Polycystic ovary syndrome (PCOS) is a complex and heterogeneous endocrine disease, including clinical features of hyperandrogenism, anovulation, and insulin resistance. Some studies report that up to 70% of women with PCOS have some degree of insulin resistance.
Which came first, insulin resistance or PCOS?
Insulin resistance may be at the root of PCOS, and elevated insulin levels may contribute to PCOS’s metabolic complications. The connection is known, but the causation of the relationship between the two conditions is somewhat unclear. Insulin resistance does not affect everyone the same way. Some women with insulin resistance develop PCOS, while others do not.
Insulin secretes in response to increased blood levels of glucose. When we eat carbohydrates, the glucose molecules enter our blood within about 15 minutes. Insulin allows cells throughout the body to take in glucose, which is later used for energy or stored as glycogen in your liver and muscles, or fat if unused. Once your glycogen stores are filled, excess glucose is stored as fat. When someone has insulin resistance, the body does not respond to insulin as efficiently or as quickly as it should. Over time, more extensive amounts of insulin are required before glucose is taken into the cells. Eventually, the body begins to deal differently with glucose (sugar). Consistently high levels of glucose in the blood can lead to pre-diabetes and then to diabetes.
Reducing insulin resistance and improving insulin sensitivity—your cells’ ability to bind to insulin is what we want to happen. Functional medicine practitioners consider an ideal fasting insulin level to be below 7.
High insulin levels exacerbate inflammation and cause the ovaries to produce more androgens (i.e., testosterone). Excess androgens are often the cause of unwanted PCOS symptoms such as acne, facial hair, weight gain, or weight loss resistance. Chronic low-grade inflammation and high androgen levels subsequently worsen insulin resistance, creating a vicious cycle for women with PCOS. Argh!
While obesity is a known risk factor for PCOS, not all women with obesity develop PCOS. Furthermore, not all women with PCOS are obese, and lean women diagnosed with PCOS are on the rise. Lean women populations with PCOS have different phenotypic, metabolic, hematologic, and neurologic characteristics than obese participants with PCOS.
Weight loss (if needed) improves insulin sensitivity, and you don’t necessarily have to reach your goal weight to receive this benefit. A modest amount of weight loss can begin to reverse symptoms of PCOS. For example, if you are 50 pounds overweight, losing 10 pounds can make a big difference in your PCOS symptoms.
Here are some lifestyle changes that can pull you out of the metabolic chaos of PCOS,
The most common contributor to insulin resistance is a diet that’s high in simple carbs and processed foods. Lower carb diets may be a better weight loss approach for middle-aged adults with overweight and obesity, especially those with diminished insulin sensitivity.
My advice for insulin resistance is to try a moderate-carb or maybe a low-carb plan. Short-term ketogenic may be therapeutic, but I’m not convinced about doing ketogenic long-term. It depends on the woman’s biochemical situation. If a woman is obese and severely insulin resistant, but her HPA axis is in pretty good shape, she might be the right candidate for a low-carb diet. A woman who is not significantly overweight but is stressed with work and young kids and does CrossFit wouldn’t be a suitable candidate. She may have high cortisol/adrenal burnout issues that will NOT thrive on a super low carb diet. The carb threshold should be super customized. Never a one size fits all.
IF may help improve insulin resistance because it improves insulin sensitivity. Fasting is a mild form of stress on the body. If you have high cortisol (HPA axis/adrenal dysfunction), try spacing your meals to improve insulin sensitivity without fasting. Try to get used to eating more substantial meals and then waiting 4-5 hours before eating again, instead of snacking. IF may also improve your leptin hormones.
Going grain-free and dairy-free may be useful. Acne is prevalent in PCOS, and dairy is a common trigger.
Physical exercise is part of the lifestyle recommendations for women with PCOS. Exercise can help your body become more sensitive to insulin because it decreases the amount of insulin you need to signal cells to lower your blood sugar. Be mindful of excessive exercise because, again, high cortisol output may increase the demand on your adrenal glands, which can cause more problems. Improvements in androgen hormones are more likely with resistance or strength training. The impact of yoga on insulin sensitivity and androgens appears promising but requires further study.
Above all, you want to lose weight at a pace you can maintain long-term. Crash diets that produce fast weight loss followed by the inevitable rebound weight gain do more harm than good.
Supplements that are depleted or beneficial to use with PCOS
Fiber intake can significantly affect blood sugar, glucose sensitivity, and insulin levels in some people. When people go low-carb, they end up going too low-fiber—using prebiotic supplements, which is the other way to get around that. There is a connection between intestinal bacteria with sex hormones and insulin resistance. Higher fiber intake, including soluble fiber, and resistant starches, is excellent for your microbiome.
Magnesium plays such an essential role in improving insulin, leptin, thyroid hormones. It’s critical to the production of estrogens and progesterone. It can also be calming on the nervous system. Take it!
Berberine seems to reduce blood sugar levels in people with diabetes slightly. One study showed berberine use for patients with metabolic syndrome helped regulate blood glucose and lipid effectively, lighten insulin resistance and reduce inflammatory response levels.
Low serum 25(OH)D levels were common in women with PCOS, which was speculated to be associated with glucose homeostasis and the androgen level. We may not have causation, but we have a correlation. Take your D3 with K2.
If you and your Dr. decide medication is best for you, Metformin is a prescription medication that improves insulin sensitivity. It’s also pretty commonly prescribed to women with PCOS to improve insulin sensitivity. Some women tolerate it really well, and others do not. It will deplete vitamin B12, so anyone on metformin should be supplementing with active forms of B12. Metformin is associated with the most common gastrointestinal side effects, such as nausea, gastrointestinal discomfort, abdominal pain, or bloating.