Polycystic ovary syndrome (PCOS) is a complex health problem characterized by absent or irregular periods of metabolic and hormonal imbalances. Many factors, including genetics, diet, lifestyle, obesity, and the environment, can contribute to the development of PCOS. Additionally, PCOS can contribute to obesity, insulin resistance (prediabetes), and diabetes, so the causes and consequences of PCOS overlap. This article will explain the relationship between PCOS and diabetes while providing information on tests and treatments for early diagnosis.

PCOS and Diabetes: What Does Science Say

PCOS is an important problem in women's health, affecting many women across all reproductive stages. According to the World Health Organization (WHO), 8 to 13% of women of reproductive age have PCOS, despite underdiagnosis.¹ The prevalence of insulin resistance is 35 to 80% among women with PCOS, and type 2 diabetes affects half of women with PCOS by the age of 40.^{2, 3}

Women with PCOS commonly have elevated blood glucose levels or insulin resistance, which is a serious warning sign for type 2 diabetes. Many factors, including genetics, age, body weight, abdominal obesity, menopausal status, general health status, and lifestyle, can affect the likelihood of diabetes in women with PCOS.

Being overweight and having abdominal obesity can be contributors to diabetes in women with PCOS. Although women within the healthy body mass index (BMI) range also experience PCOS, their counterparts with obesity have a higher risk for insulin resistance and diabetes. 

A meta-analysis (including more than three hundred thousand women) investigated the relationship between type 2 diabetes risk, PCOS, and obesity. The study concluded that obese women with PCOS are 3.24 times more likely to develop type 2 diabetes compared to obese women without PCOS. On the other hand, non-obese women with PCOS are 1.6 times more likely to develop type 2 diabetes compared to non-obese women without PCOS. Therefore, obesity can increase the risk of type 2 diabetes in women with PCOS.⁴

Menopausal status is also one of the important contributors since menopause is linked to hormonal changes. While estrogen levels decrease, androgen levels remain stable or increase during menopause. When androgen levels increase, abdominal adiposity, insulin resistance, and chronic inflammation will likely worsen. Therefore, postmenopausal PCOS patients are more likely to have insulin resistance and type 2 diabetes mellitus.⁵

Is There Really a Link With Diabetes and PCOS?

Both type 2 diabetes mellitus and PCOS are associated with abnormal insulin metabolism. Although the exact physiological mechanism is not known, hyperinsulinemia causes an increase in androgen hormones (progesterone and testosterone), which leads to PCOS. On the other hand, it is well known that insulin resistance can lead to type 2 diabetes over time.

Also, both diabetes and PCOS are associated with an increased risk for other metabolic diseases such as metabolic syndrome, non-alcoholic fatty liver disease (NAFLD), and cardiovascular diseases. Besides metabolic disturbances, many other risk factors influence diabetes development in women with PCOS, including but not limited to genetics, obesity, menopause, comorbidities, poor diet, sedentary lifestyle, and environmental toxins.

<p class="pro-tip"><strong>Also Read: </strong><a href=weight-loss-pcos>How to Lose Weight When You Have PCOS</a>.</p>

PCOS and Insulin Resistance

PCOS is associated with reproductive complications such as menstrual irregularities and infertility, as well as metabolic complications such as insulin resistance, diabetes, and cardiovascular diseases. 

The prevalence of insulin resistance is 35 to 80% among women with PCOS. Although PCOS's exact etiology is unknown, it is hypothesized that insulin resistance is a significant factor among others, such as obesity and inflammation.² Elevated insulin levels increase ovarian androgen production. Insulin binds to sex hormone-binding globulin (SHBG), increasing free androgen levels, which causes irregularities in the menstrual cycle and infertility.²

Can PCOS Lead to Gestational Diabetes?

Hormonal imbalance in PCOS can accelerate during pregnancy. Women with PCOS are more prone to gestational diabetes than women without PCOS.⁶ Besides gestational diabetes, other pregnancy and delivery complications such as gestational hypertension, preeclampsia, preterm birth, and miscarriage are also more common among women with PCOS.⁷

A study investigated the relationship between polycystic ovarian syndrome and adverse pregnancy outcomes in more than ninety thousand deliveries. The results showed that almost 4% of pregnant women had PCOS. Among those women, there was a 51% higher risk of gestational diabetes and a 25% higher risk of preeclampsia compared to pregnant women without PCOS. Additionally, babies of women with PCOS had a higher risk of preterm birth and hospitalization after delivery.⁸

Therefore, preconceptional assessment of general health, oral glucose tolerance, and blood pressure in women with PCOS can be beneficial for the health of both the mother and the baby, followed by assessments during and after pregnancy.

PCOS and Diabetes: Treatment

The treatment of polycystic ovary syndrome generally involves medication as well as lifestyle changes, such as adopting a healthy and balanced diet and engaging in regular physical activity.

An individual approach is important to meet patients' needs. Factors such as the patient's age, body weight, menopausal status, and accompanying diseases such as diabetes can influence the course of treatment. 

Medications such as metformin and glucagon-like peptide-1 (GLP-1) receptor agonists may be prescribed to women with PCOS to improve glucose metabolism and also body weight. Besides medication, your healthcare professional may suggest dietary supplementation of certain vitamins and minerals to improve nutritional deficiencies and possibly symptoms.

Lifestyle changes are an important part of the treatment for women with PCOS, whether they have diabetes or not. A meta-analysis involving almost forty thousand women concluded that women with PCOS had significantly higher cholesterol and lower magnesium levels. Most studies reported insufficient consumption of almost all major food groups, including protein, grains, fruits, vegetables, seeds, nuts, and dairy.⁹

Different dietary approaches have been shown to improve glucose metabolism and clinical features of PCOS. A meta-analysis showed that a low-glycemic index diet for more than eight weeks could improve HOMA-IR (a marker of insulin resistance), fasting insulin, total cholesterol, LDL cholesterol, triglycerides, and waist circumference compared to a high glycemic index diet.¹⁰

Although the aim is mostly to provide enough macronutrients while encouraging healthy eating behaviors, many dietary approaches such as the Mediterranean diet, low-glycemic index diet, low-carbohydrate diet, ketogenic diet, and DASH diet are available. It's best to consult your healthcare professional to determine the dietary approach that meets your nutritional requirements and needs.¹¹

PCOS and Diabetes: When to Get Tested

PCOS has been associated with metabolic disorders such as insulin resistance, diabetes, and heart disease. Therefore, early diagnosis of PCOS and treatment are crucial to prevent further health problems. 

While some guidelines (including those of the Endocrine Society and Androgen Excess & PCOS Society) recommend an oral glucose tolerance test (OGTT) for all women diagnosed with PCOS with routine follow-ups, other guidelines (including those of the Australian NHMRC and the Royal College of Obstetricians and Gynecology) recommend testing only if women with PCOS meet certain criteria, such as having a BMI higher than 25 kg/m², a history of impaired fasting glucose tolerance, gestational diabetes, a family history of diabetes, or being older than 40.¹²

Impaired fasting glucose (IFG), insulin resistance (impaired glucose tolerance), and gestational diabetes are early stages of diabetes. Patients may experience various diabetes symptoms arising from elevated blood glucose levels and inefficient or insufficient insulin secretion. 

Symptoms may include but are not limited to:

• Frequent Need to Urinate: In insulin resistance or diabetes, the body needs to reduce blood glucose levels to normal. Since insulin won't transfer glucose into the cells as it should, the blood glucose is eliminated through urine, resulting in an increased workload on the kidneys, excessive urination, and dehydration.‍
• Frequent Thirst: Elevated blood glucose levels cause frequent urination because the body needs to process excess sugar in the bloodstream. However, frequent urination causes dehydration, thus making you feel thirsty frequently.‍
• Blurred Vision: Diabetes patients may experience short- or long-term changes in their vision. Constantly elevated blood glucose levels damage the blood vessels in tissues, including the eyes. Fluid leaks from damaged blood vessels, causing swelling and resulting in blurred or distorted vision. Blurred vision may also be a sign of diabetic retinopathy.¹³‍
• Abnormally Increased Appetite: In insulin resistance or diabetes, the cells are in a state of hunger because of insulin dysfunction, so glucose stays in the bloodstream instead of entering the cells to provide energy. That's why constant hunger and increased appetite may arise as a symptom.‍
• Injuries That Take Too Long to Heal: High blood sugar levels can cause inflammation, negatively affecting wound healing. Besides, disturbed circulation due to damaged blood vessels can also slow down the healing process of wounds.¹⁴‍
• Fatigue: Fatigue is one of the common symptoms of diabetes. The cells lack glucose due to insulin resistance, so they cannot produce the energy that the body needs. Besides elevated blood glucose levels and endocrine disturbances, other factors such as nutrition, lifestyle, and psychology may influence fatigue.¹⁵

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