Clinical-evidence audit
PCOS · insulin resistance · ADHD
This is not medical advice — it's a clinical-evidence audit to help you prepare for a second opinion with a doctor. Don't start, stop, or change any prescription based on it alone.
| Conditions | PCOS · insulin resistance · ADHD · vitamin-D deficiency |
|---|---|
| The stack | AM: atomoxetine (Strattera — ADHD med) 40 mg · CoQ10 ubiquinol 200 mg · vitamin D3 50,000 IU weekly · B12 1,000 mcg · K2 100 mg · omega-3 4,100 mg (EPA-dominant) · oral minoxidil 1.5 mg + hair complex · copper 2 mg PM: spironolactone 100 mg · magnesium bisglycinate · K2 (guanfacine — not currently active) |
| Recently removed | Metformin (500→1,000 mg, removed Jan 2026 — doctor stopped it over a rising ALT) · NAC (removed, not tolerated) |
| You assumed | The stack covers what needs covering · the rising ALT was caused by the metformin |
| Your ask | Rate my medication & supplement stack — a second opinion on the whole regimen |
See exactly what you pasted — your original message, verbatim
This is the unedited stack you sent us — the table above is our cleaned-up reading of it.
AM
- Strattera — generic (Atomoxetine) — 40 mg · Rx · 1 capsule — ADHD; anxiety.
- CoQ10 Ubiquinol — 200 mg · Nordic Naturals · 2 softgels — insulin sensitivity, fatigue, endothelial function; AM timing avoids nighttime sympathetic activation.
- Vitamin D3 — 50,000 IU · Rx · 1 gelcap · Tuesdays only — deficiency on a 5,000 IU 3×/wk maintenance, so back to 50k; magnesium maintained to support D; recheck in February.
- Vitamin B12 (Methylcobalamin) — 1,000 mcg · Pure Encapsulations · 1 capsule — bring serum to higher-normal.
- Vitamin K2 — 100 mg · NOW · 1 capsule — daily even with weekly high-dose D; calcium & vascular safety during D repletion.
- Omega-3 — 4,100 mg (2,650 EPA + 650 DHA) · Nordic Naturals EPA Extra · 4 softgels (reduced from 5, Jan 2026) — EPA-dominant for PCOS/IR/inflammation; target 3:1–4:1; still low-normal after 90 days; may improve lipids.
- Oral Minoxidil + hair complex — Minoxidil 1.5 mg (Rx) + Biotin 2.5 mg, Vit C 100 mg, Zinc 50 mg, Pantothenic Acid 10 mg, Vit B6 2 mg · Rx · 1 tablet — hair loss/density from PCOS.
- Copper glycinate — 2 mg · Pure Encapsulations · 1 tablet — offset zinc in hair supplement.
PM
- Spironolactone — 100 mg · Rx · 2 tablets — hirsutism; potassium monitored quarterly.
- Guanfacine — 1 mg · Rx (not currently active) — ADHD.
- Vitamin K2 — 100 mg · NOW · 1 capsule — (as AM).
- Magnesium bisglycinate (intermittent) — 200 mg · Thorne · powder — sleep; replenish magnesium depleted by Metformin; higher-normal serum.
Recently removed
- Metformin — 500 mg · Rx (AM & PM) — removed by doctor due to increasing ALT. obesity; hyperinsulinemia. Had increased 500→1,000 mg Dec 2025. Removed Jan 2026.
- NAC — 500 mg · Thorne (AM & PM) — removed (not tolerated). glutathione/ALT/oxidative-stress support; coincided with Metformin increase. Removed Jan 2026.
Glossary
- PCOS
- polycystic ovary syndrome
- insulin resistance
- cells respond poorly to insulin so the body makes more — the suspected root driver of this cluster
- ALT
- alanine aminotransferase — a liver enzyme; a rising level signals liver irritation
- NAFLD
- non-alcoholic fatty liver disease (fat in the liver)
- OGTT
- oral glucose-tolerance test — the most accurate way to measure insulin resistance in PCOS
- atomoxetine
- a non-stimulant ADHD medication (brand: Strattera)
What's missing from what you shared — a few details would sharpen this
We deliberately didn't guess on these — and several flags below shift depending on them:
- Your age (some hormonal shifts aren't fully addressable by diet/supplements)
- Your actual ALT value and trend (mild vs significant changes the urgency)
- Recent A1C, potassium (you're on spironolactone), and vitamin D level now vs before
Reply to our email with any of these and we'll sharpen this audit for you. Otherwise, raise them with your doctor — or weigh them in your own analysis.
The four flags below are interrelated — see the diagram.
Measure the root cause — insulin resistance
"Can we measure my insulin resistance directly — an OGTT (most accurate in PCOS), or at least an A1C to screen for prediabetes?"
"And if it is the driver, should the plan focus more on treating it directly — rather than managing each downstream symptom on its own?"
Insulin resistance is the upstream driver of this whole cluster — genetic (Mendelian-randomization) evidence shows higher BMI and fasting insulin cause PCOS, not the reverse (Brower 2018), and lowering it improves real PCOS outcomes while treating the symptoms alone doesn't (Luque-Ramírez 2018). Yet it's often not measured directly.
• Metformin — ovulation OR 2.55, clinical pregnancy OR 1.93, live birth OR 1.59 (Cochrane, 48 RCTs) Morley 2017 ↗
• Low-GI diet — regular cycles in 95% vs 63% at equal weight loss Marsh 2010 RCT ↗
• Weight loss — free-androgen index −1.11 (Cochrane) Lim 2019 ↗; GLP-1 → natural pregnancy RR 1.72 Ge 2023 ↗
• Inositol — menstrual normalization RR 1.79, lowers testosterone, non-inferior to metformin Greff 2023 ↗
(Hard fertility / live-birth endpoints are weaker and less certain for inositol and diet alone.)
The metformin removal over a rising ALT
"Was my rising ALT worked up for fatty liver — and is metformin really the cause, given it's usually liver-safe?"
Metformin is an uncommon cause of liver-enzyme rises and may even lower ALT in fatty liver (LiverTox). In PCOS + insulin resistance the likely cause is fatty liver (NAFLD), which PCOS roughly doubles-to-triples (Rocha 2017; Yao 2023), and metformin is guideline-recommended for your metabolic profile (2023 PCOS guideline). The drug that was kept, atomoxetine, carries its own rare liver-injury signal (LiverTox).
↳ If metformin stays off, it's worth asking about inositol (myo- + D-chiro-inositol) — a studied insulin-sensitizing option in PCOS — since otherwise nothing in the plan is acting on the root driver.
Screen for obstructive sleep apnea
"Given my PCOS, insulin resistance, and fatigue, should I be screened for sleep apnea?"
The 2023 PCOS guideline recommends OSA screening for symptomatic women (Teede 2023); OSA is ~3.8× more common in PCOS (Kahal 2020), insulin resistance is a stronger risk factor than weight (Vgontzas 2001), and untreated OSA impairs attention and focus — overlapping the symptoms treated as ADHD (Olaithe & Bucks 2013).
Atomoxetine may be feeding the loop
"Could atomoxetine be contributing to my insomnia — and might it belong on the differential for my ALT?"
Per the FDA label, atomoxetine causes insomnia in 15% vs 8% and raises heart rate (FDA label), and it has a rare liver-injury signal (LiverTox). So a symptom (focus) treated with atomoxetine may, in turn, worsen sleep and — rarely — the ALT: a loop worth untangling. A model, not a verdict — don't change any medication on your own.
The big picture — two models for your second opinion
① Before — what your plan assumes
⤢ ExpandEach treatment (blue) points to the one symptom it's meant to manage. The targets sit side by side — nothing connects them, and no shared cause is named. And the one drug that acted on the metabolic root, metformin, was stopped (blamed for a rising ALT), leaving insulin resistance (the dark box) untreated. The "After" diagram shows what all of these actually have in common.
② After — the audited causal model
⤢ ExpandThe same picture, audited. Dark = the root (insulin resistance, Flag 1); amber = upstream exposures you can influence; red = the self-reinforcing loop (the focus problem reads as ADHD → atomoxetine → which can worsen sleep and, rarely, the ALT that led to stopping metformin → worsening insulin resistance); blue = treatments and where each acts. The four flags are labeled on it. Show both to your doctor and ask whether they agree or work from a different model — comparing the two pictures is exactly what a second opinion is for. (click a diagram to expand it full-screen)
Appendix — every claim, classified (how the audit reasons)
For the curious: every claim in your plan, classified — this is the audit's underlying logic, summarised. The simple flags above are what matters; this is the receipts.
Each claim gets a plain-English verdict: Supported · Needs a look (in your plan, but depends on facts we don't have) · Missing (not in your plan, but worth raising).
| Claim | Type | In plan? | Verdict — why | Flag |
|---|---|---|---|---|
| Explicit care-plan claims (what you wrote) | ||||
| "Metformin had to be stopped because it raised my ALT" | 💊 Rx | explicit | Needs a look — metformin is an uncommon ALT culprit; fatty liver & atomoxetine belong on the differential | 2 |
| "My supplement stack covers my PCOS / insulin resistance" | 💊 Rx | explicit | Needs a look — most of it treats symptoms; nothing is acting on the root driver since metformin came off | 1 |
| "Atomoxetine for ADHD / focus" | 💊 Rx | explicit | Needs a look — may worsen sleep and (rarely) the ALT; the focus problem may overlap untreated OSA | 3, 4 |
| "Spironolactone for hirsutism" | 💊 Rx | explicit | Supported — standard for PCOS androgen symptoms (keep monitoring potassium) | — |
| "Omega-3 / vitamin D / B12 / K2 repletion" | 💊 Rx | explicit | Supported — reasonable for the stated deficiencies / IR-inflammation adjunct | — |
| Implicit care-plan claims (assumed, unstated) | ||||
| "The rising ALT was caused by the metformin" | 🔬 Dx | implicit | Needs a look — PCOS roughly triples NAFLD; metformin can even lower ALT in fatty liver | 2 |
| "Treating each symptom on its own is enough" | 🔬 Dx | implicit | Needs a look — insulin resistance is the upstream driver of the whole cluster | 1 |
| "My focus problem is ADHD" | 🔬 Dx | implicit | Needs a look — untreated sleep apnea impairs attention and overlaps these symptoms | 3, 4 |
| Missing — not in the plan, but needed (the audit adds these) | ||||
| Measure insulin resistance directly — OGTT (best in PCOS) or A1C | 🔬 Dx | missing | Missing — the root driver is never measured | 1 |
| Work up the ALT for fatty liver (NAFLD) | 🔬 Dx | missing | Missing — the likelier cause in PCOS + IR | 2 |
| Screen for obstructive sleep apnea | 🔬 Dx | missing | Missing — guideline-recommended; OSA ~3.8× more common in PCOS | 3 |
| Consider inositol (myo- + D-chiro) if metformin stays off | 💊 Rx | missing | Missing — an insulin-sensitizing lever when nothing else is working the root | 2 |
| Lower glycemic load / weight — upstream IR levers | 💊 Rx | missing | Missing — moves the whole cluster, not one symptom | 1 |
This is a real, de-identified audit shown as an example — research and education, not medical advice. Want your own care plan audited? Email ops@nobsmed.com.