“My doctor told me that I have PCOS. I had never heard of it. She told me that if I don’t want the PCOS to lead to diabetes, I needed to lose weight. That was the only information I was given.”
Although Polycystic Ovarian Syndrome (PCOS) is a common female issue (approximately 1 in 10 women have PCOS), it is often misunderstood. All too often women diagnosed with PCOS are given little information about pathology or treatment. Furthermore, when women are educated about treatment, the information provided typically overemphasizes the weight aspect of PCOS with a misguided singular recommendation – for weight loss. This unfortunate emphasis on weight loss can contribute to the development of disordered eating, most often dieting and bulimia nervosa. Dieting and weight cycling is positively associated with depression and eating pathology, which is already more prevalent in the PCOS population compared to the non-PCOS population.
So What is PCOS?
PCOS is an endocrine disorder, affecting 6-18% of reproductive-age women, with up to 69% of women being undiagnosed. Originally called Stein-Leventhal Syndrome, PCOS was first recognized in 1935 as a syndrome involving ovarian cysts and reproductive challenges. Originally seen as a primarily reproductive issue, due to the broader understanding of the effect of androgens and insulin, PCOS is now mainly viewed as an endocrine disorder. PCOS features can be categorized into three groups: clinical, endocrine, and metabolic. The clinical features include menstrual abnormalities, hirsutism (abnormal hair growth on face and body), acne, alopecia (hair loss and baldness), elevated body weight, anovulatory (ovulation does not take place) infertility and recurrent miscarriages. The endocrine features include elevated insulin, elevated androgens (male sex hormones like testosterone), luteinizing hormone, estrogen and prolactin levels. Insulin resistance in women with PCOS exacerbates symptoms (including menstrual abnormalities, hirsutism, acne, alopecia, and weight disruptions), impairs fertility, impairs glucose tolerance, and increases risk for developing diabetes in both normal-weight and higher-weight women. (Untreated) PCOS is also associated with a higher rate of cardiovascular risk factors.
How is PCOS Diagnosed?
PCOS can be diagnosed when a female has two of the following: irregular or absent menstrual periods, excess androgens (this can be tested by measuring testosterone in the blood or by clinic symptoms including acne, hirsutism, and alopecia), and/or polycystic ovaries (shown on an ultrasound).
How Should PCOS be Treated?
The body has an easier time storing weight – especially in the midsection – when insulin resistance is not well-managed. A large part of effective PCOS treatment means treating the insulin resistance, using nutrition, exercise, and often medication. These treatments target glucose and insulin release, improving the underlying issues and the associated symptoms. So, when insulin resistance improves, we see a “ripple effect”, with symptoms improving as a result of the improved insulin release. In short, it’s not weight loss that improves PCOS. Weight change – along with other symptoms – is often a result of the insulin issue being treated. So recommending weight loss as the treatment for PCOS is focusing on a symptom (weight) of PCOS, not the cause. In addition, insulin resistance occurs with and without obesity in women with PCOS, making weight-focused dietary interventions even less appropriate for this population. Additionally, lifestyle modification interventions aimed at improving insulin sensitivity rather than weight are truly most relevant because both lean and obese women with PCOS are more insulin resistant than their non-PCOS counterparts. When PCOS is properly treated, women can see improvements in menstruation, weight, diabetes risk, and cardiovascular disease risk.
Lifestyle changes aimed at improving insulin resistance should target glucose release into the bloodstream, because the amount of insulin secreted depends on whether or not glucose is slowly or rapidly released into the bloodstream. When glucose is released into the bloodstream slowly versus rapidly, insulin levels are better and over time this can improve PCOS symptoms. Unfortunately, many diet programs claiming to improve PCOS tout going low carb as the only way to go. The idea there is that by depriving the body of the building blocks (carbs) needed to release glucose, glucose levels will be lower resulting in lower insulin levels (and lower insulin levels can improve symptoms, including the body’s tendency to hold on to weight when it wouldn’t otherwise). This concept works to lower glucose and insulin BUT there is a huge problem with this type of PCOS treatment: women with PCOS are also human beings, and human beings require ≥225 – 325 grams of carbohydrate per day to function. It is impossible to require less carbohydrate than this, and without enough carbohydrate our biology takes over causing us to think about food (specifically carbs) until we consume enough of it.
So, the diet industry is forgetting – or not caring – that their low-carb recommendations are not sustainable. The good news is that we can create the gradual glucose and insulin fluctuations that support PCOS health without starving and setting someone up for a binge. This is done by eating every 2-4 hours and distributing carbs throughout the day. Also, when we eat mixed meals with protein, fat, and carbs, this allows for a slower digestion of carbs compared to eating carbs alone. Thankfully, this can come pretty naturally because meals are very often made this way (deli sandwiches, pizza, chicken pad Thai). Making sure the protein and fat are included along with carbohydrate has the added benefit of creating a sense of satiety, which leaves us feeling more satisfied and less likely to binge.
Additional treatments that help optimize glucose and insulin levels in a woman with PCOS are exercise, medications, and stress management. Cardiovascular exercise (walking, Zumba, gardening, biking, etc.) encourages our cells to take glucose from the bloodstream and use it for energy. The tricky thing with the exercise recommendation for PCOS is that if the exercise needs to be joy-based movement, otherwise it will be less likely to become a lifelong habit and could also be triggering for the eating disorder sufferer. Joy-based movement is exercise we truly enjoy and are not at all compulsive about. The alternative, stressful-compulsive exercise that includes a lot of “should” (“I should make myself get up early and go to the gym despite the fact that I will then be exhausted all day”), is not only much less sustainable in the long-term, but can make things worse for the person who has PCOS and an eating disorder.
PCOS is very manageable once it is identified and treated. If you have experienced PCOS symptoms but are unsure about whether or not you have PCOS, make an appointment with an endocrinologist who has experience with PCOS. Find out if the endocrinologist has PCOS experience by reviewing their online bio or inquiring over the phone with the scheduling staff or nurse. An endocrinologist can help you sort out symptoms and will know what tests may need to be done. The endocrinologist will also assess whether or not medications (most often Metformin) could be a beneficial addition to exercise and nutrition in treating the insulin disruptions, and which medications might help with cosmetic symptoms related to elevated testosterone.
“I was eating normally and for some mysterious reason my weight started going up. I hadn’t dieted before, but thought I should start cutting back (calories) in order for my weight to go back down. That didn’t work so I increased my workouts until I was spending 2 hours a day at the gym, still with no weight loss. My body image was horrible, not only due to the weight gain but also because I felt like my body was betraying me. Feeling frustrated and hopeless, I started purging”.
Often times, a patient will begin eating disorder treatment and it isn’t until then that the PCOS is recognized. This can happen various ways, including a symptom checklist that indicates potential PCOS, especially the symptom of irregular periods. Or as a patient describes the development of the disordered eating, it becomes clear that the change in eating began in response to a mysterious weight change irrelevant of unchanging eating or exercise patterns. The path to disordered eating can evolve in a woman with PCOS as a result of dieting in an effort to manage weight that was irregular due to undiagnosed and/or undertreated PCOS. An additional – hypothesized – route to an eating disorder, specifically bulimia, is that PCOS may promote bulimic behavior since androgens have appetite-stimulating effects and could impair impulse control. A recent study showed the prevalence of clinical bulimia nervosa was 5.3%, subclinical anorexia nervosa 1.1% and subclinical bulimia nervosa was 10.5% among women with PCOS.
About The Author:
Meaghan Ormsby, MS, RD is a Registered Dietitian Nutritionist and a Certified Intuitive Eating Counselor in Seattle, Washington. She specializes in Polycystic Ovarian Syndrome (PCOS), disordered eating, and intuitive eating. Meaghan has worked with eating and weight concerns for over 10 years, providing individual nutrition counseling as well as group education. Her experience and expertise are focused on helping individuals to improve both their eating habits and their relationship with food using the Health at Every Size (HAES) model and a non-diet approach. Meaghan completed her undergraduate degree in Nutrition and dietetic internship at California State University, Long Beach and her Master of Science degree (MS) at Eastern Michigan University.
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Written – 2016