What You Really Need To Know About PCOS & Insulin Resistance

Polycystic ovary syndrome is often described as a circle of symptoms. Symptom A triggers Symptom B, leading to Symptom C, which keeps Symptom A going. Complicating matters further is the fact that, while PCOS affects an estimated 10-20% of women worldwide, the syndrome manifests differently from case to case. For example, not all women diagnosed with PCOS actually have cysts on their ovaries (and many women without PCOS do), leading many in the medical community to call for a new name — one which, as one doctor put it, “reflects the complex interactions that characterize the syndrome.” So far, nobody’s come up with a winner.

But there is one symptom which appears more frequently than others: Approximately 65-70% of women with PCOS have insulin resistance. Sometimes referred to as “insulin insensitivity,” this is a condition in which the body fails to properly respond when insulin is released, leading to improper metabolization of carbohydrates and therefore elevated blood glucose. That can lead to things like rapid weight cycling, which can then trigger elevated androgen levels, which, of course, leads right back to greater insulin resistance, and the cycle continues.

Here’s the good news: While insulin resistance is one of the most common symptoms of PCOS, there are many ways to manage it — some of which you may have never heard about. Typically, patients are told that medication, weight loss, and carbohydrate restriction (or even elimination) are the only solutions. But, as with everything about PCOS, the answer isn’t simple. When it comes to understanding and treating this particular symptom, it’s a lot more complicated — and hopeful — than you’d think.

Illustrated by: Janet Sung.
1. Insulin resistance affects women of all sizes.

First, it’s important to know that insulin resistance is not exclusive to PCOS. It’s associated with numerous diseases, like type-2 diabetes and Hepatitis C, as well as other endocrine issues, genetic predispositions, and lifestyle and environmental factors. In many of these cases, insulin resistance is correlated with increased body weight (as is often the case in type-2 diabetes). Add to that the fact that PCOS is also often correlated with weight gain, and it would be easy to assume that thin women don’t have this symptom. But that’s simply not the case.

“Really, it is not necessarily a fat person's disease or a thin person's,” says Dianne Budd, MD, a San Francisco-based endocrinologist. “There really is no ‘classic’ person [with PCOS].”

While an estimated half of women (or slightly more) with PCOS are deemed “overweight” or “obese,” that leaves millions of women who are not. These women have what’s often referred to as “lean PCOS,” and because of that, they and their symptoms are frequently overlooked. But numerous studies indicate that PCOS-related insulin resistance occurs in women of all weights. It’s possible that this is because the insulin resistance that happens with PCOS is caused by something different than that which occurs in, say, type-2 diabetes (more on that later). Regardless, it’s important that all women with PCOS be screened for insulin resistance.
Illustrated by: Janet Sung.
2. Yes, weight loss may help some — but there’s a catch.

This topic is even more tangled and fraught with misunderstanding than PCOS itself, so let’s just get it out of the way: Yes, there is evidence to indicate that losing a certain percentage of weight may improve insulin sensitivity. This is the consensus regarding insulin resistance in general — not specifically PCOS-related insulin resistance. Though some studies of PCOS patients did show that women of higher weights who lost weight had improvement of this and other PCOS symptoms. Again, it goes back to the cycle: Changes in weight can affect changes in hormones, which can change the way your body responds to insulin, etc.

But here’s the rub — well, several rubs: First, there is no across-the-board recommendation regarding starting points or endpoints when it comes to weight loss and insulin resistance. As usual, when it comes to weight, it all depends very much on your own physiology, genetics, activity level, etc. Second, insulin resistance can be caused by weight gain — but, crucially, there is no consensus on the underlying cause of PCOS-related insulin resistance. Research suggests that it’s likely a result of elevated androgens, at least in part. Therefore, it doesn’t make sense to treat insulin resistance, which probably wasn’t caused by weight gain alone, with weight loss — at least, not as a first-line approach.

Finally, research has long indicated that deliberate attempts at weight loss don’t work in the long term. And insulin resistance itself makes losing weight with PCOS even more difficult. “We all know that fails,” Dr. Budd says. “I mean, that seems really cruel to me, to go tell somebody to do something that fails...Let's talk about things that work.”
Illustrated by: Janet Sung.
3. Exercise helps, in more ways than one.

Exercise improves everyone’s insulin sensitivity, whether or not they have insulin resistance. That’s one of the reasons why consistent, balanced activity is good for us. The benefits kick in right away, as well. One workout increases insulin sensitivity for up to 16 hours (perhaps even longer if you have insulin resistance). Long-term exercise improves it as well, in different ways.

There are a number of reasons for this, and some researchers are still trying to ascertain exactly why and how exercise works so well. You can read myriad fascinating studies on the ways exercise changes the functioning of glucose and insulin in your body. (I mean legit fascinating, even if you’re not a scientist. Check out this graph showing the difference between an exercised leg and a rested leg.)

But if you just want to put your workout to good use, then here’s all you need to know: First, exercise lowers insulin resistance, whether or not it lowers your weight. Second, any form of consistent exercise will have some degree of benefit, but if you’re really looking to increase your insulin sensitivity, then strength-training is a must.
Illustrated by: Janet Sung.
4. Cardio is good, strength-training is great, and both combined are fantastic.

Again, there is a wealth of complex physiological reasoning behind this, but the short version is that muscles use glucose, both during exercise and after. As you use, grow, and strengthen your muscles, they use more of it, more effectively. Studies indicate that cardio alone is helpful, but not nearly as much as exercise that includes strength-training as well. Even shorter version: Seriously, just get in the weight room.

“Cardio comes after,” says Morit Summers, an athlete and personal trainer who has PCOS herself. She urges clients with the syndrome to start with strength-training, and when in doubt, make that the priority. “Cardio is like the recovery day. It’s not the focus of the workout.”

Summers recognizes that most of us think of exercise the other way around (women, in particular, often overemphasize cardio). You might not be confident lifting weights and using unfamiliar resistance machines. So, do yourself a favor and ask for help. “If the opportunity is available, try and find a personal trainer — even if it’s just for a short period of time,” Summers says. “Tell them, ‘I want to learn these things to be able to do them on my own.’”

If that’s not an option for you, Summers suggests doing research. “Google ‘how to do a squat’...and really take the time to study it.” Make sure, of course, that you’re getting advice from reputable sources (i.e. certified trainers), and if you’re still uncertain, ask. Summers says she has no problem offering advice on form, even if someone DMs her a video of their squat on Instagram.

Start with the strength-training moves that you’re confident doing, and then take steps to incorporate more. Your body and your blood sugar will thank you.
Illustrated by: Janet Sung.
5. If you’re obsessing over carbs, you’re not alone.

This is one of the most common (and infuriating) effects of insulin resistance: an impaired ability to process carbohydrates, and an increased appetite for them. Throw in the fact that mainstream diet trends reinforce the idea that carbs and sugar are Public Enemy #1, and women with PCOS can feel utterly hopeless in the face of bread.

The traditional advice is to resist, resist, resist the cravings and drastically limit carb intake. But some nutrition professionals point out that this can do more harm than good. “I find that to be one of the worst things you can recommend to women with PCOS,” says Julie Dillon, MS, RD, NCC, LD, a dietitian who specializes in PCOS. “Telling people to limit the one nutrient that their body is screaming for is only going lead to a failure.”

Instead, Dillon begins any new nutrition plan by teaching a client to actively notice their carb cravings: When do they typically spike? Are they more or less intense at certain times of day, or during particular weeks? And how do they physically feel when they eat certain foods versus others? Dietary changes are often part of the protocol, too, but shifting a client’s attitude about carbohydrates (from avoidance to observance) is crucial to long-term success.

“What's really cool is that, in the end, my clients will not end up necessarily limiting their carbohydrates, but their cravings become more consistent with what’s recommended in the first place,” Dillon says. Deliberately cutting out carbs at the start, she says, “is putting the cart before the horse.”
Illustrated by: Janet Sung.
6. Insulin resistance can be improved by diet — but not the way you think.

Erica Leon, MS, RDN, CDN, CEDRD, is another dietitian, who specializes in people with a history of disordered eating and dieting (something she often encounters in her clients with PCOS). Typically, they come to her after years of struggling to eliminate carbs, believing that’s their only recourse. “Whenever you take carbohydrates out, you create feelings of deprivation and then you’re going to have binging. It will naturally occur,” Leon says. “I think that when you take a person with PCOS — who has intense carbohydrate cravings perhaps, who becomes obsessive worrying about weight loss — you can create an eating disorder.”

Leon says that even PCOS clients with no history of ED are conditioned by years of restrictive dieting. So, like Dillon, her primary goal is to eradicate carb-panic, rather than carbs themselves. “We’re going to work on hunger and fullness cues,” Leon says. “We’re going to work on getting more physically active...eating satisfying foods, not diet foods.”

Most adults have a basic understanding of nutrition, and can use that common sense once they’re out of the diet mindset. But, since PCOS is often diagnosed during puberty, Leon sometimes has to educate her younger clients carefully. “I’m working with a 16-year-old right now, and she really does need some guidelines,” Leon says. “She has very little understanding that when she eats five packaged snacks, that’s causing her blood sugar to increase.” So, Leon is trying to teach her about the role of excess carbohydrates — without talking in absolutes. “It has to be very gentle,” she says.

Dillon echoes this sentiment. “My clients with PCOS have been through the ringer with dieting. They're always worried that they're over-consuming something, whether it's calories or carbs,” she says. “I wish I could erase that, because I feel like it would be so much easier for them.”

Both Leon and Dillon typically integrate more protein and/or fat (like fish, plant-based protein, or even chicken nuggets, if that’s what’s affordable) into the diet of someone with insulin resistance. (“Whatever kind of protein a client of mine enjoys eating, that’s what we're gonna go for,” Dillon says.) Depending on how much they’re already eating, this can really help take the edge off those carb cravings. The key, they both emphasize, is that adding more protein without purposefully removing carbs will help a client’s carb intake naturally begin to normalize.
Illustrated by: Janet Sung.
7. Medication can help support these changes.

These diet and exercise modifications can make a huge difference in managing insulin resistance. But the irritating irony is that it’s hard to start making those changes when your insulin resistance is unmanaged. You may feel sluggish and ravenous for sugar. Even the phrase “lifestyle changes” is exhausting when your body is telling you to lay on the couch and be moody. That’s why most women with PCOS are put on medication as soon as they’re diagnosed.

Metformin is the drug most commonly prescribed for PCOS, though it is technically designated as a medication for type-2 diabetes. Lowering insulin resistance is actually a secondary function of Metformin (its primary action is reducing the amount of glucose produced by the liver). Still, research indicates it’s generally safe and effective in helping to treat this symptom (and some others, indirectly) in women with PCOS — though it’s not a “magic bullet,” and it’s not without certain side effects. The most common are gastrointestinal issues, like diarrhea and gas, which may dissipate over time. But not everyone can tolerate Metformin, and there are other options out there, at least one of which may be even more effective.
Illustrated by: Janet Sung.
8. If you’re going to look into supplements, look into this one first.

Inositol is a substance made in our own bodies, which is involved in various functions, including insulin transduction. Some research suggests that women with PCOS may be deficient in inositol — and that this very deficiency could be the underlying cause of their insulin resistance. Thus, there is a growing amount of research on whether or not inositol supplementation should be the first-line treatment for women with PCOS.

You may also have seen bottles labeled “inositol” in the vitamin aisle, but before you run out and stock up, it’s important to note that it comes in many forms — not all of which can be absorbed by our bodies. It’s found in certain vegetables, for example, but that form isn’t bioavailable to us. “Inositol is interesting, but it’s not all the same substance,” Dr. Budd says. Myo-inositol and D-Chiro inositol are the primary players here, and the strongest research indicates that these two combined (in a certain ratio) may be more effective than Metformin in treating PCOS. It’s also noteworthy that it doesn’t come with the uncomfortable side-effects as Metformin.

“It’s a given than Myo-inositol is an insulin sensitizer and, overall, good for metabolism. Some feel its deficiency may even been the cause of PCOS,” Dr. Budd (who does, for the record, recommend supplementation) says. “But read that supplement bottle carefully!”

Better yet, read the research first (here’s a review of the randomized controlled studies on PCOS and inositol), and then discuss it with your doctor. As exciting as the data on inositol is, the cost is worth consideration, too. Ovasitol — the brand typically recommended — costs $90 for a 90-day supply. That may change with more time and research, but for now, Metformin may be more feasible for most PCOS patients who have health insurance.
Illustrated by: Janet Sung.
9. In fact, talk to your doctor anyway.

PCOS is a syndrome fraught with misunderstanding and, all too often, shame. When you’re first diagnosed, it can be hard to talk about the symptoms — especially those like insulin resistance, which can be both confusing and frightening. But don’t shy away from asking your doctor (or an RD or even a trainer) what else you can do to manage this better. If you have medication, and it works for you, great. But remember that PCOS, and this symptom in particular, is complex and multifaceted. It can come with all sorts of issues, but thankfully it can be tackled with many solutions.