PMOS and Weight: Why Where You Carry It Matters More Than the Number

If you have PMOS (the condition previously known as PCOS), you have probably been told at some point to "just lose weight."

Maybe more than once.

It is well-meaning advice. It is also, quite often, advice that misses what is actually happening inside the body.

Because for many women with PMOS, the issue isn't really about how much weight the body is carrying. It's about where it's being carried, and there is a fascinating piece of hormone science behind that which almost never gets explained properly.

So let's explain it.

Fat isn't just fat

It is easy to think of body fat as one single thing: Extra padding, stored energy, the number that moves (or doesn't) on the scales.

But fat tissue is not uniform. It behaves very differently depending on where it sits.

Fat stored around the hips, thighs and bottom - sometimes called a "pear" shape - tends to be metabolically fairly quiet. It stores energy steadily and doesn't interfere much with the rest of the body's systems.

Fat stored around the abdomen and internal organs - an "apple" shape, sometimes called visceral fat - behaves completely differently. It is metabolically active, it communicates with the liver, and it plays a much bigger role in insulin resistance, blood sugar regulation and cardiovascular health.

This distinction matters enormously in PMOS, because androgens - the hormones that tend to run higher in PMOS - actively influence which type of fat storage the body favours.

The insulin paradox that explains so much

Here's something that confuses a lot of women with PMOS, and honestly, I think it deserves to be far better known.

You may have been told you have "insulin resistance." Quite reasonably, you assume that means your body has become resistant to insulin - full stop. One hormone, one problem, one effect everywhere it acts.

But that isn't quite what happens in PMOS. And the detail matters.

Insulin doesn't have just one job. It has (at very least) two.

Job one is the one most of us have heard of: helping move sugar out of the bloodstream and into cells, where it can be used for energy.

Job two is far less talked about: insulin also acts as a signal to the ovaries, where it can encourage the production of androgens.

In PMOS, something quite strange happens. The body becomes resistant to insulin's first job - the blood sugar one - but stays fully responsive, sometimes even more responsive, to the second job, the one involving the ovaries.

Researchers call this "selective" insulin resistance, and I think it's one of the most genuinely interesting pieces of the PMOS puzzle.

Picture insulin sending the same instruction out to two different departments in the body. One department - muscle and liver tissue, largely responsible for blood sugar - starts tuning the message out. The other department - the ovaries - not only keeps listening, it turns the volume up.

Because the blood-sugar department has stopped listening properly, the pancreas responds the only way it knows how: it produces more insulin, trying to get the message through. Blood sugar often stays perfectly normal as a result - which is part of why insulin resistance in PMOS can go undetected on a standard blood test for years.

But that extra insulin doesn't just circulate uselessly while the blood sugar department ignores it. It reaches the ovaries too - a department that never stopped listening in the first place. And now there's more of the signal arriving than ever.

The result is more androgen production, driven directly by the very insulin resistance that a standard test might miss entirely.

This is why the phrase "you can't have insulin resistance, your bloods are normal" is one I'd love to retire. Fasting glucose is often the last thing to change, not the first sign that something's happening.

Androgens are directing traffic

Testosterone and related androgens don't just sit quietly in the background. They give the body instructions about where to store incoming energy.

In PMOS, where androgen activity tends to be higher, those instructions lean towards the abdominal, visceral pattern rather than the hip-and-thigh pattern.

There are a few reasons for this.

Fat cells around the abdomen respond more strongly to androgens. They are, in a sense, more "listening" to that hormonal signal than fat cells elsewhere in the body.

Androgens also change how existing fat cells release their contents. Abdominal fat is quicker to release fatty acids back into the bloodstream - and because of where it sits, much of what it releases goes straight to the liver. Over time, this contributes to the liver working harder, and to changes in cholesterol and triglyceride levels that show up on a standard blood panel.

And androgens can make it harder for the hip-and-thigh storage area to do its job properly. That "quiet," steady storage depot doesn't expand as easily when androgens are high, so the body has fewer places to put extra energy safely - and ends up storing more of it centrally instead.

Put simply: it isn't that women with PMOS are storing "more" fat because of some failure of willpower. It's that androgens are influencing where the body chooses to put it — often somewhere far more metabolically demanding.

And then it becomes a loop

Here is the part I think is genuinely important for anyone trying to make sense of their own body.

Visceral fat isn't just a passive result of this process. It becomes an active participant in it.

Abdominal fat tissue produces its own chemical signals - some of them promote inflammation, and it reduces production of a hormone called adiponectin, which normally helps the body stay sensitive to insulin.

So the sequence looks something like this:

Higher androgens → more fat stored centrally → that central fat further worsens insulin sensitivity → which, in turn, can push androgen levels higher still.

It's a loop, not a straight line. And once you can see it as a loop, a lot of things about PMOS start to make more sense - including why "eat less, move more" so often fails to shift things for women with this pattern. That advice doesn't touch the loop at all.

This is also why oestrogen gets mentioned

You may have come across the idea that oestrogen protects women from carrying weight centrally - and there is truth in that. Oestrogen tends to favour the hip-and-thigh storage pattern, which is part of why fat distribution often shifts more centrally after menopause, when oestrogen naturally falls.

In PMOS, higher androgen activity can tip that balance in a similar direction, even well before menopause. It isn't the main driver of the picture - the androgen story above is the bigger piece - but it's part of why this pattern can show up relatively early in life for some women with PMOS.

Why this matters more than the scales do

If you take one thing away from this, I'd like it to be this: the location of body fat tells us more about metabolic health than the total amount does.

Two women can weigh exactly the same and have very different metabolic pictures, because one is carrying more of her weight centrally and one isn't. That's not visible on a set of scales. It's not something "eat less" fixes, because it was never really about quantity in the first place.

This is also why I don't lead with weight-loss advice when working with women who have PMOS. I lead with the question underneath it: what is the metabolic environment doing, and how do we support it?

That usually looks like things that improve insulin sensitivity directly — building and maintaining muscle, eating enough protein and fibre, regular movement (resistance training in particular seems to matter here), decent sleep, and managing stress. Not because these things are a moral improvement project, but because they are genuine levers on the exact mechanism described above.

And sometimes, weight changes as a result of that. Sometimes it doesn't change much at all, while the metabolic picture - the thing that actually matters for long-term health - improves anyway.

Your body isn't working against you

I think this is worth saying plainly: if you have PMOS and have struggled to shift weight from your middle despite doing "everything right," this isn't a personal failing.

It's hormones giving your body a very specific set of instructions - and those instructions can be worked with, once you understand what they are.

Want to understand your own picture more clearly?

If you have PMOS and want support that actually works with your metabolic picture — rather than generic weight-loss advice that was never going to touch the underlying mechanism — you can get in touch with me here.

And if you'd like more explanations like this one — grounded in the science, without the overwhelm — my newsletter goes out every fortnight, and it's free.