Can you be skinny and have PCOS?

Yes!!

This type of polycystic ovary syndrome is called Lean PCOS. Lean PCOS can present its own challenges. Women with PCOS who are lean often go undiagnosed because they “don’t look like they have PCOS.”

Today, we are going to break down some of the important concerns for women with Lean PCOS and discuss how you can better understand this type of PCOS and advocate for yourself.

What is Lean PCOS?

Lean PCOS is characterized as being of normal, healthy weight, or thin. These women have a healthy body mass index or BMI.

This is not the classic presentation of PCOS which is when women tend to be overweight or obese.

Women with Lean PCOS are often forgotten about because their weight is normal but they still can suffer from PCOS symptoms as well.

Women with Lean PCOS often have higher LH levels, lack progesterone, and have androgen excess.

When women have too much testosterone, ovulation is delayed.

This can then create a lack of progesterone. Progesterone is only produced once a woman ovulates.

Without enough progesterone (progesterone reduces the production of LH), there is more LH which causes more testosterone to be produced. So it causes a vicious cycle for women with Lean PCOS.

RELATED: Tracking Ovulation with PCOS

Characteristics of Lean PCOS:

• Thin/lean or normal weight

• Higher LH level

• Androgen excess

• Lack of progesterone

• Delayed ovulation

• Poor circulation

• Reactive hypoglycemia

• Most likely have insulin resistance

Stats on Lean PCOS

About 20-30% of women with PCOS have Lean PCOS.

Approximately 5% of all lean women have PCOS.

Lean PCOS is often misdiagnosed or undiagnosed.

Diagnostic Tests for Lean PCOS

There are blood tests that can be done that can signal that your hormones are imbalanced. 

These are the tests that the doctor can run to determine if you might have Lean PCOS:

These tests should be done on cycle day 3, if you get your period.

• FSH

• LH

• Testosterone (total, free)

• Androstenedione

• Dihydrotestosterone (DHT)

• DHEA-S

• Sex Hormone Binding Globulin

• Cortisol (must be done early in AM)

• Insulin

• Glucose

These tests should be done 7 days before your expected menstrual cycle:

• Estradiol

• 17-OH Progesterone

Lean PCOS and Insulin Resistance

Women with Lean PCOS can still have insulin resistance.

In fact, research has shown that about 75% of women with PCOS that are lean have insulin resistance. 

Insulin resistance is often missed in this population of women because their fasting insulin, blood glucose, and A1C are usually within normal ranges.

Insulin resistance takes a long time to show up before it is detected in the liver and muscles.

However, after a meal, this group of PCOS women can have reactive hypoglycemia. This is when there is a drop in blood sugar approximately 1.5 hours to 5 hours after eating. 

This then increases your hunger cues. Why does this happen? It is due to elevated insulin secretion or insulin hypersensitivity.

Research shows that 50% of women with Lean PCOS have reactive hypoglycemia.

Reactive hypoglycemia is often a precursor to insulin resistance.

How to Test for Insulin Resistance?

If you aren’t sure you are insulin resistant, here are some tests that can determine if you have insulin resistance.

• Fasting glucose

• Fasting insulin

Once you get your results you can use the HOMA-IR calculator to determine your insulin ratio. According to the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), a Healthy Range is: 1.0 (0.5–1.4).

• Less than 1.0 means you are insulin-sensitive which is optimal.

• Above 1.9 indicates early insulin resistance.

• Above 2.9 indicates significant insulin resistance

Another test that can determine insulin resistance is an insulin glucose tolerance test. This test is several hours long and measures both your insulin and glucose.

Lean PCOS Diet

What should your diet look like if you have Lean PCOS?

Balance is key. Focus on eating healthy and eating a variety of vegetables and fruits high in fiber. Here is an example of what your plate should look like:

• 25 grams of protein per meal

• 2-3 cups of non-starchy veggies per meal

• ½ cup of healthy fats or 1-2 TBS of quality oil meaning either olive, avocado, or coconut oil per meal

• ¾ cup of carbs (low GI or ones that are considered to have resistant starch) per meal

Related: PCOS Diet Myths - Here’s the Truth

Stress and Lean PCOS

We all know that stress is not good for anyone! But stress can impact lean women with PCOS even more.

The pituitary gland is very sensitive to stress and women with lean PCOS are more likely to have high levels of DHEA-S (adrenal androgen). Elevated levels of DHEA-S can cause hyperandrogenism.

Stress reduction is critical in managing lean PCOS.

Figure out ways that will help you to relax whether that is journaling, meditation, yoga, breathing exercises, listening to music.

Find what works for you and make sure to use these strategies to help you relieve stress.

Exercise for Lean PCOS

Exercise for women with Lean PCOS is going to be important.

You want to increase your amount of lean muscle. Muscle uses more glucose and will lead to less glucose being stored as fat.

Exercise helps to improve insulin sensitivity.

What type of exercises should you do?

Women with lean PCOS should focus on a combination of strength training and HIIT for PCOS. 

Strength training will help you build lean muscle and the more lean muscle you have the better.

Try incorporating strength training into your routine 2-3 times a week. Try doing exercises that include the entire body.

Short on time? Make sure you always work on your legs and thighs since they are the largest muscle group in the body they can burn more glucose.

HIIT will help you improve your insulin sensitivity and increase your metabolism and burn more fat.

You can do HIIT 1-2 times a week. Each session should be about 20 minutes in duration, I wouldn’t do anything longer than 30 mins. The last you want to do is stress out your body and produce more cortisol.

Reducing Androgen Levels in Lean PCOS

We know that high androgen levels play a role in Lean PCOS. 

One way to reduce androgen levels is with myo-inositol. Studies have found that 3 grams per day reduced LH, inflammation, androgens and insulin response to oral glucose tolerance test in lean PCOS.

Want more information on how inositol can help your PCOS? Check out this post on the research behind inositol for PCOS.

There are also some plant-based anti-androgens that you can look into including:

• White peony

• Licorice

• EGCG

• Saw palmetto

• Spearmint

• Pygeum bark

Summing up Lean PCOS

Lean PCOS often goes undiagnosed for a long time because this subset of PCOS appears to look “normal” yet women with this type often exhibit issues with blood sugars, high androgens, and higher levels of stress. Lean PCOS can be managed with lifestyle modifications.

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