Are There Different Types of PCOS? Understand Your Diagnosis and More

PCOS is one of the most common causes of fertility concerns among women, and it’s rising faster than ever. The World Health Organization estimates that it affects up to 13% of reproductive-aged women. That means that you’re guaranteed to know someone with PCOS if you don’t have it your self. Given this, you might be wondering why this disorder is so common and where it comes from.

PCOS is diagnosed when a woman meets two of three criteria: elevated androgen levels on blood work, ovulatory dysfunction and polycystic appearance of ovaries on ultrasound.

1. Elevated Androgens: Testosterone and DHEA are the two androgen levels we test for in women with suspected PCOS. The tests we use to evaluate these include: free and total testosterone levels, sex hormone binding globulin, bioavailable testosterone and DHEA-sulfate. You don’t need to fast for these tests, but the test should be drawn on the third day of your cycle if you are having periods

2. Ovulatory Dysfunction: This is the driving force behind irregular periods in PCOS. Ovulatory dysfunction refers to irregular, anovulatory or absent menstrual cycles.

3. Polycystic Appearance of Ovaries on Ultrasound: First of all, this is not the same thing as true ovarian cysts. Rather, in PCOS, imbalanced hormone levels cause more than one follicle (immature egg) to develop on ovaries in any given cycle, and then they halt in an advanced but still underdeveloped stage of development. This makes the ovaries look bumpy when viewed with ultrasound. However, these cysts don’t become enlarged, burst, or bleed like the other medical condition of ovarian cysts.

Many factors contribute to an individual woman’s experience with PCOS and no two cases look exactly the same. However, there are certain similarities among the hormone imbalances and fertility problems seen in PCOS, so let’s dive into the root cause.

There Are Four Types of PCOS

Knowing which kind you have is fundamental to treating PCOS because it tells us how to get to the root cause.

Insulin-Resistant PCOS

An estimated 50-70% of PCOSis the insulin resistant type. In this category, women have difficulty regulating their blood sugar which leads to elevated insulin levels. This high insulin does a couple of key things:

1. High insulin makes the ovaries more sensitive to LH, a signal from the brain that begins maturing follicles (eggs). This causes a greater number of follicles to start differentiating.

2. High insulin also interferes with the ovary’s ability to choose a single dominant follicle, so the polycystic appearance progresses and no follicle reaches full maturity. As a result, the cycle usually ends up being anovulatory.

3. Because high insulin increases the ovary’s reactivity to LH, they produce more androgens than normal as a result. Because the FSH levels don’t match the LH levels, the ovary can’t keep up with converting this increased testosterone into other hormones so the levels keep rising.

4. These high testosterone levels feed forward into estrogen excess which stimulates the body’s fat cells to grow. As they do so, they produce even more insulin and the cycle continues.

To treat insulin-resistant PCOS, we need to interrupt the cycle, which usually involves addressing blood sugar control.

Adrenal PCOS

The adrenal glands regulate electrolyte balance, blood sugar and sex hormones. They produce small amounts of progesterone and estrogen, but relatively higher amounts of DHEA. They also produce cortisol.

1. High DHEA levels convert into high testosterone levels. Here are out elevated androgens.

2. Cortisol produces inflammation which disrupts the maturation process of ovarian follicles and can lead to arrested development…hence, a polycystic appearance.

3. high cortisol levels interrupt signaling from the brain to the ovaries, often getting in the way of ovulation. This results in anovulatory cycles and/or missed periods.

Treating adrenal PCOS necessitates finding out what’s taxing the adrenal system so much. Stress can be purely psychological and have this effect, or it may stem from many other forms.

Inflammatory PCOS

Inflammation is the culprit behind so many health problems, including PCOS. Sometimes inflammation is the driving force behind PCOS, especially if insulin is normal and DHEA/cortisol are not both elevated. However, all types of PCOS involve inflammation.

1. Inflammatory chemicals like cytokines directly stimulate the ovaries to produce androgens. [source]

2. Inflammation, especially coming from the chemical TNFα also stimulates adipocyte to produce higher levels of insulin. This higher level of insulin creates all the problems we already outlined in the previous section.

3. Inflammation disrupts follicular maturation and halts development, affecting ovulation rates and creating partially developed follicles—ergo, “polycystic ovaries”

Targeted anti-inflammatory nutrition and supplementation strategies are fundamental in treating PCOS cases that are predominantly characterized by inflammation. It’s also really important to figure out what’s going on beneath the surface that’s driving the inflammation.

Post-Pill

The whole point of the birth control pill is to override the body’s natural signaling to prevent ovulation. That’s how it gets its contraceptive function. But in many cases, ovulation remains suppressed even after a woman discontinues taking it.

1. This type of PCOS is primarily characterized by ovulatory dysfunction because the body needs to figure out how to start ovulating again after months, years or decades of being actively prevented from doing so. However, there’s also a bit more at play.

2. Coming off the pill often results in excess or “rebound” androgen production. This is especially common after using contraceptives that contain drospirenone.

Provided that periods and hormone levels were normal before using the pill, this type of PCOS is usually temporary. However, recovery can take months, sometimes up to even 2 years. I usually work with post-pill PCOS patients on detoxing from the pill in conjunction with treating the elevated androgens and utilizing anti-inflammatory lifestyle strategies.

Leave a comment below: which type of PCOS do you have?

If you loved what you read here, check out these related posts:

• How to Get Pregnant Naturally with PCOS
• Natural Alternatives to Fertility Drugs
• Progesterone Deficiency

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I’m Dr. Alexandra MacKillop, a functional medicine physician, food scientist and nutrition expert.

I specialize in women’s health & hormones, addressing concerns like fertility, PCOS, endometriosis, dysmenorrhea (painful periods), PMS symptoms like bloating and mood changes and more.

If you’re looking for a new way to approach your health, I’m here to help you through it. Click to learn more.