As an endocrinologist, understanding the complexities of Polycystic Ovary Syndrome (PCOS) is key to effectively guiding patients through the challenges of managing their symptoms, especially when it comes to weight. PCOS is not just a reproductive disorder; it is a multifaceted metabolic and endocrine condition with far-reaching effects on weight, metabolism, and overall health.
In this blog, I’ll delve into the physiological mechanisms behind weight gain and difficulty losing weight in women with PCOS, as well as offer practical, evidence-based recommendations that I would give to my patients to help them manage these challenges.
The Endocrinology of PCOS: Why Weight is A Struggle
PCOS is fundamentally a hormonal disorder, and understanding the interplay between hormones is crucial to explaining why weight management is often more difficult for women with this condition.
Insulin Resistance: A Primary Driver
Insulin resistance is one of the hallmark features of PCOS. In simple terms, this means the body’s cells do not respond as efficiently to insulin, a hormone that helps regulate blood sugar levels. When insulin resistance occurs, the pancreas compensates by producing more insulin. Elevated insulin levels (hyperinsulinemia) can have several effects:
- Increased fat storage: High insulin levels encourage the body to store fat, particularly around the abdominal area. This central adiposity is common in PCOS and increases the risk of metabolic disorders like Type 2 diabetes.
- Increased hunger and cravings: Insulin resistance can affect appetite-regulating hormones like leptin and ghrelin, leading to increased hunger and cravings for high-carb foods, making it more challenging for individuals to control their caloric intake.
This insulin-related weight gain is often the first obstacle that women with PCOS face in their weight management journey.
Hormonal Imbalance: Androgens and Weight Gain
Another key aspect of PCOS is elevated levels of androgens (male hormones like testosterone), which play a direct role in both reproductive symptoms and weight management. Elevated androgen levels can contribute to:
- Increased abdominal fat: High testosterone levels promote fat accumulation, especially in the abdominal region.
- Impaired fat metabolism: Elevated androgens may affect how the body breaks down fat, further complicating weight loss efforts.
Additionally, hormonal imbalances can alter metabolism and energy expenditure, making it harder for women with PCOS to lose weight compared to those without the condition.
Slower Metabolism: Genetic and Environmental Factors
Metabolic dysfunction is common in women with PCOS. Studies have shown that women with this condition have a lower resting metabolic rate (RMR), which means they burn fewer calories at rest. This slower metabolism is likely linked to both hormonal and genetic factors and is further exacerbated by excess weight and insulin resistance.
This reduced caloric expenditure means that women with PCOS may need to reduce their caloric intake more than others to see similar weight loss results.
Stress and Cortisol: The Link to Belly Fat
Chronic stress is another contributing factor. Many women with PCOS face emotional and psychological stress related to the challenges of managing the condition, whether it’s irregular periods, infertility, or the frustration of struggling with weight. Elevated stress levels lead to increased cortisol, the body’s stress hormone, which can promote fat storage, particularly around the abdominal area.
High cortisol levels are also linked to insulin resistance, creating yet another vicious cycle that makes it harder to manage weight.
Addressing the Weight Issue: Key Interventions for PCOS
As an endocrinologist, my approach to managing weight in women with PCOS is multifaceted. It involves not only addressing the metabolic and hormonal underpinnings of the condition but also offering practical strategies to help patients achieve long-term health goals.
Improving Insulin Sensitivity
One of the most effective ways to manage PCOS-related weight gain is by improving insulin sensitivity. Several approaches can help:
- Medications like Metformin: Metformin is commonly prescribed to women with PCOS who have insulin resistance. This medication helps lower insulin levels, improve the body’s response to insulin, and in many cases, can help with weight loss. It may also improve menstrual regularity and fertility.
- Dietary Changes: Focusing on a low-glycaemic index (GI) diet is a cornerstone of managing insulin resistance. By avoiding foods that cause rapid spikes in blood sugar, like refined carbohydrates and sugary snacks, women can help stabilise their insulin levels. Instead, incorporating whole grains, non-starchy vegetables, lean proteins, and healthy fats can help regulate blood sugar and improve insulin sensitivity.
- Regular Exercise: Exercise, especially resistance training and aerobic activities, can significantly improve insulin sensitivity. Both types of exercise help the body better utilise glucose and improve muscle mass, which in turn can boost metabolism.
Managing Hormonal Imbalances
In addition to addressing insulin resistance, it’s important to manage elevated androgen levels in women with PCOS:
- Oral Contraceptives (Birth Control Pills): Combined oral contraceptives (COCs) are often prescribed to help regulate menstrual cycles and reduce androgen levels, which can improve acne and excessive hair growth. These effects may indirectly support weight management by normalising the hormonal environment.
- Anti-Androgen Medications: Drugs like spironolactone can help block the effects of excess testosterone and reduce symptoms like hirsutism (excessive hair growth). While these medications primarily target other symptoms, managing androgens can indirectly make it easier to manage weight and body composition.
Lifestyle Modifications: Diet and Exercise
While medication can certainly help, lifestyle interventions are equally important:
- Balanced, Nutrient-Dense Diet: A diet rich in whole, unprocessed foods that stabilise blood sugar levels is essential. I recommend my patients focus on high-fibre foods, lean proteins, and healthy fats while reducing their intake of refined sugars and processed carbohydrates.
- Exercise Regimen: Physical activity is critical for managing weight and improving insulin sensitivity. I usually recommend a combination of strength training and cardiovascular exercises. Strength training is particularly helpful for building lean muscle mass, which boosts metabolism and helps with weight management.
- Weight Loss Goals: In women with PCOS, even modest weight loss (5-10% of total body weight) can have a profound impact on improving insulin sensitivity, reducing testosterone levels, and improving menstrual regularity. Setting realistic, achievable weight loss goals is essential for long-term success.
Mental and Emotional Health Support
Lastly, it’s important to address the psychological aspect of PCOS. Many women with the condition experience anxiety, depression, and stress due to the impact PCOS has on their lives. High stress can worsen hormonal imbalances and further impede weight loss. Supportive counselling, mindfulness practices, and stress management techniques are all beneficial in helping patients cope with the emotional side of PCOS.
Key messages from eGynaecologist
- By addressing the underlying metabolic, hormonal, and psychological factors that contribute to weight gain, we can help patients achieve a healthier body weight, improve overall wellbeing, and reduce the risk of long-term complications such as Type 2 diabetes and heart disease.
- The key is to work closely with a healthcare team that suits each woman’s unique needs. With the right guidance, support, and commitment, managing weight with PCOS is not only possible—it can lead to improved quality of life and long-term health.
Dr Amina Khanam, MRCP
Consultant Diabetes and Endocrinology
Lead Obesity Physician
