Viewpoint: Lifestyle Modification is First-Line Treatment for PCOS

Peter Kovacs, MD

Disclosures

February 03, 2006

Polycystic ovary syndrome (PCOS) affects about 5% to 10% of reproductive age women in the United States and is considered the most common endocrine abnormality among them. According to the latest consensus, the diagnosis can be established when 2 of the following criteria are present: oligo-ovulation, anovulation, clinical or laboratory hyperandrogenism, and polycystic ovaries on ultrasound (enlarged ovary, echodense stroma, > 10 "cysts" 2 -10 mm). PCOS is a rather heterogeneous syndrome. Although some patients are thin, about 50% are obese; some patients are clinically hyperandrogenic, whereas others have a normal phenotype; some women have insulin resistance and others have normal glucose metabolism. The presenting symptoms can vary as well. Most women are evaluated for infertility resulting from the irregular cycles, but other presenting symptoms include irregular bleeding, obesity, and cosmetic problems. Therapy has to be tailored to the patient's needs.

In recent years, it has become evident that beyond a reproductive or cosmetic problem, PCOS represents a metabolic risk. Many women with PCOS have hypertension, impaired glucose tolerance, lipid abnormalities, obesity, or any combination of these. Even those patients who are seen for infertility "only" need to be screened for these metabolic risk factors, and they require counseling regarding this risk and its management.

It was realized early on that weight control improves many aspects of PCOS. The cycles become more regular, androgen levels are reduced, lipid and glucose metabolism improves, and spontaneous pregnancy may follow. It was also realized that obese patients do not have to reach the normal body mass index; a weight reduction of even a few percent has clinical benefits. This is because visceral fat is metabolically more active, and weight loss of a few percent is associated with significant loss of visceral fat. On the basis of these observations, weight management by dieting and exercise is now recommended to all overweight/obese women with PCOS.

Folliculogenesis can be restored by several drugs, and medical treatment will have a "positive" reproductive effect sooner than lifestyle modification. That said, a pregnancy in an uncontrolled metabolic state is at a significantly higher risk. Miscarriage rates are greater, hypertension and diabetes occur more commonly, and the risks of various peripartum complications are also higher.

The randomized, prospective, multicenter study conducted by Tang and colleagues[1] assessed whether lifestyle changes alone or in combination with metformin (an insulin sensitizer) are associated with superior endocrine, anthropometric, and menstrual cycle characteristics among obese women with PCOS. The study enrolled 143 women who were randomized to lifestyle changes plus 1500 mg metformin or to lifestyle changes and placebo; 122 participants completed the study, and drop-out rates were similar in the medical intervention and placebo groups. All participants were advised by a dietician on a low-calorie (low-fat, high-carbohydrate) diet and the need for regular exercise. All baseline parameters were similar between the 2 groups.

Patients in both groups showed similar improvements in their menstrual cyclicity (1 additional cycle in 6 months), with 52.2% improvement in the metformin group and 58.1% in the placebo group. Significant weight loss was achieved in both groups. The loss was greater in the metformin group, but the difference was not significant. Androgen levels were reduced in the metformin group only. Glucose and insulin levels and insulin sensitivity did not change with either approach. Lipid levels were not altered either. Spontaneous pregnancy rates were similar in both groups.

This study showed that lifestyle management alone -- ie, weight loss -- was as effective as lifestyle management in combination with metformin regarding the improvement of menstrual cyclicity among obese women with PCOS.

Other studies[2,3] have shown that lifestyle changes (in this case, intensive exercise with a goal of ≥ 150 min/week of activity) resulting in weight loss reduced the risk of type 2 diabetes.[2] The same studies found lifestyle changes to be superior to metformin. Thus, all women with PCOS should be encouraged to follow a healthy diet and to engage in regular exercise. Their chance to achieve a pregnancy will improve and the risks during pregnancy will be reduced. A healthier lifestyle will also reduce their long-term risks for diabetes, hypertension, dyslipidemia, and cardiovascular disease. It is important for all primary care providers to identify patients who may have PCOS. These patients need to undergo the appropriate screening tests and should be counseled about diet and exercise. Pharmacologic intervention could be combined with this approach as appropriate, but the above-mentioned studies suggest that lifestyle modification is the first-line treatment.

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