The 2023 Levels Guide to PCOS and metabolic health

Polycystic ovarian syndrome (PCOS) is a condition affecting fertility, weight, and more—and it's intimately tied to metabolic health.

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age. It increases the risk of cardiometabolic conditions, is the leading cause of female infertility, and presents with largely unwanted symptoms, such as excess hair growth and weight gain. PCOS affects 6-12% of women in the U.S. and up to 20% worldwide.

The name of this condition is misleading, as PCOS involves more than just the ovaries—it is rooted in an imbalance of hormones, the messengers that send signals through the body. PCOS is considered a multi-system disorder because it impacts not only the reproductive system but also metabolic health. A majority of people with PCOS have insulin resistance.

If you have PCOS—or think you may have it—it’s essential to understand all the ways it can affect your health and what you can do to manage it. Here’s everything you need to know about PCOS, including diagnosis, symptoms, treatment, and more.

How do you know if you have PCOS?

There are no specific tests or universally accepted diagnostic criteria for PCOS. Historically, doctors have used a process called the Rotterdam criteria. This was developed in 2003 and requires someone to have at least two of these three symptoms to receive a PCOS diagnosis:

• Hyperandrogenism: This is when the body produces excessive levels of a class of hormones called androgens, which include testosterone. Hyperandrogenism is considered a hallmark feature of PCOS, as it is responsible for many common PCOS symptoms. The overexpression of androgens also impacts other hormones, such as estrogen and insulin, as well as can lead to complications such as infertility and metabolic conditions. Your doctor can identify hyperandrogenism through blood work or by symptoms [see below].
• Irregular or absent ovulation (anovulation): PCOS can affect the menstrual cycle by delaying and preventing ovulation. Ovulation is when an egg releases from the ovary so conception can occur (if the egg isn’t fertilized, your period occurs two weeks later). Delayed ovulation—which can be marked by cycles longer than 35 days—suggests that reproductive hormones are not functioning optimally. Ovulation tests and blood work can also identify ovulatory dysfunction.
• Polycystic ovaries are enlarged ovaries with multiple tiny, fluid-filled sacs, or cysts. When the ovaries create cysts rather than produce and release healthy eggs, it is another sign of an imbalance in reproductive hormones. Cysts in the ovaries can indicate PCOS, but cysts can occur in women without PCOS, and PCOS is still possible without cysts.

In 2006, the Androgen Excess Society (AES) criticized the Rotterdam criteria for implying that it’s possible to have PCOS without hyperandrogenism. The AES suggested a new set of criteria, which requires hyperandrogenism as well as either anovulation or polycystic ovaries. They argue that hyperandrogenism is a critical component of PCOS because it is responsible for symptoms and long-term risks, as well as the primary focus for treatments.

More recently, clinicians and researchers have also argued that PCOS should be classified as a metabolic disease and that symptoms related to metabolic health also warrant treatment when managing PCOS. For example, insulin resistance isn’t currently included within the diagnostic criteria, despite affecting most people with PCOS and contributing to the condition. Insulin resistance can also lead to metabolic syndrome, which affects up to 43% of adults with PCOS. Metabolic syndrome is also linked to androgen levels but isn’t currently considered when making a PCOS diagnosis.

Regardless of these diagnostic disagreements, two factors are critical in assessing one’s specific health risks and treatment options for PCOS: androgen levels and metabolic health markers. These two components are responsible for many of the adverse effects of PCOS and are vital in understanding how to manage the condition.

How does PCOS relate to metabolic health?

PCOS is tightly linked to our metabolism. Poor metabolic health—specifically, insulin resistance—can exacerbate PCOS by increasing androgen production.

It is estimated that 50-90% of people with PCOS will also have insulin resistance. Here’s how insulin resistance works: Insulin is a hormone vital for controlling blood sugar levels (or glucose). The pancreas releases insulin to move glucose out of the bloodstream and into the body’s cells. Excess sugar intake, poor sleep, chronic stress, lack of physical activity, environmental toxins, and genetic factors can lead to high glucose and insulin. Over time, this renders cells “numb” to the effects of insulin, a condition referred to as insulin resistance. When this happens, glucose has more trouble getting into cells, leading to higher circulating glucose and more insulin production in a self-feeding cycle.

Excess insulin can interfere with the release of other hormones—particularly androgens, which can ultimately lead to PCOS. Here is how that happens:

Theca cells, which are cells in the ovaries that produce hormones, have insulin receptors. When insulin stimulates theca cells, they produce higher levels of androgens than they normally do. Insulin can also cause an increase in the actual number of theca cells within the ovary, thereby increasing the capacity of the ovaries to produce androgens.

Elevated insulin levels also decrease the production of sex hormone-binding globulin (SHBG), a protein produced in the liver that works by binding to testosterone and other androgens in circulation. By reducing SHBG production, insulin further contributes to elevated androgen activity by leaving higher levels of free testosterone in circulation.

Unfortunately, this relationship works both ways, as the high androgen levels associated with PCOS can also worsen insulin resistance. Having too many androgens can cause fat to be redistributed from the hips to the abdominal area. These fat cells impair the body’s response to insulin, contributing to insulin resistance.

Androgens can also worsen insulin resistance by affecting insulin activity in skeletal muscle and fat tissue, promoting non-alcoholic fatty liver disease (NAFLD), and lowering adiponectin levels, an anti-diabetic hormone secreted by fat cells that is generally higher in women than in men.

Androgens and insulin exacerbate each other and create a vicious cycle.

What are the symptoms of PCOS?

Alongside the three diagnostic criteria  mentioned above, people with PCOS may experience additional symptoms, including:

Androgenic symptoms:

• Excessive hair growth on the face and body (hirsutism): This is seen as the primary clinical sign of hyperandrogenism, and up to 70-80% of people with PCOS have it. Common places to find excess hair are the face, stomach, and breasts.
• Acne: An estimated 17-27% of people with acne have PCOS. Androgens encourage glands in the skin to produce more oil and for follicles to get clogged, causing bacteria that live on the skin to form acne.
• Hair loss from your head (androgenic alopecia): High androgen levels can also cause hair thinning on the head in around 22% of people with PCOS.

Metabolic symptoms:

• Elevated glucose levels (hyperglycemia): A state of chronically high blood sugar is called hyperglycemia. This can lead to insulin resistance and drive other cellular dysfunction, such as oxidative stress and glycation.
• Elevated insulin levels (hyperinsulinemia): Insulin resistance leads to ever-higher insulin levels. This appears to enhance androgen production and plays a role in weight gain.
• Insulin resistance: If left untreated, insulin resistance can evolve into prediabetes and, ultimately, Type 2 diabetes. Between 1.5-12.4% of people with PCOS have Type 2 diabetes, compared to 1-3% of people of reproductive age who don’t have the condition.
• Weight gain: According to the American College of Obstetricians and Gynecologists, as many as 4 in 5 people with PCOS are obese. PCOS patients are also almost 2.8x more likely to be obese than those without PCOS. Both insulin resistance and hyperandrogenism are thought to play a role in obesity. Since insulin resistance renders the body less capable of absorbing glucose and turning it into energy, more glucose is converted and stored as fat. Increased body weight can also make insulin resistance worse. This can be frustrating because weight loss is recommended to manage PCOS symptoms. Read more about how PCOS and weight are related here.
• “PCOS belly”: This refers explicitly to weight gain around the belly, where fat is typically distributed in men. As androgens are “male” hormones, they can affect how fat cells accumulate in women, causing them to sit around the belly and increase insulin resistance. This type of fat tissue—known as visceral adipose tissue—is considered a major contributing factor to insulin resistance in PCOS.
• Skin tags: These are soft, hanging growths on the skin, generally between 1-5mm in size. High insulin levels can cause skin tags, as it encourages increased cell growth on the outer layer of the skin.

The link between PCOS and insulin resistance

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What risks come with PCOS?

PCOS not only creates unpleasant symptoms but also increases the risk of other serious health conditions.

Infertility

PCOS is the most common cause of female infertility, defined as no pregnancy within a year of trying. Infertility affects 50-75% of people with PCOS.

Everyone with PCOS has either irregular cycles or cysts on the ovaries, meaning that the menstrual cycle is dysfunctional. Often, this is because high androgen levels delay or prevent ovulation. In excess, androgens interfere with the regular cascade of hormonal interactions that need to happen for an egg to be released. Without an egg, pregnancy is impossible. Hyperinsulinemia can also influence fertility, as it also dysregulates the cascade of hormonal processes necessary for a healthy menstrual cycle.

If you have PCOS, it doesn’t mean you’ll never get pregnant or your pregnancy won’t go to plan. As opposed to a structural or irreversible issue, PCOS simply requires the restabilization of hormones so you can produce and release eggs in a healthy manner.

Pregnancy risks and complications

During the third trimester of pregnancy, the body naturally goes into a state of insulin resistance to ensure enough glucose for the fetus. If insulin resistance during pregnancy compounds with existing insulin resistance from having PCOS, the body might not be able to produce enough insulin to compensate, and blood sugar levels can rise too high.

This can lead to gestational diabetes, which is almost three times as likely to develop in people with PCOS, as well as increase the risk of preeclampsia (high blood pressure during pregnancy) and preterm birth.

What you need to know about PCOS and pregnancy

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Cardiometabolic health risks

People with PCOS have an elevated risk of many cardiometabolic conditions. These include:

• Diabetes: Type 2 diabetes is when the pancreas can’t produce enough insulin to counter high blood sugar. People with PCOS are almost four times more likely to develop Type 2 diabetes than those without PCOS. A recent, large-scale study of more than 73,000 people found that higher blood sugar levels and triglycerides (both influenced by insulin resistance) were the best predictors of whether someone with PCOS would develop Type 2 diabetes.
• Heart disease: Elevated androgen and glucose levels can influence the cells and blood vessels to release molecules and activate enzymes which can cause plaque build-up in the arteries. This increases the risk of high blood pressure and cardiovascular disease.
• Dyslipidemia: Insulin resistance can also influence how the body creates and breaks down lipids, or fats, which can contribute to heart disease. When high-density lipoprotein (HDL) cholesterol is too low or low-density lipoprotein (LDL) cholesterol levels or total cholesterol levels are too high, it’s called dyslipidemia, which affects up to 70% of people with PCOS.
• Sleep apnea: Finally, insulin resistance is associated with sleep apnea, when your breathing becomes abnormal during sleep. People with PCOS are nearly 30 times more likely to have sleep apnea than those without.

Anxiety and depression

Alongside physical symptoms, a growing body of research is looking into how PCOS impacts mental health and general life satisfaction.

The impact of dealing with PCOS has been shown to increase the risk of anxiety and depression. This may be because every physically visible PCOS symptom goes against societal constructs around female appearance and what makes someone “womanly.”

Concerns about weight gain have been linked to low body satisfaction, confidence, and depression. Meanwhile, people experiencing hair loss from the head are three times more likely to be anxious than those who don’t share that symptom. Hirsutism is also associated with anxiety and low self-esteem, while acne is linked to depression. Coping with the effects of infertility can also be challenging. Not only has this been linked to an increased risk of anxiety in PCOS-specific studies, but it’s also associated with low self-esteem, relationship issues, and social stigma in general.

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How to treat PCOS with lifestyle choices

Unfortunately, there is no cure for PCOS, but there are many ways to reduce the symptoms. Doctors may prescribe medications like metformin and birth control, which can help manage symptoms but also have side effects that can be severe for some women. Fortunately, promising research suggests that optimizing diet and lifestyle (which directly impacts insulin and glucose regulation) may improve symptoms of PCOS. If you’re able, we recommend finding a metabolically savvy forward thinking clinician to help create your decision plan.

Eat for Stable Blood Sugar

Eating foods that help keep blood sugar in a healthy range may be an effective strategy for easing PCOS symptoms because it lessens insulin resistance. This means that dietary changes can make symptoms worse or help improve them.

Several studies report that a metabolically friendly diet may be beneficial for women with PCOS.

• One study looked at 21 women with PCOS over a 24 week period. For the first 12 weeks, they were allowed to eat their usual diet. At week 12, they started an LGI diet that was calorically equivalent to the diet they consumed during the first 12 weeks of the study. After 12 weeks on the LGI diet, researchers found that insulin resistance had decreased significantly.
• Another study involving 49 women with PCOS found that independent of weight loss, women adopting an LGI diet over a period of 12 months had increased insulin sensitivity and improved menstrual symptoms compared to those using a conventional healthy diet. In fact, 95% of women in the LGI group who completed the intervention showed an increase in menstrual regularity. The women in this study on the LGI diet also reported a significant improvement in their emotional well-being based on a quality-of-life questionnaire, as compared to women on a conventional diet. Research suggests there may be an association between insulin resistance and depression.
• More recently, researchers looked at how a low-calorie, LGI diet affected women with and without PCOS. They found that after 24 weeks on the LGI diet, the 28 women with PCOS lost weight, had lower fasting insulin levels, and decreased their insulin resistance. Menstrual regularity improved in 80% of women with PCOS, and over 30% of women with PCOS experienced a decrease in the occurrence of acne!
• A study from 2020 of 14 overweight women with PCOS showed that adoption of a ketogenic Mediterranean diet for 12 weeks led to significant improvement in PCOS-associated biomarkers. The women lost an average of 20 pounds, had significantly reduced abdominal fat, and had significantly lower levels of insulin, insulin resistance, triglycerides, total cholesterol, and LDL cholesterol. Their reproductive hormone levels (namely testosterone and SHBG) also became more normalized.
• A review from 2017 that included seven research papers investigating the impact of low carb diets (i.e. diet with less than 45% of total energy coming from carbohydrates) on fertility outcomes demonstrated improvement in fertility with low carb diets. The authors concluded that “there is convincing evidence that reducing carbohydrate load can reduce circulating insulin levels, improve hormonal imbalance and result in a resumption of ovulation to improve pregnancy rates. Numerous studies have shown that low carbohydrate diets not only elicit fast and significant weight loss but also reduce serum insulin, consequently improving insulin sensitivity.”

There are a few ways to know which foods spike your blood sugar. The glycemic index of a food refers to how much it raises blood glucose levels after consumption. Eating an abundance of high glycemic index foods promotes insulin resistance and weight gain, whereas eating foods with a low glycemic index should not substantially increase blood glucose and insulin levels.

However, glycemic responses can vary among people. One person might get a blood sugar spike after eating a banana but not potatoes, while the reverse might be true for another person.

Over-the-counter finger-prick tests or continuous glucose monitors can provide insights into what foods may spike your blood sugar. Whether or not you decide to use these, the following rules of thumb will help you maintain stable blood sugar: 1) Focus on whole, nutrient-dense, fiber-rich foods. 2) Avoid sugars, processed foods, and refined carbohydrates.

What diet is best for PCOS?

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Weight Loss

For people with PCOS, the relationship between high androgens and insulin can make weight easier to gain and harder to lose. This can be frustrating because weight loss is recommended to manage PCOS.

Due to insulin resistance, studies estimate that people with PCOS can transform 35-40% less of their blood sugar into energy than those who don’t have the condition. Extra blood sugar means more insulin, which the body takes as a signal to store the glucose as fat. This creates another vicious cycle: more body fat can increase insulin resistance, insulin resistance can increase androgen levels, and androgen levels can increase body fat by causing weight gain around the belly.

Research demonstrates that moderate weight loss can be highly beneficial. Insulin resistance increases with BMI, and losing as little as 5% of your body weight (i.e., 7.5 lbs for a 150 lb woman) can help reduce PCOS symptoms.

However, it’s important to note that lean people with PCOS also have higher insulin levels than their peers without PCOS, irrespective of their weight. This suggests that while weight can influence the severity of insulin resistance, insulin resistance itself is an inherent feature of PCOS.

Thus, weight loss is a helpful strategy for those who have weight to lose. Still, in general, whether you are overweight or not, the same method applies: lowering glucose spikes and decreasing insulin resistance.

Exercise

A review of 33 studies found that people with PCOS who did high-intensity exercise had reductions in BMI and a moderate decrease in insulin resistance. Improvements were also seen in those that did moderate-intensity exercise. Overall, weight training had the most significant impact on reducing androgen levels. (Nutrition still matters: the study found that the best results were seen in people who also had a healthy diet.)

When we work out, there’s a greater demand in the body for energy, which can increase the body’s uptake of glucose. This can help people with insulin resistance to regulate their glucose levels. Exercise has such a powerful effect on our metabolism that it can reduce the risk of Type 2 diabetes and prevent the disease from progressing.

However, high-intensity exercise, at 60% or more of VO2 max, can increase levels of cortisol, aka the stress hormone. Stressors like exercise stimulate the release of adrenocorticotropic hormone (ACTH), which acts on the adrenal glands to release androgens. For people with PCOS, going too hard at the gym could potentially exacerbate your symptoms. Although more research is needed, this may be particularly relevant for lean people with PCOS.

Moderate exercise, on the other hand, can have a real impact. Research has shown that simply going for a 30-minute walk after a meal improves the body’s ability to absorb glucose and helps stabilize blood sugar.