Jennifer was a typical patient presenting for weight management. She was 42 years old with unexplained weight gain, difficulty losing weight, and a family history of type 2 diabetes. She’d had irregular periods for years, but she wasn’t concerned because she’d never wanted to get pregnant. She attributed her erratic menstrual cycle to her excess weight. Recently, she’d noticed skin tags and dark patches of skin on her neck, and she wondered if these might be caused by her obesity as well. Her labs showed an elevated insulin level.
She had never been diagnosed, but Jennifer’s symptoms immediately suggested polycystic ovarian syndrome (PCOS). PCOS is a common endocrine condition (affecting 4%–18% of women of reproductive age, depending on the diagnostic criteria used) involving changes in two types of hormones: androgens and insulin. Increased androgens can cause growth of excess body or facial hair, acne, and hair loss from the scalp, while increased insulin can lead to acanthosis nigricans and skin tags, weight gain (especially around the waist), and difficulty losing weight. Both hormones can cause menstrual irregularity, inhibit ovulation and reduce fertility. They can also increase risk of earlier onset type 2 diabetes, produce mood changes, and result in other negative psychological effects.
Naturally, not all women with PCOS experience every potential sign and symptom, but the wide variety of manifestations means that a range of health providers — primary care physicians, OB-GYNs, endocrinologists, dermatologists and obesity medicine specialists, for example — may care for patients with PCOS.
The condition frequently goes undiagnosed, though, especially in women who are on birth control and thus don’t have irregular periods. When PCOS is diagnosed, treatment often focuses on relieving specific symptoms (for example, regulating menstruation or eliminating excess hair) without addressing underlying or exacerbating factors — including, more often than not, excess weight.
The need for a weight-centric approach
While obesity’s role in the development of PCOS varies among patients, the two conditions are closely correlated. Some studies suggest that up to 80% of women with PCOS in the U.S. have overweight or obesity. Furthermore, obesity exacerbates many of the signs and symptoms associated with PCOS, as well as the underlying hormonal abnormalities. Obesity also impacts the progression of insulin resistance and development of metabolic syndrome. For this reason, treating the patient’s obesity is often an early step in managing PCOS.
Many providers are aware of the nexus between obesity and PCOS, but they either don’t realize the extent to which weight loss can improve outcomes — restoring regular menstruation, enhancing response to ovulation-inducing medications, and improving androgen levels as well as metabolic markers — or they assume their patients have already tried to lose weight so there’s no point in bringing it up. Unfortunately, many providers don’t feel comfortable talking to their patients about their weight, let alone treating it.
This hesitancy to address obesity is a disservice to patients, though, and the benefits of weight management in the treatment of PCOS need to be more widely recognized, just as they are in the treatment of type 2 diabetes. Since weight loss can lead to significantly improved health outcomes for individuals with type 2 diabetes, weight management is incorporated regularly into diabetes and pre-diabetes care. There’s also a growing focus on substituting medications that promote weight gain.
“The push in the field of endocrinology is to practice weight-centric rather than glucose-centric diabetes management,” says my endocrinologist colleague Dr. Leon I. Igel. “While controlling glucose levels remains paramount, doing so via medications that cause weight gain should be avoided, as this can lead to patients not following the treatment plan, as well as worsening of obesity-related health complications. Practitioners are encouraged to prioritize weight-loss-promoting or weight-neutral medications as first-line treatment in type 2 diabetes. We should take a similar approach in PCOS management, where certain weight-gain-promoting oral contraceptives, for example, are sometimes prescribed.”
Pharmacotherapy steps up
Not all patients with PCOS have overweight or obesity, but for the many who do, the diabetes medication metformin can be an effective first-line treatment to promote weight loss (in combination with a healthy diet and physical activity) while helping to balance hormones. A glucagon-like peptide 1 (GLP-1) receptor agonist, such as liraglutide or semaglutide, can be considered as a second-line treatment if metformin is ineffective. We have a growing armamentarium of pharmacotherapy options to support weight management, including medications approved specifically for obesity treatment and medications that treat both weight and insulin resistance that can be prescribed off-label. Finally, I couldn’t be more excited about the promising new medications in the pipeline.
Jennifer expressed relief when I suggested a potential diagnosis of PCOS because it provided an explanation for all her signs and symptoms, and it allowed her to stop blaming herself for her inability to lose weight. She responded well to metformin, which we introduced together with a low-glycemic diet and increased physical activity. Within a few months, not only had Jennifer begun to lose weight, but her periods normalized and her skin conditions improved as well.
Weight loss for better patient outcomes
Obesity is a complex multifactorial disease, and the fact that it affects so many body systems and it is linked to so many other conditions (PCOS is just one of 200 medical conditions associated with obesity!) can feel daunting. But the flipside is that effectively treating obesity can have a tremendously positive impact on many of these correlated conditions, even if we don’t understand all of the physiological mechanisms or causal pathways in every case.
And sometimes it doesn’t take much, because even a small amount of weight loss can lead to better clinical outcomes. For example, we can see improved glucose tolerance with a loss of just 2.5% of body weight. Improvements in menstrual irregularities and a subsequent successful pregnancy are more likely with a loss of 2%–5%, with more weight loss leading to a greater benefit.
Jennifer’s story is not at all unusual. Weight loss, especially with the help of a medication that simultaneously combats insulin resistance and hormone imbalance, is one of the most effective ways to treat PCOS in women with obesity — though it’s not a silver bullet, of course.
Providers who don’t feel comfortable counseling about diet and exercise or prescribing metformin or other weight-loss-promoting medications can refer their patients to an obesity specialist. An important first step is to recognize the correlation between PCOS and obesity, and start thinking about weight loss as a way to help patients achieve the outcomes that matter to them — whether that means getting pregnant, alleviating distressing acne, or reducing the long-term risk of developing type 2 diabetes and cardiovascular disease.