PCOS Series: A Return

It's time to continue our series on PCOS, Polycystic Ovarian Syndrome.

For those not familiar with it, PCOS is an endocrine condition that affects many women of size (and some women of average size). Between 5-10% of women are thought to have this condition, but  many women go undiagnosed or undertreated.

Symptoms often include irregular or missing periods; hirsutism (excess body hair); significant weight gain and difficulty losing weight; cystic acne; alopecia (thinning hair on the scalp); acanthosis nigricans (dark patches of skin on the thighs, arms, breasts, or neck); and insulin resistance.

However, you don't have to have all of these symptoms to have PCOS, and the condition can present in many different ways. You can take a survey of possible symptoms here.

PCOS is often accompanied by other conditions like hypothyroidism, diabetes, high blood pressure, and many others.  Although many people focus mainly on its effect on childbearing and appearance, PCOS can have life-long health implications.  Therefore, treating it is critical, even if you don't want children or don't care about its cosmetic effects.

A while ago, we started a periodic series about PCOS. We talked about its definition and symptoms, how it presents, its testing and diagnosis, and its possible causes.

If you have not yet read these blog posts, I urge you to do so.  Even if you don't have PCOS, it's important for more people to learn about this condition, how it presents, and its many health implications.

Now it's time to expand the PCOS series with new installments.  This time, let's talk about treatment choices for PCOS.

We're going to do an overview of treatment options for PCOS, and then discuss treatment for the metabolic issues of PCOS and treatment for the cosmetic challenges of PCOS.

Future projected installments will address other aspects of PCOS, such as treatment for fertility concerns, potential pregnancy challenges with PCOS, potential breastfeeding challenges with PCOS, and the impact of PCOS on menopause. But let's focus on treatment of metabolic and cosmetic challenges first.

Why A Series About PCOS Here?

For a long time, I didn't write much about PCOS on my blog or website because there are plenty of other resources on the internet with PCOS information, and I saw no need to duplicate what was already out there.

However, I came back to writing about the topic here because most PCOS websites have a tremendous weight-loss emphasis, leading many fat-acceptance folk to avoid these sites and miss important information about the condition. I wanted to present good, in-depth information without pushing weight loss, something that is very missing in most PCOS resources.

Of course, this is going to displease the weight loss devotees in PCOS circles...both consumers and doctors. The weight-centric paradigm runs very strong in PCOS circles, both in medical research and consumer-based resources. Even the mere suggestion that dieting may be counter-productive is absolute heresy there.

To those folks, I say....Everyone is their own boss. If you wish, you can certainly pursue weight loss as a possible treatment for your PCOS; no one here is going to stop you.  Certainly, there is some research that weight loss can be helpful for PCOS, at least temporarily.  If you want to pursue that, go ahead. There are plenty of PCOS resources out there friendly to that approach.

The problem is that this research, like most research on weight loss, is short in duration, doesn't show long-term outcomes, and completely ignores the risks that can be associated with weight loss.  Does weight loss really benefit your health if you end up heavier afterwards and with more eating-disordered behaviors?  Or if you end up with gallstones or kidney cancer from weight cycling?

Given the overwhelming evidence of poor long-term success with weight loss and the significant harms that can come from yo-yo dieting, it's important to know that there is an alternative, that you can treat your PCOS without having to resort to yet another diet that is likely to fail. This series will not ignore the possibility of weight loss as treatment, but promoting weight loss will not be its focus, unlike 99% of the other PCOS resources out there.  It's vital that we have a resource like this so that folks with PCOS know there is an alternative.

As with any medical situation, readers will have to carefully consider the pros and cons of all their choices and decide what is right for themselves, whether that involves intentional weight loss or stepping into a Health At Every Size® paradigm instead. Whatever you decide for you is fine; just make that decision from an informed place.

But this series is intended to point out that there are treatment approaches that can help mitigate the risks of PCOS without emphasizing weight loss.  

TRIGGER WARNING: If you are a person who would find any mention of weight loss offensive or triggering, you might want to be cautious about the upcoming posts on PCOS Treatments.  Although these PCOS posts will not promote weight loss (most won't even discuss it), a few will mention it as one of the common treatments recommended and why. Those posts that do mention weight loss will have a Trigger Warning clearly posted near the beginning so those who want to avoid any weight loss discussion can do so. 

You should also be very cautious about reading the research summaries and links in all of the PCOS references; these are from traditional PCOS resources, and therefore are full of weight loss promotion.  I include them because I feel it is important to always include reference citations in articles that deal with medical issues, and I include abstracts (or portions of abstracts) so that consumers can quickly scan a summary of the research and vet these arguments for themselves.

It's never my intention to promote dieting in any way, but it's difficult to discuss PCOS adequately without at least passing mention of weight loss issues and posting the relevant references. I've discussed this with the fatosphere monitors and they approved this approach. This advance notification and trigger warnings in any post that touches on weight loss was their suggested way to manage any concerns.

Postscript

At some point, I'd also love to share some stories from PCOS women who follow a Health At Every Size® model. I'd like to see stories on how they manage their condition without a weight-loss emphasis, and how they manage their dealings with weight-centric medical authorities in a proactive and positive way.

If you'd like to share your story, please email me at kmom AT plus-size-pregnancy DOT  org to share your story. Be sure to give me permission to share your story, and let me know how you want it identified (pseudonyms or first names are fine; I strongly discourage use of full names).  Brevity is very important; just give a quick summary of how you manage PCOS without a weight-loss emphasis and why you do so. I reserve the right to edit submissions and to use the submission as needed. After the next series of PCOS posts (and when I have enough entries), I will publish a blog post sharing these stories.

References

Int J Obes Relat Metab Disord. 2000 Sep;24(9):1107-10. Can anyone successfully control their weight? Findings of a three year community-based study of men and women. Crawford D, Jeffery RW, French SA.   PMID: 11033978

This study examined the prevalence, distribution and correlates of successful weight loss and successful weight maintenance over three years in a community-based sample of 854 subjects aged 20-45 at baseline. More than half (53.7%) of the participants in the study gained weight within the first twelve months, only one in four (24.5%) successfully avoided weight gain over three years, and less than one in twenty (4.6%) lost and maintained weight successfully. The findings underscore the importance of current public health efforts to prevent weight gain, and suggest that without much greater efforts to promote and support weight control the prevalence of obesity will continue to rise.

Am Psychol. 2007 Apr;62(3):220-33. Medicare's search for effective obesity treatments: diets are not the answer. Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. PMID: 17469900

The prevalence of obesity and its associated health problems have increased sharply in the past 2 decades. New revisions to Medicare policy will allow funding for obesity treatments of proven efficacy. The authors review studies of the long-term outcomes of calorie-restricting diets to assess whether dieting is an effective treatment for obesity. These studies show that one third to two thirds of dieters regain more weight than they lost on their diets, and these studies likely underestimate the extent to which dieting is counterproductive because of several methodological problems, all of which bias the studies toward showing successful weight loss maintenance. In addition, the studies do not provide consistent evidence that dieting results in significant health improvements, regardless of weight change. In sum, there is little support for the notion that diets lead to lasting weight loss or health benefits.

J Am Diet Assoc. 1996 Jun;96(6):589-92; quiz 593-4. Psychological consequences of food restriction. Polivy J.  PMID: 8655907

A review of the literature and research on food restriction indicates that inhibiting food intake has consequences that may not have been anticipated by those attempting such restriction. Starvation and self-imposed dieting appear to result in eating binges once food is available and in psychological manifestations such as preoccupation with food and eating, increased emotional responsiveness and dysphoria, and distractibility. Caution is thus advisable in counseling clients to restrict their eating and diet to lose weight, as the negative sequelae may outweigh the benefits of restraining one's eating. Instead, healthful, balanced eating without specific food restrictions should be recommended as a long-term strategy to avoid the perils of restrictive dieting.

J Am Diet Assoc. 2007 Mar;107(3):448-55. Why does dieting predict weight gain in adolescents? Findings from project EAT-II: a 5-year longitudinal study. Neumark-Sztainer D, Wall M, Haines J, Story M, Eisenberg ME.   PMID: 17324664 

OBJECTIVE: Dieting has been found to predict weight gain in adolescents, but reasons for this association remain unclear. This study aimed to explore potential mechanisms by which dieting predicts weight gain over time in adolescents. DESIGN: Population-based, 5-year longitudinal study. PARTICIPANTS: Adolescents (n=2,516) from diverse ethnic and socioeconomic backgrounds who completed Project EAT (Eating Among Teens) surveys in 1999 (Time 1) and 2004 (Time 2). MAIN OUTCOME MEASURE: Body mass index (BMI) change over 5 years. STATISTICAL ANALYSIS: Multiple regressions were used to examine associations between Time 1 dieting and Time 2 binge eating, breakfast consumption, fruit and vegetable intake, and physical activity. Associations were then examined between these behaviors and BMI change. Finally, to test for mediating effects, associations between dieting and BMI change were examined with and without the inclusion of these behaviors, and regression coefficients were compared. RESULTS: In female adolescents, dieting predicted increased binge eating (P<0.001) and decreased breakfast consumption (P=0.030). In male adolescents, dieting predicted increased binge eating (P<0.001), decreased physical activity (P=0.006), and a trend toward decreased breakfast consumption (P=0.064). These behaviors were also associated with increases in BMI. The association between dieting and BMI increase was weakened, but still remained significant, after binge eating, breakfast consumption, fruit/vegetable intake, and physical activity were included in the model being tested. Thus, the longitudinal association between dieting and BMI increase was partially mediated by these behaviors. CONCLUSIONS: In part, dieting may lead to weight gain via the long-term adoption of behavioral patterns that are counterproductive to weight management.

Am J Epidemiol. 2007 Oct 1;166(7):752-9. Epub 2007 Jul 5. Body size, weight cycling, and risk of renal cell carcinoma among postmenopausal women: the Women's Health Initiative (United States). Luo J, Margolis KL, Adami HO, Lopez AM, Lessin L, Ye W; Women's Health Initiative Investigators. PMID: 17615089

Although obesity is an established risk factor for renal cell carcinoma, the possible effect of central adiposity and long-term variation in weight has yet to be established. The authors studied 140,057 women aged 50-79 years enrolled in the Women's Health Initiative in the United States to examine the role of obesity, especially abdominal obesity, and weight cycling in relation to risk of renal cell carcinoma among postmenopausal women. Cox models were used to estimate relative risks and their corresponding 95% confidence intervals. During an average of 7.7 years of follow-up through September 12, 2005, a total of 269 incident cases of renal cell carcinoma were identified. Central adiposity, as indicated by waist-to-hip ratio, was an important risk factor for developing renal cell carcinoma (highest vs. lowest quartile: relative risk = 1.8, 95% confidence interval: 1.2, 2.5; p for trend = 0.0003). Moreover, women who had experienced weight cycling more than 10 times were at 2.6 times (95% confidence interval: 1.6, 4.2) increased risk compared with women whose weight was stable. Results add evidence that obesity, particularly central adiposity, is associated with an increased risk of renal cell carcinoma among postmenopausal women. Furthermore, they indicate that weight cycling is independently associated with further increased risk of this malignancy.

Ann Intern Med. 1999 Mar 16;130(6):471-7. Long-term weight patterns and risk for cholecystectomy in women. Syngal S, Coakley EH, Willett WC, Byers T, Williamson DF, Colditz GA. PMID: 10075614

BACKGROUND: Obesity and rapid weight loss in obese persons are known risk factors for gallstones. However, the effect of intentional, long-term, moderate weight changes on the risk for gallstones is unclear...SETTING: 11 U.S. states. PARTICIPANTS: 47,153 female registered nurses who did not undergo cholecystectomy before 1988...RESULTS: During the exposure period (1972 to 1988), there was evidence of substantial variation in weight due to intentional weight loss during adulthood. Among cohort patients, 54.9% reported weight cycling with at least one episode of intentional weight loss associated with regain. Of the total cohort, 20.1% were light cyclers (5 to 9 lb of weight loss and gain), 18.8% were moderate cyclers (10 to 19 lb of weight loss and gain), and 16.0% were severe cyclers (> or = 20 lb of weight loss and gain). Net weight gain without cycling occurred in 29.3% of women; net weight loss without cycling was the least common pattern (4.6%). Only 11.1% of the cohort maintained weight within 5 lb over the 16-year period. In the study, 1751 women had undergone cholecystectomy between 1988 and 1994. Compared with weight maintainers, the relative risk for cholecystectomy (adjusted for body mass index, age, alcohol intake, fat intake, and smoking) was 1.20 (95% CI, 0.96 to 1.50) among light cyclers, 1.31 among moderate cyclers (CI, 1.05 to 1.64), and 1.68 among severe cyclers (CI, 1.34 to 2.10). CONCLUSION: Weight cycling was highly prevalent in this large cohort of middle-aged women. The risk for cholecystectomy associated with weight cycling was substantial, independent of attained relative body weight.