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Insulin Resistance In PCOS – What You Need To Know

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Medilink Consultant clinic

Saad Ullah Siddiqui

Overview

Insulin resistance in polycystic ovary syndrome (PCOS) refers to a condition where your body makes insulin but is unable to use it effectively. 
&nbsp;

Think of your body as a house, and insulin is like a key that helps sugar get inside to give you energy. But sometimes, in PCOS, this key doesn&#39;t work as well, and the sugar has a hard time getting in.

As a result, blood sugar levels remain elevated, which can have a cascading effect on hormonal balance and overall health. Your body needs higher levels of insulin to keep blood sugar levels within the normal range. 
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Nearly 5-10% of women of childbearing age have PCOS<a href="#accordion">[5]</a>. Insulin resistance is present in about 44-70% of individuals with PCOS<a href="#accordion">[3]</a>. It can lead to elevated levels of insulin in the blood. This, in turn, triggers the ovaries to produce more androgens or male hormones. Elevated androgen levels can disrupt the normal menstrual cycle.

Insulin resistance can also disrupt normal ovarian function. The ovaries might produce more follicles, some of which can develop into cysts. These cysts are usually not harmful, but they can contribute to hormonal imbalances, too. 
&nbsp;

Causes

The exact cause of insulin resistance in PCOS is not fully understood, but a combination of genetic, hormonal, and lifestyle factors contributes to its development.

<ul>
	<li>Genetics: Genetic factors can play a significant role in how the body processes insulin. A family history of insulin resistance, type 2 diabetes, or metabolic syndrome may make you more predisposed to developing insulin resistance. 
	&nbsp;</li>
	<li>Hormonal Imbalances: PCOS is characterized by elevated levels of male hormones like testosterone. These elevated androgen levels can interfere with insulin signaling and contribute to insulin resistance. 
	&nbsp;</li>
	<li>Obesity: Excess body weight, especially central adiposity, is associated with insulin resistance in individuals with PCOS. Fat cells release inflammatory chemicals that can impair insulin sensitivity. 
	&nbsp;</li>
	<li>Inflammation: Chronic low-level inflammation is a common feature of both insulin resistance and PCOS, and the two conditions can exacerbate each other. 
	&nbsp;</li>
	<li>Gut Microbiome: Emerging research suggests that imbalances in certain gut bacteria can contribute to inflammation and insulin resistance<a href="#accordion">[6]</a>. 
	&nbsp;</li>
	<li>Others: A sedentary lifestyle, stress, and poor diet (high in refined carbohydrates, sugars, and saturated fats) can contribute to insulin resistance by reducing the body&#39;s sensitivity to insulin. 
	&nbsp;</li>
	<li>Insulin Feedback Loop: In some cases, insulin resistance can exacerbate itself. High insulin levels can lead to increased production of androgens by the ovaries, which can worsen insulin resistance, creating a feedback loop. 
	&nbsp;</li>
</ul>

Note: It&#39;s important to understand that these factors can interact and influence each other, leading to a complex interplay that contributes to insulin resistance in PCOS. Because PCOS is a heterogeneous condition, the exact causes and mechanisms can vary from person to person. If you suspect you have PCOS or are experiencing symptoms of insulin resistance, it&#39;s crucial to consult a healthcare provider for proper evaluation and guidance. 
&nbsp;

Signs and Symptoms

Insulin resistance is a common feature of PCOS and can manifest in various signs and symptoms<a href="#accordion">[2]</a>:

<ul>
	<li>Irregular Menstrual Cycles, prolonged cycles, or absence of periods (amenorrhea)</li>
	<li>Excessive Hair Growth (hirsutism) on the face, chest, back, or abdomen</li>
	<li>Scalp Hair Thinning or loss (androgenic alopecia)</li>
	<li>Darkening Of Certain Areas (acanthosis nigricans), often found in areas of skin folds such as the neck, armpits, and groin</li>
	<li>Acne Outbreaks, especially along the chin and jawline</li>
	<li>Skin Changes, like skin tags, often form around the neck and armpits</li>
	<li>Weight Gain or difficulty losing weight</li>
	<li>Elevated Levels Of Insulin and glucose in blood tests</li>
	<li>Tingling Sensations in hands or feet</li>
	<li>Fatigue or low energy</li>
	<li>Increased Hunger and thirst</li>
	<li>Increased Or Frequent Urination</li>
	<li>Cravings for sweet foods 
	&nbsp;</li>
</ul>

Note: Keep in mind that insulin resistance is interconnected with various other aspects of PCOS, such as hormonal imbalances and metabolic disturbances. Not everyone with PCOS will experience all of these symptoms, and the severity can vary. 
&nbsp;

Diagnosis

A healthcare provider will start by taking a thorough medical history, including details about your menstrual cycles, symptoms, family history of diabetes or metabolic disorders, and any existing medical conditions.

They may then proceed to a physical examination, which will involve assessing your weight, body mass index (BMI), and distribution of body fat. Skin changes like acanthosis nigricans may also be observed. 
&nbsp;

Laboratory tests also play a crucial role in diagnosing insulin resistance. Typically, doctors order the following tests to assess insulin levels and glucose metabolism<a href="#accordion">[2]</a>:

<ul>
	<li>Fasting Blood Glucose: This measures your blood sugar levels after fasting overnight or for 8 hours at least. Elevated fasting glucose levels might indicate insulin resistance.</li>
	<li>Fasting Insulin: Elevated fasting insulin levels in the presence of normal or slightly elevated glucose levels can be a sign of insulin resistance.</li>
	<li>Oral Glucose Tolerance Test (OGTT): This test involves fasting blood glucose measurements to be used as a baseline reference. You will then be asked to drink a glucose solution, and your blood glucose levels will be measured again after 2 hours. In cases of insulin resistance, your body may struggle to manage the glucose load effectively.</li>
	<li>Hemoglobin A1c (HbA1c): This test provides an average blood glucose level over 3 months. Elevated levels can suggest insulin resistance. 
	&nbsp;</li>
</ul>

In some cases, healthcare providers might order additional tests to assess related factors:

<ul>
	<li>Lipid Profile: This test measures cholesterol levels and triglycerides, as they can be affected by insulin resistance as well.</li>
	<li>Androgen Levels: Since insulin resistance can impact androgen levels, measuring hormones like testosterone can provide useful insights. 
	&nbsp;</li>
</ul>

Treatment

The treatment of insulin resistance in PCOS involves a combination of lifestyle modifications and, in some cases, medications. The goal is to improve insulin sensitivity, manage PCOS-related symptoms, and reduce the risk of long-term health complications. 
&nbsp;

<ul>
	<li>
	<h5>Lifestyle Modifications</h5>
	</li>
</ul>

These include:

<ol>
	<li>Healthy Diet</li>
</ol>

Focus on a balanced diet rich in whole foods, including fruits, vegetables, whole grains, lean proteins, and healthy fats. Also, choose complex carbohydrates that have a lower impact on blood sugar levels. Avoid or limit sugary foods, refined carbohydrates, and processed foods. 
&nbsp;

<ol start="2">
	<li>Portion Control</li>
</ol>

Pay attention to portion sizes to avoid overeating and prevent large spikes in blood sugar. 
&nbsp;

<ol start="3">
	<li>Regular Physical Activity</li>
</ol>

Engage in moderate exercise for at least 30 minutes a day to improve insulin sensitivity and aid in weight management. A combination of aerobic exercises (e.g., brisk walking, jogging, cycling) and strength training is beneficial to improve insulin resistance and lower cardiovascular risk in women with PCOS. Avoid excessive or intensive forms of exercise, as that will increase the demand on your adrenal glands and create more problems. 
&nbsp;

<ol start="4">
	<li>Weight Management</li>
</ol>

Maintaining a healthy weight or achieving gradual weight loss, if overweight, can significantly improve insulin sensitivity and PCOS symptoms. Losing just 5-10% of your body weight can help alleviate your symptoms<a href="#accordion">[3]</a>. 
&nbsp;

<ol start="5">
	<li>Other</li>
</ol>

Stop smoking and drinking alcohol. Also, get ample rest and learn to manage stress. Even chronic infections can contribute to the overproduction of cortisol, which leads to insulin resistance. 
&nbsp;

<ul>
	<li>
	<h5>Medications</h5>
	</li>
</ul>

These include:

<ol>
	<li>Insulin-Sensitizing Medications</li>
</ol>

This includes metformin, which is commonly prescribed to improve insulin sensitivity. It helps reduce insulin resistance and can also regulate menstrual cycles and improve ovulation.

Sometimes, thiazolidinediones are also prescribed to enhance insulin sensitivity. However, they are less commonly used due to potential side effects. 
&nbsp;

<ol start="2">
	<li>Anti-Androgen Medications</li>
</ol>

Medications like spironolactone can help manage symptoms of elevated androgens, such as hirsutism and acne. By addressing these symptoms, they indirectly contribute to improving overall well-being. 
&nbsp;

<ol start="3">
	<li>Combined Oral Contraceptives (COCs)</li>
</ol>

COCs are often prescribed to PCOS patients because they help regulate menstrual cycles, reduce androgen levels, and manage other symptoms like acne and hirsutism. However, research on its impact on type 2 diabetes risk in individuals with PCOS is fairly recent<a href="#accordion">[4]</a>. 
&nbsp;

<ul>
	<li>
	<h5>Management Of Other Conditions</h5>
	</li>
</ul>

Addressing insulin resistance can also involve managing other associated conditions, such as dyslipidemia (abnormal lipid levels) and hypertension. Treating PCOS also helps improve insulin sensitivity. 
&nbsp;

Important!

<ul>
	<li>Managing insulin resistance is an important part of treating PCOS.</li>
	<li>Treatment plans should be tailored to your specific needs, taking into account factors like your age, medical history, current health status, and goals.</li>
	<li>Not all individuals with PCOS require medication. Lifestyle modifications are fundamental and often the first line of treatment.</li>
	<li>Regular follow-up appointments with your healthcare provider are crucial to monitor your progress, adjust treatment plans as needed, and address any concerns. 
	&nbsp;</li>
</ul>

Insulin resistance in individuals with PCOS can lead to serious health problems, especially if you are overweight<a href="#accordion">[1]</a>:

<ul>
	<li>Stroke</li>
	<li>Fertility issues, including miscarriage, problems with proper implantation of the embryo, and anovulation</li>
	<li>Heart disease; this risk increases with age</li>
	<li>Diabetes; more than 50% of women with PCOS have diabetes by age 40</li>
	<li>Gestational diabetes; increases the risk of type 2 diabetes for both mother and child</li>
	<li>High LDL cholesterol and low HDL cholesterol levels; increase the risk of heart disease</li>
	<li>Sleep apnea; can lead to type 2 diabetes and heart disease</li>
	<li>High blood pressure; can damage the brain, heart, and kidneys, especially during pregnancy</li>
	<li>PCOS is also linked to anxiety and depression. 
	&nbsp;</li>
</ul>

Several risk factors contribute to the development of insulin resistance in individuals with PCOS. Recognizing them can help individuals understand their susceptibility to insulin resistance and take proactive steps to manage their health.

<ul>
	<li>Genetics</li>
	<li>Obesity or excess abdominal fat</li>
	<li>An Inactive Lifestyle and unhealthy diet</li>
</ul>

<ul>
	<li>Hormonal Imbalances, especially testosterone, due to PCOS</li>
	<li>Age; insulin resistance can develop at any age, but it&#39;s often observed during adolescence and early adulthood</li>
	<li>Certain Ethnic Groups, including Hispanics, Native Americans, or African Americans, are more vulnerable than Asian or white women<a href="#accordion">[2]</a></li>
	<li>Other Medical Conditions, such as a history of gestational diabetes, high blood pressure, chronic inflammation, and abnormal lipid levels</li>
	<li>Family History Of Diabetes or insulin resistance</li>
	<li>Poor Sleep Quality and insufficient sleep 
	&nbsp;</li>
</ul>

Insulin resistance is a complex and interrelated aspect of PCOS. Early detection and appropriate interventions can help manage insulin resistance and its associated symptoms, improving the quality of life for individuals with PCOS. 
&nbsp;

According to one research involving women aged 18-40 with PCOS, the homeostasis model assessment index of insulin resistance (HOMA-IR) index was linked to factors, like blood pressure, hormone levels, and liver enzyme levels.

The subjects were categorized into 4 Rotterdam PCOS phenotypes according to the presence of at least two criteria of oligomenorrhea/anovulation (O), hyperandrogenism (H), and polycystic ovary morphology (P):

<ol>
	<li>O&ndash;H&ndash;P</li>
	<li>H&ndash;P</li>
	<li>O&ndash;H</li>
	<li>O&ndash;P 
	&nbsp;</li>
</ol>

<ul>
	<li>In Overweight Or Obese PCOS Women, higher HOMA-IR was linked to higher diastolic blood pressure, androgen levels, and triglycerides, but lower hormone-binding globulin.</li>
	<li>In Normal-Weight PCOS Women, higher HOMA-IR was linked to higher liver enzyme levels and lower diastolic blood pressure.</li>
	<li>Moreover, The O&ndash;H&ndash;P Phenotype had twice the risk of developing insulin resistance.</li>
</ul>

The study suggests that categorizing phenotypes can help doctors predict metabolic issues and that women presenting with full-blown PCOS should be regularly screened for metabolic disturbances<a href="#accordion">[7]</a>. 
&nbsp;

Key Points

<ul>
	<li>The risk of insulin resistance in women with PCOS is higher when they turn 40, have high blood pressure and cholesterol, are overweight, and live a sedentary lifestyle.</li>
	<li>This insulin resistance can cause some changes in your body, like making it harder to have regular periods or leading to extra hair where you don&#39;t want it.</li>
	<li>Managing insulin resistance in PCOS involves a multi-faceted approach. A balanced diet rich in whole foods, complex carbohydrates, lean proteins, and healthy fats can improve insulin sensitivity. Regular physical activity and weight management are also crucial.</li>
	<li>Sometimes, doctors prescribe medicines, such as metformin, spironolactone, and hormonal birth control pills, to help manage insulin resistance and its associated symptoms.</li>
	<li>If your family has a history of diabetes or weight issues, you might be more likely to have insulin resistance.</li>
	<li>Remember, you&#39;re not alone in dealing with insulin resistance in PCOS. Doctors, dietitians, and other experts can help you come up with a plan to tackle it and keep you feeling your best.</li>
</ul>

[1] PCOS (polycystic ovary syndrome) and diabetes. Centers for Disease Control and Prevention. December 30, 2022. Accessed August 15, 2023.

[2] Nicole Galan R. The dual challenge of PCOS and insulin resistance. Verywell Health.

[3] The connection between PCOS and insulin resistance - healthcentral.

[4] Miller K. The pill may reduce type 2 diabetes risk for people with PCOS. Verywell Health.

[5] PCOS diet: Foods to eat and avoid. Medical News Today.

[6] Type 2 diabetes: Healthy Gut Microbiome linked to insulin response. Medical News Today.

[7] Mansour, A., Mirahmad, M., Mohajeri-Tehrani, M.R. et al. Risk factors for insulin resistance related to polycystic ovarian syndrome in Iranian population. Sci Rep 13, 10269 (2023).