‘She just needs to try harder’: Misunderstanding of PCOS and its impact on metabolic syndrome

Lack of understanding of polycystic ovary syndrome (PCOS) and its effects is leading to the condition being underdiagnosed in overweight women, said Dr. Ashley White.The Ontario physician and obesity medicine specialist dispelled myths about PCOS in her talk, “PCOS and Metabolic Syndrome” at the Black Physicians’ Association of Ontario’s Black Women’s Health conference. The talk took place in Toronto in November and looked at the condition’s impact on weight, obesity and diabetes.“Many women are being gas lit about their own physiology,” said Dr. White, adding that there seems to be a kind of blind spot when it comes to Black women and other women of colour and diagnosing PCOS. Women with PCOS, a chronic condition with symptoms like irregular or missed periods, acne, obesity, excessive facial hair and thinning hair, are at an 11-times higher risk of metabolic syndrome than other women of the same age.“Women who are presenting with these symptoms are still being told by doctors that they just need to try harder to lose weight,” said Dr. White. The symptoms that are often misdiagnosedCommon symptoms Dr. White says are misdiagnosed or ignored in PCOS fall into three categories: metabolism and appetite, sexual development and reproduction, and psychological and psychiatric.With metabolism, she says symptoms of PCOS can manifest as the emergence of insulin resistance, post-prandial sweet cravings, and central weight gain. In sexual development, irregular menses, hirsutism and an atypical adolescent sex drive can be indicators. Emotional dysregulation, low self-worth, and feeling a loss of control can be psychological manifestations of the condition. “This is not a willpower problem, or just an ovary problem or a psychatric problem,” she said.According to data Dr. White shared, 70% of women with PCOS remain undiagnosed. Recognize symptomsDifferent signs to recognize PCOS throughout a women’s lifecourse: In menarche (ages 15 to 20) Dr. White said the condition often manifests as insulin resistance which drives intense cravings, cycles of 45 to 90 days, and can leave girls confused about what’s happening with their bodies.In maturity (ages 20 to 35 ) she said that common symptoms can include a body mass index that climbs despite extreme effort, subfertility that’s discovered too late, and cycles of restriction and binge eating.During typical mothering years (ages 25 to 40) gestational diabetes and preeclampsia risk, the need for fertility treatments and anxiety and depression can be signs of the condition.In menopause (ages 45 to 55) the condition can lead to early cardiovascular disease, endometrial hyperplasia risk, and chronic distress.Throughout the meridian period of a woman’s life (ages 55 plus) women can present with multiple system complications and cancer, which can be indicators of the condition. Androgen excess, a defining feature of PCOS, can be the beginning of a vicious cycle of metabolic disorders in people with the condition, said Dr. White. Blindspots in BIPOC womenAccording to Dr. White, there can be certain blind spots as the same symptoms present differently in different populations. “We have to remember that hirsutism scoring systems were developed for white skin,” she said. Considering the clinical variations in BIPOC women with PCOS, she said there should be specific considerations for different populations. For Black women, Dr. White said that physicians should consider a lower BMI threshold for metabolic action, earlier cardiovascular screening, culturally informed dietary guidance and hair care considerations with treatment. For South Asian women, for example, she suggests that physicians should consider aggressive early insulin resistance management, family-centered care approaches, cultural dietary pattern integration and earlier metabolic screening. Testing for women with metabolic diseaseDr. White suggested testing women who are at risk of metabolic disease for specific markers more frequently than the general population. For BIPOC women specifically, she suggests testing monitoring markers (fasting glucose, fasting insulin, A1C and ALT levels) every three-to-six months, lipid panel tests every six months, blood pressure monitoring every three months and mental health screening using clinical interviews with every visit. Physicians should also consider race and ethnicity when it comes to measuring BMI cutoffs, with a cut off of 30 kg/m for white patients, 28.1 kg/m for Black, 26.9 kg/m for East Asian, 26.6 kg/m for Arab, and 23.9 kg/m for South Asian, in accordance with the World Health Organization. Providing care in the wake of new weight-loss treatmentsBy the end of 2023, there were 194,916 Ozempic claims in Saskatchewan, a massive jump from a meager 5,755 claims in 2019, according to the CBC. In the U.S., Ozempic and Wegovy prescriptions hit 9-million in 2023, a 300-per-cent jump from 2020. “The obesity community is completely shocked about this idea of there being non-responders [to hormone-based medicines like Ozempic],” said Dr. White, speaking of the women she’s treated at her own clinic with undiagnosed PCOS, “most of the time, these are the non-responders.” In her own practice, as an obesity doctor, Dr. White says she prefers to help people sensitize themselves to insulin first, she’s also advocated for guidelines on the use of medications like metformin to treat patients with PCOS who are having trouble with weight loss. What Dr. White suggests to combat the misdiagnosis of PCOS and metabolic syndrome is a transdisciplinary approach to good primary care. “If you consider the physiological difference underneath that may be more likely to show up in certain groups, then you can give a transdiagnostic transdisciplinary approach to this,” she said. “Doctors should ask themselves: ‘Is this a culturally typical androgen level?’”

‘She just needs to try harder’: Misunderstanding of PCOS and its impact on metabolic syndrome

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