Editing Polycystic ovary syndrome (section)

== Management ==
PCOS has no cure.<ref name="NICHD Is there a cure for PCOS?">{{cite web |title=Is there a cure for PCOS? |url=https://www.nichd.nih.gov/health/topics/pcos/conditioninfo/cure |website=[[Eunice Kennedy Shriver National Institute of Child Health and Human Development]] |date=31 January 2017 |access-date=13 October 2021 |archive-date=9 October 2021 |archive-url=https://web.archive.org/web/20211009211338/https://www.nichd.nih.gov/health/topics/pcos/conditioninfo/cure |url-status=live }}</ref> Treatment may involve lifestyle changes such as weight loss and exercise.<ref name=Mor2015>{{cite journal | vauthors = Mortada R, Williams T | title = Metabolic Syndrome: Polycystic Ovary Syndrome | journal = FP Essentials | volume = 435 | pages = 30–42 | date = August 2015 | pmid = 26280343 | type = Review }}</ref><ref name=Gia2009>{{cite journal | vauthors = Giallauria F, Palomba S, Vigorito C, Tafuri MG, Colao A, Lombardi G, Orio F | title = Androgens in polycystic ovary syndrome: the role of exercise and diet | journal = Seminars in Reproductive Medicine | volume = 27 | issue = 4 | pages = 306–315 | date = July 2009 | pmid = 19530064 | doi = 10.1055/s-0029-1225258 | s2cid = 260321191 | type = Review }}</ref> Recent research suggests that daily exercise including both aerobic and strength activities can improve hormone imbalances.<ref name=":3" />

[[Birth control pills]] may help with improving the regularity of periods, excess hair growth, and acne.<ref name="NIH2014Tx1" /> Combined oral contraceptives are especially effective and used as the first line of treatment to reduce acne and hirsutism and regulate the menstrual cycle. This is especially the case in adolescents.<ref name=":3" />

[[Metformin]], [[GLP-1]], and [[anti-androgen]]s may also help.<ref name="NIH2014Tx1" /> Other typical acne treatments and hair removal techniques may be used.<ref name="NIH2014Tx1">{{cite web|title=Treatments to Relieve Symptoms of PCOS|author=National Institutes of Health (NIH)|url=http://www.nichd.nih.gov/health/topics/PCOS/conditioninfo/Pages/relieve.aspx|access-date=13 March 2015|date=14 July 2014|url-status=live|archive-url=https://web.archive.org/web/20150402132607/http://www.nichd.nih.gov/health/topics/PCOS/conditioninfo/Pages/relieve.aspx|archive-date=2 April 2015|author-link=National Institutes of Health}}</ref> Efforts to improve fertility include weight loss, [[metformin]], and [[ovulation induction]] using [[clomiphene]] or [[letrozole]].<ref name="NIH2014Tx2" /> [[In vitro fertilization]] is used by some in whom other measures are not effective.<ref name="NIH2014Tx2">{{cite web|title=Treatments for Infertility Resulting from PCOS|url=http://www.nichd.nih.gov/health/topics/PCOS/conditioninfo/Pages/infertility.aspx|author=National Institutes of Health (NIH)|access-date=13 March 2015|date=14 July 2014|url-status=live|archive-url=https://web.archive.org/web/20150402200400/http://www.nichd.nih.gov/health/topics/PCOS/conditioninfo/Pages/infertility.aspx|archive-date=2 April 2015|author-link=National Institutes of Health}}</ref>

Certain cosmetic procedures may also help alleviate symptoms in some cases. For example, the use of laser hair removal, electrolysis, or general waxing, plucking, and shaving are all effective methods for reducing hirsutism.<ref name=":2" />
The primary treatments for PCOS include lifestyle changes and the use of medications.<ref name="Diagnosis and treatment of polycyst">{{cite journal | vauthors = Legro RS, Arslanian SA, Ehrmann DA, Hoeger KM, Murad MH, Pasquali R, Welt CK | title = Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline | journal = The Journal of Clinical Endocrinology and Metabolism | volume = 98 | issue = 12 | pages = 4565–92 | date = December 2013 | pmid = 24151290 | pmc = 5399492 | doi = 10.1210/jc.2013-2350 }}</ref>

Goals of treatment may be considered under these categories:{{citation needed|date=April 2023}}
* Lowering of insulin resistance
* Reducing androgen and testosterone levels
* Restoration of fertility
* Treatment of [[hirsutism]] or acne
* Restoration of regular menstruation, and prevention of [[endometrial hyperplasia]] and [[endometrial cancer]]

In each of these areas, there is considerable debate as to the optimal treatment. One of the major factors underlying the debate is the lack of large-scale clinical trials comparing different treatments. [[Sample (statistics)|Smaller trials]] tend to be [[Sampling error|less reliable]] and hence may produce conflicting results. General interventions that help to reduce weight or insulin resistance can be beneficial for all these aims because they address what is believed to be the underlying cause.<ref>{{cite journal | vauthors = Magkos F, Yannakoulia M, Chan JL, Mantzoros CS | title = Management of the metabolic syndrome and type 2 diabetes through lifestyle modification | journal = Annual Review of Nutrition | volume = 29 | pages = 223–256 | date = 2009 | pmid = 19400751 | pmc = 5653262 | doi = 10.1146/annurev-nutr-080508-141200 }}</ref> As PCOS appears to cause significant emotional distress, appropriate support may also be useful.<ref name="pmid22824735">{{cite journal | vauthors = Veltman-Verhulst SM, Boivin J, Eijkemans MJ, Fauser BJ | title = Emotional distress is a common risk in women with polycystic ovary syndrome: a systematic review and meta-analysis of 28 studies | journal = Human Reproduction Update | volume = 18 | issue = 6 | pages = 638–651 |date= 2012 | pmid = 22824735 | doi = 10.1093/humupd/dms029 | doi-access = free }}</ref>

=== Diet ===
Where PCOS is associated with being overweight or obese, successful weight loss is the most effective method of restoring normal ovulation/menstruation. The [[American Association of Clinical Endocrinologists]] guidelines recommend a goal of achieving 10–15% weight loss or more, which improves [[insulin resistance]] and all{{clarify|date=June 2022}} [[hormonal disorders]].<ref name="AACE2016">{{cite journal | vauthors = Garvey WT, Mechanick JI, Brett EM, Garber AJ, Hurley DL, Jastreboff AM, Nadolsky K, Pessah-Pollack R, Plodkowski R | title = American association of clinical endocrinologists and American college of endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity. | journal = Endocrine Practice | volume = 22 | issue = Suppl 3 | pages = 1–203 | date = July 2016 | pmid = 27219496 | doi = 10.4158/EP161365.GL | collaboration = Reviewers of the AACE/ACE Obesity Clinical Practice Guidelines | doi-access = free }}</ref> Still, many women find it very difficult to achieve and sustain significant weight loss. Insulin resistance itself can cause increased food cravings and lower energy levels, which can make it difficult to lose weight on a regular weight-loss diet. A [[scientific review]] in 2013 found similar improvements in weight, body composition and [[pregnancy rate]], menstrual regularity, ovulation, hyperandrogenism, insulin resistance, lipids, and quality of life to occur with weight loss, independent of diet composition.<ref name=Moran2013>{{cite journal | vauthors = Moran LJ, Ko H, Misso M, Marsh K, Noakes M, Talbot M, Frearson M, Thondan M, Stepto N, Teede HJ | title = Dietary composition in the treatment of polycystic ovary syndrome: a systematic review to inform evidence-based guidelines | journal = Human Reproduction Update | volume = 19 | issue = 5 | page = 432 |date= 2013 | pmid = 23727939 | doi = 10.1093/humupd/dmt015 | doi-access = free }}</ref> Still, a [[low GI diet]], in which a significant portion of total carbohydrates is obtained from fruit, vegetables, and whole-grain sources, has resulted in greater menstrual regularity than a [[macronutrient]]-matched healthy diet.<ref name="Moran2013" />

Reducing the intake of food groups that cause inflammation, such as dairy, sugars, and simple carbohydrates, can be beneficial.<ref name=":2" />

A [[mediterranean diet]] is often very effective due to its anti-inflammatory and anti-oxidative properties.<ref name=":3">{{Cite book |veditors=Diamanti-Kandarakis E |date=2022 |title=Polycystic Ovary Syndrome |url=https://doi.org/10.1016/C2018-0-03276-4 |doi=10.1016/c2018-0-03276-4 |isbn=978-0-12-823045-9 |s2cid=222263507 |access-date=22 August 2023 |archive-date=29 May 2024 |archive-url=https://web.archive.org/web/20240529161114/https://www.sciencedirect.com/book/9780128230459/polycystic-ovary-syndrome?via=ihub= |url-status=live }}</ref>

It has been suggested that [[vitamin D deficiency]] may play some undetermined role in the development of the [[metabolic syndrome]], and that treatment might be beneficial.<ref name=emedicine_treatment /><ref name="pmid24044903">{{cite journal | vauthors = Krul-Poel YH, Snackey C, Louwers Y, Lips P, Lambalk CB, Laven JS, Simsek S | title = The role of vitamin D in metabolic disturbances in polycystic ovary syndrome: a systematic review | journal = European Journal of Endocrinology | volume = 169 | issue = 6 | pages = 853–865 | date = December 2013 | pmid = 24044903 | doi = 10.1530/EJE-13-0617 | type = Review | doi-access = free }}</ref> However, a systematic review of 2015 found no evidence that vitamin D supplementation reduced or mitigated metabolic and hormonal dysregulations in PCOS.<ref name="pmid26061015">{{cite journal | vauthors = He C, Lin Z, Robb SW, Ezeamama AE | title = Serum Vitamin D Levels and Polycystic Ovary syndrome: A Systematic Review and Meta-Analysis | journal = Nutrients |date= 2015 | volume = 7 | issue = 6 | pages = 4555–77 | doi = 10.3390/nu7064555 | pmid = 26061015 | pmc = 4488802 | doi-access = free }}</ref> As of 2012, interventions using [[dietary supplements]] to correct metabolic deficiencies in people with PCOS had been tested in small, uncontrolled and nonrandomized clinical trials; the resulting data are insufficient to recommend their use.<ref>{{cite journal | vauthors = Huang G, Coviello A | title = Clinical update on screening, diagnosis and management of metabolic disorders and cardiovascular risk factors associated with polycystic ovary syndrome | journal = Current Opinion in Endocrinology, Diabetes and Obesity | volume = 19 | issue = 6 | pages = 512–9 | date = December 2012 | pmid = 23108199 | doi = 10.1097/med.0b013e32835a000e | s2cid = 205792902 }}</ref>

=== Medications ===
Medications for PCOS include [[oral contraceptives]] and [[metformin]]. The oral contraceptives increase [[sex hormone binding globulin]] production, which increases the binding of free testosterone. This reduces the symptoms of [[hirsutism]] caused by high testosterone and regulates return to normal [[menstrual periods]].<ref name=emedicine_treatment /> [[Anti-androgens]] such as [[finasteride]], [[flutamide]], [[spironolactone]], and [[bicalutamide]] do not show advantages over oral contraceptives, but could be an option for people who do not tolerate them.<ref>{{cite journal | vauthors = Alesi S, Forslund M, Melin J, Romualdi D, Peña A, Tay CT, Witchel SF, Teede H, Mousa A | title = Efficacy and safety of anti-androgens in the management of polycystic ovary syndrome: a systematic review and meta-analysis of randomised controlled trials | journal = eClinicalMedicine | volume = 63 | pages = 102162 | date = September 2023 | pmid = 37583655 | pmc = 10424142 | doi = 10.1016/j.eclinm.2023.102162 }}</ref> [[Finasteride]] is the only oral medication for the treatment of [[Pattern hair loss|androgenic alopecia]], that is [[Food and Drug Administration|FDA]] approved.<ref name=":2" />

Metformin is a medication commonly used in [[type 2 diabetes mellitus]] to reduce insulin resistance and is used [[Off-label use|off label]] (in the UK, US, AU, and EU) to treat insulin resistance seen in PCOS. In many cases, metformin also supports ovarian function and a return to normal ovulation.<ref name=emedicine_treatment /><ref name=Lord>{{cite journal | vauthors = Lord JM, Flight IH, Norman RJ | title = Metformin in polycystic ovary syndrome: systematic review and meta-analysis | journal = BMJ | volume = 327 | issue = 7421 | pages = 951–3 | date = October 2003 | pmid = 14576245 | pmc = 259161 | doi = 10.1136/bmj.327.7421.951 }}</ref> A newer insulin resistance medication class, the [[thiazolidinedione]]s (glitazones), have shown equivalent efficacy to metformin, but metformin has a more favorable side effect profile.<ref>{{cite journal | vauthors = Li XJ, Yu YX, Liu CQ, Zhang W, Zhang HJ, Yan B, Wang LY, Yang SY, Zhang SH | title = Metformin vs thiazolidinediones for treatment of clinical, hormonal and metabolic characteristics of polycystic ovary syndrome: a meta-analysis | journal = Clinical Endocrinology | volume = 74 | issue = 3 | pages = 332–9 | date = March 2011 | pmid = 21050251 | doi = 10.1111/j.1365-2265.2010.03917.x | s2cid = 19620846 }}</ref><ref>{{cite journal | vauthors = Grover A, Yialamas MA | title = Metformin or thiazolidinedione therapy in PCOS? | journal = Nature Reviews. Endocrinology | volume = 7 | issue = 3 | pages = 128–9 | date = March 2011 | pmid = 21283123 | doi = 10.1038/nrendo.2011.16 | s2cid = 26162421 | id = {{Gale|A250471047}} }}</ref> The United Kingdom's [[National Institute for Health and Clinical Excellence]] recommended in 2004 that women with PCOS and a [[body mass index]] above 25 be given metformin when other therapy has failed to produce results.<ref name="NICE2004">{{NICE | 11 | Fertility: assessment and treatment for people with fertility problems | 2004}}</ref><ref>{{cite web | vauthors = Balen A |title=Metformin therapy for the management of infertility in women with polycystic ovary syndrome |website=Scientific Advisory Committee Opinion Paper 13 |publisher=Royal College of Obstetricians and Gynaecologists |date=December 2008 |url=http://www.rcog.org.uk/files/rcog-corp/uploaded-files/SAC13metformin-minorrevision.pdf |access-date=13 December 2009 |url-status=dead |archive-url=https://www.webcitation.org/5m73m3kuM?url=http://www.rcog.org.uk/files/rcog-corp/uploaded-files/SAC13metformin-minorrevision.pdf |archive-date=18 December 2009 }}</ref> Metformin may not be effective in every type of PCOS, and therefore there is some disagreement about whether it should be used as a general first-line therapy.<ref name="pmid19697191">{{cite journal | vauthors = Leeman L, Acharya U | title = The use of metformin in the management of polycystic ovary syndrome and associated anovulatory infertility: the current evidence | journal = Journal of Obstetrics and Gynaecology | volume = 29 | issue = 6 | pages = 467–472 | date = August 2009 | pmid = 19697191 | doi = 10.1080/01443610902829414 | s2cid = 3339588 }}</ref> In addition to this, metformin is associated with several unpleasant side effects: including abdominal pain, metallic taste in the mouth, diarrhoea and vomiting.<ref>{{cite web |author=NICE |title=Metformin Hydrochloride |website=National Institute for Care Excellence |publisher=NICE |date=December 2018 |url=https://bnf.nice.org.uk/drug/metformin-hydrochloride.html#sideEffects |access-date=2 November 2017 |archive-date=10 June 2021 |archive-url=https://web.archive.org/web/20210610014142/https://www.nice.org.uk/bnf-uk-only#sideEffects |url-status=live }}</ref> Metformin is thought to be safe to use during pregnancy ([[pregnancy category]] B in the US).<ref>{{cite journal | vauthors = Feig DS, Moses RG | title = Metformin therapy during pregnancy: good for the goose and good for the gosling too? | journal = Diabetes Care | volume = 34 | issue = 10 | pages = 2329–30 | date = October 2011 | pmid = 21949224 | pmc = 3177745 | doi = 10.2337/dc11-1153 }}</ref> A review in 2014 concluded that the use of metformin does not increase the risk of major [[birth defect]]s in women treated with metformin during the first trimester.<ref name="CassinaDona2014">{{cite journal | vauthors = Cassina M, Donà M, Di Gianantonio E, Litta P, Clementi M | title = First-trimester exposure to metformin and risk of birth defects: a systematic review and meta-analysis | journal = Human Reproduction Update | volume = 20 | issue = 5 | pages = 656–669 | date = 1 September 2014 | pmid = 24861556 | doi = 10.1093/humupd/dmu022 | doi-access = free }}</ref> Liraglutide may reduce weight and waist circumference in people with PCOS more than other medications.<ref>{{cite journal | vauthors = Wang FF, Wu Y, Zhu YH, Ding T, Batterham RL, Qu F, Hardiman PJ | title = Pharmacologic therapy to induce weight loss in women who have obesity/overweight with polycystic ovary syndrome: a systematic review and network meta-analysis | journal = Obesity Reviews | volume = 19 | issue = 10 | pages = 1424–45 | date = October 2018 | pmid = 30066361 | doi = 10.1111/obr.12720 | s2cid = 51891552 | url = https://discovery.ucl.ac.uk/id/eprint/10050648/1/Hardiman_revised%20MS%5B23061%5D.pdf | access-date = 13 October 2021 | archive-date = 3 December 2021 | archive-url = https://web.archive.org/web/20211203131306/https://discovery.ucl.ac.uk/id/eprint/10050648/1/Hardiman_revised%20MS%5B23061%5D.pdf | url-status = live }}</ref> The use of [[statins]] in the management of underlying metabolic syndrome remains unclear.<ref name="Diagnosis and treatment of polycyst" />

It can be difficult to become pregnant with PCOS because it causes irregular [[ovulation]]. Medications to induce fertility when trying to conceive include the ovulation inducer [[clomiphene]] or pulsatile [[leuprorelin]]. Evidence from randomised controlled trials suggests that in terms of live birth, metformin may be better than placebo, and metformin plus clomiphene may be better than clomiphene alone, but that in both cases women may be more likely to experience gastrointestinal side effects with metformin.<ref>{{cite journal | vauthors = Sharpe A, Morley LC, Tang T, Norman RJ, Balen AH | title = Metformin for ovulation induction (excluding gonadotrophins) in women with polycystic ovary syndrome | journal = The Cochrane Database of Systematic Reviews | volume = 2019 | pages = CD013505 | date = December 2019 | issue = 12 | pmid = 31845767 | pmc = 6915832 | doi = 10.1002/14651858.CD013505 }}</ref>

=== Infertility ===
{{Main|Infertility in polycystic ovary syndrome}}

Some individuals with PCOS may have difficulty getting pregnant since their bodies do not produce the hormones necessary for regular ovulation.<ref>{{cite web|title=Erase the Dread and Stigma of PCOD|url=https://www.matria.in/blog/erase-the-dread-and-stigma-of-pcod/|access-date=19 January 2022|website=Matria|language=en|archive-date=19 January 2022|archive-url=https://web.archive.org/web/20220119062417/https://www.matria.in/blog/erase-the-dread-and-stigma-of-pcod/|url-status=live}}</ref> PCOS might also increase the risk of miscarriage or premature delivery. However, it is possible to have a normal pregnancy.{{citation needed|date=April 2023}}

For women who do, [[anovulation]] or infrequent ovulation is a common cause and PCOS is the main cause of anovulatory infertility.<ref>{{cite journal | vauthors = Balen AH, Morley LC, Misso M, Franks S, Legro RS, Wijeyaratne CN, Stener-Victorin E, Fauser BC, Norman RJ, Teede H | title = The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance | journal = Human Reproduction Update | volume = 22 | issue = 6 | pages = 687–708 | date = November 2016 | pmid = 27511809 | doi = 10.1093/humupd/dmw025 }}</ref> Other factors include changed levels of [[gonadotropin]]s, [[hyperandrogenemia]], and [[hyperinsulinemia]].<ref name="Qiao2011">{{cite journal | vauthors = Qiao J, Feng HL | title = Extra- and intra-ovarian factors in polycystic ovary syndrome: impact on oocyte maturation and embryo developmental competence | journal = Human Reproduction Update | volume = 17 | issue = 1 | pages = 17–33 |date= 2010 | pmid = 20639519 | pmc = 3001338 | doi = 10.1093/humupd/dmq032 }}</ref> Like women without PCOS, women with PCOS that are ovulating may be infertile due to other causes, such as tubal blockages due to a history of sexually transmitted diseases.<ref>{{cite web|url=https://www.nichd.nih.gov/health/topics/infertility/conditioninfo/causes/causes-female|title=What are some causes of female infertility?|website=National Institute of Child Health and Human Development, National Institutes of Health|date=31 January 2017|access-date=25 October 2019|archive-date=8 August 2020|archive-url=https://web.archive.org/web/20200808035554/https://www.nichd.nih.gov/health/topics/infertility/conditioninfo/causes/causes-female|url-status=live}}</ref>

For overweight anovulatory women with PCOS, [[weight loss]] and diet adjustments, especially to reduce the intake of simple carbohydrates, are associated with the resumption of natural ovulation.<ref>{{cite journal | vauthors = Jurczewska J, Szostak-Węgierek D | title = The Influence of Diet on Ovulation Disorders in Women-A Narrative Review | journal = Nutrients | volume = 14 | issue = 8 | pages = 1556 | date = April 2022 | pmid = 35458118 | pmc = 9029579 | doi = 10.3390/nu14081556 | doi-access = free }}</ref> Digital health interventions are particularly effective in providing combined therapy to manage PCOS through both lifestyle changes and medication.<ref>{{cite journal | vauthors = Wang L, Liu Y, Tan H, Huang S | title = Transtheoretical model-based mobile health application for PCOS | journal = Reproductive Health | volume = 19 | issue = 1 | pages = 117 | date = May 2022 | pmid = 35549736 | pmc = 9097413 | doi = 10.1186/s12978-022-01422-w | doi-access = free }}</ref>

[[Letrozole|Femara]] is an alternative medicine that raises FSH levels and promotes the development of the follicle.<ref name=":2" />

For those women that, after weight loss, are still anovulatory, or for anovulatory lean women, [[ovulation induction]] using the medications [[letrozole]] or [[clomiphene citrate]] are the principal treatments used to promote ovulation.<ref>{{cite journal | vauthors = Franik S, Le QK, Kremer JA, Kiesel L, Farquhar C | title = Aromatase inhibitors (letrozole) for ovulation induction in infertile women with polycystic ovary syndrome | journal = The Cochrane Database of Systematic Reviews | volume = 2022 | issue = 9 | pages = CD010287 | date = September 2022 | pmid = 36165742 | pmc = 9514207 | doi = 10.1002/14651858.CD010287.pub4 }}</ref><ref>{{cite journal | vauthors = Tanbo T, Mellembakken J, Bjercke S, Ring E, Åbyholm T, Fedorcsak P | title = Ovulation induction in polycystic ovary syndrome | journal = Acta Obstetricia et Gynecologica Scandinavica | volume = 97 | issue = 10 | pages = 1162–7 | date = October 2018 | pmid = 29889977 | doi = 10.1111/aogs.13395 | hdl-access = free | doi-access = free | hdl = 10852/72989 }}</ref><ref>{{cite journal | vauthors = Hu S, Yu Q, Wang Y, Wang M, Xia W, Zhu C | title = Letrozole versus clomiphene citrate in polycystic ovary syndrome: a meta-analysis of randomized controlled trials | journal = Archives of Gynecology and Obstetrics | volume = 297 | issue = 5 | pages = 1081–8 | date = May 2018 | pmid = 29392438 | doi = 10.1007/s00404-018-4688-6 | s2cid = 4800270 }}</ref> Clomiphene can cause mood swings and abdominal cramping for some.<ref name=":2" />

Previously, the anti-diabetes medication [[metformin]] was a recommended treatment for anovulation, but it appears less effective than letrozole or clomiphene.<ref>{{cite journal | title = Role of metformin for ovulation induction in infertile patients with polycystic ovary syndrome (PCOS): a guideline | journal = Fertility and Sterility | volume = 108 | issue = 3 | pages = 426–441 | date = September 2017 | pmid = 28865539 | doi = 10.1016/j.fertnstert.2017.06.026 | doi-access = free | vauthors = Penzias A, Bendikson K, Butts S, Coutifaris C, Falcone T, Fossum G, Gitlin S, Gracia C, Hansen K, La Barbera A, Mersereau J, Odem R, Paulson R, Pfeifer S, Pisarska M, Rebar R, Reindollar R, Rosen M, Sandlow J, Vernon M }}</ref><ref>{{cite journal | vauthors = Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, Carson SA, Steinkampf MP, Coutifaris C, McGovern PG, Cataldo NA, Gosman GG, Nestler JE, Giudice LC, Leppert PC, Myers ER | title = Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome | journal = The New England Journal of Medicine | volume = 356 | issue = 6 | pages = 551–566 | date = February 2007 | pmid = 17287476 | doi = 10.1056/NEJMoa063971 | doi-access = free }}{{primary source inline|date=June 2018}}</ref>

For women not responsive to letrozole or clomiphene and diet and lifestyle modification, there are options available including [[assisted reproductive technology]] procedures such as [[controlled ovarian hyperstimulation]] with [[follicle-stimulating hormone]] (FSH) injections followed by [[in vitro fertilisation]] (IVF).<ref>{{cite journal | vauthors = Homburg R | title = Management of infertility and prevention of ovarian hyperstimulation in women with polycystic ovary syndrome | journal = Best Practice & Research. Clinical Obstetrics & Gynaecology | volume = 18 | issue = 5 | pages = 773–788 | date = October 2004 | pmid = 15380146 | doi = 10.1016/j.bpobgyn.2004.05.006 }}</ref>

Though surgery is not commonly performed, the polycystic ovaries can be treated with a laparoscopic procedure called "[[ovarian drilling]]" (puncture of 4–10 small follicles with electrocautery, laser, or biopsy needles),<ref>{{Cite journal |last1=Bordewijk |first1=Esmée M. |last2=Ng |first2=Ka Ying Bonnie |last3=Rakic |first3=Lidija |last4=Mol |first4=Ben Willem J. |last5=Brown |first5=Julie |last6=Crawford |first6=Tineke J. |last7=van Wely |first7=Madelon |date=11 February 2020 |title=Laparoscopic ovarian drilling for ovulation induction in women with anovulatory polycystic ovary syndrome |journal=The Cochrane Database of Systematic Reviews |volume=2 |issue=2 |pages=CD001122 |doi=10.1002/14651858.CD001122.pub5 |issn=1469-493X |pmc=7013239 |pmid=32048270}}</ref> which often results in either resumption of spontaneous ovulations<ref name=emedicine_treatment /> or ovulations after adjuvant treatment with clomiphene or FSH.<ref>{{cite journal | vauthors = Ghanem ME, Elboghdady LA, Hassan M, Helal AS, Gibreel A, Houssen M, Shaker ME, Bahlol I, Mesbah Y | title = Clomiphene citrate co-treatment with low dose urinary FSH versus urinary FSH for clomiphene resistant PCOS: randomized controlled trial | journal = Journal of Assisted Reproduction and Genetics | volume = 30 | issue = 11 | pages = 1477–85 | date = November 2013 | pmid = 24014214 | pmc = 3879942 | doi = 10.1007/s10815-013-0090-2 }}</ref> (Ovarian wedge resection is no longer used as much due to complications such as [[adhesions]] and the presence of frequently effective medications.) There are, however, concerns about the long-term effects of ovarian drilling on ovarian function.<ref name=emedicine_treatment />

In a small UK randomized trial, [[bariatric surgery]] led to more spontaneous ovulations than behavioral interventions combined with medical therapy in adult women with PCOS, raising the prospect that surgery could enhance prospects of spontaneous fertility.<ref>{{Cite journal |last=Smarasinghe |first=Suhaniya SNS |date=8 June 2024 |title=Bariatric surgery for spontaneous ovulation in women living with polycystic ovary syndrome: the BAMBINI multicentre, open-label, randomised controlled trial |url=https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)00538-5/fulltext |journal=The Lancet |volume=403 |issue=10443 |pages=2489–2503|doi=10.1016/S0140-6736(24)00538-5 |pmid=38782004 }}</ref>

=== Mental health ===
Women with PCOS are far more likely to have depression than women without. Symptoms of depression might be heightened by certain physiological manifestations of this disease such as hirsutism or obesity that can lead to low self-esteem or poor body image.<ref name=":1" />  Researchers suggest that there be mental health screenings performed in tandem with PCOS assessment to identify these complications early and treat them accordingly.<ref name="Berni_2018">{{cite journal | vauthors = Berni TR, Morgan CL, Berni ER, Rees DA | title = Polycystic Ovary Syndrome Is Associated With Adverse Mental Health and Neurodevelopmental Outcomes | journal = The Journal of Clinical Endocrinology and Metabolism | volume = 103 | issue = 6 | pages = 2116–25 | date = June 2018 | pmid = 29648599 | doi = 10.1210/jc.2017-02667 }}</ref>

PCOS is associated with other mental health-related conditions besides depression such as [[anxiety]], [[bipolar disorder]], and [[obsessive–compulsive disorder]].<ref name=":1" /> Additionally, it has been found to significantly increase the risk of eating disorders.<ref name="Berni_2018" />  Screening for these mental health conditions will also be helpful in the treatment of PCOS.

Lifestyle changes for people with PCOS have been proven to be difficult due to a lack of intrinsic motivation, altered risk perception, or other PCOS-related barriers. However, self-management techniques and behavior change can be taught in a multidisciplinary approach to support women with PCOS in managing their symptoms.<ref>{{cite journal | vauthors = Ee C, Pirotta S, Mousa A, Moran L, Lim S | title = Providing lifestyle advice to women with PCOS: an overview of practical issues affecting success | journal = BMC Endocrine Disorders | volume = 21 | issue = 1 | pages = 234 | date = November 2021 | pmid = 34814919 | pmc = 8609880 | doi = 10.1186/s12902-021-00890-8 | doi-access = free }}</ref>

=== Hirsutism and acne ===
{{Further|Hirsutism}}
When appropriate (e.g., in women of childbearing age who require contraception), a standard contraceptive pill is frequently effective in reducing hirsutism.<ref name=emedicine_treatment /> Progestogens such as norgestrel and levonorgestrel should be avoided due to their androgenic effects.<ref name=emedicine_treatment /> Metformin combined with an oral contraceptive may be more effective than either metformin or the oral contraceptive on its own.<ref>{{cite journal | vauthors = Fraison E, Kostova E, Moran LJ, Bilal S, Ee CC, Venetis C, Costello MF | title = Metformin versus the combined oral contraceptive pill for hirsutism, acne, and menstrual pattern in polycystic ovary syndrome | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 8 | pages = CD005552 | date = August 2020 | pmid = 32794179 | pmc = 7437400 | doi = 10.1002/14651858.CD005552.pub3 }}</ref>

In the case of taking medication for acne, Kelly Morrow-Baez PHD, in her exposition titled ''Thriving with PCOS,'' informs that it "takes time for medications to adjust hormone levels, and once those hormone levels are adjusted, it takes more time still for pores to be unclogged of overproduced oil and for any bacterial infections under the skin to clear up before you will see discernible results." (p.&nbsp;138) <ref name=":2" />

Other medications with anti-androgen effects include [[flutamide]],<ref name=flutamide>{{cite web|url=http://www.nhs.uk/Conditions/Polycystic-ovarian-syndrome/Pages/Treatment.aspx|title=Polycystic ovary syndrome&nbsp;– Treatment|publisher=National Health Service|location=United Kingdom|date=17 October 2011|access-date=19 November 2011|url-status=live|archive-url=https://web.archive.org/web/20111106005039/http://www.nhs.uk/Conditions/Polycystic-ovarian-syndrome/Pages/Treatment.aspx|archive-date=6 November 2011}}</ref> and [[spironolactone]],<ref name=emedicine_treatment /> which can improve hirsutism. Metformin can reduce hirsutism, perhaps by reducing insulin resistance, and is often used if there are other features such as insulin resistance, diabetes, or obesity that are likely to respond to metformin. [[Eflornithine]] (Vaniqa) is a medication that is applied to the skin in cream form, and acts directly on the hair follicles to inhibit hair growth. It is usually applied to the face.<ref name=emedicine_treatment /> [[5-alpha reductase inhibitor]]s (such as [[finasteride]] and [[dutasteride]]) may also be used;<ref name=emedicine_medications>{{EMedicine|article|256806|Polycystic Ovarian Syndrome|medication}}</ref> they work by blocking the conversion of [[testosterone]] to [[dihydrotestosterone]] (the latter of which is responsible for most hair growth alterations and [[Acne vulgaris#Hormones|androgenic acne]]).

Although these agents have shown significant efficacy in clinical trials (for oral contraceptives, in 60–100% of individuals<ref name=emedicine_treatment />), the reduction in hair growth may not be enough to eliminate the social embarrassment of hirsutism or the inconvenience of plucking or shaving. Individuals vary in their response to different therapies. It is usually worth trying other medications if one does not work, but medications do not work well for all individuals.<ref>{{cite journal | vauthors = van Zuuren EJ, Fedorowicz Z, Carter B, Pandis N | title = Interventions for hirsutism (excluding laser and photoepilation therapy alone) | journal = The Cochrane Database of Systematic Reviews | volume = 2015 | issue = 4 | pages = CD010334 | date = April 2015 | pmid = 25918921 | pmc = 6481758 | doi = 10.1002/14651858.CD010334.pub2 }}</ref>

=== Menstrual irregularity ===
If fertility is not the primary aim, then [[menstruation]] can usually be regulated with a contraceptive pill.<ref name=emedicine_treatment>{{EMedicine|article|256806|Polycystic Ovarian Syndrome|treatment}}</ref> The purpose of regulating menstruation, in essence, is for the patient's convenience, and perhaps their sense of well-being; there is no medical requirement for regular periods, as long as they occur sufficiently often.<ref>{{cite web |url=https://www.nhs.uk/conditions/irregular-periods/ |title=Irregular periods - NHS |publisher=Nhs.uk |date=21 October 2020 |accessdate=19 July 2022 |archive-date=19 July 2022 |archive-url=https://web.archive.org/web/20220719140924/https://www.nhs.uk/conditions/irregular-periods/ |url-status=live }}</ref>

If a regular menstrual cycle is not desired, then therapy for an irregular cycle is not necessarily required. Most experts say that, if a menstrual bleed occurs at least every three months, then the endometrium (womb lining) is being shed sufficiently often to prevent an increased risk of endometrial abnormalities or cancer.<ref name=verity_risks>{{cite web|url=http://www.verity-pcos.org.uk/guide_to_pcos/what_is_pcos/health_risks|title=What are the health risks of PCOS?|website=Verity&nbsp;– PCOS Charity|publisher=Verity|year=2011|access-date=21 November 2011|url-status=dead|archive-url=https://archive.today/20121225050404/http://www.verity-pcos.org.uk/guide_to_pcos/what_is_pcos/health_risks|archive-date=25 December 2012}}</ref> If menstruation occurs less often or not at all, some form of progestogen replacement is recommended.<ref name=emedicine_medications />

=== Alternative medicine ===
A 2017 review concluded that while both myo-inositol and D-chiro-inositols may regulate menstrual cycles and improve ovulation, there is a lack of evidence regarding effects on the probability of pregnancy.<ref>{{cite journal | vauthors = Pundir J, Psaroudakis D, Savnur P, Bhide P, Sabatini L, Teede H, Coomarasamy A, Thangaratinam S | title = Inositol treatment of anovulation in women with polycystic ovary syndrome: a meta-analysis of randomised trials | journal = BJOG | volume = 125 | issue = 3 | pages = 299–308 | date = February 2018 | pmid = 28544572 | doi = 10.1111/1471-0528.14754 | s2cid = 21090113 | url = https://pure-oai.bham.ac.uk/ws/files/41620024/Pundir_et_al_Inositol_treatment_BJOG.pdf | access-date = 13 October 2021 | archive-date = 24 October 2021 | archive-url = https://web.archive.org/web/20211024092854/http://pure-oai.bham.ac.uk/ws/files/41620024/Pundir_et_al_Inositol_treatment_BJOG.pdf | url-status = live }}</ref><ref>{{cite journal | vauthors = Amoah-Arko A, Evans M, Rees A |title=Effects of myoinositol and D-chiro inositol on hyperandrogenism and ovulation in women with polycystic ovary syndrome: a systematic review |journal=Endocrine Abstracts |date=20 October 2017 |doi=10.1530/endoabs.50.P363 }}</ref> A 2012 and 2017 review have found [[myo-inositol]] supplementation appears to be effective in improving several of the hormonal disturbances of PCOS.<ref name="pmid22296306">{{cite journal | vauthors = Unfer V, Carlomagno G, Dante G, Facchinetti F | title = Effects of myo-inositol in women with PCOS: a systematic review of randomized controlled trials | journal = Gynecological Endocrinology | volume = 28 | issue = 7 | pages = 509–515 | date = July 2012 | pmid = 22296306 | doi = 10.3109/09513590.2011.650660 | s2cid = 24582338 }}</ref><ref>{{cite journal | vauthors = Zeng L, Yang K | title = Effectiveness of myoinositol for polycystic ovary syndrome: a systematic review and meta-analysis | journal = Endocrine | volume = 59 | issue = 1 | pages = 30–38 | date = January 2018 | pmid = 29052180 | doi = 10.1007/s12020-017-1442-y | s2cid = 4376339 }}</ref> Myo-inositol reduces the amount of gonadotropins and the length of controlled ovarian hyperstimulation in women undergoing in vitro fertilization.<ref>{{cite journal | vauthors = Laganà AS, Vitagliano A, Noventa M, Ambrosini G, D'Anna R | title = Myo-inositol supplementation reduces the amount of gonadotropins and length of ovarian stimulation in women undergoing IVF: a systematic review and meta-analysis of randomized controlled trials | journal = Archives of Gynecology and Obstetrics | volume = 298 | issue = 4 | pages = 675–684 | date = October 2018 | pmid = 30078122 | doi = 10.1007/s00404-018-4861-y | s2cid = 51921158 }}</ref> A 2011 review found not enough evidence to conclude any beneficial effect from [[D-chiro-inositol]].<ref name="pmid21142777">{{cite journal | vauthors = Galazis N, Galazi M, Atiomo W | title = D-Chiro-inositol and its significance in polycystic ovary syndrome: a systematic review | journal = Gynecological Endocrinology | volume = 27 | issue = 4 | pages = 256–262 | date = April 2011 | pmid = 21142777 | doi = 10.3109/09513590.2010.538099 | s2cid = 1989262 }}</ref> There is insufficient evidence to support the use of [[acupuncture]], current studies are inconclusive and there's a need for additional [[randomized controlled trial]]s.<ref>{{cite journal | vauthors = Lim CE, Ng RW, Cheng NC, Zhang GS, Chen H | title = Acupuncture for polycystic ovarian syndrome | journal = The Cochrane Database of Systematic Reviews | volume = 2019 | pages = CD007689 | date = July 2019 | issue = 7 | pmid = 31264709 | pmc = 6603768 | doi = 10.1002/14651858.CD007689.pub4 }}</ref><ref>{{cite journal | vauthors = Wu XK, Stener-Victorin E, Kuang HY, Ma HL, Gao JS, Xie LZ, Hou LH, Hu ZX, Shao XG, Ge J, Zhang JF, Xue HY, Xu XF, Liang RN, Ma HX, Yang HW, Li WL, Huang DM, Sun Y, Hao CF, Du SM, Yang ZW, Wang X, Yan Y, Chen XH, Fu P, Ding CF, Gao YQ, Zhou ZM, Wang CC, Wu TX, Liu JP, Ng EH, Legro RS, Zhang H | title = Effect of Acupuncture and Clomiphene in Chinese Women With Polycystic Ovary Syndrome: A Randomized Clinical Trial | journal = JAMA | volume = 317 | issue = 24 | pages = 2502–14 | date = June 2017 | pmid = 28655015 | pmc = 5815063 | doi = 10.1001/jama.2017.7217 }}</ref>