Ketogenic versus Mediterranean Diet in the Management of PCOS: A Comparative Review on Endocrine Profiles, Lipid Remodeling, and Athletic Considerations
DOI:
https://doi.org/10.12775/QS.2026.66.73842Keywords
Polycystic ovary syndrome, ketogenic diet, Mediterranean diet, hyperandrogenism, sports performanceAbstract
Introduction. Polycystic ovary syndrome (PCOS) places unprecedented demands on the metabolic-endocrine system. Targeted dietary interventions and habitual modifications have proven highly effective in supporting reproductive reserve, thereby protecting the local ovarian microenvironment and boosting insulin sensitivity. Nevertheless, serious concerns stand regarding common therapeutic dilemmas and the risk of compromising skeletal muscle mass retention and high-intensity glycolytic exercise capacity. Research objective. This literature review summarizes current knowledge on the pathophysiology, distinct kinetics, modulation of endocrine profiles, lipid remodeling, athletic considerations, and long-term compliance of the ketogenic diet (KD) versus the Mediterranean diet (MED) in patients with PCOS, with a focus on sequential clinical integration. Methodology. The review is based on a structured search of peer-reviewed literature through May 2026. Keywords included: “polycystic ovary syndrome”, “ketogenic diet”, “Mediterranean diet”, “hyperandrogenism”, “insulin resistance”, and “sports performance”. Priority was given to clinical trials, randomized controlled trials, systematic reviews, and international consensus documents regarding the nutritional management of endocrine disorders. Articles were analyzed for their relevance to describing acute biochemical cutoff mechanisms versus gradual receptor optimization cascades. Conclusions. Immediate carbohydrate restriction and targeted anti-inflammatory macronutrient models constitute significant progress in the care of patients with PCOS, helping to preserve ovulatory function and cardiometabolic health; however, their implementation requires careful monitoring of body composition parameters and avoidance of physical performance impairment. The use of a sequential therapeutic protocol is necessary to optimize endocrine balance, preserve lean tissue, and ensure sustainable, long-term lifestyle adherence.References
1. Gautam, Rohit, et al. "The Role of Lifestyle Interventions in PCOS Management: A Systematic Review." Nutrients, vol. 17, 2025.https://doi.org/10.3390/nu17020310.
2. Zhao, Han, et al. "Insulin resistance in polycystic ovary syndrome across various tissues: an updated review of pathogenesis, evaluation, and treatment." Journal of Ovarian Research, vol. 16, 2023.https://doi.org/10.1186/s13048-022-01091-0.
3. Calcaterra, V., et al. "Polycystic Ovary Syndrome in Insulin-Resistant Adolescents with Obesity: The Role of Nutrition Therapy and Food Supplements as a Strategy to Protect Fertility." Nutrients, vol. 13, 2021.https://doi.org/10.3390/nu13061848.
4. Sadeghi, H., et al. "Polycystic Ovary Syndrome: A Comprehensive Review of Pathogenesis, Management, and Drug Repurposing." International Journal of Molecular Sciences, vol. 23, 2022.https://doi.org/10.3390/ijms23020583.
5. Shabbir, Sania, et al. "The interplay between androgens and the immune response in polycystic ovary syndrome." Journal of Translational Medicine, vol. 21, 2023.https://doi.org/10.1186/s12967-023-04116-4.
6. Ni, Muchu, et al. "Adipose-androgen crosstalk in polycystic ovary syndrome: mechanisms and therapeutic implications." Frontiers in Endocrinology, vol. 16, 2025.https://doi.org/10.3389/fendo.2025.1731179.
7. Lonardo, M., et al. "Hypothalamic-Ovarian axis and Adiposity Relationship in Polycystic Ovary Syndrome: Physiopathology and Therapeutic Options for the Management of Metabolic and Inflammatory Aspects." Current Obesity Reports, vol. 13, 2024, pp. 51 - 70.https://doi.org/10.1007/s13679-023-00531-2.
8. Mancini, A., et al. "Oxidative Stress and Low-Grade Inflammation in Polycystic Ovary Syndrome: Controversies and New Insights." International Journal of Molecular Sciences, vol. 22, 2021.https://doi.org/10.3390/ijms22041667.
9. Di Rosa, C., et al. "Mediterranean Diet versus Very Low-Calorie Ketogenic Diet: Effects of Reaching 5% Body Weight Loss on Body Composition in Subjects with Overweight and with Obesity—A Cohort Study." International Journal of Environmental Research and Public Health, vol. 19, 2022.https://doi.org/10.3390/ijerph192013040.
10. Surugiu, Roxana, et al. "Molecular Mechanisms of Healthy Aging: The Role of Caloric Restriction, Intermittent Fasting, Mediterranean Diet, and Ketogenic Diet—A Scoping Review." Nutrients, vol. 16, 2024.https://doi.org/10.3390/nu16172878.
11.Muscogiuri, G., et al. "European Guidelines for Obesity Management in Adults with a Very Low-Calorie Ketogenic Diet: A Systematic Review and Meta-Analysis." Obesity Facts, vol. 14, 2021, pp. 222 - 245.https://doi.org/10.1159/000515381.
12. Malinowska, Dominika, and M. Żendzian-Piotrowska. "Ketogenic Diet: A Review of Composition Diversity, Mechanism of Action and Clinical Application." Journal of Nutrition and Metabolism, vol. 2024, 2024.https://doi.org/10.1155/2024/6666171.
13. Devranis, Paschalis, et al. "Mediterranean Diet, Ketogenic Diet or MIND Diet for Aging Populations with Cognitive Decline: A Systematic Review." Life, vol. 13, 2023.https://doi.org/10.3390/life13010173.
14. Berisha, Hygerta, et al. "Nutrition and Lifestyle Interventions in Managing Dyslipidemia and Cardiometabolic Risk." Nutrients, vol. 17, 2025.https://doi.org/10.3390/nu17050776.
15. Schutz, Y., et al. "Low‐carbohydrate ketogenic diets in body weight control: A recurrent plaguing issue of fad diets?" Obesity Reviews, vol. 22, 2021.https://doi.org/10.1111/obr.13195.
16. Ahmad, Yusra, et al. "Metabolic Effects of Ketogenic Diets: Exploring Whole-Body Metabolism in Connection with Adipose Tissue and Other Metabolic Organs." International Journal of Molecular Sciences, vol. 25, 2024.https://doi.org/10.3390/ijms25137076.
17. Barrea, L., et al. "Ketogenic Diet as Medical Prescription in Women with Polycystic Ovary Syndrome (PCOS)." Current Nutrition Reports, vol. 12, 2023, pp. 56 - 64.https://doi.org/10.1007/s13668-023-00456-1.
18. Di Lorenzo, M., et al. "Pathophysiology and Nutritional Approaches in Polycystic Ovary Syndrome (PCOS): A Comprehensive Review." Current Nutrition Reports, vol. 12, 2023, pp. 527 - 544.https://doi.org/10.1007/s13668-023-00479-8.
19. Cincione, R., et al. "Effects of Mixed Ketogenic Diet in Overweight and Obese Women with Polycystic Ovary Syndrome." International Journal of Environmental Research and Public Health, vol. 18, 2021.https://doi.org/10.3390/ijerph182312490.
20. Paulukinas, Ryan D, et al. "Conversion of Classical and 11-oxygenated Androgens by Insulin-Induced AKR1C3 in a Model of Human PCOS Adipocytes." Endocrinology, 2022.https://doi.org/10.1210/endocr/bqac068.
21. Cincione, I., et al. "Short-time effects of ketogenic diet or modestly hypocaloric Mediterranean diet on overweight and obese women with polycystic ovary syndrome." Journal of Endocrinological Investigation, vol. 46, 2022, pp. 769-777.https://doi.org/10.1007/s40618-022-01943-y.
22. Mei, S., et al. "Mediterranean Diet Combined With a Low-Carbohydrate Dietary Pattern in the Treatment of Overweight Polycystic Ovary Syndrome Patients." Frontiers in Nutrition, vol. 9, 2022.https://doi.org/10.3389/fnut.2022.876620.
23. Barber, T., et al. "The Effects of the Mediterranean Diet on Health and Gut Microbiota." Nutrients, vol. 15, 2023.https://doi.org/10.3390/nu15092150.
24. Dicks, Leon M T. "How important are fatty acids in human health and can they be used in treating diseases?" Gut Microbes, vol. 16, 2024.https://doi.org/10.1080/19490976.2024.2420765.
25. Fleigle, Dayelise, et al. "Polycystic Ovary Syndrome and the Effects of a Ketogenic Diet: A Scoping Review." Nutrients, vol. 17, 2025.https://doi.org/10.3390/nu17172893.
26. Khalid, K., et al. "Effects of Ketogenic Diet on Reproductive Hormones in Women With Polycystic Ovary Syndrome." Journal of the Endocrine Society, vol. 7, 2023.https://doi.org/10.1210/jendso/bvad112.
27. Tsushima, Yumiko, et al. "Ketogenic diet improves fertility in patients with polycystic ovary syndrome: a brief report." Frontiers in Nutrition, vol. 11, 2024.https://doi.org/10.3389/fnut.2024.1395977.
28. Diha, Arpita Misra, et al. "Effects of Ketogenic Diet (KD) on Metabolic, Endocrine, and Reproductive Outcomes in Overweight/Obese Women With Polycystic Ovary Syndrome (PCOS): A Systematic Review." Cureus, 2026.https://doi.org/10.7759/cureus.103615.
29. Rossetti, Rebecca, et al. "A Ketogenic Diet Followed by Gradual Carbohydrate Reintroduction Restores Menstrual Cycles in Women with Polycystic Ovary Syndrome with Oligomenorrhea Independent of Body Weight Loss: Results from a Single-Center, One-Arm, Pilot Study." Metabolites, vol. 14, 2024.https://doi.org/10.3390/metabo14120691.
30. Meneghini, C., et al. "The Impact of Nutritional Therapy in the Management of Overweight/Obese PCOS Patient Candidates for IVF." Nutrients, vol. 15, 2023.https://doi.org/10.3390/nu15204444.
31. Saeed, Aya Muhammed A., et al. "Nutritional and herbal interventions for polycystic ovary syndrome (PCOS): a comprehensive review of dietary approaches, macronutrient impact, and herbal medicine in management." Journal of Health, Population, and Nutrition, vol. 44, 2025.https://doi.org/10.1186/s41043-025-00899-y.
32. Turetta, Camilla, et al. "Impact of Ketogenic Diet on Weight, Metabolic, and Endocrine Parameters in Women with Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis." Gynecologic and Obstetric Investigation, vol. 90, 2025, pp. 515 - 534.https://doi.org/10.1159/000543941.
33. Paoli, A., et al. "Effects of a ketogenic diet in overweight women with polycystic ovary syndrome." Journal of Translational Medicine, vol. 18, 2020.https://doi.org/10.1186/s12967-020-02277-0.
34. Magagnini, Maria Cristina, et al. "Does the Ketogenic Diet Improve the Quality of Ovarian Function in Obese Women?" Nutrients, vol. 14, 2022.https://doi.org/10.3390/nu14194147.
35. Masood, Iqra, et al. "Effect of ketogenic diet and hypocaloric Mediterranean diet on metabolic and endocrine parameters in women suffering from Polycystic Ovary Syndrome." International Journal of Food Properties, vol. 26, 2023, pp. 3187 - 3196.https://doi.org/10.1080/10942912.2023.2275528.
36. Kotusiewicz, Wiktoria, et al. "Impact of various dietary interventions on the reduction of symptoms in polycystic ovary syndrome (PCOS)." Journal of Education, Health and Sport, 2023.https://doi.org/10.12775/jehs.2023.13.04.037.
37. Yang, Wenwen, et al. "Breaking the metabolic–inflammatory vicious cycle in polycystic ovary syndrome: a comparative review of ketogenic and high-fat diets." Lipids in Health and Disease, vol. 24, 2025.https://doi.org/10.1186/s12944-025-02693-5.
38. Kim, Nayeon, and Changwon Yang. "Butyrate as a Potential Modulator in Gynecological Disease Progression." Nutrients, vol. 16, 2024.https://doi.org/10.3390/nu16234196.
39. Koerich, Ana Clara C, et al. "Effects of the ketogenic diet on performance and body composition in athletes and trained adults: a systematic review and Bayesian multivariate multilevel meta-analysis and meta-regression." Critical Reviews in Food Science and Nutrition, vol. 63, 2022, pp. 11399 - 11424.https://doi.org/10.1080/10408398.2022.2090894.
40. Kaufman, Matthew W., et al. "Popular Dietary Trends’ Impact on Athletic Performance: A Critical Analysis Review." Nutrients, vol. 15, 2023.https://doi.org/10.3390/nu15163511.
41. Ashtary-Larky, D., et al. "Ketogenic diets, physical activity and body composition: a review." The British Journal of Nutrition, vol. 127, 2021, pp. 1898 - 1920.https://doi.org/10.1017/s0007114521002609.
42. Leaf, A. et al. "International society of sports nutrition position stand: ketogenic diets." Journal of the International Society of Sports Nutrition, vol. 21, 2024.https://doi.org/10.1080/15502783.2024.2368167.
43. Wachsmuth, N., et al. "The Impact of a High-Carbohydrate/Low Fat vs. Low-Carbohydrate Diet on Performance and Body Composition in Physically Active Adults: A Cross-Over Controlled Trial." Nutrients, vol. 14, 2022.https://doi.org/10.3390/nu14030423.
44. Vargas-Molina, S., et al. "The effect of the ketogenic diet on resistance training load management: a repeated-measures clinical trial in trained participants." Journal of the International Society of Sports Nutrition, vol. 21, 2024.https://doi.org/10.1080/15502783.2024.2306308.
45. Calcaterra, V., et al. "High Fat Diet and Polycystic Ovary Syndrome (PCOS) in Adolescence: An Overview of Nutritional Strategies." Nutrients, vol. 16, 2024.https://doi.org/10.3390/nu16070938.
46. Ashtary-Larky, D., et al. "Effects of resistance training combined with a ketogenic diet on body composition: a systematic review and meta-analysis." Critical Reviews in Food Science and Nutrition, vol. 62, 2021, pp. 5717 - 5732.https://doi.org/10.1080/10408398.2021.1890689.
47. Sihui et al. "A Low-Carbohydrate Ketogenic Diet and Treadmill Training Enhanced Fatty Acid Oxidation Capacity but Did Not Enhance Maximal Exercise Capacity in Mice." Nutrients, vol. 13, 2021.https://doi.org/10.3390/nu13020611.
48. Xie, Yongchao, et al. "Effects of Different Exercises Combined with Different Dietary Interventions on Body Composition: A Systematic Review and Network Meta-Analysis." Nutrients, vol. 16, 2024.https://doi.org/10.3390/nu16173007.
49. Cowan, S., et al. "Lifestyle management in polycystic ovary syndrome – beyond diet and physical activity." BMC Endocrine Disorders, vol. 23, 2023.https://doi.org/10.1186/s12902-022-01208-y.
50. Onu, Ana, et al. "Integrative Strategies for Preventing and Managing Metabolic Syndrome: The Impact of Exercise and Diet on Oxidative Stress Reduction—A Review." Life, vol. 15, 2025.https://doi.org/10.3390/life15050757.
51. Pandurevic, S., et al. "Efficacy of very low-calorie ketogenic diet with the Pronokal® method in obese women with polycystic ovary syndrome: a 16-week randomized controlled trial." Endocrine Connections, vol. 12, 2023.https://doi.org/10.1530/ec-22-0536.
52. Kim, C., and Seon-Heui Lee. "Effectiveness of Lifestyle Modification in Polycystic Ovary Syndrome Patients with Obesity: A Systematic Review and Meta-Analysis." Life, vol. 12, 2022.https://doi.org/10.3390/life12020308.
53. Cannarella, R., et al. "Effects of ketogenic diets on polycystic ovary syndrome: a systematic review and meta-analysis." Reproductive Biology and Endocrinology : RB&E, vol. 23, 2025.https://doi.org/10.1186/s12958-025-01411-1.
54. Godos, J., et al. "Mediterranean Diet and Quality of Life in Adults: A Systematic Review." Nutrients, vol. 17, 2025.https://doi.org/10.3390/nu17030577.
55. Sharifi, Maryam, et al. "The effects of portfolio moderate-carbohydrate and ketogenic diets on anthropometric indices, metabolic status, and hormonal levels in overweight or obese women with polycystic ovary syndrome: a randomized controlled trial." Nutrition Journal, vol. 23, 2024.https://doi.org/10.1186/s12937-024-01056-7.
56. Calcaterra, V., et al. "Low-Calorie Ketogenic Diet: Potential Application in the Treatment of Polycystic Ovary Syndrome in Adolescents." Nutrients, vol. 15, 2023.https://doi.org/10.3390/nu15163582.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Emilia Browarska, Igor Mszyca, Katarzyna Miemczyk, Anna Aksamit, Filip Wołek, Łukasz Michalski, Nicole Gajewska, Karolina Mularczyk, Kacper Kucharski, Katarzyna Superson
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Stats
Number of views and downloads: 0
Number of citations: 0
