In this episode, we are going to continue talking about the Types of PCOS that we have seen. As we have said, (repetitively) PCOS is not a one size fits all. There are some women that have most of the symptoms to just a few. We have three types that we have seen in treating patients since 2004. It is important to have this distinction when it comes to health goals and treatment plans. Doctors that routinely treat PCOS will tell you there are different types. They might have their types that they have seen. But in our experience, these are three types that we have seen most regularly.
The three types of PCOS
Concealed: This type of PCOS is never picked up on. These are the women that have gone to many doctors looking for answers. This is because they have just a small few of the symptoms but not enough to point to PCOS. But they do have a hormone imbalance, and when you break it down, it is a type of PCOS. It seems to get worse when a Concealed Type hits perimenopause or late 30’s to early 40’s. The female hormones are changing, and the body cannot maintain.
This is typically what you will see in the Concealed-Type:
- May have a child, so it looks like there are no fertility issues
- Really irritable–all the time, and way worse before their period
- Yes, they have regular periods but the worst PMS
- Anxiety –it seems that they have a lot of low-grade anxiety all the time.
- Hair is thin
- Slender until they hit mid to late 30’s to early 40’s. This is when they gain weight, especially in the stomach. No matter what they do, they cannot lose weight. Even with severe caloric restriction and lots of crazy exercise, there is no real budge to the weight.
- Carbohydrate cravings especially for sugar
- All these symptoms of the Concealed are blown off as genetics or lifestyle. I have had so many patients with Concealed PCOS say that their previous doctors did not believe that they had a healthy lifestyle.
This is what their blood work typically looks like:
- LH : FSH ratio : the LH is higher than the FSH just a little. There is no 2:1 ratio like you see in the Classic-Types.
- High normal testosterone or just over the edge of normal testosterone. Let me explain again those ridiculous reference ranges for testosterone blood labs. Most labs have the reference range for testosterone to be 2-45, which is a very wide range. Those with Concealed PCOS will have a testosterone at 35-55. The average levels of testosterone for women regardless of age or menstrual status is about 25, so the Concealed are higher than the average.
- Low progesterone
- High normal DHEA-sulfate
- Lower thyroid function but not hypothyroid
- Low normal FreeT3
- Normal FreeT4
- Normal TSH
If you would like more information, visit our website: progressyourhealth.com
We have a free hormone video series on PCOS, Perimenopause, Menopause, and Hypothyroid.
Thank you for being part of our Progress Your Health community
PYHP 065 Full Transcript:
Dr. Maki: Hello everyone. Thank you for joining us for another episode of the Progress Your Health Podcast. I’m Dr. Maki.
Dr. Davidson: And I’m Dr. Davidson.
Dr. Maki: So on this episode, this is the last of our five-part series. Today we’re going to talk about the concealed type of PCOS. The last one we talked about the common type, the one before that we talked about the classic type. This one, you know, the concealed definitely is the most confusing in some respects.
Dr. Davidson: It is. It’s a little bit more vague. So we have, you know, since being in practice and working with, you know, hormonal imbalance and whatnot with PCOS we found three different types. Of course, the classic that we talked about, that’s easy to spot. They’ve got it all. They both got the full gamut. Now the classic really isn’t that common even though everybody knows about all the common symptoms or the classic symptoms of PCOS with that classic type. And then we have the common, which is what we mostly see, which should be diagnosed easily but isn’t because they don’t have all those classic symptoms. So it’s kind of like a watered down version of classic. So the common type is a watered down version of the classic type of PCOS.
But the concealed is where it gets a little more, like I said, vague or a little bit more tricky because it’s, I wouldn’t say it’s a watered down type of common, but it’s a little bit different because you still have some of the symptoms, but it’s not picked up on, like for example, these women that have the concealed type of PCOS have gone to doctor and doctor and doctor looking for answers, but never finding them. Their symptoms are blown off as, “Oh, it’s just your lifestyle.” Or maybe that’s your family genetics, but it still doesn’t mean that they’re getting any better. Now, they might not have the huge risk factors that you see in the classic like diabetes type two in high blood pressure but you still, they still have these symptoms that are going to affect their quality of life.
Dr. Maki: Yeah. So one of the things that, no, granted, this is not an every single woman, but one thing that you may give you a clue as to the concealed type is they’re going to have really, really bad PMS you know, on a monthly basis, cycle after cycle. It’s almost like each they are almost dread when their cycles is coming because they’re at 7-10 days before they’re going to be, before they actually menstruate, where all the symptoms that are possible are just going to be exacerbated for these type of people.
Dr. Davidson: Yeah. So everybody says with that classic type of PCOS, they miss their periods. In common types they might miss their periods every once in awhile, but in the concealed PCOS, they’re getting a period every month. They’re getting a period every single month since they started puberty. But they have that terrible PMS. And so in fact, some women will say, like, Dr. Mackey, you know, it’s 10 days before my period, and I tell them, that’s like 1/3 of your life sometimes happier life, you know, half of the month you’re going to feel terrible. So that’s probably one of the few things that doctors, unfortunately, they think PMS is not going to kill you, so they just blow you off. But PMS not feeling good for 50% of your month is a terrible feeling.
Dr. Maki: Yeah. Right. And I mean, again, this is why we deal with these kinds of issues because, you know, you’re right. I mean, we talk to women all the time. They’ll have two good, sometimes they’ll have one good week, which is usually the week they menstruate, they might have two good weeks and two bad weeks or one okay week, one bad week two bad weeks you know, I mean, you’re right. That’s a lot of time where you’re not feeling your best. And just to accept that, like there’s no options for that. I think it can be a little bit demoralizing. I mean, you know, and that’s not necessarily the person’s fault or the patient’s fault that’s on the doctor not having any ability or any way to be able to help them effectively.
Dr. Davidson: Exactly. So that’s one of the things that we’re so into is balancing the hormones for that quality of life. I mean, a concealed PCOS woman is healthy, you know, she’s healthy, her blood work is going to come back amazing. And the doctor’s going to say, you have, you are so healthy, but they’re going to say, well, I don’t feel like it. I feel terrible because like I said, they go doctor to doctor looking for answers because they have terrible PMS. Their periods might even be really bad, really heavy. These are the women that might get an ablation. You know, the uterine lining burned off because their periods are so heavy and uncomfortable. Now all it does is it corrects periods, but it does nothing for the other, you know, the other symptoms, because not only will you have terrible PMS, but the whole month long and these women are irritable, they’re anxious and they’re mentally tired.
Dr. Maki: Yeah, right? Yeah. They’re just– Now, granted we’re going to talk about stress in a minute, but they’re just, you know, kind of drained both physically and mentally because you know, they have probably a lot going on in their lives, right? They have work, they have kids, they have a family, they have all these different things and this is the one that conceal type, which we use kind of, I just kind of glossed over there. They may actually have a child already you know, where the classic type is probably not going to have a child just because that’d be very, you know, that’d be very challenging for a classic type to have a pregnancy relatively fairly easy. This one would have a child or I’ve had, you know pregnancy and therefore that infertility part kind of gets, you know, kind of just gets missed, they kind of declassifies them because they’ve already had a pregnancy.
Dr. Davidson: But it, and also to these concealed types, we don’t normally see them cause they were going doctor to doctor. They walk into our office right around their mid thirties, you know, to their early forties. And that’s because usually they can, they can buffer it, they can blow off the symptoms. You know, in their twenties and early thirties. They just have to work really hard. But by the time they hit their mid thirties, they’re so mentally exhausted, they’re not feeling good. They’re irritable. That’s when they start to gain weight. So everyone thinks, Oh, PCOS you’re going to have weight gain. Yes, you do have weight gain and PCOS, but with the concealed type, it doesn’t start to manifest until you hit about your mid thirties.
And that’s when they say, Oh my gosh, I put on 12 pounds overnight and I have no idea how to get rid of it. In fact, I’m eating less and exercising more and it’s even creeping up a little bit more. So you’ll see that weight gain and when you break it down, like I said, it almost seems like, you know, so different from the classic PCOS. The concealed type does have that, those higher levels of androgens, just like the common, they’ll have kind of high normal DHEA sulfate. They’ll have high normal testosterone, which you wouldn’t expect in someone that had been cause typically cause we consider the concealed type, not necessarily genetic but more, I guess you could say like adrenal derived PCOS.
Dr. Maki: Yeah, right. They have, usually they have, they’ve either had or have lots of stress whatever kind of stress that might be. And it and for whatever reason, as those female hormones, like you said, once they get into their mid thirties to mid forties, those female hormones are declining a little bit. So now they’re more responsive to the cortisol and some of the insulin issues that you might see in the other two usually happens via the, you know, the cortisol route. In some ways if you have a cortisol problem, you have an insulin problem. If you have an insulin problem, you have a cortisol problem. So they both kind of feed off each other a little bit. This one is more on the cortisol side that creates issues based on that, you know, based on other hormone problems, based on the cortisol. Oh, how would you say it? The cortisol dysfunction.
Dr. Davidson: Exactly. So it’s almost like a delayed PCOS that starts to manifest in their mid thirties, but then it just gets blown off because they might have a child and Hey, you’re getting older, you know, or your lifestyle. But it is, it’s like a delayed you know, a delayed common PCOS that starts in their mid thirties now, like Dr. Maki said, is they, you know, having stress, you know, a lot of stress chronically is not great for our adrenal glands. You know, our bodies are meant to run from a bear and then get away and then be happy, not, you know, 15 seconds of, you know, intense stress, not 15 years of intense stress or 15 months of intense stress. So you see in these women, they’ve had a lot of stress. Their cortisol goes up and then when they hit their mid thirties, their female hormones start to change a little bit so it can’t buffer those higher levels of androgens, like the DHEA sulfate or the DHEA in particular the testosterone, so that starts to come to a head then because of the high levels of cortisol for so long, then you see the insulin start to come up.
So that’s where you’ll see those delayed symptoms. They will have had the terrible PMS probably their whole life, but once it hits 35, it gets really bad and almost feels like it’s permanent PMS. So they have that anxiety, they have the irritability, they go up, maybe you know two sizes in there, you know, when their dress size or their pants size. Like for example, I have a patient and she’s that classic concealed PCOS, you know, she’s in her early forties and she’s very, you know, very good willpower. She works very hard during the week, but on the weekends all she does is lay in bed all day and she tells me how tired she is that she just binge watches Netflix Saturday and Sunday so she can get ready for Monday through Friday and she’s so tired. But I tell her you go to pilates a couple of times a week.
If you had to help me pack up these books in this bookcase and this desk, you could help me do it. You have the physical energy. She doesn’t have the mental energy. Her female hormones are starting to dip. She’s went from, you know, a size four to a size seven so she or her size seven pants are fairly comfortable but that, she’s never been more than a size four. So we see that her hair starting to fall out, you know, she’s not necessarily breaking out in having acne, but looking at her blood work, you would think after all the stress of all the years that she has had to deal with, that her adrenal glands, her adrenal hormones would be low, you think the DHEA sulfate would be low, but in anything it’s high normal. Her testosterone is high normal, which you know it, which is unusual. So she has that delayed or that concealed PCOS and in some respects people say, well you know, she’s fine, just blow it off. But no, we want to address that but we might not address it exactly like that classic type.
Dr. Maki: Yeah. Right. Cause you just start throwing female hormones at them, right? You know, they’re just not–
Dr. Davidson: She will feel awful.
Dr. Maki: Yeah, they’re not– Those are the ones that, Oh as we are talking before we actually started recording, we were talking about that. They are the ones that they take birth control and they just feel worse, you know, or we try to give them progesterone. They might not tolerate it very well you know, and now granted some of the symptoms that the concealed type, that’s why the name the descriptor PCOS doesn’t really fit this one. Okay. But it’s not exactly PMS. It’s not exactly perimenopause in some ways it’s kind of a transition between the two of those. So concealed PCOS really doesn’t fit all that well, but the other two don’t really fit either, cause they’re, you know, they’re different than PMS. It’s different than just straight perimenopause.
Dr. Davidson: But you do see that higher normal androgen status, but it never affected them. They might’ve had a lot of stress and you know, tear it maybe not the greatest periods. You know, PMS, you know, was yucky in their twenties and early thirties, but they at least had that mental energy. They’re at least able to get through everything. And then they, it’s like they hit a wall in their mid-thirties and early forties. I hit a wall, I’m done. And that’s when you look at that picture and you see, hey that insulin is starting to come up. You know, in their 20s these concealed do not have high levels of insulin.
Like you would see in a classic or even moderate elevated levels of fasting insulin in their blood, like a common, but once they hit 35, 40 you’re like, you know what, they’re eating less or exercising more and their insulin is coming up to a nine why would it, you know, why would it be that? So you see it delayed, the insulin is coming up, you know their androgen status is up, but their blood pressure is low, or like, you know, that classic type, they have high blood pressure. If anything, the concealed PCOS, their blood pressure is low because it really is coming from, there might be a predisposition, but then you put all that adrenal stress on there and then that’s when it manifests. Now this is kind of a form of adrenal fatigue or adrenal dysfunction, but in adrenal fatigue you see low DHEA sulfate.
Dr. Maki: Yeah, right? Yeah, yeah. Someone’s got a, and that’s why again, we, that’s why we’re looking at DHEA and women all the time DHEA sulfate, because these are the exact ones that when you hear their story and they tell you what’s going on, if you didn’t look at their blood work ahead of time, you would expect them, like you said, you expect their DHEA level DHEA sulfate to be less than a hundred, maybe even less than 75. It might be somewhere between let’s say 25 to 65 or something like that. But here it is, it comes back and now it’s, you know, 195 to 185. It’s, you know, it’s 175. It’s almost exactly the opposite of what you would expect it to be. Same thing with the testosterone. You might expect their testosterone to be in the single digits in here. Their testosterone is high normal.
Dr. Davidson: So treating these women with let’s say we didn’t let say somebody didn’t know they have this concealed type of PCOS and they of course know that, Hey, I got to work on my adrenals and they work on their adrenals. Maybe take some adrenal supplementation, they’re going to do better, they’re going to do better. But when you’re looking at this concealed type of PCOS, you want to focus on those androgens and in some respect trying to balance out the higher level of androgens. So if you could get them down just a little bit, like for example, that one patient I was talking about, her testosterone level is 41, the reference range request is two to 45 and what’s LabCorp? Like nine to 49 or something. So hers was 41 that’s a pretty good level of testosterone. That was one of those things that kind of jumped out at me.
And then she says she’s anxious all the time. She’s irritable, her patience is short, she’s mentally exhausted. So we want to try to bring, if we could bring that testosterone down to about 32, 30 just by 10 points, that would help tremendously. So there are lots of ways we can do that. But like, but you know, so that’s why I really love working with the concealed PCOS because you want to focus, you have a particular treatment plan that goes along with what would ideally you would work with, with PCOS that gets missed because doctors will be like, hey, let’s put you on antidepressants. Maybe you get a great functional medicine doctor that might not pick this part up but want to work on the adrenals, they’ll get better, but they won’t do great.
Dr. Maki: Yeah. Right. And that’s why we’re talking about this one and the other ones are fairly obvious, you know, even the common type, you know, especially nowadays with the internet and symptoms and you know, symptom quizzes and you know, conditioned quizzes and things like that, people can usually figure those things out fairly easy. This is the one that even for us sometimes becomes a little confusing because it doesn’t fit into the name of it for one concealed PCOS. You would never classify this one exactly as PCOS. It’s just like you said, those high androgens and some of the other things that are similar to the other 2 the classic and the common type. So we understand that the name might not be perfect, but it’s not exactly PMS. It’s not exactly perimenopause. It’s kind of a, in some ways it’s almost like a hybrid between the two of those but because of those high normal androgens, we can sort of attach it to the common and the classic and it makes, at least in our brains, it makes sense to do that.
Dr. Davidson: Exactly. And you do see, we kind of call it like I guess adrenal derived PCOS because it is coming from the adrenals as opposed to the female reproductive hormones. But at the same time, the reason why we broke it down this way. And the reason why I love working with women that have that concealed PCOS is we’re still doing some of the same things that you would do with the classic and the common. And then you just interject a little bit with the adrenals at the same time and they do great. You know, it’s like you’re coming at it with the, you know, the right treatment plan as opposed to, you know, a shotgun and hopefully, I hit the target. This is where, okay, we’re streamlining it. We know exactly what we need to change. We have our objective data, we have our subjective data and we have it really more of kind of like a sharpshooter on what we want to get done.
Dr. Maki: Yeah. Right. As opposed to taking a prescription or supplementation or something for kind of broad strokes. This is a, you know, there’s enough information there to be able to pinpoint and then hopefully there’s an improvement on some of those numbers, like you said, lowering a testosterone from 41 to 32, which may seem very subtle and not really, you know, like that’s really going to do that much. But you know, testosterone for women is a very powerful hormone, getting some kind of a change at least that way you know that you’re going in the right direction. And usually there is a, at least some level of clinical improvement, they’re going to feel better in some respects.
Dr. Davidson: Yeah. Working on that cortisol, working on the insulin. So you’re kind of coming at it from a few different angles, but really, you know, it really gets it right on that bullseye. So I do think, you know what, you know, like we always say PCOS is a spectrum of this, of symptoms. It’s a spectrum. You might have all the symptoms, you might have some of the symptoms you might have very just a little bit. So, that’s why you wanted to break it up because everybody is a little bit different.
Dr. Maki: Yeah. So hopefully this gives you some insight certainly this one, the concealed type is really the most confusing and this is the one also, conventionally, you’re not going to get a diagnosis of PCOS with these types of symptoms, even if you have the high normal DHA and androgens because again, conventionally, if the numbers are normal, then you don’t have something. Okay? That’s why you have to, you know, understand and look at the subtleties. And this one really is a lot about how they present a lot about their subjective symptoms, their emotional state, their, you know, their mood, all those things. And then a little tiny little little pieces of objective information in their labs that kind of points you in that direction. And as like you said, it’s enough to help you focus on, you know, working on those adrenals and they usually you know, they respond fairly well that way.
Dr. Davidson: Yeah. Cause you don’t necessarily see the lower thyroid function like you do in the classic and the common, but they will have low levels of T3. Their T4 is great, their TSH is fantastic, but they have low normal to low levels of T3. That’s pretty common with the concealed, that LH FSH ratio we talked about in the previous episodes, the luteinizing hormone to the follicles demining hormone ratio. You don’t see the LH as high as the FSH like you do in the classic of course. And even the common has a little bit higher LH to FSH.
You might not see this here but or it might be just a touch or doing the blood work over time. You notice that LH tends to trend a little higher than the FSH for this person because we have patients that we’ve had for, you know, 15 years and I have in, which is awesome. I have 15 years of blood work that I look at to see how are things changing because I always tell them we want things to get better, you know? Right? As we’re getting older we want things to get better. So it’s great to have all that objective data to watch that through. But like Dr. Maki said, the concealed is very slight at, you know, almost like slight of hand. It’s not picked up on that easy, but you can put it together. So that is, you know why we wanted to talk about this on the podcast.
Dr. Maki: Yeah, well in some ways it’s not going to be picked up on because it’s not really a true diagnosis, you know? So it’s in some ways it’s kind of like a hybrid diagnosis that we’ve come up with over the years because it doesn’t fit into the any of the other categories. So again, like I said a few minutes ago, it’s maybe not the best name. I think the concealed is a great name, concealed PCOS, but just the fact that we’re categorizing it in pieces the only real reason why we’re doing that is because of those high normal androgens.
That’s the commonality between the other two types. In some ways this one is its own situation or its own syndrome or problem, but because those lab values tend to be somewhat similar and how they present, like some of their symptoms tend to be somewhat similar. That’s why we decided to include it into the PCOS umbrella anyways, so. Hopefully that shed some light, hopefully you’ve identified if you’re listening to where you are on that, on the three different types, I’m sure that that was fairly easy to do based on what we talked about, you’re probably resonating with one of the three types. If you would like more information, you can visit our website progressyourhealth.com. You can enter your email right there on the homepage. There is a free hormone video course there we go through similar profiles. We have a PCOS profile, we have a hyperthyroid profile. We have a perimenopause and a menopause profile where we talk about actual patients, not, you know, we saved their identity. We don’t talk, you know, we don’t give their any identity away, but we have, you know, a fictitious names and a very specific profile for each one of those. So if you’re interested, you can download that. Just enter your email, you get direct access right away. Dr. Davidson, do you have anything to add to the concealed type?
Dr. Davidson: No, no, no. This was great. Thank you.
Dr. Maki: Yep. Until next time, I’m Dr. Maki.
Dr. Davidson: I’m Dr. Davidson.
Dr. Maki: Take care. Bye bye.
Dr. Davidson: Bye now.