been a pharmacy tech 20 years and somehow still got missed. no weight gain, labs mostly normal, no insulin resistance jumping out at you. my cycle just started getting weird - random gaps, barely any LH surge - and everyone was like you’re fine, just getting older.
turns out it was elevated androgens, anovulation, the lean version nobody warned me about. docs kept passing me by bc i don’t look like what PCOS should look like. finally found an endocrinologist who actually checked androgens instead of just eyeballing my weight.
lean PCOS is its own tracking nightmare. anyone else diagnosed late bc you didn’t have the obvious signs?
“no insulin resistance jumping out at you” is the entire story, because docs are usually looking for high glucose, not high insulin. my a1c was 6.1 but my fasting insulin was 14, and that’s the number that was quietly running in the background for who knows how long. that hyperinsulinemia is what suppresses SHBG production by the liver.
when SHBG is low, even a total testosterone that’s technically in range can mean your free testosterone is high. the androgens aren’t a separate problem, they’re downstream of the metabolic dysregulation. it’s a classic mechanism for lean PCOS that gets missed when the screening is just a BMI check.
if they start you on metformin or something similar now, that’s its own variable to track. it means any labs you pull a year from now won’t be a clean read on any other intervention, because the metformin was already remodeling the system the whole time. it just stacks another confound on top.