How is polycystic ovary syndrome (PCOS) treated?

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting individuals of reproductive age, characterized by chronic anovulation, hyperandrogenism (e.g., hirsutism, acne, alopecia), and polycystic ovarian morphology on ultrasound—though ultrasound findings alone are not diagnostic. Management is individualized and focuses on addressing both metabolic and reproductive manifestations.

Lifestyle modification remains the cornerstone of first-line therapy, particularly for those with overweight or obesity. Evidence-based interventions include sustained weight loss of 5–10% through caloric restriction and regular physical activity, which can significantly improve insulin sensitivity, restore ovulatory function, reduce androgen levels, and alleviate menstrual irregularities.

For menstrual regulation and endometrial protection, combined oral contraceptives (COCs) are often recommended as first-line pharmacologic therapy in non–childbearing-desiring individuals. COCs suppress ovarian androgen production, improve cycle regularity, and reduce hirsutism and acne over time. Progestin-only options (e.g., micronized progesterone or levonorgestrel-releasing intrauterine system) may be considered when estrogen is contraindicated.

In individuals seeking fertility, ovulation induction is initiated with clomiphene citrate or letrozole—the latter now preferred due to higher live birth rates and lower multiple gestation risk. Metformin may be added in cases of insulin resistance or glucose intolerance, though it is not FDA-approved for ovulation induction and is less effective than letrozole as monotherapy. Gonadotropins or assisted reproductive technologies (e.g., IVF) are reserved for refractory cases.

For hyperandrogenic symptoms, anti-androgens such as spironolactone (typically 50–200 mg/day) are used off-label and require concurrent contraception due to teratogenic risk. Topical treatments (e.g., eflornithine cream) and cosmetic procedures (e.g., laser hair removal) provide adjunctive symptom control.

Long-term monitoring is essential: screening for type 2 diabetes (fasting glucose, HbA1c, or oral glucose tolerance test), dyslipidemia, hypertension, and obstructive sleep apnea should occur regularly. Cardiovascular risk assessment and mental health support—including evaluation for anxiety, depression, and disordered eating—are integral components of comprehensive PCOS care.