Do I Have Lean PCOS?

PCOS, or polycystic ovarian syndrome, is a hormone-related condition that can affect your cycle and fertility. If untreated, PCOS can eventually develop and increase the risk of type 2 diabetes. It is diagnosed by having two out of the following three listed below. As a syndrome, it is a collection of symptoms that are person-dependent. Because of this, PCOS can present very differently from person to person. It is important to understand the root causes driving your polycystic ovarian syndrome.

Polycystic Ovarian Syndrome is diagnosed when you have 2 out of the 3 (or possibly all) of the following:

1. ELEVATED ANDROGENS (TESTOSTERONE / DHEA)

Testosterone (ovarian) can be elevated due to insulin resistance. This is because increased blood insulin signals the ovaries to produce more testosterone
DHEA (adrenal) can be elevated due to stress/inflammation. DHEA is an enzyme combined with testosterone, and at elevated levels leads to acne and hair loss.

2. POLYCYSTIC OVARIES ON ULTRASOUND

Small cysts due to the follicle trying to produce an egg
DIFFERENT from an ovarian cyst

3. ANOVULATORY CYCLES / IRREGULAR PERIODS

Irregular periods due to lack of or delayed ovulation
Stress, high testosterone levels can affect ovulation

Common Symptoms of PCOS:

Irregular periods
Acne
Hair loss
Hirsutism (unwanted hair growth)
Long menstrual cycle
Irritability
Depression
Oily skin
Insulin resistance
Infertility
Dark skin patches
Headaches
Food cravings
Anxiety

While weight struggles may be a common symptom those with PCOS may experience (often linked to insulin resistance and/or adrenal dysregulation), not every person with PCOS will experience weight gain or difficulty losing weight. You can have PCOS in a lean body.

Everybody with PCOS will benefit from understanding their unique root causes. When you uncover and address the root causes driving your symptoms, that is when you can truly find long-term symptom relief. PCOS is a life-long condition, but you can manage symptoms naturally.

Identifying your root causes:

DO I HAVE ELEVATED ANDROGENS? IF SO, WHICH ONES?

Check testosterone and DHEA
Knowing if you have elevated androgens is important because elevated androgen levels can induce symptoms like hirsutism (unwanted facial hair growth), acne, low libido, and hair loss. These elevated levels contribute to PCOS and can result in insulin resistance which if untreated can develop into type 2 diabetes.

Source: University of Rochester Medical Center, 31466345, 25008465

DO I HAVE POLYCYSTIC OVARIES ON AN ULTRASOUND COMPLETED BY MY DOCTOR?

Diagnostic criteria: A polycystic ovary is one that contains 25 or more follicles using new ultrasound technology measuring 2 to 9 mm in diameter or an ovary that has a volume of greater than 10 mL on ultrasonography.
The polycystic ovaries mean the follicle is trying to produce an egg, but having a difficult time and may result in anovulatory cycles
These are different than ovarian cysts that can cause pain. Pain is not a symptom of PCOS. It is possible to experience period pain if you have PCOS but it would have a different root cause.

Source: 26807298

AM I OVULATING? IS MY PERIOD IRREGULAR?

Diagnostic criteria: A period is considered irregular if your cycle is less than 21 days or more than 35 days, missing 3 or more periods in a row, or if your flow is much lighter or heavier than usual. Having a regular period is dependent on ovulation and also hormones. It is vital to have a normal period because if you don’t this is your body sending you a signal that there is something imbalanced with your hormones.
It is common to experience a long cycle when you have PCOS

Source: NIH

DO I HAVE INSULIN RESISTANCE?

70% of those with PCOS have insulin resistance.
It is important to note if you have it because this could be driving higher testosterone levels.

Source: 22192137

AM I FAVORING THE 5-ALPHA PATHWAY FOR ANDROGEN METABOLISM?

Androgens will utilize either the 5-beta or 5-alpha pathway.
The 5 alpha pathway is an enzyme that helps to convert testosterone into DHT and can cause acne, hair loss, and hirsutism. This pathway's usage can be an answer to what is polycystic ovarian syndrome for you.
Using the 5-alpha pathway means that you can be up to 3x more symptomatic than if you are favoring the 5-beta pathway. This is why even if your testosterone or DHEA is not significantly elevated, but you are favoring this way of metabolism then you can experience symptoms like acne, hair loss, and hirsutism.

Source: 7636302

HOW IS MY GUT HEALTH?

Inflammation in the gut can impact hormone levels.
Patients with PCOS have been found to contain a fewer diversity of gut bacteria and this is inversely related to androgen levels.

Source: 32109968

DO I HAVE SIGNS OF INFLAMMATION?

Signs of inflammation include chronic digestive issues, autoimmune conditions, skin issues, fatigue, headaches, joint pain, food sensitivities. You can also test a marker of systemic inflammation called hs-CRP.

Source: 29467962

HOW ARE MY OTHER HORMONES?

Hormones are such a key feature for what is polycystic ovarian syndrome.
Hormones are all connected and an imbalance in one means there is usually a compensation somewhere else. Checking estrogen, progesterone, and cortisol levels can be helpful in addition to FSH, LH, SHBG, and prolactin to get a picture of your overall hormone levels.
PCOS is a hormonal condition, so it is important to not only check your androgens but also your other sex and adrenal hormones to better understand your hormone health.

HOW ARE MY ADRENAL GLANDS?

Stress can affect our delicate hormone balance.
If DHEA (androgen) is elevated this can be a sign of stress and inflammation. DHEA is your adrenal androgen and if it is elevated could be one of the diagnostic criteria for PCOS
Additionally, check cortisol levels at 4 points throughout the day. First thing in the morning, before lunch, before dinner, and then right when you go to bed.
Understanding these 4 points can give a clue into how you manage stress and also how it varies throughout the day.

Source: 29681710

Important considerations for lean PCOS:

20-30% of all women with PCOS are an average weight or considered to have a lean body type. 5% of all lean women have PCOS. Lean PCOS means that you have a leaner body composition with more muscle mass than the average. This classification is not a representation of good or bad, it is just a measurement. The word lean does not only consider BMI because BMI does not factor in body fat percentage, muscle mass, and water retention. The better measurement to use is the waist to height ratio, this will take into account the proportion of your body. The waist to height ratio has been used to predict the risk of diabetes, and insulin resistance.

Source: 29285778, 20436797

1. Insulin Resistance

Around 75% of those with lean PCOS are insulin resistant. Insulin is the hormone that carries sugar into cells for energy, when cells reject the insulin this is called insulin resistance. To know if you are insulin resistant you should check markers such as HOMA-IR, QUICKI, Hyperinsulinemic, and Glycemic Clamp because insulin resistance is not always shown using just fasting glucose and hemoglobin A1c methods. This is because many women with lean PCOS have an extreme hypersensitivity to insulin after meals. As a result, these women will have hypoglycemia (drop in blood sugar 1-1.5 hours after eating) after eating because their insulin quickly shuttles blood sugar into cells. Checking for hypersensitivity to insulin is therefore an early indicator of insulin resistance.

Source: 24353584

2. Progression of insulin resistance in lean PCOS

Since insulin hypersensitivity is an early indicator of insulin resistance, here is the progression women with lean PCOS take. Usually, this starts with a genetic predisposition to have insulin hypersensitivity where after meals women release insulin and the cells rapidly uptake the glucose from the insulin. This leads to a rapid decline in blood sugar called hypoglycemia. Following hypoglycemia after meals, women with lean PCOS will increase their food intake to bring blood sugar levels back up which will increase stored fat. This is because the cells are already full with glucose so the insulin has to take it to the fat cells instead. As a result, insulin resistance can occur in lean women with PCOS because of excess energy stored in fat cells.

Source: 15181081, NIH

3. Labs to Check

To see if you have lean PCOS you need to check a few labs. First, you need to test fasting insulin and fasting glucose to check how well you are utilizing glucose for energy. Then take these numbers and put them in the HOMA-IR calculator online to see if you are lean, average, or below average. Next, take your results and input them into the QUICKI calculator to see if you are insulin resistant. This method may be more sensitive and it is always good to use more than one method to check for insulin resistance.

Source: 31384717, 31108989

4. Hormonal Communication

Hormone communication is also important to consider in those with lean PCOS. Luteinizing hormone (LH) generally is found to be higher in ratio to follicular stimulating hormone (FSH) in classic PCOS. Those with lean PCOS can make this ratio even larger. To check these levels, test them on day 3 of your cycle.

Source: 33041447

5. High DHEA-S

DHEA stands for dehydroepiandrosterone sulfate and is the adrenal androgen that is more common in lean PCOS because it increases metabolism to make their lean body mass higher than classic PCOS.

Source: 25008465

6. Balance Blood Sugar

Balancing blood sugar is important for classic and lean PCOS. There are many misconceptions that those with PCOS can’t eat carbohydrates but this is false. PCOS can be regulated and maintained while keeping carbohydrate intake moderate. The way to balance blood sugar is to eat consistently throughout the day and at every snack or meal try to incorporate a fat, protein, and fiber source each time. This will slow the absorption of glucose into the bloodstream.

Source: 29419785

7. Incorporate Strength Training

Strength training will greatly improve insulin delivery to the muscle tissues in those with lean PCOS. Growing muscle mass aids in the delivery of glucose to the muscle cells for energy and power.

Source: 20351587, 15628572

8. Manage Stress

Stress is a large thing to consider in those with lean PCOS. Stress is the root cause of elevated adrenal DHEA. This androgen leads to the progression of PCOS and insulin resistance. In addition, high stress results in decreasing all the other reproductive hormone levels like estrogen and progesterone. The limiting of these hormones leads to infertility, irregular periods, and hair loss.