The main types of PCOS

Polycystic ovarian syndrome (PCOS) is a hormone imbalance that impacts 10% of people with ovaries. It is important to understand that PCOS can manifest differently depending on the person: each case is unique in its own way, thus management strategies need to be catered to the specific individual’s needs, goals, and lifestyle. One basic way of understanding this is through how PCOS manifests in your body, which is how the different “types” of PCOS are categorized. Having this knowledge can lead to more productive discussions with your doctor and ultimately fine tune your PCOS treatment options. 

When it comes to recognizing the different types of PCOS, you may have noticed there are varying categorizations and labels. That’s because there is still no official breakdown of the different “types” of PCOS in the 2018 international guidelines, which leaves room for interpretation of how PCOS is categorized. This can quickly become confusing, but rather than getting wrapped up in the label itself, focus more on what the definition means for the body! We know that’s easier said than done, which is why this blog is here to guide you through those differences and clarify what all the different “types” of PCOS really mean.

In order to do so, we will be answering the following questions:

• What are the ways PCOS is characterized in the world of research?
• What are the similarities and differences between the clinical and functional definitions?
• What catalyzes symptoms for each “type?” 
• How does treatment strategy tend to differ?
• How will Pollie be referring to the types of PCOS?

The research and clinical worlds have identified three main “types” of PCOS

The research and clinical worlds largely agree that the condition is an umbrella diagnosis for different types of patient phenotypes. This is what makes PCOS so difficult to treat: there truly is no one-size-fits-all. 

As we mentioned previously, there is not currently an official “types” breakdown of PCOS in the 2018 international guidelines. However, based on Pollie’s research and clinical advisors, we currently split PCOS into three subtypes: Metabolic, Reproductive, and Inflammatory. When we talk about the different PCOS on social media, or blog, app, or elsewhere, we will be referring to these types based on recommendation from our advisory team.

Let’s take a quick look at each of these types below.

As noted above, each type of PCOS tends to respond differently to treatment. 

Metabolic PCOS

Metabolic PCOS constitutes a majority of PCOS cases. If you have PCOS in tandem with metabolic imbalance such as insulin resistance, high blood sugar, or even high lipids, you most likely fit into this type.  

When it comes to Metabolic PCOS, having a lifestyle that encourages increased insulin sensitivity and balanced blood sugar has been shown repeatedly through research to decrease symptom severity. That means focusing on low glycemic carbohydrates paired with fat and protein to avoid blood sugar spikes, consistent daily movement and ideally some strength or resistance training, and proper stress management.

Medication like metformin and supplements like myo-inositol can also be highly effective for Metabolic PCOS.

Metabolic PCOS closely aligns with “Insulin Resistant PCOS” as commonly referenced by the functional medicine world. More on that below!

Reproductive PCOS

Reproductive PCOS is often seen in families, meaning there is likely a genetic component. Since there is no history of a metabolic imbalance with this type (although you can still have a higher BMI and fit into this category), it can be less responsive to dietary changes than Metabolic PCOS. However, lifestyle changes are still worth making as they can still improve the condition. 

Although the research is early, evidence indicates that stress management, proper recovery, and adequate sleep are all musts for this type. If you fall into this type and are significantly restricting both simple and complex carbohydrates, or partaking in regular intense exercise, you may be likely to further disrupt symptoms. 

People that fall into this category often report a greater perceived sensitivity to stress, which is known to disrupt or hormonal and reproductive health. 

Reproductive PCOS closely aligns with “adrenal PCOS” as commonly referenced by the functional medicine world. More on that below!

Inflammatory PCOS

Inflammatory PCOS is not a standalone type, but can occur alongside Metabolic or Reproductive PCOS. 

If you have issues with inflammation detected through lab work, symptoms, or an accompanying diagnosis like an autoimmune disorder, you may fit into this type in addition to either Metabolic or Reproductive PCOS. 

Following general PCOS guidelines (e.g., eating a blood sugar-balancing diet, engaging in regular movement that feels good for your body) is helpful for inflammatory PCOS, but you may find it beneficial to add extra inflammation support to your routine. That may look like emphasizing a diet rich in fatty fish, avocado, olive oil, and other quality fat sources, taking an omega 3 supplement, and making sure you are giving yourself plenty of time to recover in between workouts. 

If you have Inflammatory PCOS and the more general tips are not working for you, considering an elimination diet under the supervision of a nutrition specialist or physician may also be helpful to identify whether there is something in your diet that is causing systemic inflammation. 

But what about the “four types” of PCOS I’ve seen on social media and in the functional medicine world?

If you have researched PCOS, you most likely have come across four PCOS types (insulin resistant, adrenal, inflammatory, and post-pill). These types are typically referenced by experts in functional medicine and you may also see the terms being used on social media as well. Keep in mind there is no right or wrong way to categorize PCOS and they ultimately address the same imbalances within the body. 

Let’s talk about these four different types and what they mean!

Insulin-resistant PCOS 

What is insulin-resistant PCOS?

Insulin-resistant PCOS is frequently used to characterize high levels of insulin in addition to fulfilling the diagnostic criteria for PCOS in the functional medicine world. This is also the most common type, so it might sound familiar! As discussed, this is most similar to Metabolic PCOS where individuals have some sort of metabolic imbalance that may be addressed through lifestyle adjustments and/or medication.

But what exactly is insulin? Insulin is a hormone secreted by our pancreas. Its main job is to convert glucose, or the sugar in our blood that we get from food, into the right form of energy that can be used by our muscles and other bodily systems to properly function.

If you are insulin resistant, this means that your body has a tough time converting blood sugar into energy with the help of insulin. Because of this, your pancreas must continue churning out insulin in an effort to lower your blood sugar. Over time your pancreas is not able to keep up elevated insulin production, and blood sugar gets higher as a result. 

While a blood sugar spike once in a while is nothing to worry about, if your body spends a long time with chronically-high blood sugar a multitude of health issues are likely to develop such as obesity, energy crashes, pre-diabetes and diabetes, hypertension, and more. 

Also known as metabolic syndrome, insulin resistance can be tested with blood work. That said, signs and symptoms of insulin resistance in females include (1):

• A waistline over 35 inches
• Blood pressure of 130/80 or higher 
• A fasting glucose level of 100 mg/dL or higher 
• A fasting triglyceride level over 150 mg/dL
• A HDL cholesterol level under 50 mg/DL
• Skin tags 
• Patches of dark, velvety skin called acanthosis nigricans

Adrenal PCOS 

What is adrenal PCOS?

Next is adrenal PCOS. You fit into the adrenal PCOS type if your adrenals, endocrine glands that are located just above your kidneys, are driving hyperandrogenism (elevated androgens). This type of PCOS is most similar to Reproductive PCOS due to the way it manifests and catalyzes through stress.

For most females, the ovaries produce roughly 60% of androgens while the adrenals produce the remaining 40% (2). Most people with PCOS will have an elevated level of androgens such as testosterone, DHEA, DHEA-sulfate (DHEA-S), and androstenedione. 

If you have recently completed an androgen blood panel with Pollie or an external provider, it’s time to turn to your DHEA-S and DHEA levels. The adrenals produce all of the DHEA-S in our body and roughly 80% of DHEA. Since DHEA-S is not produced by the ovaries at all, it is used as an indicator of adrenal androgen secretion along with 11-androstenedione, which is also produced only by adrenal glands (3).

If your adrenal androgens are high but your androgens that are produced solely by your ovaries are normal (e.g., testosterone), you have adrenal type PCOS. 

Inflammatory PCOS

What is inflammatory PCOS?

Inflammatory PCOS is also a type of PCOS in the functional medicine world and good news, they are essentially the same thing with just one notable difference: inflammatory PCOS is not a standalone type in the clinical definition.

Oftentimes the bodily inflammation can come from other sources such as environmental or physiological reactions, and therefore inflammatory PCOS can also be known as “hidden cause” PCOS. This includes (but is not limited to) things like food sensitivities, intestinal permeability, environmental toxins, thyroid disease, and autoimmune disorders.

Common signs of inflammation include fatigue, headaches, skin conditions, joint pain, digestive issues such as IBS, and more. You also may test positive for inflammatory biomarkers such as thyroid antibodies, gluten antibodies, vitamin D deficiency, abnormal blood count, and others. 

Post-pill PCOS

What is post-pill PCOS?

Lastly, there’s post-pill PCOS. Post-pill PCOS is catalyzed by using a hormonal birth control method that results in disrupting your hormones and putting you into a state of PCOS either while you are still using this method of birth control or, more commonly, once you have discontinued use. 

In many cases, post-pill PCOS is temporary and symptoms can diminish or even disappear entirely with time.

Why is post-pill PCOS not included in Pollie’s types?

You may have noticed we do not include post-pill PCOS in Pollie’s clinical types. When it comes to diagnosing PCOS, it is highly recommended that you wait 6-12 months after stopping hormonal contraceptives before seeking out a diagnosis. 

This is because some hormonal contraceptives can cause hormonal disruptions that technically qualify people for a PCOS diagnosis temporarily. If you were diagnosed with PCOS after less than 12 months of stopping a hormonal contraceptive method, we recommend you get re-evaluated at at least the 6 month mark, but ideally the 12 month mark. 

What catalyzes each type? What about treatment options?

We know these varying types and definitions of PCOS can be confusing, but keep in mind they are simply different categorizations for describing how the body is behaving. In this next section, we will go over what catalyzes each type of PCOS to further explain what is happening internally and common treatments used for each one.

Metabolic (or Insulin-Resistant) PCOS 

What catalyzes this type?

As mentioned, out of range metabolic markers (elevated fasting glucose, elevated HbA1c) and elevated lipids may mean you fall into this category. High levels of insulin can drive androgen levels up while also decreasing estrogen levels. Both of these relationships can lead to a host of common PCOS symptoms such as weight issues, hair loss, hirsutism, acne, irregular periods, and more. 

High insulin could be driving your androgen levels up and is also associated with lower estrogen levels (2, 3). These relationships, particularly between insulin resistance and hyperandrogenism, can drive severity of PCOS symptoms. 

Beyond immediate symptoms relating to dermatological health and fertility, it’s important to be aware of additional health risks that may occur due to these imbalances. Because over half of PCOS cases fall into this category, PCOS is often accompanied by other conditions. This population has an increased risk of developing diabetes by 50% and are 4x-7x more at risk of heart disease depending on age (2, 3). Although this may seem overwhelming, being aware of these risks can help you figure out what treatment strategy suits you best.

What are common treatments?

Both metabolic and insulin resistant PCOS respond readily to lifestyle modifications, particularly with diet and exercise. Medication is also leveraged for many cases, particularly if insulin resistance is serious and uncontrolled. 

• Diet: Similar to diabetes, eating a lower-carb diet and being sure to eat ample protein and fat at each meal can help regulate our blood sugar. If you work with a nutritionist or registered dietitian (RD) to combat your insulin resistance head on, chances are they will advocate you focus on complex carbohydrates such as sweet potatoes, brown rice, and vegetables. While there is a lot of focus on eating keto to take back control of insulin and your blood sugar, keep in mind that for many of us, insulin can still be managed with less extreme lifestyle modifications. You can try adopting an intuitive eating approach for a sustainable way to nourish your body.
• Exercise: Exercise has also been shown to help increase insulin sensitivity, thereby improving insulin resistance. Short, high intensity workouts and interval training work better for insulin-resistant cases of PCOS than the other types. Be sure to also get plenty of gentle movement such as aiming for 10k steps per day. 
• Medication: A common pharmaceutical for managing insulin-resistance is a drug called metformin (also known as: Fortamet, Glucophage, Glumetza, or Riomet). In cases of severe insulin resistance or diabetes, it is often the best way to quickly get a dangerous situation under control. While metformin works for many people, it’s important to be aware of common side effects such as gastrointestinal issues. If you’ve experienced stomach problems from your metformin, be sure to bring this up with your doctor in case they suggest changing your dosage. Learn more about PCOS and medication here.

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Reproductive (or adrenal) PCOS

What catalyzes this type?

Reproductive and adrenal PCOS can be harder to detect and may have a genetic component. This type of PCOS is not triggered by inflammation or high insulin levels, but rather a physiological reaction to stress. 

This can be emotional stress from work, relationships, or other external circumstances. It can also be physical stress from overexercising, undereating, or injury. Although low impact exercises are often recommended to limit stress on the body, there are still ways to train if you prefer higher intensity movement. Read more about how you can balance cardio and PCOS here.

It is important to rule out other hormone issues like functional hypothalamic amenorrhea (FHA) if chronic stress is driving your symptoms. One key marker that differentiates PCOS from FHA is your luteinizing hormone (LH) to follicle stimulating hormone (FSH) ratio. This can be tested on day 3 of your cycle and is generally high in people with PCOS and low for those with FHA. 

What are common treatments?

Stress management is key for both reproductive and adrenal PCOS. In general, treatment strategies include:

• Stress management techniques: 1-1 therapy, group counseling, support groups, mindfulness and meditation are all common tactics that may help reduce your stress levels. Be mindful that patience is key when it comes to developing a new routine to lower stress. Learn more about the complex feedback loop of stress and PCOS here.
• Proper rest: In addition to stress management, ensuring that you are giving your body adequate rest is key. This may mean increasing your rest days between workouts or finding a bedtime routine that can optimize the quality of your sleep. 
• Eat a nutrient-dense diet, and eat enough: Much PCOS literature, particularly on social media, points to low carb diets as a necessary symptom management tool. However, with reproductive and adrenal PCOS, this advice can actually backfire, particularly if high activity levels are driving your symptoms. While you should be aware of your intake of simple and liquid carbs, be wary of jumping into an extreme low carb diet like keto if your adrenals are stimulating androgen production. Complex carbohydrates, colorful fruits and vegetables, healthy fats, quality dairy products if tolerated, and lean protein is generally a safe bet (4, 5). 

Inflammatory PCOS

The Pollie team recognizes that Inflammatory PCOS occurs alongside Metabolic or Reproductive PCOS. If you have Inflammatory PCOS in addition to Metabolic or Reproductive PCOS, you may be more prone to inflammation and find that you have certain food sensitivities, allergies, or intolerances that worsen your symptoms. As mentioned previously, conducting an elimination diet with the help of a medical professional can help identify if there’s anything in your diet that may be triggering inflammation. Additionally, PCOS has been associated with a higher likelihood of autoimmune disorders (like Hashimoto’s), so it is also important to determine if your inflammation is caused by an autoimmune disease.

What are common treatments?

If an autoimmune disease is fueling your inflammation, you will need to work with a doctor to receive a diagnosis and treatment protocol. However, if your inflammation is resulting from lifestyle factors, there are a variety of ways you can start to take back control. 

• Diet optimization: While elimination diets are not for everyone, if there is a specific food or food group that you know is catalyzing your PCOS symptoms it may be worth considering removing said item(s) from your diet for several weeks or months to see if any improvement is found. We highly recommend you work with a qualified provider before making any major dietary adjustments. We dive deeper in how you can safely do an elimination diet here. Doing a food sensitivity blood test can help you identify if anything you are eating is increasing inflammation and worsening your symptoms, although clinical feedback on these tests is mixed. We recommend you reach out to your care coordinator for the pros and cons of different food sensitivity tests if you are interested in completing one. 
• “Clean up” your household and beauty products: Environmental toxins can also contribute to inflammation. Try to avoid plastics containing bisphenol A (BPA), synthetic fragrances and air fresheners, and other products containing harmful chemicals. While fully committing to a 100% all natural, toxin-free lifestyle is likely not feasible for most of us, it can be worthwhile to make sure the items you are using most are hormone-friendly. Learn more about how the external environment impacts hormones here.
• Stress management: Our stress hormone cortisol has the ability to both damper and overstimulate the immune system, leading to inflammation. For this reason, keeping stress in check is key. 1-1 therapy, group counseling, support groups, mindfulness and meditation, and healthy movement can all be helpful strategies. 
• Gentle exercise: If you are suffering from inflammation, high intensity exercise should perhaps take a backseat until your body is on the mend. When we exercise vigorously, our body produces stress hormones like cortisol. If we have proper recovery time, this cortisol will decrease and ultimately make us stronger. But, if you are already suffering from inflammation, many people find success in switching to more gentle forms of exercise like yoga, pilates, and walking to help calm down their immune response.

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Post-Pill PCOS

What catalyzes symptoms for type?

If you’ve recently gone off of a birth control pill with drospirenone or cyproterone, it can be common to have withdrawal effects that qualify as a PCOS diagnosis temporarily. If you fall into this situation, you will likely find that it takes you longer than friends and family who have discontinued hormonal birth control to regain your regular cycle. With that said, Pollie recommends getting re-evaluated 6-12 months after stopping hormonal contraceptives before a diagnosis. 

What are common treatments for this type?

It can be frustrating to wait for months before a diagnosis, which is why patience is key if you believe your symptoms are triggered from stopping birth control. Luckily, there are still ways to manage symptoms while your body adjusts to no longer receiving synthetic hormones.

• Lifestyle factors: Nutrition and exercise are both good ways to encourage your body to “reset”. Be sure to drink plenty of water, get enough fiber from whole grains, leafy greens, and cruciferous vegetables, and make sure you are eating a variety of nutrient-dense foods. 
• Supplements: There are a variety of supplements like turmeric, vitamin D3, fish oil, and probiotics that have anecdotally been shown to speed up recovery from post-pill PCOS. Many people find success working with a functional-trained provider to discuss what may work for you. Be sure to speak with a medical professional before starting a new supplement regimen; your care coordinator can help you decide if this is something Pollie can help you with. 

Understanding all the different ways PCOS can be categorized is a lot of information to process, but having this knowledge can ultimately help you better navigate different educational resources on the condition! If you are wondering what type you fall into, download Pollie and our care team can help you figure out the best way to manage your PCOS.

References

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1. Dansigner, M. (2021, June 23). Insulin resistance: Symptoms, causes, tests, treatment, and prevention. WebMD. Retrieved August 19, 2022, from https://www.webmd.com/diabetes/insulin-resistance-syndrome 
2. Baptiste, C. G., Battista, M. C., Trottier, A., & Baillargeon, J. P. (2010). Insulin and hyperandrogenism in women with polycystic ovary syndrome. The Journal of steroid biochemistry and molecular biology, 122(1-3), 42–52. https://doi.org/10.1016/j.jsbmb.2009.12.010
3. Abdel-Rahman, M. Y. (2022, February 7). Androgen excess. Practice Essentials, Pathophysiology, Epidemiology. Retrieved August 19, 2022, from https://emedicine.medscape.com/article/273153-overview
4. Remer, T., Pietrzik, K., & Manz, F. (1998). Short-term impact of a lactovegetarian diet on adrenocortical activity and adrenal androgens. The Journal of clinical endocrinology and metabolism, 83(6), 2132–2137. https://doi.org/10.1210/jcem.83.6.4883
5. Soltani, H., Keim, N. L., & Laugero, K. D. (2019). Increasing Dietary Carbohydrate as Part of a Healthy Whole Food Diet Intervention Dampens Eight Week Changes in Salivary Cortisol and Cortisol Responsiveness. Nutrients, 11(11), 2563. https://doi.org/10.3390/nu11112563
   

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