The Complicated Ways Weight and PCOS Are Connected

There's a close but complicated relationship between weight and PCOS, or polycystic ovary syndrome. PCOS statistics show more than half of people who have the condition have overweight, according to the Cleveland Clinic. PCOS is a common cause of infertility and can also up a person's risk for heart disease and type 2 diabetes.

People with PCOS are also more likely to gain weight and often find it harder to shed extra pounds. But why is weight gain so common for PCOS — and are there tactics to help maintain a healthy weight?

This is still a chicken-and-egg question: It's not clear if extra weight causes PCOS, if PCOS is the reason for the added pounds or if the relationship works both ways, per Johns Hopkins Medicine.

Here are some possible factors behind the connection between PCOS and weight gain.

If you have PCOS, it's likely that you'll have higher levels of androgens, the so-called "male" hormones such as testosterone. While everyone has androgens in their bodies, levels are generally elevated for people with PCOS compared to people with ovaries who don't have the condition.

This uptick in androgens not only contributes to weight gain but is also implicated in common PCOS symptoms such as irregular periods and unwanted facial hair (called hirsutism), per Penn Medicine.

Insulin resistance is a key part of the weight and PCOS relationship. This occurs when your body doesn't use insulin, a hormone made by your pancreas, the way it should. Normally, insulin takes sugar from foods you eat out of your bloodstream and deposits them into cells to be used as energy, according to the Mayo Clinic.

But with insulin resistance, sugar stays in your bloodstream and doesn't get stored in cells. Instead, "it's shipped off into fat," explains Libby Mills, RD, a national spokesperson for the Academy of Nutrition and Dietetics.

This is a risk factor for type 2 diabetes. Indeed, more than half of the people diagnosed with PCOS go on to develop type 2 diabetes before the age of 40, according to the Centers for Disease Control and Prevention (CDC). Insulin may also contribute to high androgen levels, per Penn Medicine.

Many with PCOS do find it difficult to shed those extra pounds, says Jennifer Wu, MD, an ob-gyn with Lenox Hill Hospital in New York City. That may be due to insulin resistance as blood sugar is diverted into fat instead of being stored for energy.

Extra weight can also have psychological effects that double down on this difficulty. One is self-esteem. Symptoms like hirsutism and extra weight "can fold into emotional eating, which can compound the problem," Mills says.

Here's something we do know: Losing weight, if you need to, can help ease symptoms of PCOS such as irregular periods and infertility, per the Office on Women's Health. It can also reduce the risk of future complications like heart disease and type 2 diabetes.

"Typically the severity of PCOS symptoms increases as a person gets heavier," Mills says.

Again, science points to the role of insulin resistance. For people with PCOS, losing weight improved insulin resistance while also lowering blood sugar levels, body mass index, weight and belly fat, per a July 2020 meta-analysis in the ‌Journal of Clinical Endocrinology and Metabolism‌. More fat around the middle has been linked with a higher risk of hypertension, heart disease and type 2 diabetes, according to the National Institutes of Health.

There's no cure for PCOS so doctors rely on medications to relieve specific symptoms and, not surprisingly, lifestyle changes. High on the list of lifestyle changes: losing weight or maintaining a healthy weight.

"That's one of the first things we tell patients: Let's try to have you achieve an ideal body weight," Dr. Wu says.

Here are the strategies commonly used to help manage this condition:

There's no official (or unofficial) PCOS diet. Instead, patients are advised to follow the same type of balanced diet that all of us should be adhering too, with a couple of emphases added.

• ‌Include all your food groups.‌ It's important to get carbs, protein and healthy fats in your meals. Calorie-restricted diets and the DASH Diet might be good choices for losing weight and improving insulin resistance, per the ‌Journal of Clinical Endocrinology and Metabolism‌ meta-analysis.
• ‌Focus on fruits, vegetables and fiber from whole grains.‌ Fiber helps control blood sugar — that keeps your energy level up, which helps with exercise, Mills says.
• ‌Make your fats healthy.‌ That means poly- and monounsaturated fats as well as omega-3s, which are plentiful in fatty fish (such as sardines, salmon, mackerel, tuna), flax seed, spinach and walnuts, Mills says.
• ‌Consider fermented foods and beverages like yogurt, kefir and sauerkraut.‌ People with PCOS may have less diverse bacteria in their gut, per a small January 2017 pilot study in ‌PLOS One‌. (Having more diverse bacteria is associated with better health.) There's some evidence that people with PCOS may benefit from these fermented foods, Mills says. Eating them introduces probiotics, aka good-for-you bacteria, to your gut.
• ‌Don't eat too late.‌ "Unfortunately, a lot of Americans eat their biggest meal at dinner and lie right down to sleep," Dr. Wu says. "I tell people to move the time earlier so they finish eating around 7 or 7:30." Then you'll have some time to burn it off.

Exercise is important, too, with studies showing that it can affect waist circumference and body fat. "Physical activity has to be part of the weight-loss equation," Mills says.

Getting enough shut-eye is also a priority for weight loss. "When we don't sleep, it's a stressor to the body and can make it really difficult to lose weight," Mills notes.

Metformin is a diabetes drug doctors sometimes prescribe as PCOS treatment to help regulate blood sugar and insulin. Some people also lose weight with the drug, Dr. Wu says. One early (but usually temporary) side effect can be nausea, Mills says.

Talk to your doctor about whether any weight-loss medications would be beneficial. "It's certainly a topic of discussion if the person is really struggling," Mills says.

Gastric bypass surgery is a last resort for people with PCOS, Dr. Wu says. Evidence is emerging that these procedures can resolve problems like insulin resistance, according to a July 2020 study in ‌Therapeutic Advances in Endocrinology and Metabolism‌.