In this article, we explore the four distinct types of PCOS, how to identify your type through comprehensive hormone testing, and the most effective next steps for your journey.
Understanding which type of PCOS you have is crucial for targeted, effective treatment.
Key Takeaways for the Four Types of PCOS
- PCOS stands for the polycystic ovarian syndrome.
- The four types of PCOS are insulin-resistant PCOS, post-pill PCOS, inflammatory PCOS, and adrenal PCOS.
- Insulin resistant PCOS is the most common type of PCOS. There is much we can do to reverse insulin resistance including balancing blood sugar.
- 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.
- We believe Anovulatory Androgen Excess (AAE) is a more appropriate and accurate name for PCOS.
What is PCOS?
Before exploring the four types of PCOS, it’s important to understand what PCOS is – and what it isn’t.
PCOS (polycystic ovarian syndrome) is an endocrine-metabolic disorder affecting 4-20% of women worldwide, making it the most common hormonal condition in women of reproductive age. It’s also the most common cause of anovulatory sub-fertility in women of reproductive age (when pregnancy is difficult due to lack of ovulation).
Despite its widespread impact, PCOS is often misunderstood. That’s because, contrary to what the name suggests, PCOS has nothing to do with cysts. The “cysts” actually refer to follicles, which are a normal presence inside the ovary. However, in PCOS, hormonal imbalances prevent one follicle growing and maturing to release an egg each month. Instead, immature follicles accumulate inside the ovary.
PCOS is not a single condition, but rather a complex disorder with different underlying causes. While it’s commonly known as PCOS, many experts, including Professor Jerilynn Prior, advocate for the more accurate term: Anovulatory Androgen Excess (AAE).
The key characteristic of PCOS is androgen excess (after ruling out other potential causes), which often presents with symptoms like irregular or missing periods, weight gain, acne and hair loss / body hair growth.
A true diagnosis comes from identifying signs of androgen excess combined with irregular cycles. That means you cannot be diagnosed from ultrasound alone.
However, some women may show few visible symptoms while having significant hormonal imbalances – which is why comprehensive hormone testing is crucial for accurate diagnosis and identifying your specific type of PCOS.
Common Signs & Symptoms of PCOS
Common symptoms of PCOS include:
- Weight gain
- Acne
- Irregular periods or missing periods
- Hirsutism or body hair growth
- Head hair loss
- Fertility issues
- Skin tags
What Causes PCOS?
At the core of all four PCOS types lies a disruption in the HPO (hypothalamus-pituitary-ovarian) axis – the vital communication network between your brain and ovaries. This disruption then creates a cascade of hormonal events:
- The brain increases its pulses of gonadotropin-releasing hormone (GnRH)
- This leads to increased pulses of luteinising hormone (LH)
- Higher LH levels instruct the ovaries’ theca cells to produce excess androgens (e.g. testosterone) from cholesterol
- These elevated androgens disrupt normal follicle development
- Without proper follicle development, ovulation may not occur, leading to irregular or missing periods
Understanding these hormone patterns through comprehensive testing is crucial, as the severity and pattern of these imbalances can vary significantly between the four types of PCOS, leading to different symptoms and requiring different treatment approaches. Our Advanced Hormone Test tests all androgens (not just testosterone) as well as helping us to identify your PCOS type.
The Four Types of PCOS
As the title of this article suggests, there are four types of PCOS: insulin resistant PCOS, post-pill PCOS, inflammatory PCOS and adrenal PCOS.Â
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.Â
Why It's Important to Know Which of the Four Types of PCOS You Have
In this video, lead nutritionist Francesca explains why knowing your PCOS type is important and how we take it into account at FUTURE WOMAN.
The Four Types of PCOS Explained
1. Insulin-resistant PCOS
Insulin resistant PCOS is the most common of the four types of PCOS. In fact, research says that around 70% of people with PCOS have insulin-resistant PCOS (although we believe the number to be higher). Insulin resistance can be both a driver and symptom of PCOS.Â
With this type of PCOS, high insulin levels in the body (caused by factors such as stress, high levels of fructose in the diet, inflammation or imbalanced blood sugar) increase LH pulsatility. And as we’ve already seen, increased LH levels stimulate the ovaries to produce androgens like testosterone, which in turn causes and contributes to symptoms such as irregular periods, acne, facial hair and weight gain.
Do I have insulin resistant PCOS?
At FUTURE WOMAN we assess whether insulin resistance is a driver of your PCOS in two key ways:
- Testing 5a reductase preference:
- This is a less favorable hormone metabolism pathway that converts testosterone into 5a DHT.
- 5a DHT is 3-4x more potent than testosterone!
- Insulin resistance is strongly linked to 5a reductase preference
- Hormone metabolism can only be tested in a comprehensive urine test (it’s not detectable in blood). We recommend the Advanced Hormone Test.Â
- Comprehensive assessment:
- As part of the testing process, we’ll ask you detailed questions about your diet, symptoms and medical history to understand if insulin resistance is a likely driver of your PCOS.
Another simple test for insulin resistance that you can easily do at home is to measure your waist-to-height ratio. That’s because weight gain around the waist (apple-shaped obesity) is a symptom of insulin resistance. To do this test, simply measure the smallest point on your waist and divide that by your height (both in cm). A ratio of more than 0.5 is linked to an increased risk of developing health problems.
How can we 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.Â
Check your PCOS Symptoms Now
2. Post Pill PCOS
The second type of PCOS is post-pill PCOS. This type of PCOS occurs once you come off the oral contraceptive pill, specifically an androgen suppressing pill such as Yasmin. So 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. It’s important to note that these symptoms start as you come off the pill and are temporary.Â
Do I have Post Pill PCOS?
You can only have post-pill PCOS if you have recently stopped hormonal contraception. That means you can’t have post-pill PCOS if you have insulin resistance.Â
Reminder: You can’t have more than one PCOS type. For example, if you have PCOS with both insulin resistance and inflammation, then you have insulin resistant PCOS.
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.Â
Insulin resistance and inflammation are not the cause of PCOS in this case. Instead, it is an up-regulation of adrenal androgens that can be caused by a combination of genetic tendencies and environmental factors such as stress.Â
Do I have Adrenal PCOS?
The key marker for adrenal PCOS is elevated DHEA-S with normal levels of other androgens. This specific pattern can only be identified through comprehensive hormone testing. Our Advanced Hormone Test measures all androgens individually, allowing us to distinguish adrenal PCOS from other types – a crucial difference as the treatment approach varies significantly.
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. Â
Do I have inflammatory PCOS?
To have inflammatory PCOS you must meet the PCOS diagnostic criteria as well as showing symptoms of inflammation such as an existing autoimmune disease, fatigue, skin disorders, joint pain, or headaches.Â
Inflammation markers will also be raised in testing. Our Advanced Hormone Test provides a comprehensive view of inflammation by measuring:
- Neuro-inflammationÂ
- Gut inflammation
- Oxidative stress levels
- DHEA-S and total DHEA levelsÂ
Understanding your specific type of PCOS is crucial for effective treatment, as each type requires a different approach. Our practitioners utilise these detailed test results to create personalised recommendations for supplements, diet, and lifestyle changes tailored to your unique hormonal pattern.
The FUTURE WOMAN Approach to PCOS Treatment
At FUTURE WOMAN we believe that managing PCOS should start with comprehensive hormone testing (we recommend the Advanced Hormone Test for clients with PCOS), determining your PCOS type with the help of a practitioner and then following a personalised plan of supplements and diet recommendations. Hormone therapy may also be required.
Read more about the FUTURE WOMAN approach to PCOS treatment.
Next Steps for Managing The Four Types of PCOS
Here are our top tips if you think you may have PCOS:
- Test your hormones with a comprehensive hormone test. This will help to identify i) if you actually have PCOS, and ii) which type you are most likely to have. We recommend the FUTURE WOMAN Advanced Hormone Test. This test allows us to look at your estrogen, progesterone, and ALL androgens plus their metabolites to understand your hormone production and metabolism. This test also looks at your stress response, inflammation markers, gut health and nutrients to understand the complex drivers of your unique PCOS picture.Â
- Balance your blood sugar. As mentioned, at least 70% of those with PCOS have insulin-resistant PCOS. This means it is vital to improve insulin sensitivity. Start by eating a high protein, high fat breakfast.
- Track your cycles. It can be helpful to track your cycles and period dates in an app, or in your phone calendar to assess whether your periods are in fact irregular. As a general rule, variation of more than 8 days in a calendar year is considered irregular (e.g. one cycle of 28 days and one cycle of 37 days in the same year would be considered irregular).Â
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 Â
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
