PCOS and insulin resistance: what helps bring the cycle back

Key points

What PCOS is, in plain words

Polycystic ovary syndrome is not a disease of the ovaries themselves but a hormonal imbalance of the whole body. The “cysts” seen on ultrasound are many immature follicles: eggs start to mature but rarely reach ovulation.

The diagnosis is made if two of three features are present:

• infrequent periods or none at all — ovulation happens rarely or not at all;
• an excess of male hormones: acne, hair growth on the face and body, hair loss on the scalp — or high testosterone on a blood test;
• many follicles in the ovaries on ultrasound; since 2023, adults can have an AMH (anti-Müllerian hormone) test instead of ultrasound (Teede HJ J Clin Endocrinol Metab 2023. PMID 37580314^[6]).

The 2023 international guideline stresses that PCOS is also about metabolism, the heart and blood vessels, sleep and mood, not just the cycle (Teede HJ J Clin Endocrinol Metab 2023. PMID 37580314^[6]). Before the diagnosis is made, causes with similar features are ruled out — thyroid disease, high prolactin, congenital disorders of the adrenal glands.

Why it all starts with insulin

When cells don't hear insulin well, the pancreas releases more of it. High insulin spurs the ovaries to produce more testosterone and lowers SHBG (sex hormone-binding globulin) — so there is even more free testosterone.

This creates a vicious circle: insulin stores fat on the belly, and that fat increases insulin resistance. The circle can be broken from any side — with your plate, exercise, weight, sleep, nutraceuticals or medication. How insulin resistance is assessed with a blood test is explained in the article The HOMA-IR index: the test doctors don't order.

Five pillars of a holistic approach

5. Nutraceuticals — inositol, berberine and spearmint tea; more on them below.

Natural helpers

Berberine is an alkaloid from barberry. In a meta-analysis of 12 studies, compared with placebo or no treatment, it lowered total testosterone (8 studies, 577 women) and the LH/FSH ratio (luteinising and follicle-stimulating hormones), and compared with metformin it reduced cholesterol and waist circumference more (Xie L Evid Based Complement Alternat Med 2019. PMID 31915452^[9]).

What the studies showed

Not everything is equally well proven: according to a Cochrane review, lifestyle changes, on low-quality evidence, reduced weight and the free androgen index, while their effect on glucose handling remained unclear (Lim SS Cochrane Database Syst Rev 2019. PMID 30921477^[1]); after 30 days of spearmint tea, the doctor's assessment of hair growth did not change significantly — the author attributes this to the short duration (Grant P Phytother Res 2010. PMID 19585478^[10]); there is no reliable evidence yet that berberine increases the live birth rate, and in women planning pregnancy there were more births on letrozole than on berberine (Xie L Evid Based Complement Alternat Med 2019. PMID 31915452^[9]).

Which tests to discuss with your doctor

• total testosterone and SHBG — they are used to calculate the free androgen index;
• fasting glucose and insulin for HOMA-IR — not part of the international guideline's essential minimum, but they show insulin resistance clearly;
• TSH (thyroid-stimulating hormone) and prolactin — to rule out thyroid and pituitary problems;
• 17-OH progesterone — to rule out congenital disorders of the adrenal glands;
• AMH or pelvic ultrasound;
• lipid profile.

You can check whether you have signs of PCOS with our online test.

What your doctor may prescribe

Metformin is the classic medication that increases insulin sensitivity; its common downside is digestive upset (Greff D Reprod Biol Endocrinol 2023. PMID 36703143^[4]). Combined oral contraceptives are used to regulate the cycle and lower androgens, and letrozole to stimulate ovulation when planning pregnancy (Teede HJ J Clin Endocrinol Metab 2023. PMID 37580314^[6]). The choice is up to the doctor after the tests.

Who should be more careful

• During pregnancy and breastfeeding, take berberine and any supplements only with your doctor's approval.
• If you take diabetes medication, discuss the dose of inositol and berberine with your doctor first: blood sugar may drop more.
• If you have had no periods for more than three months, or hair is growing quickly, or your voice is deepening — see a doctor without delay.

Bottom line

PCOS is a signal from the whole body, and it responds best to systematic work: a low-GI plate, intense exercise, sleep, gentle weight loss and nutraceuticals that have been studied in PCOS. Start with tests and the PCOS signs test. You can book an appointment with an endocrinologist here, and with obstetrician-gynaecologist and andrologist Dr. Igor Pereligyn here.

This material is for information only and does not replace a consultation with a doctor. Medications and supplements are prescribed by a doctor based on examination results.