She’s active.
She eats whole foods. She cooks. She moves her body most days.
She has a PCOS diagnosis, a prescription for metformin, and a body that holds onto weight no matter how consistent she is.
What she’s asking for isn’t another prescription.
She wants to understand her body.
I hear some version of this story often. And I want to ask a different question than the one she’s usually been asked.
Not how do we manage the symptoms?
But what is her body responding to?
In short: For many women with PCOS, the pattern appears to begin upstream with an insulin surge: insulin that stays elevated long before glucose looks abnormal. That signal can drive ovarian androgen production, disrupt ovulation and keep the body in storage mode. It can be evaluated through fasting glucose, A1c, fasting insulin, triglycerides and HDL, and supported by changing the conditions that create it.
PCOS Has a New Name, and It Points Upstream
In May 2026, after a global consensus process published in The Lancet, polycystic ovary syndrome was renamed polyendocrine metabolic ovarian syndrome, or PMOS.
The old name pointed at the ovary.
The new one puts metabolic in the middle.
That is the field acknowledging what many clinicians have seen for years:
The ovary is often where the pattern shows up.
It isn’t always where the pattern begins.
(I’ll keep using “PCOS” here, because it’s still the name most people search for.)
The Most Common Upstream Signal: The Insulin Surge
Insulin’s familiar job is moving glucose out of the blood and into cells.
But insulin is also the body’s primary storage signal.
When insulin is high, the message is: store, don’t release.
With insulin resistance, cells respond less to that signal. The pancreas adapts by making more.
For a long time, that works. Glucose stays in range.
But it stays in range because insulin is working overtime.
That’s the insulin surge: a high-output state that can persist for years before fasting glucose or A1c ever raise a flag.
Why effort alone stalls
This is why a woman can eat well, exercise and still struggle to lose weight or keep it off.
It isn’t a willpower problem.
Her body may be following a storage signal that hasn’t changed.
That isn’t the body failing. It’s the body adapting, intelligently, to the conditions it’s been given.
Change the signal, and the adaptation has room to change too.
What the ovary hears
The ovaries listen to insulin.
Elevated insulin can amplify the signal for ovarian androgen production. It can also lower SHBG, the protein that keeps testosterone bound and quiet. More free androgen activity may disrupt how follicles develop, and ovulation becomes unreliable.
Acne, hair changes, irregular cycles and difficulty conceiving can all sit downstream of the same upstream signal.
I walk through that cascade step by step in Insulin Resistance and Female Hormones: The PCOS Connection.
Not every woman with PCOS has insulin resistance. Presentations differ, and other signals, like adrenal androgens, inflammation and stress load, can contribute.
But insulin resistance is common enough in PCOS, including in lean women, that it’s where I look first.
How We Evaluate It: Five Markers, One Pattern
Glucose alone can’t tell us how hard the pancreas is working to keep glucose where it is.
So I look at five markers together.
| Marker | What it may reflect | Why it matters in PCOS |
|---|---|---|
| Fasting glucose | Where glucose settles overnight | Often normal early; a later signal |
| Hemoglobin A1c | Average glucose over about three months | Can look fine while insulin is high |
| Fasting insulin | How much insulin it takes to hold glucose steady | Often the earliest sign of the surge |
| Triglycerides | How the liver is handling surplus fuel | Tend to rise when insulin stays elevated |
| HDL cholesterol | Part of how the body moves and clears fats | Tends to run low in the same pattern |
Triglycerides and HDL read well together. A higher triglyceride-to-HDL ratio is widely used as an indirect marker of insulin resistance, and research in women with PCOS suggests it tracks with insulin sensitivity.
No single number makes the call.
A fasting glucose of 90 with a high fasting insulin, high triglycerides and low HDL fits a very different pattern than a fasting glucose of 90 with everything else quiet.
The pattern is the diagnosis.
Alongside these markers, I want the cycle history, the symptoms, the reproductive hormones and body composition. Context turns numbers into a story.
If you want to go deeper on reading glucose patterns, start with Blood Sugar Dysregulation: The Pattern Beneath So Much Else.
When the thyroid is part of the picture
Many women with PCOS are also managing a thyroid condition. The two often travel together, and both shape energy, metabolic rate and weight.
If you’re on thyroid medication and still don’t feel like yourself, it’s worth looking at the whole system rather than one gland at a time. I cover that in Hypothyroid Symptoms but Normal Labs?
The Conventional Model: Quieting the Expression
The standard approach to PCOS usually reaches for two tools.
Birth control. Hormonal contraceptives can regulate bleeding, lower free androgens and quiet acne and hair growth. That relief matters.
But the monthly bleed on the pill is a withdrawal bleed, not the result of ovulation.
The pill doesn’t restore the cycle. It replaces it.
And while it’s in place, the signal we most need to read, whether she ovulates on her own, is hidden.
Metformin. Metformin lowers the liver’s glucose output and can improve insulin sensitivity. It’s a legitimate tool, and for some women an important one.
But on its own, it doesn’t change the conditions that created the surge: how she eats, sleeps, recovers and carries stress.
Neither tool is wrong.
Both are incomplete.
They manage the expression of the pattern without asking what the pattern is responding to.
That isn’t a critique of medicine. It’s a critique of fragmentation.
There is more to the story.
If you’re taking any of these medications, changes stay between you and your prescriber. Understanding your pattern makes that conversation better.
What We Do Instead: Change the Conditions, in Order
I don’t start with “lose weight.”
Weight is part of the presentation. It isn’t the starting point.
The starting point is the signal.
And the order matters. Regulation precedes repair.
- Fuel adequately. Under-eating is a stress signal, and a body that senses scarcity holds on. That means enough protein, enough food and consistent meals.
- Stabilize blood sugar. Build meals around protein and fat, match carbohydrate to your tolerance, and reduce the spikes that call for more insulin. Muscle matters here, because it’s the body’s largest place to store glucose.
- Lower the sleep and stress load. Short sleep and high cortisol can both push glucose up and reduce insulin sensitivity. A nervous system that never stands down can keep the surge going even when the food is right.
- Get nutrients from food. Protein, minerals and fat-soluble nutrients come from real food first. Supplements are for a deficiency we’ve tested and confirmed.
- Address the gut and inflammation. Once the terrain is steadier, deeper repair has somewhere to land.
This isn’t a diet.
It’s a sequence.
Where This Work Happens: The Systems Reset Intensive
This is the work of the Systems Reset Intensive™, the first phase of care in my method: Regulate.
Over eight weeks, we focus on the two foundations everything else rests on: blood sugar stability and nervous-system regulation.
The labs above set the baseline. So we’re working from your pattern, not a template, and we can see how your system responds instead of guessing.
Where Fertility Fits
For many women, the real question underneath is fertility.
I take that seriously, and it’s exactly why I don’t rush it.
Ovulation is evidence that the system has both the resources and the signal to reproduce.
When the metabolic terrain is steadier, the fertility conversation starts from a stronger place.
Regulate first. Then repair. Then the next conversation.
I don’t promise timelines. Biology keeps its own schedule.
Follow the Signal
PCOS isn’t a random malfunction of the ovaries.
It fits the pattern of a body responding, intelligently, to a signal it keeps receiving.
Quiet the expression, and the signal is still there.
Change the conditions, and the body has something new to respond to.
That’s where I want to start.
Frequently Asked Questions
What is the root cause of PCOS?
PCOS, now called PMOS, has more than one contributor. For many women, though, the pattern appears to begin with elevated insulin. Insulin can increase ovarian androgen production and disrupt ovulation, which may explain the irregular cycles, acne and hair changes associated with PCOS.
Can you have PCOS without insulin resistance?
Yes. Not every woman with PCOS has insulin resistance, and adrenal, inflammatory and stress-related signals can contribute too. But insulin resistance is common in PCOS, including in lean women, so it’s worth testing rather than assuming.
What labs show insulin resistance in PCOS?
Fasting insulin, fasting glucose, hemoglobin A1c, triglycerides and HDL, read together. Fasting insulin often rises first, and a high triglyceride-to-HDL ratio is a useful indirect marker. Glucose and A1c alone can look normal while insulin is elevated.
Is metformin enough for PCOS?
Metformin can lower glucose output and improve insulin sensitivity, and it helps some women. On its own, though, it doesn’t change the food, sleep, stress and movement conditions that drive the insulin surge. It tends to work best as one piece of a larger care plan.
Should I stop birth control for PCOS?
That’s a decision to make with your prescriber. It’s useful to know that the bleed on the pill is a withdrawal bleed, not ovulation, so it can mask the pattern underneath. Understanding that pattern makes the conversation about next steps clearer.
Why can’t I lose weight with PCOS when I eat well and exercise?
Elevated insulin is a storage signal. If that signal stays high, effort alone often stalls, and under-eating or over-training can add stress that reinforces it. Stabilizing blood sugar, fueling adequately and supporting sleep and stress tend to matter more than doing more.
What to Do Next
If you see yourself in this, the next step isn’t another protocol.
It’s understanding your pattern.
👉 Start Here: A Systems-Based Approach to Understanding Your Health
Or, if you’re ready to look at your own labs and history:
Final Thought
Your body isn’t producing the wrong hormones at random.
It’s responding to a signal.
Find the signal, and the pattern starts to make sense.
