Unique Challenges of Lean Women With 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.

Diabetes: 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.

Heart disease: 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, 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 your 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.

Calculate Your Hip-to-Waist Ratio

  1. Without holding in your stomach, use a cloth measuring tape to measure the circumference of your waist where it is smallest.
  2. Measure your hips at the point where the circumference is largest. (This will be where your buttocks stick out the most.)
  3. 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 lean woman with 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.

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.

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.

So, What Should You Do?

If you have PCOS and you're at a normal weight, what are the best things you can do for your health?

Begin resistance training: A regular exercise routine is a good idea, but also make sure your exercise regimen includes resistance training. This will increase your lean muscle while reducing the "bad fat" in your body, which is good for hormonal balance and your PCOS symptoms.

Get your insulin and glucose levels tested: Your doctor may not think to test your sugar levels if you're not obese, but having PCOS puts you at risk for developing insulin resistance even if you're not overweight. Also, ask them to test your insulin levels and not just your glucose.

Maintain your healthy weight: Having PCOS makes it more difficult to maintain your weight, but it's important that you do. It's more difficult to lose weight once you gain it, and if you gain weight, your PCOS risks go up.

Reach out for emotional support: Women with PCOS are more likely to experience problems with depression and anxiety. Reach out for support, both from friends and professionals.

Eat a healthy diet and avoid high sugar foods: Eating well is vital to your health. This is true for all people, but especially so for those with PCOS.

Advocate for yourself when you see your doctor: If you feel your doctor isn't giving you the care you deserve, seek out a second opinion.

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. Know that you are not invisible, and normal weight and thin women with PCOS do exist. You're not the only one.

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