Treating PCOS: From Lifestyle to Medication to Assisted Reproduction

Introduction

There is no cure for PCOS, but it is one of the most manageable endocrine conditions when approached systematically. Treatment is personalised to the woman\'s primary concerns and her reproductive plans. The 2023 International PCOS Guideline provides the most comprehensive and up-to-date evidence-based framework — and it consistently places lifestyle modification as the cornerstone of management, ahead of or alongside all pharmacological interventions.

1. Lifestyle Modification: The Foundation

For all women with PCOS, regardless of phenotype or BMI, lifestyle optimisation is recommended first-line. For those who are overweight:

• 5–10% weight loss significantly improves insulin resistance
• reduces androgen levels
• restores ovulation in 40–50% of anovulatory women
• and improves metabolic and psychological outcomes.
• Even weight neutral lifestyle interventions (when BMI is normal) improve insulin sensitivity and cycle regularity.
• Dietary approaches: Low-glycaemic index (GI) diet or Mediterranean diet have the most evidence for reducing insulin resistance in PCOS. Both approaches emphasise whole grains
• legumes
• vegetables
• lean protein
• and healthy fats while limiting refined carbohydrates and ultra-processed foods.
• Exercise: Both aerobic exercise and resistance training improve insulin sensitivity. A combination of moderate aerobic exercise (150 min/week) and resistance training 2–3 times/week is recommended.
• Sustained behaviour change is the goal — crash dieting is counterproductive and may worsen HPA axis dysfunction.

2. Menstrual Regulation and Contraception

For women who do not wish to conceive, managing irregular cycles (and preventing complications from anovulatory, estrogen-unopposed cycles) is a primary goal.

3. Treating Insulin Resistance and Metabolic Complications

• Metformin: Reduces hepatic glucose production
• improves insulin sensitivity. Evidence for: improving cycle regularity
• modest androgen reduction
• preventing progression to type 2 diabetes
• and as adjunct to ovulation induction. Recommended by the 2023 guideline for all women with PCOS and impaired glucose regulation
• and is reasonable in those with BMI ≥25.
• Management of dyslipidaemia: Statins if indicated by cardiovascular risk.
• Blood pressure: ACE inhibitors or ARBs if hypertension present.
• Screening: Annual fasting glucose
• lipid profile; OGTT every 2 years in high-risk women; blood pressure monitoring.

4. Treating Hyperandrogenism (Hirsutism and Acne)

5. Fertility Treatment (see Article 26 for full detail)

Letrozole is first-line for ovulation induction. Clomiphene second-line. Gonadotrophins third-line. IVF if other approaches fail or co-morbid infertility factors exist. Metformin as adjunct in insulin-resistant women.

6. Psychological Support

Mental health screening is recommended at every clinical encounter with PCOS patients. Up to 67% of women with PCOS experience anxiety or depression. Validated screening tools (PHQ-9 for depression, GAD-7 for anxiety) should be used. Referral to psychology or psychiatry should be low-threshold. Online and peer support groups can complement clinical care.

References: 2023 International PCOS Guideline; ACOG Practice Bulletin on PCOS; Teede H et al., Nat Rev Endocrinol 2023; Legro RS, Am J Obstet Gynecol 2023.