Understanding The Link Between PCOS And Insulin Resistance

Overview

Polycystic Ovary Syndrome (PCOS) is an endocrine disorder that occurs in females. In this disorder, females produce more male sex hormones than usual, which can lead to various complications in the body. The symptoms of this disorder usually start to show soon after puberty or anytime later during the reproductive years. Although there is no specific cure, PCOS can be effectively managed in many ways. 

PCOS has been strongly linked to insulin resistance. In this disorder, the body's organs do not respond well to insulin, so they cannot efficiently take up glucose from the blood or store it. This leads to more insulin being produced than is needed which can lead to excessive insulin in the body known as hyperinsulinemia. 

The development of insulin resistance is a significant factor of PCOS and many symptoms of PCOS are brought about by this resistance to insulin. A large part of the management of PCOS is linked to the management of insulin resistance. 

Understanding PCOS

In the female reproductive system, two, egg-shaped glands are found on either side of your uterus, called ovaries. These ovaries are responsible for the production and storage of eggs (ovum) that are stored in fluid-filled sacs called ovarian follicles. Each month, one egg is released from an ovary to facilitate fertilisation and this release is known as ovulation. In addition, ovaries are also responsible for producing female sex hormones (oestrogen and progesterone) which play a role in maintaining pregnancies and the menstrual cycle. 

Parts of the reproductive system of people are assigned females at birth (AFAB). The eggs are stored in ovarian follicles, inside ovaries present on both sides of the uterus. During ovulation, the eggs are released into fallopian tubes, where fertilisation occurs. Adapted from: Wikimedia Commons.

PCOS occurs when there is an imbalance in your hormones; your ovaries produce more male hormones (androgens) than is normal. PCOS is a fairly common phenomenon and according to WHO, it affects about 3.4% of people AFAB of reproductive age, which means about 116 million people AFAB in the world are currently affected by this disorder.¹ Although the exact causes of PCOS are not fully understood, some risk factors have been established such as: 

• History of PCOS among your first-degree relatives 
• Lack of physical activity 
• Obesity 
• Insulin resistance 

Symptoms of PCOS

Some common symptoms of PCOS include:²

• Abnormal or irregular periods: your periods can be delayed or missed. You may have excessive bleeding during your periods
• Hirsutism: a fairly common symptom that involves excessive and heavy hair growth in places such as on the face (chin and upper lip area), chest, and abdomen
• Acne: This usually involves large, cystic acne on the face, and chest and may extend to the back. This is also a common and often distressing symptom, especially among teenagers
• Obesity: PCOS may make you gain excessive weight, especially around your lower abdominal area and it may make it harder for you to lose weight as well
• Alopecia: hair loss and thinning, one of the harder symptoms to treat
• Hyperpigmentation: a dark discolouration of the skin around the neck, armpits, and under the breasts
• Skin tags: These are small flaps of skin that may occur around the face and neck. They are harmless and may only need to be removed for cosmetic reasons 
• Subfertility: PCOS may result in anovulatory cycles which means that eggs might not be released during the menstrual cycle. For some people AFAB, this can make it harder to conceive, but it is by no means impossible. There is also a small increased risk of miscarriage in patients who suffer from PCOS.²

Most of these symptoms which occur in PCOS are due to excessive androgens and insulin resistance. The severity of these symptoms varies from person to person. There is a possibility that the patient may not experience any symptoms of PCOS and only be diagnosed after a routine abdominal ultrasound. 

Diagnostic test for PCOS

There have been certain diagnostic criteria, known as the Rotterdam Criteria³, that have been laid out for the proper diagnosis of PCOS. After having some blood tests and ultrasounds done, you must have at least two of the following symptoms to be diagnosed with PCOS: 

• Absent or irregular menstrual cycles (after other causes have been ruled out)
• Symptoms of a high blood level of androgens such as hirsutism, acne, alopecia
• A “polycystic” appearance of ovaries on ultrasound would include more than 20 follicles seen in either ovary, each measuring more than 10 cm.³

The appearance of ovaries in people without PCOS (on the left) and with PCOS (on the right). The ovaries are full of fluid-filled follicles, giving a characteristic appearance of polycystic ovaries on the ultrasound. Source: Wikimedia Commons 

Understanding insulin resistance

We eat many different types of food throughout the day and after we consume sugar or glucose, our bodies convert this glucose to glycogen. Glycogen is the storage form of glucose, mostly in the muscles and liver. This conversion of glucose to glycogen happens with the help of the hormone insulin. Insulin is secreted from a gland in our bodies known as the pancreas. When our bodies need energy, the glycogen is converted back to glucose and metabolised to produce energy. 

In insulin resistance, which commonly occurs during PCOS, our bodies do not respond to insulin as well as they should. This results in glucose not being converted to glycogen and in response, the pancreas begins to secrete more insulin. Eventually, the body goes into a state of excessive insulin in the body, which is known as hyperinsulinemia. Elevated levels of insulin can lead to the development of type 2 diabetes. 

Insulin resistance is linked to PCOS because it causes an increased amount of androgens to be secreted from the ovaries and it suppresses ovulation⁴, which brings about many of the symptoms of PCOS. Obesity is also a major risk factor for developing insulin resistance in PCOS. 

Managing PCOS and insulin resistance

Lifestyle modifications

Although there is no cure for PCOS, it can be effectively managed and at times this can be achieved by simple lifestyle changes. The mainstay of lifestyle changes for PCOS involves plenty of exercise, a good diet, and maintaining a healthy body weight. 

A good diet would typically entail a diet that is rich in fruit, vegetables, fibre, and good carbohydrates and low in fats and processed sugars. It is also important to drink plenty of water every day and stay hydrated. Exercise and being physically active is also important and NHS guidelines for recommended exercise can be found here. Some people with AFAB who suffer from PCOS are also overweight and need to maintain a healthy body weight. 

Medications

• One of the most common medications used to control symptoms of PCOS, in people AFAB who are not trying to conceive are hormonal birth control devices. These can be taken as pills, IUDs and IUS, injections, or rings, depending on your personal choice. Hormonal birth control releases hormones that can help regulate the menstrual cycle and combat some symptoms such as acne and hirsutism.⁵
• Insulin-sensitising drugs, such as metformin, can be used by people who are trying to conceive. These drugs are typically used in people who have diabetes but they have also proven to be effective in managing PCOS. They work by helping your body to process the extra insulin which is in your body and this can reduce the effects of insulin resistance. After this is controlled, some symptoms of PCOS might be relieved such as weight gain, irregular menstrual cycles, and anovulation.⁶ These drugs are beneficial in PCOS people who are also overweight.
• At times, androgen-blocking drugs can be used to block the effects of excessive androgens in females. This can help alleviate symptoms such as acne and hirsutism.
• If a PCOS patient is suffering from anovulation but wishes to conceive, drugs to induce ovulation can be prescribed such as clomiphene citrate. This drug needs to be taken at a particular time in the menstrual cycle ovulation and increase the chances of pregnancy.

After starting any medications, you might need to follow up with your doctor to evaluate if they are working. You might begin to notice some improvements in your symptoms yourself such as improved menstrual regularity, less acne and hirsutism, and healthier body weight. Your doctor might request more blood tests to check your blood sugar and insulin levels. They might like to perform a repeat ultrasound to recheck the size of your ovaries and the number of follicles in each ovary, to further evaluate any improvements. If no improvements are seen, your doctor might increase or change your medication. 

Summary 

PCOS is a fairly common disorder that affects people AFAB throughout their reproductive years and though some symptoms can be quite distressing, they can be managed. Often, PCOS is diagnosed after the menstrual cycle commences, and it is best to visit your doctor if you experience any of the symptoms which are listed in this article. Some blood tests and ultrasounds might be conducted for proper diagnosis.

Insulin resistance plays a vital role in some cases of PCOS; it causes many of the symptoms and managing it is key to reducing them. An increased amount of insulin can increase androgens in the blood which can cause symptoms such as acne and hirsutism. Often, these symptoms can be efficiently controlled by lifestyle modifications but in severe cases, insulin-sensitising drugs such as metformin might be prescribed. People AFAB who suffer from PCOS can go on to live normal and healthy lives, with the right adjustments in their lives and the right type of medication.