“Is it harder for me to lose weight because of PCOS?”


Is it harder for you to lose weight because of PCOS? Does PCOS-related hair growth reduce after weight loss? Will your period come back if you lose weight? And why does Dr. Fox sometimes recommend his female patients to eat throughout the day?

Get the answers to these questions in this week’s Q&A with fertility specialist Dr. Fox:

PCOS and keto


I was diagnosed with PCOS when I was 19, was told to lose weight and come back when I wanted a baby.

I’m now 33, still heavy (234 lbs – 106 kg), 5’5″ (165 cm). And still not wanting a baby but….I was at my wit’s end when I stumbled across this website.

I have been following keto for about 5-6 weeks, had a couple off-the-wagon days, and have lost 7 lbs (3 kg) so far, which for me is amazing so I have three questions.

1. Is it harder for me to lose the weight because of PCOS? Will it take me longer because of PCOS? I used it as an excuse in the past – “Oh, cause I have this condition I can’t lose weight as quick as normal people”. Is that even true?

2. My other question is: Will my hair growth get better with weight loss? I have to wax my face, chest, abdomen and shoulders once a week because of dark hair, and it makes me feel like a man and I was hoping that if I lose weight, this will get better. Will it ever go away?

3. My last question is if my period will come back if I lose weight? I’ve never had a natural period, but had to take a pill to have one. Now I have a mirena coil but hoping when I take that out we may be able to start a family naturally. Or is that a case of waiting and seeing what happens once I lose the weight?

As I live in the UK, it’s been sometimes difficult to see a specialist as we have to go via the GP, so your advice will be amazing.

Thank you in advance,

Dr. Fox:

Your story is so typical. In my opinion, the goal really is insulin reduction, not weight loss. If insulin is reduced, weight loss should follow. To answer your questions, your cycles should become more regular with improved insulin and the hair growth stimulation should decrease.

The hair may or may not change much. Flutamide and similar drugs are very helpful with the hair growth. If you have a doctor who can prescribe this for you it could be very helpful.

To answer the question regarding weight loss difficulty, we have to put it in context. If you are trying to lose weight in a starvation (low-calorie) format, you will find it much harder than those with normal insulin function.

In a low-carb high-fat strategy, you will lose weight equally with others if you meet the carb restriction required to maximally drop your insulin.

Good luck – you are on to the right answer.


Intermittent fasting and LCHF

I am a doctor myself and have the following question: I have read the work of Jason Fung and he quotes studies, that the basal metabolic rate is not reduced with intermittent fasting, nor is the body using muscles for protein.

You – on the contrary – mentioned the importance to eat every couple of hours. I wonder about the rationale behind it. Regarding sustainability and the lifestyle changes it makes of course sense. But regarding the hormonal imbalance?

In my opinion there shouldn’t be a need to eat if the patient is not hungry, should it? The presence of food throughout the day releases insulin (insulinogenic effect of any food, e.g. protein – while of course smaller), thus: Is this constant eating really beneficial for the human body? Wouldn’t a combination of intermittent fasting and LCHF be ideal for the patients who don’t lose much weight on 20 g carb-LCHF (there are quite a few)?

Is there any data on this topic?


Dr. Fox:

These are great questions. I think the exact answers to your questions still elude us to some degree. My aversion to intermittent fasting is only for women. In my experience, working shoulder to shoulder with women who are great followers of the keto approach (direct observation), is that they become hungry and hypoglycemic (by symptoms alone) after a certain time period without calories. My number is not high but the observations are very consistent and we hear the same from patients. We work in an OR setting a great deal and after about 4-5 hours, these women are getting in trouble with hypoglycemia. I understand that other doctors have a different experience, but that is what I have seen personally (possibly related to the patient population I see most).

On the other hand we, in our practice, have become very interested in physiologic stress as it relates to fertility and estrogen suppression which can be problematic for many women. Our most common offender is too much aerobic exercise, but many women report hypoglycemia symptoms if they don’t eat every 3-4 hours. Obviously they are average carb intake people, not low-carb followers, and usually experience reactive hypoglycemia. It is likely that their cortisol is increased and its downstream effects are in play. Given these two associations/observations, I feel that intermittent fasting can be a problem for women, especially when following a higher-carbohydrate diet.

I do think however, women can increase their time between meals after they become keto-adapted and we tell patients that as they approach ideal body weight, they will likely need to think more in terms of overall calories if they want to achieve the ideal BMI of 21-23.

After dealing with thousands of patients who “don’t lose weight” on 20 g/day or less, I find that two things are primarily at play. One, unfortunately, patients are not truthful about where they are eating. It happens in all areas of medicine. Patients fail to report medication compliance and studies report 40-60% significant non compliance rates and most patients don’t admit this to their physicians. For most patients with significant BMI elevation, they need strict adherence to the process. Most “keto websites” now promote foods and products that won’t work for these people.

Secondly, physiologic stress and cortisol increase is a huge factor (again I work mostly in women’s health). When I trained in reproductive endocrinology from 1992-1994, I was taught that anyone with a cortisol >10ug/dl needed to be screened for Cushing’s with a dexamethasone suppression test. It was unusual then to see these levels. Obesity was the most common recognized “cause” of this finding. We check cortisol as part of our standard work up panel and it is rare now to see a value below 10. The range has been revised up for the lab normals over time due to this phenomenon. Out of 50-100 such tests per month, I only see values under 10 maybe once or twice. This is an incredible change in a short amount of time.

There are many factors affecting this but things such as caffeine (2X cortisol), adrenal function, the exercise revolution that started in 1980, the food pyramid starting about 1980 causing increased hyper- and hypoglycemia, the smart phone and increased “connectivity stress,” sleep abnormalities including circadian disruption and sleep apnea, two working member households with increased parenting demands due to lack of safety for our children in society, etc. etc. This incredible increase in stress placed on our female population does cause a physiologic block (cortisol and stress response) to metabolic improvement.

On top of all this, we then take this stressed person and tell them that we are taking their drug of choice away (carbs) which is stressful in and of itself and may cause more stress for some. This is where behavior modification comes in. The need for psychological intervention is great, yet it is difficult to get patients to seek this type of care and support. Look at what goes into cessation of smoking, alcohol, narcotic use.

In summary and sorry for the long response, I think this is a very complicated, social, physiological, psychologic, and addictive problem that really needs a multi-disciplinary approach to correct for many people. Unfortunately, the system does not allow for this well-rounded approach. Thanks for a great question.


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