The four types of PCOS

FeaturedImage_4TypesofPCOS

PCOS or polycystic ovarian syndrome affects as many as 10% of women in the UK and up to 20% of women worldwide. In this article we cover the four types of PCOS, how to identify which type you may have, and recommended next steps.

Key takeaways:

  • PCOS stands for the polycystic ovarian syndrome.
  • PCOS is an endocrine-metabolic disorder that affects up to 20% of women worldwide.
  • PCOS is the most common cause of anovulatory (lack of ovulation) sub-fertility in women of reproductive age. 
  • PCOS has nothing to do with cysts on the ovaries (despite its name). PCOS is in fact eggs or follicles on the ovaries, which are a normal presence in the ovaries. 
  • The medical diagnosis of PCOS vs. our preferred FUTURE WOMAN diagnosis of PCOS.
  • Why Anovulatory Androgen Excess (AAE) is a more appropriate and accurate name for PCOS. 
  • The four types of PCOS, including insulin-resistant PCOS. 
  • The other types of PCOS, which are post-pill PCOS, inflammatory PCOS, and adrenal PCOS.

So what is PCOS?

PCOS stands for the polycystic ovarian syndrome, and it is an endocrine-metabolic disorder that affects 4-20% of women worldwide. PCOS is the most common endocrine and metabolic condition in women of reproductive age. 

It is also the most common cause of anovulatory (lack of ovulation) sub-fertility in women of reproductive age. Therefore PCOS needs more attention and focuses in the medical world, as it affects so many women. 

PCOS has nothing to do with cysts on the ovaries, despite its name. “Cysts” in fact here refer to eggs or follicles on the ovaries, which are a normal presence in the ovaries.

https://drive.google.com/file/d/1JpxFiW1sSoEQdG6eRQA3MI25MioE_cY-/view?usp=sharing

PCOS is not in fact just one disease, but a disorder with different underlying factors. 

Typically it is defined as androgen excess (when all other causes of androgen excess have been ruled out) and is often accompanied by symptoms such as weight gain, fertility issues, acne, and excess body and facial hair growth. 

Anovulatory androgen excess (AAE) is a more appropriate and accurate name for PCOS. This term was coined by Professor Jerilynn Prior. Anovulatory androgen excess is diagnosed when there are signs of androgen excess as well as irregular cycles.

Common signs and symptoms of PCOS 

Common symptoms include:

  • Weight gain
  • Acne 
  • Irregular periods 
  • Hirsutism 
  • Head hair loss 
  • Infertility 
  • Missing periods 
  • Skin tags 

What causes PCOS in general?

In PCOS there is typically poor HPO axis communication. 

This causes increased pulsatility of gonadotropin-releasing hormone (GnRH) in the brain, which in turn increases luteinising hormone (LH) pulsatility. 

This increase in LH pulsatility causes the ovaries to make excess testosterone and androstenedione (androgens), which results in abnormal follicle growth in the ovaries. The increased LH also inhibits the development and release of an egg (lack of ovulation), which can cause irregular or missing periods. 

Increased LH leads to increased androgen production from the ovaries.

How does this work?

Under the instruction of LH, the theca cells in the ovaries convert cholesterol to androgens. Therefore with increased LH levels, there is increased androgen production.

PCOS and HPO Axis

As the title of this article suggests, there are four types of PCOS. It is vital to determine which type of PCOS you have as it can change the direction of how you address it with diet, supplementation, and lifestyle. 

First, to help us understand how each type of PCOS is diagnosed, let’s look at how PCOS is typically diagnosed by GPs.

How PCOS is typically diagnosed by GPs

The medical diagnosis of PCOS is based on having two of the following criteria providing that other causes of your symptoms have been ruled out:

  • Signs of raised androgens (male hormones) either clinically (e.g. acne, facial hair or rarely male pattern baldness) or on blood tests (raised testosterone levels)
  • Irregular periods or no periods at all

Polycystic ovaries on an ultrasound scan

FUTURE WOMAN’s preferred diagnosis of PCOS

We at FUTURE WOMAN prefer a PCOS diagnosis is when a woman meets all three of the following:

  • Androgen excess in a blood test or symptoms of androgen excess such as hirsutism, acne, and weight gain.
  • Irregular periods or polycystic ovaries on an ultrasound
  • Exclusion of any other conditions that would cause high androgens

(Sourced from AE-PCOS foundation)

What are the four types of PCOS?

4 Types of PCOS
1. Insulin-resistant PCOS. 

This is the most common of the four types of PCOS; roughly around 70% of people with PCOS have insulin-resistant PCOS. Essentially this means that insulin resistance is both a driver and symptom of PCOS for this person. 

High insulin levels in the body (caused by factors such as stress, a diet high in fructose, inflammation, imbalanced blood sugar, and more) increase LH pulsatility and, as we’ve discussed, increased LH stimulates the ovaries to produce testosterone, which causes and contributes to symptoms such as acne, facial hair and weight gain.

Diagnosis:

Firstly, insulin-resistant PCOS is diagnosed through the previous diagnostic criteria. Secondly, we can measure our waist-to-height ratio because weight gain around the waist (apple-shaped obesity) is a symptom of insulin resistance. There are also other signs and symptoms that can indicate we have insulin resistance.

Measuring waist to height ratio
This simple measurement compares your waist to height ratio.

Measure the smallest point on your waist (cm)
Divide that by your height (cm)
= your waist to height ratio
A ratio of more than 0.5 is linked to an increased risk of developing health problems.

Thirdly, we can use blood testing.

Our nutrient blood panel at FUTURE WOMAN includes two important markers for insulin resistance:

  • HBA1C 
  • HDL/ triglycerides ratio
2. Post-pill PCOS 

The second type of PCOS is post-pill PCOS. This occurs once you come off the oral contraceptive pill, specifically an androgen suppressing pill such as Yasmin. If you have had normal periods before going on the pill, only to find you have irregular periods post-pill, alongside symptoms of androgen excess, then you are likely to have post-pill PCOS. These symptoms start as you come off the pill and are temporary. 

Diagnosis:

You can only have post-pill PCOS if you have recently stopped hormonal contraception. You do not have post-pill PCOS if you have insulin resistance. This would mean you have insulin-resistant PCOS instead. 

3. Adrenal PCOS 

Of the four types of PCOS, Adrenal PCOS is a less common and less well-known type. Adrenal PCOS is defined as PCOS where the only androgen that is raised is DHEA-S. This means a person with adrenal PCOS has normal testosterone and androstenedione levels. Insulin resistance and inflammation are not the cause of PCOS in this case. Instead, it is an upregulation of adrenal androgens that can be caused by a combination of genetic tendencies and environmental factors such as stress. 

Diagnosis:

To be diagnosed with adrenal PCOS the only raised androgens must be DHEA-S (not testosterone). Therefore testosterone levels are normal. 

4. Inflammatory PCOS 

The final type of PCOS is inflammatory PCOS. This type of PCOS is due to underlying chronic inflammation in the body. This may be due to factors such as an underlying disease, food sensitivity, gut permeability, or histamine intolerance. The underlying inflammation causes an upregulation of androgens from the ovaries. 

Diagnosis:

To be diagnosed with inflammatory PCOS you must meet the PCOS diagnostic criteria as well as showing signs of inflammation such as an existing autoimmune disease, fatigue, skin disorders, joint pain, or headaches. CRP may also be raised in a blood test. It is important to note that to have inflammatory PCOS there is no insulin resistance, you have not recently come off the pill and you have signs of inflammation. 

It is important to understand what type of PCOS you have, as each PCOS type has a different underlying root cause or contributing factor that needs to be addressed. Our practitioners can help you determine which type of PCOS you have, and recommend specific supplements, diet, and lifestyle changes to get you back on track.

What can we do to prevent or reverse insulin resistance?

Of the four types of PCOS, Insulin Resistant PCOS is the most common. But the good news is, there is much we can do to prevent and even reverse insulin resistance.

Here are our top three tips if you think you may have PCOS:

  1. Testing first and foremost. This will help to identify if you actually have PCOS, and if so which type you are most likely to have. We recommend the FUTURE WOMAN Advanced Hormone Test – this test allows us to look at your oestrogen, progesterone, and androgens (plus their metabolites) to understand your hormone production and metabolism. This test also looks at your stress response and HPA axis to understand if stress may be a contributing factor to any hormone imbalance. 
  2. Look at balancing your blood sugar. As mentioned, over 70% of those with PCOS have insulin-resistant PCOS. This means it is vital to improving insulin sensitivity. There are many ways to do this including focusing on sleep, exercise, and blood sugar balance. Start by eating three main meals a day with no snacks and prioritising protein with each meal, especially your breakfast.
  3. Book a 1:1 consultation with a FUTURE WOMAN practitioner. As mentioned, with PCOS it is important to understand what type YOU have and understand what personal changes are best for you including supplementation. These 1:1 consults are created to provide you with personalised advice and a personalised health plan.

References:

Deswal, R., Narwal, V., Dang, A., & Pundir, C. S. (2020). The Prevalence of Polycystic Ovary Syndrome: A Brief Systematic Review. Journal of human reproductive sciences, 13(4), 261–271. https://doi.org/10.4103/jhrs.JHRS_95_18

Garg, A., Patel, B., Abbara, A., & Dhillo, W. S. (2022). Treatments targeting neuroendocrine dysfunction in polycystic ovary syndrome (PCOS). Clinical endocrinology, 10.1111/cen.14704. Advance online publication. https://doi.org/10.1111/cen.14704

Khan, M. J., Ullah, A., & Basit, S. (2019). Genetic Basis of Polycystic Ovary Syndrome (PCOS): Current Perspectives. The application of clinical genetics, 12, 249–260. https://doi.org/10.2147/TACG.S200341

Nautiyal, H., Imam, S. S., Alshehri, S., Ghoneim, M. M., Afzal, M., Alzarea, S. I., Güven, E., Al-Abbasi, F. A., & Kazmi, I. (2022). Polycystic Ovarian Syndrome: A Complex Disease with a Genetics Approach. Biomedicines, 10(3), 540. https://doi.org/10.3390/biomedicines10030540

Rosenfield, R. L., & Ehrmann, D. A. (2016). The Pathogenesis of Polycystic Ovary Syndrome (PCOS): The Hypothesis of PCOS as Functional Ovarian Hyperandrogenism Revisited. Endocrine reviews, 37(5), 467–520. https://doi.org/10.1210/er.2015-1104

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