A few years ago, a longtime patient of mine who I see to help manage her polycystic ovary syndrome (PCOS) told me that since her previous visit, she had started working with a therapist who specializes in eating disorders. She admitted to me that she had developed an unhealthy pattern of binge eating.
She noted that one of the driving factors surrounding this behavior was that she would severely limit her carbohydrate intake in an effort to try to lose weight, which she had been told would help improve her PCOS symptoms. But then cravings for sugar would become too intense to ignore and she would binge.
She’s not alone here. This is something I have heard frequently from my patients, and is just recently supported by data.
Is PCOS associated with disordered eating?
PCOS is a syndrome, not a disease. It is a constellation of symptoms that includes irregular periods, signs of high male hormone levels like acne and body hair growth, and cysts on the ovaries. For many women, unexplained weight gain associated with insulin resistance are prominent features. Despite the fact that PCOS is common, affecting about 10% of women, we do not understand what causes it.
The association between PCOS and mental health disorders such as depression and anxiety is well established. But until recently, the connection between disordered eating and PCOS was not as well understood. Studies looking at possible connections were small, despite the fact that PCOS is the most common endocrine disorder in women.
A recent meta-analysis increases our understanding of the connection between PCOS and disordered eating. The authors analyzed data from 20 studies, including a total of nearly 29,000 participants. They found that women with PCOS were about 50% more likely to be diagnosed with an eating disorder. The eating disorders most commonly associated with PCOS involve binging behaviors, both binge eating disorder and bulimia nervosa — a disorder that involves binge eating and purging either by self-inducing vomiting or the use of laxatives.
Of the 20 studies included in the analysis, five stratified participants by body mass index (BMI). Interestingly, increased risk of eating disorders was seen among women at all BMIs. This means that body size alone does not explain the risk for disordered eating. And it means women with PCOS of any body size are at increased risk for disordered eating.
Why is disordered eating more common in women with PCOS?
This study does not tell us why women with PCOS are at increased risk for disordered eating, merely that they are. But there are a few theories out there. Because women with PCOS are at increased risk for metabolic diseases, such as diabetes and heart disease later in life, they are often advised to lose weight.
The authors note that the increased emphasis placed on encouraging weight loss among women with PCOS may trigger disordered eating. We know that women with PCOS often have insulin resistance, which makes it more difficult to lose weight. As a result, women may resort to extreme dieting in an effort to follow the advice from their doctor.
Though the mechanisms are not well understood, insulin resistance may play a role in driving cravings and binging behaviors. Researchers are currently looking into how medications that improve insulin sensitivity may be useful in treating binge eating disorder. Early trials are promising, but we larger-scale randomized controlled trials to fully understand the role of insulin in binge eating and how medications that improve insulin sensitivity might be useful for managing those behaviors in women with PCOS.
How does this association inform my approach to managing PCOS?
This study, along with the recent study suggesting that BMI is a less important determinant of chronic health risks than previously thought, is helping me redefine my goals for my patients with PCOS. Rather than focusing on weight as an outcome, I work with my patients to take a holistic view of their PCOS symptoms.
My patients and I work together to help them develop a healthy lifestyle that includes a diet rich in lean proteins, green leafy vegetables, and whole grains, as well as an exercise routine focused on developing physical fitness rather than on weight loss. I talk to my patients with PCOS about their risk for mental health disorders and ask about disordered eating explicitly. Now more than ever, I partner with patients’ therapists and psychiatrists to develop a plan that may include GLP-1 receptor agonists like semaglutide (Ozempic/Wegovy) if appropriate.
I find that de-emphasizing weight loss and focusing more broadly on PCOS symptom management leaves patients feeling healthier and more satisfied with their progress.
The bottom line
- A new meta-analysis suggests that women with PCOS are at increased risk of developing binge eating disorder and bulimia nervosa.
- We don’t understand the mechanisms driving this risk, but an emphasis on weight loss and insulin resistance may play a role in increasing binging behaviors.
- Taking a holistic approach to managing the metabolic health of women with PCOS may help them reduce their risk for chronic disease without triggering disordered eating.
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