The Role of Insulin and Testosterone in the Weight Gain of PCOS and Menopause

Struggling with hormonal weight gain around your middle? It’s a common problem with PCOS and menopause but it’s not caused by estrogen.

In women, estrogen is beneficial for weight loss. The abdominal weight gain of PCOS and menopause is more likely to be caused by insulin and testosterone.

Let’s take a closer look.

Insulin resistance and weight gain

Insulin resistance is the condition of having chronically elevated levels of insulin. It’s also called hyperinsulinemia, metabolic syndrome, or pre-diabetes.

There’s growing evidence that high insulin causes abdominal obesity and that it does so by increasing appetite, preventing fat-burning, and promoting the growth of fat cells.

Do you have insulin resistance? Are you sure?

A test for blood glucose is not a test for insulin resistance. To assess insulin, you have to test insulin either as fasting insulin or a glucose tolerance test with insulin (also called an insulin assay or Kraft test, named after Dr Kraft, a clinical pathologist).

You then look at your insulin reading, not your glucose reading. A healthy fasting insulin should be less than 60 pmol/L (8 mIU/L). One hour after the sugar challenge, insulin should be less than 410 pmol/L (60 mIU/L).

High insulin can cause abdominal weight gain. So can high testosterone.

The link between testosterone and insulin resistance

In women, higher levels of testosterone increase the risk of insulin resistance and abdominal obesity. In men, it’s the opposite; higher levels of testosterone reduce the risk of insulin resistance and abdominal obesity.

The link between testosterone and insulin resistance is most clear with the hormonal condition PCOS, which is the classic condition of “testosterone dominance,” or too much testosterone or other male hormones (androgens) compared to estrogen and progesterone.

With PCOS, there’s a bi-directional relationship between high testosterone and insulin resistance.

In one direction, insulin resistance or high insulin increases testosterone by stimulating ovarian cells to make more testosterone. That’s the more conventionally understood aspect of PCOS.

In the other direction, testosterone worsens insulin resistance, and there’s growing evidence that in at least some cases of PCOS, high testosterone comes first and then causes or worsens insulin resistance.

It becomes a vicious cycle of more testosterone leading to more insulin resistance leading to more testosterone. All made worse by the relative lack of estrogen and progesterone — two hormones that help to reduce both insulin and testosterone.

Estrogen and progesterone to the rescue

Estrogen improves insulin sensitivity and reduces the risk of insulin resistance. That’s why losing estrogen with menopause increases the risk of insulin resistance and abdominal weight gain. Estrogen also helps to lower testosterone by increasing sex hormone binding globulin (SHBG) — a protein that binds and inactivates testosterone.

Progesterone also improves insulin sensitivity to some extent but its main benefit is that it lowers testosterone. For more information about progesterone’s natural anti-androgen effect, read The 7 Best Natural Anti-Androgen Supplements.

👉 Tip: There’s no progesterone in hormonal birth control. Contraceptive drugs are progestins, some of which are “androgenic” or testosterone-like and so can cause abdominal weight gain.

Two situations of testosterone dominance: PCOS and menopause

PCOS and menopause are similar in the following ways:

  • Relatively low level of estrogen.
  • No progesterone.
  • Relatively high level of free or active testosterone due to a low level of SHBG.
  • Insulin resistance.

PCOS and menopause are different in that with PCOS, it’s possible to ovulate and make estrogen and progesterone. With menopause, ovulation is no longer possible.

👉 Tip: Testosterone does not increase with menopause. The higher level of “free testosterone” is due to a lower level of SHBG. (Less SHBG binding to the same amount of total testosterone.)

How to treat the hormonal weight gain of PCOS and menopause

If you’re in a situation of abdominal weight gain and testosterone dominance, your strategy is two-fold: 1) reverse insulin resistance and 2) lower androgens.

The first part is relatively straight-forward with a combination of diet, exercise, and magnesium. Read my updated blog post: Reverse Insulin Resistance in 4 Easy Steps.

The second part (reducing androgens) can be a little harder to do.

First, you can look at using a natural anti-androgen supplement such as those discussed in The 7 Best Natural Anti-Androgen Supplements. There’s not yet a lot of research but conventional anti-androgen treatment has been shown to improve insulin resistance in women with excessive testosterone.

You can also look at increasing estrogen and progesterone for their natural anti-androgen properties and their beneficial effects on insulin and weight.

If you have PCOS, the way to make estrogen and progesterone is to ovulate. Try to identify the underlying driver of PCOS, and correct that. (Read The 4 Types of PCOS.)

If you are in menopause, you can no longer make estrogen and progesterone, but you could look at taking body-identical hormone therapy. Read 4 Things to Know About Menopausal Hormone Therapy.

Ask me in the comments!

43 thoughts on “The Role of Insulin and Testosterone in the Weight Gain of PCOS and Menopause”

  1. I am 51, periods are now several months apart. I have always struggled with mid section weight, only ever losing it from upper and lower body. I have no menopausal symptoms other than dryness, insomnia and the sporadic periods. Should I be considering estrogen as about five years ago I was diagnosed with fibroids?

    • certainly, it’s worth looking at a vaginal estrogen for the dryness.
      In terms of the mid-section weight, the first priority is to try to obtain a test for insulin.

  2. Lara, thank you for taking the time to reply. It’s been so confusing and so many doctors have said so many different things. I am a Certified Birth Doula and I recommend your book to all of my clients, my sisters, my sister-in-law’s, and my friends.

  3. Hi Lara! Thanks for your response. I’m 47, have Hoshimotos, stopped having periods 5 months ago which my dr said is due to perimenopause/menopause, and just these last two days had a bit of spotting. I have blood work from three months ago. (I’m from Alberta too, but I live in Utah so the numbers are American, if that matters) Progesterone LC/MS 0.5, Testosterone total MS 34, Testosterone free 2.8, Estradiol 145. My bloodwork shows only my glucose, which is normal, but I just requested to have my insulin checked. My My thyroid panel was low so my Armor thyroid has been bumped up, I’ve been taking the B6, Taurine, Magnesium, and an oral trochee of bio identiical hormones with 200mg Progesterone and 0.6 Testosterone which has reduced the horrible hot flashes to almost nothing. (today I’m picking up a new one with a slightly less testosterone dose), I’m also taking a small amount of iodine, and a supplement with Vitex/White peony/Raspberry leaf/Yarrow/Dong quai/Blessed thistle/Licorice. Before my periods stopped I was also taking a lot of Turmeric. I feel forgetful but my brain races, my body feels lethargic and tired and it’s hard to move, and I’ve gained a lot of weight especially around my middle. Going by my abdominal measurement and how I respond to sugar I’m sure I have insulin resistance. I CANNOT stop eating it. I NEED it. And all my body does is gain weight. I feel stuck. I feel like I can’t and won’t change. It’s a very helpless, depressing feeling. Thank you for your help.

    • As I discuss in this blog post, I fear that testosterone worsens insulin resistance so I am highly doubtful of the wisdom of including testosterone in menopausal formulas — especially for anyone who already has insulin resistance.

      Your #1 step is probably to reverse insulin resistance and that means finding a way to break the sugar addiction. Read Reverse insulin resistance in 4 easy steps and Chapter 7 of Period Repair Manual.

  4. I’m 47 years old and stopped having periods five ago. My doctor says my estrogen is high, testosterone normal, no progesterone, even though I’m using oral progesterone. I’ve got lots of weight gain around my middle. What can I do with that combination of circumstances?

    • your estrogen is high? are you sure? Is your lack of periods due to PCOS or menopause? And the most important question: do you have insulin resistance?

  5. Hi Lara. I m really struggling to decide whether to take the HRT route or not. I ve always been a naturalist and lived off grid in nature and the idea of HRT really is against my principals in life but on the other hand l don t want to risk my life expectancy and be there for my only daughter. I entered early menopause at 32 refused Hrt back then and had spontenous pregnancy and gave a birth at 34. Breastfed for 3 years and when l weaned the nightmare started. Heart beats, insomnia, depression, brain fog… Eventually took the bodyidentical route. I am 37 now and been told to use it for the next 10 years. I want to know if l can manage to ease the symptoms with herbal medicine and life style, would l still risk my hearth health and bone health in the long run? Shortly do l really need the Hrt ? I was also thinking that my not having it l could perhaps cut down my risk of breast cancer although it is said that in my situation there is no risk however on the other hand there is really no data on the long term effects of bodyidentical hormones on women with premature menopause. Thank you,

    • Most of the evidence suggests that women with premature menopause benefit from hormone replacement — preferably in the form of estradiol patch plus micronized (natural) progesterone capsule — which is the safest type of hormone therapy.

  6. Incredibly interesting and informative article! For me now this question is very relevant since I am almost 40 years old and I have already begun to feel the symptoms of perimenopause. Many of them began to appear from the age of 35-36. These are such as insomnia, stress, changes in mood and sometimes sweating. But only closer to 39 years old, I realized that my lifestyle has not changed, and excess weight began to appear. I immediately connect this with hormonal imbalance and perimenopause, and when I read your article I understood in detail the whole connection between hormones and women’s health, weight gain, etc. Many thanks to the author for a really good and clear article!

  7. I would be interested to know this also! I have high androstenedione and DHEAS – I have managed to lower DHEAS slightly through your blog post and book recommendations but my androstenedione remains high at 10 (ref range is 3 – 9.5). Would love to know your thoughts here Lara?

  8. Hi Laura,
    Thank you for sharing your wealth of knowledge on women’s health. I have your book but wondering if there is any evidence you’ve seen in your research or clinical experience that women experience neuralgia sensations after menopause? Due to drastic shift in hormones.
    Thank you,

  9. Thank you for your great article. I am 44 years old and for the past year I started developing acne again. I had bad acne as a teenager but it cleared up and my skin has been good. I was diagnosed with PCOS in my twenties. My periods are around a 5/6 week cycle but I managed to have 3 children. I am not overweight but I do watch what I eat and exercise regularly. I do suffer from hirutism. My skin as I explained earlier has been good but lately I feel like a teenager again with red spots, infected acne. I went to a herbalist who prescribed Vitex, it did work for a bit but acne flared up again. I noticed that my skin is worse during ovulation and much better during my period which is opposite to what normal people experience. I have been searching and searching for alternative methods so I am so thrilled to have discovered your website. 10 days ago, I started taking wild yam and sage herb but acne seems to be worse. Can you please help..

    Many thanks

    • As I describe in Period Repair Manual, zinc is one of the simplest and most effective treatments for acne. It works in part by reducing androgens. Please also consider whether you have insulin resistance, which is possible even if you are normal weight.

  10. Hi Lara,

    My daughter is 16 with possibly high testosterone (not tested but she has acne, body hirsutism, no periods etc). You’ve mentioned in past comments not to use Vitex before the body has a chance to communicate to get periods started but you said that some time ago.

    We use Thorne Zinc often, can I use the other options on the 7 Best Natural Anti-Androgens safely. She has all the signs of puberty.

    I can’t stop her from eating deserts and junk (she doesn’t consume direct milk products as she doesn’t like a1 or a2 milk).

    • I hate to say it, but she’ll probably have symptoms for as long as she keeps eating sugar. There’s no herb or supplement that can counteract the insulin and testosterone promoting effects of sugar.

      If I was going to choose one supplement for a teen in that situation, it would probably be magnesium to help insulin and try to relieve sugar cravings.

      You could also try to talk her into a protein breakfast (eggs or meat in the morning), which can help to prevent sugar cravings later in the day.

  11. I too would really appreciate help with this! 6 days of sharp one-sided pain (alternating each month) and bloating in the lead up to ovulation. I refuse to go on the pill which is the only advice I have been given. Thank you for all your help on this topic.

  12. Odd I cannot reply on the site so will try this.

    For me a must is Spironolactone and unfortunately natural progesterone made my hair fall out and gave me horrible acne. These hormones are just a nightmare. Thanks for your information, I appreciate your site 🙂
    thanks for commenting.
    I’ve never heard of natural progesterone causing hair loss. Just a quick question about the timing of the hair loss because there is always a 2-4 month delay after the initiating event. Had anything else happened with your health 4 months previously? ie coming off birth control? or heavy bleeding causing iron deficiency?
    From what I was told progesterone can take the path to create androgens but it’s rare, I just happened to be that person. Nothing happened 2-4 months prior but I will say that I started taking the 20-40 mg (can’t recall now) that was recommended then increased the dose substantially after getting a different opinion so do you think it was the amount I took?
    I know how beneficial progesterone is but now I’m just scared to try it again. It also affected my emotions making me extremely moody.

  13. Hi Lara! Thanks for another excellent article. I have PCOS and my only high androgen is androstenedione. I have tried and am currently doing all of the androgen lowering techniques in your book and blogs, however my androstenedione just doesn’t seem to respond. Is there a different way you would go about lowering it?

  14. You do know that the liver converts excess Estrogen into Testosterone right? lol so this isnt entirely accurate. bu I get what you’re trying to say 🙂

    • Thanks for commenting.
      It’s actually the other way around. Most cells in the body can convert testosterone to estrogen with the enzyme aromatase.
      But, high or excess testosterone is still a thing.

  15. For me a must is a Spironolactone and unfortunately natural progesterone made my hair fall out and gave me horrible acne. These hormones are just a nightmare. Thanks for your information, I appreciate your site 🙂

    • thanks for commenting.
      I’ve never heard of natural progesterone causing hair loss. Just a quick question about the timing of the hair loss because there is always a 2-4 month delay after the initiating event. Had anything else happened with your health 4 months previously? ie coming off birth control? or heavy bleeding causing iron deficiency?

  16. Testosterone was tested by blood. When I use it I actually have a libido. Without it I’d really rather do laundry or dishes. I have not been tested for IR and do not know how to convince my dr to order the test. I don’t know if insurance will cover it, that is usually the biggest hang up with the dr.

  17. My testosterone is low and I’m estrogen dominant. I’m on Prometrium and compounded testosterone cream. I’ve gained back the 5 pounds I lost earlier in the year. I have not had labs done recently. Any other signs of insulin resistance to convince my dr to test for that? I’m pretty sure I have blood sugar issues, maybe reactive hypoglycemia. I’m also hypothyroid but have not lost weight despite free T3 being optimal. I’m still cycling regularly and have signs of ovulation but not sure how to know if I’m actually ovulating.

    • Have you been tested for insulin resistance?
      Also, how was your testosterone tested? I don’t love the idea of women taking testosterone.

  18. Yes, I’ve read Period repair manual. Which actually helped me to ask my doctor about testing certain hormones. But they are all fine, apparently. Only testosterone is at the upper limit of the referance range, others including LH/FSH, prolactin, SHBG etc. are completely normal. Ugh, I wish I would find a way to get that insulin tested.

  19. Hi Dr. Briden,

    I am 29 years old and this summer was diagnosed with premature ovarian insufficiency. This diagnosis was given by my obgyn after missing periods for four months at the time, spotting, receiving an ultrasound that showed slightly large ovaries and multiple cysts (some up to 3cm) on each ovary, and a hormone panel that showed FSH at 82, testosterone at 38 ng/dl, AMH at .534, LH at 44.3, estradiol at 28, and TSH at 1.15. I never took birth control. I am seeing an RE soon and am really worried. I have been receiving acupuncture and herbs, but recently discovered my acupuncturist who initially gave me hope that I could correct this, though at a natural fertility clinic, is completely inexperienced and and now I’m losing hope. What are the main things you suggest I do? I do not want to be in menopause at such a young age and am willing to do anything. I have a hard time finding any resources or even message boards with people with a similar experience, unless it’s an article about how terrible it is. Last fall, my fsh was 13, so it increased a lot under a year. I lost 35 lbs last year and eat a pretty healthy and am vegetarian, but not restrictive.

    Do you have any advice? I feel very lost.


  20. I am three years post partial hysterectomy and dealing with all this. Cystic acne and hair loss are my top two symptoms, also chin hair and lower belly fat. I exercise daily and not over weight. Derm put me on spironolactone. I do a low carb diet 50-100 carbs daily and fasting insulin is in the 90s. Not sure to go from here. Help please😔

    • were you told PCOS? because you probably want to look at the treatments that I discuss for insulin-resistant PCOS both in Chapter 7 of period repair manual and in the blog post The 4 types of PCOS. If you’re younger than 45 (and still have your ovaries) you should be able to ovulate and make progesterone. Although, spironolactone does suppress ovulation, depending on the dose.

  21. Thank you for another useful post Dr. Lara.
    Would it be possible to do a post on causes and treatments for ovulation bloating and pain?
    Not sure if there are any ladies out there struggling with the same issue, but recently I’ve been experiencing heavy bloating and severe pain during ovulation. It would be wonderful to read more about it and how to address it 🙂
    Thank you Dr. Lara!

    • Oh I would love this too. I have terrible bloating and pain the entire second half of my cycle. My doctor says the only thing I can do to fix it is go on hormonal birth control, but I feel like that’s a terrible idea.

  22. Have you encountered patients who where relatively slim with low triglycerides and still had insulin resistance? No doctor is willing to test me for insulin resistance because of that. But I do have some acne on the forehead, irregular cycles and I gain fat predominantly around the middle.

    • low triglycerides does suggest that it’s probably not insulin resistance.
      Are you in a country where you can self-order an insulin test?

      • Unfortunately no, I can’t self-order an insulin test in my country.
        Interestingly, my sister has perfect 29-day-cycles and the only difference in our lifestyle is that I have often eaten too many sweets as a teenager, which she’s never done. She also doesn’t have any acne. That’s the reason why I was confident it has to be insulin resistance, but then on the other hand, there’s the low triglycerides. So confusing.
        So, would you say low triglycerides rule this condition out or is there still a chance it could be insulin resistance?

  23. What about weight gain that is less in the middle/tummy and far more significantly in the thighs and calves…can that still indicate androgen dominance?


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