Insulin appears to act on the theca cells by increasing androgen production as well. This is probably related to increased cP450 activity. One other factor in the pathophysiology of PCOS is that increased androgens and insulin result in decreased sex hormone binding globulin levels. This results in increased free androgens. This generally will manifest itself in the form of hirsutism or acne.
Adipose tissue is an active endocrine compartment.
Androgens are aromatized to estrogens in fat cells. This causes tonic feedback and increased LH release. PCOS is thought to be transmitted by an autosomal dominant mechanism. This appears to have variable penetration. Insulin effects three major target cells.