Tuesday, February 22, 2011

Are Polycystic Ovary Syndrome and Eating Disorders Related?
By Angela Grassi, MS, RD, LDN
Today’s Dietitian
Vol. 8 No. 10 P. 32
Life the age-old chicken and egg debate, what comes first: the eating disorder or PCOS? Resarchers theorize that disordered eating could lead to PCOS and vice versa.

The first time I heard of polycystic ovary syndrome (PCOS) was in 1999 while working for an eating disorder treatment facility. A patient named Sarah, age 27, tearfully explained the symptoms she was experiencing: severe acne and hair growth on her face, absent periods, thinning hair, and her weight had been increasing nearly 2 pounds per month for the past year. She hated her body and believed it was out of control. She had been diagnosed with PCOS three weeks prior and her doctor recommended that she try the Atkins diet to manage her insulin and lose weight. Through the tears, Sarah admitted that she had tried to follow the diet but just kept bingeing on carbohydrates and felt so guilty afterward that she purged to get rid of them. Sarah also had a long history of bulimia nervosa (BN).

What Is PCOS?
PCOS is perhaps the most complex endocrine disorder, affecting 5% to 10% of reproductive-age women, and is the No. 1 cause of infertility.1 It is characterized by high levels of androgens (male hormones such as testosterone) from the ovaries as well as elevated follicle-stimulating hormone (FSH) and low levels of luteinizing hormone (LH). Tiny cysts, hence, “polycysts,” usually, but not always, surround the ovaries, appearing on ultrasound as a strand of pearls. The cysts are a result of hormonal imbalances, not the cause of them.

An estimated 50% to 70% of women with PCOS are also insulin resistant and experience weight gain in the abdominal area, difficulty losing weight, hypoglycemic episodes, and intense cravings for carbohydrates.2,3 In addition, many women with PCOS are overweight or obese and are at risk for developing diabetes and heart disease. Other signs and symptoms of PCOS may vary among individuals both in intensity and type and include excessive hair growth on the face and body (hirsutism), alopecia, acne, skin problems, and irregular or absent periods. Because most of these signs and symptoms have a direct effect on body image, not to mention struggles with weight and intense carbohydrate cravings, many researchers have questioned the theory that a relationship exists between PCOS and eating disorders.

Menstrual Disturbances
It is widely accepted that women with eating disorders, including anorexia nervosa, BN, or a combination of several symptoms of eating disorders commonly referred to as eating disorder not otherwise specified (EDNOS), have menstrual disturbances.4-6 And much like with PCOS, these menstrual disturbances include anovulation and oligomenorrhea (menstrual cycles longer than 40 days).7

In a recent study, researchers examined the hormonal dysfunctions associated with improper eating habits among 14 subjects with BN and 22 subjects with EDNOS.7 They found decreased levels of FSH and LH among both groups, and the EDNOS group had the lowest levels of the two hormones as well as higher amounts of testosterone than subjects in the control group. The researchers suggest that a reason why many women with BN and EDNOS may have menstrual disturbances is related to low levels of LH, which is a sensitive variant affected by dramatic changes in eating habits.7 Thus, crash dieting or restricting—common behaviors for individuals with BN and compulsive eating habits—may cause low levels of LH, resulting in an insufficient luteal phase and producing oligomenorrhea or anovulation.

The Emotional Toll
Like my patient Sarah, the symptoms many women with PCOS endure can have a direct effect on their body image and self-esteem and may lead to the development of distorted eating habits or eating disorders.8 Although there does seem to be a genetic component to PCOS development, with studies indicating that some girls are even born with cysts on their ovaries, most symptoms do not appear until the onset of puberty—another factor in common with eating disorders.9

For example, at a time when a young woman’s self-esteem is vulnerable, she may start to experience acne, excessive hair growth on her face and other parts of her body, and weight gain in her midsection—setting her apart from her peers. Not knowing she has PCOS or why her body is reacting the way it is, she may begin to blame herself and hate her body. Struggling with these issues at such a vulnerable time can lead many young women to deal with emotional distress through unhealthy dieting practices such as taking laxatives and diet pills, fasting, and engaging in excessive exercise and vomiting—all of which could set the stage for a lifetime of eating issues and body hatred.

Researchers have investigated the relationship between monozygotic and dizygotic twins with PCOS and BN by using the BITE (Bulimia Investigation Test, Edinburgh) questionnaire, a self-rating scale used to diagnose BN that includes 30 questions about dieting and binge behaviors such as, “Does your pattern of eating severely disrupt your life?” “Do you ever experience overpowering urges to eat and eat?” and “Do you ever fast for a whole day?”10

They found that 76% of twins with PCOS had elevated scores on the BITE, suggesting that a relationship does exist between BN and PCOS. Other studies conducted using the BITE questionnaire support a relationship between PCOS and binge eating, with one third of women with PCOS in one study having binge eating behavior.11

Jessica Setnick, MS, RD, LD, creator of Eating Disorders Boot Camp and a specialist in eating disorder treatment, has noted the connection between binge eating and PCOS. She says, “Many women with PCOS are so frustrated with their diagnosis. They feel immense pressure because they really want to lose weight and improve their symptoms, so they’ll restrict carbohydrates in order to lose weight.” But, she adds, “sometimes they eat such little amounts of food and, combined with their carbohydrate cravings, they end up bingeing and feeling even more horrible about themselves.” Thus, a vicious cycle ensues.

In addition, women with PCOS, because of their hormonal imbalances, may be more prone to mood swings and depression than women without PCOS. Elevated testosterone may make women with PCOS more aggressive, angry, anxious, and depressed, but many women with PCOS may also have mood disturbances from dealing with the symptoms associated with their diagnosis.12 Codiagnosis of other mental health problems is common among people with eating disorders.

The Insulin Effect
It is understandable that women with PCOS may become more susceptible to developing an eating disorder and suffer from body image disturbances, but can women with eating disorders develop PCOS?

Researchers have proposed that insulin may have an appetite-stimulating effect and can perpetuate binge behavior.4 For example, during an eating binge when large quantities of food are consumed over a relatively short amount of time, there is a surge of excess insulin—much more than experienced during a normal meal. Constant bingeing could, therefore, result in a chronic state of elevated insulin and when insulin levels become elevated, androgen levels can become elevated as well.4 As a result, women with PCOS who engage in binge eating will further increase insulin levels and cause a worsening of their PCOS symptoms.

Researchers have investigated whether women with BN are insulin resistant and examined the relationship between insulin and androgen levels, ovarian morphology, and severity of bulimic behavior.4 Although their study did not find that women with BN had insulin resistance, they did find that they were chronically hyperinsulinemic, with 10 of 12 normal weight subjects having polycystic ovaries.4 This leads researchers to speculate that hyperinsulinemia may be one reason why BN and PCOS are connected, with the bulimic pattern of bingeing followed by starvation and/or vomiting perpetuating the insulin response and leading to the development of polycystic ovaries.4 It may also suggest why some women who are overweight or obese develop PCOS through overfeeding.

There is some encouraging news: It appears that when women with PCOS and BN can return to normalized eating patterns with treatment involving cognitive behavioral therapy, it can result in improved ovarian morphology.6 Thus, chronic bingeing can worsen the appearance of polycystic ovaries, but ovarian morphology does seem to resolve when bingeing ceases and normal eating patterns are established.

The Cholecystokinin Connection
New research suggests that women with PCOS also have impaired secretion of the hormone cholecystokinin (CCK), resulting in a reduced feeling of satiety.3 CCK is released from the small intestine in response to the presence of food and plays an important role in regulating appetite. It was previously believed that women with BN also have impaired CCK secretion, which could also explain the tendencies of women with PCOS, BN, or EDNOS to crave sweets, binge eat, or be overweight because of their impaired ability to feel full.13 It is not known why women with PCOS have impaired CCK secretion following meals, but researchers have suggested that like individuals with BN and diabetes, women with PCOS may have delayed gastric emptying.3

Nutrition and Lifestyle Management
Although studies are lacking on the best dietary and lifestyle treatments for PCOS, the most commonly agreed upon recommendations to improve insulin levels and other symptoms in PCOS are to consume a diet low to moderate in carbohydrates with an emphasis on low-glycemic index foods and to engage in regular exercise.2 However, because women with PCOS may be more prone to binge eating, it is imperative that dietitians screen patients with PCOS for eating disorders first before recommending dieting or changes in eating behavior. Effective questions to ask during the initial assessment include the following:

• “How do you feel about your weight?”

• “Do you ever feel out of control with food?”

• “Are you able to tell when you are physically satisfied with food or full?”

• “How do you feel about eating foods containing carbohydrates?”

• “Have you ever dieted, vomited, or taken laxatives or diuretics to control your weight?”

If you suspect the client may have an eating disorder, your first focus should be to help her normalize eating patterns to control insulin levels and prevent bingeing and weight gain. Even without weight loss, ovarian morphology and insulin levels may improve by the restoration of normal eating patterns.6 Clients need to be educated on the importance of eating regular meals and snacks throughout the day to stabilize blood sugar levels and prevent cravings and hypoglycemic episodes. This may include eating every three to five hours with the addition of at least one to two protein exchanges with meals and snacks.2 In addition, I have noticed that many clients with PCOS who take insulin-lowering medications such as Metformin or Avandia report little or no hypoglycemic episodes, less carbohydrate cravings, and reduced interest in food overall.

“Dieting is a losing battle with PCOS,” says Setnick, “as patients have to cut back drastically in comparison to their peers in order to achieve any weight loss.” And because of their struggles in maintaining weight through dieting, many women with PCOS may have lost their internal ability to regulate food. For example, they may not be able to effectively distinguish when they are hungry, which could result in unnecessary eating or waiting long periods to eat. Or, if they do use food to cope with emotions, perhaps they are unable to distinguish when they are physically satisfied with food, leading them to eat more than they need.

Part of establishing lifelong normalized eating patterns should involve education on self-care and mindful eating. The use of food logs to rate hunger and satisfaction levels before and after meals can be an effective technique for promoting self-awareness in addition to conscious eating exercises used with clients in nutrition sessions and at home.

Most of all, women struggling with PCOS and eating disorders need to learn effective ways to deal with their emotions without abusing food. Dietitians can help clients identify possible alternative coping skills other than food and should support clients to apply these new skills in their life.

For example, I encourage my clients to make a list of things they can do when they have urges to binge, such as walking, reading, writing in a journal, calling a friend, surfing the Internet, or taking a bath. Clients are encouraged to apply some of the activities on the list to overcome urges and find the ones that work best for them. In addition, working with a psychotherapist may help individuals identify their emotional triggers and encourage mindfulness and behavior change.

Once normalized eating patterns have been established and clients are able to respond to internal cues of hunger and satiety without using eating disorder symptoms, further recommendations on diet and exercise may be advised with caution and should focus more on continuing to improve metabolic fitness rather than weight loss.14,15

— Angela Grassi, MS, RD, LDN, is a speaker, an author, and a consultant in Haverford, Pa. She specializes in polycystic ovary syndrome and eating disorders and is currently working on her first book, The Dietitian’s Guide to PCOS. Visit her Web site at www.pcosnutrition.com.


1. Azziz R, Woods KS, Reyna R, et al. The prevalence and features of polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab. 2004;89(6):2745-2749.

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3. Hirschberg AL, Nassen S, Stridsberg M, et al. Impaired cholecystokinin secretion and disturbed appetite regulation in women with polycystic ovary syndrome. Gynecol Endocrinol. 2004;19(2):79-87.

4. Raphael FJ, Rodin DA, Peattie A, et al. Ovarian morphology and insulin sensitivity in women with bulimia nervosa. Clin Endocrinol (Oxf). 1995;43(4):451-455.

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9. Bridges, NA, Cooke A, Healy MJ, et al. Standards for ovarian volume in childhood and puberty. Fertil Steril. 1993;60(3):456-460.

10. Jahanfar S, Eden JA, Nguyent TV. Bulimia nervosa and polycystic ovary syndrome. Gynecol Endocrinol. 1995;9(2):113-117.

11. McCluskey S, Lacey JH, Pearce JM. Binge-eating and polycystic ovaries. Lancet. 1992;340(8821):723.

12. Weiner CL, Primeau M, Ehrmann DA. Androgens and mood dysfunction in women: Comparison of women with polycystic ovarian syndrome to healthy controls. Psychosom Med. 2004;66(3):356-362.

13. Geraciotti TD Jr, Liddle RA. Impaired cholecystokinin secretion in bulimia nervosa. N Engl J Med. 1988;319(11):683-688.

14. Morgan JF. Bulimic eating patterns should be stabilised in polycystic ovarian syndrome. BMJ. 1999;318(7179):328.

15. Moran L, Norman RJ. Understanding and managing disturbances in insulin metabolism and body weight in women with polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol. 2004;18(5):719-736.

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