Polycystic Ovary Syndrome (PCOS): A Complete Guide for Italian Women

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age: it affects 6–10% of Italian women between 18 and 44 years old. Yet, it is often diagnosed late—on average, 2–3 years after the first symptoms—and just as often managed partially, treating only visible symptoms without addressing the underlying mechanism.

This guide explains what PCOS is, how to recognize it, and why glycemic and metabolic control is at the core of every effective approach.

What is PCOS: More Than an Ovarian Problem

PCOS is not simply an ovarian problem. It is an endocrine-metabolic syndrome characterized by three domains:

1. Ovarian dysfunction: irregular or absent cycles (oligomenorrhea/amenorrhea), polycystic ovaries on ultrasound (≥20 follicles per ovary or ovarian volume >10 ml)
2. Hyperandrogenism: excess male hormones (testosterone, DHEA-S) → acne, hirsutism (excess hair), androgenetic alopecia
3. Insulin resistance and metabolic dysfunction: present in 65–80% of women with PCOS, regardless of weight

Diagnostic Criteria: Rotterdam 2003

The diagnosis of PCOS according to the Rotterdam criteria (the international gold standard) requires at least 2 out of 3 of the following criteria, after excluding other causes:

Epidemiological Data in Italy

• 6–10% of Italian women of reproductive age have PCOS (ISS 2024)
• 70–80% of women with PCOS have insulin resistance
• Women with PCOS have a 4–7 times higher risk of type 2 diabetes compared to the general population
• The risk of gestational diabetes is increased by 3 times
• The risk of metabolic syndrome is increased by 2–3 times
• The long-term cardiovascular risk is increased by 30–50%
• The incidence of type 2 diabetes in women with PCOS before the age of 40 is 10–15%

PCOS Symptoms: Why It Is So Often Misunderstood

PCOS manifests in a very heterogeneous way—not all women have all symptoms:

Cycle symptoms

• Irregular cycles (every 35–90 days) or absence of menstruation
• Difficulty conceiving (PCOS is the primary cause of anovulatory infertility)
• Recurrent early miscarriages

Symptoms of hyperandrogenism

• Persistent adult acne, often on the jawline and neck
• Hirsutism: hair on the face, abdomen, thighs, areolas (Ferriman-Gallwey scale >6)
• Androgenetic alopecia: hair thinning with a male pattern (vertex, frontal hairline)
• Seborrhea (oily skin)

Metabolic symptoms

• Difficulty losing weight, especially in the abdominal area
• Cravings for sugar and carbohydrates, especially in the afternoon
• Intense fatigue after meals
• Acanthosis nigricans (dark skin in the folds of the neck and armpits)
• Metabolic syndrome: abdominal fat + high triglycerides + low HDL + elevated blood sugar + high blood pressure

Psychological symptoms

• Anxiety and depression (double the prevalence compared to the general population)
• Sleep disturbances
• Reduced self-esteem related to visible symptoms (acne, hair, weight)

The Connection Between PCOS and Insulin Resistance

This is the central mechanism that many are unaware of: insulin resistance is present in 65–80% of women with PCOS, regardless of body weight. Even lean women with PCOS can have significant insulin resistance.

The mechanism: compensatory hyperinsulinemia stimulates the ovaries to produce more androgens (testosterone)—worsening hyperandrogenism—and reduces hepatic production of SHBG (Sex Hormone Binding Globulin), increasing the proportion of free and biologically active androgens.

It's a vicious cycle: insulin resistance → hyperinsulinemia → ovarian hyperandrogenism → ovarian dysfunction → irregular cycles → worsening body composition → worsening insulin resistance.

Breaking this cycle—by acting on insulin resistance—is the most effective therapeutic pillar for PCOS.

Diagnosis: Tests to Request

In addition to ultrasound and gynecological examination, these blood tests are essential in the evaluation of PCOS:

• Hormone profile: LH, FSH, estradiol (day 2–5 of the cycle), total and free testosterone, DHEA-S, 17-OH-progesterone (to rule out congenital adrenal hyperplasia), prolactin
• Thyroid function: TSH (hypothyroidism mimics PCOS)
• Glycemic metabolism: fasting glucose, fasting insulin, HOMA-IR, OGTT with insulinemia (75 g glucose, samples at 0-30-60-120 min)
• Lipid profile: total cholesterol, LDL, HDL, triglycerides
• Body composition: BMI, waist circumference, waist/hip ratio—or, better, BIA scale for visceral fat and muscle mass

Treatment: The Integrated Approach

1. Lifestyle (first line)

Even a weight loss of 5–10% in overweight women with PCOS restores ovulation in 55–60% of cases (Kiddy et al., Lancet 1992—confirmed by dozens of subsequent studies). But even in lean women with PCOS, exercise and a low-GI diet improve insulin sensitivity and reduce testosterone.

• Low glycemic index diet: reduces insulinemia and ovarian androgens. Meta-analysis 2023: 12% reduction in testosterone in 12 weeks with low-GI diet vs standard.
• Aerobic exercise: 150 min/week improves HOMA-IR by 25–35% in 3 months
• HIIT training: particularly effective in women with PCOS for insulin sensitivity and abdominal fat loss

2. Metformin (metabolic treatment)

Metformin is the first-choice drug for the metabolic component of PCOS. It reduces hepatic glucose production, improves insulin sensitivity, and—consequently—reduces ovarian hyperandrogenism. In many women with PCOS and insulin resistance, it restores ovulation and regularizes the cycle.

3. Inositol (supplement)

Myo-inositol (2000 mg/day) + D-chiro-inositol (50 mg/day) is the integrative treatment with the most evidence in PCOS: it improves insulin sensitivity, reduces androgens and LH, and improves oocyte quality. Approved as a supplement, it does not require a prescription.

4. Combined oral contraceptives

First-line treatment for cycle regularization and control of hyperandrogenism (acne, hirsutism) in women not seeking pregnancy. They do not treat the metabolic component—and some formulations can worsen insulin sensitivity.

5. Antiandrogens

Spironolactone, flutamide: for severe hirsutism not responsive to contraceptives. Only with a medical prescription.

Glycemic Monitoring in PCOS: Why It Is Important

Given that 65–80% of women with PCOS have insulin resistance, and the risk of developing type 2 diabetes is 4–7 times higher, regular glycemic monitoring is a fundamental component of PCOS management.

Practical recommendations:

• Fasting glucose every 6–12 months (to intercept the transition to pre-diabetes)
• OGTT with insulinemia (to assess insulin resistance before it manifests with hyperglycemia)
• For women with PCOS in pregnancy: gestational diabetes screening from 14–16 weeks (earlier than standard guidelines)

The VitaeChek G1 Pro allows women with PCOS to monitor postprandial blood sugar in response to different meals—a tool to understand which foods raise insulin the most and optimize their diet in a personalized way.

PCOS and Fertility: What You Need to Know

PCOS is the leading cause of anovulatory infertility, but it is also one of the most treatable:

• With lifestyle modifications alone (5–10% weight loss), 55–60% of women ovulate spontaneously
• Ovulation induction with clomiphene citrate has a success rate of 60–70%
• With letrozole (aromatase inhibitor), the pregnancy rate in women with PCOS is higher than with clomiphene
• Exogenous gonadotropin and IVF are reserved for refractory cases

Frequently Asked Questions About PCOS

I have PCOS but I'm lean: is that possible?

Yes—20–30% of women with PCOS have a normal weight ("lean" PCOS). Insulin resistance is also present in many of these women, even without being overweight. Diagnosis is based on clinical and biochemical criteria, not on weight.

Does PCOS go away with menopause?

Partially. With menopause, irregular cycles naturally cease. But insulin resistance, cardiovascular risk, and type 2 diabetes risk persist—and are even exacerbated with the reduction of estrogen.

Does the pill "cure" PCOS?

No—it masks it. The pill regularizes the cycle and controls acne while taking it, but it does not alter the underlying mechanism (insulin resistance, hyperandrogenism). When the pill is stopped, symptoms return. Treating the cause requires a metabolic approach.

Can I measure my blood sugar at home if I have PCOS?

Yes, and it's a good practice, especially if you already have documented insulin resistance or are pregnant. Postprandial measurement helps you understand how each meal affects your blood sugar and to make more informed dietary choices.