What we get wrong about PCOS

A systems approach to a misunderstood condition - how nutrition, movement, and targeted interventions can change its course

Aug 08, 2025

Polycystic Ovary Syndrome (PCOS) is one of the most common endocrine disorders in women of reproductive age, yet it remains poorly understood by patients and clinicians alike. Affecting an estimated 6 – 20% of women globally, depending on diagnostic criteria, PCOS presents as a constellation of symptoms that span reproductive, metabolic, dermatological, and psychological systems. Far from being a disorder limited to ovarian cysts or fertility concerns, PCOS is a complex neuroendocrine-metabolic condition with serious long-term health implications and visible external manifestations that often lead to stigma and diminished quality of life.

Diagnosis and symptoms

The diagnostic criteria for PCOS reflect the diversity of symptoms. The widely adopted Rotterdam criteria require the presence of any two out of three features: ovulatory dysfunction (e.g., infrequent or absent ovulation), clinical or biochemical signs of hyperandrogenism, and polycystic ovarian morphology on ultrasound. This broad definition acknowledges that a woman can have polycystic ovaries without having PCOS, and that not all cases involve all three characteristics. Further complicating the picture are the four phenotypes of PCOS, ranging from the classic form that includes all three criteria to less metabolically active versions without signs of hyperandrogenism. These symptoms vary in both their appearance and disease severity, particularly in the degree of insulin resistance.

At the core of PCOS is a breakdown of hormonal and metabolic regulation. Hyperandrogenism, excess male-pattern hormones such as testosterone and DHEAS, is a defining feature and the primary driver of many visible symptoms, including unwanted facial and body hair, cystic acne and thinning of scalp hair. These symptoms, though often minimized, have a significant psychosocial impact and are directly linked to hormonal imbalances originating in the ovaries and adrenal glands. Ovarian theca cells, stimulated excessively by luteinizing hormone and amplified by hyperinsulinemia, overproduce male hormones that disrupt follicle maturation and ovulation. Compounding the issue is a decrease in sex hormone-binding globulin (SHBG), which is suppressed by insulin and leaves more free testosterone in circulation. The result is a vicious cycle of reproductive dysfunction and visible androgen excess.

Long-term disease implications

These surface-level signs are often the first reason women seek help, but the underlying pathology runs much deeper. PCOS is strongly associated with insulin resistance, independent of weight. Up to 70% of lean women and 95% of those with obesity who have PCOS also exhibit insulin resistance. This metabolic disruption places women at significantly higher risk for type 2 diabetes, hypertension, dyslipidemia (obesity), and cardiovascular disease. Studies show that many women with PCOS will develop diabetes by age 40, and they also face elevated long-term risks for endometrial cancer due to chronic anovulation and unopposed estrogen exposure. In addition to disease consequences, PCOS is increasingly recognized as a condition with chronic low-grade inflammation. Elevated markers such as C-reactive protein (CRP), TNF-α, IL-6 (inflammatory markers) are common, particularly among women with obesity, though lean women are not exempt. These inflammatory pathways are now being implicated in both insulin resistance and ovarian dysfunction, contributing to the systemic nature of the disorder.

Lifestyle and non-pharma treatments

Treatment for PCOS must be multi-dimensional, yet the standard of care still too often defaults to medicinal treatment of symptoms: oral contraceptives for menstrual regulation, metformin for insulin resistance, and spironolactone or other anti-androgens for hair growth. While these may play a role in advanced cases, the international guidelines increasingly recognize that lifestyle interventions should be the first-line therapy, particularly for newly diagnosed or milder symptoms.

Dietary approaches have shown significant promise in mitigating both metabolic and reproductive symptoms of PCOS. Low glycemic index (GI) diets, Mediterranean-style eating patterns, ketogenic diets, and anti-inflammatory diets rich in fiber and omega-3s have all demonstrated improvements in insulin sensitivity, testosterone levels, and ovulatory function, even without weight loss. Nutraceuticals such as inositol, vitamin D, magnesium, zinc, and N-acetylcysteine have been shown to reduce insulin resistance, regulate ovulation, and lower systemic inflammation, offering a more targeted and potentially better-tolerated option than pharmaceuticals for many women.

Movement, too, plays a central role. A combination of aerobic and resistance training improves insulin action, reduces visceral adiposity, and enhances fertility outcomes. These benefits appear to be independent of BMI, highlighting the need to move away from the “just lose weight” narrative that dominates so much of the clinical dialogue around PCOS.

Sleep hygiene, stress reduction, and psychological support are also critical but underutilized components of care. Women with PCOS experience higher rates of anxiety, depression, disordered eating, and poor body image, all of which can further dysregulate the HPA axis and worsen hormonal symptoms. Mind-body interventions such as yoga, mindfulness, cognitive behavioral therapy, and even acupuncture have shown preliminary efficacy in improving mental well-being and hormone regulation.

In conclusion

In sum, PCOS is not a one-system problem; it is a full-body, full-spectrum disorder. While pharmaceutical tools have their place, especially in later-stage or treatment-resistant cases, a growing body of evidence supports the use of comprehensive, individualized, lifestyle-first care, emphasizing anti-inflammatory nutrition, movement, targeted supplementation, and stress reduction, as the true front line in managing and potentially reversing the trajectory of this condition. It’s time to stop asking women to “just lose weight” and start addressing the hormonal, metabolic, and inflammatory terrain that underlies PCOS. When we shift our approach from reactive symptom control to systems-level restoration, we don’t just manage PCOS; we change its course.

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