PCOS and the Gut Microbiome: A New Frontier in African Women’s Health

Abstract

Purpose

This study examines the emerging role of the gut microbiome in polycystic ovary syndrome (PCOS) and explores novel microbiome-targeted treatments for PCOS, with a focus on African populations. PCOS is a common endocrine-metabolic disorder in women of reproductive age (global prevalence ~5–20%)[1][2]. However, data from Africa are scarce. We review current evidence linking gut dysbiosis to PCOS pathophysiology and consider interventions (diet, probiotics, fecal transplants, etc.) that could be practical in Africa.

Findings

PCOS patients often exhibit gut microbial dysbiosis: reduced diversity and altered taxa (e.g. increased Escherichia/Shigella, Bacteroides vulgatus, decreased Lactobacillus, Akkermansia, Ruminococcus)[3][4]. These changes can contribute to inflammation, insulin resistance, and hyperandrogenism[5][2]. Interventions like high-fiber/low-glycemic diets, traditional African fermented foods, and probiotic/synbiotic supplements have shown promise in improving metabolic and hormonal parameters in PCOS[6][7][8]. Fecal microbiota transplantation (FMT) is a potent but still experimental option[8]. For example, meta-analyses indicate that probiotic and synbiotic therapy can significantly lower insulin resistance and fasting glucose in PCOS patients[9].

Research Limitations/Implications

Most studies are cross-sectional and conducted outside Africa. Data on African women with PCOS and their gut microbiomes are lacking, and evidence is often of low certainty[10][11]. Causality remains unproven; confounders like diet, BMI, and genetics may influence findings. More large-scale, well-controlled trials (especially in Africa) are needed to validate microbiome-based therapies and to understand how local diets and genetics affect outcomes.

Practical Implications

Microbiome-modulating strategies (nutritional interventions, probiotics, etc.) are low-cost and culturally adaptable. In African contexts, leveraging high-fiber staples and indigenous fermented foods (e.g. injera, ogi) can enrich gut probiotics/prebiotics[12]. Healthcare practitioners should incorporate gut-friendly dietary counseling into PCOS management. Public health programs can promote awareness of PCOS and gut health, integrating them into women’s reproductive care.

Social Implications

Improved PCOS management can enhance women’s reproductive and metabolic health, reducing infertility and diabetes burdens. Addressing PCOS through diet and lifestyle may be more acceptable and sustainable than long-term medications, aligning with resource constraints in African healthcare. Education campaigns can reduce stigma and empower women with PCOS. Involving local communities in fermenting nutritious foods and promoting probiotics can also stimulate economic and social development.

Originality/Value

This article synthesizes the latest global research on PCOS and gut microbiota while emphasizing African-specific contexts. It highlights under-recognized opportunities for microbiome-targeted treatments in Africa and calls for regionally relevant research. To our knowledge, this is among the first comprehensive overviews linking PCOS, gut health, and new treatments with an African perspective.

Keywords: Polycystic ovary syndrome (PCOS); gut microbiome; dysbiosis; probiotics; insulin resistance; African diet

Article Type: Original Research

Introduction

Polycystic ovary syndrome (PCOS) is a heterogeneous endocrine disorder affecting women of reproductive age. It is diagnosed by the Rotterdam criteria (requiring two of three features: oligo-anovulation, clinical or biochemical hyperandrogenism [HA], and polycystic ovarian morphology [PCOM])[2]. PCOS manifests with infertility, menstrual irregularity, hirsutism/acne, insulin resistance, dyslipidemia, and obesity[1][2]. Globally, PCOS prevalence is estimated at 5–20% of women of reproductive age[1]. Affected women carry long-term risks of type 2 diabetes, cardiovascular disease, and psychological disorders[1][2]. These burdens are also present in African populations, although precise epidemiology is under-studied. For example, a community study in Nigeria found at least 8.6% prevalence of PCOS among reproductive-aged women[13]. Clinic-based African reports suggest even higher rates (16–32% in some cohorts)[14], likely reflecting referral bias or diagnostic criteria differences. However, many African regions lack systematic PCOS surveys[15]. This gap in knowledge hampers effective screening and management of PCOS in Africa[15].

Standard PCOS treatments (lifestyle modification, metformin, hormonal therapy) target metabolic and reproductive symptoms but often offer only symptomatic relief. New insights suggest that gut microbiota – the trillions of microbes in the intestine – may play a role in PCOS pathogenesis[5][3]. The gut microbiome influences host metabolism via fermentation metabolites (short-chain fatty acids, SCFAs, like acetate and butyrate), immune modulation, and endocrine signaling[16][17]. Dysbiosis (imbalanced gut flora) can increase gut permeability, allowing bacterial components (e.g. lipopolysaccharide) to enter circulation, triggering chronic inflammation and insulin resistance[5]. These changes promote hyperinsulinemia and androgen excess, key features of PCOS. Emerging research in animal models and humans shows that PCOS is often accompanied by reduced gut microbial diversity and characteristic shifts in specific bacterial taxa[5][3]. This review explores how such gut–ovary interactions might be harnessed to develop new PCOS treatments, particularly suitable for African settings.

Prevalence and Challenges of PCOS in Africa

Epidemiological data from Africa are limited, but existing studies indicate PCOS is a significant yet under-recognized problem. In Africa’s high-fertility context, PCOS contributes to infertility and metabolic disease burdens. In Nigeria, an unselected community sample yielded 8.6% PCOS prevalence[13], similar to global rates. Among infertility clinic patients in sub-Saharan Africa, PCOS often accounts for ~17–30% of cases[14]. Phenotypic presentations may also differ: for example, Sudanese studies found phenotype D (ovulatory PCOM without hyperandrogenism) was most common[18]. Limited awareness and lack of specialized care mean many cases go undiagnosed, perpetuating reproductive health inequities. Traditional African diets (often high in fiber and fermented foods) and genetic diversity may influence PCOS expression and microbiome composition[12][19], but this remains unexplored. Thus, understanding PCOS in African women requires research that accounts for unique environmental, dietary, and socioeconomic factors[19][11].

Gut Microbiome and PCOS: Mechanisms

The gut microbiota is now recognized as a metabolic regulator. Dietary nutrients (fibers, polyphenols) are fermented by gut bacteria into bioactive metabolites (SCFAs, bile acids, tryptophan derivatives) that influence host physiology[20][5]. SCFAs like butyrate strengthen the intestinal barrier and improve insulin sensitivity, whereas imbalances can promote inflammation. In PCOS, gut dysbiosis may exacerbate insulin resistance and androgen production via multiple pathways[5][2]. For example, a high-fat/high-glycemic diet can alter gut flora, increasing pro-inflammatory taxa; their cell wall components and toxins stimulate cytokine release, which impairs insulin signaling and stimulates ovarian androgenesis[5]. Indeed, recent data show women with PCOS have elevated fecal acetate and propionate levels, which correlate with obesity and insulin resistance[21][17]. Conversely, beneficial metabolites may be reduced: in PCOS patients, circulating indole-3-propionic acid (a gut-derived anti-inflammatory compound) is often lower[21]. These findings suggest that gut microbiome alterations are not merely bystanders but could help drive the metabolic and endocrine derangements of PCOS.

Animal models support this: mice given PCOS-inducing agents (like letrozole) develop gut dysbiosis characterized by loss of Bacteroides and Firmicutes diversity[22]. In humans, several studies report that PCOS is associated with reduced microbial alpha-diversity and altered beta-diversity compared to healthy controls[3][4]. Common observations include enrichment of pro-inflammatory genera (Escherichia/Shigella, Alistipes) and reduction of anti-inflammatory or metabolic-regulating genera (Lactobacillus, Akkermansia, Roseburia, Ruminococcus)[3][23]. For instance, Zheng et al. found lower overall gut diversity in PCOS women, with Escherichia–Shigella and Alistipes as distinguishing taxa[3]. These microbial shifts are linked to PCOS clinical features: Slack et al. observed in Black women with PCOS that higher abundance of SCFA-producing bacteria (e.g. Ruminococcus, Blautia, Roseburia) correlated with lower fatigue and better metabolic profiles[24]. Another study showed that specific serum lipid metabolites (like lysophosphatidylcholines) were strongly correlated with gut microbiota profiles in PCOS, implying a gut–liver–ovary axis[25][26].

Overall, the evidence indicates that PCOS involves a gut–endocrine axis: dysbiosis contributes to metabolic inflammation and hormonal disruption[5][3]. However, it remains unclear whether microbiome changes cause PCOS features or are a consequence of metabolic status. Nonetheless, these insights open the possibility of manipulating the gut ecosystem to mitigate PCOS.

Potential Microbiome-Targeted Treatments

Given the gut–PCOS link, therapies aimed at restoring a healthy microbiome are being explored. Potential interventions include:

• Dietary and Lifestyle Modification: High-fiber, low-glycemic diets promote beneficial microbes and SCFA production. Low glycemic index/load diets have been associated with improved insulin sensitivity in PCOS[27]. Our center’s data found that women with PCOS on a low-GI diet had altered microbiota and increased beneficial metabolites (higher serum indole-3-propionic acid, lower acetate/propionate) compared to controls[21]. Incorporating traditional African foods may enhance this effect: for example, fermented staples (like sorghum injera or maize ogi) are rich in prebiotics and probiotics[12], potentially supporting eubiosis. Reducing processed sugars and unhealthy fats, and increasing fruits, vegetables, and legumes, can be universally recommended.
• Probiotics and Synbiotics: Live beneficial microbes can be given as supplements. Meta-analyses of randomized trials indicate that probiotics (alone or with prebiotics) can modestly improve PCOS-related parameters[9]. Talebi et al. (2023) found that probiotic supplementation significantly lowered HOMA-IR and fasting glucose in PCOS patients[9]. Synbiotics (combination of probiotics and prebiotics) showed benefits on glycemic control and lipid profiles, though evidence quality is still low[9][10]. Specific strains like Lactobacillus and Bifidobacterium have been shown to reduce intestinal permeability and systemic inflammation, thereby improving insulin signaling and possibly reducing androgen levels[9]. These supplements could be locally produced or standardized for African markets.
• Prebiotics: Non-digestible fibers (e.g. inulin, oligosaccharides) feed beneficial bacteria. Some clinical trials in PCOS have used inulin or resistant starch, showing favorable changes in gut flora and insulin sensitivity. For instance, intake of soluble fiber from fruits/vegetables increased SCFA production and improved metabolic markers. In African settings, promoting naturally high-fiber foods (beans, green vegetables) is a culturally appropriate prebiotic strategy.
• Fecal Microbiota Transplantation (FMT): Transferring stool from a healthy donor to a PCOS patient has been tested in animal models and small human trials. FMT introduces a full spectrum of gut microbes (bacteriome, virome, etc.), potentially offering a rapid reset of gut ecology[8]. Corrie et al. (2021) note that FMT could be the most holistic microbiome therapy for PCOS[8]. In PCOS-like rodent models, FMT (or even donor fecal filtrate) has improved estrous cyclicity and metabolic parameters. However, FMT’s practicality is limited by cost, donor screening, and patient acceptance. Repeated FMT is impractical, so strategies are being developed to sustain benefits (e.g. combining FMT with dietary polyphenols like curcumin[28] or maintenance probiotics). While FMT is not yet standard care, it remains a promising research avenue.
• Traditional Fermented Foods: African diets are rich in natural probiotics (e.g. fermented milk, cereals)[12]. Promoting these foods could deliver beneficial strains (such as Lactobacillus plantarum, L. fermentum) and prebiotic substrates to PCOS patients. For example, daily consumption of fermented porridge might help restore gut balance without requiring expensive supplements[12]. Nutrition education programs can encourage such practices, bridging modern science with culinary traditions.

These interventions are supported by a growing body of evidence. A recent umbrella review concluded that probiotic/synbiotic therapy for PCOS has statistically significant but modest effects on insulin resistance and other metabolic markers[9]. Importantly, no major safety issues have been reported with these approaches. Integrating microbiome-targeted therapies with existing PCOS care (diet/exercise programs, metformin) could yield additive benefits.

Discussion

Harnessing the gut microbiome represents a novel frontier in PCOS management. Our synthesis suggests that even incremental shifts in gut ecology may yield systemic benefits. In Africa, where resource constraints limit expensive therapies, microbiome interventions align well with public health needs. Encouraging diets high in whole grains, beans, fruits, vegetables, and fermented products can simultaneously address undernutrition and metabolic health[12]. Medical guidelines should incorporate gut-health counseling as part of PCOS care. Community health workers and nutritionists can emphasize locally available prebiotic and probiotic foods to manage insulin resistance and reproductive symptoms.

From a social perspective, reducing PCOS complications can improve women’s quality of life and socioeconomic participation. PCOS is often stigmatized due to its fertility impacts. Framing management in terms of diet and gut health may be more culturally acceptable and less medicalized, promoting early lifestyle changes. Moreover, as microbiome research grows, there is an opportunity for Africa to lead with context-specific solutions: for example, characterizing regionally dominant gut microbes and fermented food strains.

However, significant limitations remain. Most microbiome-PCOS studies are small and cross-sectional, limiting causal inference[10][11]. Few include women from sub-Saharan Africa[19]. Diet, obesity, and genetics all influence the microbiome, so studies must control for these factors. Many published meta-analyses rate the evidence quality as low-to-moderate[10]. Additionally, the gut microbiome is only one piece of PCOS etiology; genetics, endocrine disruptors, and socio-environmental factors also play roles. Future research should include randomized controlled trials of microbiome-targeted therapies in diverse populations. Use of standardized protocols (whole-genome shotgun sequencing, metabolomics) will improve reproducibility.

Despite these gaps, the current data are compelling enough to justify innovation. We propose that primary care guidelines in African countries incorporate questions about diet, exercise, and potentially pre/probiotic use when evaluating PCOS. Endocrine and obstetric clinics should collaborate with nutrition programs. Investment in local microbiome research is critical: for example, identifying unique microbial signatures of African women with PCOS could lead to customized probiotics. Policy support for agriculture of high-fiber crops and traditional fermented foods will indirectly promote a healthier microbiome in the population.

Conclusion

PCOS is a global reproductive health challenge with growing prevalence. Traditional treatments, while helpful, do not address underlying metabolic dysfunction. Recent advances reveal that the gut microbiome is intimately connected to PCOS pathogenesis. Dysbiosis – manifested as reduced diversity and shifts in key bacteria – appears to exacerbate insulin resistance and inflammation in PCOS. Encouragingly, microbiome-focused therapies (dietary fiber, fermented foods, probiotics/synbiotics, and potentially FMT) show promise for improving metabolic and reproductive outcomes. For African women, these approaches are appealing because they can leverage indigenous foods and low-cost supplements. Our review underscores the urgent need for Africa-centric PCOS research and guidelines. By integrating gut health into PCOS management, we may achieve better control of the syndrome with strategies that are feasible and culturally acceptable in Africa and worldwide.

References:

• Allali, I., Abotsi, R. E., Tow, L. A., Thabane, L., Zar, H. J., Mulder, N. M., & Nicol, M. P. (2021). Human microbiota research in Africa: a systematic review reveals gaps and priorities for future research. Microbiome, 9(241). https://doi.org/10.1186/s40168-021-01195-7[19][11].
• Corrie, L., Gulati, M., Vishwas, S., Kapoor, B., Singh, S. K., Awasthi, A., & Khursheed, R. (2021). Combination therapy of curcumin and fecal microbiota transplant: Potential treatment of polycystic ovarian syndrome. Medical Hypotheses, 154, 110644. https://doi.org/10.1016/j.mehy.2021.110644[8].
• da Silva, T. R., Marchesan, L. B., Rampelotto, P. H., Longo, L., de Oliveira, T. F., Landberg, R., de Mello, V. D., & Spritzer, P. M. (2024). Gut microbiota and gut-derived metabolites are altered and associated with dietary intake in women with polycystic ovary syndrome. Journal of Ovarian Research, 17, 232. https://doi.org/10.1186/s13048-024-01550-w[21][27].
• Elasam, A. N., Ahmed, M. A., Ahmed, A. B. A., Sharif, M. E., Abusham, A., & Adam, I. (2022). The prevalence and phenotypic manifestations of polycystic ovary syndrome (PCOS) among infertile Sudanese women: a cross-sectional study. BMC Women’s Health, 22, 165. https://doi.org/10.1186/s12905-022-01762-6[1][2].
• Hanna, A., Abbas, H., Yassine, F., AlBush, A., & Bilen, M. (2025). Systematic review of gut microbiota composition, metabolic alterations, and the effects of treatments on PCOS and gut microbiota across human and animal studies. Frontiers in Microbiology, 16, 1549499. https://doi.org/10.3389/fmicb.2025.1549499[4][29].
• Kukaev, E., Kirillova, E., Tokareva, A., Rimskaya, E., Starodubtseva, N., Chernukha, G., Priputnevich, T., Frankevich, V., & Sukhikh, G. (2024). Impact of gut microbiota and SCFAs in the pathogenesis of PCOS and the effect of metformin therapy. Metabolites, 14, 1907. https://doi.org/10.3390/metabo14101907[17].
• Talebi, S., Zeraattalab-Motlagh, S., Jalilpiran, Y., Payandeh, N., Ansari, S., Mohammadi, H., Djafarian, K., Ranjbar, M., Sadeghi, S., Taghizadeh, M., Shab-Bidar, S., & Taghizadeh, M. (2023). The effects of pro-, pre-, and synbiotics supplementation on polycystic ovary syndrome: an umbrella review of meta-analyses of randomized controlled trials. Frontiers in Nutrition, 10, 1178842. https://doi.org/10.3389/fnut.2023.1178842[9][10].
• Slack, J. E., Kosyakova, N., Pelkmans, J. L., Houser, M. C., Dunbar, S. B., Spencer, J. B., Ferranti, E. P., & Narapareddy, S. L. (2025). Association of gut microbiota with fatigue in Black women with polycystic ovary syndrome. Nursing Research, 74(1), 56–63. https://doi.org/10.1097/NNR.0000000000000788[24].
• Zheng, Y., Qin, E., Cheng, S., Yang, H., Liu, R., Xu, T., Liu, Y., Yuan, J., Yu, S., Yang, J., & Liang, F. (2022). Gut microbiome in PCOS associates to serum metabolomics: a cross-sectional study. Scientific Reports, 12, 22184. https://doi.org/10.1038/s41598-022-25041-4[3][30].

---

[1] [2] [15] [18] The prevalence and phenotypic manifestations of polycystic ovary syndrome (PCOS) among infertile Sudanese women: a cross-sectional study | BMC Women’s Health | Full Text

https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-022-01762-6

[3] [22] [23] [25] [26] [30] Gut microbiome in PCOS associates to serum metabolomics: a cross-sectional study | Scientific Reports

https://www.nature.com/articles/s41598-022-25041-4?error=cookies_not_supported&code=f11ad560-b9bd-48f8-a4f6-04a1aeb2d33e

[4] [29] Frontiers | Systematic review of gut microbiota composition, metabolic alterations, and the effects of treatments on PCOS and gut microbiota across human and animal studies

https://www.frontiersin.org/journals/microbiology/articles/10.3389/fmicb.2025.1549499/full

[5] [6] [16] [20] [21] [27] Gut microbiota and gut-derived metabolites are altered and associated with dietary intake in women with polycystic ovary syndrome | Journal of Ovarian Research | Full Text

https://ovarianresearch.biomedcentral.com/articles/10.1186/s13048-024-01550-w

[7] [9] [10] Frontiers | The effects of pro-, pre-, and synbiotics supplementation on polycystic ovary syndrome: an umbrella review of meta-analyses of randomized controlled trials

https://www.frontiersin.org/journals/nutrition/articles/10.3389/fnut.2023.1178842/full

[8] [28] Combination therapy of curcumin and fecal microbiota transplant: Potential treatment of polycystic ovarian syndrome – PubMed

https://pubmed.ncbi.nlm.nih.gov/34332209

[11] [19] Human microbiota research in Africa: a systematic review reveals gaps and priorities for future research | Microbiome | Full Text

https://microbiomejournal.biomedcentral.com/articles/10.1186/s40168-021-01195-7

[12] African fermented foods: overview, emerging benefits, and novel approaches to microbiome profiling | npj Science of Food

https://www.nature.com/articles/s41538-022-00130-w?error=cookies_not_supported&code=35f762c5-c250-4067-b472-590582e070ff

[13]  SAT363 The Prevalence And Phenotype Of Polycystic Ovary Syndrome (PCOS) In A Community-Based Population In Sub-Sahara Africa: The Nigeria-PEP Study – PMC

https://pmc.ncbi.nlm.nih.gov/articles/PMC10554000

[14] Prevalence of Polycystic Ovary Syndrome (PCOS) Among Infertile Women Attending Fertility Clinic at a University Teaching Hospital in Nigeria

https://juniperpublishers.com/jgwh/JGWH.MS.ID.555922.php

[17]  Impact of Gut Microbiota and SCFAs in the Pathogenesis of PCOS and the Effect of Metformin Therapy – PMC

https://pmc.ncbi.nlm.nih.gov/articles/PMC11477200

[24] Association of Gut Microbiota With Fatigue in Black Women With Polycystic Ovary Syndrome – PubMed

https://pubmed.ncbi.nlm.nih.gov/39666468