4 Types of PCOS - How To Choose The Right Protocol

September 26, 2022

September is PCOS Awareness Month, and we continue our exploration of how this condition – which affects 1 in 10 women – impact fertility and reproductive health.

If you joined us last week, you’ll know that not all PCOS is created equal. In fact, there are 4 kinds of PCOS, and knowing which one you are dealing with is key to understanding how best to manage it.

Today we dive deep into each type of PCOS, including what it is, how it’s diagnosed, and which protocols – such as specific foods, supplements, herbs and lifestyle changes – are best suited for each type of diagnosis.

Type 1: Insulin Resistant PCOS

What it is

Insulin-Resistant PCOS is the most common (affecting 70% of women with PCOS). When we eat, our blood sugar rises and the pancreas releases insulin (a chemical messenger) into our blood to take in the glucose from our food into our cells. Insulin Resistance occurs when your body becomes desensitized to this message, therefore the pancreas has to produce more and more insulin to help regulate blood sugar. This can make it difficult to maintain a healthy weight because the body stores excess blood sugar as fat. That’s why women with insulin-resistant PCOS often struggle with weight loss. They also often hold weight around the stomach/abdomen, have sugar cravings and may have other symptoms related to disglycemia (a broad term refering to an abnormality in blood sugar regulation) such as fatigue, brain fog, or increased thirst. It may also be connected to other symptoms of PCOS such as excess hair, male pattern hair loss and acne. That’s because it is the high levels of insulin that drive up androgen levels.

How to know if you have it

The most common test for Insulin-Resistant PCOS is HbA1c - a screening test to measure for glucose levels in the blood. However, to fully rule out insulin resistance, consider having your fasting insulin tested as well. Normal fasting insulin levels should be below 10 mIU/L (60 pmol/L) and fasting glucose should be under 90.

Tips to manage it naturally

The key to managing Insulin-Resistant PCOS is to focus on balancing blood sugar and improving insulin sensitivity. This can include (but is not limited to)…

• Avoiding all foods high in processed sugar.
• Eating foods which have a low Glycemix Index score, especially later into the day/evening.
• Avoiding meals which are high in carbs but low in protein, and when eating carbs, choose complex carbohydrates (such as whole grains) over simple carbohydrates (such as white, processed grains).
• Eating foods high in fiber, especially fiber from fresh fruits and vegetables, whole, grains and legumes.
• Prioritizing clean and lean protein in every meal (including snacks), which can help to minimize blood sugar spikes.
• Incorporating healthy fats into every meal (mains an snacks) such as olive oil, or fats from nuts and seeds.
• Choosing foods high in magnesium and chromium (which has been show to help balance blood sugar).
• Eating foods high in myo-inositol such as oranges, cantaloupe, black beans, prunes and almonds.
• Considering additional supplementation with Myo-Inositol, Vitamin D, berberine, and possibly additional magnesium & chromium. Consider working with a nutritionist to find out what is best for you at what dosage, as this will vary from person to person and is key to getting results.
• Having a regular fitness routine and incorporating natural movement throughout the day (which can help your body to burn sugar, build muscle and improve your sensitivity to insulin).
• Prioritizing sleep and reducing stress (which is also key to manage blood sugar and insulin levels).

Type 2: Inflammatory PCOS

What it is

Inflammatory PCOS is the second most common type of PCOS. In this case, the ovaries make excess testosterone as a response to chronic inflammation. This can manifest as physical symptoms (such as headaches, joint pain, fatigue, skin issues and bowel issues) as well as issues with ovulation and fertility.

How to know if you have it

To check for Inflammatory PCOS, your doctor may take a blood test and look for certain biomarkers in your bloodstream such as C-reactive protein (CRP). Women with Inflammatory PCOS tend to have CRP levels above 5. (In addition to measuring inflammation levels, your doctor may still recommend a fasting glucose test as inflammation can sometimes affect insulin numbers as well.)

Tips to manage it naturally

The key to managing Inflammatory- PCOS is to focus on reducing inflammatory triggers while increasing anti-inflammatory nutrients. A protocol of this kind can include (but is not limited to)…

• Removing any foods that you are allergic or sensitive too. For many people (but certainly not all) this can include gluten and/or dairy.
• Removing foods which are shown to trigger an inflammatory response in most such as highly processed foods, white (processed) sugar, trans fats, deep fried foods, processed meats (like hot dogs), etc…
• Eating foods high in omega-3 (which has an anti-inflammatory effect) such as cold water fish, chia seeds, hemp seeds, flax seeds, while balancing omega-3 with omega-6 in the diet.
• Balancing gut bacteria with foods high in probiotics (such as yogurt, kefir, sauerkraut, kimchi) and/or possibly supplementing with probiotics.
• Eating foods high in prebiotics (food for the good gut bacteria) from fresh fruits and vegetables such as artichokes, garlic, onion, leeks, asparagus, bananas.
• Repairing any leaky gut issues (aka increased intestinal permeability) if they are present. I highly advise working with a nutritionist on this.
• Increasing intake of anti-inflammatory herbs such as ginger and turmeric.
• Considering supplements such as digestive enzymes, fish oil (DHA+EPA), and antioxidants such as NAC. It is best to speak to a nutrition practitioner first to see if these are right for you, and in what dosages are right for your bioindivituality.
• Choosing regular and moderate exercise over high-intensity exercise with can also create an inflammatory response.
• Having an excellent self-care stress-management routine as stress can also cause inflammation in the body.

Type 3: Pill-Induced PCOS

What it is

Pill-Induced PCOS is a kind of PCOS that can occur after a woman stops taking the oral contraceptive pill. This happens because the pill works by suppressing the communication pathway between your brain and your ovaries, which in turn stops ovulation. For most women, when they stop taking the pill, this communication returns to normal right away, along with regular menstruation and ovulation. For some, however, this can take longer - months or even years. Pill-Induced PCOS may come with other PCOS symptoms such as acne, excess hair growth, a high LH to FSH ratio or possible polycystic ovaries, but no insulin resistance. Unlike other types of PCOS, in Pill-Induced PCOS these symptoms were not present prior to starting the pill at all. The good news is Pill-Induced PCOS is temporary. Once those communication pathways rebalance, and ovulation returns, all other symptoms also stop.

How to know if you have it

Your doctor may diagnose Pill-Induced PCOS if your period does not return after 3 months of being off the pill, if you are experiencing PCOS symptoms that were not present prior to taking the pill, and if your insulin-levels are normal.

Tips to manage it naturally

The most important thing about managing Pill-Induced PCOS is having patience. However, you can help move things along with lifestyle changes that include (but is not limited to)…

• Focusing the diet on nutrient density including fresh ingredient, whole foods, and a balanced plate with foods from all food groups including fruits, vegetables, nuts, seeds, legumes, whole grains.
• Avoiding intense restrictive diets, excessive fasting, or calorie restriction.
• Avoiding low-fat diets (You need fat in the diet to make sex hormones like estrogen and testosterone – which are fat-soluble molecules). The key is to choose healthy fats such as those found in fatty fish, eggs, nuts, seeds and olive oil, while limiting saturated fats (and completely eliminating trans fats).
• If dairy is part of your diet, only purchase full-fat dairy products. Low or non-fat dairy can lead to elevated estrogen levels and disrupt the balance of estrogen and progesterone.
• Some women benefit from a seed cycling protocol. This involves rotating between the follicular phase and the luteal phase of your menstrual cycle and taking different seeds at different times to help regulate hormones. (Women with irregular periods can take the seeds according to the moon's cycle.)
• Minimizing processed sugar and refined carbohydrates (which can affect estrogen-progesterone balance).
• Considering supplements such as magnesium, Vitamin E, and Vitamin B6, Vitamin D. If using supplementation, it is best to work with a professional for dosage and sources appropriate to your bioindividuality.
• Considering herbal remedies. A combination of Peony and Licorice can be very effective, taken for a period of 3-4 months (or sooner if regular cycles return). This is particularly helpful in cases of high LH levels (luteinizing hormone). It is important to note, however that licorice root should be avoided in women with high blood pressure or high cortisol levels. For women who DO NOT have elevated LH, another herb to consider is Vitex (also called chaste tree or chaste berry) which can help to balance hormones and support ovulation. However, remember that all these herbal remedies are powerful so please seek professional advice to explore if they are right for you.
• Prioritizing sleep and stress management. Chronically high stress levels and disrupted sleep can amplify any hormone imbalance, including pill-induced PCOS.

Type 4: Adrenal PCOS

What it is

The final type of PCOS (which presents in roughly 10% of PCOS cases) is called Adrenal PCOS. This type is triggered by an abnormal stress response in the body. Elevated stress can cause the adrenal glands to release more cortisol, which can cause the adrenals to produce more DHEA-S (another type of androgen). Cortisol and DHEA-S disrupt the balance of other hormones that can then lead to PCOS symptoms like irregular periods, acne, and unwanted hair growth or hair loss.

How to know if you have it

In Adrenal PCOS, DHEA-S will be elevated, but levels of testosterone and androstenedione will usually be normal. A doctor may test for DHEA-S levels in your blood. Most women with PCOS tend to have DHEA-S levels 200 ug/dl or above. Note that you may need to be referred to an endocrinologist to have your DHEA-S levels tested.

Tips to manage it naturally

Stress management and adrenal support are key aspects of a natural protocol for Adrenal-PCOS. This includes (but is not limited to)…

• Without question, #1 on this list is stress-management. It is not realistic to avoid stressful situations (life is stress), but the key is learning to control how you react to stressful situations, and how to process stress hormones from the body. Methods for lowering cortisol include activities like yoga, tai chi, deep breathing, meditation, time spent in nature, laughing, aromatherapy, Epsom salt baths, journaling and more. It is important to find that which works for YOU and then MAKING TIME for those activities.
• Significantly limiting (or better yet, completely removing) your consumption of stimulants such as caffein, alcohol, and processed sugar.
• Eating foods high in all B-Vitamins, but especially B5 as found in lentils, eggs, split peas, soybeans, mushrooms, avocados, broccoli, cauliflower and kale.
• Increasing intake of foods high in magnesium as found in green leafy vegetables, pumpkin seeds, sesame seeds (also tahini) salmon and halibut.
• Some research suggests resveratrol (a plant compound, or polyphenol) may help lower DHEA-S levels in women with PCOS. It can be found in grapes, berries, and certain nuts. 
• Considering apoptogenic herbs such as ashwaganda, rodiola, reishi mushroom, siberian ginseng, and/or licorice root extract
• Prioritizing Sleep! Getting enough (min 6-8 hours) of quality, uninterrupted sleep each night will support your stress levels and recovery.
• Choosing the right kind of exercise. Limiting excessive and high intensity training to no more than 4 hours per week (as this can further put a stress on your adrenals).

If you suspect you may have PCOS, I hope this guide has helped to answer some questions for you, but please remember that this is just the beginning. If I can leave you with three final pieces of advice, they would be:

1. Book an appointment with your primary physician right away, and advocate for yourself to get the testing and answers you need.
2. Once you have a clear diagnosis, get support. Working with the right team of practitioners and PCOS experts can help you manage your symptoms and create a protocol that respects your bioindividuality. This is especially important if you are considering taking herbs or supplements, as not all herbs, vitamin sources, or dosages will be right for you.
3. Do not loose hope! With the right lifestyle changes, and a little help, PCOS can be managed! It can be a challenging chapter in your life, but remember, this too shall pass!

Until next time, take care and be well!

Ewa Reid, RHN

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About the author

Ewa Reid is a Registered Holistic Nutritionist, certifying Fertility Support Practitioner, nutrition & fertility educator, wife, and mother. You can learn more about Ewa on our About page.

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