The four main types of PCOS

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, and there is no one-size-fits-all fix. One basic way of understanding this is through the different “types” of PCOS. 

There are 4 main types of PCOS:

  • Insulin-resistant PCOS
  • Adrenal PCOS
  • Inflammatory (hidden cause) PCOS
  • Post-pill PCOS

Note that these types are not mutually exclusive. That is, you can fall into more than one bucket (e.g. insulin-resistant and adrenal PCOS, and so on). 

In discussing the different types, our goal is to answer the following questions: 

  • What characterizes each type of PCOS?
  • What catalyzes symptoms for each type of PCOS? 
  • How does treatment strategy tend to differ for each type of PCOS?

While this article is by no means enough personalization to tackle your specific case of PCOS, our intention is for it to serve as a guide to answer the above questions and open up a dialogue around the importance of understanding the root cause of your specific symptoms. Be sure to talk with your doctor before making any changes to your routine.  

Insulin-resistant PCOS 

What is insulin-resistant PCOS?

You have insulin-resistant PCOS if you have high levels of insulin in addition to fulfilling the diagnostic criteria for PCOS. 

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):

  • A waistline over 35 inches
  • Blood pressure of 130/80 or higher 
  • A fasting glucose level of 100 mg/dL or higher 
  • A fasting triglyceride level over 150 mg/dL
  • A HDL cholesterol level under 50 mg/DL
  • Skin tags 
  • Patches of dark, velvety skin called acanthosis nigricans

What catalyzes symptoms for this type?

As mentioned, 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. 

This is because 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 the long-term risks insulin resistance brings. As a population, people with PCOS have a 50% chance of developing diabetes by the age of 40 and 4x - 7x higher risk of heart disease depending on age (2). This is largely driven by the 70% of PCOS cases that fall into the insulin-resistant type (3). 

What are common treatments for this type?

Insulin-resistant PCOS responds readily to lifestyle modifications, particularly with diet and exercise. Medication is also leveraged for many cases, particularly if insulin resistance is serious and uncontrolled. 

  • Diet: Similar to diabetes, eating a lower-carb diet and being sure to eat ample protein and fat at each meal can help regulate our blood sugar. If you work with a nutritionist or registered dietitian (RD) to combat your insulin resistance head on, chances are they will advocate you focus on complex carbohydrates such as sweet potatoes, brown rice, and vegetables. While there is a lot of focus on eating keto to take back control of insulin and your blood sugar, keep in mind that for many of us, insulin can still be managed with less extreme lifestyle modifications. 
  • Exercise: Exercise has also been shown to help increase insulin sensitivity, thereby improving insulin resistance. Short, high intensity workouts and interval training work better for insulin-resistant cases of PCOS than the other types. Be sure to also get plenty of gentle movement such as aiming for 10k steps per day. 
  • Medication: A common pharmaceutical for managing insulin-resistance is a drug called metformin (also known as: Fortamet, Glucophage, Glumetza, or Riomet). In cases of severe insulin resistance or diabetes, it is often the best way to quickly get a dangerous situation under control. While metformin works for many people, it’s important to be aware of common side effects such as gastrointestinal issues. If you’ve experienced stomach problems from your metformin, be sure to bring this up with your doctor in case they suggest changing your dosage. 

Adrenal PCOS 

What 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). 

For most females, our ovaries produce roughly 60% of our androgens while our adrenals produce the remaining 40% (4). 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. Our 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 our adrenal glands (5).

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. 

What catalyzes symptoms for this type?

Adrenal 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, under-eating, or injury.

Love heart-pounding workouts? Check out this article on how you can safely do cardio with PCOS. 

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. 

What are common treatments for this type?

Stress management is key if you are suffering from adrenal type PCOS.. In general, treatment strategies include:

  • Stress management techniques: 1-1 therapy, group counseling, support groups, mindfulness and meditation are all common tactics that may help reduce your stress levels. Be mindful that patience is key when it comes to developing a new routine to lower stress. Learn more about the complex feedback loop of stress and PCOS here.
  • Eat a nutrient-dense diet, and eat enough: Much PCOS literature, particularly on social media, points to low carb diets as a necessary symptom management tool. With adrenal type PCOS, this advice can actually backfire, particularly if high activity levels are driving your symptoms. While this does not mean you should subsist solely on donuts and pizza, be wary of jumping into an extreme low carb diet like keto if your adrenals are stimulating androgen production. Complex carbohydrates, colorful fruits and vegetables, healthy fats, quality dairy products if tolerated, and lean protein is generally a safe bet (6, 7). 

Post-pill PCOS

What is 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.

What catalyzes symptoms for this type?

If you’ve recently gone off of a birth control pill with drospirenone or cyproterone, such as Yasmin, Yaz, Brenda or Diane, it can be common to have withdrawal effects such as an androgen surge. These birth control types are referred to as having a “low androgen index.” Other lower estrogen pills have also been shown to increase your androgen levels as a side effect. 

If you have post-pill PCOS, you will likely find that it takes you longer than friends and family who have discontinued hormonal birth control to regain your regular cycle. That said, as mentioned, an upside of this PCOS type is that symptoms generally diminish with time. 

What are common treatments for this type?

Patience is key when it comes to post-pill PCOS. Many of our providers lean on making sure our body is primed for optimal detoxification to help flush out any excess synthetic hormones from the previously-used birth control method. 

  • Lifestyle factors: Nutrition and exercise are both good ways to encourage detoxification. Be sure to drink plenty of water, get enough fiber from whole grains, leafy greens, and cruciferous vegetables, and make sure you are eating a variety of nutrient-dense foods. 
  • Supplements: There are a variety of supplements like turmeric, vitamin D3, fish oil, and probiotics that have anecdotally been shown to speed up recovery from post-pill PCOS. Many people find success working with a functional-trained provider to discuss what may work for you. Be sure to speak with a medical professional before starting a new supplement regimen; your care coordinator can help you decide if this is something Pollie can help you with. 

Inflammatory PCOS (also known as “hidden cause” PCOS)

What is inflammatory PCOS?

Chronic inflammation can trigger our bodies to release too much testosterone, and when this inflammatory cascade is the primary agent, then it can be inflammatory PCOS. 

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. 

What catalyzes symptoms for this type?

As mentioned, chronic inflammation can lead to higher levels of androgens, particularly DHEA and androstenedione (8). The presence of inflammation also disrupts ovulation (9). 

In terms of the root cause of inflammatory PCOS, several potential triggers include:

  • Food sensitivities, allergies, or intolerances: If your body has an adverse reaction to a food or food group, over time this can lead to chronic inflammation. We have all heard of celiac disease, a digestive and autoimmune condition that is triggered by the gluten protein. But, you can have an inflammatory response to food without having a full-blown autoimmune response in the form of a minor allergy or intolerance. Read more about the link between food sensitivities and hormones here.
  • Intestinal permeability (“leaky gut”): The intestinal gut lining is the barrier that separates the host from its environment. When this lining becomes compromised, it becomes permeable or “leaky” and allows the passage of antigens (i.e., foreign toxins, food particles, and bacteria) to enter the bloodstream. This phenomenon is known as intestinal permeability, or “leaky gut.” Intestinal permeability is directly associated with the development of autoimmune disease. Three common external triggers that can induce intestinal permeability include gluten (derived from wheat and wheat related products), environmental chemicals, and toxins that are released from pathogenic bacteria. In order to heal a leaky gut, it’s important to remove all of the offending triggers (10). Read more about how you can optimize your immune system, gut health, and hormones here
  • Autoimmune disease: PCOS has been associated with a higher likelihood of autoimmune disorders, most notably autoimmune thyroid diseases like Hashimoto’s. Depending on diagnostic criteria used and ethnicity, autoimmune thyroid disease has been found in 18 - 40% of people with PCOS (11). Having an autoimmune issue like Hashimoto’s inherently increases inflammation and results in additional hormonal disruption. 

What are common treatments for this type?

If an autoimmune disease is fueling your inflammation, you will need to work with a doctor to receive a diagnosis and treatment protocol. But, if your inflammation is resulting from more minor lifestyle factors, there are a variety of ways you can start to take back control. 

  • Diet optimization: While elimination diets are not for everyone, if there is a specific food or food group that you know is catalyzing your PCOS symptoms it may be worth considering removing said item(s) from your diet for several weeks or months to see if any improvement is found. We highly recommend you work with a qualified provider before making any major dietary adjustments. We dive deeper in how you can safely do an elimination diet here. Doing a food sensitivity blood test can help you identify if anything you are eating is increasing inflammation and worsening your symptoms, although clinical feedback on these tests is mixed. We recommend you reach out to your care coordinator for the pros and cons of different food sensitivity tests if you are interested in completing one. 
  • “Clean up” your household and beauty products: As mentioned earlier, environmental toxins can contribute to inflammation. Try to avoid plastics containing bisphenol A (BPA), synthetic fragrances and air fresheners, and other products containing harmful chemicals. While fully committing to a 100% all natural, toxin-free lifestyle is likely not feasible for most of us, it can be worthwhile to make sure the items you are using most are hormone-friendly. Learn more about how the external environment impacts hormones here.
  • Stress management: Our stress hormone cortisol has the ability to both damper and overstimulate the immune system, leading to inflammation. For this reason, keeping stress in check is key. 1-1 therapy, group counseling, support groups, mindfulness and meditation, and healthy movement can all be helpful strategies. 
  • Gentle exercise: If you are suffering from inflammation, high intensity exercise should perhaps take a backseat until your body is on the mend. When we exercise vigorously, our body produces stress hormones like cortisol. If we have proper recovery time, this cortisol will decrease and ultimately make us stronger. But, if you are already suffering from inflammation, many people find success in switching to more gentle forms of exercise like yoga, pilates, and walking to help calm down their immune response.

Get started on your personalized treatment plan by signing up for the Pollie waitlist and feel free to email hello@pollie.co with any questions you may have!

References

  1. Dansinger, M. (Ed.). (2021, June 23). Insulin resistance: Symptoms, causes, tests, treatment, and prevention. WebMD. Retrieved May 9, 2022, from https://www.webmd.com/diabetes/insulin-resistance-syndrome 
  2. Asagami, T., Holmes, T. H., & Reaven, G. (2008). Differential effects of insulin sensitivity on androgens in obese women with polycystic ovary syndrome or normal ovulation. Metabolism: clinical and experimental, 57(10), 1355–1360. https://doi.org/10.1016/j.metabol.2008.05.002
  3. Suba Z. (2012). Interplay between insulin resistance and estrogen deficiency as co- activators in carcinogenesis. Pathology oncology research : POR, 18(2), 123–133. https://doi.org/10.1007/s12253-011-9466-8
  1. Baptiste, C. G., Battista, M. C., Trottier, A., & Baillargeon, J. P. (2010). Insulin and hyperandrogenism in women with polycystic ovary syndrome. The Journal of steroid biochemistry and molecular biology, 122(1-3), 42–52. https://doi.org/10.1016/j.jsbmb.2009.12.010
  2. Suba Z. (2012). Interplay between insulin resistance and estrogen deficiency as co- activators in carcinogenesis. Pathology oncology research : POR, 18(2), 123–133. https://doi.org/10.1007/s12253-011-9466-8
  3. Remer, T., Pietrzik, K., & Manz, F. (1998). Short-term impact of a lactovegetarian diet on adrenocortical activity and adrenal androgens. The Journal of clinical endocrinology and metabolism, 83(6), 2132–2137. https://doi.org/10.1210/jcem.83.6.4883
  4. Soltani, H., Keim, N. L., & Laugero, K. D. (2019). Increasing Dietary Carbohydrate as Part of a Healthy Whole Food Diet Intervention Dampens Eight Week Changes in Salivary Cortisol and Cortisol Responsiveness. Nutrients, 11(11), 2563. https://doi.org/10.3390/nu11112563
  5. González F. (2012). Inflammation in Polycystic Ovary Syndrome: underpinning of insulin resistance and ovarian dysfunction. Steroids, 77(4), 300–305. https://doi.org/10.1016/j.steroids.2011.12.003
  6. Lorenz, T. K., Worthman, C. M., & Vitzthum, V. J. (2015). Links among inflammation, sexual activity and ovulation: Evolutionary trade-offs and clinical implications. Evolution, medicine, and public health, 2015(1), 304–324. https://doi.org/10.1093/emph/eov029
  7. Mu, Q., Kirby, J., Reilly, C. M., & Luo, X. M. (2017). Leaky Gut As a Danger Signal for Autoimmune Diseases. Frontiers in immunology, 8, 598. https://doi.org/10.3389/fimmu.2017.00598
  8. Romitti, M., Fabris, V. C., Ziegelmann, P. K., Maia, A. L., & Spritzer, P. M. (2018). Association between PCOS and autoimmune thyroid disease: a systematic review and meta-analysis. Endocrine connections, 7(11), 1158–1167. https://doi.org/10.1530/EC-18-0309