Your diagnosis of PCOS may not mean very much. For one thing, you may have been mistakenly told you have “lean PCOS” when you actually have hypothalamic amenorrhea or are in a temporary post-pill situation.
Or, you may truly have PCOS but not the insulin-resistant type.
Here’s what you need to know about the four types of PCOS. (Full flowchart at the end of the article.)
First things first, what is PCOS? Despite the name, polycystic ovary syndrome has absolutely nothing to do with cysts on the ovaries. The things your doctor saw on ultrasound are follicles or eggs, which are normal for the ovary. You can have many eggs and still have normal hormones, and that’s why ultrasound cannot diagnose (or rule out) the hormonal condition PCOS.
PCOS is best defined as an excess of male hormones (androgen excess) when all other causes of androgen excess have been ruled out.
So, step 1 in the flow chart is:
Is it really PCOS?
It’s really PCOS if you have some sign of androgen excess:
- androgens measurable on a blood test,
- facial hair, or
- significant jawline acne.
PLUS other reasons for androgen excess have been ruled out.
Other reasons for androgen excess include certain types of birth control, congenital adrenal hyperplasia (which accounts for up to 9 percent of cases of androgen excess), and high prolactin.
Having irregular periods (or no periods) could mean you have PCOS, or it could mean you have hypothalamic amenorrhea, which is lack of periods due to undereating or undereating carbs.
👉 Tip: Women with hypothalamic amenorrhea can have polycystic ovaries on ultrasound.
For more information read:
- Maybe it’s not PCOS (and PCOS cannot be diagnosed by ultrasound)
- Pain is not a symptom of PCOS
- Is it PCOS or hypothalamic amenorrhea or both?
If you’re certain you have PCOS, then let’s move on.
Is it insulin-resistant PCOS?
Insulin resistance means having high insulin. It’s also called metabolic syndrome or pre-diabetes. The best way to test for insulin resistance is to measure the hormone insulin.
If your insulin is high, then you have insulin resistance and insulin-resistant PCOS.
👉 Tip: These are functional types of PCOS based on my observations of the underlying physiological driver. They are different from the four PCOS phenotypes defined by the Rotterdam criteria.
The treatment of insulin-resistant PCOS is to reverse insulin resistance with diet, exercise, and supplements like magnesium and inositol.
Do you have insulin resistance? If you want to say “no,” then my next question is “are you sure?”
70 percent of PCOS diagnoses are insulin-resistant PCOS.
Did your doctor test for the hormone insulin or only glucose? A test for blood glucose or HbA1c is not a test for insulin resistance.
If you’re certain you do not have insulin resistance, then let’s move on.
Is it post-pill PCOS?
It’s pretty common to experience a temporary surge in androgens when coming off a drospirenone or cyproterone pill like Yasmin, Yaz, Diane, or Brenda.
Under current diagnostic guidelines, that temporary surge in androgens is enough to qualify for the diagnosis of PCOS or post-pill PCOS.
With my post-pill PCOS patients, I recommend the following:
- Stay calm and know the symptoms are part of temporary drug-withdrawal process.
- Consider using a natural anti-androgen supplement like zinc, DIM, or peony & licorice combination for a few months. Read the 7 best natural anti-androgen supplements.
You have post-pill PCOS if you meet the criteria for PCOS (excess androgen and other conditions ruled out), plus you do not have insulin resistance, plus symptoms started when trying to come off the pill.
If you did not just come off the pill or if you had a problem before birth control, then let’s move on.
Is it inflammatory PCOS?
Chronic inflammation can stimulate the ovaries to make too much testosterone and is a contributing factor for every type of PCOS.
When chronic inflammation is the primary factor or driver, it’s inflammatory PCOS.
The treatment for inflammatory PCOS is to identify and correct the underlying source of inflammation. That could mean avoiding a food sensitivity such as dairy, or fixing an underlying gut problem or addressing chronic mast cell activation or histamine intolerance. The supplements zinc and N-acetyl cysteine work particularly well for this type of PCOS.
You have inflammatory PCOS if you meet the criteria for PCOS, plus you do not have insulin resistance, plus you’re not in a temporary post-pill phase, plus you have signs and symptoms of inflammation, as follows:
- unexplained fatigue
- bowel problems like IBS or SIBO
- joint pain
- a chronic skin condition like psoriasis, eczema, or hives.
If you do not have signs of chronic inflammation, then let’s move on.
Is it adrenal PCOS?
Most women with PCOS have an elevation of all androgens including testosterone and androstenedione from the ovaries and DHEAS from the adrenal glands.
If you have only elevated DHEAS (but normal testosterone and androstenedione), then you may have adrenal PCOS, which accounts for about 10 percent of PCOS diagnoses.
Adrenal PCOS is not driven by insulin resistance or inflammation. Instead, it’s an abnormal response to stress. Treatments include stress reduction, magnesium, adaptogen herbs (including licorice), and vitamin B5, the “anti-stress factor.”
For information about the 4 types of PCOS and their treatments, see Chapter 7 of Period Repair Manual.
👉 Tip: Thinking you have more than one type? The types are listed in order of priority. So, if you have insulin resistance, then you have insulin-resistant PCOS — even if you also have inflammation and a post-pill situation.
What if you’ve been told you have PCOS, but you do not seem to meet any of the criteria discussed here?
Go back to the drawing board. Do you truly have PCOS? As in, do you have high androgens? Either measurable on a blood test or the clear physical sign of facial hair.
👉 Tip: Your androgen symptoms could be from birth control. Some progestins such as levonorgestrel are very “testosterone-like” and cause acne and hair loss. Read 4 causes of androgen excess in women.
If you don’t have high androgens, and lack of periods (and maybe mild acne) is your only symptom, then you need to go back to your doctor and ask if you could actually have hypothalamic amenorrhea. (And look at your luteinizing hormone — it’s high with PCOS and low with hypothalamic amenorrhea.)
See the full flowchart below and ask me in the comments.