A report by the Androgen Excess and PCOS Society concluded that lifestyle management, either alone or combined with antiobesity pharmacologic and/or surgical treatments, should be used as the primary therapy in overweight and obese women with PCOS (31). Lifestyle management of obesity in PCOS is multifactorial. Dietary management of obesity should focus on reducing body weight, maintaining a lower long-term body weight, and preventing weight gain. An initial weight loss of greater than or equal to 5% to 10% is recommended. In obese and overweight women with PCOS, dietary interventions with a resultant weight reduction of more than 5% to less than 15% over the starting body weight is associated with a reduction in either total or free testosterone, adrenal androgens, and improvement in SHBG levels. Metabolic improvements in fasting insulin, glucose, glucose tolerance, total cholesterol, triglycerides, plasminogen activator inhibitor-1, and free fatty acids are reported. Clinically, hirsutism, menstrual function, and ovulation are all improved (31).
Structured exercise improves insulin resistance and offers significant benefits in PCOS. The incorporation of structured exercise, behavior modification, and stress management strategies
Table 31.5 Lifestyle Modification Principles Suggested for Obesity Management in Polycystic Ovary Syndrome (PCOS) 1.
Lifestyle modification is the first form of therapy, combining behavioral (reduction of psychosocial stressors), dietary, and exercise management.
2.
Reduced-energy diets (500–1,000 kcal/day reduction) are effective options for weight loss and can reduce body weight by 7% to 10% over a period of 6 to 12 months.
3.
Dietary plans should be nutritionally complete and appropriate for life stage and should aim for <30% of calories from fat, <10% of calories from saturated fat, with increased consumption of fiber, whole-grain breads and cereals, and fruit and vegetables.
4.
Alternative dietary options (increasing dietary protein, reducing glycemic index, reducing carbohydrate) may be successful for achieving and sustaining a reduced weight but more research is needed in PCOS specifically.
5.
The structure and support within a weight-management program is crucial and may be more important than the dietary composition. Individualization of the program, intensive follow-up and monitoring by a physician, and support from the physician, family, spouse, and peers will improve retention.
6.
Structured exercise is an important component of a weight-loss regime; aim for >30 min/day.
Reprinted with permission from Moran LJ, Pasquali R, Teede HJ, et al. Treatment of obesity in polycystic ovary syndrome: a position statement of the Androgen Excess and Polycystic Ovary Syndrome Society. Fertil Steril 2009;92:1966–1982.
as fundamental components of lifestyle management increases the success of the weight loss strategy (Table 31.5).
Even though lifestyle management strategies should be used as the primary therapy in obese and overweight women with PCOS, they are difficult to maintain long term. Alternative approaches to the treatment of obesity include the use of pharmacologic agents, such as orlistat, sibutramine, and rimonabant, or bariatric surgery (31). The NIH clinical recommendations advise bariatric surgery when BMI is greater than 40 kg/m2 or greater than 35 kg/m2 in patients with a high-risk, obesity-related condition after failure of other treatments for weight control (31,77).