Are there different types of PCOS? Find out about the polycystic ovarian syndrome PCOS phenotypes and the different types of PCOS according to underlying mechanisms as well as lifestyle approaches to PCOS.
What is PCOS?
PCOS, or polycystic ovarian syndrome, is the most common hormonal-metabolic condition in women of reproductive age. PCOS affects up to 1 in 10 women. It has it’s roots in metabolic health. PCOS can cause symptoms such as irregular periods, lack of ovulation, weight gain, oily skin, acne, excess facial or body hair growth as well as thinning of hair on the head.
There are a combination of genetic and lifestyle factors that contribute to the condition of PCOS.
How is PCOS diagnosed?
PCOS is diagnosed if they meet at least 2 of the following criteria:
- Oligo- or anovulation: Oligomenorrhea is irregular menstrual cycles. Anovulation means no ovulation, which can occur with regular periods, or e associated with irregular or no periods.
- Androgen excess. Hyperandrogenism is a state where the androgens in the body such as testosterone, androstenedione and dehydroepiandrosterone sulfate (DHEAS) are high. For a PCOS diagnosis you can either have high levels of androgens in the blood or symptoms suggesting high androgen levels such as acne, increased facial or body hair growth or thinning hair or hair loss.
- Polycystic ovaries: Polycystic ovaries are present if on vaginal ultrasound there are 20 or more follicles present on a single ovary OR if there is an increase in size of at least one ovary >10ml.
Insulin resistance is a major additional feature of PCOS, although tests of insulin resistance are not yet been incorporated into diagnostic criteria.
However there are surrogate markers of insulin sensitivity such as fasting blood sugars, HBA1C and fasting insulin which can be used to calculate insulin resistance.
The 4 Phenotypes of PCOS
Phenotypes are the way genes and the environment interact to create observable characteristics in individuals. For example your eye color is part of your phenotype.
According to the International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2018, there are 4 recognized phenotypes of PCOS, or in other words 4 symptom combinations that can be expressed.
The 4 phenotypes are are known as:
- Phenotype A: Androgen excess + ovulatory dysfunction + polycystic ovarian morphology
- Phenotype B: Androgen excess + ovulatory dysfunction
- Phenotype C: Androgen excess + polycystic ovarian morphology
- Phenotype D: Ovulatory dysfunction + polycystic ovarian morphology
These phenotypes describe what symptoms people with PCOS have, but do not describe the underlying mechanisms that contribute to PCOS.
What are the 4 Types of PCOS: underlying mechanisms of PCOS
Polycystic Ovary Syndrome (PCOS) is a condition caused by an imbalance of hormones. A number of mechanisms have been identified as contributing to PCOS. These can be divided into 4 different types of PCOS, although women may have multiple underlying mechanisms contributing to their PCOS.
Knowing which underlying mechanisms contribute to your type of PCOS is important for understanding how to best investigate and manage your condition.
4 underlying mechanisms of PCOS include:
- Insulin resistance: insulin resistance PCOS
- Chronic inflammation: Inflammatory PCOS
- Post-pill PCOS
- Adrenal PCOS
1. Insulin resistance: insulin resistance PCOS
Insulin resistance is the most commonly recognized underlying mechanism of PCOS. What this means is that the body does not respond to regular amounts of insulin so the body needs to produce more insulin to get the same response in managing blood sugars.
Insulin resistance and the compensatory elevated insulin levels affects 65–70% of women with PCOS. Insulin resistance affects with 70–80% of women with PCOS with a high BMI over 30.
Even 20-25% of women with a BMI of less than 25 demonstrate insulin resistance.
Some women with insulin resistance PCOS also have symptoms of metabolic syndrome including high cholesterol, high blood pressure and increased abdominal body fat.
Women with insulin resistant PCOS have higher levels of insulin in their blood, and this drives increased production of androgens by the ovaries and adrenal glands leading to symptoms such as irregular periods, acne and excess hair growth. Elevated insulin also drives body fat storage.
Weight loss or altering body composition to increase muscle mass can be used to improve symptoms to treat insulin resistant PCOS as it improves the body’s sensitivity to insulin.
Muscle tissue is metabolically active and an important tissue for uptake and storage of glucose. When muscle is being used during exercise, it takes up glucose, improves the body’s insulin sensitivity and reduces the body’s overall insulin resistance.
Diagnosis of insulin-resistant PCOS is not always easy, but some clues include if you have features of metabolic syndrome, have a high fasting glucose, high fasting insulin, high HBA1C or a HOMA-IR of < 1. An insulin curve with a glucose tolerance test can also be useful.
2. Chronic inflammation: Inflammatory PCOS
When people speak of inflammatory PCOS, they are referring to elevated markers of inflammation in the blood. A blood test can identify a few markers that can be associated with PCOS including high white blood cell counts, C reactive protein. Specialized inflammatory markers include:
- Tumor necrosis facto-alpha (TNF-α),
- Interlekin 6 (IL-6)
- Interlekin 1 beta (IL-1β)
- High sensitivity c-reactive protein (hs-CRP)
- Serum resistin.
This chronic low grade inflammation in the body directly stimulates excess androgen production by the ovaries (Gonzalez 2012). This contributes to ovulatory dysfunction as well as typical PCOS symptoms such as weight gain, acne and increased body or facial hair.
If there is insulin-resistance underlying your PCOS, there is also likely an inflammatory component to it, as higher glucose levels in the blood is pro-inflammatory.
3. Post-pill PCOS: Otherwise known as post-pill amenorrhea
Women with post-pill PCOS may have had regular or irregular periods before starting oral contraceptive pills, but after stopping the pill their periods have not come back.
This condition is also called post-pill amenorrhea or post-pill ovulatory dysfunction.
The oral contraceptive pill essentially acts as an endocrine disruptor. The high levels of synthetic hormones feed back to the brain that there are high estrogen and progesterone levels in the body. This shuts down the normal cyclical pulses of hormones from the brain to the ovaries to set ovulation in motion.
When the pill is stopped, as the body adjusts to lower estrogen and progestin hormone levels, the brain’s cyclical hormone release needs to re-emerge. As this happens there is a change in hormonal sensitivity caused by the pill, which can lead to temporary ovulatory dysfunction and symptoms of androgen excess.
Post-pill ovulatory dysfunction is common, but 98 percent of women experience normal hypothalamic-pituitary function 90 days after stopping the oral contraceptive.
You should see your medical provider if you have stopped the contraceptive pill and:
- have had no period for 3 months in people with previously regular menstrual cycles or
- 6 months in patients with irregular menstrual cycles.
4. Adrenal PCOS
In women with adrenal PCOS, the source of high androgen levels is predominantly from the adrenal glands rather than the ovaries. This can be seen with elevated DHEA-S levels in the blood, and may also involve increased cortisol production leading to symptoms such as weight gain and fatigue.
Some women have a genetic type of adrenal PCOS. It is called congenital adrenal hyperplasia (CAH). In this condition, the adrenal glands produce higher levels of hormones including:
- 17-hydroxyprogesterone (17-OHP)
Many countries screen for CAH at birth. However if it is not picked up it can show up in women with symptoms similar to ovarian PCOS such as
- irregular periods,
- early appearance of pubic and/or arm hair
- excessive hair on face and body
- deeper voice
- enlarged clitoris.
A blood test to look at 17-hydroxyprogesterone (17-OHP) can determine if you have CAH.
A blood test to look at adrenal androgens such as androstenedione, DHEA and DHEAS can determine if you have adrenal PCOS
Lifestyle management of PCOS
Treating the underlying root cause of your PCOS with lifestyle health habits can improve your longer term health. Many of the same lifestyle changes can benefit you regardless of the type of underlying causes of your PCOS.
1: Insulin-resistant PCOS
Treating the insulin resistance in PCOS is crucial for managing PCOS where insulin resistance is a contributor.
Top tips for managing insulin resistant PCOS include:
A low to moderate carbohydrate diet
It’s really important to manage your blood sugars when you are insulin resistant. This can be done by eating a lower carbohydrate diet. Eating a diet of highly refined carbohydrates such as added sugar will give you high blood sugar.
The most important foods to eliminate include high sugar foods such as:
- soft drinks/sugar sweetened beverages or juices
- cakes, cookies, doughnuts, baked goods
- candy, lollies, sweets
- processed foods with added sugar – often these are foods labelled as low-fat
Eat a variety of fruit and vegetables, protein sources such as beans, nuts, seeds, legumes, unprocessed meats and whole grains.
You can read about the following lower carbohydrate diets listed below:
Any exercise that build muscle (such as resistance training) or works muscle (such as aerobic exercise) increases the muscle demand for glucose so will lower your blood sugar and your high insulin levels.
- Make exercise a part of your daily routine.
- Walk or cycle to work, pr park the car a few blocks further away.
- Take the stairs not the elevator.
- Do squats in the kitchen while cooking dinner.
- Jog on the spot in your office for 2 minutes every hour.
How do you like to move you body? Could you take up dance classes, join a hockey team, running club or walking group. Find a way to move and get your heat racing that you enjoy and can do with others.
Sleep is essential for blood sugar management. Reduced sleep results in increased insulin resistance. Staying up late and shift work can have negative effects on your insulin and blood sugar regulation so try to maintain a good sleep routine.
2: Inflammatory PCOS
You can try an anti-inflammatory diet to improve reduce inflammation in your body.
Anti-inflammatory foods includes:
- plenty of fresh vegetables and fruits. These foods are high in vitamins, and polyphenols which act as anti-inflammatory agents on your genes.
- Whole grains, lean protein sources such as lentils, beans and fish and poultry have neutral effects on your blood sugars and inflammation.
- Healthy fats such as olive oil and nuts, contain anti-inflammatory oils.
Inflammatory foods include junk foods, processed foods and sugary drinks. You should avoid foods containing refined sugars and processed oils such as the following:
- Processed foods
- Refined and hydrogenated oils
- Sugary snacks
- Fried foods
- Red meat and dairy products
For more information on anti-inflammatory diets, you can speak to your medical provider or read about the Mediterranean diet here.
3: Post-pill PCOS
After taking the pill there may be side effects such as post-pill amenorrhea or irregular periods.
Getting off of the birth control pill can cause a huge fluctuations in your body.
Treatment for post-pill amenorrhea involves time; in more than 98 percent of cases your period will return in 3 months.
If this has not happened or your periods have been irregular for 6 months after stopping the pill you should see your health provider so they can work with you to find out if something else is going on.
In terms of improving your own health and wellbeing, the following will be beneficial while your body adjusts to it’s own hormone rhythms:
- ensuring you are eating an anti-inflammatory diet that is fueling you sufficiently,
- getting regular movement into your day,
- getting early morning sun exposure
- adequate sleep
- managing your stress with adequate relaxation.
4: Adrenal PCOS
If you have congenital adrenal hyperplasia (CAH), you should see an endocrinologist who is an expert in this area.
If you have adrenal PCOS associated with high stress levels, there are a lot of ways you can modify your lifestyle to reduce cortisol which drives adrenal androgen production. You may find the following to be beneficial ways to reduce stress:
- ensuring you are eating an anti-inflammatory diet full diverse fruit and vegetables.
- getting regular movement into your day, especially something that gets your heart pumping and the muscle moving.
- adequate sleep
- mindfulness, yoga, meditation.
Supplements such as Vitamin B5, Vitamin C, Magnesium and Withania are helpful for supporting the adrenal axis.
Frequently Asked questions – FAQs
What is PCOS?
PCOS is a condition that affects hormones and can lead to unpleasant symptoms. Symptoms of PCOS can include irregular periods, infertility, and obesity. There are four different types of PCOS and each requires different treatment. The symptoms of PCOS can be reversed with the help of a good diet, lifestyle and nutritional support.
What are androgens
Androgens are reproductive hormones. For men these are the dominant male hormones. Women also have androgens but typically in lower amounts. The main androgens are testosterone, androstenedione and dehydroepiandrosterone sulfate (DHEAS).
What are the four types of PCOS?
Insulin resistant PCOS is the most common type and is characterized by high levels of insulin in the blood. This type of PCOS is often caused by lifestyle choices, such as poor diet and lack of exercise.
Inflammatory PCOS is associated with an overproduction of inflammatory cytokines, which can lead to weight gain, acne, and mood swings. The treatment for this type of PCOS includes stress management techniques and medication that block inflammation.
Post-Pill PCOS occurs after women take the birth control pill and affects 5-10% of users. It’s most commonly caused by elevated levels of insulin resistance. Post-PillPCOS can be treated with lifestyle changes such as regular exercise and a balanced diet, or medications that help reduce insulin resistance.
Adrenal PCOS is caused by a problem with the adrenal glands and typically manifests with high levels of testosterone. This type of PCOS can be treated with medication, weight loss, and a healthy diet.
What is the root cause of PCOS?
PCOS is an condition caused by a combination of factors. These can include insulin resistance and too much androgen, which can lead to problems such as increased appetite, weight gain, and hirsutism (a type of hair growth). There is no one-size-fits-all answer to determining who will develop the syndrome, but genetics may play a role. PCOS is often diagnosed in sisters or mothers and daughters, and often runs in families. Treatment for PCOS includes lifestyle changes (such as diet and exercise) as well as medication.
What are the treatments for PCOS?
Treatment for PCOS depends on the type of PCOS and the symptoms being treated. Treatment options may include dietary changes and medications to increase ovulation or reduce symptoms such as bloating and pain. If you plan to become pregnant, your treatment may include changing your diet and activity as well as medications to induce ovulation. There is no cure for PCOS but treatments can help reduce symptoms.
The Takeaways: Are there different types of PCOS?
- There are 4 different phenotypes of PCOS which is the way the condition is manifest in different individuals.
- There are 4 different, but often interlinked underlying contributors to PCOS which include: insulin resistance, inflammation, post-pill effects or adrenal PCOS.
- In addition to medications for PCOS there are a number of lifestyle interventions which can have beneficial influences on the root causes of PCOS such as an anti-inflammatory, low glycemic diet, exercise, adequate sleep, and stress management.
Ganie MA, Sahar T, Rashid A, et al. Comparative Evaluation of Biomarkers of Inflammation Among Indian Women With Polycystic Ovary Syndrome (PCOS) Consuming Vegetarian vs. Non-vegetarian Diet. Front Endocrinol (Lausanne). 2019 Nov 8;10:699.
DeUgarte CM, Bartolucci AA, Azziz R. Prevalence of insulin resistance in the polycystic ovary syndrome using the homeostasis model assessment. Fertil Steril. 2005;83(5):1454-1460.
Teede HJ, Misso ML, Costello MF et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. International PCOS Network. Clinical Endocrinology (Oxf). 2018 Sep;89(3):251-268.