Polycystic ovary syndrome beyond ovulation: the metabolic and inflammatory picture

PCOS is commonly diagnosed in the context of irregular cycles, acne, unwanted hair growth or difficulty conceiving, and it is commonly managed with those concerns as the sole focus. That focus is understandable and incomplete.

The women I see in their thirties and forties with PCOS are often dealing with insulin resistance, central weight gain, dyslipidaemia and rising cardiometabolic risk that nobody discussed with them at diagnosis.

The metabolic core

Insulin resistance is present in a large proportion of women with PCOS, including many with a normal body mass index, which is a point regularly missed. Elevated insulin contributes to increased ovarian androgen production, which in turn drives several of the features by which the syndrome is recognised.

This creates a loop rather than a one way process, and it explains why interventions that improve insulin sensitivity frequently improve cycle regularity and androgenic symptoms as well. It also explains why women with PCOS carry higher lifetime risk of type 2 diabetes and gestational diabetes.

A fuller assessment

What I look for at diagnosis and at review goes beyond cycles and androgens.

• Glycaemic status, ideally with more than a fasting glucose, and repeated over time rather than once
• Waist circumference and its trajectory, not weight alone
• Lipid profile, including triglycerides
• Blood pressure
• Liver enzymes, given the association with fatty liver
• Screening for obstructive sleep apnoea in symptomatic women, which is underdiagnosed in this group
• Mood, since anxiety and depression are more prevalent and are frequently untreated
• Thyroid function and prolactin, to exclude conditions that present similarly

What helps

The interventions with the best evidence are, again, not proprietary. Resistance training combined with aerobic activity improves insulin sensitivity independently of weight change, which matters for lean women with PCOS who are often told, unhelpfully, that they have nothing to work on. Modest sustained weight reduction where appropriate improves ovulatory function, androgenic symptoms and metabolic markers together.

Sleep and psychological load are legitimate targets, not soft ones. Metformin has a role in selected patients. Combined hormonal contraception manages several symptoms effectively and is a reasonable choice for many women, though it does not address the underlying insulin resistance and that should be said rather than implied.

On supplements, myo inositol has attracted genuine research interest with some encouraging findings, and it is not equivalent to established treatment. Most of the rest of what is marketed for PCOS has little supporting evidence, and women with this diagnosis are targeted heavily by that market.

The conversation to have at diagnosis

PCOS is not only about fertility, and it does not end when a woman has completed her family. It is a lifelong metabolic condition with reproductive features, and the years between diagnosis and midlife are the years in which its long term risk is most modifiable.

Telling a nineteen year old that her irregular cycles can be managed with the pill is accurate and insufficient. Telling her that she has a condition worth monitoring metabolically for the rest of her life, and that regular resistance training and attention to sleep are clinical interventions rather than general advice, changes what happens over the following twenty years.

This article is written for education and professional discussion. It is not medical advice and it is not a substitute for consultation with a clinician who knows your history. Nothing here should be used as a reason to stop or alter prescribed treatment without the involvement of the doctor who prescribed it.