Irregular periods, acne, hair loss, weight gain despite normal eating, exhaustion without an obvious reason. Many women spend years treating these symptoms separately. Yet, they can all be related. PCOS is complex, but understandable.
What happens in the body with PCOS
PCOS is not a single disease, but a syndrome: a combination of symptoms caused by a common set of underlying factors. At its core are three interconnected mechanisms.
Insulin Resistance and Hyperinsulinemia:Insulin resistance is present in 44 to 75 percent of all women with PCOS. Body tissues respond less sensitively to insulin, leading the pancreas to release more of it.²This elevated insulin directly stimulates the ovaries to produce more androgens. At the same time, high insulin levels reduce the liver's production of SHBG, the protein that binds and inactivates free testosterone in the blood. Less SHBG means more free, biologically active testosterone.
Hyperandrogenism:The elevated androgen level is responsible for many of the visible symptoms: acne, hirsutism (excessive body hair), hair loss on the head, and suppression of ovulation. Follicle maturation in the ovaries is disrupted. Eggs do not fully mature, leading to the characteristic polycystic morphology.³
Ovulatory Dysfunction:Without regular ovulation, the cycle remains irregular or absent. This has consequences for fertility, progesterone production, and, in the long term, for endometrial risk.
PCOS is not a matter of discipline or diet alone. It is a metabolic and hormonal disorder with genetic, hormonal, and metabolic roots.
Symptoms that may indicate PCOS
The clinical picture is heterogeneous. No two women with PCOS are identical. The most common symptoms include:
- Cycle irregularities:Cycles under 21 or over 35 days, fewer than 8 cycles per year, or absence of menstruation
- Signs of Hyperandrogenism:Acne (especially in the jawline area), hirsutism on the upper lip, chin, chest, abdomen, or thighs, androgenetic hair loss
- Metabolic Symptoms:Weight gain (especially abdominal), carbohydrate cravings, energy dips after meals, sleep disturbances
- Psychological Symptoms:The 2023 guideline explicitly emphasizes the high prevalence of anxiety disorders, depressive episodes, and reduced quality of life in PCOS.¹
- Fertility Problems:PCOS is the most common cause of anovulatory infertility.²
How PCOS is diagnosed
Diagnosis is made according to the Rotterdam criteria (2003, updated 2023). At least two of the following three criteria must be met, and other causes must be excluded:
- Clinical and/or biochemical hyperandrogenism with elevated androgen levels in the blood or symptoms such as hirsutism or acne
- Ovulatory dysfunction with irregular, infrequent, or absent ovulation
- Polycystic ovary morphology (PCOM) with a characteristic ultrasound image and/or elevated AMH levels in the blood (new since 2023 as an alternative to sonography in adults)
Important: Differential diagnoses must be excluded, including thyroid disorders, hyperprolactinemia, adrenal disorders, and Cushing's syndrome. A diagnosis should always be made by a physician.
What really helps: evidence-based approaches
The 2023 international guideline and the new German S2k guideline agree: lifestyle interventions are the first-line therapy for PCOS, not medication. What does this mean in concrete terms?
Exercise and sports
A systematic review and meta-analysis of 10 RCTs with 382 women (2024) shows that physical activity significantly improves insulin levels, lipid values, and hormonal parameters. A Bayesian network meta-analysis of 19 RCTs with 808 women (2025) compared six forms of exercise: yoga achieved the strongest effects on HOMA-IR and testosterone levels, HIIT followed for insulin sensitivity, and moderate intensity continuous training (MICT) for testosterone.
Even a 5 percent reduction in body weight measurably improves insulin resistance and cycle regularity, without medication. Consistency is more crucial than the exact diet type.
Nutrition
There is no PCOS-specific universal diet with strong RCT evidence. What research shows: A blood sugar-stabilizing diet (low-glycemic, adequate protein, high in fiber) supports insulin sensitivity. Meta-analytic data show that diet-induced weight loss significantly lowers androgen levels and inflammation markers.
Micronutrients and Supplements for PCOS
Inositol (Myo-Inositol and D-Chiro-Inositol)
Inositol is the most well-researched supplemental agent for PCOS. A systematic review and meta-analysis of 26 RCTs involving 1,691 patients shows: Inositol increases the likelihood of a regular menstrual cycle by a factor of 1.79 compared to placebo and achieves similar efficacy to metformin, without its gastrointestinal side effects.
Vitamin D, Magnesium, Zinc, and Selenium
Women with PCOS often have lower levels of these micronutrients. They are involved in the PI3K/Akt insulin signaling cascade, steroidogenesis, and antioxidant defense. Their deficiency exacerbates insulin resistance, oxidative stress, and hormonal dysregulation. Evidence for many of these substances is still limited to observational studies and smaller RCTs. Supplementation should be decided individually and based on blood values.
What can help in everyday life
- Regular exercise: 3 to 5 sessions per week. A combination of yoga, HIIT, and moderate endurance training shows the broadest effect.
- Blood sugar stabilization: Protein and fiber with every meal, reduce processed carbohydrates.
- Sleep and stress management: Cortisol directly affects insulin sensitivity.
- Laboratory control: At least annually: fasting insulin, HOMA-IR, androgen profiles, vitamin D, thyroid values, and AMH.
- Psychological well-being: The 2023 guideline emphasizes: actively address emotional health in PCOS, do not treat it as secondary.
Overview of Hormonic PCOS Articles
As a PCOS hub, this article links to all in-depth guides on the individual aspects of the syndrome:
