Insulin Resistance Emerges as a Hidden Metabolic Burden in Saudi Women With PCOS

Polycystic ovary syndrome affects an estimated four to twenty percent of women of reproductive age worldwide, yet the full metabolic toll of the condition remains stubbornly difficult to quantify, particularly in populations of the Middle East. A new cross-sectional study conducted at the Center of Excellence for Osteoporosis Research at King Abdulaziz University in Jeddah now offers one of the most detailed portraits to date of how insulin resistance, the endocrine disruptions of PCOS, and skeletal health intertwine in Saudi women. The research, published in Archives of Osteoporosis, enrolled 144 participants—72 women with confirmed PCOS and 72 healthy controls matched precisely for age and body mass index—and subjected them to a battery of anthropometric measurements, fasting biochemical assays, and dual-energy X-ray absorptiometry scans of the lumbar spine and femoral neck.

The headline finding is stark: insulin resistance was significantly more common among women with PCOS than among their matched counterparts under every one of the three diagnostic criteria the researchers applied. Using fasting serum insulin as the yardstick, 77.8 percent of the PCOS group crossed the threshold for insulin resistance compared with 58.3 percent of controls. When the homeostasis model assessment, or HOMA, was used—calculated as fasting plasma glucose in millimoles per litre multiplied by fasting insulin in microunits per millilitre and divided by 22.5—half of the PCOS participants qualified as insulin resistant, against just 16.7 percent of controls. The glucose-to-insulin ratio, a more direct gauge of peripheral insulin sensitivity, told a similar story, identifying insulin resistance in 44.4 percent of women with PCOS versus 16.7 percent of the control group, with all comparisons reaching statistical significance at p below 0.01.

The divergence among these three metrics is itself scientifically instructive. Fasting insulin, the authors note, has a tendency to overestimate insulin resistance, while HOMA can underestimate it, because the model assumes a stable relationship between hepatic glucose output and insulin secretion that does not always hold in practice. The glucose-to-insulin ratio, by contrast, provides a more direct quantitative readout of insulin-stimulated glucose disposal and the completeness of hepatic glucose suppression, which is why the team adopted a cutoff of less than 4.5 as its primary classification tool, consistent with thresholds validated previously in obese women and in women with PCOS. Insulin resistance was flagged whenever any single criterion was abnormal—fasting insulin above 64.4 picomoles per litre, HOMA above 3.82, or the ratio below 4.5—and the consistency of the signal across all three measures lends considerable weight to the conclusion that Saudi women with PCOS carry a genuine and substantial metabolic burden.

That burden extends deep into the hormonal machinery of the syndrome. Women with PCOS in the study exhibited luteinizing hormone concentrations of 9.4 plus or minus 8.6 international units per litre, more than double the 4.1 plus or minus 3.7 observed in controls, a difference significant at p below 0.001. The ratio of luteinizing hormone to follicle-stimulating hormone, a classical marker of the disordered gonadotropin signalling seen in PCOS, was likewise markedly elevated, and the gap was most pronounced among women who were both non-obese and insulin resistant. Correlation analysis sharpened the picture further: glucose-to-insulin ratio scores correlated positively with luteinizing hormone levels (r equal to 0.45, p below 0.01) and with the luteinizing hormone to follicle-stimulating hormone ratio (r equal to 0.38, p below 0.05), indicating that the worse a woman’s peripheral insulin sensitivity, the more deranged her gonadotropin profile tended to be.

This coupling is biologically coherent. Hyperinsulinemia is known to amplify gonadotropin dysregulation, driving the ovaries toward increased androgen production and thereby feeding the hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology that define the syndrome. Insulin acts synergistically with luteinizing hormone on ovarian theca cells, stimulating steroidogenesis, while simultaneously suppressing hepatic synthesis of sex hormone-binding globulin, raising the fraction of circulating free androgen. The Jeddah data, showing insulin-resistant women with PCOS bearing fasting insulin levels of 34.6 plus or minus 11.8 microunits per millilitre against 22.4 plus or minus 2.5 in insulin-resistant controls, with higher HOMA values and lower glucose-to-insulin ratios, suggest that this vicious cycle operates with particular intensity in the Saudi cohort. Clinically, the implication is that metabolic intervention—through lifestyle modification or insulin-sensitizing therapy—may do double duty, easing not only diabetes and cardiovascular risk but also the endocrine symptoms that bring many women to the clinic in the first place.

Bone health, by contrast, emerged as a surprisingly quiet frontier. Despite the profound metabolic and hormonal alterations documented in the PCOS group, dual-energy X-ray absorptiometry using a GE Healthcare Lunar iDXA system revealed no statistically significant differences in bone mineral density or T-scores at the lumbar spine or femoral neck between women with PCOS and controls. Classification by World Health Organization criteria—normal for T-scores above minus one, osteopenia between minus one and minus two point five, and osteoporosis below minus two point five—showed comparable skeletal status across the cohort. This null result aligns with a growing body of international literature, including studies reporting comparable hip bone geometry and unaltered bone mineral density in women with PCOS, and it complicates the hypothesis that insulin resistance, which has been implicated in impaired bone quality in other populations, inevitably translates into measurable skeletal deficits in premenopausal women.

Yet the bone story may simply be unfinished. Stratified analyses hinted at a non-significant trend toward higher T-scores among obese women with PCOS, a pattern the authors interpret through the well-established influence of body weight on bone mass. Mechanical loading from excess adiposity, together with adipokine-mediated effects on bone metabolism, may exert a protective influence on the skeleton—at least temporarily—that offsets any catabolic pressure from insulin resistance or hormonal disruption. Whether that protection persists through menopause, when the loss of estrogen removes a major skeletal safeguard, is a question the current study, limited to women aged 24 to 44, cannot answer. The researchers are careful to frame these stratified signals as trends requiring confirmation rather than established findings, particularly given the exploratory design and the absence of formal correction for multiple comparisons.

Vitamin D adds another layer of regional complexity. Mean serum 25-hydroxyvitamin D concentrations were strikingly low in both groups—21.1 plus or minus 15.1 nanomoles per litre in women with PCOS and 22.0 plus or minus 19.5 in controls, a non-significant difference—mirroring the widespread hypovitaminosis D documented across the Middle East. Parathyroid hormone levels were similarly comparable between groups. Because vitamin D status did not differ between cases and controls, the investigators deliberately excluded it as a covariate in their primary bone analyses, reasoning that it was unlikely to confound between-group comparisons. Even so, they acknowledge that individual-level effects of vitamin D on skeletal outcomes cannot be entirely ruled out, and they call for larger, longitudinal studies with adjusted analytical models to clarify whether vitamin D metabolism interacts with insulin resistance and obesity to shape bone health in PCOS over time.

The study’s design carries inherent constraints that temper, though do not diminish, its contribution. As a cross-sectional investigation conducted between December 2018 and June 2019, it captures a single moment in time and cannot establish whether insulin resistance causes the observed hormonal derangements, results from them, or arises in parallel from shared underlying mechanisms. The sample of 72 cases, recruited prospectively from the infertility clinic at King Abdulaziz University Hospital, is modest, and its restriction to a single ethnic group in one city limits generalizability. Twenty-nine initially recruited women were excluded for thyroid disorders, other endocrine conditions, ovarian tumours, severe obesity, pregnancy, psychological conditions, or withdrawal of consent, underscoring the care taken to isolate a clean PCOS phenotype.

What the study loses in causal inference, however, it gains in precision and relevance. By triangulating three independent measures of insulin resistance in a carefully matched cohort, it demonstrates beyond reasonable doubt that the metabolic burden of PCOS among Saudi women is heavy, that it tracks closely with gonadotropin disruption, and that bone mineral density, at least in the reproductive years, is not yet paying a measurable price. The authors argue that early identification and management of insulin resistance—alongside obesity—should be central to the clinical care of women with PCOS in regions where metabolic and endocrine disorders are highly prevalent, a prescription aimed at heading off type 2 diabetes, cardiovascular disease, and any delayed skeletal consequences before they take root. With PCOS prevalence in Saudi Arabia reported at roughly sixteen percent, the public health stakes of that prescription are considerable, and the Jeddah findings give clinicians in the region a clear, evidence-based target at which to aim.

Subject of Research: Insulin resistance, hormonal profiles, and bone mineral density in Saudi women with polycystic ovary syndrome

Article Title: Polycystic ovary syndrome, insulin resistance, and bone health in Saudi women: a cross-sectional study

Article References: Albaik, M., McGuigan, F. E. A., Altyar, A. E., Khan, J. A., & Akesson, K. E. (2026). Polycystic ovary syndrome, insulin resistance, and bone health in Saudi women: a cross-sectional study. Archives of Osteoporosis, 21(1), Article 139. https://doi.org/10.1007/s11657-026-01707-8

Image Credits: AI Generated

DOI: 10.1007/s11657-026-01707-8

Keywords: polycystic ovary syndrome, insulin resistance, bone mineral density, Saudi women, HOMA, glucose-to-insulin ratio, luteinizing hormone, vitamin D deficiency, obesity, osteoporosis, DXA, endocrine disorders