Treatment of Polycystic Ovary Syndrome (PCOS)

Foundational Lifestyle Intervention

The American Academy of Family Physicians recommends weight loss of just 5% of initial body weight through lifestyle modification as the mandatory first-line treatment for all women with PCOS, regardless of reproductive goals, as it improves metabolic, reproductive, and hormonal outcomes 1, 2
Target an energy deficit of 500-750 kcal/day, with total intake of 1,200-1,500 kcal/day adjusted for individual energy requirements 2
Any balanced dietary approach creating an energy deficit is acceptable—no specific diet type has proven superior in PCOS 1, 2
Prescribe at least 150 minutes/week of moderate-intensity exercise or 75 minutes/week of vigorous activity, plus muscle-strengthening activities on 2 non-consecutive days/week for weight maintenance 2
Exercise provides metabolic benefits even without weight loss 1, 2

For women not attempting to conceive, combined oral contraceptive pills (OCPs) are the first-line pharmacological treatment, as they suppress ovarian androgen secretion, increase sex hormone-binding globulin, regulate menstrual cycles, prevent endometrial hyperplasia, and reduce hirsutism and acne 1, 2, 3
Add metformin 500-2000 mg daily when insulin resistance or glucose intolerance is documented, lifestyle modifications alone are insufficient for metabolic control, or the patient has obesity or elevated cardiovascular risk factors 2
For hirsutism specifically, combine OCP with spironolactone 50-200 mg daily, as this combination provides superior results compared to monotherapy 3, 5

Screen all PCOS patients for metabolic abnormalities at diagnosis and at least annually, including fasting glucose, 2-hour glucose tolerance test, fasting lipid profile, and calculation of BMI and waist-hip ratio 2, 7
Use ethnic-specific BMI and waist circumference categories for Asian, Hispanic, and South Asian populations who are at higher cardiometabolic risk 2

GLP-1 receptor agonists show promise for weight reduction and metabolic improvement when combined with lifestyle interventions, and may be considered for patients with obesity or elevated cardiovascular risk factors when lifestyle and metformin are insufficient 2
Bariatric surgery is emerging as a potential adjunct therapy for PCOS patients with clinically severe obesity, with reported improvements in hirsutism, menstrual regularity, and fertility 8

Do not delay lifestyle intervention, as it must be the foundation of treatment 2, 7
Do not assume normal weight excludes metabolic dysfunction, and screen all PCOS patients regardless of BMI 2, 7
Do not use spironolactone as monotherapy in patients attempting to conceive, and use clomiphene citrate instead 3, 7
Do not exceed recommended clomiphene dosage and duration, and limit to six total cycles 1, 7