Unlocking the Link Between Insulin Resistance and PCOS: A Root Cause Approach
Polycystic Ovary Syndrome (PCOS) is one of the most common endocrine disorders among women of reproductive age, affecting as many as 1 in 10. While its hallmark symptoms often include irregular menstrual cycles, acne, and unwanted hair growth, PCOS is far more than a reproductive condition. At the heart of it lies a powerful but often underappreciated driver: insulin resistance. Understanding this root metabolic imbalance opens the door to more effective, sustainable strategies for reversing symptoms and improving whole-body health.
The Role of Insulin in PCOS: Beyond Blood Sugar
Insulin is a hormone most known for its role in regulating blood glucose levels, but it also acts as a growth and signaling molecule in many tissues, including the ovaries. In PCOS, the body's cells become resistant to insulin's effects, prompting the pancreas to produce more insulin in an attempt to compensate. This state of hyperinsulinemia sets off a cascade of downstream effects, especially within the ovaries.
Unlike other tissues where insulin resistance dampens insulin's actions, the ovaries retain their sensitivity to insulin's mitogenic (growth-promoting) effects. This is particularly true for theca cells, specialized ovarian cells that produce androgens like testosterone. When insulin teams up with another hormone, luteinizing hormone (LH), it co-activates androgen production, resulting in theca cell hypertrophy (growth in size) and excess testosterone. The result? Disrupted follicle development, irregular ovulation, and the classic signs of PCOS.
How Excess Androgens Disrupt the Cycle
High levels of testosterone and other androgens interfere with the normal feedback loop between the ovaries and the brain. Follicles that would normally mature and release an egg each month get stuck in development, leading to the "poly-cystic" appearance seen on ultrasound. This disruption in ovulation leads to irregular menstrual cycles, infertility, and mood fluctuations. But the hormonal imbalance doesn’t end there.
Elevated insulin levels also reduce the liver’s production of sex hormone-binding globulin (SHBG), a protein that binds excess androgens and keeps them in check. With less SHBG available, free testosterone levels rise even higher, exacerbating symptoms like acne, hirsutism (excess hair growth), and scalp hair thinning.
PCOS and the Metabolic Web
Insulin resistance doesn’t just affect the ovaries—it creates ripples throughout the entire body. Women with PCOS are at significantly higher risk of developing:
Type 2 diabetes
Gestational diabetes
Metabolic associated liver disease (MASLD)
Cardiovascular disease
Obesity or difficulty losing weight
Because of this, many experts now view PCOS as a metabolic condition with reproductive consequences—not the other way around. IN FACT - I have proposed renaming the condition to HOAMD: HyperAndrogenic Ovulatory Metabolic Disturbance. Addressing insulin resistance head-on is the most direct way to improve both metabolic health and reproductive function.
Lifestyle: The First Line of Treatment
Fortunately, insulin resistance is modifiable, and lifestyle interventions can have profound impacts. Studies consistently show that even modest weight loss (5-10% of body weight) can restore ovulation and regulate cycles in women with PCOS. But it’s not just about the scale.
Nutrition plays a critical role. Emphasizing:
High-fiber vegetables and legumes
Lean proteins
Healthy fats (like avocado, olive oil, nuts)
Low glycemic-index carbohydrates
can help stabilize blood sugar and reduce insulin demand. Reducing intake of ultra-processed foods and sugary beverages is also key.
Exercise is another powerful insulin sensitizer. Both resistance training and cardiovascular exercise have been shown to improve insulin sensitivity, lower androgens, and support weight loss. Aiming for at least 150 minutes of moderate activity per week—including strength training twice a week—can make a significant difference. There has been an unfortunate thread of misinformation propagated on the internet about individuals with PCOS avoiding strength training due to increase in cortisol. THIS IS FALSE. Individuals with PCOS should absolutely do strength training to build muscle mass, which in turn helps improve insulin sensitivity!
Targeted Medical Therapies
For many women, lifestyle changes alone may not be enough, especially when insulin resistance is severe or long-standing. Medications that improve insulin sensitivity can be incredibly helpful:
Metformin: Originally developed for type 2 diabetes, metformin improves insulin sensitivity, lowers androgen levels, and can help restore ovulation.
Inositol supplements (especially myo-inositol and D-chiro-inositol): These vitamin-like compounds mimic insulin's actions and have shown promising results in improving ovulation, reducing testosterone, and supporting metabolic health.
GLP-1 receptor agonists: A newer class of medications (like semaglutide and liraglutide) originally used for diabetes and obesity, GLP-1s enhance insulin function, reduce appetite, and have been shown in emerging studies to help regulate cycles and reduce weight in women with PCOS.
A Whole-Person Strategy
Ultimately, PCOS (ahem, HOAMD) is not a one-size-fits-all condition. The expression of symptoms, degree of insulin resistance, and metabolic impact can vary widely. That’s why a personalized approach is essential. The good news is that by targeting insulin resistance at its core—through food, movement, and medication if needed—many women can not only improve their cycles and fertility, but also protect their long-term health.
PCOS isn’t just a reproductive disorder. It’s a window into your metabolic health. And when we use that insight to guide meaningful, root-cause interventions, real transformation is possible.