• Caroline Spurr

Learn the Different Types of PCOS from a PCOS Nutritionist

PCOS is complex in nature. There are varying degrees of how the condition will look among women including the type or severity of PCOS symptoms including physical symptoms, hormonal changes, or metabolic changes.

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While it may be more commonly known to cause infertility for women of reproductive age, there are other manifestations of the condition such as obesity, insulin resistance, type 2 diabetes, metabolic syndrome, fatty liver, and altered blood lipids.


Diagnosing PCOS has evolved over the years, with the last ten years expanding knowledge of the condition exceptionally.


PCOS Diagnosing Criteria


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:

1) high testosterone levels

2) the absence of or irregular menstruation

3) discovering cysts on the ovaries via an ultrasound


In addition to these diagnostic criteria, in 2012 NIH defined the four distinct phenotypes we know today, allowing women for a more specific diagnosis.


In redefining the diagnostic criteria for PCOS over the years to encapsulate more factors, the prevalence worldwide has climbed from 4-6.6% to as high as 21%.


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The Four Types of PCOS


There are four different phenotypes:

  1. Phenotype A

  2. Phenotype B

  3. Phenotype C

  4. Phenotype D


The severity of the types decreases as you descend from phenotype A to D with the highest severity for phenotype A and lowest severity for phenotype D.


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


Phenotype A: ‘Classic PCOS’

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

1) high testosterone levels

2) an irregular or absent period

3) the presence of cysts on the ovaries


More than half of published research indicates the presence of this phenotype. Being the most common form, it is also known as ‘Classic PCOS’ and presents the highest hormonal imbalance and health risks.


Some of the characteristics of this type include:

  • 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

  • Unhealthy fats in the blood - high triglycerides, high ‘bad’ cholesterol, and low ‘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 include acne, excess hair growth on the face or body, and hair loss (female pattern baldness).


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Phenotype B: The Other ‘Classic PCOS’

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

1) high testosterone levels

2) irregular or infrequent periods


It encompasses the same characteristics as listed above for phenotype A with the exception of polycystic ovary morphology:

  • 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 study (Kar) found that women with phenotype B had more than double the occurrence of metabolic syndrome (~53% in phenotype B compared to ~20% in phenotype A). Metabolic syndrome increases your risk for developing cardiovascular disease and diabetes. It becomes imperative to treat metabolic syndrome to prevent the onset of such conditions which are known to cause morbidity and mortality.


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’
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Phenotype C, or Ovulatory PCOS, occurs with:

1) high levels of testosterone

2) the presence of ovarian cysts.


Phenotype C is less severe than the A and B types of PCOS, phenotype C has ‘intermediate’ levels of:

  • Testosterone levels and/or symptoms of high testosterone include acne, excess hair growth on the face or body, and hair loss (female pattern baldness).

  • Insulin resistance or hyperinsulinemia which is linked to blood sugar control

  • Levels of unhealthy fats in the blood

  • Prevalence or risk of developing metabolic syndrome


Kar’s study also found that the prevalence of metabolic syndrome in women with PCOS increased with age and BMI, and was three to five times higher in phenotypes A, B, and C - or those with high testosterone.


Phenotype D: ‘Nonhyperandrogenic PCOS’

The least severe form, Phenotype D, is classified by:

1) irregular or absent periods

2) presence of ovarian cysts

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It is also called Nonhyperandrogenic PCOS because it lacks the high testosterone levels normally found in other types of PCOS. It may present some hormone and metabolic abnormalities and periods may cycle between regular and irregular cycles.



Generally, women with this phenotype have normal insulin functions and metabolisms and have the lowest risk for developing metabolic syndrome.


Treating Different Phenotypes


As each phenotype has unique characteristics, the treatment options will differ too. It’s important to distinguish between the phenotypes, as phenotype A has more health risks and hormonal imbalances than some of the other types. By understanding the specific etiology, a personalized care plan can address your body’s unique needs.


It is clear that depending on the type of PCOS, long-term health implications differ. Women with phenotype D may be asymptomatic and have the lowest risk for metabolic syndrome or other conditions, whereas women with phenotypes A and B are at a high risk of developing comorbidities that require a more aggressive intervention to treat.


Despite differences between phenotypes, all women with PCOS have a ten times higher chance of developing diabetes, and an eleven times higher chance of developing metabolic syndrome than healthy women.


Fertility Medications


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.


Clomiphene citrate is a common medication used to treat infertility in PCOS. One study (Sachdeva et al.) measured whether this drug is more or less effective depending on the PCOS phenotype. Clomiphene resistance was noted as significantly higher in phenotype A than in phenotype D - about 65% and 17%, respectively. While phenotype A may be less responsive to drug treatment, nutrition again becomes a high-priority treatment option.


Metformin, a common drug used to treat diabetes, has also been indicated to treat PCOS, but caution must be taken for long-term use as it can cause low vitamin B12 levels.

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


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Nutrition Interventions: Diets for PCOS


Depending on the phenotype of PCOS, a variety of nutrition interventions can be designed to help optimize your health outcomes. For instance, women with phenotype A would benefit from understanding the role of fats and carbohydrates in the diet, whereas the less severe phenotype D may benefit from nutrition recommendations to optimize skin health.


A study (Clark et al.) found that women who experience 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 outcomes, 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. The browning of foods at high temperatures is the result of this reaction between proteins and sugar. Higher levels of AGEs have been found in women with PCOS, particularly with phenotype A.


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 the various benefits of treating your type of PCOS. It has also highlighted the side effects and risks associated with PCOS.


Working With a Registered Dietitian

types of pcos nutritionist in canada

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


Details and specificity deliver results. Understanding the nuances of something helps with the creation of a better plan. By honing on the specifics of your condition, care providers are better able to meet your individual needs.


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 through creating nourishing lifelong habits with Edge Nutrition's Coaching Program. Reach out for a clarity call on which nutrition plan suits your needs best.

 

Written by Caroline Spurr.


Caroline is a co-dietitian with Edge Nutrition and she has 4 years of experience in women’s health, healthy relationships with food, weight management, and PCOS. Follow Edge Nutrition on Instagram & Facebook, or join our email list for more helpful tips.


References

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  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. 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.

  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/

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