PCOS treatment: what works, starting with weight and insulin

In 1992 Kiddy, Franks and colleagues at St Mary's Hospital in London followed 24 women with PCOS on a lower-calorie diet for six to seven months. In the 13 who lost more than 5% of their weight, free testosterone fell and fasting insulin dropped sharply. Of the 11 among them with period problems, nine either conceived or became more regular, and facial hair lessened in 40%. In the women who lost less, nothing much changed.

A few years later Clark's group in Australia ran a weekly diet and exercise programme for overweight women who were not ovulating, the fertility problem PCOS most often causes. Over six months they lost 6.3 kg on average; 12 of the 13 began ovulating again and 11 became pregnant, five without any fertility treatment. These were small studies, and later trials have been more modest, but the direction has held.

For Fatima, at 78 kg, 5% means about four kilos. That is a target she can picture, and far less daunting than the 20 kilos a relative once told her to lose.

The best kind is whatever you will still be doing in six months.

Cheryce Harrison's team at Monash University gathered every study that tested exercise on its own in women with PCOS. Most lasted 12 or 24 weeks. The steadiest benefits were better ovulation, insulin resistance down by between 9% and 30%, and weight down by 4.5% to 10%, and it did not seem to matter much whether women walked, cycled or lifted.

The 2023 guideline suggests at least 150 minutes a week of moderate activity, such as brisk walking, cycling or dancing, or 75 minutes of something harder, with muscle-strengthening on two days. The strength part is the one most women skip and the one that matters for insulin, because muscle is where most blood sugar ends up.

Fatima walks for 30 minutes after school with a colleague from the maths department, five days a week, past the Necklace Road lakefront when the traffic allows. On Saturday and Sunday mornings she does a 20-minute routine of squats, lunges, wall push-ups and band rows from a video. Her husband laughed at the resistance band until he started borrowing it.

And being unmarried is no reason to put off a doctor.

Many young Indian women are told, by relatives and sometimes by clinics, to deal with PCOS after marriage. It is bad advice. Irregular periods, rising weight and insulin resistance are much easier to turn round at 21 than at 31, and nothing in the first steps depends on whether you are married.

A gynaecologist can examine an unmarried woman without an internal examination, and if a scan is needed it can be done through the abdomen with a full bladder. Blood can be collected at home on a weekday morning before college or work. The home part is the plate, a daily walk, two strength sessions a week, and a bedtime that does not drift to 2 am with the phone.

Fatima's younger sister Sana, 20 and in her second year of BCom, was diagnosed last year. She walks with friends round the college ground after lectures, has swapped the canteen samosa for a bowl of chana chaat, and does a strength video with Fatima on Sunday mornings.

The methi water, cinnamon tea and seed-cycling packs sold for PCOD have little trial evidence. They are harmless in kitchen amounts, but they are no substitute for the steps above.

An endocrinologist is worth seeing when weight, blood sugar or thyroid are the bigger worry, and a dietitian turns the advice into meals you will actually cook.

The best PCOS care is joined up, because the condition sits across all three. Fatima saw a gynaecologist for four years who managed her cycle well and never once checked her sugar. Her HbA1c, when an endocrinologist finally ordered it, was 6.0%, just inside the prediabetes range.

The guideline is clear that this should not happen. It asks for blood pressure at every visit and sugar at diagnosis and every one to three years afterwards, more often for women who are heavier or have diabetes in the family. A lipid profile belongs in the same blood draw. In India's national study 91.9% of women with PCOS had an abnormal cholesterol result, and 43.2% had obesity.

Metaboliq is set up as that kind of joined-up team, and the aim we set with members is "Lose up to 20% of your body weight — and keep your muscle". Results vary; your doctor decides what is right for you. With PCOS the muscle half matters most, because muscle is what soaks up blood sugar. It starts with a home blood test covering insulin, HbA1c, lipids and thyroid, which a doctor reads with you.