PCOS patients need tailored treatment for disordered eating

Disordered eating behaviours are more common in women with polycystic ovary syndrome (PCOS) than other women, reinforcing guidelines to screen for disordered eating and eating disorders in women newly diagnosed with PCOS.

An Australian cross-sectional study of almost 900 women screened using the Eating Disorder Examination Questionnaire (EDE-Q) found disordered eating in 21% of women with PCOS compared to 15% of women without PCOS (p=0.012).

Eating disorders that met the DSM-5 criteria for a diagnosis were seen in more than half the women but as a combined group of disorders were not significantly different between women with and without PCOS (62% v 56%, p = 0.076).

Only anorexia nervosa (0% v 1.3%, p=0.012) and atypical anorexia nervosa (0% v 5.8%, p=<0.001) were significantly different, given they were not seen at all in the women with PCOS.

Binge eating was the most prevalent eating disorder.

“As androgens have been proposed to act as appetite-stimulants, induce binge-eating behaviours and impair impulse control, the elevated levels of testosterone commonly observed in PCOS may explain the more common observance of binge-eating behaviours in comparison to anorexia nervosa,” the study said.

Interestingly, the study found only older age and elevated BMI, and not PCOS, were independently associated with the increased odds of disordered eating on multivariable analysis.

The influence of the high BMI typically seen in PCOS on eating behaviours might be more a component of a vicious cycle of body dissatisfaction, mood disorders and poor quality of life.

“The elevated prevalence of overweight and obesity in PCOS may therefore be a contributing factor to the higher occurrence of disordered eating in PCOS, rather than PCOS itself.”

Younger women and elevated BMI were more at risk of having a diagnosable eating disorder.

First author Stephanie Pirotta, an accredited practising dietitian and PhD candidate in the Monash Centre for Health Research and Implementation, told the limbic that there was increasing recognition of disordered eating that did not meet DSM-5 criteria for an eating disorder.

However the women required tailored treatment that addressed their concerns about weight and shape and dietary restraint.

“Generally speaking, the first line of treatment for women with PCOS is lifestyle management, with or without medication. And in that lifestyle management, weight loss is seen as a way to improve symptoms, generally because of insulin resistance.”

She said weight loss of 5-10% was suggested to improve symptoms, and then weight management for the long term.

“But women find it quite hard to lose weight and that’s because of insulin resistance, but also because of the increase in testosterone that provides women with cravings, for example for sweet things.”

She said whether to approach disordered eating in PCOS from an obesity management focus or eating disorders approach was a controversial area.

For example, a focus on weight loss through energy restriction and self-monitoring weight change can promote disordered eating, she said.

“Weight loss should just be an outcome of lifestyle management and not promoted, particularly if they have a eating disorder.”

“Clinicians should be screening women using a questionnaire such as EDE-Q before they prescribe any treatment or make referrals so it is taken into account and a management plan is tailored to the patient’s needs.”

It may be more appropriate for a clinician to refer women to a psychologist to help change their mindsets than for weight loss per se.

She added that not all women with PCOS and disordered eating were overweight or obese.

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