Lifestyle interventions in terms of diet and regular exercise are the first line management procedures in those who are overweight (approximately 50%). Although low glycaemic (GI) index diet seems the most logical solution to the problem evidence for it's superiority over other types of diets is lacking. It appears that around 5% loss of body weight can restore normal ovulation (fertile menstrual cycles) in majority of overweight women with PCOS. Exercise in the form of sustained brisk walking resulted in decrease in waist circumference and regular periods in a proportion of obese women with PCOS.
Metformin - Initial anecdotal reports of pregnancies achieved with metformin in previously amenorrhoeic (without menstrual periods) PCOS women were followed by numerous studies assessing the effectiveness of metformin alone or in combination with conventional induction of ovulation on ovulatory and pregnancy rates. The available data from the controlled studies have shown a modest improvement in ovulation rates with metformin or no effect. In a number of studies ovulation rates increased with no change in weight which suggests that the effect is independent of weight loss. There seem to be inverse relationship between a body mass index (BMI) and the response to metformin. Anecdotal reports suggest that the best responders are slim and amenorrhoeic patients.
Several studies have shown that continuing metformin throughout pregnancy in women with PCOS appears to safely reduce early pregnancy loss as well as the development of gestational (pregnancy induced) diabetes. All these studies also point to the safety of metformin throughout pregnancy as no adverse foetal outcomes were reported among women treated with metformin. It is however still questionable whether metformin should be continued during pregnancy unless gestational diabetes is present.
Clomiphene citrate in the doses between 50 and 150 mg between day 2 and 6 of the cycle has been used for many years. This therapy is associated with a risk of multiple pregnancies. Prolonged treatment with clomiphene increases the risk of ovarian cancer. The use of metformin in addition to ovulation induction with clomiphene citrate in PCOS women, resistant or not to clomiphene has expanded rapidly over the past few years. Indeed the combined therapy may be preferred after three to four months of no response to metformin.
Laparoscopic ovarian diathermy is the modern version of the wedge resection of the ovaries. This procedure can result in regular ovulatory cycles and better responsiveness to clomiphene in a significant proportion of patients. The effect is transient.
Induction of ovulation with Gonadotrophins - Various types of gonadotrophin preparation used in clinical practice (hMG, pure-FSH, rec-FSH) seem to be equally effective in terms of ovulatory and pregnancy rates. This method requires skilled monitoring. The main problem is risk of ovarian hyperstimulation syndrome (OHSS).
In vitro fertilisation (IVF) - Fertilization and implantation rates are the same for women with PCOS and for those who do not have PCOS. However, because of high risk of OHSS in women with PCOS transfer of one embryo only is recommended.