Photograph by Sora Shimazaki

Does PCOS Cause Fatigue?

How PCOS and chronic fatigue are linked
Updated
May 13, 2024
Written by
Abby Courtenay

Do you feel like exhaustion is ruling your life? Are you waking up feeling tired all the time, and all you can think about is your next opportunity to take a nap but each nap never feels long enough? You’re not alone. 

According to the PCOS Awareness Association, fatigue is one of the leading symptoms for women with polycystic ovary syndrome (PCOS)1. The good news is that if you have PCOS, you have some evidence-based strategies you can explore to improve your fatigue. 

In this article, we’ll uncover the main cause of PCOS fatigue and what you can do about it! Before we dive into understanding the link between PCOS and fatigue, let's define some key terms.

What is PCOS?

PCOS (or polycystic ovary syndrome) is one of the most common hormonal disorders affecting an estimated 8-13% of women2,3.

PCOS is often underdiagnosed or misdiagnosed, with the World Health Organization suggesting that up to 70% of cases may remain undiagnosed3. As a result, the true prevalence is likely higher than the estimated range.

PCOS is characterized by hormonal imbalances, primarily involving insulin resistance and elevated levels of androgens (such as testosterone). These hormonal imbalances can lead to a range of symptoms, including irregular or absent menstrual periods, acne, excessive facial and body hair (hirsutism), hair loss (alopecia), anxiety, depression, and metabolic issues like appetite dysregulation, sugar crashes, cravings, stubborn weight gain, and fatigue.

If you're struggling with PCOS symptoms and have only been offered birth control as a solution, without comprehensive evaluation through proper blood testing or a clear, individualized treatment plan for symptom management, you're not alone. Feeling dismissed, misunderstood, and helpless with PCOS is unfortunately way too common for women struggling with PCOS worldwide.

PCOS and Fatigue

Fatigue can be described as an overwhelming feeling of tiredness or lack of energy irrespective of your sleep patterns4. No matter how much sleep and rest you get, you feel constantly low, out of energy, things take more effort, feel harder, you feel no motivation to get things done, and nothing seems to make a difference. Unfortunately, this feeling is all too common for women with PCOS. In fact, the PCOS Awareness Association (PCOSAA) and the Royal College of Obstetricians and Gynaecologists both note that one of the leading symptoms reported by people with PCOS is fatigue1,5

So how does PCOS affect your energy levels? As PCOS can manifest in so many different ways, there can be a number of reasons why you are feeling fatigued. Let’s take a look at the most common culprits.

The link between PCOS and insulin resistance

According to the International Evidence-based Guideline for the assessment and management of polycystic ovary syndrome 2023 6, insulin resistance affects 75% of lean women and 95% of women with a BMI of more than 25 kg/m2. In fact, a growing body of evidence suggests that instead of insulin resistance being a symptom of PCOS, it may actually be the leading cause behind PCOS6,7. Insulin resistance and fatigue are closely linked4,6,7. So the key to getting to the root of your fatigue, could be understanding insulin resistance in more detail.

Every time you eat, the sugar (or glucose) levels in your bloodstream increase. Insulin’s main role is to normalize your blood sugar levels by helping the blood sugar enter your cells so that it can be used for energy. When this mechanism doesn’t function properly, your cells don’t obtain the fuel they need, and the excess sugar gets stored in your fat tissue. When your cells don’t get the energy they need to function, fatigue arises.

In insulin resistance, body cells don’t respond appropriately to insulin, which means they can’t efficiently take up glucose from the blood to utilize it8. As a result, your cells are not getting the fuel they need, no matter how much you eat. 

To try to overcome the increasing blood glucose levels, the pancreas pumps out large amounts of insulin. When this happens on a regular basis, the less sensitive the cells become to the insulin, worsening insulin resistance and preventing the body from being able to clear sugar from the blood. This leads to high blood sugar levels, or hyperglycemia. In an attempt to get rid of some of this excess blood sugar, the body increases your thirst, subsequently increasing urination. All this urinating can lead to dehydration and one of the first signs of dehydration is fatigue. Which adds fuel to the fatigue fire.

Insulin resistance and sleep disruptions

One factor that can further aggravate insulin resistance is chronically poor sleep8,9. The connection between insulin production and sleep is a vicious cycle: poor sleep impairs your insulin sensitivity, however, impaired insulin sensitivity can also interfere with getting good quality sleep. 

One particular sleep condition that has been studied in relation to PCOS is obstructive sleep apnoea (OSA)10

OSA happens when your upper airway becomes blocked many times while you sleep, reducing or completely stopping airflow. When you stop breathing, your body will briefly wake you up meaning that you never get a solid night's sleep! Some of the symptoms of OSA include snoring in combination with waking unrefreshed from sleep, daytime sleepiness or fatigue. 

PCOS and Sleep Apnea

OSA and PCOS are linked and one study even found that women with PCOS are 30 times more likely to have breathing related sleep disorders than their non-PCOS counterparts10

As we’ve learned, women with PCOS are likely to have high insulin levels. High insulin levels can increase androgen levels (like testosterone). One of the things that testosterone does is increase fat deposition around your stomach (leading to what is known as an ‘apple’ shape).. In return, the chronic sleep deprivation from OSA itself, increases insulin resistance which in turn drives more androgen production restarting the cycle10-12.

If you suspect you have OSA, ask your doctor about OSA screening using scientifically-validated tools like the STOP-bang questionnaire13.

What you can do about insulin resistance

Insulin resistance can be effectively improved by appropriate dietary and lifestyle modifications as well as supplementation, if necessary. 

While physicians often recommend weight management as the first line treatment, it brings up a few problematic questions. First, weight management does not apply to women with lean PCOS. And for those with excess weight, insulin resistance can make it especially challenging to see results from conventional strategies for weight loss. 

Instead of the standard advice of telling women to ‘just lose weight’ with PCOS, at Mohana, we believe in a root-cause-centric approach to insulin resistance. That is, when working with our users, we always start by first establishing a benchmark to understand what may be triggering the insulin resistance in each unique person’s case.

How to test insulin resistance at home

To understand if you have an underlying problem with your insulin, you have a number of tests available to you:

  • Fasting glucose, fasting insulin, or HbA1c levels - These tests are the go-to tests physicians will order first to understand your metabolic health. It’s important to note that these tests may not always pick up early signs of insulin troubles. That said, it’s a great starting point, and you can easily access this in the at-home format, via companies like Mohana.
  • The oral glucose tolerance test (or OGTT) - This is a more involved test where a physician will measure your glucose response multiple times after you drink 75g of glucose. This test is much more accurate than only looking at a one-time measure of your fasting glucose and insulin, however, in some cases, it can also miss the early signs of insulin problems.
  • Continuous Glucose Monitor (CGM) - This is the gold standard for measuring your body’s glucose response after eating. It gives you a real-time measure of how your body is dealing with glucose, and how efficiently your body produces insulin to normalize your blood glucose levels.

If these tests are not available to you, you can also tune into the symptoms of insulin problems like hunger pangs, sugar crashes, cravings, energy slumps, mood swings, elevated heartbeat, anxiety among others.

How to naturally reverse insulin resistance

Once you know how insulin works in your body, two focus areas to look into is mitigating your insulin production and increasing your insulin sensitivity. If you manage your blood sugar levels and prevent sudden blood sugar spikes, then your body will secrete less insulin which can reduce insulin resistance over time. To do this, you can consider the following interventions:

  • Prioritize protein, high-fiber carbs and healthy fats at meal times. All three slow down gastric emptying which can help to keep you feeling fuller for longer, possibly helping to manage cravings for food that may raise your sugars substantially like refined carbs and sugars). In addition to this, 
  • Stay away from high-sugar drinks to hydrate your body. Switch to water instead.
  • Switch refined carbs to complex carbs.
  • Know your fats: When choosing what kinds of fats to include in your diet, opt for minimally processed plant-based fats (like extra virgin olive oil, avocado, nuts and seeds) over highly processed fats (usually found in ultra-processed foods) and animal fats. Your choice of fat can have a significant impact on how sensitive your cells are to the insulin that your body is producing. 

The more sensitive the cells are, the less insulin your body needs to make! 

PCOS and Fatigue: Other Possible Causes

While there is compelling evidence that insulin resistance may be the main driving force behind PCOS fatigue, there are also a number of other common explanations. These include:

  • Low iron levels
  • Vitamin B12 deficiency
  • Underactive thyroid
  • Endometriosis
  • Adrenal fatigue
  • Depression

Unfortunately, the above conditions are not rare, and a large percentage of the female population are living with these problems, often undetected. For this reason, when trying to get to the bottom of your fatigue, it’s important to get a comprehensive snapshot of your body with proper blood testing. This will help you feel reassured that you’re working on the right underlying problem.

Supplements for insulin resistance

While our suggestion is to always focus on diet and lifestyle modifications as the first-line treatment for insulin resistance, there are a number of supplements that can help you with short-term symptom relief. Here is a list of a few supplements you can read up on:

  • Myo-inositol
  • N-Acetyl Cysteine (NAC)
  • Curcumin
  • Chromium
  • CoEnzyme Q10
  • Ceylon cinnamon

Just as with medication, please always make sure to first consult your doctor before you begin a new supplement protocol.

Wrapping up

Fatigue is one of the most common and often debilitating symptoms of PCOS that can impact your everyday. But the good news is that feeling exhausted all the time is not your lot in life and you don’t have to just accept it and move on. Identifying your unique triggers and understanding how you can work on your triggers with the appropriate lifestyle changes can provide effective relief!

Looking to understand more about your PCOS, and get informed about what you can do to improve your unique root causes? Mohana helps women like you learn about their bodies with the right functional tests, and personalized health plans uniquely tailored to target your worst symptoms.

References

  1. PCOS and Fatigue — [Internet]. PCOS Awareness Association. [cited 2024 May 17]. Available from: https://www.pcosaa.org/pcos-and-fatigue
  2. Polycystic ovary syndrome [Internet]. [cited 2024 May 17]. Available from: https://www.womenshealth.gov/a-z-topics/polycystic-ovary-syndrome
  3. Polycystic ovary syndrome [Internet]. [cited 2024 May 17]. Available from: https://www.who.int/news-room/fact-sheets/detail/polycystic-ovary-syndrome
  4. Fatigue [Internet]. Cleveland Clinic. [cited 2024 May 17]. Available from: https://my.clevelandclinic.org/health/symptoms/21206-fatigue
  5. Polycystic ovary syndrome (PCOS): what it means for your long-term health [Internet]. RCOG. [cited 2024 May 17]. Available from: https://www.rcog.org.uk/for-the-public/browse-our-patient-information/polycystic-ovary-syndrome-pcos-what-it-means-for-your-long-term-health/
  6. Teede HJ, Tay CT, Laven JJE, Dokras A, Moran LJ, Piltonen TT, et al. Recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Eur J Endocrinol [Internet]. 2023 Aug 2 [cited 2024 May 17];189(2). Available from: https://pubmed.ncbi.nlm.nih.gov/37580861/
  7. Zhao H, Zhang J, Cheng X, Nie X, He B. Insulin resistance in polycystic ovary syndrome across various tissues: an updated review of pathogenesis, evaluation, and treatment. J Ovarian Res [Internet]. 2023 Jan 11 [cited 2024 May 17];16(1):1–17. Available from: https://ovarianresearch.biomedcentral.com/articles/10.1186/s13048-022-01091-0
  8. Insulin Resistance [Internet]. Cleveland Clinic. [cited 2024 May 17]. Available from: https://my.clevelandclinic.org/health/diseases
  9. Zuraikat FM, Laferrère B, Cheng B, Scaccia SE, Cui Z, Aggarwal B, et al. Chronic Insufficient Sleep in Women Impairs Insulin Sensitivity Independent of Adiposity Changes: Results of a Randomized Trial. Diabetes Care [Internet]. 2024 Jan 1 [cited 2024 May 17];47(1). Available from: https://pubmed.ncbi.nlm.nih.gov/37955852/
  10. Vgontzas AN, Legro RS, Bixler EO, Grayev A, Kales A, Chrousos GP. Polycystic Ovary Syndrome Is Associated with Obstructive Sleep Apnea and Daytime Sleepiness: Role of Insulin Resistance1. J Clin Endocrinol Metab [Internet]. 2001 Feb 1 [cited 2024 May 17];86(2):517–20. Available from: https://academic.oup.com/jcem/article-pdf/86/2/517/9129902/jcem0517.pdf
  11. Tasali E, Van Cauter E, Ehrmann DA. Polycystic Ovary Syndrome and Obstructive Sleep Apnea. Sleep Med Clin [Internet]. 2008 Mar [cited 2024 May 17];3(1):37. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2390828/
  12. Sam S, Tasali E. Role of obstructive sleep apnea in metabolic risk in PCOS. Current opinion in endocrine and metabolic research [Internet]. 2021 Apr [cited 2024 May 17];17:46. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8341449/
  13. STOP-Bang Questionnaire [Internet]. [cited 2024 May 17]. Available from: http://www.stopbang.ca/translation/pdf/caeng.pdf