Insulin Resistance in PCOS: Pathophysiological Mechanisms of Menstrual Dysfunction and Evidence-Based Treatment Strategies

Abstract Purpose: Polycystic ovary syndrome (PCOS) affects 5–10% of women of reproductive age, with insulin resistance (IR) playing a central role in its pathophysiology in up to 80% of cases. This review aims to elucidate the molecular mechanisms by which insulin resistance disrupts ovarian function, contributing to menstrual irregularities and hyperandrogenism. It also evaluates current and emerging therapeutic strategies, with an emphasis on individualized management. Methods: A comprehensive review of recent literature was conducted, focusing on molecular studies, clinical trials, and meta-analyses related to insulin signaling pathways in PCOS, as well as therapeutic interventions. Special attention was paid to ethnic variations, particularly in East Asian populations, and advances in genomic and metabolomic profiling. Results: PCOS is characterized by selective insulin resistance, wherein metabolic insulin signaling is impaired, but steroidogenic and mitogenic pathways remain responsive, promoting hyperandrogenism and anovulation. East Asian women exhibit significant insulin resistance despite lower BMI compared to Western populations. Insulin resistance in PCOS also increases cardiometabolic risks and psychological burden. While lifestyle modification, insulin sensitizers, and hormonal therapy remain first-line treatments, novel approaches such as microbiome-targeted therapies and anti-inflammatory agents show promise. Conclusion: Understanding the complex interplay between insulin resistance and ovarian dysfunction is crucial for effective PCOS management. Integrating emerging molecular insights with digital health tools can facilitate personalized, multidisciplinary approaches that address both reproductive and metabolic aspects of PCOS, ultimately improving patient outcomes.