The 4 Types of PCOS – What You Need to Know

Did you know that everyone’s PCOS is not the same? In fact: there are four types of PCOS. 

By understanding the four types of PCOS, you can get to the root causes of your PCOS symptoms and how to better manage them. Continue reading to learn more information from a registered dietitian specializing in women’s health. 

What is PCOS?

Polycystic Ovarian Syndrome (PCOS) is a hormonal health problem that impacts 4-20% of women of reproductive age all over the world (1). It’s one of the most common causes of infertility. 

While we know that PCOS is a metabolic condition that impacts the reproductive system, there is no consensus on what causes it. Underneath the label, there is a complicated dance between gut health, stress, inflammation, and thyroid health. 

How is PCOS diagnosed?

Before I dig into the four types of PCOS, let’s review how PCOS is diagnosed. 

To be diagnosed, you must meet at least two of the following three criteria: 

1. Irregular periods. 

There are two ways to define “irregular periods”. 

• You could miss a period for 3 months or longer or 
• have periods that last longer than 7-10 days AND come more frequently than once a month. 

2. High levels of male hormones, also known as androgens. 

While we all have some male hormones, having too much can cause issues. 

Symptoms of high male hormones include:

• No ovulation
• Dark, coarse facial hair growth on the face, neck, chin, jawline, chest, back, shoulders, and the belly hairline 
• A deepening voice
• Acne
• Hair loss on the head or balding 
• Low libido
  

3. Polycystic ovaries, as seen on a pelvic ultrasound. 

Despite the name of the condition, not all women with PCOS have polycystic ovaries, and having polycystic ovaries is not enough to get a diagnosis. 

In fact, polycystic ovaries are actually not cysts. What is being assessed is the size of the ovaries and the number of follicles (2). Enlarged ovaries can occur when your body is trying to ovulate, but can’t because of hormonal imbalances. 

Checking two of the above three options can mean a diagnosis of PCOS. But before you and your doctor land on that diagnosis, it is important to rule out any other possibilities, especially Hypothyroidism. 

Before a PCOS Diagnosis, Hypothyroidism Should Be Ruled Out

Interestingly enough, actual cysts on your ovaries are a symptom of hypothyroidism. It’s important to have hypothyroidism ruled out before a PCOS diagnosis (3). 

There are many symptoms that are exactly the same for hypothyroidism and PCOS. These include:

• Irregular periods
• Hair loss
• Weight gain
• Insulin resistance
• Gut problems, such as dysbiosis or irritable bowel syndrome (4)
• Physical changes in the ovaries (5) 

Thyroid disorders are also more common in women with PCOS, which means you might have both! (6,7) 

5-10% of women with PCOS have subclinical hypothyroidism (8). Subclinical hypothyroidism (SCH) is seen as a milder form of hypothyroidism. With SCH, you may have symptoms of hypothyroidism, but normal thyroid labs. 

The combination of PCOS and SCH can:

• Cause poor fertility
• Cause complications during pregnancies
• Lead to higher weight, BMI, and insulin levels
• Cause a sluggish thyroid 

This is why you simply cannot manage PCOS well without optimizing thyroid function. 

Knowing the health of your thyroid is essential for managing your PCOS. You cannot understand your thyroid health without the right lab tests. Oftentimes, that means seeking out an endocrinologist who will take your symptoms seriously instead of just looking at one single thyroid lab test that doesn’t provide you with enough info. 

To see if you have a thyroid disorder, ask your doctor to check your thyroid levels, including antibody tests, such as thyroid peroxidase antibodies, thyroglobulin antibodies, and thyroid-stimulating hormone receptor antibodies. 

Hypothyroidism can also cause insulin resistance, which is present in 65 -70% of women with PCOS and one of the types of PCOS. 

Type 1 – Insulin Resistant PCOS 

Okay, let’s get into the four types of PCOS.

The first one is insulin-resistant PCOS. 65-70% of women with PCOS have insulin resistance (9).

What is Insulin? 

Insulin is a hormone naturally produced in your body to help regulate your blood sugar levels, which controls how much energy you have. 

Insulin is released after we eat and knocks on the door of each of our cells to tell them, “hey, there’s extra sugar in the blood, please take some in.” If everything is working as it should, cells open their doors and take in extra sugar from the blood. 

Cells are dependent on insulin knocking to know when to take sugar out of the blood. 

What is Insulin Resistance? 

Insulin resistance happens when the sound of insulin’s knock gets dimmed and cells cannot hear it clearly anymore. If our cells cannot hear the knock, then they cannot open the door to take sugar in. 

This leaves too much sugar in the blood. In response, the body produces more and more insulin to get sugar inside cells. This is problematic because the body becomes resistant to the insulin and needs even more to hear the same signals. 

Symptoms of insulin resistance include sugar cravings, skin tags, inability to lose weight, dark velvety patches, facial hair, etc. 

How Insulin Resistance Causes PCOS 

1. Too much insulin increases male hormone production from the ovaries. This leads to symptoms like coarse, dark facial hair and hair loss on the head (10). 

2. Insulin resistance blocks the liver from producing sex hormone binding globulin (SHBG). SHBG is a protein found in the blood that holds onto testosterone and estrogen, controlling how much is accessible to your body. Not having enough of this protein means testosterone and estrogen levels build up in the body, which makes PCOS symptoms worse (11). ⁣

3. Insulin resistance can cause weight gain or make it harder to lose weight. This causes excess estrogen to be made in the body, because fat tissue releases estrogen. Too much estrogen is a big contributor to PCOS symptoms. It’s also a part of a vicious cycle, where estrogen can make insulin resistance worse (12). 

4. Insulin resistance can disrupt ovulation, which can show up as: not having a period, having very long cycles (a few periods a year), or even menstruation without ovulation (called anovulatory cycles) (13).⁣ 

You have insulin resistant PCOS if you have symptoms and labs that reflect insulin resistance and fit the PCOS diagnosis. 

Type 2 – Adrenal or Stress PCOS 

Women with adrenal PCOS may also have high levels of an androgen that is produced by the adrenal glands, small organs that sit on top of the kidneys. 

The primary androgen that can be measured in a blood test for adrenal PCOS is DHEA-S.

The adrenal glands’ production of DHEA-S is a protective mechanism. DHEA-S offsets the negative effects of cortisol (14). Cortisol is a hormone that is released in response to stressful situations. 

So what causes high DHEA-S in women with PCOS? 

The short answer is stress! 

You might think about stress as something that’s external– finances, family, or social life. But stress from the body’s perspective is as simple as too much demand and not enough resources. 

Stress experienced by the body in controlled environments can be healthy. An example of this is exercise. During exercise, you might push beyond your comfort zone to lift more weight or get through those last five minutes. In the right amounts, exercise can be a stress your body is able to manage properly.

However, many people are chronically stressed–every day of every week of every month. Which means their stress hormones are constantly high. It’s like constantly running on the battery saver mode on your phone – your body is doing its best to survive. 

Women with PCOS are more likely to have high stress levels, which means they are at a higher risk of:

• Chronically high blood sugar, leading to insulin resistance
• Disruptions in how much stress hormone, (cortisol), and salivary amylase is made, which can cause weight gain (15) 
• High levels of DHEA-S, which can get converted to testosterone and estrogen. These two hormones in excess can cause symptoms of PCOS (16) 
• Lower fertility because the body does not want to reproduce when it is constantly dealing with high stress (17) 

Learn more about how you can become resilient to stress HERE. 

You have adrenal PCOS if you have high levels of DHEA-S, symptoms of PCOS, but do not have insulin resistance or are not recently coming off the pill, or have high inflammation. 

Type 3 – Inflammatory PCOS 

Inflammation is the body’s natural response to an injury, infection, or disease to promote healing. Inflammation in response to an injury is helpful and natural. However, it becomes harmful when it’s constantly on. With chronic inflammation, your immune system is pumping out white blood cells and chemical messengers 24/7. This might lead white blood cells to attack healthy tissue and organs and lead to autoimmune problems. 

Chronic inflammation is linked to PCOS, Hashimoto’s, cancer, diabetes, cardiovascular disease, autoimmune diseases, and others (18).  

You could have inflammatory PCOS if you don’t have insulin resistance, high androgens, or high DHEA-S, but have symptoms like:

• Body pain
• Chronic fatigue
• Insomnia
• Depression, anxiety, or mood disorders
• Gut problems, like irritable bowel syndrome (IBS), small intestinal bacterial overgrowth (SIBO), or inflammatory bowel disease (IBD)
• Weight gain or weight loss
• Frequent infections or getting sick easily

If you don’t fit into any of the categories, you may have post hormonal birth control PCOS. 

Type 4 – Post Hormonal Birth Control PCOS 

Many hormonal birth control options contain progestins – a synthetic version of progesterone, which is not the same as natural progesterone. 

Most progestins used in birth control are derived from testosterone. This can cause a temporary rise in androgens when you come off of the pill.

You could have post-hormonal birth control PCOS if you:

• Fit the criteria for PCOS (high testosterone, irregular periods, or polycystic ovaries)
• Don’t have insulin resistance 
• And your symptoms started when you discontinued birth control

If you got on birth control to manage your PCOS symptoms, you may have worsening symptoms when you come off of birth control. However, this doesn’t necessarily mean birth control is the only answer to managing PCOS.

In fact, most of the women with PCOS come to me because they don’t want to manage their PCOS with birth control. If you’re looking to manage PCOS without using birth control or would like to come off of birth control to manage your PCOS naturally, reach out. Book your free consultation right here. 

Summary

There are 4 different types of PCOS – insulin resistant, adrenal or stress, inflammatory, and post-hormonal birth control. It’s also important to rule out hypothyroidism before getting a PCOS diagnosis. Taking the time to accurately identify your root cause (or causes) can help you take the right action for symptom management and relief. 
If you’re ready to get the support you need to manage your PCOS, reach out to learn more about how I can help. Book your free consultation right here.