The Four Types of PCOS + Flowchart
You may have heard of the four types of PCOS. The purpose of the four types is to help identify a root cause of PCOS and target treatment to the root cause. There is a difference in the types of PCOS discussed in research literature and types of PCOS discussed in clinical practice.
I will break down both.
First up, research:
Research currently doesn’t classify PCOS into four types but rather looks at four different phenotypes of PCOS: (19279045)
The different phenotypes of PCOS are:
Phenotype A
Hyperandrogenism + Ovulatory Dysfunction + Polycystic Ovary Morphology
Sometimes referred to as the complete PCOS phenotype or “classic” PCOS. Individuals with phenotype A present with hyperandrogenism (elevated androgens = male hormones), ovulatory dysfunction (irregular periods), and polycystic ovary morphology (presence of cysts on ovaries).
But if you remember, having ovarian cysts on their own doesn’t necessarily mean you have PCOS! (Read more - What is PCOS?)
Individuals with this PCOS phenotype may experience higher body weights, hirsutism (excessive hair growth in areas male tend to grow hair), and irregular menstrual patterns. They appear to be more likely to have insulin resistance, dyslipidemia (abnormal blood lipids), and be at a higher risk of metabolic syndrome.
Phenotype B
Hyperandrogenism + Ovulatory Dysfunction
Also sometimes referred to as a “classic” form of PCOS, individuals with phenotype B present with hyperandrogenism and ovulatory dysfunction. They lack the presence of polycystic ovaries on ultrasound. Similar to phenotype A, due to the high levels of androgen and the irregular periods, individuals with this phenotype may experience higher body weights, hirsutism, and irregular menstrual patterns. Individuals with phenotypes A and B appear to be more likely to have insulin resistance and risk of metabolic syndrome than ovulatory (phenotype C) or non-androgenic phenotypes (phenotype D).
Phenotype C
Hyperandrogenism + Polycystic Ovary Morphology
(without Ovarian Dysfunction)
This phenotype is referred to as “ovulatory PCOS,” as individuals typically present with high androgens and cystic ovaries, but have regular periods or ovulate regularly. They tend to have hirsutism, high androgens, elevated lipid levels, and risk of metabolic syndrome somewhere between classic PCOS and phenotype D.
Phenotype D
Ovarian Dysfunction + Polycystic Ovary Morphology
(Without Hyperandrogenism)
Phenotype D is referred to as non-hyperandrogenic PCOS, as individuals present with normal androgen levels and a mild degree of insulin resistance. This phenotype appears to have the lowest prevalence of metabolic syndrome. This PCOS phenotype is slightly controversial as to whether or not this is actually true PCOS. According to the Androgen Excess Society PCOS diagnostic criteria, hyperandrogenism is a requirement for PCOS diagnosis. Thus, if an individual doesn’t have higher androgens, but only ovarian dysfunction, meaning they have irregular menstrual cycles, they may not actually have PCOS.
As more research emerges on the four phenotypes, specific treatments for each phenotype are being studied.
Now moving onto clinical practice:
In clinical practice, there are four “types” or “presentations” of PCOS that are common. These aren’t recognized in the research literature, but are talked about in clinical practice (9780648352402). I will mention where these clinical presentations overlap with the research phenotypes discussed above.
A note: you might resonate with more than one of these types, that’s okay!
Typically, there is a primary driving type of PCOS that you might fall under. Identifying your PCOS type, will help you in identifying the root of your symptoms, or what is driving your PCOS, which will help you identify strategies to effectively manage your symptoms and start thriving with PCOS.
The four types:
Insulin Resistance
Insulin resistant PCOS is the closest to the classic phenotypes of PCOS described above. Insulin resistance is one of the biggest drivers of PCOS. Insulin resistance is present in over 50% of PCOS cases (22192137). Insulin resistance is when your body doesn’t respond well to insulin and thus, can’t take glucose (blood sugar ) into the cells. Insulin is a hormone produced by the pancreas that is released in response to glucose, or sugar, in the blood. Insulin works by helping cells take glucose out of the blood stream and into the cells to be used for energy. When your cells don’t response well to insulin, or you are insulin resistant, your body may increase the amount of insulin released to help bring the blood sugar into the cells. This may lead your blood sugar to stay higher for longer as your body has a harder time taking glucose into the cells. Insulin resistance can eventually lead to pre-diabetes and diabetes.
But in addition to that, insulin plays a large role in PCOS. Insulin resistance can lead to higher levels of androgens (male hormones), as too much insulin can cause the ovaries to make too much testosterone. Also, too much insulin can impair ovulation, thus making periods irregular.
If you meet all the criteria for PCOS (irregular period and elevated androgens) plus insulin resistance, you have insulin resistant PCOS.
How to identify insulin resistance:
One way to identify potential insulin resistance is to look at your body shape. Individuals who tend to store more body weight in their abdomen, may have insulin resistance. Though this isn’t a completely accurate way of determining insulin resistance.
Blood tests: a blood test for fasting insulin, HOMA-IR index, or insulin glucose challenge test (or glucose tolerance test with insulin), can help you identify insulin resistance .
How to manage insulin resistance:
Eat regularly - eating at regular intervals throughout the day helps with balancing blood sugars. It prevents your blood sugar from having big dips and spikes. This paired with the tip below are great places to start.
Pair carbohydrates with protein and fat - when consuming foods containing carbohydrates (think your grains like breads, pastas, as well as starchy vegetables, potatoes, corn, peas, and fruits) pair them with foods that contain protein and/or fat. Consuming carbohydrate foods as part of a mixed meal prevents large spikes in blood sugar that occur when consuming the carbohydrate food alone.
Exercise regularly - exercise has been shown to improve insulin resistance. A single exercise session can improve insulin sensitivity for nearly 16 hours! (10683091). Choose a type of movement that feels empowering for you, such as walking, yoga, pilates, or others.
Consider supplementation - there are some supplements that have been shown to be helpful in improving insulin resistance in individuals with PCOS.
Magnesium - Magnesium is known for its role in glucose metabolism and insulin sensitizing nature. There is growing research that demonstrates the potential for magnesium in improving insulin sensitivity in individuals with PCOS (31696157).
Inositol - both myo-inositol and d-chiro-inositol, in combination, has been shown to be helpful for managing several PCOS symptoms, including insulin resistance (27730087; 35236761).
Zinc - has also been shown to improve insulin sensitivity in individuals with PCOS (32824334) - though, too much zinc can cause a copper deficiency so do not exceed the tolerable upper limit of 40 mg/d.
Vitamin D - Many individuals with PCOS are vitamin D deficient, particularly if you live in an area where you don’t have much access to sunlight. Low dose Vitamin D supplementation has shown to be helpful in improving insulin resistance in individuals with PCOS (30400199).
Post-Pill
Post-Pill PCOS sort of gets lumped into the PCOS diagnosis, but isn’t truly PCOS. After coming off hormonal birth control, your hormones, particularly androgenic (male) hormones, can surge. What hormonal birth control does is suppress ovulation, so after coming off of the pill it can take time to resume normal ovulation.
So if you come off hormonal birth control and have a surge of androgens (male hormones) and do not resume ovulation right away - you, in theory, may meet the definition for a PCOS diagnosis.
But the caveat here is that post-pill PCOS is usually temporary, as your body and hormones reset.
You may be dealing with post-pill PCOS if you were fine and your periods were normal before starting the pill. This is the biggest indicator that your body is just resetting after coming off of the pill. But if your periods were irregular or you suffered from acne or other symptoms that might point to PCOS prior to the pill, then you might actually qualify for a PCOS diagnosis and you do not have post pill PCOS.
One thing you can do is look at your LH to FSH ratio. Look for high LH compared to FSH, while this can be a finding in all types of PCOS, it might be the only finding in post-pill PCOS as LH prevents ovarian follicles from developing properly and stimulates the production of androgens.
Remember that post-pill PCOS is temporary. Be patient and give it time. Your provider may recommend re-starting hormonal birth control, but that will again only temporarily reduce your symptoms, which will reoccur after coming off the pill.
Some strategies to support yourself during this time include:
Eating enough - your body needs ample nutrition and carbohydrates to ovulate.
Potentially consider zinc supplementation to aid in the androgenic symptoms -but caution with zinc, too much can cause copper deficiency, do not exceed the tolerable upper limit of 40 mg/d
With post-pill PCOS, you should start to see some improvements within approximately 6 months.
Inflammatory
Inflammatory PCOS is driven by inflammation and environmental toxins. While inflammation plays a role in all types of PCOS, if you have PCOS and you do NOT have insulin resistance, but you have signs and symptoms of inflammation such as:
Digestive problems (bloating, constipation, irritable bowel syndrome)
Headaches
Joint pain
Unexplained fatigue
Skin conditions, such as eczema or psoriasis
then you may have inflammatory PCOS as your primary symptom driver.
With inflammatory PCOS the best strategies are:
Follow an anti-inflammatory diet - An anti-inflammatory diet consists of lots of fruits, vegetables, whole grains, beans and legumes, fish, lean meats, and herbs and spices.
Avoid any food allergies and food sensitivities - some but certainly NOT all individuals with inflammatory PCOS may need to monitor their intake of gluten and/or dairy (but I caution with this one, this should not be taken to mean you should cut out entire food groups unnecessarily). I advise having a conversation with your doctor and/or your registered dietitian about your eating behavior history as well as possible food intolerances.
Be mindful of environmental toxin exposure - through household cleaning products and beauty products. Aim to limit your exposure to endocrine disrupting chemicals.
Supplements to consider
Zinc - Zinc has been noted to improve inflammation in women with PCOS, paired with magnesium (remember the caution above about too much zinc).
Magnesium - as noted above, magnesium has a lot of potential benefits for PCOS. In addition to insulin resistance, magnesium may improve mood, sleep, and anxiety. Also, magnesium has been shown to improve inflammation (magnesium and zinc paired together has been shown to improve inflammation in individuals with PCOS) (29127547; 28445426; 35918728).
Probiotics - have been shown to improve inflammatory markers in individuals with PCOS (32372265)
Adrenal
Adrenal PCOS is the primary driver if you meet the criteria for PCOS, do not have insulin resistance, have no signs of inflammation, have normal ovarian estrogens (testosterone and androstenedione) but elevated adrenal androgens (DHEAS).
Most individuals with PCOS will have elevated androgens in one or more of these forms:
Testosterone from ovaries
Androstenedione from ovaries and adrenal glands
DHEAS from adrenal glands
If you have elevated ovarian androgens (testosterone and androstenedione), then you likely have an earlier type of PCOS.
If DHEAS is the only elevated androgen and you have normal testosterone and androstenedione then you might be looking at adrenal PCOS.
Your doctor should first rule out other causes for elevated DHEAS. Once those are ruled out, you can identify if you have adrenal PCOS.
Adrenal PCOS accounts for approximately 10% of PCOS cases (18950759; 27336356; 9780648352402).
Adrenal PCOS is different from the other types of PCOS discussed, as you can ovulate regularly with adrenal PCOS. Thus, it is most similar to phenotype C discussed above. Adrenal PCOS is driven by an abnormal stress response.
Key steps to manage adrenal PCOS:
Manage stress - stress is a big driver of adrenal PCOS. Your adrenal glands are the glands that produce your stress hormones (fact check this).
Prioritize sleep - sleep is when your body rests and repairs. Good quality sleep aids in your body’s ability to manage and thwart off stress.
Consider supplements
Zinc - Zinc has shown to be an anti-androgen in women with PCOS, lowering testosterone and DHEAS (32824334)
Magnesium - as stated above magnesium can aid in improving stress and anxiety and thus, helping in adrenal PCOS.
Resveratrol - the antioxidant found in red wine, has been shown to lower both ovarian and adrenal androgens, testosterone and DHEAS, respectively, in women with PCOS (27754722)
While you may resonate with more than one type of PCOS, though, if you have insulin resistance, then insulin resistant PCOS would be considered your primary type and you should start there in terms of treating your symptoms.
Here is a flow chart you can use to help determine your PCOS type:
These certainly aren’t the only ways to manage these particular types of PCOS, nor do you have to take all of these supplements or make all of these changes to see benefits.
Questions about identifying your PCOS type? Let’s connect. I would love to work with you on this journey.