Sarah Rice BSc.(Hons) MCOptom (UK), MHP, NNP

In general, women are under-represented in medical research, so this month it was encouraging to see several studies aimed at exploring women’s reproductive health with a focus on metabolic interventions.

Overweight and obesity are associated with hormonal imbalances, menstrual symptoms, and other disorders like abnormal uterine bleeding and polycystic ovary syndrome (1). Insulin resistance and inflammation, which may be associated with overweight or obesity, appear to be key contributors to gynaecological disorders through hormonal disruptions and the effect on the uterus as an end organ (1).

Menopause is a significant metabolic disrupter due to the effects of hormone decline. Other sex-specific endocrine disorders associated with insulin resistance include irregular menses, amenorrhoea, and fertility problems (2). Therapeutic carbohydrate restriction (TCR) and other interventions like intermittent fasting (IF) can modulate hormone profiles and reduce insulin resistance, thereby supporting women’s health.

Abnormal uterine bleeding

Abnormal uterine bleeding (AUB) affects around 30% of women of reproductive age and is trending upwards (1). The causes of AUB may be structural or non-structural and are commonly associated with metabolic disorders like obesity, diabetes, and hypertension.

A recent study from Salcedo et al. (2025) underscores the association between hyperinsulinaemia and common causes of AUB, and AUB may precede polycystic ovary syndrome, another condition known to associate with insulin resistance (1). 

In a study from 2024, Kackley et al. found that a ketogenic diet administered to women of reproductive age positively modulated menses (independent of weight loss) as well as improved body composition and insulin sensitivity. Both the low-fat and ketogenic diets were able to improve insulin sensitivity (both diets were hypocaloric and isocaloric), but only the ketogenic diet produced favourable changes in menses. This finding points to a unique benefit of carbohydrate restriction in this setting (2).

Polycystic ovary syndrome (PCOS)

Recent systematic reviews continue to show the benefits of therapeutic carbohydrate restriction for PCOS, the most common endocrine disorder found in women of childbearing age (3, 4) The wide range of sex and metabolic hormonal imbalances contribute to menstrual abnormalities, infertility, and other metabolic effects like insulin resistance, obesity, and risk of developing gestational diabetes. 

Łagowska et al. (2025) indicate improvements in body weight, waist circumference, fasting plasma glucose, insulin, luteinizing hormone, and sex hormone-binding globulin may occur with the administration of a ketogenic diet (4).

Testosterone levels have also been found to decrease when compared to baseline values (3). In addition, a recent study found a ketone supplementation to acutely lower androgen and glucose levels in women with PCOS, opening up another avenue for further research (5). These studies add to the significant evidence base showing benefits of TCR for PCOS.

Endometriosis

Endometriosis is a condition with a complex pathophysiology associated with oestrogen signalling, inflammation, oxidative stress, and angiogenesis. In this chronic condition, tissue that is functionally similar to that of the uterus lining develops outside of the uterine space, bleeding and shedding during the menstrual cycle leading to painful symptoms. 

A recent study from Naeini et al. proposed that a ketogenic diet may be able to ameliorate endometriosis and related symptoms by inhibiting pathways contributing to this condition including reducing inflammation and oxidative stress, suppressing angiogenesis and cell division, and upregulating apoptosis (6). They used an MCT-modified ketogenic diet (3:1) as an adjunct therapy and found improved pelvic pain scores and significant improvements in dyspareunia and dyschezia (pain during sexual intercourse and bowel movements) when compared to the control group (6). 

Menopause

Menopause is a life stage associated with metabolic dysregulation associated with declining hormone levels. In particular, oestrogen is an insulin-sensitising hormone that also modulates lipoprotein lipase (LPL), which collectively contribute to increased central adiposity, a common feature of menopause.

Up to 75% of women may be affected by vasomotor symptoms (hot flushes) during menopause and menopause transition, which appears associated with insulin resistance (7).

This cluster of metabolic changes typically increases the risk of cardiovascular disease and other conditions associated with metabolic dysregulation, like autoimmune and inflammatory diseases (7, 8). 

Two recent studies have considered the role of intermittent fasting (IF) during menopause to improve metabolic status. Garg et al. take a broad perspective on the possible benefits of IF, while Ranjbar et al. (2025) conducted a randomised controlled trial looking at IF for postmenopausal women with overweight or obesity and rheumatoid arthritis (8). This study used a 16/8 h daily IF for 8 weeks, and participants experienced significant effects on weight, disease activity, and quality of life (8). 
While specific studies on menopause and therapeutic carbohydrate restriction are underexplored in terms of research, existing studies show promise and have demonstrated benefits in women with cardiometabolic risk and hypertension (10), sleep apnoea (11), and weight loss and improved mood (12). A range of  studies have looked at TCR in women across all ages with beneficial effects on body mass, hormone profiles, and metabolic markers (13).

Lipoedema

Finally, hormonal changes such as puberty, pregnancy, and menopause can trigger lipoedema, a condition primarily affecting women. This condition is often misunderstood and misdiagnosed as obesity or lymphoedema and may occur across a range of body weights. Recent studies have shown a ketogenic diet may benefit this condition (you can read about lipoedema in a previous focus article) (14). A study last month from Sanlier et al. has reviewed the emerging evidence on this topic, outlining the various mechanisms and how ketogenic diets may be beneficial (15).

Conclusion

Overall, there is good evidence that TCR effectively improves insulin resistance in women, and this may include improvements in various pathways related to that metabolic state. More specific studies targeting women’s health issues are needed to strengthen the evidence base and tailor recommendations accordingly.

Resources

The Nutrition Network reference resource includes a subsection on reproductive health, and there is a training program focused on women’s health where experts teach on the specific applications of TCR for women.

References

1. Salcedo, A.C. et al. (2025) ‘The uterus is an end organ: a preliminary study of the association between abnormal uterine bleeding and hyperinsulinemia’, Menopause [Preprint]. Available at: https://doi.org/10.1097/GME.0000000000002548.
2. Kackley, M.L. et al. (2024) ‘Self-reported menses physiology is positively modulated by a well-formulated, energy-controlled ketogenic diet vs. low fat diet in women of reproductive age with overweight/obesity’, PLOS ONE. Edited by L. Yanes Cardozo, 19(8), p. e0293670. Available at: https://doi.org/10.1371/journal.pone.0293670.
3. Cannarella, R. et al. (2025) ‘Effects of ketogenic diets on polycystic ovary syndrome: a systematic review and meta-analysis’, Reproductive Biology and Endocrinology, 23(1), p. 74. Available at: https://doi.org/10.1186/s12958-025-01411-1.
4. Łagowska, K. et al. (2025) ‘Effects of a ketogenic diet on the anthropometric, metabolic, and hormonal parameters in women with polycystic ovary syndrome: A systematic review of randomised controlled trials’, Acta Scientiarum Polonorum Technologia Alimentaria, 24(3). Available at: https://doi.org/10.17306/J.AFS.001327.
5. Rittig, N. et al. (2025) ‘Ketone supplementation acutely lowers androgen and glucose levels in women with polycystic ovary syndrome (PCOS): A randomised clinical trial’, European Journal of Endocrinology, p. lvaf106. Available at: https://doi.org/10.1093/ejendo/lvaf106.
6. Naeini, F. et al. (2025) ‘MCT-modified ketogenic diet as an adjunct to standard treatment regimen could alleviate clinical symptoms in women with endometriosis’, BMC Women’s Health, 25, p. 232. Available at: https://doi.org/10.1186/s12905-025-03798-w.
7. Min, S.H. et al. (2022) ‘Are there differences in symptoms experienced by midlife climacteric women with and without metabolic syndrome? A scoping review’, Women’s Health, 18, p. 17455057221083817. Available at: https://doi.org/10.1177/17455057221083817.
8. Ranjbar, M. et al. (2025) ‘Effects of intermittent fasting diet in overweight and obese postmenopausal women with rheumatoid arthritis: A randomized controlled clinical trial’, Complementary Therapies in Medicine, 91, p. 103189. Available at: https://doi.org/10.1016/j.ctim.2025.103189
9. Garg, R. et al. (2025) ‘Intermittent Fasting and Weight Management at Menopause’, Journal of Mid-life Health, 16(1), pp. 14–18. Available at: https://doi.org/10.4103/jmh.jmh_227_24.
10. Pala, B. et al. (2024) ‘Very low-calorie ketogenic diet reduces central blood pressure and cardiometabolic risk in post-menopausal women with essential hypertension and obesity: a single-center, prospective, open-label, clinical study’, Nutrition, metabolism, and cardiovascular diseases: NMCD, p. 103838. Available at: https://doi.org/10.1016/j.numecd.2024.103838.
11. Franklin, K.A. et al. (2022) ‘Effects of a palaeolithic diet on obstructive sleep apnoea occurring in females who are overweight after menopause—a randomised controlled trial’, International Journal of Obesity, pp. 1–7. Available at: https://doi.org/10.1038/s41366-022-01182-4.
12. McPhee, J.C., Zinn, C. and Smith, M. (2018) ‘Exploring the acceptability of, and adherence to a carbohydrate-restricted diet as self-reported by women aged 40-55 years’. Available at: https://hdl.handle.net/2292/48085 (Accessed: 11 June 2025)
13. ‘Metabolic Disorders’ (2025) Nutrition Network. Available at: https://nutrition-network.org/research/metabolic-disorders/ (Accessed: 11 June 2025).
14. Network, N. (2024) ‘Lipoedema and therapeutic carbohydrate restriction’, Nutrition Network, 19 December. Available at: https://nutrition-network.org/lipoedema-and-therapeutic-carbohydrate-restriction/ (Accessed: 11 June 2025).

Sanlier, N. and Baltacı, S. (2025) ‘Therapeutic Applications of Ketogenic Diets in Lipedema: A Narrative Review of Current Evidence’, Current Obesity Reports, 14(1), p. 49. Available at: https://doi.org/10.1007/s13679-025-00642-y.