You may have come across quizzes or articles on how to figure out your type of PCOS. In fact that’s probably why you’re here.
They are typically categorized as adrenal, inflammatory, insulin-resistant, thyroid, and post-pill PCOS.
At the end of this article you’ll have a clear understanding if there is anything to PCOS-typing and how to assess what’s driving YOUR unique picture of the syndrome.
Spoiler: Knowing your drivers and root causes is important, but it’s not this simplistic.
What is PCOS?
First, the basics. PCOS is a complex, chronic inflammatory condition that affects mainly the reproductive, metabolic and hormonal systems of the body.
It is currently believed to be caused by a complex interplay of genetic/epigenetic and environmental factors, but this has not yet been clearly established.
It is estimated to affect 1 in 10 women and is the leading cause of infertility.
The presentation of the syndrome and root causes are highly variable to each individual.
The impact of PCOS is great and linked with higher long-term risks for conditions like atherosclerosis, high blood pressure, heart attack, stroke, type 2 diabetes, fatty liver disease, sleep apnea, anxiety and depression, and eating disorders.
Diagnosis is typically made based off of the Rotterdam criteria, in which at least 2 of the following need to be present:
- Polycystic ovaries
- Elevated androgens (male hormones) on bloodwork or clinical signs of high androgens (facial hair growth, acne, hair loss)
- Irregular menstrual cycles/ovulation
Now that we’re clear on the landscape of PCOS, let’s unpack these supposed “types” one at a time.
The “Types of PCOS”
Post-pill PCOS
Let’s first talk about what the pill does.
Combined oral contraceptives (COCs) use synthetic estrogen and progesterone to suppress ovulation by disrupting the body’s own hormonal signaling.
A design and consequence of COCs is decreased production of the body’s own sex hormones like testosterone (1).
COCs also increase the production of sex hormone binding globulin (SHBG). SHBG is a carrier protein that binds sex hormones, like testosterone, and carries them around the body in circulation.
Once bound to SHBG, testosterone is then inactive and unable to exert its effects on the body (2).
In fact, both of these effects are why COCs are used for symptom management in PCOS. The combined decrease in testosterone production and increase in SHBG can improve androgenic signs and symptoms.
When the medication is stopped, SHBG can decrease leading to more free androgens in circulation. This coupled along with a rebound in testosterone production may lead to androgenic symptoms that LOOK like PCOS.
It can take some time for the body’s own hormones to rebalance after stopping COCs. This is temporary and is not PCOS, unless it is PCOS. Here’s what I mean.
Many women are put on COCs in their teen years and stay on them for years, even decades. This may mask PCOS symptoms due to the effects it has on decreasing free testosterone.
And because they are suppressing ovulation, these women do not know if their cycles have been irregular, because the pill is giving them a withdrawal bleed every month right on schedule.
When these women finally come off the pill, androgenic symptoms may present or return, and in that case a doctor may make a diagnosis of PCOS. It was not caused by coming off the pill. It was there the whole time.
Further, PCOS is a lifelong condition and does not go away.
Summary: There is no such thing as “temporary/post-pill PCOS”. Although coming off COCs can cause/worsen androgenic symptoms, it is not PCOS itself.
Thyroid PCOS
The thyroid gland is a butterfly-shaped organ that sits on the front of your neck. Its main function is producing thyroid hormones that regulate body processes like metabolism, breathing, digestion, heart rate, body temperature and fertility.
Hypothyroidism, or underactive thyroid, is when the gland does not make adequate amounts of thyroid hormones in order to efficiently carry out these body processes.
One of the most common causes of this is an autoimmune condition called Hashimoto’s thyroiditis. This is when the immune system mistakenly attacks and damages the thyroid gland leading to its increasing dysfunction.
Research has revealed high rates of hypothyroidism in women with PCOS (3). In particular, a significant increased risk for Hashimoto’s, therefore thyroid health is recommended to be FULLY screened in every PCOS patient (4, 5, 6).
Hypothyroidism itself can promote similar effects of PCOS like insulin resistance and disruptions in fertility. It can also cause symptoms like hair loss, fatigue, mood disturbances and weight gain/weight loss resistance.
Knowing what the thyroid does, it can certainly worsen PCOS. However, currently these are considered two separate conditions.
Summary: Hypothyroidism is a common finding in women with PCOS. Although it can worsen the picture, it’s not a type of PCOS itself.
Insulin-resistant PCOS
Insulin is a hormone made by the pancreas that helps to regulate normal blood sugar, or glucose, levels.
When carbohydrates are consumed, they eventually break down into glucose and make their way into the bloodstream.
When the pancreas senses that rise in blood glucose it releases insulin. Insulin’s job is to help cells uptake glucose for energy/storage and thus restore blood glucose levels to normal.
Insulin resistance (IR) occurs when those cells no longer respond as efficiently to insulin’s signal. More insulin is thus required to have the same effect. This is called hyperinsulinemia (high blood levels of insulin).
Insulin resistance is present in varying degrees in up to 80% of PCOS cases (7). It is a driver of androgen excess, inflammation, weight gain, sugar and carbohydrate cravings, fatigue, and other things.
Did you catch that? IR itself causes inflammation. So it isn’t either insulin resistant or inflammatory PCOS. It can absolutely be both.
That’s what PCOS typing gets wrong.
Summary: Insulin resistance is a major root cause of signs and symptoms in most cases of PCOS. But, if you have IR, it doesn’t mean that’s the only bucket you fall in.
Inflammatory PCOS
Inflammation is the normal and healthy response of the body to injury, infection or a toxin/chemical. The process involves recruitment of an army of chemicals and immune cells to protect the body.
When the threat is handled, inflammation subsides. This is meant to be a short-term event; hours, days, a week. What is problematic is when inflammation is chronic over months, years, decades.
Chronic inflammation is involved in all of our major diseases in the United States like diabetes, heart disease, autoimmunity, and cancer (8).
PCOS itself is described as a condition of low-grade inflammation, so this is involved to varying degrees any way you slice it.
Research has repeatedly found higher levels of inflammatory markers in women with the condition compared to those without it (9).
Although inflammation is attributable to PCOS itself, it is further aggravated by other phenomena that also independently cause inflammation: insulin resistance, obesity, androgen excess, etc.
Inflammation may be MORE significant in one person over another, but EVERYONE with PCOS needs to address it.
Addressing the sources of inflammation will be highly individual.
Summary: Every case of PCOS involves some degree of inflammation caused by the syndrome itself. Other contributing factors to inflammation should be addressed.
Adrenal PCOS
The ovaries are not the only source of androgen production. The adrenal glands that sit atop both kidneys also contribute to production of these hormones.
The androgen DHEA-S is produced almost 100% in the adrenals, making it a direct marker of adrenal androgen output.
About 20-30% of women reflect an adrenally-based PCOS, usually indicated by higher levels of DHEA-S (10). In these cases, the androgen excess is driven mainly by the adrenals, not the ovaries.
Stress triggers the brain to activate the adrenals and produce the stress hormone cortisol. But, this activation ALSO stimulates the production of DHEA-S.
It appears women with PCOS may have an exaggerated response to this stress trigger which leads to increased levels of the adrenal androgens.
And though everyone with PCOS needs to manage stress, in these women, focusing on this may be a primary focus.
Adrenal-based PCOS is less clear and understood. But, the current research shows women with higher DHEA-S often tend to have a lower BMI and less insulin resistance (11, 12).
Summary: Adrenal PCOS is less understood, and appears to effect a smaller number of women with the syndrome. They often tend to be leaner with less insulin resistance.
The PCOS Phenotypes
Although the types discussed above are not recognized in this manner within the scientific research, there actually are four phenotypes recognized within the Rotterdam criteria.
These are used more to assess the scope of risk in an individual. The types A-D decrease in severity of the syndrome and risk factors for related conditions.
Type A & B: Classic
Both types A and B are considered “classic” PCOS.
Type A is the most severe and as the chart shows includes all three of the diagnostic markers. Type B includes both androgen excess and irregular menstrual cycles, but no presence of polycystic ovaries.
Those with classic PCOS tend to have a higher BMI, more severe disruption in menstrual cycles and higher rates of insulin resistance, cardiometabolic dysfunction, and pregnancy health risks (13).
Type C: Ovulatory
Women with ovulatory PCOS have androgen excess and polycystic ovaries, but normal menstrual cycles.
Although still present, type C women generally have lower elevations of insulin, serum androgens and lipids (LDL-C, triglycerides, etc.) when compared with classic PCOS. And hirsutism than those with classic. Metabolic syndrome is common (14).
Type D: Non-hyperandrogenic
Type D includes polycystic ovaries, irregular cycles and normal androgen levels.
This phenotype carries the lowest risk of metabolic dysfunction and less severe menstrual cycle irregularities (15).
Again, this is controversial as some researchers believe that androgen excess is a key feature of all PCOS and should be required for diagnosis.
So, which phenotype are you?
Are types of PCOS something to care about?
Hopefully, you now understand why the thyroid PCOS and post-pill PCOS types are not accurate.
However, the other factors- insulin resistance, inflammation and adrenal dysfunction- are very valid things to address within the syndrome.
What is problematic about focusing on this categorization of types of PCOS, is it oversimplifies a very complex and layered condition.
Despite the fact that PCOS types are a bit misleading and incomplete, it is still important to know which elements are contributing to your unique presentation.
If this is something you are still unsure of, it may be helpful to visit your doctor and discuss running a wide panel of labs to fully grasp what is contributing to your unique picture.
This will help you assess where androgen excess may be coming from, to what degree inflammation and insulin resistance are playing a role, and what other risk factors and conditions may be involved and aggravating the condition.
A Better Way: The Root Cause Approach
A more helpful way to approach PCOS is not by typing, but by looking at root causes.
This allows us to assess the entire constellation of things that can contribute to an individual’s unique presentation of the syndrome. These include addressing:
- Inflammation
- Insulin resistance
- Hormone imbalances
- Nutrient deficiencies
- Disruptions in gut health
- Environmental toxins
When it comes to managing all of these factors, it can be overwhelming. This is why it is a game-changer to work with a dietitian that specializes in PCOS.
We have the luxury of time to break down some of these more complex concepts and create the hierarchy of what will be most important for you to address.
And it’s not just the knowledge. We possess the skill of distilling down the nuance of nutrition and lifestyle recommendations into something that is personalized and sustainable for the patient that sits before us.
This leads to less overwhelm for you and provides the confidence in knowing that your efforts are well-placed.
My 16 week PCOS Pro one-on-one program unpacks all of these root causes, discerns which are the most relevant for you (and in what order), and provides a clear path with personalized, sustainable actions to improve them.
A root cause approach will finally get you the results you’ve been looking for- weight loss, improved fertility, less hair growth, hair loss, and acne and the gift of feeling better in your body.