Living Well with PCOS:
A Practical Guide to Exercise, Eating, Screening and Treatment

Polycystic ovary syndrome (PCOS) is a lifelong condition, but it can be managed well with the right habits, regular checks and effective treatments. The 2023 International Evidence-based Guideline, developed with input from women with PCOS, emphasises that healthy eating and physical activity bring benefits "even without weight loss". It recommends 150-300 minutes of moderate activity or 75-150 minutes of vigorous activity a week, plus muscle strengthening twice a week, with more (250 or 150 minutes) for weight loss. No single diet is best; a sustainable, healthy eating pattern that suits you is what matters. Regular screening is essential: blood sugar every one to three years, blood pressure every year, and checks for depression, anxiety, eating disorders and sleep apnoea. Effective treatments are available for every concern, from the combined pill for irregular periods and excess hair to metformin for metabolic health. For women trying to conceive, letrozole is now the first-line medicine: in a US trial of 750 women, it led to more live births than clomiphene (27.5% vs 19.1%). This guide turns the evidence into practical steps for everyday life.

Key numbers

Understanding your PCOS

PCOS affects each woman differently. Some mainly have irregular periods, others excess hair or acne, others weight and metabolic issues, and many a combination. Because PCOS is closely linked to insulin resistance and raises the long-term risk of type 2 diabetes and heart disease, living well with it means looking after both your symptoms and your long-term health (see Polycystic Ovary Syndrome (PCOS) and Insulin Resistance).

What the evidence shows

Physical activity: benefits with or without weight loss. The 2023 guideline recommends that adults with PCOS do 150-300 minutes of moderate-intensity activity, such as brisk walking, or 75-150 minutes of vigorous activity, such as running or fast cycling, each week, plus muscle-strengthening activities on two non-consecutive days. For modest weight loss or preventing weight regain, it suggests at least 250 minutes of moderate or 150 minutes of vigorous activity a week. It also advises cutting down sitting and screen time, noting that "replacing sedentary time with physical activity of any intensity" brings benefits.

Eating: no single "PCOS diet". The guideline found "no evidence to support any one type of diet composition over another". It recommends general healthy eating principles tailored to individual preferences, culture and goals. In practice, this means plenty of vegetables, pulses, whole grains and lean protein, and fewer sugary drinks, sweets and refined carbohydrates such as large portions of white rice and white bread. Restrictive diets you can't sustain are less helpful than steady, realistic changes.

Weight: modest change, without stigma. For women with excess weight, losing 5-10% of body weight improves both metabolic and reproductive features of PCOS. The guideline also highlights the harm of weight stigma and supports weight-neutral care where appropriate: healthy habits benefit women of all sizes. Anti-obesity medicines can be considered according to general population guidelines, with effective contraception, as some aren't safe in pregnancy.

Medicines for symptoms and metabolic health.

• The combined oral contraceptive pill is the first-line treatment for irregular periods and excess hair and acne. It also protects the womb lining.
• Metformin should be considered for adults with a BMI of 25 or more, mainly for metabolic benefits, and can be combined with the pill.
• Anti-androgen medicines can be added for excess hair when the pill alone isn't enough, with reliable contraception.
• Laser hair removal should be considered for facial hair.
• Inositol has "limited clinical benefits", and the guideline advises that metformin should be considered over inositol (see Fertility Supplements).

Fertility: letrozole first. The guideline recommends letrozole as the "first-line pharmacological treatment for ovulation induction". In a US trial of 750 women with PCOS, letrozole led to more live births than the older medicine clomiphene (27.5% vs 19.1%) and more ovulation (61.7% vs 48.3% of cycles), with no significant difference in birth defects. Twin rates were 3.4% with letrozole and 7.4% with clomiphene. If medicines don't work, other options include injected hormones, keyhole ovarian surgery and IVF.

Mental health and sleep. Depression and anxiety are common in PCOS. The guideline recommends screening for depression and anxiety in all adults with PCOS, considering eating disorders "regardless of weight", and assessing for obstructive sleep apnoea, which is more common in PCOS independent of weight. Psychological therapy is a first-line treatment for depression and anxiety, and treating symptoms such as acne and excess hair also improves wellbeing.

Your screening schedule

The guideline notes that endometrial cancer risk is higher in PCOS, but the overall chance is low, so routine screening isn't recommended. Very infrequent periods, or bleeding between periods, should be checked.

Recommendations by scenario

Preparing for pregnancy is covered in Preconception Health Guide.

Practical notes

Living well with PCOS is about steady habits and regular checks rather than perfection. Aim for regular physical activity, including muscle strengthening, and a sustainable healthy eating pattern; benefits come even without weight loss. Have your blood sugar, blood pressure and mental health checked regularly, and use effective treatments for symptoms and fertility. With the right support, most women with PCOS can manage their symptoms, conceive if they wish, and protect their long-term heart and metabolic health.