Key Takeaways

• Polycystic ovary syndrome, or PCOS, is a condition involving imbalanced hormones in women.

• Many women with PCOS have insulin resistance. This means that the body is not able to respond normally to insulin, which is a hormone that acts to lower blood sugar.

• In the early stages, insulin resistance triggers the body to produce higher levels of insulin.

• Type 2 diabetes occurs when insulin resistance becomes too severe, and the body can no longer produce enough insulin to compensate.

• Women with PCOS are nearly 9 times as likely to develop type 2 diabetes as women without PCOS.

• It’s believed that high insulin levels cause changes in the function of the ovaries, leading to PCOS. 

• Insulin resistance can be treated with lifestyle changes and medication. 

Is there a link between PCOS and diabetes?

Polycystic ovary syndrome, or PCOS, is a relatively common condition involving imbalanced hormones in women. Research has found that this condition affects up to 20% of all women who are in their reproductive years (after puberty and before menopause). Women with PCOS have higher levels of androgens, which are hormones like testosterone. They also have small cysts (fluid-filled sacs) on their ovaries, and their ovaries produce fewer eggs than normal, which often leads to fertility problems.

Type 2 diabetes is a condition in which levels of glucose (sugar) in the blood rise because the body is resistant to the effects of the hormone insulin. This is by far the most common type of diabetes, accounting for about 95% of all cases. Rates of type 2 diabetes have been rising in Singapore over the past few decades.

While these two conditions are not exactly the same, there is a strong link between them. In fact, research has discovered that women who are diagnosed with PCOS as young adults are almost nine times as likely as women without PCOS to be diagnosed with type 2 diabetes later in their lives. They also have more than double the likelihood of experiencing gestational diabetes if they get pregnant.

The connection between PCOS and type 2 diabetes is that they both usually involve a condition known as insulin resistance. While not all women with PCOS experience insulin resistance, it’s very common, and is believed to play a role in the development of the condition. Type 2 diabetes is also a condition of insulin resistance.

What is insulin resistance?

Insulin resistance occurs when the body is not able to respond normally to insulin. 

Insulin is a hormone that’s produced by the pancreas in response to rising levels of glucose in the bloodstream. After you eat, glucose levels in your blood will begin to rise as you absorb carbohydrates from your food, and the pancreas will produce insulin in response to this. Insulin causes cells throughout the body to take up glucose from the blood. They will either use it for energy or store it for later use.

When the body is resistant to insulin, cells don’t receive the signal from insulin to take up sugar. This means that excess glucose stays in the blood instead of entering into cells. This is how insulin resistance can lead to high blood glucose levels.

In the early stages of insulin resistance, the body is usually able to make extra insulin to compensate. Blood sugar levels may remain normal, but insulin levels are high. As insulin resistance becomes more severe, the body won’t be able to make enough insulin to compensate, and blood sugar levels will start to rise.

How are insulin resistance and PCOS related?

Research has found that up to 90% of women with PCOS have insulin resistance.

Obesity is a strong risk factor for both PCOS and insulin resistance. A significant majority of women with PCOS are either overweight or obese. However, women with PCOS who are not overweight often still have insulin resistance.

Although it’s very clear that PCOS and insulin resistance are related, researchers are still working to understand how these conditions are connected. People with insulin resistance have high insulin levels in the blood, and it’s believed that these high insulin levels act in the ovaries and affect their function. This causes the ovaries to secrete higher levels of androgens like testosterone, and also leads to the development of the abnormal cysts.

High insulin levels also change the levels of other hormones involved in the reproductive system. For example, luteinizing hormone (LH) is a hormone secreted by the pituitary gland, and it triggers ovulation. Levels of LH can also be affected by high insulin levels.

Both insulin and testosterone tend to promote weight gain, especially around the abdomen. Weight gain then triggers additional insulin resistance, leading to a vicious cycle. As insulin resistance gets worse, the body will secrete even higher levels of insulin to compensate, worsening the symptoms of PCOS. 

Eventually, when the body is unable to make enough insulin, type 2 diabetes will result, and blood sugar levels will start to rise.

Getting tested for insulin resistance

People who have insulin resistance don’t always experience any symptoms or have any physical signs of this condition. Some people do show signs of insulin resistance, such as: 

• Weight gain, especially around the abdomen

• Skin tags (small, painless growths on the skin)

• Darkening of the skin of the armpits and back of the neck

• High blood pressure

However, even if you don’t have these signs, you could still have insulin resistance. Particularly in the early stages, when the body is still producing enough insulin to compensate for the resistance of the tissues, many people don’t have any apparent signs of this condition.

Testing is often needed to accurately detect insulin resistance. Because insulin resistance is so common in women who have PCOS, it’s a good idea to consider testing for insulin resistance in anyone who’s been diagnosed with PCOS. 

Common tests used to screen for diabetes include a fasting blood glucose test or a hemoglobin A1c (HbA1c) test. Although these tests will tell you whether your blood sugar levels are high, they won’t always reveal insulin resistance. If the body is still making enough insulin to compensate, then you could have normal blood sugar levels even though you have insulin resistance.

In order to check for insulin resistance, a test called HOMA-IR is used. This involves testing the levels of both insulin and glucose in your blood at the same time. If your insulin levels are higher than expected given your glucose level, this indicates insulin resistance.

Treatment options for insulin resistance

If you have insulin resistance, there are a few different treatment options that can help. Because insulin resistance is involved in the development of PCOS, addressing insulin resistance often makes a difference in PCOS symptoms. It can also reduce the risk of progression to type 2 diabetes.  

The first step is usually healthy lifestyle changes, such as:

• Work towards a healthy body weight. There is a very strong correlation between being overweight and insulin resistance. People who are obese are more than three times as likely to have insulin resistance as those who are of a more normal body weight. Even losing just 5 to 10% of your body weight has been shown to have a significant impact on insulin resistance. Working with a health coach is helpful for many people in developing an effective weight loss program.

• Exercise. When you exercise, this causes changes that promote insulin sensitivity in tissues throughout the body. The most beneficial type for this purpose is aerobic exercise, which causes your heart rate and breathing to speed up. Even a few minutes a day of walking will help, but try to work up to 20 to 30 minutes of exercise each day.

• Get enough sleep. Research has shown that when a person is sleep-deprived, their body becomes more resistant to insulin. To help address insulin resistance, it’s essential to prioritize getting eight hours of sleep every night.

• Eat less sugar. Sugar is absorbed rapidly in your digestive tract, so it spikes your blood sugar quickly, forcing your pancreas to produce a lot of insulin. Eating more complex carbohydrates, such as fruits, vegetables, and whole grains, helps to slow down the absorption and reduce the blood sugar spike. Eating protein along with your carbohydrates will also help to slow absorption.

• Consider intermittent fasting. This involves restricting your eating window to particular times each day. Some studies have shown that intermittent fasting can improve insulin sensitivity. Many people find it helpful to work with a health coach to develop an intermittent fasting schedule that works for them.

• Learn stress-management techniques. Stress causes your adrenal glands to secrete a hormone called cortisol, which reduces your body’s insulin sensitivity. Managing stress can help to reduce your cortisol levels, which in turn helps your body respond better to insulin. There are many options for helping to manage stress. You could try meditation, breathing techniques, yoga, or listening to relaxing music.

In addition to these lifestyle changes, some people also benefit from using medications that can help to improve the body’s insulin sensitivity. The most common is metformin. Thiazolidinediones (TZDs, such as pioglitazone and rosiglitazone) are another option. These medications trigger the body to become more sensitive to insulin. In many cases, this makes a difference in PCOS symptoms.

Although some people achieve significant weight loss through lifestyle changes, others find it useful to take medications known as GLP-1 RAs. These medications have a variety of effects throughout the body, including slowing down the emptying of the stomach after eating as well as acting in the brain to reduce hunger and food cravings. This causes people taking GLP-1 RAs to eat less without severe hunger, which leads to weight loss. In turn, weight loss reduces insulin resistance.

GLP-1 RAs work best when used in combination with healthy lifestyle changes, like exercise and a healthy diet. They’re not a substitute for these factors, but a way to supplement them.

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