Now that we have clarified several of the misconceptions of PCOS, it is important to dive into treatment. This generally splits into lifestyle management and medical treatment.

Lifestyle changes to improve PCOS

To best understand treatment, we need to remind ourselves that the underlying issues behind PCOS are related to insensitivity or resistance to insulin. This affects the production of elevated level of male hormones. It also affects the normal variation in reproductive hormones that allow a woman to ovulate. Hence, we need to think about ways to improve insulin resistance. The most straightforward approach is to improve diet and exercise. Ideally, no more than 40% of the calories taken in daily are carbohydrates. As for exercise, ideally, one should do 30 minutes of moderate level activity five times each week. What does moderate level mean? This implies the exercise should lead to an elevated heart rate and quicker breathing.

However, it’s not easy for most of us to find 30 minutes each weekday to exercise. One way to compensate is to do higher intensity activity for shorter periods. This is like moderate intensity, but with a greater heart rate and being in some discomfort. Bottom-line, the more calories you burn, the better off you’ll be. A very important factor to note is that both aerobic (running, biking, etc.) and strength-training exercises are necessary since building muscle increases calorie-burning ability and improves insulin sensitivity.

PCOS Medication Options

Going beyond diet and exercise, there are additional options to improve insulin sensitivity. These include the daily supplement myo-inositol which is the best-studied of all the supplements for PCOS. Then there are medications, the most common of which is Metformin. The advantage of Metformin is that it a woman can try to conceive while on it. Weight loss medications such as Phentermine and the newer injectables like Ozempic and Wegovy are effective, but are not recommended for anyone activity trying to conceive. In fact, for the injectable medications, you should stop them at least two months prior to becoming pregnant given the risk for birth defects.

To further control other symptoms of PCOS such as male hormone production and irregular periods, numerous options are available. The most common option if the use of oral birth control pills. These pills have estrogen which increases the level of certain blood proteins that help soak up extra male hormones. In addition, they have a progestin component that can help control the growth of the uterine-lining and, when taken cyclically, can help a woman maintain a regular period. Maintaining a regular or even a semi-regular period is important to limit the risk of a common form of endometrial cancer which can arise from long-standing lack of ovulation (usually six months or more). The main drawback with birth control pills is that they generally prevent a woman from conceiving.

Trying to conceive with PCOS

When a woman is ready to conceive, ovulation induction or even IVF may be needed. However, with a 5-10% loss in weight, a woman may start ovulating regularly again and then conceive on her own.

Ovulation induction:

If ovulation induction is needed, it can be done with oral medications such as Letrozole. A note must be made about Clomid: this medicine was shown to be inferior for PCOS patients at inducting ovulation. It should only be tried if a woman is intolerant or unresponsive to Letrozole and does not wish to proceed to injectable options.

Injectable medications:

If oral medications do not induce ovulation then injectable medications could be used. One word of warning for injectable medications is that getting the optimal dose requires careful and SLOW increases; since it is very easy to increase the dose to the point where a patient will be at too high of a risk for twins or triplets.

If a patient does not succeed with the above options or is not good candidate for such options, then IVF is the best next step. PCOS patients are at higher risk for ovarian hyperstimulation, therefore close monitoring and careful dosing is key to making an IVF cycle successful for a patient with PCOS.

In short, PCOS treatment can be and must be addressed in a multifaceted fashion. By using a combined approach with lifestyle interventions, addressing insulin resistance, and influencing ovarian function, PCOS can improve and be overcome.

< PCOS Part I : Diagnosis: To ovulate or not to ovulate, that’s the monthly question