What is Lean PCOS?

While the stereotype for women with PCOS is generally those who are overweight and obese, the reality is that women with PCOS come in all shapes and sizes. This is because the syndrome affects women in various ways. What exactly is a syndrome? A syndrome is "a group of symptoms that together are characteristic of a specific disorder or disease." Having to meet only two of the three characteristics from the Rotterdam criteria (elevated androgens, missed periods, and "cysts") partly explains the vast differences seen outwardly in PCOS sufferers. You don't even need "cysts" to be diagnosed with the condition, at all. I prefer the term "follicles" anyway as they really aren't actually cysts!

Most women with PCOS, regardless of size, often have one thing in common: issues with their insulin levels. This is because insulin is often responsible for meeting said criteria: elevated androgens, missed periods, and "cysts". For some women, this shows up as severe insulin resistance (leading to effortless weight gain) while other women may have higher-than-necessary insulin spikes (leading to reactive hypoglycemia after consuming simple carbohydrate rich meals). This can be the culprit for energy crashes throughout the day. Some lean women with PCOS are insulin resistant; however, the chance of having insulin resistance is much higher if you have a genetic predisposition along with being overweight and sedentary. It is believed that genetics and environmental factors play a large role in this misunderstood condition. Getting checked for insulin resistance is recommended for all PCOS sufferers.

Often times, “lean” PCOS women (making up about 20-30% of the PCOS demographic) may not receive a diagnosis until adulthood when they are trying to conceive because they otherwise lack obvious outward symptoms of the condition. Why? Symptoms such as acne and irregular cycles are commonplace among teenagers; furthermore, these symptoms become hidden if treated with hormonal birth control. Even then, some health care professionals down the road may suspect them to have hypothalamic amenorrhea because of their lean frame. Receiving the correct diagnosis is essential for determining proper management since the two conditions have different lifestyle recommendations.

It has been shown that lean women with PCOS have a higher incidence of lipid abnormalities (HDL, LDL) compared to lean women without PCOS. The general consensus is that all women with PCOS are at some risk for heart disease and diabetes; moreover, lean women working to maintain their lean frame (in a healthful way) can reduce these risks. In addition, lean women and overweight women with PCOS are both known to suffer from anovulation, anxiety, depression, hirsutism, and endometrial cancer, and even sleep apnea.

Lean PCOS can bring on it's own challenges because traditional practitioners don't always accept it or don't know what lifestyle changes to recommend; therefore, medication often becomes first-line treatment. However, a nutritious, well-rounded diet is essential for managing lean PCOS in order to promote healthy hormonal balance, regular ovulation, and ultimately a healthy pregnancy if desired.

Beth Benesh is owner of Beth Benesh Nutrition, specializing in nutrition counseling for women with PCOS. She's a mother of two and avid runner who loves movies, mornings, and coffee.

References:

Goyal M, Dawood AS. Debates Regarding Lean Patients with Polycystic Ovary Syndrome: A Narrative Review. J Hum Reprod Sci. 2017 Jul-Sep;10(3):154-161. doi: 10.4103/jhrs.JHRS_77_17. PMID: 29142442; PMCID: PMC5672719.

Livadas S, Kollias A, Panidis D, Diamanti-Kandarakis E. Diverse impacts of aging on insulin resistance in lean and obese women with polycystic ovary syndrome: Evidence from 1345 women with the syndrome. Eur J Endocrinol. 2014;171:301–9. [PubMed] [Google Scholar]

Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004 Jan;19(1):41-7. doi: 10.1093/humrep/deh098. PMID: 14688154.