Underdiagnosed, Common Women’s Hormonal Imbalance

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Insulin resistance affects 50-70% of patients with:

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Clinical Quiz: Insulin Resistance
Metabolic disturbances affect many women with PCOS, and the comorbidity is likely part of the underlying cause of the disorder. In addition to 50-70% of women with PCOS having insulin resistance, these patients have other cardiac abnormalities.(1) Depression and anxiety are also much more common in this population, even when compared with BMI-matched controls.(2)
1. Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol. 2013;6(1):1-13. doi:10.2147/CLEP.S37559. 2. Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol. 2013;6(1):1-13. doi:10.2147/CLEP.S37559.

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Where would you start if Joelle, a 25-year-old female, came to you reporting years of hirsutism, cystic acne, and irregular and painful periods? What if that patient also had an elevated BMI with high abdominal adiposity, elevated testosterone, prediabetes, and a single cyst found in a pelvic ultrasound?

PCOS is a complex endocrine and metabolic condition.1 Although estimates vary due to different standards for diagnosis, it potentially affects up to 15-20% of women.1 Despite being the most common hormone disorder in reproductive-age women, it is underdiagnosed.2 Patients with PCOS do not all seek care and are not always aware that their symptoms can be ameliorated.3

One survey showed that two-thirds of PCOS patients are unsatisfied with their experience of diagnosis, and only 15% were satisfied with the information and materials they received.4 Almost half of the women saw more than three clinicians before a diagnosis was obtained.4

PCOS comes with major health risks, so early diagnosis can reduce the long-term health impacts. Common comorbidities include infertility, hypertension, type 2 diabetes, depression, anxiety, sleep apnea, menstrual irregularities, and more.1,2 In one study, 42% of women with PCOS also had irritable bowel syndrome (IBS), and these patients had both higher BMI and higher body fat percentages.5 Insulin resistance is found in 50-70% of females with PCOS.1 Women with PCOS are also more likely to have anxiety or depression, even when compared with controls with the same BMI.6

In a primary care practice, patients with PCOS are common. One estimate found that 500,000 patient visits a year are associated with PCOS.7 Functional Medicine offers tools to diagnose and treat these patients effectively. For example, a comprehensive Functional Medicine physical exam can aid in an accurate diagnosis, as acanthosis nigricans and hirsutism are common physical findings in these patients.8

Expand your physical exam skills

A recent Cochrane review concluded that lifestyle interventions “may improve the free androgen index, weight, and BMI in women with PCOS.”9 Lifestyle modifications are crucial to help patients with PCOS alleviate symptoms and reduce ongoing health risks.10 For instance, a plant-based diet (without energy restriction), lifestyle education, and aerobic exercise reduced PCOS symptoms in a cohort of 30 women over 16 weeks more than the Therapeutic Lifestyle Changes cardioprotective diet, though both groups showed improvements during the study.11

Accurate diagnosis followed by multimodal interventions can not only help patients like Joelle with immediate concerns, but also improve health in the long term.12



  1. Sirmans SM, Pate KA. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol. 2013;6(1):1-13. doi:10.2147/CLEP.S37559
  2. Sirmans SM, Parish RC, Blake S, Wang X. Epidemiology and comorbidities of polycystic ovary syndrome in an indigent population. J Investig Med. 2014;62(6):868-874. doi:10.1097/01.JIM.0000446834.90599.5d
  3. Ding T, Hardiman PJ, Petersen I, Wang FF, Qu F, Baio G. The prevalence of polycystic ovary syndrome in reproductive-aged women of different ethnicity: a systematic review and meta-analysis. Oncotarget. 2017;8(56):96351-96358. doi:10.18632/oncotarget.19180
  4. Gibson-Helm M, Teede H, Dunaif A, Dokras A. Delayed diagnosis and a lack of information associated with dissatisfaction in women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2017;102(2):604-612. doi:10.1210/jc.2016-2963
  5. Mathur R, Ko A, Hwang LJ, Low K, Azziz R, Pimentel M. Polycystic ovary syndrome is associated with an increased prevalence of irritable bowel syndrome. Dig Dis Sci. 2010;55(4):1085-1089. doi:10.1007/s10620-009-0890-5
  6. Cooney LG, Lee I, Sammel MD, Dokras A. High prevalence of moderate and severe depressive and anxiety symptoms in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod. 2017;32(5):1075-1091. doi:10.1093/humrep/dex044
  7. Jason J. Polycystic ovary syndrome in the United States: clinical visit rates, characteristics, and associated health care costs. Arch Intern Med. 2011;171(13):1209-1211. doi:10.1001/archinternmed.2011.288
  8. Schmidt TH, Khanijow K, Cedars MI, et al. Cutaneous findings and systemic associations in women with polycystic ovary syndrome. JAMA Dermatol. 2016;152(4):391-398. doi:10.1001/jamadermatol.2015.4498
  9. Lim SS, Hutchison SK, Van Ryswyk E, Norman RJ, Teede HJ, Moran LJ. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev. 2019;3:CD007506. doi:10.1002/14651858.CD007506.pub4
  10. Lua ACY, How CH, King TFJ. Managing polycystic ovary syndrome in primary care. Singapore Med J. 2018;59(11):567-571. doi:10.11622/smedj.2018135
  11. Kazemi M, McBreairty LE, Chizen DR, Pierson RA, Chilibeck PD, Zello GA. A comparison of a pulse-based diet and the therapeutic lifestyle changes diet in combination with exercise and health counselling on the cardio-metabolic risk profile in women with polycystic ovary syndrome: a randomized controlled trial. Nutrients. 2018;10(10):E1387. doi:10.3390/nu10101387
  12. Wolf WM, Wattick RA, Kinkade ON, Olfert MD. The current description and future need for multidisciplinary PCOS clinics. J Clin Med. 2018;7(11):E395. doi:10.3390/jcm7110395

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