I often get the question questions about the 4 types of PCOS and how to tell which type you have.
Let’s jump into talk about whether or not there are different types and how to approach improving your PCOS symptoms!
What are the 4 Types of PCOS?
If you’ve googled around or follow PCOS influencers on social media then you may have heard that there are four different “types” of PCOS:
Insulin resistance type
Post-pill type
Adrenal type
Inflammatory type
I want to stress that these types are not part of the International Evidence-Based Guidelines for Treating PCOS and your doctor may not have even heard of them.
I’m honestly not quite sure where these originally came from but they’re very popular in the naturopathic and functional medicine spaces.
While I definitely appreciate that there’s not a lot of PCOS research out there outside of research around fertility and we often time uses client individual experiences to guide our treatment, I find that categorizing these “type” of PCOS to be misleading and confusing to PCOS patients. I’m going to explain why:
- Most People with PCOS Have Insulin Resistance
Most people with PCOS, around 70-80%, have insulin resistance. High insulin levels can cause the ovaries to produce extra testosterone, which cause symptoms like a missing period, acne, hair loss, and hirsutism. This also increases your risk for prediabetes and type 2 diabetes.
Here’s why I don’t love that this is a separate category for PCOS. Research has really pointed to insulin resistance being at the center of PCOS for most people. Even those who currently don’t have insulin resistance are more predisposed to developing it. And people with insulin resistance can also have excess inflammation or elevated DHEA-S as we’ll discuss below.
Sometimes I work with clients who think they don’t have insulin resistance because their A1c or fasting glucose is within normal limits. Then they go searching and diagnose themselves with “another type”.
But by looking into their labs further (evaluating a fasting insulin level with a fasting glucose level to look at a HOMA-IR or using the gold standard oral glucose tolerance test), we find that they DO actually have insulin resistance and just didn’t understand how insulin resistance presents itself with PCOS.
I find that the topic of insulin resistance and PCOS can feel especially confusing because the appropriate labs are not being checked to rule out insulin resistance. A fasting glucose and A1c alone cannot rule out insulin resistance with PCOS, and it’s common that these can be “normal” but underlying insulin resistance is still occurring.
If you want more information about this then check out my PCOS lab guide for the appropriate labs to request to see if you have insulin resistance. It’s not just your fasting glucose!
If you have insulin resistance, you can work with a trusted dietitian to help improve your symptoms. This is what I help my clients with, and I also have a few blog posts on nutrition and supplements to get you started.
- PCOS is an inflammatory condition.
It’s a bit misleading to categorize a type of PCOS by inflammation because we know that PCOS is an inflammatory condition and most people with PCOS have higher levels of inflammatory markers compared to those who don’t have PCOS.
Insulin resistance is also inflammatory.
This type of “category” is presented with the thought that there is something in your body causing inflammation, which is then driving hormonal imbalances and elevated androgens like testosterone. While I totally agree that inflammatory medical conditions (ex: unrelated Celiac disease) can cause extra inflammation, this again is really confusing to have as an entire different category.
Decreasing inflammation IS an important part of managing PCOS. Working on sleep, stress management, and adding in anti-inflammatory foods is definitely a strategy for managing PCOS. And having other inflammatory issues like gut issues or an autoimmune condition likely makes PCOS worse.
But again, I am unsure about this as an entirely different category. So many people with PCOS have insulin resistance + inflammation.
- Adrenal PCOS
One of the “4 types of PCOS” is adrenal PCOS, which is described as when more DHEA is produced from your adrenal glands due to stress.
Stress management and decreasing stress on the body is the recommended treatment here.
This was specifically brought up at the latest PCOS symposium, and PCOS researchers (many of whom are endocrinologists) disagreed with this theory. They stated that newer research suggests DHEA can be produced in other parts of the body and that we don’t really know enough about elevated DHEA to categorize PCOS in this way.
It’s important to note that stress management is important for anyone with PCOS! It’s not just a separate category. Stress can make insulin resistance worse and is inflammatory.
The functional medicine space describes this type of PCOS as “lean PCOS”. I want to stress a few things here. We do see that some people with PCOS have insulin resistance and some people do not. But I also see many people diagnosed with PCOS who actually have hypothalamic amenorrhea from not eating enough or exercising too much. If you are someone who has NO signs and symptoms of elevated androgens (like excess body hair, cystic acne, etc.), you’re very health-conscious, and you were diagnosed with lean PCOS then I recommend screening for HA.
- Post-Pill PCOS
The last “type” of PCOS from these categories is described as post-pill PCOS. This refers to a period of time after you stop taking birth control pills, and androgens (male sex hormones) increase. You may experience physical symptoms like irregular periods and acne. This “type” is thought to resolve after a few months as your body adjusts to not taking birth control.
There is no research to suggest that the birth control pill causes PCOS, or that PCOS occurs when coming off of the pill.
Sometimes people think they have “post-pill” PCOS when they come off of the pill and then get diagnosed with PCOS. It’s important to remember that birth control pills can mask your PCOS symptoms (such as acne and irregular periods or ovulation). If you came off the pill and were diagnosed with PCOS, ask yourself if you had ANY PCOS symptoms before you started the pill.
PCOS Phenotypes
As of now, the only official categories for PCOS are the PCOS phenotypes listed in the The Rotterdam criteria for diagnosing PCOS.
They’ve created categories based on which diagnostic criteria someone meets.
- Phenotype A: All 3 criteria are met – Elevated androgens (male sex hormones such as testosterone), irregular periods, and cysts on ovaries (ultrasound evidence of excess follicles on the ovaries from not ovulating)
- Phenotype B: Elevated androgens & irregular periods
- Phenotype C: Elevated androgens & cysts on ovaries
- Phenotype D: Irregular periods & cysts on ovaries
Even though these phenotypes exist, they are not typically not used in treatment of PCOS. So far the only time these are really discussed is understanding that someone in Phenotype A is probably going to experience more severe physical symptoms of PCOS. There aren’t separate treatments or nutrition recommendations for the specific phenotypes.
Should You Worry About the 4 Types of PCOS?
To sum things up, please don’t stress about the 4 types of PCOS ‘PCOS type’ or how this affects your treatment.
PCOS treatment should be based on your own individual labs and symptoms.
There IS a lot of chatter in the PCOS research space delving into how PCOS develops and why people experience different symptoms. I do strongly believe in the future that there may actually be separate categories in different types of treatments depending on certain circumstances, especially for those who have insulin resistance compared to those who don’t.
Sources
- National Human Genome Research Institute, https://www.genome.gov/genetics-glossary/Phenotype.
- Sachdeva, G., Gainder, S., Suri, V., Sachdeva, N., & Chopra, S. (2019). Comparison of the Different PCOS Phenotypes Based on Clinical Metabolic, and Hormonal Profile, and their Response to Clomiphene. Indian journal of endocrinology and metabolism, 23(3), 326–331. https://doi.org/10.4103/ijem.IJEM_30_19
- Abstract: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6683693/
- Rebar, R. W. (2020, September). Ovulatory Dysfunction . Merck Manuals Professional Edition. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/infertility/ovulatory-dysfunction
- National Library of Medicine, Riaz, Y., & Parekh, U., https://www.ncbi.nlm.nih.gov/books/NBK560575/.