PCOS, weight and metabolic health: what you need to know

“I eat less than my sister and still gain weight.” Many women with PCOS say something like this, and they are often not believed. There is a real biological reason. PCOS changes how your body handles insulin, and that affects weight, appetite and long-term health. This is one reason experts chose the word “metabolic” in its new name, PMOS. Read what is PCOS for the background.

Why is weight harder to manage with PCOS?

Most women with PCOS have some degree of insulin resistance, where the body’s cells respond less well to insulin. The pancreas makes extra insulin to compensate. High insulin levels:

• encourage fat storage, especially around the waist
• push the ovaries to make more male hormones, which worsens periods, acne and hair growth
• may increase hunger and cravings

Extra weight then worsens insulin resistance, creating a cycle. This is why weight gain often makes PCOS symptoms worse, and why modest weight loss often improves them.

Do lean women with PCOS also have metabolic risk?

Yes. Insulin resistance is found in many lean women with PCOS too, though usually to a lesser degree. South Asian women tend to carry more fat around the abdomen and internal organs at any given BMI. So a normal BMI does not mean you can skip checks. Read waist size and health risk.

What health risks are linked with PCOS?

• Prediabetes and type 2 diabetes. The risk is several times higher than in women without PCOS, and appears to be higher in Asian women. Read what prediabetes means.
• Gestational diabetes in pregnancy.
• Fatty liver (now called MASLD).
• Abnormal cholesterol and high blood pressure.
• Heart disease and stroke later in life. A 2024 analysis for the international guideline found a higher risk of clinical cardiovascular events in women with PCOS.
• Sleep apnoea, especially with obesity.

In the large Indian study published in 2024, about four in ten women with PCOS had obesity, about a third had fatty liver, and abnormal cholesterol was found in the large majority.

Which checks should I have?

The 2023 international guideline advises, for women with PCOS:

• weight, waist and blood pressure at diagnosis and regularly afterwards
• a sugar test at diagnosis, preferably a glucose tolerance test, and then every one to three years depending on your risk
• a glucose tolerance test before or early in pregnancy
• a lipid profile (cholesterol) at diagnosis, repeated depending on the result and risk
• screening for low mood, anxiety and eating disorders

Your doctor may also check liver tests or a liver scan if fatty liver is suspected.

What helps most?

Lifestyle care is the foundation, whatever your weight:

• Food. There is no single “PCOS diet”. Choose an eating pattern you can keep up: more vegetables, dal, pulses, whole grains in sensible amounts, enough protein, and less refined rice, maida, sweets, sugary drinks and fried snacks. Regular meal times help many women.
• Activity. The guideline suggests at least 150 minutes a week of moderate activity, or 75 of vigorous activity, plus muscle-strengthening on two days. More helps with weight loss and maintenance.
• Weight. If you are overweight, losing 5% to 10% of body weight can make periods more regular, improve ovulation and lower diabetes risk.
• Sleep and stress. Poor sleep worsens insulin resistance and appetite.

Avoid crash diets and “PCOS cleanses”. They rarely last and can trigger disordered eating.

What about medicines?

Your doctor may discuss:

• metformin, which improves insulin resistance and can help weight and periods modestly, especially alongside lifestyle care
• anti-obesity medicines such as GLP-1 medicines, for women who meet medical criteria and are not trying to conceive. Read who should consider weight-loss medicines.
• the combined pill for periods, acne and hair, which does not treat the metabolic side. Read how the 21-day pill pack is used for PCOS.
• bariatric surgery in a small number of women with severe obesity

These decisions depend on your goals, including whether you plan a pregnancy soon, so discuss them with your doctor.

What should I ask my doctor?

• When should I have a glucose tolerance test and cholesterol check?
• Is my waist size a concern, even if my BMI is normal?
• How much weight loss would help me, and what is a realistic pace?
• Would metformin or another medicine help in my situation?

For a personal plan, book a consultation.