Learn the Different Types of PCOS from a PCOS Nutritionist

If you are a woman with Polycystic Ovarian Syndrome (PCOS), you know how hard it can be to manage the various symptoms—from acne and fertility issues to weight gain, fatigue, mood disturbances, and more. Figuring out what’s causing your PCOS symptoms and dealing with them through diet is hard—but it doesn’t have to be! As an experienced PCOS Nutritionist, I’m here to help you learn about the different types of PCOS so that you can better understand their causes, identify potential solutions to manage them, and even discover alternative treatments that could improve your quality of life. Let’s dig in together!

What Other Health Conditions are Caused by PCOS?

PCOS is complex. The condition will look different among different women including the type or severity of PCOS symptoms like physical symptoms, hormonal changes, or metabolic changes.

While infertility is probably the top symptom of PCOS that comes to mind, there are other lesser know outcomes of the PCOS such as obesity, insulin resistance, type 2 diabetes, metabolic syndrome, fatty liver, and high blood lipids (fats).

Diagnosing PCOS has evolved over the years, with the last ten years gaining knowledge of the condition greatly.

Diagnosing PCOS

In 1990, the US National Institutes of Health (NIH) was the first to set diagnostic criteria for PCOS. Just two conditions had to be met to diagnose PCOS – high testosterone levels (hyperandrogenism) and an absent or irregular period.

In 2003, the European Society for Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM) expanded the diagnostic criteria to include two of three criteria (otherwise known as the Rotterdam criteria):

1. High testosterone levels
2. Absent or irregular period
3. Discovering cysts on the ovaries via an ultrasound

In addition to these diagnostic criteria, in 2012 NIH defined the four different phenotypes we know today, giving women a better understanding of their condition.

Redefining how PCOS is diagnosed caused more women to be diagnosed, from 4-6.6% to as high as 21%.

As you will learn, there are many similarities between the different types of PCOS, but also differences. When identifying your specific type of PCOS, you can design a better plan to meet your unique needs!

The 4 Types of PCOS

There are 4 types of PCOS, otherwise known as ‘phenotypes’:

1. Phenotype A: ‘Classic PCOS’
2. Phenotype B: ‘The Other Classic PCOS’
3. Phenotype C: ‘Ovulatory PCOS’
4. Phenotype D: ‘Non-hyperandrogenic PCOS’ aka ‘Lean PCOS’

Symptoms are typically the most severe for type A, decreasing as you descend from type A to D.

Since a diagnosis of PCOS requires two of three conditions, each type represents a unique combination of diagnostic criteria.

Phenotype A: ‘Classic PCOS’

As phenotype A is the most severe, it has all three diagnostic criteria:

1. High testosterone levels
2. Absent or irregular period
3. Cysts on the ovaries

More than half of published research includes type A. Being the most common form, it is also known as ‘Classic PCOS’ and has the highest hormonal imbalance and health risks.

Some of the characteristics of type A include:

• Most common to have issues with their cycle, but tends to normalize with age
• Higher insulin levels and higher rates of insulin resistance
• More likely to be in a larger body
• Higher risk for metabolic syndrome
• Unhealthy fats in the blood – high triglycerides, high LDL ‘bad’ cholesterol, and low HDL ‘good’ cholesterol
• Increased risk for fatty liver
• Highest Anti-Mullerian Hormone levels, because of the presence of many small follicles with PCOS
• High testosterone levels and/or symptoms of high testosterone: oily skin, acne, excess hair growth on the face or body, and hair loss (female pattern baldness)

Phenotype B: The Other ‘Classic PCOS’

Phenotype B, also called ‘Classic PCOS’, is diagnosed by:

1. High testosterone levels
2. Absent or irregular periods

It has the same characteristics as type A listed above, with the difference being there are no polycystic ovaries.

• Menstrual dysfunction is most pronounced – but normalizes with age
• Dysregulation of sugar metabolism – increased insulin levels and higher rates of insulin resistance
• Higher risk for obesity and/or high body-mass index (BMI)
• Higher risk for metabolic syndrome which is a group of conditions that occur together which increases the risk of developing diabetes heart disease, and stoke.
• Unhealthy fats in the blood – high triglycerides, high ‘bad’ cholesterol, and low ‘good’ cholesterol
• Increased risk for fatty liver
• High testosterone levels and/or symptoms of high testosterone include acne, excess hair growth on the face or body, and hair loss (female pattern baldness).

Interestingly, one study¹ found that women with type B had more than double the occurrence of metabolic syndrome (~53% in type B compared to ~20% in type A). Metabolic syndrome increases your risk for developing cardiovascular disease and diabetes. It is essential to treat metabolic syndrome to prevent worsening of your health from complications of PCOS.

Diabetes Canada defines metabolic syndrome as having three or more of the following:

• Waist circumference ≥88cm
• Blood pressure ≥130/85 mmHg
• Fasting blood sugar ≥ 5.6 mmol/L
• Triglycerides (fat in blood) ≥ 1.7 mmol/L
• High density lipoprotein (HDL) ‘good’ cholesterol < 1.3 mmol/L

In addition, the World Health Organization (WHO) recognizes cultural differences and notes women of Asian ethnicity have a cut-off of 80cm for waist circumference.

Phenotype C: ‘Ovulatory PCOS’

Ovulatory PCOS or type C, occurs with:

1. High levels of testosterone
2. Cysts on the ovaries

Type C is less severe than the A and B types of PCOS, type C still has ‘intermediate’ levels of:

• High testosterone levels and/or symptoms of high testosterone: oily skin, acne, excess hair growth on the face or body, and hair loss (female pattern baldness)
• Higher insulin levels and higher rates of insulin resistance
• Unhealthy fats in the blood – high triglycerides, high LDL ‘bad’ cholesterol, and low HDL ‘good’ cholesterol
• Higher risk for metabolic syndrome

Metabolic syndrome in women with PCOS increases with age and BMI. Furthermore, types A, B, and C are 3-5 times more likely to have metabolic syndrome – or all typs of PCOS with high testosterone.

Phenotype D: ‘Non-hyperandrogenic PCOS’ or ‘Lean PCOS’

The least severe of the types of PCOS, is type D, which has:

1. Absent or irregular periods
2. Cysts on the ovaries

It is called Non-hyperandrogenic PCOS because it is the only type of PCOS without high testosterone levels. Despite this, women with type D may still have hormonal imbalances.

Women with this type may have normal insulin function and have the lowest risk for developing metabolic syndrome.

Treating Different Types of PCOS

As each type is unique, the treatments should be too. By understanding your specific type of PCOS, a personalized care plan can be created to address your body’s unique needs.

It is clear that depending on the type of PCOS, long-term health differs. Women with type D may not even show symptoms and they have the lowest risk for metabolic syndrome or other conditions. Women with types A and B are at a high risk of developing further health issues that require a more aggressive treatment.

Despite differences between types, all women with PCOS have a 10 times higher chance of developing diabetes, and an 11 times higher chance of developing metabolic syndrome than healthy women. So yes, even type D should take this condition seriously!

Fertility Medications to Treat PCOS

Your doctor may prescribe you medications to help you ovulate; please remember that this blog is for information only and not to diagnose or treat any medical condition.

A common medication used to treat infertility in PCOS is Clomiphene Citrate. One study² measured whether this drug is more or less effective depending on the type of PCOS. Clomiphene resistance was significantly higher in type A than in type D – about 65% and 17%, respectively. Since type A may be less responsive to this drug treatment, nutrition and lifestyle interventions should be prioritized as treatment options.

Metformin, a common drug used to treat diabetes, is also commonly used to treat PCOS. While this can lower blood sugars and control insulin, caution must be taken here since long-term use can cause low vitamin B12 levels.

All women with PCOS used to be prescribed Metformin; however, it is mostly used only for women with insulin resistance and metabolic syndrome (mostly types A & B).

Nutrition Interventions: Diets for PCOS

Regardless of your type of PCOS, nutrition can be used to help optimize your health. For instance, women with type A would benefit from a diet to help with insulin resistance, cravings and weight loss, whereas type D may benefit from nutrition recommendations to restore their cycle.

A study³ found that women who have facial hair growth also tended to have higher BMI and higher fasting insulin. With higher levels of insulin, nutrition management of the amount and type of carbohydrates becomes essential.

In addition, reducing your intake of advanced glycation end products (AGEs) could improve your health, since AGEs interfere with hormones. AGEs can form when foods, particularly high in protein and/or fat, are cooked at high heat and react with sugar. Examples include grilling meat at high temperatures, broiling cheese, or frying egg yolks on hot heat. While delicious, these are not “every day foods”. The browning of foods at high temperatures is the result of this reaction between proteins and sugar. Women with type A have been found to have higher levels of AGEs.

The Benefits of Treating Your Type Of PCOS

Polycystic ovary syndrome is a hormonal disorder that affects a significant amount of women. This article has talked about some of the benefits of treating your type of PCOS. It has also highlighted the side effects and risks associated with PCOS.

Working With a Registered Dietitian

Given the complexity of treating PCOS, a Registered Dietitian can help you hone your individual nutrition requirements. While your type of PCOS will determine the appropriate nutrition protocol, PCOS Nutritionists also take into account your unique life circumstances.

Sometimes all of the information in the world still doesn’t help us make changing nutrition habits any easier, that’s where we come in! We help women with PCOS reclaim their vitality & confidence by creating nourishing lifelong habits with Edge Nutrition’s Coaching Program. Reach out for a clarity call on which nutrition plan suits your needs best.

References

1. Kar S. Anthropometric, clinical, and metabolic comparisons of the four Rotterdam PCOS phenotypes: A prospective study of PCOS women. J Hum Reprod Sci. 2013 Jul;6(3):194-200. doi: 10.4103/0974-1208.121422. PMID: 24347934; PMCID: PMC3853876.
2. Sachdeva G, Gainder S, Suri V, Sachdeva N, Chopra S. Comparison of the Different PCOS Phenotypes Based on Clinical Metabolic, and Hormonal Profile, and their Response to Clomiphene. Indian J Endocrinol Metab. 2019 May-Jun;23(3):326-331. doi: 10.4103/ijem.IJEM_30_19. PMID: 31641635; PMCID: PMC6683693.
3. Clark NM, Podolski AJ, Brooks ED, Chizen DR, Pierson RA, Lehotay DC, Lujan ME. Prevalence of Polycystic Ovary Syndrome Phenotypes Using Updated Criteria for Polycystic Ovarian Morphology: An Assessment of Over 100 Consecutive Women Self-reporting Features of Polycystic Ovary Syndrome. Reprod Sci. 2014 Aug;21(8):1034-1043. doi: 10.1177/1933719114522525. Epub 2014 Feb 11. PMID: 24520081; PMCID: PMC4126218.
4. Lizneva D, Suturina L, Walker W, Brakta S, Gavrilova-Jordan L, Azziz R. Criteria, prevalence, and phenotypes of polycystic ovary syndrome. Fertil Steril. 2016 Jul;106(1):6-15. doi: 10.1016/j.fertnstert.2016.05.003. Epub 2016 May 24. PMID: 27233760.
5. Livadas S, Diamanti-Kandarakis E. Polycystic ovary syndrome: definitions, phenotypes and diagnostic approach. Front Horm Res. 2013;40:1-21. doi: 10.1159/000341673. Epub 2012 Oct 18. PMID: 24002401.
6. Alison Goldin, Joshua A. Beckman, Ann Marie Schmidt and Mark A. Creager. Advanced Glycation End Products Sparking the Development of Diabetic Vascular Injury. Originally published8 Aug 2006 https://doi.org/10.1161/CIRCULATIONAHA.106.621854 Circulation. 2006;114:597–605
7. https://advancedfertility.com/infertility-testing/amh-fertility-testing/
8. https://fertility.womenandinfants.org/services/women/anovulation
9. https://www.uptodate.com/contents/ovulation-induction-with-clomiphene-citrate
10. https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=tm6339spec
11. https://guidelines.diabetes.ca/cpg/chapter3#sec4