Lean PCOS: what it is, how to spot and treat it

Have you wondered if you may have PCOS with your weight being normal or lower? Although the condition’s link to higher weight is notorious, lean PCOS is not rare. In fact, it is much more prevalent than you may expect.

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What is lean PCOS?

Polycystic ovary syndrome (PCOS) has traditionally been associated with higher weight. According to the World Health Organization, it is a body mass index (BMI) of 25 or higher (23 or higher for Asians). 

Lean PCOS, which is the official term, or skinny PCOS, as some may put it, is associated with a BMI below 25 (below 23 for Asians). The term is quite self-explanatory: it is PCOS in people who are not overweight.

Why is lean PCOS a separate term? 

'Lose weight!' is the first advice many people with PCOS receive. Even coming from a doctor, it can stem from fat shaming instead of knowledge and promote eating disorders. The weight stigma around PCOS is so prevalent that the 2023 International Guideline for the Assessment and Management of PCOS specifically instructs how to avoid it.

The flip side is that many people get no advice at all because their lean PCOS symptoms are overlooked. Some researchers suggest that both their colleagues and health practitioners tend to neglect PCOS in individuals with a 'healthy body type' as they are biased to look for a certain ‘PCOS body type.’

Lean PCOS is growingly evident yet underresearched and underdiagnosed. What is lean PCOS prevalence?

How prevalent is lean PCOS?

If it is not your first time searching “What is lean PCOS?” or “What is lean PCOS prevalence." you might have read something like “It comes in all sizes.” Some articles state those are ‘smaller’ or ‘minor’ proportions of skinny PCOS.

The true numbers are astonishing. A meta-analysis of 35 studies with a total of 15,129 participants demonstrated that lean PCOS constitutes almost 40% of all cases.

The proportion of women with PCOS who were overweight and obese ranged from 6% to 100% with a pooled estimated prevalence of 61% (95% CI: 54–68%).

Have we not just mentioned that researchers may overlook lean PCOS symptoms and not include people with them in their studies? With that in mind, the prevalence of skinny PCOS can be even higher.

Meanwhile, the numbers may vary significantly in ethnicities and geographies. These aspects beg for even more research. For example, studies show that the lean PCOS type is more prevalent in Asian women than in their White counterparts. However, the data on Asian women comes only from a few countries and yet manages to scatter. Studies focused on PCOS in Black people are even more scarce.

Despite a huge room for improvement, the research confirms we are speaking of not an outlier but a lived experience for many. They deserve diagnosing informed of their presence and lean PCOS treatment tailored to their needs. Let's see what that means!

What are lean PCOS symptoms?

Lean PCOS symptoms start where any PCOS symptoms do: with Rotterdam criteria or its upgraded interpretations. To diagnose skinny PCOS, as much as any other PCOS, at least two should be present: irregular or infrequent periods, hyperandrogenism, and polycystic ovary morphology.

Irregular or infrequent periods

Regular cycles last for 21–35 days. While your cycles can differ from each other, ideally, they fall within this range. Otherwise, you may want to talk to your healthcare provider. 

However, this might not be the case in the first 1–3 years after menarche, and in perimenopause, when periods are less regular naturally. 

Hyperandrogenism symptoms

You can spot elevated levels of androgens before having tests as they often visibly alter the skin and hair:

• Acne in adults/severe acne in youths
• Hair loss
• Hirsutism (male-pattern excessive hair growth)
• Enlarged clitoris
• Elevated levels of testosterone, androstenedione, or DHEAs.

Polycystic ovarian morphology

This symptom has lent its name to the Polycystic ovary syndrome itself. However, the term ‘polycystic' might be confusing. Often, there are no cysts, simply many visible follicles.

How many? The threshold used to be at 12 while modern evidence-based studies recommend it at 20, with some at 25 follicles per ovary in adults — detected with ultrasound. An alternative method is the serum Anti-Mullerian hormone (AMH) test.

It is important to notice that polycystic ovarian morphology in youths is not representative of PCOS. 

In adults, It is unlikely to spot it out of thin air: it requires special tests, so probably some indirect lean PCOS symptoms have already alerted you.

What are indirect lean PCOS symptoms?

PCOS is associated with certain features, and their presence may urge you to discuss the lean PCOS treatment with a healthcare provider. Again, most features apply to all PCOS body types, but some are unique to skinny and slim figures.

Indirect lean PCOS symptoms include:

Acanthosis nigricans 

Patches of darker and thicker skin may appear because of the condition or its comorbidities.

Endometrial cancer

While cancer is probably the main concern at its discovery, identifying the underlying conditions is vital in the long term.

Infertility

The saddening point at which some people discover they have unfavorable health conditions is when they cannot conceive.

Insulin resistance (IR) 

This feature is among the most common for PCOS. However, some studies suggest that IR is less prevalent in lean PCOS symptoms than in higher-weight PCOS. This means it may not be the first cue to look for and the lean PCOS treatment is less likely to center around improving it.

Type 2 diabetes (T2D)

PCOS is associated with higher risks of developing type 2 diabetes for any weight and vice versa, so if T2D is diagnosed, it makes sense to make screening for PCOS.

Metabolic syndrome

MS is a group of metabolic disturbances that increases the risks of heart disease and other serious problems. MS itself is a tricky condition with several criteria to consider for diagnosis. The majority go hand in hand with PCOS.

High blood glucose and fasting glucose

High glucose is prevalent in people with PCOS and may also indicate IR, MS, and T2D accompanying it. This has been proven true for lean people, too. 

Apple-shaped body / PCOS body type

PCOS can affect people of all sizes and body types. However, people with PCOS are more prone to gain weight around their waist. If there is a PCOS body type, it is probably a body with a higher waist-to-hip ratio. This is valid for both leaner and fuller people with PCOS.

Lipid profile abnormalities

Testing and improving lipid profiles is important for PCOS patients to decrease cardiovascular disease risks.

Lean women with PCOS were shown to have elevated levels of leptin compared to women with similar BMI without PCOS. That was not the case for women with other PCOS body types. Leptin plays a part in lipid metabolism and may indicate the adipose tissue concentration.

Unbalanced diet

Regardless of their weight and calorie intake, people with PCOS tend to have nutritionally unbalanced diets increasing the risks of its adverse effects.

Lower intakes of key nutrients associated with health, such as complex carbohydrates, fiber, unsaturated fatty acids, omega-3 polyunsaturated fatty acids, vitamin A, folate, vitamin C, vitamin D, and magnesium, have been reported for individuals with PCOS compared to individuals without. Moreover, higher intakes of nutrients associated with poorer health outcomes, such as simple carbohydrates and saturated fatty acids, … a larger intake of foods high in salt, sugar, fat, and energy, with little to no protein, vitamins or minerals.

Family history

While the exact causes of PCOS are yet unknown, male relatives of people with PCOS have been shown to have increased chances of MS, T2D, and hypertension. If you are looking into your family history to calculate PCOS chances, it is not only your maternal side that matters.

What is lean PCOS treatment?

PCOS is a complex and lifelong condition, and each case requires consideration of many factors. Moreover, there is less clinical evidence for lean PCOS treatment strategies than for people with other PCOS body types. 

Pharmacological therapy often includes oral contraceptives for cycle regulation and hirsutism alleviation and metformin for cycle regulation and improving cardiometabolism. Comorbid conditions, including depression and anxiety, may all need separate therapy lines.

What is universal across different PCOS cases and for people of all body types is that lifestyle management will most likely help.

Diet management

PCOS diet management does not necessarily imply weight loss for people with higher weight and definitely does not for people with normal and low BMI. Instead, it focuses on the dietary content to improve the cardiometabolic profile.

There is no consensus on the best diet for lean PCOS treatment. Some have shown promising results, though.

Low-Carb Diet

Replacing carbohydrates with other nutrients will likely improve insulin sensitivity and cholesterol and glucose levels.

Low-Glycemic Index Diet

Similarly, cutting off products with higher glycemic index improves insulin sensitivity in women with PCOS.

Breakfast Diet

A study from Poland demonstrated that having 54% of your calories from breakfast, 36% from lunch, and only 10% from dinner improves glucose levels, insulin sensitivity, and even ovulation. While fasting may not sustainable because of increased appetite and cravings, a smart reallocation of calories among the regular meals may be the answer.

Exercise

Like with diet, there is no universal type of exercise recommended for lean PCOS treatment. Moreover, the existing comparison of high-intensity interval and moderate-intensity training, or other types of training have not shown significant differences for women with PCOS.

However, it is safe to claim that any accessible exercise is better than being inactive.. Moreover, lifestyle management programs combining diet and exercise have more cardiometabolic benefits than each component alone. After this long article you have read, it is time to get some movement!

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