The 4 PCOS Types & How to Identify Yours
Are you confused with all the conflicting advice, when it comes to treating Polycystic Ovarian Syndrome (PCOS) naturally?
"Just cut out carbs, exercise more"
"Don't go too low carb though as this will make your symptoms worse!"
"Add in this supplement, but only if you have insulin resistant PCOS"
I doubt you were taught about the different types of PCOS by your doctor. In their eyes, the standard protocol is for you to lose weight, move more, take the birth control pill and maybe Metformin too.
But let me tell you, this advice is damaging for the vast majority of us ladies with this condition. This is because PCOS is a complex, metabolic condition that can present with many different symptoms and driving factors.
In order to be diagnosed with PCOS, you need to have 2 out of the 3 following criteria present (Rotterdam Criteria):
1. Elevated Androgens (present in blood work or symptom wise)
2. Irregular menstrual cycle (ovulation issues, long menstrual cycles 35+ days)
3. Polycystic ovaries on ultrasound
PCOS is commonly misdiagnosed because there are many other conditions that can cause similar symptoms. However it can also be under diagnosed if women aren't displaying the 'classic' appearance or set of symptoms.
Many of my clients have been told that they can't possibly have PCOS because they aren't overweight and don't look like someone with this condition. PCOS is a syndrome, meaning that it's just a collection of symptoms! Yes, a lot of women do struggle with their weight, however there are many women with PCOS who are at a healthy weight. You can even be underweight and still have it!
If your Doctor diagnosed you with PCOS solely based on an ultrasound, then this doesn't actually qualify for a diagnosis and you need to request further investigation.
If doctors were to perform a pelvic ultrasound on a random group of women, a lot of them would have this 'string of pearls' appearance on their ovaries at certain times of the month, however that doesn't automatically indicate PCOS!
There are actually 4 types of Polycystic Ovarian Syndrome (PCOS), that you should know about, so in this post I am going to share what they are, how to identify which you are personally dealing with and how to address the types naturally.
These are insulin resistant, adrenal, post-pill and the hidden cause/inflammatory type.
It's very common for women to have multiple driving factors, and fit into more than one type. At one point in time I was personally dealing with all four at once! Let me tell you.... it was NOT fun!
1. Insulin resistant
This is the most common and recognised type, affecting around 70% of women with PCOS. Insulin resistance occurs when our cells become 'numb' to the hormone insulin, and it is the precursor to the development of type 2 diabetes.
When we consume food (mainly carbohydrates), our blood glucose levels rise. This signals our pancreas to release the storage hormone insulin, which acts like a key, unlocking our cells and letting glucose in, to be used as fuel.
If the key or lock becomes damaged (aka our insulin hormone or cell receptors) then glucose remains elevated in the bloodstream and the cells are 'starving for energy'.
Our pancreas continues to pump out insulin as a way to try and lower blood glucose and fuel the cells, however in women with PCOS, insulin also stimulates the ovaries to produce androgens like testosterone.
Androgens drive the common symptoms such as hirsutism (face/body hair growth), male pattern hair loss, cystic acne and can also halt ovulation, therefore affecting fertility and our menstrual cycles.
Causes of insulin resistance...
Consuming too many carbohydrates and sugars for your personal needs, frequent snacking, sedentary lifestyles, high stress levels, nutrient deficiencies (especially chromium, magnesium, vanadium), inflammation and environmental toxins can all lead to insulin resistance.
Other common signs & symptoms...
Weight gain, difficulty loosing weight, fat storage around the midsection, skin tags, velvety patches of skin (acanthosis nigricans), sugar/carb cravings, blood sugar instability, a family history of type 2 diabetes, fatigue after eating (especially carbohydrate rich meals), elevated liver enzymes or fatty liver disease, acne, frequent urination and excessive thirst.
It is important to note that you can be lean and still have insulin resistance. There are also different degrees of insulin resistance, even lean women can be struggling with this. If you are overweight or obese, then you are likely dealing with this as a driver of your PCOS.
How to test...
The best ways to test for insulin resistance are to request the following blood tests from your GP: HBA1C, fasting blood glucose and fasting insulin levels. (Lab measurements and units differ depending what country you are in, work with a practitioner to analyse your results)
You can also monitor your blood glucose levels at home using a glucometer to see how much your levels increase 1 and 2 hours after eating. Most of us respond differently to different types and amount of carbohydrates, so you may need to experiment to find which work best for you.
It is important to note that all of your labs may come back 'normal', however you could still be dealing with insulin resistance, so don't rule it out. In some cases insulin is so high that blood glucose levels don't elevate much at all, and the glucose is immediately stored as glycogen and fat tissue.
Luteinising hormone (LH) will likely be elevated and greater than a 2:1 ratio to Follicle Stimulating Hormone (FSH).
Our adrenals are two walnut sized glands that sit on top of our kidneys and manage our stress response. Stress hormones such as cortisol and adrenaline are beneficial and even life saving (to a point), however chronic, over production of these hormones can lead to burnout, immune dysfunction and a host of chronic health conditions.
Not many people know that our adrenal glands can produce androgens, not just the ovaries and testes. In PCOS, the ovaries are often to blame for the high levels of male hormones such as testosterone, DHEA and androstenedione, however our adrenal glands can also be pumping out high amounts too!
It is estimated that 20-30% of women with PCOS have adrenal androgen excess. Stress can worsen the other causes of PCOS and therefore adrenal androgens are often elevated alongside markers of insulin resistance and inflammation. High cortisol can also disrupt ovulation and therefore the production of progesterone which is anti-androgenic in nature.
Causes of adrenal PCOS...
Over-exercising, under eating, low carbohydrate diets, lack of sleep, phycological stress, a fast paced lifestyle, chronic cardio, hidden infections and blood sugar imbalances can all lead to the adrenal production of androgens.
There is also a condition known as Non Classic Congenital Adrenal Hyperplasia (NCAH) which can cause many similar symptoms to PCOS. It is an inherited condition where a person does not make enough of a specific enzyme, 21-hydroxylase, which is responsible for converting progesterone into cortisol. When this enzyme doesn’t work more progesterone is shifted into testosterone and other androgens.
It has fairly high prevalence, with statistics showing between 0.6%-9% of women with androgen excess have NCAH, with even higher prevalence in Mediterranean, Middle-Eastern Ashkenazi Jewish and Indian populations.
Other common signs & symptoms...
Anxiety, overwhelm, feeling 'wired but tired', a second wind of energy in the evenings, insomnia, palpitations, 3-4pm energy slump, teeth grinding, jumpiness, increased sweating and blood sugar imbalances.
In NCAH, androgens will be high plus cortisol levels will be low, possibly leading to symptoms such as fatigue, poor immunity, hypotension and anxiety. If you suspect that you may be dealing with this rather than PCOS, ask your doctor to rule it out.
How to test...
I would recommend testing DHEA-S levels in the blood or urine, as this androgen is produced uniquely by the adrenal glands, whereas we cannot really determine whether other hormones like DHEA, testosterone, androstenedione and etiocholanolone are being produced by the ovaries or adrenals.
My favourite test to help identify if the adrenal glands are playing a role in your case is the DUTCH test, which is a comprehensive dried urine test. This measures not just your sex hormones, but also your stress hormones like cortisol and cortisone.
If your daily cortisol pattern is out of whack, this indicates that you may have some degree of adrenal/stress related PCOS. It also measures DHEA-S through the urine.
Many women are put on hormonal birth control to 'manage' their PCOS symptoms like acne, and 'regulate' their menstrual cycle. This however, is a band-aid solution and often leads to worsening of the underlying condition in the long run.
For the entire time that we are on the pill, our own natural hormone production and brain to ovary communication is shut down. We are instead controlled by these synthetic versions of hormones, that may look similar to our body, however they do not act the same or provide the same benefits.
Causes of post-pill PCOS...
The birth control pill can be effective in clearing up acne, oily skin and slowing down hair loss, because it helps to bind up excess androgens in the bloodstream. It does this by increasing sex hormone binding globulin (SHBG), which acts like a sponge in soaking up these male hormones. In some women, this mechanism can work a little too well and can lead to vaginal dryness, inability to gain muscle and poor bone health due to low testosterone levels.
When we stop taking the pill, our body has to relearn how to ovulate and communicate with our ovaries. Our ovaries and adrenals can start to pump out excess levels of androgens and our skin can produce more sebum, often leading to oiliness and acne. This usually begins 3-6 months after stopping the pill and is one of the reasons women fear coming off birth control.
The pill also depletes us of many nutrients which are crucial for hormonal balance and detoxification. These include zinc and B vitamins which are needed for detoxication of 'used' hormones. If we cannot effectively eliminate these hormones, they are able to recirculate and cause symptoms such as PMS, acne, hair loss and irregular cycles.
It can also create inflammation, gut and thyroid dysfunction and can impair insulin sensitivity, all of which can be underlying factors in the development of PCOS symptoms.
The good thing is that this situation is often temporary, however due to the symptoms and elevated male hormones, many women are given the diagnosis of PCOS during this time.
Other common signs & symptoms...
Acne, oily skin, hair loss, irregular or absent periods, mood swings, depression, anxiety, hirsutism, infertility, symptoms of nutrient deficiencies and weight gain.
If you had a regular menstrual cycle, no indications or family history of PCOS prior to going on the pill, then you are likely dealing with pill induced PCOS.
Many doctors will say that you will have always had PCOS and that your symptoms are just returning once you stopped the pill, however for most women, true PCOS symptoms start to occur within the first few years after menstruation begins.
How to test...
There isn't a test to tell you whether you have post-pill PCOS, however I recommend thinking back to your health before you started the pill and identify if you may have displayed signs of PCOS.
You can also use functional labs like DUTCH test to assess your overall hormone profile and on blood work, androgens may be elevated, as can the hormone prolactin.
LH levels may be high in comparison to FSH, and in some cases they can both be quite low.
4. Inflammatory / Hidden Cause
Chronic inflammation, along with insulin resistance, are the two biggest drivers of PCOS. Inflammation is beneficial to a point, however chronic, uncontrolled inflammation is a huge driver of PCOS and other, more chronic diseases.
In PCOS, inflammation can worsen insulin resistance and is stressful to the body. It can up-regulate a certain enzyme called 5-alpha reductase, which turns testosterone into a more potent form, dihydrotestosterone (DHT).
Inflammation can negatively impact thyroid health and can prevent the conversion of T4 to the active T3, and increases our chance of developing an autoimmune thyroid condition. It is believed that 25% of women with PCOS have a thyroid issue and they are much more likely to develop hypothyroidism, than women without.
Gut health is also crucial and should not be overlooked in women with PCOS. The gut hosts 70% of our immune system, therefore if we are dealing with dysbiosis or inflammation within the digestive tract, this can affect the whole entire body! Women with PCOS are much more likely to have an imbalance of good and bad bacteria in their gut, hence why an IBS diagnosis and PCOS often go hand in hand.
If you have ruled out the other types of PCOS but are still struggling with symptoms, then you are likely dealing with inflammatory/hidden cause PCOS. The aim is to now uncover what is driving chronic inflammation and your hormone imbalance.
Causes of inflammatory/hidden cause PCOS...
Hypothyroidism, chronic stress, nutrient deficiencies, poor diet, intestinal permeability, an imbalance of omega 3/6 fats, excessive alcohol intake, recreational drug use, high consumption of artificial sweeteners, chronic infections, heavy metal toxicity, exposure to endocrine disruptors and underlying food sensitivities.
Other common signs & symptoms...
Digestive issues like bloating, constipation and diarrhoea, skin complaints, joint pain, food sensitivities, neurological problems, headaches, immune dysfunction, water retention and fatigue.
You may also have other health issues or diagnoses such as hypothyroidism, IBS, arthritis, psoriasis, eczema, autoimmune disease and depression.
How to test...
I recommend testing markers of general inflammation such as CRP and ESR, a full thyroid panel including antibodies, vitamin D, fasting glucose, fasting insulin and HBA1C.
If you have access to functional lab testing I recommend checking your omega fatty acid ratio, environmental toxin exposure and also a comprehensive stool test like GI-MAP.
I hope I have left you feeling more empowered and knowledgable about this condition!
Next week I will be sharing the nutrition and lifestyle recommendations for each type, so that you can start to address your root causes and symptoms naturally. Stay tuned ladies!
Have you signed up for your free 30 minute 'PCOS Troubleshooting call' yet? If not, you can arrange this here. In this call we can discuss your PCOS type in more detail and I will help you figure out the next steps to take with your health, so that you can overcome this hormone imbalance.