A Note From Our Chief Medical Officer
While the notion of PCOS types is indeed interesting, this topic is of the opinion of the author, and current medical opinion differs and further research/consensus is required to confirm or deny the presence of PCOS types. As a result, any benefits with regards to alternative treatment methods is currently unproven. If you have any questions about your PCOS and treatment, do not hesitate to consult your doctor. See more information here and here.
Polycystic Ovary Syndrome (PCOS) is a common but complex hormonal diagnosis that affects between 8-13% of women of reproductive age (1). PCOS can impact fertility and overall emotional and physical well-being. Ultimately, it is a group of symptoms related to anovulation (lack of ovulation) and high levels of androgens (sometimes referred to as male hormones). These symptoms can include excessive facial and body hair (known as hirsutism), acne, hair loss, weight gain, irregular or long cycles (why I love OvuSense and cycle tracking for my PCOS clients) and infertility. Sadly, it is also associated with longer-term health risks such as diabetes and heart disease (2,3). Yet, there is no one single test for PCOS and up to 70% of cases are thought to be undiagnosed (1).
We won’t dive into the diagnosis criteria in this article, but it’s important to know that PCOS cannot be diagnosed on ultrasound alone. In fact, polycystic ovaries do not have to be present to make a diagnosis, and the finding of them does not alone establish PCOS (4). Diagnosis of PCOS should also only be made when other causes of irregular cycles or androgen excess, such as thyroid dysfunction, have been excluded. So, if you have been given a diagnosis of PCOS, it’s always important to understand why and how you have been diagnosed.
What makes PCOS particularly complex is its varied presentations, this really highlights the importance of tailoring support approaches to the specific drivers of PCOS an individual woman may have. In this article, we will delve into some of the key drivers and “types” of PCOS – insulin-resistant PCOS, post-pill PCOS, inflammatory PCOS, and adrenal PCOS – and explore why understanding these is crucial for effective symptom management and improved fertility outcomes.
Decoding the Four “Types” of PCOS
You may have heard PCOS categorised into “types”, Lara Briden was a pioneer in this terminology (5). What we’re really looking at when we consider “types” is an individual’s unique drivers that may have pushed them into a PCOS diagnosis. Yes, there can be genetic susceptibilities with PCOS, but there are also drivers that can turn those susceptibilities into a diagnosis. Identifying your key driver(s) (as there can be overlaps) can be hugely beneficial in finding the best support for your symptoms. We’ll cover some of the main types below, starting with the two I most often see in my clinic.
1. Insulin-Resistant PCOS
Insulin resistance is the most common driver of PCOS, so if you’ve been diagnosed it’s important to understand if you have insulin resistance. This is best tested via blood tests that may review factors such as fasting insulin and HOMA-IR (Homeostatic Model Assessment for Insulin Resistance). Insulin resistance is a condition where the body becomes less responsive to the effects of the hormone insulin, which works to reduce blood sugar levels. Therefore, blood sugar levels can increase. However, you can also maintain normal blood sugar levels but your body has to produce more and more insulin. Either elevated blood sugar levels or too much insulin have negative health effects, and can lead to weight gain and obesity – which in turn can also contribute to the development of PCOS (6).
Why Does This Drive PCOS?
There are thought to be a number of mechanisms which link PCOS and insulin resistance. Elevated insulin levels may cause the ovaries to produce too much testosterone, which can interfere with the development of follicles and ovulation. It can stimulate the pituitary gland in the brain to make more luteinising hormone (LH), which in turn encourages more androgens and can lower Sex Hormone Binding Globulin (SHBG) resulting in more free androgens. In a negative cycle, this androgen increase can encourage fat to accumulate around the abdomen, these fat cells can also become more resistant to insulin; worsening PCOS (7,8).
If you have the symptoms of PCOS (infrequent or no ovulation), elevated androgens and insulin resistance, this may be your driver type of PCOS.
Key Factors to Support Insulin-Resistant PCOS
- Regular movement – exercise sensitises your muscles to insulin, strength training can be really useful here.
- Avoiding high-sugar foods - focusing on a lower carbohydrate diet that is rich in protein and healthy fats can help to balance blood sugar levels.
- Get enough sleep – a lack of sleep can impact hunger hormones and sugar cravings.
- Supplementation of key nutrients and nutraceuticals can be really helpful. However, I strongly recommend you work with a registered nutritionist to really find out what is best for your unique situation (some supplements can do more harm than good), what dosage is right for you, the best form, and any medication contraindications.
2. Post-Pill PCOS
Although not widely recognised as an ‘official condition’, this unique type can arise after coming off certain oral contraceptives. The pill suppresses ovulation (which it’s meant to do), typically when you stop taking the pill, your body will begin to ovulate after a small period of readjustment. However, for some women ovulation will not return for months or even years. This longer adjustment period can result in irregular cycles and hormonal turmoil, during this time you may receive a PCOS diagnosis.
Why Can This Drive PCOS?
Some oral contraceptives are also “antiandrogenic”, so they reduce the amount of androgens in the body. Coming off these pills can cause a temporary surge in androgens, which can lead to androgenic symptoms for a period of time contributing to PCOS diagnosis (5).
For some, hormonal birth control may cause or worsen insulin resistance (9), potentially contributing to insulin-resistant PCOS. If you had no issues prior to starting the pill, and do not have insulin resistance, it could be that Post-Pill PCOS is your driver. It can take a little time, but by identifying this and applying tailored support your hormones can get back into their natural rhythm.
Key Factors to Support Post-Pill PCOS
- Eat enough – it’s really important to eat well, but equally as important to eat enough quality unrefined carbohydrates and healthy fats. This can help ensure we have enough fibre to aid proper elimination (crucial for hormone balance) and healthy fats are the building blocks of our hormones.
- Try not to panic and remember that this may take a little time for your hormones to find their rhythm again, but it is an impact of the ovulation-suppressing drugs and should be a temporary situation.
- Speak to a practitioner about personalised supplementation – certain nutrients and supplements can be helpful to support ovulation and lower excess androgens. It’s always important to work with a registered nutrition practitioner to ensure you are selecting the right supplements for your situation, the best quality, and any nutrient-medication interactions are checked.
3. Inflammatory PCOS
Inflammatory PCOS highlights the intricate connection between chronic inflammation and hormonal imbalance. Inflammation can play a role in all ‘types’ of PCOS and many hormonal conditions or period problems. However, if you don’t have insulin resistance or the post-pill PCOS picture is not relevant, it could be that inflammation is a primary driver of your PCOS (10).
Why Does This Drive PCOS?
Inflammation is part of the body’s defence mechanism. It is vital for our immunity and how the body recognises and removes harmful and foreign threats and instigates healing. Inflammation can be acute or chronic. Chronic inflammation, is slow, longer-term inflammation. This type of inflammation can disrupt hormonal harmony by impacting hormone receptors, causing ovarian dysfunction, and increasing androgens (11,12). Other signs of inflammation include digestive issues (such as IBS, diarrhoea & acid reflux), body or joint pain, skin conditions, headaches, unexplained fatigue, and frequent infections. Several risk factors can promote chronic inflammation, including diet (if rich in saturated fats, trans fats, sugar and low in antioxidants), smoking, obesity, and a heavy environmental toxin load.
Key Factors to Support Inflammatory PCOS
- Anti-inflammatory diet – focus on an abundance of plants, a rainbow of colour, and include omega-3 rich fatty fish, herbs and spices such as turmeric.
- Address gut health – if you have digestive symptoms, it’s really key to get to the root cause of these, often best done with an experienced nutritionist. Working on gut integrity, balancing the microbiome, eliminating any pathogenic bacteria and improving digestive function can all help to reduce chronic inflammation.
- Clean up toxins from your home, skincare, and diet – feel free to download my free toxin-free living guide to help support this (available via my Instagram links @alexandramariemsc)
These factors are also helpful for all types of PCOS.
4. Adrenal PCOS
If you meet all the criteria for PCOS, but do not have insulin resistance, were not impacted when coming off the pill, and have no signs of inflammation; it could be that the stress response is a key driver for your PCOS. Most women with PCOS have an increased output of one or all of the androgens, but if only your DHEAS is elevated it could indicate “adrenal PCOS” (all other reasons of elevated DHEAS should first be ruled out by your healthcare provider) (13).
Why Does This Drive PCOS?
Adrenal PCOS is closely linked to the adrenal glands, these are walnut-sized glands that sit atop each of the kidneys. These glands produce hormones such as cortisol, DHEA and DHEAS. Excess stress, whether physical or emotional, can trigger these glands to overproduce these hormones which can disrupt the balance of other hormones, that may lead to the development of PCOS symptoms.
Whilst insulin resistance and elevated insulin levels can drive the ovarian production of testosterone in other PCOS drivers, it is the hypothalamus-pituitary-adrenal (HPA) axis responsible for the stress response that can stimulate the production of DHEA and DHEAS with adrenal-driven PCOS. The body can then convert these hormones to testosterone without involvement from insulin or the ovaries. Therefore, a woman can experience PCOS symptoms and diagnosis, with no insulin resistance and no ovarian cysts but adrenals driving the excess androgens (14).
Key Factors to Support Adrenal PCOS:
- Identify hidden stressors – I always work with a client to identify these. These are the small things you might not consider that add to your stress bucket, but you have a lot of control over. Think about if you’re getting enough sleep, do you have any nutrient deficiencies, is there enough or even too much exercise, are you well hydrated, do you have chronic infections, dieting etc…
- Avoid strenuous endurance exercise and extended fasting – these can both put further stress and pressure on your adrenals. Reducing workouts to shorter high-intensity strength sessions, and activities such as walking and swimming can be beneficial.
- Introduce stress-balancing activities – it’s important to find what works for you, try breathwork, yoga, meditation, mindfulness, time in nature, journaling etc – and try to incorporate this daily.
- Work with a nutrition practitioner to identify any nutrient imbalances or deficiencies, and work with you on diet, lifestyle and potentially some key supplements that can support the adrenals.
Understanding Your Unique Factors
With any new PCOS client in my clinic, the first step is always digging deeper to recognise the distinct types or main drivers of their PCOS diagnosis. This is the critical foundation for their tailored and personalised approach to support PCOS and fertility. This is why a one-size-fits-all plan, and what worked for your colleague or friend might not work for you, as it likely won’t be targeting your unique set of root causes and drivers. For example, periods of fasting may be beneficial for some women with insulin-resistant PCOS, but may be detrimental if the adrenals are a key driver in their PCOS.
By embracing knowledge about the specific type, seeking professional guidance, and implementing tailored strategies, women can navigate their PCOS journey with greater confidence. Remember, empowerment through understanding is key to unlocking improved fertility and overall well-being.
Alexandra Emerson White, MSc, BSc (Hons), MBANT, CNHC, is a registered nutritionist and functional medicine practitioner specializing in fertility, pregnancy and motherhood. If you want to find out more about supporting nutrition and lifestyle throughout your journey to, and through motherhood download your free QuickStart guide here or your free toxin-free living guide via her Instagram here.
If you have any questions or would like to find out more about personalized nutrition and lifestyle support with Alexandra, contact her via her website, Instagram, or book a complimentary nutrition review call to find out more.
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