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Why Weight Loss Is So Hard With PCOS

by | Apr 18, 2024

If you are diagnosed or suspected to have polycystic ovary syndrome (PCOS), it’s possible you were told to “just lose weight” or pop a birth control pill until you’re ready to have babies. First of all – I’m sorry that our healthcare system didn’t do better. As I’ll explain in this article, a lot of the conventional treatment and dietary advice for PCOS is outdated and not individualized. This leaves many without actual solutions they can stick to and that improve their health. 

This article is the first in a 3-part series about PCOS. My goal is to explain why weight loss is so hard with PCOS so you can find the confidence to make a different plan – something that actually improves your symptoms. In the next article in this series, I’ll explain how to use Intuitive Eating with PCOS and the other important lifestyle factors you can tweak to improve your well-being.

Also, just a standard disclaimer that this article does not constitute a patient-clinician relationship and you should seek out individual care if you need it. 

Why I Specialize in PCOS

I help a lot of women with PCOS, but that wasn’t always my plan. This specialty has sorta fallen into my lap over the 8 years I’ve had my private practice. A large percentage of the women coming to me for support in recovering from chronic dieting and disordered eating also had PCOS. 

Over time, I’ve learned a lot about the condition and about how super common it is for these women to develop disordered eating. There’s a complex web of genetic and environmental factors that create this crossover. 

One thing is true for all of them: they just want to take good care of their body. But they’re often scared. Scared that they can’t stick to a low-carb diet, that they can’t seem to lose weight, and that they really don’t know what they’re supposed to do to feel better.  

Most people who come to me to lose weight with PCOS have tried to a million other plans already, and maybe even had some short-term weight loss success. But unfortunately, they gained the weight back – often more. If this is your situation, I want you to know that you can manage your PCOS without another freaking diet. I want to help you understand why.

Polycystic Ovary Syndrome (PCOS) Basics

Polycystic Ovary Syndrome (PCOS) is the most common endocrine (hormonal) disorder and affects 10-15% of people with ovaries, particularly those of reproductive age. That’s a ton! Unfortunately, we still don’t know exactly what causes it. It’s likely a combination of a genetic predisposition and an environmental trigger which sets off a cascade, leading to PCOS.

PCOS is an inflammatory condition, with inflammation playing a central role in the physical issues that arise, including insulin resistance, androgen production, ovarian health, and infertility.

Unfortunately, there is no cure for PCOS. Folks are usually just given medication and rarely given a recommendation to see a dietitian or someone who can really help them. But diet and lifestyle are the KEY to improving PCOS.

Symptoms vary a ton from one person to the next. And sadly, some doctors aren’t great at using the proper screening & diagnostic criteria for PCOS, leaving many without a diagnosis, and many with incorrect diagnosis. It’s kinda a mess! 

It can be confusing and so many women are left trying to lose weight, googling “PCOS diet”, and getting bad advice from randos on the internet. 

PCOS Diagnosis

PCOS is defined by a combination of at least two of the following three criteria, known as the Rotterdam criteria:

  1. Missed or Irregular Periods: This is caused by missed or irregular ovulation, which can lead to difficulty conceiving.
  2. Hyperandrogenism: Elevated levels of male sex hormones (like testosterone), which often cause physical signs like hirsutism (excessive hair growth in areas where men typically grow hair, such as the face, chest, and back), acne, and sometimes male-pattern baldness.
  3. Polycystic Ovaries: The presence of multiple small cysts in the ovaries. An ultrasound must be conducted to see these. Cysts alone do not mean someone has PCOS, as many people with ovaries can have cysts without other symptoms of PCOS.

PCOS Symptoms

The symptoms of PCOS can vary widely among individuals but often include:

  • Irregular Periods: Infrequent, irregular, or prolonged periods.
  • Excess Androgen: High levels result in acne, male-pattern baldness, and hirsutism (unwanted hair growth).
  • Polycystic Ovaries: Ovaries might be enlarged and contain follicles that surround the eggs. This causes ovaries to malfunction.
  • Weight Gain: Many individuals with PCOS gain weight (as I’ll talk about more below) as a result of hormone imbalance.
  • Infertility: PCOS is one of the leading causes of infertility due to irregular ovulation or anovulation.
  • Insulin Resistance: Many people with PCOS also have insulin resistance, which can increase the risk of developing type 2 diabetes.
  • Fatigue: High levels of insulin or blood sugar can lead to fatigue.
  • Mood Changes: Including depression and anxiety
  • Sleep Apnea: Sleep disturbances are very common in folks with PCOS.

Symptoms can start soon after puberty, but can also develop during teenage years and early adulthood. Symptoms are often attributed to other causes or conditions, therefore PCOS can go undiagnosed for some time. And often does. Sigh.

PCOS, Insulin Resistance, & Weight Gain

It is a common misconception that everyone with PCOS is in a larger body. Reports vary, but it is likely somewhere between 40-80%. However, the metabolic disturbances with PCOS do make weight gain common and weight loss extremely difficult. 

Insulin resistance is common with PCOS and diabetes, where the cells aren’t as great at using the insulin as they used to be, so glucose doesn’t get into the cells. Your body then does two things: makes more insulin and signals hunger to your brain. 

Cells have reduced ability to listen to insulin → more insulin gets pumped out

If this process keeps working on repeat, it can eventually wear out and then blood sugar can stay high, potentially leading to diabetes. With PCOS, insulin resistance can lead to weight gain and make any weight loss plan impossible. 

The Conventional Approach to Treating Weight Gain With PCOS

For years, many doctors have been advising folks with PCOS, who are also “overweight”, that a weight loss plan is the key to feeling better. Plus birth control, Metformin, and other drugs to manage symptoms.

It’s frustrating that short-term lab improvement is interpreted as good enough evidence that something works… (1 of my many soapboxes).

Weight loss advice should not be given flippantly, especially because we know that diets do not work, especially for those with insulin resistance, as is so common with PCOS. Plus, intentional weight loss usually just causes weight regain and overshoot, disordered eating, worsened body image, and can even exacerbate the condition. That is if it’s even possible to begin with. 

As I say often, just because this is not what we want to hear does not mean we should keep ignoring it.

Luckily the 2023 International Evidence-based Guideline for PCOS recommends healthcare professionals acknowledge the weight stigma common with PCOS. And – very importantly – the health benefits from lifestyle intervention even in the absence of weight loss. Hoorah!

I consider this a win even though I don’t think it goes quite far enough, as weight loss is still recommended and mentioned 75 times in the document. 🙄

This New York Times article does a good job of summarizing these and debunking the idea that restricting calories is a good idea. 

Why Your Body Fights Against Weight Loss if You Have PCOS

I can’t tell you how many stories I’ve heard about doctors giving very sketchy diet advice to patients with zero evidence to back them up. It’s shocking sometimes. 

Regardless of what your doctor told you, you probably have read that you should avoid carbs, or that you should not eat dairy, beans, meat, or any number of other things.

I see you.

These are the reasons why “just lose weight” is horrible advice and will not work long-term, no matter how much willpower you have. I want you to understand why weight loss is so hard with PCOS so you can stop blaming yourself and find a plan that does actually work for you.

PCOS Causes Carb Cravings

High levels of insulin in the blood cause carb cravings. Insulin is literally an appetite stimulant. With insulin resistance, your cells do not get the energy they need and so they tell your body to get more – cue hunger and cravings for the stuff that raises blood sugar – carbs! These cravings can be intense. The hunger is real, not something willpower is great at solving.

Going too long in between meals can make blood sugar swings worse and increase your cravings for sugary and starchy foods. Being overly hungry also makes eating past fullness more likely and can trigger binge eating. 

Low-Calorie Diets Stress Your Hormones

Cortisol is your stress hormone. It is released from your adrenal gland in response to the fear response in the body. This happens when something super scary happens, like a car jutting out in front of you in traffic, but also in response to regular life stuff, like a busy work life, family drama, and systemic issues like racism, fatphobia, and gender-based discrimination.

Cortisol increases in response to a low-calorie diet. Yep – dieting is stressful

When we feel stress, our body releases blood sugar to give us enough energy to run from that stress. So for some folks, their stress response is running a lot, and their blood sugar follows. If you have been intent on losing weight and not eating enough because of it, your blood sugar could be raised. This won’t only make your plan for weight loss fail, but can exacerbate the hormone imbalances present with PCOS.

Not getting enough sleep regularly also causes an increase in cortisol release, which is why sleep is so important for healthy metabolism. 

Diet Backlash (or Rebellious Eating)

If you’ve tried all the weight many plans under the sun, you’ve probably experienced diet backlash, or as I like to call it “rebellious eating”. This is that f-it experience, that little voice in your head that tells you to get more, more, more, or that you might as well choose the “worse” thing on the menu since you already blew it. 

This is a state of reaction, a state of rebelling against the rules of the last diet, or the last many diets. Food restriction comes with consequences. This can last for years even if you’ve been stuck in chronic dieting cycles for a long time without support. 

One day you’re just eating salads and chicken, then something “lifey” happens. A breakup, a fight with your partner, or just a stressful day at work. So you order pizza. Then more and more pizza and you stop eating vegetables all-together.  

Diets are more likely to cause binge eating, weight regain, or weight overshoot in folks with PCOS, which can worsen symptoms.

Dieting also tends to skew most of your eating toward the end of the day. If you’re trying to eat less all day long, you’re going to be ravenous by dinner time. I explain fully why ditching dieting is the best thing you’ll ever do for your relationship with food.

This is disordered eating. This does not mean you have no willpower, just that you’re extremely hungry and your body has figured out how to get what it needs, despite your best efforts. Not only does this make you feel guilt and shame, but this inconsistent eating – restricting and binging – is also pretty bad for your blood sugar.

Slowed Metabolism 

If you severely restricting your intake, it’s possible you’re eating less than your body needs to perform its many functions. Under-eating can have many negative effects including putting your body into starvation mode. This can cause you to hold onto weight that you may not if you gave your body enough food, not to mention seriously mess with your hormones. 

So if you have been eating 1200 calories a day and are confused about why you’re not losing weight – this could be why. Your body is smarter than your diet.

Hormone Dysfunction

Eating too few calories is one of the most common reasons that women struggle with fertility – and this can be the case even if you are not in a thin body. Your body needs adequate nutrition. Specifically carbohydrates and fats, to synthesize hormones appropriately and allow you to ovulate and conceive. 

Regardless of your condition, under eating can cause you to stop ovulating. Eating less is not the cure for PCOS, even though you may hear that on the internet. You need to eat enough to get and maintain a healthy menstrual cycle

That said, with PCOS, increased androgens and decreased progesterone and estrogen cause missed and irregular periods, so you must get lab work done to understand your situation. 

Eating Disorders

People with PCOS are about 4x more likely to have an eating disorder than those without PCOS. This is true regardless of weight and is especially strong for women with anxiety. 

If a condition that is often characterized by weight gain also sees a lot of eating disorders, it’s easy to draw a connection. Women with PCOS can easily spend years (often before getting a diagnosis) trying all sorts of plans to lose weight with little success. You may become extremely preoccupied with the size and shape of your body, and feel like you can’t stop obsessing about food.

Plus, anxiety and depression predispose you to develop an eating disorder.  

What to do for PCOS Instead of Trying Another Frustrating Weight Loss Plan

In the next article in this series, I’ll go into detail about the four main diet and lifestyle factors to focus on with PCOS and how you can use intuitive eating alongside them. The last article in this series is about binge eating and PCOS.

If you’re ready to get a hold of your PCOS while making sure to keep your relationship with food in fact, I’d love to support you. Book a discovery all today and we can talk about which of my offerings would best suit you.

About Emily

Emily Van Eck, MS, RDN specializes in Intuitive Eating, eating disorders, body image, women’s reproductive health, and healing from years of weight-bias and disordered eating. She helps women+ find balance, consistency, and peace with their eating habits so they can feel confident to get outta their heads and into their bodies. Emily is a registered dietitian and certified intuitive eating counselor with a master’s degree in nutrition science. Read more about her practice, values, and experience here.

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Emily Van Eck sitting on the couch smiling

Hey there, I´m Emily

A non-diet and weight-inclusive dietitian, intuitive eating coach, and body image healer. Here on the blog, I focuses on exploring intuitive eating, gentle nutrition, the complex arena of body image and feminism, anti-oppression, and all the ways these things intersect. I want us all to be free to own our appetites, and our desires, and eat really, really well. 

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