15 February 2021

PCOS and binge eating: a vicious circle

Clinical Mental Health Women

Polycystic ovarian syndrome (PCOS), diagnosed by the Rotterdam criteria (see box 1) affects 8-13% of women of reproductive age, and up to 70% of those have not been diagnosed1.

Standard treatment includes medications and lifestyle changes.

A recent meta-analysis shows that patients with PCOS are almost four times more likely to meet criteria for an eating disorder, compared to women without PCOS2. In particular, close to 40% of patients with PCOS experience clinically significant binge eating3.

This article will discuss binge eating in the context of PCOS.

Binge eating (box 2) is a feature of several eating disorders, including binge eating disorder, bulimia nervosa and anorexia nervosa, binge/purging subtype.

Binge eating disorder (BED) affects approximately one in 100 adults, and up to 97% have not been diagnosed4. Both PCOS and eating disorders lead to poor quality of life and potential adverse metabolic outcomes. Because of the low diagnosis rates of these conditions, identifying one condition presents an opportunity to screen for the other.

The causes of PCOS are not completely understood, but mechanisms are likely to be related to insulin wherein the woman has a genetic susceptibility to insulin resistance. The consequent hyperinsulinaemia triggers an increase in the body’s production of androgens which can affect ovulation and cause other side effects such as acne and hirsutism which are typical of PCOS5

What are the likely reasons for increased incidence of binge eating in PCOS?

The reasons for increased incidence of eating disorders in PCOS is likely to be multifactorial and circular. Women with PCOS have poorer mental health overall, including increased levels of depression, anxiety, and body image dissatisfaction, all risk factors for eating disorders6. Additionally, PCOS is known to interfere with appropriate appetite regulation, increasing the likelihood of binge eating. This may be linked to increased insulin resistance in PCOS7. Furthermore, binge eating itself may increase the expression of PCOS, due to binge eating increasing serum insulin levels, triggering further increased testosterone.

Due to the high incidence of disordered eating in women with PCOS, it is recommended to screen each patient presenting with PCOS for symptoms which may indicate an eating disorder. A validated screening method is the “SCOFF” (box 3).

Managing the eating disorder and PCOS concurrently

Comorbid PCOS and an eating disorder with binge eating features presents a unique problem. Without addressing the binge eating, any intervention to modify diet to manage PCOS is likely to be ineffective. In order for eating disorder treatment to reduce binge eating in PCOS, standard psychological treatment is likely to be inadequate. PCOS must also be managed concurrently, in order to address the appetite dysregulation.

Pharmacological management of PCOS has been shown to have some effectiveness, including the combined oral contraceptive pill, metformin, the supplement inositol, or anti-androgens such as spironolactone, but are recommended in addition to lifestyle changes1. Unfortunately,most research into lifestyle interventions for PCOS has been focused on weight loss as a primary outcome. It has been found8 that the presence of binge eating often increases the drop-out rate in weight management programs.

CBT-e, the most common treatment for eating disorders, has a key focus of reducing dietary restraint, but attempted weight loss increases dietary restraint, and is likely to increase binge eating.

In Australia, an increasing number of dietitians are taking a “non-diet” approach in managing chronic disease, which involves improving health outcomes without a focus on weight loss9. Evaluation of these approaches have been positive10.

After screening for disordered eating in PCOS, GPs may find it helpful to refer those patients with comorbid PCOS and binge eating to a dietitian who has experience in eating disorders and PCOS. This will give patients strategies to improve their physical health, reduce binge eating and alleviate symptoms of PCOS.

Box 1 – Rotterdam criteria for the diagnosis of PCOS11

Two of the following three criteria are required:
1. oligo/anovulation
2. hyperandrogenism, either
– clinical (hirsutism or less commonly male-pattern alopecia) or
– biochemical (raised FAI or free testosterone)
3. polycystic ovaries on ultrasound

Box 2 – DSM 5 definition of binge eating12

An episode of binge eating is characterized by both of the following:
1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances.
2. The sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

Box 3 – Screening for an eating disorder: the “SCOFF”

1. Do you ever make yourself sick (vomit) because you feel uncomfortably full?
2. Do you worry you have lost control over how much you eat?
3. Have you recently lost more than one stone (~6kg) in a three month period?
4. Do you believe yourself to be fat when others say you are too thin?
5. Would you say that food dominates your life?
Each positive answer is given a score of one. A score of two or more indicates a likely clinical eating disorder, however a score of one may be indicative of disordered eating, and could be used to facilitate further discussion.  

Jessica Bailes is a senior dietitian at The Talbot Centre.

1. Teede, Helena et al. “International evidence based guideline for the assessment and management of polycystic ovary syndrome.”, 2018, Monash University, Melbourne Australia 2018

2. Lee, Iris et al. “Increased Odds Of Disordered Eating In Polycystic Ovary Syndrome: A Systematic Review And Meta-Analysis”. Eating And Weight Disorders – Studies On Anorexia, Bulimia And Obesity, vol 24, no. 5, 2018, pp. 787-797. Springer Science And Business Media LLC, doi:10.1007/s40519-018-0533-y.

3. Jeanes, Y. M., et al. “Binge Eating Behaviours and Food Cravings in Women with Polycystic Ovary Syndrome.” Appetite, vol. 109, 2017, pp. 24–32. Crossref, doi:10.1016/j.appet.2016.11.010.

4. Cossrow, Nicole, et al. “Estimating the Prevalence of Binge Eating Disorder in a Community Sample From the United States.” The Journal of Clinical Psychiatry, vol. 77, no. 08, 2016, pp. e968–74. Crossref, doi:10.4088/jcp.15m10059.

5. Nestler, J. E. “Insulin Regulation of Human Ovarian Androgens.” Human Reproduction, vol. 12, no. suppl 1, 1997, pp. 53–62. Crossref, doi:10.1093/humrep/12.suppl_1.53.

6. Paganini, Chiara, et al. “The Overlap Between Binge Eating Behaviors and Polycystic Ovarian Syndrome: An Etiological Integrative Model.” Current Pharmaceutical Design, vol. 24, no. 9, 2018, pp. 999–1006. Crossref, doi:10.2174/1381612824666171204151209.

7. Moran, L., and R. J. Norman. “Understanding and Managing Disturbances in Insulin Metabolism and Body Weight in Women with Polycystic Ovary Syndrome.” Best Practice & Research Clinical Obstetrics & Gynaecology, vol. 18, no. 5, 2004, pp. 719–36. Crossref, doi:10.1016/j.bpobgyn.2004.05.003.

8. Teixeira, P. J., et al. “Pretreatment Predictors of Attrition and Successful Weight Management in Women.” International Journal of Obesity, vol. 28, no. 9, 2004, pp. 1124–33. Crossref, doi:10.1038/sj.ijo.0802727.

9. Willer, Fiona, et al. “Australian Dietitians’ Beliefs and Attitudes towards Weight Loss Counselling and Health at Every Size Counselling for Larger?bodied Clients.” Nutrition & Dietetics, vol. 76, no. 4, 2019, pp. 407–13. Crossref, doi:10.1111/1747-0080.12519.

10. Bacon, L., et al. “Evaluating a ‘Non-Diet’ Wellness Intervention for Improvement of Metabolic Fitness, Psychological Well-Being and Eating and Activity Behaviors.” International Journal of Obesity, vol. 26, no. 6, 2002, pp. 854–65. Crossref, doi:10.1038/sj.ijo.0802012.

11. “Revised 2003 Consensus on Diagnostic Criteria and Long-Term Health Risks Related to Polycystic Ovary Syndrome (PCOS).” Human Reproduction, vol. 19, no. 1, 2004, pp. 41–47. Crossref, doi:10.1093/humrep/deh098.

12. Call, Christine, et al. “From DSM-IV to DSM-5.” Current Opinion in Psychiatry, vol. 26, no. 6, 2013, pp. 532–36. Crossref, doi:10.1097/yco.0b013e328365a321.

COVID-19 live update