Higher-Weight Patients, Gynecological Care, and PCOS
Collaboration with Nicola Salmon
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Recently I’ve received a number of reader questions about ob/gyn care for fat* patients, so I reached out to Nicola Salmon, fat-positive fertility coach and author of “Fat and Fertile" who agreed to work with me on a series of articles for the newsletter. This is the first of those pieces and I’m so grateful for her expertise! The second talks about fat people and fertility, and the third talks about higher-weight patients and obstetrics. Please check out her work at http://nicolasalmon.co.uk/
A quick note – Nicola has included end note references here, please be aware that the studies cited often come from a place of weight bias and pathologizing higher-weight bodies in harmful ways and can be triggering.
When fat folks try to access gynecological care, they are routinely told that any concerns are related to their weight and that weight loss will solve issues such as heavy or painful periods and irregular cycles. They are often denied further testing and told that weight loss will fix it.
This denial of care, along with the shame that often accompanies these appointments impacts the way that fat folks access gyn care and can lead to folks accessing routine gynecological exams such as pap smears much less frequently (1).
Delays in healthcare, both from refusal to test folks who come in with symptoms and folks feeling unable to access preventative screening is a big factor in why fat folks may experience higher risks of illness (1).
Some common gynecological symptoms that many folks face are heavy, painful and/or irregular periods. These are often blamed on someone's weight when actually they could have many different underlying conditions such as Endometriosis, Polycystic Ovarian Syndrome (PCOS), Hypothalamic Amenorrhea or Thyroid issues. All of these conditions can be managed and improved without weight loss and dieting.
Let’s look at PCOS as an example.
PCOS is a syndrome that impacts the hormonal and metabolic systems. Folks can experience PCOS with very different symptoms but the generally accepted three diagnostic criteria are:
· irregular or absent periods,
· the appearance of lots of follicles on your ovaries using an ultrasound scan
· increased levels of androgens using a blood test.
You need at least 2 of these criteria to be officially diagnosed. (2)
PCOS is often considered a fat person’s syndrome with the typical description being someone who is in a bigger body (2). We know that PCOS occurs in folks with all different BMIs. A research study that looked at users of a period tracking app (3) found that whilst confirmed diagnosis of PCOS did increase with BMI, there were significant numbers of folks diagnosed in each of the BMI brackets. (from 9.4% for BMI <18.5 up to 26% for BMI >40)
Unfortunately, the study then erroneously uses this correlation to state that having a high BMI causes PCOS. Correlation does not equal causation and it’s well recognized that insulin resistance which drives PCOS plays a role in weight gain. (4) One other interesting note from this study was that this correlation did not exist for app users in India.
The cause of PCOS is unknown (5) but it’s commonly thought to be partly genetic with the underlying assumption that an “unhealthy lifestyle” will make the condition worse and of course it’s assumed that all fat folks have an “unhealthy lifestyle”.
My own experience with PCOS was that I was diagnosed at 16 after being put on low-fat diets through puberty. This association is now being further investigated with some promising research (6) coming out that is looking at the link between dieting and eating disorders through puberty and PCOS.
For folks who are in bigger bodies, weight stigma can play a big role in their diagnosis and management of their PCOS. This can be dangerous in two ways.
The first is by doctors making assumptions about someone's health based on their body and misdiagnosing them. I know so many folks that have been diagnosed with PCOS based on their body size, rather than using the diagnostic criteria. This leads to them taking medication which is at best useless and at worst could cause further issues with their health.
The second is by doctors missing key diagnostic information because they refuse to test people until they've lost weight. This leads to a delay for when folks are diagnosed and treated for conditions. That time lost could be really valuable in the disease progression and their recovery.
The standard treatment of PCOS is the oral contraceptive pill to induce a monthly bleed and a prescription of weight loss (7)
But there are many strategies we can utilize without weight loss and dieting. The majority of studies that focus on PCOS and weight loss only follow their progress for 2-6 months (8,9,10) which, alongside the majority of weight loss research does not show the real impact of these interventions, such as weight regain, weight cycling and their impact on mental health.
For some ideas on weight-neutral options for treating PCOS you can also take a look at the weight-neutral healthcare guide here!
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More research and resources:
https://haeshealthsheets.com/resources/
*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.
References:
1. Fontaine KR, Faith MS, Allison DB, Cheskin LJ. Body weight and health care among women in the general population. Arch Fam Med. 1998 Jul-Aug;7(4):381-4. doi: 10.1001/archfami.7.4.381. PMID: 9682694.
2. Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod. 2004 Jan;19(1):41-7. doi: 10.1093/humrep/deh098. PMID: 14688154.
3. Jain T, Negris O, Brown D, Galic I, Salimgaraev R, Zhaunova L. Characterization of polycystic ovary syndrome among Flo app users around the world. Reprod Biol Endocrinol. 2021 Mar 3;19(1):36. doi: 10.1186/s12958-021-00719-y. PMID: 33658043; PMCID: PMC7927251.
4. Teede HJ, Joham AE, Paul E, Moran LJ, Loxton D, Jolley D, Lombard C. Longitudinal weight gain in women identified with polycystic ovary syndrome: results of an observational study in young women. Obesity (Silver Spring). 2013 Aug;21(8):1526-32. doi: 10.1002/oby.20213. Epub 2013 Jul 2. PMID: 23818329.
5. Bednarska S, Siejka A. The pathogenesis and treatment of polycystic ovary syndrome: What's new? Adv Clin Exp Med. 2017 Mar-Apr;26(2):359-367. doi: 10.17219/acem/59380. PMID: 28791858.
6. Steegers-Theunissen RPM, Wiegel RE, Jansen PW, Laven JSE, Sinclair KD. Polycystic Ovary Syndrome: A Brain Disorder Characterized by Eating Problems Originating during Puberty and Adolescence. Int J Mol Sci. 2020 Nov 3;21(21):8211. doi: 10.3390/ijms21218211. PMID: 33153014; PMCID: PMC7663730.
7. https://www.webmd.com/women/treatment-pcos
8. Stamets K, Taylor DS, Kunselman A, Demers LM, Pelkman CL, Legro RS. A randomized trial of the effects of two types of short-term hypocaloric diets on weight loss in women with polycystic ovary syndrome. Fertil Steril. 2004 Mar;81(3):630-7. doi: 10.1016/j.fertnstert.2003.08.023. PMID: 15037413.
9. Moran LJ, Pasquali R, Teede HJ, Hoeger KM, Norman RJ. Treatment of obesity in polycystic ovary syndrome: a position statement of the Androgen Excess and Polycystic Ovary Syndrome Society. Fertil Steril. 2009 Dec;92(6):1966-82. doi: 10.1016/j.fertnstert.2008.09.018. Epub 2008 Dec 4. PMID: 19062007.
10. Brennan L, Teede H, Skouteris H, Linardon J, Hill B, Moran L. Lifestyle and Behavioral Management of Polycystic Ovary Syndrome. J Womens Health (Larchmt). 2017 Aug;26(8):836-848. doi: 10.1089/jwh.2016.5792. Epub 2017 Jun 1. PMID: 28570835.