Unique Challenges of Lean Women With PCOS

When You’re Thin or at a Normal Weight and Have PCOS

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Can you be lean and have PCOS? Yes. Up to 20 percent of women with PCOS are thin or at a normal weight. These healthy-weight women still face fertility challenges, increased androgens, and the resulting symptoms (like acne, unwanted hair growth, hair loss, etc.), and an increased risk of diabetes and cardiovascular disease.

Most of the information written on PCOS is for the overweight majority, and the number one bit of advice is to lose weight.

What if you’re already at a normal weight?

Below are the unique challenges of those with lean PCOS, and what you can do to improve your quality of life and possibly lessen troublesome symptoms.

Delayed Diagnosis Time

Because PCOS is associated so strongly with obesity, lean women with PCOS often go undiagnosed for years. Overweight women with PCOS may be diagnosed when they are still in high school, especially if their cycles are absent or very irregular. Comparatively, lean PCOS women may not be diagnosed until they struggle to conceive.

The PCOS diagnosis itself isn’t the only delayed diagnosis.

Studies have found that lean women with PCOS have a 3 to 10 percent incidence of missed diabetes diagnosis. This is likely because doctors don’t generally expect normal weight adults to develop diabetes or insulin resistance.  (More on this below.)

That said, the risk of developing diabetes in normal weight PCOS women is not as significantly increased like it is for obese women.

Some experts recommend that all women with PCOS have their insulin levels checked, regardless of their weight.

Also, lean women with PCOS are more likely to have a delayed or missed diagnosis of cardiovascular disease.

Researchers have compared the cholesterol levels of normal-weight women with PCOS to women without PCOS.

They found that the healthy-weight PCOS women were more likely to have lower levels of the “good” cholesterol (HDL) and higher levels of the “bad” cholesterol (LDL.)

Insulin Resistance Possible, Even With a Healthy BMI

Insulin resistance is usually associated with obesity. However, as mentioned above, lean women with PCOS may be at an increased risk of developing insulin resistance despite not being overweight. It is estimated that between 6 and 22 percent of normal-weight women with PCOS are insulin resistance or have hyperinsulinemia.

How can this be? While the connection between insulin and PCOS is not yet well understood, women with PCOS are not the only ones who can be insulin resistant and yet have their weight fall into the normal range for their height.

The key-dividing factor between those at a normal weight who develop insulin resistance and those who don’t seems to be abdominal obesity. Abdominal obesity is when the abdominal area of your body carries more fat than it should. This is, of course, more common in those who are obese, but it can also occur in those at a normal weight. You don't necessarily have control over where you body stores fat; this is likely related to genetics.

Wondering if you’re at risk? One way to check is to find your hip-to-waist ratio. Women are more likely to have elevated levels of insulin if their hip-to-waist ratio is higher than 0.85.

You can calculate this yourself. Take a cloth measuring tape. Without holding in your stomach, measure the circumference of your waist where it is smallest. Then, measure your hips at the point where the circumference is largest. (This will be where your buttocks stick out the most.)

Divide your waist measurement by your hip measurement. If you get 0.85 or higher, your risk of developing insulin resistance and other health problems related to obesity is higher.

This is true even if your BMI falls in the normal or healthy range.

Emotional Health in Lean Women With PCOS

PCOS is associated with an increased risk of depression and anxiety. One study found that lean women with PCOS—when compared to obese women with PCOS—were more likely to have problems with anxiety, have lower resistance to stress, and have higher levels of the hormone ACTH, which is associated with increased long-term stress.

They also found that the more anxiety a woman with lean PCOS experiences, the higher levels of plasma ghrelin they had. Ghrelin is a hormone that causes you to feel hungry.

Some have theorized that the psychological struggles of women with lean PCOS are what disturb the hormonal balance. In other words, anxiety triggers or further exasperates PCOS-hormonal imbalances.  While both lean and overweight women with PCOS are at an increased risk of anxiety and mood disturbances, it may be that lean women are more likely to face anxiety than their obese sisters.

Fertility Treatment in 'Thin Cysters'

The most common fertility treatments used for women with PCOS are Clomid, letrozole, metformin, and, if those are not successful, injectable fertility drugs. The most common advice given to women wanting to get pregnant with PCOS is to… lose weight first.

It is true that, for women who are obese, losing 5 to 10 percent of their current weight can help fertility drugs be more effective. However, this doesn’t apply to lean PCOS women.

In fact, there’s good news: lean women with PCOS have much higher pregnancy rates with fertility treatments when compared to their overweight peers.

As mentioned above, metformin is sometimes used to help women with PCOS conceive. Metformin is not a fertility drug; it’s actually intended for insulin resistance. However, it may improve ovulation in women with PCOS.

One study found that lean women with PCOS who were treated with metformin were twice as likely to have menstruation and ovulation return, when compared to obese women with PCOS. They also found that testosterone levels decreased and fasting glucose improved in lean women with PCOS. These improvements were not seen at all in the obese women with PCOS.

In another study, researchers found that lean women with PCOS had a 52 percent pregnancy success rate when treated with ovulatory fertility drugs plus intra-uterine insemination (IUI). The pregnancy rates for obese women with PCOS were much lower. (Just 22 percent.)

Being a thin or normal weight woman with PCOS doesn’t mean you won’t struggle to conceive, or that fertility treatment is guaranteed. But, you are more likely to have success when compared to those who are overweight or obese with PCOS.

Lifestyle and Diet Solutions for Lean 'Cysters'

As mentioned above, the usual advice to lose weight doesn’t apply or make sense. However, there are lifestyle habits and changes you can make that may improve your overall health.

For one, it’s important for normal-weight PCOS women to maintain their weight. It can be frustrating to be at a good BMI but still have PCOS. Some may assume being a healthy weight doesn’t matter… so why try?

Research has found that as women with PCOS age, they are more likely to develop insulin resistance. But the risk was lower for lean women. Maintaining your weight can help reduce your diabetes risk.

Maintaining your weight may not be easy, though. Studies have found that women with PCOS must eat fewer calories than same-weight women without PCOS. This means it’s more difficult to stay at a healthy weight.

One possible solution to this could be resistance exercise. Progressive resistance exercise is weight training specifically intended to increase strength and muscle mass. This is done by slowly increasing the weight being lifted or the repetitions being completed. (Some women are afraid that lifting weights will lead to them bulking up “like a man” but this is an unfounded fear.)

A study on women with lean PCOS found that adding resistance training helped decrease visceral fat (the abdominal fat that increases your risk of insulin resistance), decreased elevated androgen levels, improved menstrual and ovulatory irregularities, and increased lean muscle mass.  (By the way, the more muscle mass you carry, the more calories you require to maintain your weight. This means you can eat more, an important benefit for those with PCOS.)

Another way to improve your quality of life when living with PCOS is receiving professional counseling, especially if you experience anxiety or depressed moods. Women with PCOS are more likely to experience anxiety problems, and lean PCOS women may be more likely to have these struggles when compared to obese women with PCOS.

While therapy may not completely eliminate these emotional struggles, it can help significantly.

A Word From Verywell

When you’re diagnosed with PCOS, but all the information you can find is targeted to overweight women, it can be frustrating and invalidating. You may even have other women with PCOS saying they “doubt” your diagnosis—solely because you are not obese.

The PCOS diagnostic criteria do not include “being overweight.” Obesity is a risk of PCOS. In fact, one in five women with PCOS are thin or at a healthy BMI.

At your yearly well check, make sure your doctor tests your insulin and glucose levels and your lipid profile, so any metabolic imbalances are caught and treated quickly.

The most important things you can do to stay healthy are maintain your weight with a good diet, practice a regular exercise routine, and seek support for the emotional challenges that come with PCOS.

Sources:

Goyal M1, Dawood AS2. “Debates Regarding Lean Patients with Polycystic Ovary Syndrome: A Narrative Review.J Hum Reprod Sci. 2017 Jul-Sep;10(3):154-161. doi: 10.4103/jhrs.JHRS_77_17.

Kogure GS1, Miranda-Furtado CL, Silva RC, Melo AS, Ferriani RA, De Sá MF, Dos Reis RM. “Resistance Exercise Impacts Lean Muscle Mass in Women with Polycystic Ovary Syndrome.” Med Sci Sports Exerc. 2016 Apr;48(4):589-98. doi: 10.1249/MSS.0000000000000822.

Komarowska H1, Stangierski A2, Warmuz-Stangierska I2, Lodyga M2, Ochmanska K2, Wasko R2, Wanic-Kossowska M3, Ruchala M2. “Differences in the psychological and hormonal presentation of lean and obese patients with polycystic ovary syndrome.” Neuro Endocrinol Lett. 2013;34(7):669-74.

Pelanis R1, Mellembakken JR1, Sundström-Poromaa I2, Ravn P3, Morin-Papunen L4,5, Tapanainen JS4,5,6, Piltonen T4,5, Puurunen J4,5, Hirschberg AL7,8, Fedorcsak P1,9, Andersen M10, Glintborg D10. “The prevalence of Type 2 diabetes is not increased in normal-weight women with PCOS.” Hum Reprod. 2017 Nov 1;32(11):2279-2286. doi: 10.1093/humrep/dex294.

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