July 2010

Polycystic Ovary Syndrome and Disordered Eating

Erica Leon, RD

T.R. was a 17 year old female referred by her pediatrician for weight loss. She had gained 50 pounds over the past 18 months accompanied by extreme cravings for carbohydrate-containing foods. She was depressed and anxious, and had attempted to lose weight with little success. She was also troubled by bad acne and felt unattractive. Upon initial assessment, she revealed that she had tried many diets, had even starved herself and ultimately, binged on foods she had restricted. She recognized she needed help when she began vomiting several times per week to control her weight.

S.G. was a 29 year old female self-referred for weight loss. She had been obese most of her young adult life, and was now engaged and wanted to lose weight for her wedding. She said that she did not have regular periods and was concerned that her weight might interfere with a healthy pregnancy. She admitted having had laser hair removal on her chin due to heavy hair growth when she was younger. She called herself a “sugar addict” and often felt out of control around food. She said her mother had similar symptoms, and was now a diabetic.

These are two examples of real patients with symptoms of polycystic ovary syndrome, a hormonal imbalance causing significant distress to those who are afflicted.

What is Polycystic Ovary Syndrome?

Polycystic Ovary Syndrome (PCOS) is a complex endocrine disorder affecting as many as one in ten women of reproductive age (12–45 years old). The ovaries, which usually produce tiny amounts of male sex hormones (androgens) make more than usual. This can lead to irregular or absent periods, excessive hair growth (hirsutism), rapid weight gain and difficulty losing weight, depression, male pattern baldness, blood sugar issues and ultimately, infertility.

PCOS symptoms, which often begin in the teen years, are commonly overlooked as they can range from mild to severe. More than half of those diagnosed with PCOS have some degree of insulin resistance which can cause blood sugar levels to rise over time leading to diabetes. Many women develop intense cravings for carbohydrates leading to weight gain. Repeated attempts at weight loss can be highly frustrating, causing mood swings, depression and low self esteem, and can lead to extreme and unhealthy practices including starvation, binging, purging, laxative use and excessive exercise.

How is Polycystic Ovary Syndrome Diagnosed?

PCOS is usually diagnosed by a blood test to determine elevated androgen levels, elevated fasting insulin and/or glucose, and an imbalance in the female hormones LH and FSH. A doctor will perform an ultrasound to detect cysts on the ovaries, although this is not always diagnostic. A doctor will also check for the presence of PCOS symptoms.

How should the registered dietitian screen for PCOS and eating disorders?

A registered dietitian should conduct a baseline assessment of all patients with PCOS to screen for eating disorders. Likewise, the dietitian needs to recognize the potential for those patients with eating disorders to have PCOS. Appropriate screening questions include:

Nutrition/Lifestyle Management

If a patient presents with any form of disordered eating or thinking, the first step is to help regulate eating patterns. Meals and snacks containing carbohydrate and protein will assist in blood sugar control and help prevent cravings and binging behavior. Eating at three to four hours intervals should be an initial goal.

As many women with PCOS tend to have lost their internal ability to regulate food, it is helpful to utilize a non-diet approach. Food journals with hunger and satiety scales can be very useful counseling tools as the nutrition therapist helps patients reconnect to their physical hunger and satisfaction before and after meals. Working in partnership with a skilled psychotherapist, patients with PCOS can learn new methods of dealing with cravings and emotional hunger, particularly if they have disordered eating or thinking patterns.

Diet and exercise are the cornerstones of treatment for PCOS, and they should be introduced as the patient is ready. While each meal plan needs to be individualized, studies suggest women with PCOS who are insulin resistant and obese tend to lose weight more readily with lower carbohydrate diets. This does not mean that all women should reduce their intake of carbohydrates; simply put, the best eating plan is one that is balanced with a variety of foods from all food groups, and can be enjoyed without deprivation. Healthy fats, lean proteins, and high quality, lower glycemic carbohydrates including fruits, vegetables, whole grains, legumes and milk products will assist with weight loss.

Exercise is a powerful tool in the management of PCOS as it reduces insulin resistance, enhances mood and assists in weight loss and maintenance. Components of fitness include aerobic exercise, resistance and flexibility training. Joyful, mindful movement can be incorporated into a weight loss program as the patient is ready and willing.

Medication Management

Metformin, an insulin sensitizing medication, is often prescribed to reduce hunger and cravings. Other medications often prescribed include oral contraceptives and spironolactone to reduce androgen levels. Over the counter acne medications can be used, and some women with PCOS employ a variety of treatments for unwanted hair.

Bottom Line

Women with PCOS tend to have a harder time with weight loss, and may present with disordered eating symptoms. The dietitian needs to be mindful of the hormonal influences on weight, and slowly guide the patient towards normal eating and exercise patterns that can be successfully maintained. Symptoms can improve with even a small amount of weight loss, and a team approach will often be needed. This will usually involve a physician/endocrinologist, registered dietitian and psychotherapist, if appropriate.