What Is PCOS Belly?

Polycystic ovary syndrome (PCOS) is an endocrine disorder in women caused by hormonal imbalances that creates problems with the ovaries. Women with PCOS experience issues with menstruation, unpredictable ovulation and, in many cases, the development of fluid-filled sacs called cysts on the ovaries. Additional symptoms include excessive body and facial hair growth, acne and weight gain. Weight gain can be especially noticeable in the abdominal area, sometimes called PCOS belly. 

In this blog, we speak to Deepa Philip, M.D., a board-certified endocrinologist with INTEGRIS Health Medical Group Endocrinology, to learn more about why this occurs and how you can address it through lifestyle changes.

What is PCOS and why does it cause weight gain?

In most women, the hormone estrogen assists with the release of an egg every four weeks, a process called ovulation. Women with PCOS have higher amounts of androgens, sex hormones (testosterone is the most common androgen) that are far more prominent in men than women. 

“PCOS essentially is a mismatch in the balance of male to female hormone ratios, leading to a spectrum of problems that can not only effect reproductive health but mainly also disrupts metabolic function,” Philip says. 

The abnormally high amounts of androgens, clinically referred to as hyperandrogenism, affect the release of eggs and can create issues with fertility and menstruation. When ovulation doesn’t occur, cysts can eventually form on the ovaries.

Additionally, many women with PCOS also battle insulin resistance, a condition in which the body does not respond well to insulin. Insulin resistance creates chronically high levels of insulin in the body, which can lead to more androgen production. It also affects the liver’s ability to produce sex hormone binding globulin (SHBG), a protein that transports estrogen and androgens in the blood. As a result, more androgens, such as testosterone, remain in the blood.

Philip explains, “Polycystic ovarian syndrome is a bit of a misnomer. There are plenty of patients without polycystic ovaries who have PCOS. The diagnosis is one of exclusion and generally patients only need to meet two of the following three criteria: 1.) elevated androgens or signs of hyperandrogenism 2.) evidence of insulin resistance and 3.) abnormalities in menstrual cycles (not necessarily polycystic ovaries).”

PCOS and weight gain

Many people with PCOS experience weight gain. High androgens, insulin resistance and increased cortisol levels can cause more fat cells to form that leads to weight gain. 

PCOS belly isn’t a medical term, rather it is a colloquial phrase to describe weight gain that tends to occur in the abdominal area. In short, males tend to gain weight in the abdomen, and since PCOS is driven by male-dominant hormones, the condition can cause fat to compile around the waistline.

The weight gain is different from typical weight gain – even smaller women of average weight can experience increased fat cells in the abdomen and have an apple-shaped body (more fat in the midsection and less fat in the hips, thighs and buttocks). For example, a study of PCOS patients, whether obese or nonobese, had elevated levels of abdominal fat when compared to women without PCOS.

• Increase in androgens: Typically, women make one-twelfth of the amount of androgens than men. These levels are much higher in women who have PCOS. Elevated levels of androgens cause many changes in a woman’s body, including insulin resistance and elevated levels of estrogen. Fat cells contain estrogen precursors, which can be converted to estrogen. Estrogen dominance (when estrogen is high, and progesterone is low) can increase your appetite and cravings.
  
  
• Insulin resistance: Whenever you eat, the body releases insulin to convert sugars and starches into energy. People with PCOS can have cells that do not respond to insulin, which causes the pancreas to create more insulin. This overproduction of insulin causes weight gain because it increases adipose tissue, which usually first develops in the midsection. It creates a vicious cycle because more insulin leads to weight gain, and the more weight you gain, the more insulin is produced. Insulin resistance also triggers androgen production.
  
  
• Cortisol: People with PCOS tend to have higher levels of cortisol, a steroid hormone that serves as your main stress hormone. Abdominal fat cells have four times more cortisol receptors, which explains why weight gain can occur there when more cortisol is released during stressful times.

The problem with abdominal fat

The fat that develops in the abdomen from PCOS is problematic because it is a type of fat called visceral fat. Unlike subcutaneous fat that is found near the skin and can be pinched, visceral fat surrounds internal organs.

Visceral fat is metabolically active and releases proteins called cytokines that cause inflammation. This inflammation is associated with an increased risk of major health problems. The more visceral fat you have, the higher the risk of developing health conditions such as heart disease, diabetes, high cholesterol, high blood pressure, stroke and certain types of cancers.

What does a PCOS belly look like?

PCOS weight gain can cause fat accumulation in the midsection without gaining weight anywhere else in the body, which explains why “skinny” women can develop a belly.

PCOS belly typically involves a larger waistline (waist-to-hip ratio of greater than 0.87) that may appear large and bloated. Some women also have a midsection that is small and round. The midsection may also feel firm to the touch.

Bloating can become worse when eating certain foods, including those that contain a carbohydrate called raffinose. Some people cannot digest raffinose well, which allows it to pass undigested to the large intestine. In the large intestine, bacteria interactions cause fermentation that leads to excess gas production. Beans contain large quantities of raffinose. Other examples of foods with raffinose include cruciferous vegetables such as cabbage, brussels sprouts, broccoli, kale and cauliflower. 

How to get rid of PCOS belly

Unfortunately, there is not a cure for PCOS. 

“PCOS is best managed by lifestyle changes that include changes in diet and activity that help facilitate weight loss,” Philip says. “Finding good nutritionists helps too.”

• Lose weight: PCOS, combined with being overweight, increases your risk of developing high cholesterol, high blood pressure, diabetes and cardiovascular disease. Losing just five percent of your body weight can lower health risks. Talk to your doctor about implementing a diet and increasing exercise.
• Focus on high-fiber foods: Fruits, vegetables and whole grains all contain fiber that slows down digestion time, thus limiting blood sugar spikes. Beans, whole grain bread, raspberries, broccoli, green peas and chia seeds are all examples of high-fiber foods.
• Avoid certain foods: In general, stay away from processed foods, foods high in saturated fat, sugary foods and simple carbohydrates that can raise blood sugar levels. For example, avoid the so-called “white carbs” – pasta, tortillas, bread, pizza and white rice.
• Ask your doctor about medications: People with PCOS who also have prediabetes or diabetes may benefit from metformin, a drug that treats high blood sugar. Some birth control pills and anti-androgen medications can also control male hormones that contribute to weight gain.
• Eat small meals: Many people skip breakfast and only eat two meals a day. Consuming larger meals will spike blood sugar levels. Instead, focus on smaller portions by eating four to six meals a day.
• Stay active: Try to exercise three to four times a week, even if that means a 20-minute walk in the morning or before bed. Exercise can help reduce insulin resistance.
• Manage stress: Stress produces cortisol, which causes the release of glucose in your blood. Over time, stress can cause insulin resistance and weight gain.
• Improve sleep habits: Consistently not getting a good night’s sleep can throw off hormone levels and contribute to insulin resistance, two things that make PCOS worse. Strive to get seven or eight hours of sleep per night.

Diet options for PCOS

There isn’t a one-size-fits-all dieting approach when it comes to PCOS. Ultimately, it depends on each person and what they will respond to. The low-GI diet, the anti-inflammatory diet and the DASH diet are three of the most common options.

• Low-GI diet: The glycemic index is a measure of how long it takes a food to increase glucose. Foods high on the GI index cause a rapid spike in glucose, while foods low on the GI index cause a slower release of glucose. Avoiding blood sugar spikes can help treat PCOS, so that means focusing on fruits, vegetables, seeds, nuts, whole grains and lean protein. In addition to being low on the GI index, many of these foods are full of fiber and will keep you satiated to prevent overeating.
  
  
• Anti-inflammatory diet: Inflammation can lead to insulin resistance and this diet focuses on foods that have been linked to lowering inflammation. Examples include tomatoes, olive oil, nuts, leafy greens, fatty fish, and fruits such as strawberries, blueberries, oranges and cherries.
  
  
• DASH diet: This diet, also called Dietary Approaches to Stop Hypertension, was created to lower blood pressure. The main focus is to eat foods low in sodium and saturated fat and high in fiber and other nutrients. DASH diet foods include whole fruits and vegetables, avocado, low-fat dairy products, nuts, seeds and lean proteins (fish, chicken and poultry).

If you suspect you have PCOS, Philip recommends contacting your primary care physician or request an appointment with a provider. They may also be able to provide a referral to a nutritionist or dietician for weight management. In the event PCOS patients develop metabolic problems such as type 2 diabetes, and it becomes difficult to manage, then a referral to an endocrinologist may be the next step. 

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