Understanding the Different Types of PCOS

Articles suggest that there are four distinct types of Polycystic Ovary Syndrome (PCOS), each with its own cause: insulin resistance, inflammation, adrenal dysfunction, or post-pill effects. However, experts argue that these claims can be misleading.

Polycystic Ovary Syndrome (PCOS) is a common health issue (affecting 1 in 7 women) caused by hormonal imbalances. If you've been diagnosed with PCOS, you might have many questions. You may be surprised to learn that PCOS is not actually a disease, but a collection of symptoms resulting from hormonal imbalances. Since each woman is unique, these symptoms can present differently in each individual.

What is PCOS? Conventional and Functional Medicine Types

PCOS is a chronic condition that disrupts female hormonal balance, affecting about one in seven women worldwide. Contrary to what the name suggests, PCOS is not directly related to the presence of cysts on the ovaries but rather to a hormonal imbalance.

PCOS is characterized by an excess of androgens (male hormones elevated in women), leading to various symptoms such as hirsutism, hair loss, and excessive hair growth in certain areas (abdomen, face, nipples). A PCOS diagnosis requires high androgen levels measured through blood tests and/or visible symptoms of acne, facial or jaw hair, after excluding other causes of excess androgens.

Other causes of excess androgens include:

• Congenital adrenal hyperplasia (about 9% of cases)
• High prolactin levels
• Hormonal contraception with a high androgen index

If you don't have excess androgens, you don't have PCOS, even if you have polycystic ovaries or irregular periods.

Types of PCOS in Conventional Medicine

The origin of PCOS is multifactorial: many environmental factors are involved. Its clinical expressivity varies based on ethnic origin and age, making diagnosis challenging in younger women.

PCOS diagnosis is based on three characteristics:

1. Hyperandrogenism (hirsutism, hair loss, acne)
2. Persistent menstrual irregularities
3. Enlarged ovaries, referred to as ovarian dystrophy

According to conventional medicine, PCOS is divided into four main types:

• Type A: Elevated androgens, irregular periods (or absence of periods), and polycystic ovaries.
• Type B: Elevated androgens and irregular periods (or absence of periods).
• Type C: Elevated androgens and polycystic ovaries.
• Type D: Irregular periods (or absence of periods) and polycystic ovaries.

Type A is considered the most severe and typical form of PCOS, while Type D is the mildest. It is possible to move from one category to another with appropriate treatment, a balanced diet, and lifestyle changes.

Types of PCOS in Functional Medicine

In functional medicine, often discussed on social media and in PCOS books, the types are:

• Insulin-Resistant PCOS: Characterized by high blood sugar, dark skin around the neck and armpits, cravings for carbohydrates and sugar, and weight gain. An HOMA test (reimbursed in the laboratory) greater than 2.5 indicates insulin resistance.
• Inflammatory PCOS: Marked by chronic inflammation symptoms such as acne, rashes, fatigue, joint pain, intestinal issues, and weight gain.
• Adrenal PCOS: Dominated by high levels of DHEA, an androgen primarily produced by the adrenal glands (as opposed to testosterone, which is mainly produced by the ovaries).
• Post-Pill PCOS: Occurs in women who had normal periods before taking the pill but develop PCOS symptoms after stopping it.

Experts' Opinions

Cheruba Prabakar, a gynecologist at Lamorinda Gynecology and Surgery in Lafayette, California, states that there is no evidence of these subtypes existing in the medical literature. Felice Ramallo, chief dietitian at Allara, an online platform for PCOS treatment, explains that most people with this syndrome exhibit both inflammation and insulin resistance, not just one or the other.

Although these four distinct types of PCOS do not exist, Felice Ramallo sometimes finds it useful to describe the different causes of individual symptoms. For example, excessive carbohydrate cravings are usually the result of insulin resistance. Treatments that regulate blood sugar levels can help mitigate these cravings.

Additionally, symptoms can evolve over a woman's lifetime: women in their twenties are more likely to experience increased facial hair and acne, while women in their thirties and older may suffer more from metabolic effects such as obesity and high cholesterol.

New Research on PCOS Subgroups

Recent research has proposed a new categorization based on genetic markers, grouping women into:

• Reproductive Group: Elevated LH and SHBG, low BMI and insulin.
• Metabolic Group: Elevated BMI, glucose, and insulin, low LH and SHBG.
• Indeterminate: Does not fit either of the two groups.

This research indicates distinct types of PCOS, suggesting a future for more individualized treatments. However, this approach is still in its early stages.

Identifying Your Type of PCOS

In my practice, I do not strictly categorize PCOS into these types as most women do not fit perfectly into a single category. They often present a combination of symptoms from different types. For example, it is rare to see someone with purely adrenal PCOS; most women present a mix of symptoms.

Rather than focusing strictly on these categories, it is important to identify and address the underlying causes of your PCOS symptoms. Blood tests help to characterize and diagnose the specific type of PCOS, aiding in the development of an individualized treatment plan.

Insulin-Resistant PCOS

Insulin Resistance: This means your body no longer responds correctly to the hormone insulin, which helps lower your blood sugar levels. Consequently, blood sugar levels become higher than they should be, and your body produces even more insulin to compensate for these elevated sugar levels. When insulin levels are high, your metabolism stops burning fat. This is why symptoms such as weight gain and increased abdominal fat may appear. Other symptoms may arise from this primary cause, such as fatigue, acne, pigmentation spots, frequent cravings, anxiety, irregular cycles, and hyperandrogenism (hirsutism, hair loss).

It is also crucial to understand that insulin resistance inevitably leads to a form of inflammation. Insulin resistance and chronic inflammation are closely linked, forming a vicious cycle where one exacerbates the other.

Characteristics:

• Elevated blood sugar
• Dark skin around the neck and armpits (acanthosis nigricans)
• Cravings for carbohydrates and sugar
• Weight gain

Biological Tests for Insulin Resistance:

• Fasting blood sugar test
• Glucose tolerance test (GTT)
• Serum insulin levels
• Hemoglobin A1c (HbA1c)

Natural Treatment for Insulin-Resistant PCOS

Herbs:

• Cinnamon (Cinnamomum verum): Helps improve insulin sensitivity and regulate blood sugar.
• Gymnema (Gymnema sylvestre): Known to reduce sugar cravings and improve glucose regulation.

Vitamins:

• Inositol (Myo-inositol and D-chiro-inositol): Helps improve insulin sensitivity and regulate menstrual cycles.
• Vitamin D: A deficiency in vitamin D is common among women with PCOS and can worsen insulin resistance.
• Magnesium: Helps regulate blood sugar levels and improve insulin sensitivity.

 

Link Between Inflammation and Insulin Resistance

Inflammation Causing Insulin Resistance:

• Pro-inflammatory cytokines (such as TNF-α and IL-6) interfere with insulin signaling in cells.
• This reduces the cells' sensitivity to insulin, increasing blood glucose levels and forcing the pancreas to produce more insulin.

Insulin Resistance Aggravating Inflammation:

• Excess glucose and insulin promote fat accumulation, particularly in adipose tissues, which also release inflammatory cytokines.
• Hyperinsulinemia stimulates inflammatory pathways, increasing the production of pro-inflammatory cytokines.

Vicious Cycle:

• Insulin resistance leads to increased inflammation, which in turn exacerbates insulin resistance.
• This cycle perpetuates the inflammatory state and metabolic imbalances, worsening the risks of chronic diseases such as type 2 diabetes, cardiovascular diseases, and polycystic ovary syndrome (PCOS).

Inflammatory PCOS:

Inflammation is behind many health issues, including PCOS. Inflammation prompts your ovaries to produce more androgens, which many women with PCOS do excessively. Inflammation can affect almost every part of your body, leading to symptoms such as:

• Chronic pain (joint, muscle, painful periods, headaches)
• Skin eruptions (acne, eczema)
• Digestive issues (diarrhea, constipation, abdominal pain, bloating, gas)
• Persistent weight gain or loss
• Chronic fatigue
• Recurrent viral infections
• Chronic diseases
• Mood disorders (depression, anxiety)

Types of Inflammation: There are two very different types of inflammation. Acute inflammation starts quickly and usually resolves within a few days, while chronic inflammation can last for months or years if the cause is not addressed.

Causes of Chronic Inflammation and PCOS:

• Prolonged exposure to pollutants, heavy metals, and toxic substances
• Weakened or damaged immune system, inability to eliminate aggressors
• Autoimmune diseases, where the immune system attacks healthy cells
• Imbalances in the gut microbiota, presence of aggressive bacteria
• Oxidative stress caused by harmful lifestyle habits (smoking, alcohol, drugs, sedentary lifestyle, overweight, chronic stress)

Biological Tests for Inflammatory PCOS:

• C-reactive protein (CRP) level
• Erythrocyte sedimentation rate (ESR)
• Inflammatory cytokines (IL-6, TNF-alpha)
• Intestinal inflammation markers (fecal calprotectin)

Consequences on Health and Menstrual Cycle:

• Hormonal imbalance: Disruption of estrogen and testosterone, affecting ovarian function and ovulation.
• Insulin resistance: Reduced sensitivity of cells to insulin, leading to uncontrolled weight gain.
• Vicious cycle of inflammation: Excess insulin stimulates the production of male hormones, worsening PCOS. Chronic inflammation severely impacts overall health and the menstrual cycle, requiring specific management to break this vicious cycle.

Link Between Microbiota and Inflammation:

An imbalance in gut bacteria can lead to inflammation, which may cause several digestive problems, such as irritable bowel syndrome, as well as issues outside the digestive system. "Microbiome-related problems can contribute to inflammatory conditions such as arthritis, depression, and neurological diseases."

The Microbiota and PCOS are Closely Linked:

It has been shown that many women with PCOS suffer from dysbiosis, an imbalance between beneficial and harmful bacteria in the gut. This imbalance not only affects your digestive system but can manifest in many other parts of your body. Besides digestive issues such as constipation, bloating, and diarrhea, this underlying cause can also contribute to symptoms such as mental health disorders like anxiety and depression, food sensitivities, asthma, and environmental allergies.

Natural Treatment for Inflammatory PCOS

Herbs:

• Turmeric (Curcuma longa): Has powerful anti-inflammatory properties due to curcumin.
• Ginger (Zingiber officinale): A natural anti-inflammatory that helps reduce systemic inflammation.
• Green Tea (Camellia sinensis): Contains polyphenols with anti-inflammatory and antioxidant effects.

Benefits of Supplements for PCOS, Preconception, and Women's Fertility

Vitamins:

• Vitamin E: A potent antioxidant that helps reduce inflammation.
• Omega-3 (EPA and DHA): Essential fatty acids that help reduce inflammation.
• Vitamin C: An antioxidant that helps reduce inflammation and strengthen the immune system.

Adrenal PCOS

This type of PCOS is characterized by an overproduction of androgens by the adrenal glands, leading to a hormonal imbalance. Women with adrenal PCOS often exhibit symptoms related to excessive cortisol production, the stress hormone, which exacerbates hyperandrogenism and insulin resistance.

Main Symptoms of Adrenal PCOS:

• Irregular menstrual cycles
• Acne
• Hirsutism (excessive hair growth)
• Alopecia (hair loss)
• Weight gain
• Fertility issues
• Anxiety, distress, sleep disturbances, mental fog, attention difficulties, irritability, depression

Hormonal Consequences of Stress:

• Excess cortisol production: In response to stress, the pituitary gland secretes ACTH, stimulating the adrenal glands to produce cortisol, which can disrupt other hormones.
• Androgen secretion: Excess stress increases DHEA production, leading to an overproduction of male hormones.
• High blood sugar: Cortisol raises blood sugar levels, causing hyperglycemia and chronic inflammation, disrupting hormones, and promoting weight gain.
• Thyroid function disruption: Cortisol inhibits the conversion of T4 to T3, affecting ovarian function and the menstrual cycle.
• Inhibited hormone production: Stress inhibits the production of FSH and LH, lowering estrogen levels and blocking ovulation.
• Increased prolactin: Stress elevates prolactin levels, inhibiting GnRH and ovarian function.
• Reduced progesterone: During stress, cortisol production is prioritized, reducing progesterone levels, which are crucial for fertility and premenstrual syndrome.

Hormonal Profile of Adrenal PCOS

• Elevated DHEA levels (Dehydroepiandrosterone)
  • Mainly produced by the adrenal glands

Biological Tests for Adrenal PCOS:

• DHEA sulfate (DHEAS)
• Total and free serum testosterone
• Serum and urinary cortisol
• 17-hydroxyprogesterone (17-OHP)

Natural Treatments for Adrenal PCOS

• Herbs for Adrenal PCOS:

  • Rhodiola (Rhodiola rosea): An adaptogen that helps regulate cortisol levels and supports adrenal glands.
  • Ashwagandha (Withania somnifera): An adaptogen that reduces stress and balances cortisol levels.
  • Lemon balm (Melissa officinalis): Soothes the nervous system and reduces stress levels.

Benefits of Supplements for Stress, PCOS, and Managing Emotions

• Vitamins for Adrenal PCOS:

  • Vitamin B5 (Pantothenic acid): Essential for adrenal hormone production.
  • Vitamin C: Supports adrenal glands and reduces oxidative stress.
  • Zinc: Crucial for hormone production and adrenal function support.

Benefits of Supplements for PCOS, Pregnancy, Breastfeeding, and Preconception

Post-Birth Control PCOS

Birth control pills contain hormones designed to interfere with the natural female cycle, including stopping ovulation and preventing sperm from fertilizing an egg. Quitting these synthetic hormones can cause a withdrawal-like reaction, which can resemble PCOS but is temporary. Hormonal contraceptives (pill, hormonal IUD, implant) contain synthetic hormones similar to estrogen and progesterone. Their goal is to block ovulation and prevent pregnancy, effectively halting the natural menstrual cycle.

Symptoms after Stopping the Pill:

• Long and irregular cycles, infertility
• Accumulation of follicles in the ovaries
• Temporary increase in androgens (acne, hair loss, post-pill hair growth)
• Mood swings

These symptoms can mimic those of long-term Polycystic Ovary Syndrome (PCOS).

Duration of Post-Pill Syndrome: After discontinuing hormonal contraceptives, the body must eliminate synthetic hormones and restart natural hormone production. This process can lead to a temporary hormonal imbalance. For some women, ovulation and menstruation return quickly, while for others, it may take several months or even years. Generally, in post-pill syndrome, the absence of menstruation can last up to six months. If bleeding occurs more than eight weeks after stopping the pill, a hormonal evaluation may be needed.

Biological Profile of Post-Birth Control PCOS

• Characteristics:
  • Develops after stopping birth control pills
  • PCOS symptoms appear post-discontinuation

Biological Tests for Post-Pill PCOS:

• Total and free serum testosterone
• Luteinizing hormone (LH) and follicle-stimulating hormone (FSH)
• Prolactin
• Thyroid function evaluation (TSH, free T4)
• Hormone level assessment before and after stopping the pill

These tests help accurately diagnose the type of PCOS, guiding personalized treatment plans.

Eliminating Synthetic Hormones:

• Support the liver: Limit alcohol, tobacco, fried foods, processed, and sugary foods. Consume beneficial foods such as black radish, garlic, lemon, green vegetables, beets, turmeric, and ginger. Drink ginger, rosemary, or peppermint herbal teas.
• Herbal remedies: Milk thistle or rosemary can support hormone elimination.

Natural Treatments for Post-Birth Control PCOS

• Herbs for Post-Pill PCOS:
  • Vitex (Vitex agnus-castus): Helps balance hormone levels after stopping the pill.
  • Macafem (Lepidium meyenii): Helps regulate menstrual cycles and balance hormones.
  • Black cohosh (Cimicifuga racemosa): Used to regulate hormone levels and alleviate symptoms of hormonal imbalance.
  • Milk thistle: Supports the elimination of hormones.

Vitamins:

• Vitamin B6: Helps regulate hormone levels and reduce symptoms of hormonal imbalance.
• Vitamin E: Supports reproductive health and helps balance hormone levels.
• Omega-3: Helps reduce inflammation and regulate hormone levels.

When considering these root causes, it's important to keep in mind that some women may have only one underlying cause, while others may experience a combination of several. To understand how to identify these root causes and how each affects your symptoms, a consultation with me can help you better grasp this phenomenon and, most importantly, find the source of the issue.