A Natural Approach
In this article, we’ll dive into what lean PCOS is, the unique health challenges associated with it, and a holistic approach to tackling it.
Polycystic ovarian syndrome (PCOS) affects 6 to 12% of women of reproductive age in the United States.1 It’s a common cause of female infertility, but it’s often a lot more than that. Left untreated, it can lead to serious health problems.
A common misconception is that all women with PCOS are overweight or obese. But this isn’t always the case.
What is Lean PCOS?
PCOS is a set of symptoms related to a hormonal imbalance between androgens and other hormones. The condition affects women and girls of reproductive age.
Androgens, like testosterone, are hormones that primarily influence male reproductive health and body development. Despite this association, healthy women have small amounts of androgens as well.
But the balance between androgens and other hormones can be thrown off for a variety of reasons. Insulin is the major driving force for excess androgen production. Other underlying factors are still unclear. But what is clear is that this imbalance results in PCOS.
Approximately 80% of women with PCOS have an above average or high body mass index (BMI). That leaves 20% of women who don’t fit the weight criteria but exhibit many of the other symptoms of PCOS.
PCOS in women with normal or below normal BMI are often said to have “lean PCOS.”
Symptoms of Lean PCOS
Symptoms of lean PCOS tend to be similar to those of non-lean PCOS and can include:2
- Darkening of skin creases
- Menstruation cycles issues, such as irregular or heavy periods, or no bleeding
- Excessive growth of dark or coarse hair in a male-like pattern
- Loss or thinning of hair
- Unusual thickening of the endometrium
- Fertility issues
- Insulin resistance
To learn more about how these symptoms may come about, check out my blog post Holistic Approach to Polycystic Ovarian Syndrome.
Diagnosing Lean PCOS
Getting an accurate diagnosis of PCOS prior to starting treatment is critical. I prefer to use the Rotterdam criteria created by the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine.
The Rotterdam criteria indicates that a diagnosis of PCOS can be made only if at least two of the following three features are met:3
- Polycystic ovaries on ultrasound
- Anovulation (no egg released from ovary) or oligo-ovulation (irregular or infrequent periods)
- Clinical and/or biochemical signs of high androgen levels, such as facial hair growth, acne, or alopecia
PCOS – regardless of type – is a diagnosis of exclusion. Your provider should also work with you to rule out other endocrine disorders, such as Cushing’s syndrome and thyroid dysfunction.
Unique Challenges of Lean PCOS
Because PCOS has such a strong link to obesity, many women with lean PCOS are misdiagnosed or not diagnosed for years. Some women may not be diagnosed until they struggle to conceive.
Lean PCOS isn’t the only diagnosis that can be delayed. Lean women with PCOS may also experience delayed diagnosis of other conditions commonly associated with excess weight, such as type 2 diabetes and heart disease.
Lean women with PCOS may also experience more anxiety, according to one study. Although the study was small, the results showed that lean women tended to have a lower resistance to stress compared to overweight women with PCOS. The lean women in the study also had higher levels of the hormone adrenocorticotropic hormone (ACTH), which is associated with chronic stress.4
Fertility treatments like metformin can help normalize menstrual cycles, improving fertility outcomes in overweight women with PCOS. Research so far is inconclusive as to whether the same holds true for lean women with PCOS.
Some studies have shown that metformin could have great benefits for women with lean PCOS, such as higher ovulation and increased pregnancy rates.5 In one study, metformin also reduced androgen levels.6
But results from other studies suggest little to no benefits.7
Insulin is a hormone produced by your pancreas in response to food being broken down into glucose molecules. As glucose enters your bloodstream, insulin helps push the molecules into your body’s cells, where they are stored for later use. Once they’re properly stored, your blood sugar levels decrease, signaling insulin levels to decrease as well.
But this intricate system can quickly go haywire.
In some cases, your body finds it difficult to break down a large amount of glucose. Your pancreas is forced to produce more and more insulin in an effort to keep up. Over time, your cells stop responding to insulin, a condition called insulin resistance. Eventually, your blood sugar levels continue to rise as your pancreas can no longer keep up with the demands.
The exact cause of insulin resistance remains unclear. And even though excess weight can contribute to insulin resistance, experts agree that other factors are involved, since between 6 to 22% of women with lean PCOS have insulin resistance.8
More information about insulin resistance can be found in my article Blood Sugar and Insulin: Finding Balance for Fertility and PCOS.
A Holistic Approach to Treating Lean PCOS
Treating PCOS – lean and non-lean – can be complex. That’s why I use a holistic approach, taking into account your symptoms, history, whole person picture, and lab work.
I recommend starting with in-depth hormone testing and basic blood work to measure your insulin and lipids.
I also work with my patients to identify the factor(s) driving their symptoms — adrenal/stress, metabolic, inflammatory, or post-pill.
My approach to treating lean PCOS involves 6 key components:
Diet for Lean PCOS
You’ve likely heard the saying “you are what you eat” – and that includes your hormones.
Despite the acknowledgement that nutrition plays an important role in PCOS treatment, there is no consensus on which diet is best.9
Eating to improve blood sugar stability and reduce insulin levels lies at the heart of treating lean PCOS. One of the main goals is to increase your metabolic flexibility, or the ease by which your body adapts to and uses whatever fuel is available (fat or sugar).
When you lack metabolic flexibility, your body is unable to switch between burning carbs and burning fat for energy. This may lead to increased amounts of fat stored in your body and androgen excess. Research shows that the metabolic inflexibility among women with PCOS is similar to that of women with type 2 diabetes.10
But a diet for PCOS isn’t all about insulin resistance. It’s important to develop a healthy relationship with food by moving away from fad diets to mindful eating.
There’s no single diet that will work for all women with lean PCOS.
Any diet changes I make for my patients are personalized to meet their unique needs. Some women have to be really vigilant with blood sugar control while others can make simple modifications. Keeping a food log or journal will help both of us understand what works best for you.
Weight-Bearing Exercise for Lean PCOS
Women with lean PCOS typically have metabolic changes that put them at a higher risk for cardiovascular disease. Fortunately, there is now irrefutable evidence that exercise can reduce your risk.
But which type of exercise is best for lean PCOS?
According to one meta-analysis of 16 studies, resistance training was the most effective at reducing androgen levels. Resistance training includes all forms of exercise (including yoga) that use some form of weight, including your own body weight. In contrast, moderate and vigorous aerobic exercise only resulted in small reductions in androgrens.11
The same analysis found that exercise frequency influenced androgen levels. In other words, the participants who strength trained more frequently tended to have greater decreases in their androgen levels.11
What does this mean for you?
Aim for 30-minutes of weight bearing activity 3 times per week. Not sure where to start? Try joining a class or getting a workout buddy. Surrounding yourself with people who support your goals will help raise your chances for success.
Sleep for Lean PCOS
Growing up, you may have been told to get 7 to 9 hours of sleep every night to stay healthy. Sleep disturbances can have significant social and health consequences, including depression.14
But fulfilling those 7 to 9 hours is a challenge for many, especially for women with PCOS. One study looked at questionnaire responses from over 6,500 Australian women with and without PCOS. Investigators found that women with PCOS were more likely to have difficulty sleeping and severe tiredness compared to women without PCOS.15 The findings were true even after accounting for other factors that can result in sleep disturbances, such as BMI.
Why does PCOS affect your sleep?
One of the primary reasons is the higher risk of obstructive sleep apnea — the intermittent blockage of your airways during sleep — among women with PCOS.16
Hormonal imbalance can also wreak havoc on your sleep. In turn, poor sleep can affect your hormone levels, leaving you stuck in a vicious cycle. We also know that women with PCOS often have lower progesterone levels due to anovulation. Progesterone, a calming hormone, is important for reducing anxiety and supporting calm and restful sleep.
To optimize your sleep, try some of the following tips:
- Avoid caffeine after noon
- Aim to be in bed by 10:00 PM
- Take multivitamin- and B-vitamin-containing supplements before noon
- Create a soothing bedtime routine
- Stop eating three hours before bedtime
- Avoid stimulating media before bed
Find more tips in 20 Tips for Sleep and Women’s Health.
It’s especially important to avoid lights and screens one to three hours before bedtime. Research studies have found that women with PCOS have higher levels of melatonin than those without PCOS, suggesting that the hormone may be involved in the development of the disorder.
Women with PCOS also exhibit a greater vulnerability to disruption in their menstrual cycles from light exposure than healthy women do, indicating the need to avoid light before bedtime.17
Stress Management for Lean PCOS
One of the primary diagnostic criteria for PCOS is excess androgen levels, also known as the “male” sex hormones. In addition to testosterone, androgens include:
- Dehydroepiandrosterone (DHEA)
- DHEA sulfate (DHEA-S)
- Dihydrotestosterone (DHT)
So what causes these “male” hormones to be elevated in women?
While ovaries typically get the blame, a large source of androgens actually come from your adrenal glands.18 When you’re under stress, your pituitary gland secretes ACTH. In turn, ACTH stimulates the production of your adrenal androgens: DHEA, DHEA-S, and androstenedione.
Normally, these hormones help protect your brain from damage, including from the negative effects of stress.19 But they’re also responsible for the common symptoms of lean PCOS.
A diagnosis of lean PCOS can pose a significant psychological burden throughout your life. Some stress is inevitable in your daily life, but it’s essential to find healthy stress management methods. Find effective ways to help you manage stress, like engaging in activities you enjoy.
Bioidentical Hormone Replacement Therapy for Lean PCOS
Many women turn to hormone replacement therapy (HRT) to correct hormone imbalances. Among the many imbalances is progesterone, which helps regulate your menstrual cycle and pregnancy, among other things.
Several studies suggest that there is receptor resistance to progesterone in women with PCOS.20 This means the tissues on which progesterone acts are less responsive to its effects, resulting in symptoms like abnormal menstrual cycles.
At this point, you may be wondering: would adding progesterone help correct this imbalance?
Possibly. HRT can be a useful and effective tool to help manage your symptoms. But the source of the hormone could make a big difference.
Traditional HRT uses synthetic hormones isolated from pregnant horse urine.21 While they may be effective, research studies have repeatedly linked traditional HRT to certain types of cancer and cardiovascular disease.22
Such risks clearly outweigh the benefits of traditional HRT.
Women with lean PCOS may find relief from their symptoms with bioidentical hormone replacement therapy, or BHRT.
The hormones used in BHRT come from plants. Because they are chemically identical to the natural hormones found in your body, they create fewer harmful by-products. The result? Fewer risks and greater, faster benefits.23
Herbs and Supplements for Lean PCOS
Natural supplements and herbs may help enhance your well-being and treat symptoms of lean PCOS. They include:
- Inositol: This naturally occurring sugar helps regulate your blood sugar and may help raise your insulin sensitivity. A 2018 review found that inositol may help regulate menstrual cycles and improve ovulation in women with PCOS.24
- Berberine: The primary active compound of the plant Rhizoma coptidis, berberine may help manage symptoms associated with PCOS, such as high blood sugar.25 One analysis of 5 studies (1,078 women total) found that berberine helped increase insulin sensitivity and reduce visceral fat. The results showed that berberine may be effective in boosting fertility and live birth rates.26
- Reishi: Known as the “mushroom of immortality,” reishi is well-known and well-studied for its immune-modulating effects. What many people may not know is that reishi can also inhibit testosterone. In an animal study, researchers found that reishi can prevent the conversion of testosterone into the more potent DHT.27
- Peony: Paeoniflorin is a compound found in white peony, an important herb in traditional Chinese medicine. A laboratory study showed that paeoniflorin can block the production of testosterone and promote the conversion of testosterone to estrogen.28
- Probiotics: Some experts have raised the possibility of gut dysbiosis (disturbances in the gut microbiome) as the root cause of PCOS.29 Animal studies have confirmed that certain species of gut bacteria are lower in those with PCOS than in their healthy counterparts.30 A clinical study showed that probiotics can raise insulin sensitivity and lower systemic inflammation.31 While this study was done in male volunteers, it raises the possibility that probiotics could support insulin sensitivity in women in PCOS.
- Methylated vitamins: Another potential cause of PCOS is a mutation in the methylenetetrahydrofolate reductase (MTHFR) gene. The MTHFR gene is responsible for producing an enzyme that makes folate available to your body through a process called methylation. During methylation, a methyl group (a carbon atom bonded to three hydrogen atoms) is added to another molecule. When MTHFR isn’t working as it’s intended to, your body can’t convert folate to methyl-folate. Low folate concentrations are also associated with high homocysteine levels — a risk factor for cardiovascular disease.32 If you have an MTHFR mutation, you may benefit from methylated folate supplements and others like zinc.
You can find a few of my favorite supplements for lean PCOS here.
Keep in mind that lean PCOS is a complex condition, and what works for one person might not work for you.
Always talk to your doctor before starting any new treatments. It’s critical that you also check your thyroid and iron status prior to taking any supplements as they can worsen your symptoms.
It’s Possible to Thrive With Lean PCOS
If you have lean PCOS, you may have suffered for years without clear answers because you never “fit” the picture of the typical PCOS patient.
You knew there was something not right with your body, but you were told again and again that there was nothing wrong.
I get it. There’s so much to lean PCOS that we don’t yet understand. But it’s possible to not only live, but thrive, with lean PCOS. It won’t be a quick fix – it’ll take about 3 months for you to see positive changes in your symptoms. After six months of consistent care, your hormones should establish a more regular pattern.
As a woman’s hormone health expert, I can help you put all the pieces together and find harmony again. Schedule a free 15-minute consultation to learn more about how I can help you.