You've tracked your cycle, tried cutting sugar, maybe even had your ovaries scanned. But has anyone ever asked about your liver?

Here's the short answer: PCOS/PMOS and your liver are deeply connected. Women with PCOS/PMOS are more likely to build up fat in the liver, and a struggling liver makes less of a protein called SHBG. Less SHBG means more "free" testosterone circulating, which may make acne, hair changes and irregular cycles worse. It's a two-way loop, and it's one of the most overlooked parts of the condition.

As a registered medical herbalist who works with women with PCOS/PMOS every week, I find this is often the missing piece. So let's talk about it.

The quiet hormone job your liver does every single day

Your liver isn't just a detox organ. It's also a hormone manager.

One of its jobs is making SHBG (sex hormone-binding globulin). Think of SHBG as a sponge that soaks up testosterone in your blood and keeps it out of action. When SHBG is high, less testosterone is free to cause trouble. When it's low, more is free to reach your skin, hair follicles and ovaries.

Here's where PCOS/PMOS comes in:

• High insulin tells your liver to make less SHBG. Insulin resistance is common in PCOS/PMOS, so SHBG often runs low.

• Low SHBG means more free testosterone. That may show up as acne along the jaw, thinning hair, extra facial hair or irregular cycles.

• Insulin and androgens both encourage fat to build up in the liver. And a fatty liver tends to make even less SHBG.

So it becomes a loop: insulin and testosterone push fat into the liver, and a fatty liver lets more testosterone run free. Low SHBG is often one of the clearest clues on a blood test that this loop is running.

The numbers back this up. In a 2025 study of 87 women with PCOS who were above a healthy weight, 68% had fatty liver on MRI. SHBG below 25 nmol/L was one of the strongest independent predictors, alongside high fasting insulin (source).

"But I'm slim" — why this isn't only about weight

This is the part that surprises women most. Fatty liver is often talked about as a weight issue, but in PCOS/PMOS testosterone itself seems to play a role.

A UK study using MRI scans found that women with the high-androgen type of PCOS had more liver fat than both women with other PCOS types and women without PCOS. That held true even after accounting for body weight, belly fat and insulin resistance (Jones et al., 2012).

Clinically, I see this pattern regularly. A woman with a normal BMI, signs of high androgens (acne, hair changes) and low SHBG on her bloods is often told her metabolic health is "fine" because the scales say so. Your liver doesn't read the scales.

The takeaway: if you have the high-androgen pattern, your liver deserves attention whatever your size.

The clues worth taking to your GP

Fatty liver is usually silent in its early stages, so you won't necessarily feel anything. These are the signs worth raising:

• Low SHBG on a hormone panel (many labs flag below about 25–30 nmol/L)

• A high free androgen index or free testosterone

• Raised liver enzymes (ALT) on routine bloods, even mildly

• High fasting insulin or triglycerides

• Weight that settles around your middle

• Ongoing fatigue or a heavy, sluggish feeling after rich meals

If several of these sound familiar, ask your GP whether liver checks are appropriate for you. Simple blood tests and, if needed, an ultrasound can give you a clearer picture.

How to support your liver (and your hormones with it)

The good news? The liver is remarkably responsive. Small, consistent changes may help shift the loop in the right direction.

Everyday foundations

• Steady your blood sugar. Protein and fibre at every meal, and fewer sugary drinks, may help lower the insulin signal that suppresses SHBG.

• Move after meals. A 10–15 minute walk after eating helps your muscles use glucose.

• Go easy on alcohol and ultra-processed foods. Both add to the liver's workload.

• Prioritise sleep. Short sleep is linked to worse insulin resistance.

The herbal approach

Western herbal medicine doesn't mask a symptom; it supports the pathway. In clinic, I look at the liver as part of the whole PCOS/PMOS picture, alongside insulin, androgens and the cycle. Herbs traditionally used to support the liver include:

• Milk thistle — traditionally used to support liver health; research suggests it may support liver function.

• Globe artichoke — traditionally used for liver and digestive support, including bile flow.

• Dandelion root — a traditional bitter herb used to support digestion and the liver.

• Turmeric — studied for its anti-inflammatory action.

These herbs aren't right for everyone. Some interact with medications, including the pill and metformin, so please don't self-prescribe. A registered medical herbalist will tailor a prescription to your pattern, your bloods and your medication.

Your questions, answered

Can PCOS/PMOS cause fatty liver? PCOS/PMOS doesn't automatically cause it, but research suggests women with the condition are more likely to develop it. Insulin resistance and high androgens both appear to play a part.

Can you have fatty liver with PCOS if you're slim? Yes. Studies suggest the high-androgen type of PCOS is linked to more liver fat even after accounting for weight. Slim women with signs of high testosterone are worth checking too.

What does low SHBG mean in PCOS? Low SHBG means more of your testosterone is "free" and active. It's often a sign of high insulin and may point to extra fat in the liver.

Will supporting my liver help my PCOS symptoms? It may help. Because the liver makes SHBG, supporting it alongside blood sugar balance may help lower free testosterone over time. Everyone responds differently.

Should I take milk thistle for PCOS? Please speak to a qualified practitioner first. Milk thistle is traditionally used for liver support, but it isn't suitable for everyone and can interact with some medications.

Find out which PCOS/PMOS pattern is driving yours

The liver is one piece of the puzzle. Whether insulin, inflammation, stress or post-pill changes are leading your symptoms changes which approach may help most.

Take my free PCOS/PMOS Pattern Finder to discover your main pattern, and where herbs may support it.

This article is for educational purposes only and isn't a substitute for medical advice. Please speak to your GP before making changes, especially if you take medication.

Sources

• Biochemical, sex hormonal, and anthropometric predictors of non-alcoholic fatty liver disease in polycystic ovary syndrome (PMC)

• Jones et al. (2012), Polycystic ovary syndrome with hyperandrogenism is characterized by an increased risk of hepatic steatosis, J Clin Endocrinol Metab

• Controlled attenuation parameters to assess liver steatosis in obese patients with PCOS, Frontiers in Endocrinology (2023)