Complex Case Study: PCOS with Insulin Resistance and Mood Symptoms

PCOS is associated with higher rates of depression, anxiety and disordered eating, including binge eating disorder. These conditions are often missed, and when they are, standard advice to lose weight can worsen them. This case, an illustrative composite, shows how recognising the whole picture changed the order and content of care.

Presentation

A 28 year old nurse with PCOS, diagnosed at 19, has irregular cycles every 2 to 3 months, acne and a BMI of 33. She hopes to become pregnant within 2 years. She has been told repeatedly to lose weight and has tried many diets, losing weight each time and regaining more. She reports low mood for a year, poor sleep on night shifts and feeling “out of control” with food. Her HbA1c is 41 mmol/mol, triglycerides are raised and her ALT is mildly raised. She is not taking any medicines except the occasional antihistamine.

Assessment beyond the metabolic picture

Because of the known associations with PCOS, the practitioner screens for depression, anxiety and eating disorders.

• Depression: PHQ 9 score indicates moderate depression; no thoughts of self harm.
• Anxiety: mild.
• Eating: she describes eating large amounts of food in a short time, 2 to 3 times a week, with a sense of loss of control, eating alone because of embarrassment and feeling disgusted afterwards, without compensatory purging or exercise. These features are consistent with binge eating disorder, subsequently confirmed by a psychologist.
• Dieting history: repeated restrictive diets, each followed by increased binge eating.
• Sleep: night shifts, short and fragmented sleep.

Why weight loss advice was deferred

Binge eating disorder is commonly maintained by a cycle of dietary restriction, hunger and loss of control. Advice to diet can intensify this cycle. Guidelines for PCOS emphasise screening for eating disorders and adapting lifestyle advice accordingly. The first priorities were therefore to treat the binge eating disorder and depression, establish regular eating, and address metabolic risk without restrictive dieting.

The team

Phase one: months 0 to 4

Psychological treatment

Cognitive behavioural therapy for binge eating disorder begins, focusing on regular eating, identifying triggers and reducing restriction.

Regular eating

The nutrition plan, agreed with the psychologist, establishes 3 meals and 2 or 3 planned snacks each day, including on night shifts, with no forbidden foods. Meals are built around protein, fibre and vegetables to support satiety and glucose control, but without calorie targets or weight goals.

Mood

Her doctor discusses treatment options for depression; she chooses to start with therapy and review in 8 weeks. Behavioural activation is part of her therapy.

Sleep and shifts

Strategies for night shifts: anchor sleep periods, blackout blinds, planned meals during shifts, and reduced caffeine late in shifts. She discusses a more regular rota with her manager.

Activity

Enjoyable movement rather than exercise for weight loss: she chooses dance classes with a friend and walks on days off.

Metabolic care

Her doctor discusses metformin for insulin resistance and cycle regulation, which she starts gradually to minimise gastrointestinal effects. Folic acid is started in preparation for pregnancy. Weight is not measured at every visit.

Phase 2: months 4 to 12

By 4 months, binge episodes have fallen from 2 or 3 a week to fewer than one a fortnight, and her PHQ 9 score has improved to the mild range. With her agreement, and with her psychologist’s support, the nutrition plan shifts gently towards health focused changes: reducing sugary drinks on shifts, more legumes and whole grains, and a protein rich breakfast after night shifts. Strength training is added twice a week.

Outcomes at 12 months

She is referred for fertility assessment when she feels ready, with a plan to continue her psychological support through pregnancy planning.

Reasoning notes

• Screening changed everything. Without identifying binge eating disorder, standard weight loss advice would likely have worsened it.
• Sequence matters: treating the eating disorder and depression first created the conditions for sustainable metabolic improvement.
• Weight neutral does not mean health neutral: metabolic markers improved through regular eating, activity, sleep and medication.
• Team coordination ensured that nutrition advice supported, rather than undermined, psychological treatment.
• Language mattered: avoiding weight stigma helped her engage with care after years of feeling judged.

Whole person, right order

PCOS is a metabolic, reproductive and psychological condition. In this case, recognising depression and binge eating disorder, and addressing them first within a coordinated team, allowed metabolic and reproductive health to improve in ways repeated diets never had.