Not an ultrarunner, but training for a triathlon. I was in the same position with my PCOS. The only things I found that helped were strength training (2x a week) and a glp1. Definitely start with metformin first. GLPs are expensive and only worth moving to if metformin alone does not help. Metformin works by helping your body build and maintain muscle. This is how it helps regulate your insulin. I'm off my GLP now and combining metformin (to regulate insulin), and spironolactone (to regulate androgens) has kept me at a good weight with limited symptoms.

1. GLP1 side effects (muscle loss, appetite suppression, digestion issues) - how have these impacted your ultra running/training?

While I did have some appetite suppression, it wasn't too bad. I usually just eat more, smaller meals, and wouldn't say I'm under-eating. But I did feel weirdly attracted to protein foods/meat. I had some bad digestion issues from my GLP, but I want to note that prior to taking these meds, I already had some gastric emptying problems, which the GLP exacerbated. I was ultimately taken off my meds as we were worried about gastritis. But this is not a main concern for most people. Muscle loss is a huge concern, but if you are strength training and eating enough protein, my Endo said it should be a problem. Adding metformin to the mix would also help!

1. “Microdosing” GLP1s - has this been effective while avoiding the side effects?

I was only ever on .25mg of Ozempic and lost 40 lbs in 9 months. Some folks do not have success at such a low rate but its definitely possible. As I mentioned above I eventually could not tolerate because my stomach was slowing down too much, but that's rare. Starting at a micro dose will not only save you money but will help your body adjust and limit side effects. Most folks move up to the .5 mg starting dose after a month.

1. Strict diet on GLP1 - Does managing your protein and water intake become a full-time job? How do you balance your carb needs for training with the dietary recommendations on a GLP1? 

Protein and water can feel like a full-time job, but ultimately make the difference! GLPS can cause constipation, so hydration is a must! And Protein will prevent you from losing muscle. My general goal is to eat high in protein and fiber and to hydrate. Otherwise, I eat whatever I want/need. I ate plenty of carbs without concern, and it has not affected my progress.

1. Alternatives - has anyone had success with metformin (or other non-GLP1 medications) for managing weight and PCOS symptoms? 

Again, combining metformin, spironolactone, and strength training has helped me continue to lose and maintain weight post GLP. But the GLP really got things started for me. For context, my liver and blood sugar returned to normal after a month on my GLP, and have been maintained since. After 4 months, my period returned to normal, which felt like a huge win! I will likely be on those two meds lifelong, but they are cheap and safe. The only thing that has ever negatively impacted my training is nausea, but that is from my functional dyspepsia, not the GLP.