PMOS · PCOS

By Dr. Mélanie DesChâtelets, ND · Naturopathic Doctor and Menopause Society Certified Practitioner · Burnaby and virtual care across BC

Here’s what usually happens… you get diagnosed with something like PMOS (formerly known as PCOS), and you learn that insulin resistance is often part of that story. But you don’t actually know if it applies to you. It’s not very clear. And yet everyone talks about it, because it seems to matter. So here’s the visual that helps most people make sense of where they actually sit: insulin resistance lives on a spectrum, and where you catch yourself on that spectrum changes what’s actually possible.

One scoping note before we go further. This is all about metabolic insulin resistance. I’m not talking about type 1 or autoimmune (LADA) diabetes, where the immune system attacks the pancreas. That’s a completely different mechanism and a completely different conversation, so if that’s your situation, this isn’t the piece for you.

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Does PMOS (PCOS) always cause insulin resistance?

Not always. Insulin resistance isn’t part of the diagnostic criteria for PMOS · PCOS. It’s common, somewhere around 60 to 80% of people with PMOS have some level of it, but it’s not everyone. How likely it is depends on which criteria you met when you were diagnosed, your phenotype, your body size, your ethnicity, and your genetics. Which is exactly why I don’t think we should treat everyone with PMOS the same way. We assess what’s true for that person.

What does the insulin resistance spectrum actually look like?

Clinicians like cut-offs and guidelines, the clean yes-you-have-it, no-you-don’t. But the truth is it’s a slow progression, so as a human taking charge of your own health, I think a spectrum is far more useful.

Picture insulin sensitivity as a line, not a box. On one end is normal sensitivity: you eat, your blood sugar rises, and your body handles it efficiently, with just the right amount of work. As you trend toward insulin resistance, your body can still get the job done, but instead of the same crew of insulin workers, it has to recruit a much bigger team to do the same job. Insulin isn’t giving the same strong signals it used to, so your body is working a lot harder behind the scenes.

Keep going and you reach glucose intolerance, where blood sugar only struggles after it’s challenged. If we just glanced at it we’d probably miss it. That’s what the oral glucose tolerance test is for (the 2-hour sugar test some of you may remember from pregnancy). And at the far end is type 2 diabetes, where blood sugar runs high because insulin can’t keep up anymore.

The point of seeing it as a spectrum: if we can figure out roughly where you sit, we’ve got so much more time to work with.

Why does catching insulin resistance early matter?

Here’s the honest reason I care so much about this. Once blood sugar runs high for a long stretch, that high-sugar state itself is hard on the pancreas. So even if later on you go all in… the habits, the movement, all of it… your pancreas may not recover the way it could have if those same changes had happened earlier.

I don’t want to meet someone only to say, “congratulations, your pancreas is already struggling to do this on its own.” I’d so much rather have the chance to coach early, when there’s breathing room, knowing this won’t move fast, so we have time to build the skills and the mindset that improve your relationship with blood sugar for the long run.

Can insulin resistance be reversed?

For many people, and especially when it’s caught early, yes. Insulin resistance isn’t a one-way street. We don’t have a crystal ball, and not everyone progresses, but we do know that the things that help reverse or halt it are far more powerful in the earlier stages than the later ones. That’s the whole case for catching it early.

To be clear about the line: we don’t reverse PMOS · PCOS itself. But the insulin resistance that can ride along with it? That’s often something we can move, and the earlier we start, the more room we have. And here’s the thing… even if your insulin sensitivity is already normal, the same good blood-sugar habits help you keep it that way.

Can you have insulin resistance with “normal” labs?

Yes. Think of it like a foggy glass. Just because you can’t see it clearly in your labs doesn’t mean it’s not there, or that it’s not affecting how your body talks to sugar.

A standard HbA1c is a good example. It can sit comfortably in the normal range and still not rule insulin resistance out. HbA1c reflects your average blood sugar, and blood sugar is often the last thing to budge. Your insulin can be working overtime to keep that number looking normal long before the number itself ever moves.

Sometimes insulin resistance has no symptoms at all. Other times it shows up quietly… feeling a bit off, tired after meals, strong sugar cravings. None of those are exclusive to insulin resistance, so they’re not a perfect test, but they’re worth paying attention to. For some people, simply getting a clearer picture becomes a powerful driver, because it makes the invisible visible.

Which labs actually give us a hint?

No single lab gives a clean yes-or-no for insulin resistance, and that’s genuinely one of the tricky parts of it. But a few can give us a flavour, as long as we hold them with the right context.

• Fasting insulin and glucose (and HOMA-IR). These give a sense of how hard your body is working to manage blood sugar. The big caveat: insulin resistance scores like HOMA-IR aren’t very reproducible. The lab you went to, and even what you did close to the test, can shift the value, and studies themselves use different cut-offs. So I take any single score with a grain of salt. For the right person who understands that nuance, it can still give a ballpark sense of whether there’s a lot of insulin working to do the job, or whether it’s happening efficiently.
• The oral glucose tolerance test (OGTT). The 2-hour test that challenges your body with sugar and watches how it responds, which is how we catch glucose intolerance that a casual glance would miss. The PMOS · PCOS guidelines do recommend an OGTT at diagnosis for people in a larger body, again when you’re thinking about conceiving, and during pregnancy.
• The triglyceride-to-HDL ratio. Many people already have a cholesterol panel on file, and an elevated triglyceride-to-HDL ratio has been associated with insulin resistance. It’s indirect and it’s not a diagnostic cut-off, just one more small, almost-free piece of context.

Notice the guidelines don’t routinely recommend insulin-resistance testing, and there’s reason for that (the reproducibility issue above). My take: because at this stage we’re usually talking about lifestyle, not medication, then for the right person, with the right nuance, slightly imperfect labs can still give us something useful… as long as everyone’s on the same page about exactly what we’re doing and it isn’t anxiety-inducing. Whether any of these makes sense for you is a conversation for your own healthcare provider, who can read them through the lens of your individual health.

So how do I figure out where I sit on the spectrum?

The honest answer: the labs above give real hints, but no single value sorts it cleanly, and the right next step depends so much on your individual pattern. If you’re in BC and you’d like to look at your own picture with someone, that’s what a Clarity Call is for. It’s a short, no-pressure fit conversation, not a medical visit, to see whether working together makes sense and to point you in the right direction either way.

Watch the full video: PCOS and Insulin Resistance: Even with “Normal” Labs?, and subscribe to my YouTube channel so the next one finds you.

If your labs came back normal and you still feel like something is off, this is the follow-on: Insulin Resistance Test: Why Your Normal PMOS · PCOS Labs Might Be Missing It.

Main references

1. Teede HJ, et al. Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. J Clin Endocrinol Metab. 2023. PubMed

This article is educational, not medical advice or a diagnosis. If something here resonates, bring it to your healthcare team, who can look at it through the lens of your individual health.