If you have Polycystic Ovary Syndrome (PCOS), you have likely been told to lose weight. If you are trying to get pregnant with PCOS, I have no doubt you've been told to lose weight. The typical recommendation from doctors is to lose 5-10% of your total body weight.

The truth is, it's not all about losing weight. I'd argue that it's the behavior changes that help weight loss happen that actually drive most of the benefits for fertility.

[00:00:00.730] - Caitlin Johnson, RD

Welcome to the PCOS Answers Podcast with Caitlin Johnson, your functional medicine dietician. This podcast is a private podcast only available through the PCOS Dot. It will provide practical sciencebased answers to all of your PCOS questions and every episode will leave you with something you can do today to help your PCOS. I'm so glad you're here.

[00:00:27.610] - Caitlin Johnson, RD

We are off to another episode about weight loss, but we are going to consider it within a different context tonight. So instead of talking about necessarily how to lose weight with PCOS, I want to talk about why this weight loss recommendation is so often provided to those of us with PCOS, from our physician or from our other medical provider. On the blog, we just published a really thorough article that talks about why weight loss is recommended to women with PCOS, specifically those that are trying to get pregnant. But I would like to pose to you the question of is weight the problem? If you've been following me for any amount of time, you know that I like to talk about weight or weight gain or weight loss resistance as a symptom of PCOS.

[00:01:20.730] - Caitlin Johnson, RD

If you have PCOS, you've been told to lose weight before. I know you have. If you're trying to get pregnant with PCOS, I absolutely know you've been told to lose weight. Most doctors will actually recommend a specific percentage of weight loss, typically between five and 10% of your body weight. So let's give a few examples of what that figure could look like.

[00:01:43.090] - Caitlin Johnson, RD

If you weigh 250#, 5% of your body weight is #12..50 and a half pounds before being exact. 10% is #25. Well, asking somebody to lose #25 is a lot of weight to be asking them to lose. If you're #200, you're being told to lose between ten and #20. If you're #175, you're being told to lose between nine and #18.

[00:02:12.170] - Caitlin Johnson, RD

Some of these numbers may feel more attainable. Of course, if you have more weight to lose, losing a bigger number is something that may actually even seem appealing to you. However, those of us that have weight to lose, including myself at this very moment, know that we have weight to lose. We don't need one more doctor to tell us, hey, you'd be healthier and probably ovulate if you lost weight. And especially when we're talking about a subject as sensitive as trying to get pregnant when you might already be struggling to get pregnant.

[00:02:44.450] - Caitlin Johnson, RD

It is kind of a hard thing to hear, especially with all the things that go in trying to conceive and all the insecurities and anxieties that go along with it, in my opinion. And take that for what it is. It's an opinion, but it is an educated, informed opinion. And I have treated many hundreds of women with PCOS at this point, one on one, many more hundreds in my course, and thousands of people that I affect with my online education. I do not believe it's all about weight.

[00:03:19.970] - Caitlin Johnson, RD

I'd argue that behavior changes that improve insulin resistance, improve overall health, and that may yield weight loss are actually what is providing benefit and ovulation when doctors are telling women to go lose weight. Because when you go lose weight, typically you're moving your body more. You may focus a little bit more about what you're eating, whether it's a portion size or changing what you're actually eating or going on a full blown diet, there is oftentimes more attention given to your behavior choices, to your daily activities, to what groceries come into your home, or what you choose to order when you're out. I don't think it's just weight loss. I honestly don't think it's just improvements in insulin resistance.

[00:04:09.880] - Caitlin Johnson, RD

And I don't think it's just behavior change. I think it's the synergy of all those. I think you could have two of the three of those and still see benefits in your fertility. When somebody with PCOS gets pregnant, if we've already addressed excess weight, that would be benefited if you lost them or we've already addressed insulin resistance. It's not just getting pregnant that we are impacting.

[00:04:39.010] - Caitlin Johnson, RD

We're also impacting the health of your pregnancy and even the health of your baby. And as we all know, you've heard me say this before, for sure. It's not about getting pregnant. It's about having a baby and being a mother and living this long healthy life with your family. So if you've been to a doctor trying to conceive or you've been to the doctor with PCOS or even to get your PCOS diagnosis, the story may have gone something like this you go to the doctor struggling to lose weight, my hair is falling out.

[00:05:10.850] - Caitlin Johnson, RD

I have hair growing on my nipples. I have really bad acne. I haven't had a period in a year. Whatever your symptoms or health concerns, typically with enough digging, they will come to the conclusion that you have PCOS and then they will offer you a prescription for metformin or birth control. And if you sought medical intervention or help or this diagnosis in the context of trying to get pregnant, they may move on to talk about what you can do right then to get pregnant.

[00:05:40.050] - Caitlin Johnson, RD

But for a lot of people, they don't get the diagnosis while they're trying to conceive. They get it younger in life or for many of us, at points of higher stress in our early 20s or so. And the doctor tells us, well, when you're ready to get pregnant, you just come back. I have a different medication for that. So you go about your life, you don't get any help with diet or exercise or any of the metabolic factors that go along with PCOS.

[00:06:04.860] - Caitlin Johnson, RD

And when you're ready to get pregnant, you show back up to the doctor, you go off birth control and maybe you don't get a period. And you go back to the doctor and the doctor says, well, you need to lose 5% to 10% of your body weight, and then you're likely to ovulate on your own. So you need to go do that and at least spend a year trying to conceive and then come back to me. Well, you can't conceive if you're not ovulating. So if you're listening to this and this is the first time you've ever thought about it, if you are not having a period and you're not on an oral or some type of hormonal contraceptive, you are not ovulating.

[00:06:44.490] - Caitlin Johnson, RD

And so there's no chance of you getting pregnant. Many women go off the oral contraceptive pills that they've been on since their mid teens and expect to get pregnant right away and their period doesn't show, and then they think they're pregnant and a lot of heartbreak ensues, and then they finally realize that they have a PCOS diagnosis or that they're not ovulating at all. So there are opportunities within this story for things to go better. First of all, the doctor could not have just handed the person a prescription. They could have said, hey, did you know that insulin resistance is a big piece of PCOS?

[00:07:19.990] - Caitlin Johnson, RD

And I'd like to offer you a referral to a dietitian or somebody that can help you learn about this and how you can manage your health to impact this. Most of us don't get that benefit, and so we go years just thinking the birth control is fixing this for us. And you know what the birth control also does? It makes insulin resistance worse. And so it's even harder for you to manage your weight with PCOS on the birth control pill.

[00:07:44.680] - Caitlin Johnson, RD

I'm not anti birth control pill. This is just the story that I hear over and over and over again. And we lose years of our life not managing other areas of our health so that when we're ready to try to conceive, we have kind of an uphill climb instead of flat road in front of us where it's just a matter of time. So oftentimes I get the question, why is it 5% to 10% of our body weight? Well, there are a number of reasons for this.

[00:08:15.260] - Caitlin Johnson, RD

First of all, it's really hard to measure eat a big breakfast, eat more protein. But your doctor can measure what you weighed this time at your visit and what you weighed next time at your visit. So it's just something that they can measure. That's one of the reasons. Okay.

[00:08:33.750] - Caitlin Johnson, RD

The other thing is that as weight loss occurs, insulin resistance improves. Now, this is one of those kind of chicken and egg situations. Sometimes weight loss happens because insulin resistance has improved because of nutrition and lifestyle changes. Sometimes insulin resistance improves because you've lost weight. And maybe it had everything to do with just eating less calories and had nothing to do with blood sugar regulation, or maybe you just started moving more.

[00:09:02.190] - Caitlin Johnson, RD

So this is kind of one of those chicken and egg situations. But we do see, as insulin resistance improves, as weight loss happens, the other one happens. Does that make sense? So when we get to this 5% body weight, especially in the research of those that are overweight or obese with PCOS, we start seeing significant improvements in insulin resistance and free testosterone levels. Free testosterone, again, is that hormone that floats around and does the testosterone dirty work.

[00:09:37.670] - Caitlin Johnson, RD

It's the one that's touching the ovary and saying, hey, don't let that follicle get to the point of being able to ovulate. It floats around and touches your chin and makes pimples happen and hair fall out off the top of your head. It's that free testosterone that's not bound, that's different than total testosterone. We want both those numbers to come down typically. But as weight loss occurs, we typically see free testosterone go down.

[00:10:01.540] - Caitlin Johnson, RD

We also see a protein that the liver makes sex hormone binding globulin go up, which is partly why free testosterone is going down. Weight loss improves those things. So weight loss alone can help improve hormonal abnormalities that are present in a PCOS woman's body that help improve ovulation. So one of the recommendations is there to just say, hey, weight loss that occurs at least at this percentage of your body weight, gives you a chance to ovulate at all or more frequently. Because if you're somebody that only gets a period bleed maybe three or four times a year, maybe every three months, if you're ovulating in those cycles, there's an asterisk on that if you're only ovulating three or four times a year.

[00:10:46.510] - Caitlin Johnson, RD

So when they send you off to go try for a year and then come back if you're not pregnant, you had three, maybe four chances to ovulate, whereas, like, the girl next door had twelve. Okay, so this is partly why we see it takes longer for women with PC us to get pregnant. Not that there are low chances of pregnancy, but it just takes longer for many of us because we have less frequent ovulation. Well, weight loss improves that. So does insulin sensitivity.

[00:11:13.580] - Caitlin Johnson, RD

So if we can get your body more sensitive to insulin, less resistant to it, we can help improve ovulation rates. So I dug into all the research to find, where did these numbers come from? What are these numbers? And I actually found some older research that showed weight loss less than 5 kg. So that's about £11 did not significantly improve ovulation rates.

[00:11:43.790] - Caitlin Johnson, RD

So there tends to be this amount of, like, okay, we need greater than #10 of weight loss to at least start to see these benefits. If you're somebody listening to this and you weigh #130 and you're like five foot four, you probably don't have #10 to lose. Okay? So we're not just talking weight loss at all costs. We're talking about weight loss that's indicated there is evidence that getting to this 5% to 10% weight loss does help improve pregnancy outcomes, not just ovulation pregnancy pregnancy outcomes and live birth rates.

[00:12:28.510] - Caitlin Johnson, RD

Because so many of us with PCOS struggle with weight, it can be really hard to hear one more person on top of our own internal dialogue all the time, telling us weight is something that's standing between you and what you want. Let me just say that again. It's really hard to hear a message that weight is the thing that's standing in between you right now and the you that you want. Motherhood, you holding that baby. So sometimes when we hear this, we shut down.

[00:13:06.410] - Caitlin Johnson, RD

Understandably so. And if you go into a doctor's appointment and all the doctor offers you is advice to lose weight and sends you out the door without a solid plan or help or a compassionate conversation about why this is probably more hard and difficult as somebody with PCOS, then I'm sorry, and you do need a new doctor. Don't settle for medical care like that. But just because I myself have been that patient, being told to lose weight and know how painful that is and know how painful it is to want to have a baby and see an uphill battle in front of me, I cannot disregard the literature and the evidence that weight loss helps improve these things. Now, listen to me clearly.

[00:13:58.970] - Caitlin Johnson, RD

I do not believe weight loss alone is the reason why it's easier to get pregnant. I think it's the improvements that happen with insulin and the hormones that trickle down from there and the behavior changes that also affect things like your circadian rhythm and stress levels. All of that. The whole package is improving. Ovulation, pregnancy, live birth rates.

[00:14:25.360] - Caitlin Johnson, RD

Okay, why does insulin matter in this equation? Well, insulin levels impact sex hormones. Insulin, high levels of it turn your ovary from an estrogen producing thing to a testosterone producing thing. Your actual follicles that become the eggs that get ovulated are the ones that make most of the estrogen and most of the testosterone. In an environment where your ovary is bombarded by insulin, you make a lot of testosterone.

[00:15:02.360] - Caitlin Johnson, RD

And when you make a lot of testosterone, it impacts your ability to ovulate. It basically stops the follicles from developing to be the egg that gets ovulated and leaves them in this immature form, and they're held in something called a cyst, and that is the polycystic ovary. It's a little baby immature follicle sitting in a little encasement of fluid that is normal. It's not bad. And they're stuck there.

[00:15:32.220] - Caitlin Johnson, RD

They're not maturing because they have way too much testosterone. If that isn't like, it just makes me laugh. Just makes me think of so many teenage hormone boys. That's basically what's going on in your ovary. And we need to switch those little teenage boys over into estrogen producing follicles for you to help you ovulate.

[00:15:54.520] - Caitlin Johnson, RD

One of the ways we do that is to lower your insulin levels. So when we talk about weight loss for ovulation, I'm going to step away from talking about the insulin and the testosterone. Right now I want to talk about one study. It was actually two different randomized clinical trials. And then in 2016, somebody went in and did a secondary analysis.

[00:16:19.210] - Caitlin Johnson, RD

They considered people who are trying to conceive with PCOS overweight or obese, and they give them an ovulation inducing medication called clomafine citrate for short. We call this chlomid. Group A gets chlomid. Group B gets a period of time with helpful lifestyle, education, intervention counseling, nutrition, education, and there's a period of time that allows for weight loss. And then they're given chlorine.

[00:16:57.080] - Caitlin Johnson, RD

And then a third arm of this study was where they provided birth control. Okay, so this period of preconception, they got birth control, oral contraceptive pill, plus education and nutrition, cognitive behavioral therapy. All the things that group two got, they got. And then at the same time that group two got told, okay, go try to get pregnant, group three also got Chlomid. So each group one, two, and three got Chlomid.

[00:17:28.520] - Caitlin Johnson, RD

Groups two and three had time before they got Chlomid to lose weight. Group three also had birth control during that time. Group one just got given Chlomid. Both groups two and three had more pregnancy rates, more ovulation, more live birth rates compared to just the Klomid group. It was significant that the hormone, the oral contraceptive piece of this study, it was kind of ruled out, statistically insignificant, that that helped improve outcomes, but that it was in fact, the weight loss that happened in groups two and three that impacted these ovulation rates, pregnancy rates, and live birth rates.

[00:18:20.190] - Caitlin Johnson, RD

When you consider a study like this, it's interesting to look at those outcomes because nobody just says, like, what? I can't wait to just be pregnant. I want to be pregnant for the rest of my life. No, the goal of pregnancy is a baby. The goal of ovulation is typically pregnancy.

[00:18:36.410] - Caitlin Johnson, RD

I have a very strong argument that you should be ovulating, whether you're trying to conceive or not. That is for a different day. But so when we look at a study, we want to look at the findings of not just did they ovulate, not just did they get pregnant, but did they get a baby out of that pregnancy? There's a poignant quote from the study that I want to read to you. It says, one of the striking findings of the study is the marked improvement in live birth rates out of proportion to the more modest but still significant improvement in ovulation rates, suggesting yet again that improving the quality of ovulation is as important as improving the frequency of ovulation.

[00:19:16.130] - Caitlin Johnson, RD

So weight loss helped us see those higher live birth rates. So we're not just trying to lose weight to lose weight. We're not just trying to lose weight to get access to Chlomon. The whole synergistic approach helps improve this end goal of a healthy mom, healthy baby at the end of this. So again, I pose the question, is it weight or is it something else?

[00:19:44.810] - Caitlin Johnson, RD

I believe that it is a synergistic effect of behavior change, weight loss, insulin improvements, and how insulin improvements help trickle down to other hormones. Let me talk to you a little bit about that. We talked about weight loss and insulin improvements, how that trickles down and affects testosterone levels and how those testosterone levels can trickle down and impact ovulation and even egg quality. While there are a number of other hormones that insulin high levels of insulin impact, one of those is called luteinizing hormone. Your pituitary gland sends out follicle stimulating hormone, the one that gets the eggs ready to be ovulated.

[00:20:28.950] - Caitlin Johnson, RD

And then luteinizing hormone, and you get a big surge of luteinizing hormone to signal the ovary to ovulate. Okay? When this big surge happens, the brain tells the ovary, it's time you've got a follicle ready, do it. Well, high levels of insulin can yield high levels of luteinizing hormones. So it's high all the time.

[00:20:51.060] - Caitlin Johnson, RD

So your ovaries getting bombarded with this, like, ovulate ovulate message. And it's not like it gets resistant to it like we get insulin resistant. It's that it's so attuned to this higher frequency that it doesn't know what is a surge of this hormone anymore because it's always getting told it's surging and so it doesn't really know what a surge is. High levels of insulin can also impact progesterone. And progesterone is that progestate?

[00:21:24.150] - Caitlin Johnson, RD

It is the pregnancy hormone. It's what keeps you pregnant. It's what keeps your body temperature higher so that your body can incubate multiplying cells and actually hold a baby inside of it. When we have too much insulin, that impacts things like inflammation and can lower progesterone production. So aside from just wanting to lose weight, as we impact insulin sensitivity within the body, we start seeing a number of hormonal abnormalities that are very common in PCOS, but not good.

[00:21:57.300] - Caitlin Johnson, RD

We see these improve. Now, if you're listening to this and you're saying I'm that girl that's like 130 and 54 or whatever variation, but I really just don't think that I have weight to lose. You are what many people would call lean PCOS. So lean PCOS is literally a term that refers to anyone that's not a BMI of 25 or more. Okay?

[00:22:21.680] - Caitlin Johnson, RD

So if you're in this BMI range of 18 and a half to 25, which we would call normal, this is not a podcast about the BMI ranking system. I'll talk about that on a different day. I'm just trying to define this term right here. You can even be underweight and be called lean PCOS. So a lot of times I think people hear lean PCOS and they think, oh, that really skinny girl.

[00:22:47.530] - Caitlin Johnson, RD

It's just any normal body weight. If you are in the overweight or obese categories, you're not considered this quote unquote, lean PCOS. This is kind of a misnomer, in my opinion, because in my lifetime I have been obese, overweight and a normal weight never been underweight. And I have had insulin resistance in all of those contexts of my body. I'm currently in a BMI in between 25 and 30 and my body is not altogether that different or reacting very differently than I was in a normal BMI.

[00:23:26.830] - Caitlin Johnson, RD

So a lean PCOS person is somebody that still fits that router dam criteria because remember, insulin resistance is not actually diagnostic for PCOS. It's an infrequent or anovulation it's polycystic ovaries and it's signs and symptoms or lab work that shows hyperandrogenism or high male hormones. So if you're in a quote unquote normal BMI range or even an underweight BMI range, you can still have PCOS. Now, the common misconception is that in a lean PCOS body there is not insulin resistance and we just know that that is not true. There are different estimations on how much of the lean PCOS population struggles with insulin resistance.

[00:24:20.110] - Caitlin Johnson, RD

Some reports put it between 20 and 25%, some reports put it closer to 60% to 70%. I think it's likely that higher number. We do have studies that show individuals in this kind of lean PCOS just a normal weight PCOS compared with controls similar age weight but not diagnosed with PCOS. Individuals that have lean PCOS have higher levels of insulin than their age matched and weight match controls. So whether it's full blown insulin resistance or just higher levels of insulin, you just may have won the genetic lottery that you make more insulin and your ovaries are extra sensitive to it and it's making them pump out testosterone.

[00:25:07.890] - Caitlin Johnson, RD

I also see individuals with lean PCOS often struggle with higher androgens that come from their adrenal glands, namely Dhgas. This can be highly related to stress levels, but also related to high levels of insulin or inflammation. All those things can still impact fertility. So for somebody with lean PCOS, you do still need to focus on insulin resistance, you still need to focus on blood sugar regulation, stress management, circadian rhythm support. All of these things will help with improving fertility, but you just may not need to lose weight.

[00:25:47.320] - Caitlin Johnson, RD

I have seen plenty of people, PCOS and otherwise, who don't need to lose weight that are very insulin resistant. So there are things that are still there to optimize. But if you go to a doctor's appointment and they just give you the normal protocol, hey, you need to lose weight because you have PCOS and you're trying to get pregnant, if that doesn't sound right to you, don't go about trying to lose weight, just focus on behavior changes. But this begs the next question what if it's not really lean PCOS? What if it's something called hypothalamic gamenorrhea?

[00:26:19.330] - Caitlin Johnson, RD

What if it's something else like hyperthyroidism or another autoimmune disease? Most commonly if you have lean PCOS or you get this recommendation to lose weight to improve your fertility with PCOS and you're like, that doesn't sound right, to me, you may have something called hypothalamic aminurrhea. This is just a fancy medical term for you're not eating enough for the amount of activity and energy your body needs. That's unfortunate, but it's fixable people with Ha, obviously very infrequently, if at all. Sometimes they have really short cycles where they'll tell me that they're bleeding like every 16 days or every 18 days.

[00:27:01.820] - Caitlin Johnson, RD

This is different than mid cycle spotting. They're actually having a short but full period in that period of time. Many times they are ovulating, but they are not eating enough for their body to make enough progesterone and actually build a uterine lining that's healthy and ready for implantation. It's a different etiology or reason for infertility or fertility struggles or an ovulation than PCOS, but it is still something that it's highly treatable with diet and lifestyle changes. If you're somebody that's like, I don't know, if it's Ha or PCOS, schedule another appointment with your physician and have an open, honest conversation about how much you're exercising, how much you're eating, and what this might look like and how you think maybe it's not a PCOS diagnosis.

[00:27:56.870] - Caitlin Johnson, RD

I will tell you that a lot of times, doctors, especially in the OBGYN area that are not as familiar with hypothalamic aminuria, may diagnose you with PCOS and tell you that you have lean PCOS and the treatments they're providing are not getting at the root cause of the issue, and thus they may not be very helpful. I've seen many patients go, Do IUI and IVF with hypothalamic amino, and these treatments aren't as successful because their body just literally doesn't have the building blocks to feel safe to provide an environment for pregnancy. If you believe your lean PCs is a misdiagnosis and you might actually have hypothalamic aminuria, weight loss is the exact wrong thing to do to get pregnant. Typically, these individuals need to eat more and stop exercising as much, not eat less and lose weight. We'll talk about hypothalamic acumeniah on its own podcast coming up in the upcoming months.

[00:28:59.960] - Caitlin Johnson, RD

But I want to move on to this question of, okay, so maybe this is me. I'm trying to lose weight. I know I need to lose weight. How do I lose weight with PCOS? Well, in order to lose weight, typically we need something called a calorie deficit.

[00:29:13.400] - Caitlin Johnson, RD

Essentially, you need to burn more calories than what you're taking in with your food and drink. With PCOS, it can be difficult to lose weight. And it's especially difficult to reach this calorie deficit because of two key hormones, one being insulin and one being leptin. Now, we've talked a lot about insulin today in the context of insulin resistance, but insulin has kind of like one big job, and then you can break that up into smaller categories. It's basically trying to move energy around from being like, this could be energy for yourself to it is energy for yourself.

[00:29:48.170] - Caitlin Johnson, RD

So let's say you have too much energy, then what do you want to do with that? You're going to save it for later because your body's smart, wants to keep you alive. It's going to put it in the fat. Well, that's good and bad. Okay, so insulin's secondary job is like, hey, there's enough energy.

[00:30:05.440] - Caitlin Johnson, RD

Let's put some in adipose or fat tissue and save it for later. If you're in a calorie deficit but you still have a lot of insulin floating around, it's hard for your body to manage these two messages, we're not eating enough, but store a lot of this for later. We're not eating enough, but store a lot of this for later. The other issue is leptin resistance. So regardless of your weight with PCOS, you're more likely to have something called leptin resistance.

[00:30:33.680] - Caitlin Johnson, RD

And leptin is your I'm full hormone. I feel good, I don't need any more food. Well, those of us with PCOS have a harder time getting this signal to our brain to stop eating. And particularly for those of us with insulin resistance and food cravings, high appetites, slower metabolisms, this leptin resistance is quite an issue. So for effective weight loss to happen, I believe that you really need to strategize to consider how to improve insulin resistance and help your body get the signal that you're full after you're done eating in, I want to say tricky ways, but not really tricky ways.

[00:31:18.490] - Caitlin Johnson, RD

Like, this is science, this will work, but you have to employ the principles and you'll get so tired of hearing it. But essentially more protein, more fiber, healthy fats, eat enough, don't starve yourself, and basically create balance and safety for your body, but eat a little bit less than you need. That's really the take home. This is how you lose weight with PCOS. Now, a lot of the research shows that very low calorie diets to the tune of helping somebody lose more than 15% of their body weight, will really help with fertility, ovulation, pregnancy outcomes.

[00:32:02.470] - Caitlin Johnson, RD

Very low calorie diets, though, in the context of preconception, concern me as a fertility dietitian because you're about to grow a baby and we want this baby to have all that it needs for its brain to develop and its spine to develop. We want you to have all that you need so that if you have a first trimester of pregnancy that's really hard and you're super nauseous, your body has some nutrient stores to pull from. And if I basically starve you to get you to lose 15% of your body, you're not going to go into pregnancy feeling really well. And weight loss fat extreme is not going to be only fat. Some of it will be water, but a lot of it will also be your lean muscle tissue.

[00:32:45.990] - Caitlin Johnson, RD

And we don't want to be pulling from that right before we're going to ask your body to do something really hard, which is grow a baby. So I believe that going for a. Very low calorie diet is not the long term solution. I think that you should pair increasing protein, increasing fiber, eating healthy fats with a moderate calorie restriction, whether that is created by increased physical activity or just eating a little bit less portion control at all your meals. This is the most effective way to lose weight that actually impacts behavior change that you can keep for a lifetime and also improve your fertility right now.

[00:33:30.000] - Caitlin Johnson, RD

Now a lot of questions come up because doctors, the best way that they know how to help in situations like this is providing medication or surgery. So a lot of people will ask, should I take a medication to help with weight loss? And medications come in the form of things like metformin, ozimpic, Victoza, trulicity. Many of these are meant to help improve insulin resistance and insulin signaling so that you make less insulin so that you can lose weight. They also can suppress your appetite or make you slightly nauseous so that food just doesn't sound good to you.

[00:34:06.580] - Caitlin Johnson, RD

And then I've even had doctors prescribe Centrine. And I do mean that it's not just the when people took it to lose weight. Like I've seen doctors use it very recently with my fertility patients to help them lose weight. The things to consider and have these conversations with your doctor are is this safe for me to take if I'm currently trying to conceive? If you are thinking 5,6 or 12 months down the road, you should still have this conversation.

[00:34:36.030] - Caitlin Johnson, RD

But if you're like playing fast and loose and there's no protection stopping you from getting pregnant, you need to have a conversation with your health care provider about all the medications you're on. Not just weight loss or insulin improving medications, but antidepressants everything, everything that you're on. You need to have a conversation with your prescribing provider and say, hey, I'm trying to get pregnant. Is this safe for me to be on right now? I see many doctors leave patients on metformin throughout entire pregnancies.

[00:35:07.900] - Caitlin Johnson, RD

Many of these others are not compatible with pregnancy. So this is an important thing to consider in the research. They talk about a quote unquote washout period between taking the medication and continuing your efforts towards conceiving or having unprotected sex. So this is actually something that's really important for you to understand, and I'm not going to go into this at length. Have a conversation with your doctor.

[00:35:33.440] - Caitlin Johnson, RD

I've seen a lot of even endocrinologists and reproductive endocrinologists focus on weight loss with clients for the reasons we mentioned above in that study, that weight loss did help improve live birth rates, ovulation pregnancy outcomes with even just using chlomed. I've seen these doctors use these other medications. But you need to have a thorough conversation about this. Okay, I think I've beaten that horse dead. Should you consider supplements for fertility preconception specifically with a view towards weight loss?

[00:36:05.750] - Caitlin Johnson, RD

I believe you should. Myoinostatol is something that performs really well in head to head randomized controlled studies with things like metformin for improving insulin resistance and ovulation rates. So that's a really good option. Taking a myoin osteol on its own is not likely to yield weight loss. You have to pair it with nutrition changes, behavior changes.

[00:36:30.460] - Caitlin Johnson, RD

But it performs really well in the research and really helps within the ovary itself and how it signals and communicates with insulin and can help shift production of testosterone into production of estrogen anesthetic cysteine, or we call it neck often is another one that I might consider. Both my own osteol and neck are safe in pregnancy and so it's not something that you need to be concerned on. You can even overlap these. Neck is also a really powerful precursor to an antioxidant in your body and can really help with egg quality. The other one that I consider is magnesium.

[00:37:10.450] - Caitlin Johnson, RD

It's really hard to take too much magnesium. It improves insulin resistance. It helps improve things like bowel, regularity relaxation, soothing sore muscles. It can also help with sleep quality. And sleep quality is really important for weight loss for a number of reasons.

[00:37:31.720] - Caitlin Johnson, RD

But if you've ever had a really poor night's sleep, you know that you're reaching for coffee and sugar all day long. And so improving sleep quality can actually improve weight loss and help you sustain weight loss that you've already had. Now, what if your doctor recommends bariatric surgery? This is a very extreme treatment. I have seen no research in PCOS looking as far forward as live birth rates.

[00:38:02.570] - Caitlin Johnson, RD

We do know that bariatric surgeries are very helpful for improving metabolic parameters and have a fairly good success rate at long term weight loss maintenance. However, bariatric surgery really limits nutrient absorption. I have worked with a number of women who have had bariatric surgery and then come to me to help make sure that they're eating enough in preconception and getting enough nutrients and then getting enough nutrients in pregnancy and breastfeeding. But I've never actually worked with somebody with PCOS trying to conceive that goes on to have bariatric surgery and followed them all the way through the process. I think that in many cases there are other ways to lose weight.

[00:39:00.190] - Caitlin Johnson, RD

Now, there is research in women with a BMI of over 40 that this may be an effective way to lose weight and sustain weight loss with PCOS. But again, we do not have research that looks forward enough to live birth rates. It makes sense that things like ovulation rates would improve after bariatric surgery as insulin resistance improves and weight loss occurs. I believe that bariatric surgery has its place as an intervention for PCOS in a limited population, but that it should only be considered when attempts have been made already to improve somebody's health and obtain the weight loss needed for their health goals. There are other extreme, in my opinion, interventions that would fall under kind of the category of surgery.

[00:39:56.670] - Caitlin Johnson, RD

Something like ovarian drilling or an ovarian wedge surgery, where they take out just like a small kind of like a wedge of cheese. They take out a little block of your ovary and that actually has been shown to improve ovulation rates. I've never dug into the research to see how those specific surgeries on the ovary impact weight. So I don't know what to say about that. I don't have a clear understanding of if those surgeries help impact weight loss.

[00:40:31.350] - Caitlin Johnson, RD

My understanding is that we're basically limiting the amount of testosterone production for a period of time that allows recovery of the organ to help the follicles to make the needed estrogen to then mature and be ovulated. So weight loss has its place. Weight loss can help you achieve pregnancy in the wild or naturally. Weight loss can help improve rates of ovulation, pregnancy and life. Birth rates.

[00:41:05.260] - Caitlin Johnson, RD

Even if you go on to take something like chlomid or lettrazole, weight loss can help you have a healthier pregnancy and lower risks of things. Weight loss at all costs is not a recommendation. Weight loss with no education and guidance on a way to do it, that's patient centered and helpful in considering your health goals and your preferences and your diet choices and your finance situation. How many hours in a day that you can cook? A lot goes into behavior change, ladies.

[00:41:39.030] - Caitlin Johnson, RD

So if you've just been told to lose weight, I know how frustrating that can be. I also see in the research that it's not a bad recommendation or goal, but it's not just the weight that happens that gets the ovulation to take place. Insulin resistance, behavior change, hormonal changes, these are really like the secret sauce for this to work. So we're talking about weight loss, especially in this month of January, and if you're listening to this any other month of the year, great. I hope that this has been really helpful, but as a lot of people focus on weight loss, I want to kind of recenter ourselves and see why this is a specific recommendation, why it does have merit, and why we don't necessarily need to take it as judgment or a fat bias or anything like that.

[00:42:39.170] - Caitlin Johnson, RD

I think doctors really do have our health and our best interest at heart when they make this recommendation and they are trying to make it based on research. Okay? It's not just like willy nilly just looking at you and saying, hey, you need to lose weight if you're going to get pregnant. There is merit behind it, but we need to approach it in a really healthy way, in a way that supports you, in a way that's sustainable, in a way that feels good to you, in a way that's not so overwhelming to you and in a way that your body will receive the change as well. I hope this was really helpful.

[00:43:18.680] - Caitlin Johnson, RD

If you have questions, hop into the community section and post them there. I absolutely love supporting you and I love creating content for you. And I want to continue to support you in your journey. And if you are trying to lose weight with PC us so that you can become a mom, I want you to know that I see you. I know how hard you're working and I know how much you want this goal.

[00:43:43.130] - Caitlin Johnson, RD

And I want you to know that it is more possible to get pregnant with PCOS than you think or that you've been made to think, and your efforts are not in vain. I'll see you next week.

Ep 12: Why Weight Loss is Recommended to Women with PCOS to Improve Fertility