Knowing which "type" of PCOS you are can help personalize your treatment plan. Be sure to talk with your care team if you are unsure!
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:
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 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 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 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.
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 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):
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 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.
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.
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.
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.
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.
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.
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.
Stress management is key for both reproductive and adrenal PCOS. In general, treatment strategies include:
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.
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.
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.
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.
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.