PCOS.
South Africa's Most Common Hormone Condition.

Elevated insulin directly stimulates ovarian theca cells to produce excess testosterone. It also suppresses hepatic SHBG production — lowering the binding capacity for free testosterone.

High insulin disrupts the LH:FSH ratio and impairs normal follicle maturation — multiple small follicles develop (the 'polycystic' appearance) but none reaches dominant status to ovulate.

Women with PCOS have a 10-fold increased risk of type 2 diabetes, elevated cardiovascular risk, non-alcoholic fatty liver disease and metabolic syndrome. Annual metabolic screening is essential throughout life.

Fasting insulin + fasting glucose (calculate HOMA-IR = insulin × glucose / 22.5; >2.5 suggests IR). Fasting glucose and HbA1c alone can appear normal while fasting insulin is already significantly elevated.

Prioritise vegetables, lean protein, legumes and healthy fats; reduce refined carbohydrates and added sugars significantly. A low-GI/GL dietary pattern reduces insulin, androgens and restores ovulation — more powerfully than the OCP in studies.

Muscle is the primary site of glucose disposal. Resistance training improves insulin sensitivity, reduces androgens and improves body composition independently of weight loss. 3–4 sessions/week of compound movements is optimal.

In overweight women with PCOS, even a 5–7% weight reduction can restore menstrual regularity and ovulation. The mechanism is primarily through improved insulin sensitivity.

Poor sleep worsens insulin resistance. Chronic stress raises cortisol, which further impairs insulin signalling. Both are important, often-overlooked PCOS treatment targets.

Myo-inositol (2000mg) and D-chiro-inositol (50mg) combination has good clinical evidence for improving insulin sensitivity, reducing androgens and restoring ovulation in PCOS. Well-tolerated with minimal side effects.

First-line insulin sensitiser in PCOS. Reduces hepatic glucose production, improves insulin sensitivity and directly reduces androgen production. Start low (500mg with meals), titrate slowly to reduce GI side effects.

Suppresses LH-driven androgen production and raises SHBG. Choose a formulation with an anti-androgenic progestin (drospirenone, cyproterone acetate, dienogest) for maximum androgen-blocking effect. Does not treat underlying insulin resistance.

Anti-androgen — blocks androgen receptors. Very effective for skin and hair symptoms. Must be used with reliable contraception (teratogenic in male foetuses). 50–200mg/day. Often combined with COCP.

An aromatase inhibitor that induces ovulation more effectively than clomiphene with fewer side effects and lower multiple pregnancy risk. Now first-line per ESHRE/ASRM guidelines.

An oestrogen receptor antagonist that triggers LH/FSH surge and ovulation. Still used but superseded by letrozole as first-line in most guidelines.

Evidence-based supplement with a very favourable safety profile. Myo-inositol 2000mg + D-chiro-inositol 50mg twice daily. A viable first step before metformin for mild-moderate insulin resistance.