The photograph in the hallway
You're at someone's seventieth birthday party, standing in the hallway with a paper plate, looking at a framed photo of the women in your family. There's your grandmother, your mother, two aunts, and you at the end.
You all have the same build, and you all carry your weight in the same place, the way a family shares a nose.
In the kitchen behind you, the conversation is the usual one. Your uncle's stent, and how lucky it was they caught the blockage in time. Whether your cousin's blood pressure pills are the ones that make you cough. Your grandmother's "sugar." Nobody ever calls it diabetes. It's just her sugar, mentioned like the weather. Someone brings up the aunt who spent two days thinking her heart attack was indigestion. The room goes quiet for a moment, and then the conversation moves on.
And what you're really thinking about is whether you should have worn a different top.
For fifteen years you've treated your stomach as something to fix, hide or apologize for. A problem for the tailor, or for summer, or for before the wedding. Nobody ever told you it might be connected to what the whole kitchen was talking about.
Not a mirror problem
Where your body stores fat tells you much more about your heart and blood vessels than about how you look. You've been treating it as a sign of your self-control, when it's really closer to a test result that nobody ever showed you.
And a test result is something you can act on. Of everything your family was talking about that night, the stent, the pills and the sugar, the main thing behind most of it is also one of the most treatable.
The same illness under different names
In an earlier post I explained why PCOS sends fat to your middle instead of your arms and legs. High insulin raises androgens, which are hormones like testosterone, and androgens move fat toward your organs instead of under your skin. This post is about what that can lead to.
Insulin resistance runs in families. Sisters of women with PCOS who don't have PCOS themselves, with regular periods and nothing to diagnose, still show lower insulin sensitivity than women from other families. It's there in relatives before anything shows up.
So think about that kitchen again. The same underlying problem was probably in most of those people. It just showed up differently in each of them. In your uncle it caused chest pain and ended in a stent. In your grandmother it was called her sugar. In your aunt it looked like two days of indigestion. In you, it has a name: PCOS.
The numbers back this up. A review of studies that included more than a million women found that PCOS was linked to about two and a half times the odds of a heart attack, and about 1.7 times the odds of stroke and of heart disease overall. The same review didn't find a clear link to dying from heart disease, so that part is less certain. The higher rates of heart attacks and strokes are well established.
That's why the 2023 international guideline says every woman with PCOS should have her heart risk assessed regardless of her weight, and should have her blood sugar checked when she's diagnosed and every one to three years after that.
If you're slim, this applies to you too. Among women who aren't overweight, those with PCOS still have more insulin resistance than those without it. The risk isn't tied to your size, and thin women often get missed because everyone, their doctors included, is looking at the scale.
Why your thirties matter
The evidence has limits here. Nobody has given metformin to a group of twenty-five-year-olds with PCOS and followed them to sixty to count heart attacks. That study doesn't exist, and anyone who promises metformin will prevent a stent like your uncle's is claiming more than we know.
We do know this much. In people whose blood sugar was already starting to climb, a major study called the Diabetes Prevention Program found that metformin lowered the risk of developing type 2 diabetes by about 31 percent over three years. An intensive lifestyle program lowered it by about 58 percent. Both groups still had less diabetes more than twenty years later. That study didn't include women with PCOS, and the people in it were older and heavier than most of my readers, so it's strong evidence but not proof for you.
Still, the pieces connect. Insulin resistance drives the risk. It can be treated. And diabetes is one of the main ways people end up with the kind of heart disease that runs in your family.
Treating this in your thirties is an investment in your fifties. The evidence for that is strongest in the middle steps and thinner at either end. But waiting is a choice too, and it's the one where the years go by and nobody checks anything.
The numbers to ask for
Ask for tests, and bring your family history with you. Ask for an HbA1c, a blood test that shows your average blood sugar over about three months, or better, a glucose tolerance test, which the guideline calls the first choice. Add a lipid panel (a cholesterol test) and a blood pressure check. And tell your doctor who in your family has diabetes or has had a heart attack or a stent, and how old they were at the time. That can change how your doctor reads all your other results.
Metformin lowers the sugar your liver releases and helps your body respond to insulin. The international guideline recommends it for the metabolic side of PCOS. It's approved for type 2 diabetes and prescribed off-label for PCOS, which means it's approved for something else but can legally be used for this, and that's routine. It can upset your stomach at first, though the extended-release version is gentler, and your B12 should be checked if you take it for years.
GLP-1 medications improve insulin sensitivity and usually lead to weight loss, with clear benefits for blood sugar and metabolism, though there's still not much research on fertility in PCOS. The downsides include nausea and constipation, insurance battles, muscle loss if you don't get enough protein and strength training, and weight regain for many people who stop. They can't be used during pregnancy and need to be stopped well before you try to conceive.
You could put it to your doctor this way:
Type 2 diabetes and heart disease run on both sides of my family, and I have PCOS. I'd like an HbA1c or a glucose tolerance test, a lipid panel and a blood pressure check now, and I'd like to talk about whether metformin makes sense at my age rather than later.
Knowing your own risk
Start with your primary care doctor, your OB-GYN or an endocrinologist (a hormone specialist). Write down your family history before you go, and ask for copies of your results.
It's worth knowing your own risk instead of counting on the system to catch it. When women have heart attacks, they're 50 percent more likely than men to be given the wrong diagnosis at first, according to a study of more than half a million patients. People who got the wrong first diagnosis had a 70 percent higher risk of dying within thirty days. Your aunt's two days of "indigestion" weren't unusual. If an appointment about any of this goes badly, that says more about the doctor than about your risk.
For care focused on PCOS, Allara Health is an online practice for PCOS and women's hormone and metabolic health. It pairs doctors with dietitians and takes many major insurance plans, though it isn't available in every state. Sesame lets you book a specific doctor at a set price without insurance or a referral.
I have no financial relationship with either company. I'm not an affiliate, and I don't get paid if you book. I mention them because telling you to find a doctor who understands PCOS isn't much help without somewhere to start.
PCOS can't be cured, and no medication erases your family history. But inheriting a risk doesn't mean inheriting the outcome, and the part that does the damage is the part that responds to treatment. The women in that photo never had this conversation at your age. You get to have it now, while it can still make the biggest difference.
This is my experience and my reading of the research, not medical advice. Nothing here should replace a conversation with a clinician who knows your history.
Sources
- 2023 International Evidence-Based PCOS Guideline Update: meta-analysis on elevated clinical cardiovascular disease in PCOS — Journal of the American Heart Association, 2024
- Altered glucose disposition and insulin sensitivity in peri-pubertal first-degree relatives of women with PCOS — International Journal of Pediatric Endocrinology, 2012
- Adolescent "lean PCOS" is characterized by higher insulin resistance and adverse adipokine profile — Journal of Clinical Endocrinology & Metabolism, 2025
- Diabetes Prevention Program Outcomes Study: persistent reduction of type 2 diabetes over 22-year average follow-up — American Diabetes Association, 2025
- Women are 50 per cent more likely than men to be given an incorrect diagnosis following a heart attack — British Heart Foundation / University of Leeds, 2016
- Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of PCOS — Teede et al., Journal of Clinical Endocrinology and Metabolism, 2023