Perimenopause, Menopause & PCOS in Midlife Women

Understanding the intersection of perimenopause, menopause, and polycystic ovary syndrome (PCOS) is vital, particularly as you transition through midlife. These are not isolated conditions but interconnected states that influence your metabolism, mood, cardiovascular risk, and long-term vitality.

Many women are never told how PCOS evolves with age—or how it might still be impacting them well into their 40s, 50s, and beyond. Here’s what you need to know.

What Is PCOS?

Polycystic Ovary Syndrome (PCOS) is a complex, multisystem hormonal condition that affects 1 in 10 women—and that’s likely an underestimate due to underdiagnosis. While often framed as a reproductive disorder, PCOS is far more than irregular periods or infertility. It is fundamentally a metabolic-endocrine disorder with lifelong implications.

Core Features of PCOS (According to the Rotterdam Criteria)

To be diagnosed, women must meet two of the following three criteria:

Oligo- or anovulation (irregular or absent ovulation)
Hyperandrogenism (clinical signs like acne, hirsutism, or elevated androgens [testosterone and DHEA-S] on labs)
Polycystic-appearing ovaries on ultrasound (increased number of follicles or enlarged ovaries)

Note: You don’t need to have ovarian cysts to have PCOS. And having cysts alone does not mean you have PCOS.

How PCOS Affects Women Throughout the Lifespan

In the Teens and 20s:

Often diagnosed with irregular cycles, acne, weight struggles, or excess hair growth.
May experience difficulty with weight management despite healthy eating and activity.
Frequently misunderstood as “just hormonal” or “part of puberty.”
May have trouble with conception due to inconsistent ovulation.

In the 30s and 40s:

Fertility challenges may persist—but many women with PCOS do conceive naturally with age and ovulatory maturity.
Metabolic risks increase: insulin resistance, prediabetes, gestational diabetes, and dyslipidemia.
Increased risk of mood disorders, especially anxiety and depression.

In Perimenopause and Menopause:

Here’s where the plot thickens—and where most conversations stop short.

PCOS in Perimenopause and Menopause: What Changes, What Doesn’t

As you approach menopause, your ovarian function naturally declines, and ovulation becomes less consistent for all women—but women with PCOS already have an ovulatory dysfunction baseline, making this transition more complex.

1. Ovulatory Dysfunction & Menstrual Irregularity

In perimenopause, all women have irregular cycles—but for women with PCOS, this can make it harder to recognize when the transition starts.
Because women with PCOS may have a higher follicle count, some enter menopause slightly later than average (though not always).

2. Androgen Levels

In reproductive years, women with PCOS often have elevated testosterone or DHEA-S.
With menopause, ovarian androgen production falls, but adrenal production (DHEA-S) may persist.
This can lead to ongoing symptoms such as:
- Hirsutism
- Scalp hair thinning
- Persistent acne

Important: Persistent hyperandrogenism in postmenopausal women should be evaluated carefully to rule out other causes, such as adrenal tumors or late-onset congenital adrenal hyperplasia.

3. Insulin Resistance and Metabolic Risk

Insulin resistance is a hallmark of PCOS—and it doesn't disappear at menopause.
In fact, with the drop in estrogen that occurs in menopause, insulin sensitivity often worsens, increasing risk for:
- Type 2 diabetes
- Nonalcoholic fatty liver disease (NAFLD)
- Cardiovascular disease (CVD)
- Obstructive Sleep Apnea
- Dyslipidemia (abnormal cholesterol levels)
- Alzheimer’s and cognitive decline (emerging research)

Women with PCOS enter menopause with pre-existing metabolic vulnerabilities, making proactive screening and lifestyle interventions critical.

4. Body Composition

PCOS is associated with higher visceral fat even in normal-weight women.
After menopause, estrogen withdrawal accelerates fat redistribution to the abdomen, compounding the risk for metabolic syndrome.
Resistance training and protein optimization become even more important.

5. Mental Health

Women with PCOS experience higher lifetime rates of anxiety and depression.
Hormonal fluctuations in perimenopause can exacerbate these symptoms.
And yet, women are often told these symptoms are “normal for your age” or offered a blanket SSRI without looking at root causes like inflammation, cortisol, or insulin resistance.

What You Can Do: Proactive Strategies for PCOS in Midlife

1. Know Your Labs—and Monitor Regularly

Ask your provider to test:

Fasting insulin and glucose
HbA1c (glycemic control)
Lipid panel and lipoprotein(a)
Free and total testosterone, DHEA-S
hs-CRP (inflammation)
Thyroid panel (TSH, free T4, T3, and antibodies)
Consider liver function tests and ultrasound if NAFLD is a concern

2. Optimize Nutrition for Insulin Sensitivity

Prioritize protein (30g/meal), healthy fats, and complex carbs with fiber
Reduce added sugars and ultra-processed carbs
Consider myo-inositol or D-chiro inositol to improve insulin sensitivity and reduce androgens
Support gut health with fermented foods and prebiotic fiber

3. Move with Purpose

Resistance training 2–3x/week to preserve muscle and insulin sensitivity
Zone 2 cardio (e.g., brisk walking, cycling, swimming) to support metabolic flexibility
Stretching and yoga for nervous system regulation

4. Explore Evidence-Based Treatment Options

Metformin or GLP-1 RA medications may be helpful for insulin resistance in PCOS
Menopausal hormone therapy (MHT) is not contraindicated in PCOS and may offer cardiometabolic and bone benefits when appropriately prescribed
Anti-androgens like spironolactone can be helpful in persistent hirsutism or acne (if blood pressure and labs allow)
Supplements like omega-3s, berberine, and magnesium may support insulin regulation and inflammation—but always use high-quality, vetted sources

Bottom Line: PCOS Doesn’t End at Menopause

Too many women are told their PCOS “burns out” after menopause. While ovulation may stop, the underlying metabolic and hormonal imbalances often persist—and can even worsen without estrogen’s protective effects.

Whether you’ve lived with PCOS for decades or were recently diagnosed, perimenopause and menopause are critical windows to reevaluate, intervene, and optimize your health for the decades ahead.

Let’s Redefine What Midlife Health Looks Like.

You're not broken. You're shifting. And with the right information, tools, and support, you can thrive in this next chapter—with clarity, energy, and confidence.

Midlife PCOS: What should I know?