A common condition doesn’t always look the same in every patient

Polycystic Ovarian Syndrome (PCOS) is one of the most frequently diagnosed gynecological conditions, and is often characterized by irregular periods, excesses of androgenic hormones, and insulin resistance. The frustrating reality is that most folks who receive a diagnosis of PCOS will also be told that their primary treatment options are hormonal birth control and weight loss. While these approaches may yield results in some, neither directly address the underlying metabolic and hormonal picture of an individual PCOS patient. These are generalized recommendations that gloss over the specific features of each person showing signs of PCOS.

There are several subtypes within the diagnosis, and treatment of each subtype is not the same. Not all folks with PCOS exhibit an excess of androgen hormones, or struggle with insulin regulation. So treatments to reduce androgens are not always indicated, and neither are treatments to support insulin regulation. In order to develop an effective treatment strategy, we need to understand what areas of an individual’s physiology are affected, and understand how these areas impact menstrual regularity, ovulation and the growth of cysts on the ovaries.

Sounds science or medicalized fatphobia?

The most common (and often only) recommendations within conventional medicine are to regulate menstrual cycles with hormonal birth control and to lose weight. While there is a correlation between metabolic dysfunction and struggles with weight management, the real issue that causes problems and that therefore we should be treating is the metabolic mis-firing, not the number on a scale.

Weight loss is often used as a goalpost to reach even though it may not directly affect outcomes. Unfortunately, the quick recommendation in the case of most PCOS patients that they lose weight is rooted in medicalized fatphobia rather than supported by best practices and patient outcomes.

In a world overwhelmed with toxic body image messaging, drowning in fad diets and promises of sure-fire ways to a slimmer figure, it is really important to cut through the noise and talk about health, not weight. When you tell someone to lose weight, you may trigger internalized narratives that are harmful to the person’s self-worth. Focusing on weight loss can make someone feel that they are weak or not worthy, or that their health situation is entirely their fault. Activating shame is not a great starting point for making change. This is not only unhelpful, it may even be dangerous, particularly for folks with a history of disordered eating.

Although some research has correlated obesity with worsened symptoms in folks with PCOS, this does not prove a causal relationship. We know that we can see healthy metabolic function at any size, so why tell someone to lose weight as if this is the only way to achieve health? We also know that unhealthy weight loss can pose a number of health risks.

If we don’t know exactly what’s going on in our body, or what may be preventing our metabolism from working optimally, how do we know what approach to weight loss will be safe and effective? What are we really trying to achieve when we tell a patient to lose weight? How do we separate the importance of metabolic health from the measure of weight?

We have many ways to clinically discern the symptoms of various types of metabolic challenges, as well as lab tests that can confirm and clarify these issues. That is the way forward – focus on the physiological pathways that need support, and health will follow.

Focus on physiology not aesthetics

When we talk about insulin dysregulation associated with PCOS, we are talking about pathways in the body’s normal metabolic function that are being challenged or are functioning differently than expected. This leads to certain outcomes such as increases in circulating insulin, resistance to insulin, unmanaged blood sugar, increased estrogen production, changes in the microbiome, and inflammation. These changes interact with alterations in the normal levels of various circulating hormones (often the group of hormones called androgens). These are the issues that aggravate symptoms associated with PCOS, and these are issues we can address directly.

If we shift our perspective to managing physiological dysregulation, look at repairing functional pathways in each person, then we can resolve the downstream effects of these issues without placing shame and blame on patients. Body image and weight management are complex, loaded topics. As healthcare providers, we need to stop using these as surrogates for health. We are primarily looking to manage symptoms, help folks feel better, and see improvements on objective measures (such as hormone levels, inflammatory markers, functional insulin and glucose testing). The number on a scale may correlate with some of these changes, but it is the wrong indicator to use as a primary guide or goalpost.

I would like to see healthcare practitioners stop telling PCOS patients they need to lose weight and go on birth control, and that these are their only treatment options. These are just two aspects of care that can be considered, whereas there’s a wealth of nutritional, botanical, and lifestyle treatments that can yield powerful results in the treatment of PCOS. When we regulate metabolic dysfunction, when we regulate drivers of inflammation and support hormone signaling pathways we can achieve massive improvements in the symptoms associated with PCOS, without activating the complex and often detrimental associations around body image along with a false sense of what it means to be well.