treatment, with medication and other interventions added as needed.
From the FDA Drug Label
Clomiphene citrate is indicated for the treatment of ovulatory dysfunction in women desiring pregnancy. Impediments to achieving pregnancy must be excluded or adequately treated before beginning clomiphene citrate therapy Those patients most likely to achieve success with clomiphene therapy include patients with polycystic ovary syndrome Clomiphene citrate should not be used in patients with ovarian enlargement except those with polycystic ovary syndrome.
The best treatment for polycystic ovarian syndrome (PCOS) is clomiphene citrate for patients with demonstrated ovulatory dysfunction, as it can help induce ovulation.
- Key considerations for using clomiphene citrate in PCOS patients include:
- Starting with the lowest recommended dose and shortest treatment duration for the first course of therapy
- Monitoring for ovarian enlargement and adjusting the dosage or duration of the next course if necessary
- Managing ovarian cysts conservatively, unless surgical indication for laparotomy exists 2
- Being aware of the potential risk of ovarian hyperstimulation syndrome (OHSS), particularly in patients with PCOS who are unusually sensitive to gonadotropin 2
From the Research
Treatment Options for Polycystic Ovarian Syndrome (PCOS)
The treatment for PCOS is mainly symptomatic and involves lifestyle interventions and medications. The following are some of the treatment options:
- Lifestyle modification (LSM) is considered the first-line treatment, regardless of fertility status, without the addition of metformin 3
- Oral contraceptive (OC) pills should be used as a first-line treatment for long-term management for patients with no reproductive requirements 3
- For patients with fertility requirements, ovulation therapy is an effective treatment 3
- Metformin, Oral contraceptives, and Antiandrogens are commonly used medications for PCOS 4
- Novel therapeutic modalities for treatment/management of PCOS include the use of newer insulin sensitizers, such as Inositols, Glucagon-like peptide-1(GLP-1) agonists, Dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium-glucose transport protein 2 (SGLT2) inhibitors 4
- Letrozole is a better option than combined Clomiphene and metformin for inducing ovulation in patients with Clomiphene-resistant PCOS, with higher clinical pregnancy rate and unexpectedly higher multiple pregnancy rate 5
Pharmacologic Treatments for PCOS
Pharmacologic treatments for PCOS include:
- Clomiphene citrate
- Letrozole
- Metformin
- Oral contraceptives
- Antiandrogens
- Newer insulin sensitizers, such as Inositols, Glucagon-like peptide-1(GLP-1) agonists, Dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium-glucose transport protein 2 (SGLT2) inhibitors 4, 6
- Combination treatment of clomiphene citrate with letrozole may potentially improve fertility outcomes in PCOS subfertility in terms of the likelihood of ovulation and higher post-ovulatory progesterone levels 7
Fertility Outcomes
Fertility outcomes following combined Clomiphene and Letrozole versus Letrozole therapy for the treatment of PCOS subfertility have been studied, and the results suggest that combination treatment may improve fertility outcomes 7