There are three main types of PCOS that we have seen treating patients since 2004. As you have heard from the past podcasts, PCOS is a spectrum of symptoms. It is a spectrum of symptoms coming from a set of hormonal imbalances. Every woman with PCOS might have some to all to a few of the symptoms of PCOS. That is because there might be varying degrees of hormonal imbalances.
While there might be some disagreement, there are three types that we have encountered the most. And each of these three have different goals and treatment plans.
These are the main types we have seen in treating patients with PCOS. As I mentioned before, PCOS is a spectrum. There can be some women that have all the symptoms to others that have just a few. This is a key concept for treatment. Someone with many symptoms is going to have a completely different treatment plan than someone that has some of the symptoms.
The three types that we commonly see, we have named: CLASSIC, COMMON, and CONCEALED.
Classic PCOS: Honestly, this is not seen that often. A Classic-PCOS, you will see all of the symptoms.
- Dark facial hair
- Chronic cystic acne.
- Thin hair, especially the top of the head and temples
- Weight gain–being it is super easy to gain weight and what feels like, impossible to lose
- High blood pressure
- High cholesterol
- High blood sugar
- High insulin: leading to insulin resistance and possibly diabetes, if not already diabetic.
- Terrible carb cravings, especially for sugar.
- Miss multiple periods for consecutive months in a row. They might get maybe two periods a year.
- These are the women that have many cysts in and on their ovaries. They have the ‘Classic’ string of pearls visualized on a transvaginal ultrasound.
You will see the full gamete of the blood work readings:
- LH to FSH ratio is 2:1 or even more
- High levels of testosterone: well above the normal levels. You can see the testosterone anywhere up to 90 or more
- No progesterone levels
- Normal levels of estradiol and sometimes there can be higher levels such as Estrogen-Dominance from the conversion of testosterone to estradiol.
- High DHEA-sulfate
- High insulin, high teens to well over 20
- High blood sugar and Hemoglobin A1c
- Hypothyroid/low thyroid function
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 063 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: I’m Dr. Davidson.
Dr. Maki: So on this episode we’re going to continue our series on PCOS. The first two we did on the– basically, what is PCOS. The last one was on the diagnosis of PCOS, looking at some of the lab values. This one is going to be the first one of the next three, looking at the different types of PCOS.
Dr. Davidson: So, we’ve been dealing with patients since 2004 with PCOS. We’ve actually found that as a lot of other practitioners have as well is that PCOS isn’t just either you have it or you don’t. It’s almost like a spectrum of symptoms where some women might have all of the symptoms. Some women might have just a few of the symptoms. So, what we’ve seen since 2004 is kind of three different types of PCOS that we want to break that down and tell you a little bit about because these different types are going to have different symptoms, different health goals and different treatment plans.
Dr. Maki: Yes. Right. The conventional approach—oh, with a lot of the things that we do with patients is that the conventional approach really isn’t really all that great. Metformin, a couple of other prescription–
Dr. Davidson: Birth control pills.
Dr. Maki: Yes. Right. None of that really helps them get any better. It has to be– now granted, we might use some prescription. Some of those might be part of the different treatment plans. But there needs to be more to it than just Metformin or birth control pills that’s not going to really solve anything. I think that’s where some people that have– some women that are struggling with PCOS, they get a little frustrated because those conventional approaches really– there’s a lot to be desired with them because it really doesn’t solve much of anything.
Dr. Davidson: Exactly. Actually if you go online and on the famous Google is you’ll see that there are a lot of doctors or practitioners that talk about PCOS. There might be other types that they develop, too. So, these three that we’ve come up with are the ones that we typically have seen. So, we’re just going to break that down in a three part series for you.
Dr. Maki: Yes. The point of that whether you– have you done some– now granted, if you think you have PCOS or you know you have PCOS you probably done lots of research. So you might have seen that there’s other types. The point of it is whether it’s our types or someone else’s types, the point is that we all feel that there are multiple types of PCOS. Again, usually from a symptom picture and a diagnosis perspective, there is a spectrum from low to moderate risk or severity to a high level of severity. We’re going to– hopefully get that across over the next three episodes.
Dr. Davidson: So, the three types that we have seen is we call them classic, common and concealed.
Dr. Maki: Yes. Right. So, the classic is kind of the name would emulate is this is– if you’re going to look in a textbook, a gynecological textbook and you’re going to look up PCOS, these are the things that you would expect to see in there.
Dr. Davidson: Then we have the common which is, I guess, you could say like medium and then the concealed which really isn’t found that often. So, we’re going to break these three types up into three different podcasts so that we can really kind of hash it out a bit.
Dr. Maki: Yes. Right. So, the classic in some ways, you could say is, like I said, if you looked up in a gynecological textbook, that’s what would be in that textbook. They would have many– maybe not all, but they’d have many of the symptoms listed there. Once that we talked about a couple of episodes ago. So, they might have– on an ultrasound, they might have the string of pearls or multiple cysts. They might have the facial hair in areas where they don’t want which is also called Hirsutism. They might be struggling with an acne issue.
Dr. Davidson: Those of course, if you’ve been listening to the previous podcast or coming from a lot of having those higher androgens. Honestly, the classic, like if you looked it up in a dictionary and you have all these, the classic symptoms. But it’s not that common. Honestly, we don’t see classic PCOS that often. But that’s what a lot of the doctors are saying is PCOS, so that’s why a lot of people get missed. But they do. They have the full monty of symptoms when it comes– for the classic PCOS. Like you said the dark hair, the dark facial hair. But unfortunately, they’re losing it on their head and they’re growing it elsewhere. They have the cystic acne. Definitely, probably the weight gain is probably the worst for the classic.
Dr. Maki: Yes. Right. They might have a weight range somewhere between, let’s say, 175 to 225. They also are the ones that have the absolute hardest time trying to get that weight to come off. A lot of them– a lot of women that have the classic types are, a very disciplined there. It’s not a matter of—you know, sometimes they know that when it comes to weight issues there’s this stigma or prejudice or whatever it is. But they, a lot of times are working the hardest, to try to get their weight to change. It’s almost like no matter what they do, the scale doesn’t change at all.
Dr. Davidson: Yes. So easy to gain and so impossible to lose. Granted, because of the levels of hormones being imbalanced, there are a lot of cravings. I mean, don’t get me wrong, there are a lot of sugar cravings and carb cravings but like you said, the classic PCOS women, they are disciplined and they are working so hard and I can understand where it’s frustrating to have such trouble losing the weightiness, so easy to gain when you’re looking at your friend next to you and they’re eating pizza and ice cream.
Dr. Maki: Yes. Now some of that is the approach that people take, right? Some of them, they are trying to eat less, exercise more. So, they’re going on a diet and exercising a lot. We’re going to talk about that more in subsequent episodes because if for that, for the classic type PCOS, that eat less, exercise more approach could actually make the entire situation worse. So, you have to be a little bit careful and you have to know what is best depending on some of these variables. You certainly might see, very classically, high blood pressure, high cholesterol, high blood sugar and maybe even high insulin. Right off the bat, that kind of paints that picture, that very specific PCOS picture.
Dr. Davidson: Yes. That’s that triad that we mentioned earlier in the previous podcast is that cholesterol, the triglycerides are elevated, the blood sugar could be elevated and then you’ll also see that high insulin which leads to insulin resistance and also is a risk of course for diabetes type 2, if they don’t already have diabetes type 2. Because it’s pretty common for the classic PCOS women to eventually get diabetes type 2.
Dr. Maki: Sure. Yes. Now, they might not get diabetes in their 20’s because they’re only in their 20’s. But as time goes on and that problem continues and progresses and progresses and progresses and the person becomes more insulin resistant, then it eventually develops into a problem like that. So, part of it in the beginning is age kind of protecting you. Your body just hasn’t really quite become that dysfunctional yet. Which is why sometimes diagnosis isn’t really made early on. But as that is left to continue, it just gets worse and worse over time. When it’s that hormonal problem like that in American society is very, very much kind of a hormonal nightmare sometimes. They just kind of tend to get worse and worse and worse as time goes on.
Dr. Davidson: Exactly. They’re always, “Hey, we’ll fix it when it’s broken.” We’re, “No. We want to prevent it.” We see this in someone in their 20’s, we want to prevent that diabetes type 2. Then just like Dr. Maki had mentioned, if you’d did a transvaginal ultrasound, looking at the ovaries, you’ll see that classic string of pearls which are really all these little cysts that have developed, which then on the flip side, if you’re making that classic string of pearls of that that chronic cystic, polycystic as they call it PCOS, Polycystic Ovarian Syndrome, that’s going to reduce if not make your ovulation to zero, which then creates that infertility.
Dr. Maki: Yes. Right. That underlying piece is the part that needs to be somewhat focused on. So, that way eventually pregnancy is a possibility. I know that these are– I think– not I think, but PCOS, this classic type is probably the number one reason for infertility. That’s why we’re talking about this as well because even the common and the concealed type can certainly play a role into that. If you’re struggling on the fertility side, this might be the reason why. So, that can be very one, very frustrating. But also very important to help someone to be able to achieve that goal of getting pregnant, staying pregnant and having a baby.
Dr. Davidson: Yes. Balancing those hormones because typically with the classic PCOS, these women will miss periods for three months, six months. They might get two periods a year. They are the ones that are continuously missing periods.
Dr. Maki: Now, there might be some other– a mood related things going on. Certainly a high level of irritability. Now, that’s a very subjective thing. But certainly it’s an emotion, if you want to call irritability an emotion, something that we hear a lot from patients that they’re– just the littlest things. They have a short temper. They have a short fuse. Small things tend to set them off. We see that in some of the other female hormone related things. But certainly in PCOS, there’s– irritability is one that we get a lot of feedback on.
Dr. Davidson: Yes. You think high estrogens, high testosterone, they’re going to feel testy. They’re going to feel irritable. But at the same time, we also see which isn’t shown so much in the list of symptoms, if you look it up on the web is always with the classic PCOS women is we always see anxiety. I don’t– either it’s– because I do think higher levels of insulin can create anxiety, having higher levels of androgen, having low levels of progesterone really contributes to anxiety. But there is a lot of kind of that anxiousness or they’re feeling really wound up.
Dr. Maki: Yes. Definitely, I think those two are very common. You did mention, of course, which again is kind of where part of that cycle continues. They have terrible sugar and carb cravings, that can kind of continue to all the things we just mentioned, kind of exacerbate all of them over time. It’s not a matter of– honestly, again, part of that stigma and the prejudice that happens sometimes is not a matter of they don’t have any willpower. Their hormones are kind of driving some of that behavior. So, then it kind of disempowers them. It makes him feel bad about their self. Really it’s just their hormones that are driving a lot of that behavior.
Dr. Davidson: Like Dr. Maki is saying, willpower, they have lots of willpower. But biology will always overpower. I guess, overpower willpower. But truly, that biology will always win in the long term. But you can balance those hormones. That’s the whole goal is to rebalance those hormones whether you’re doing it, partly with medication or supplementation or changing their dietary or lifestyle. Change that. So then, when you change that biology, then it makes it easier to make the changes that you want to.
Dr. Maki: Yes. Right. With a such a complicated issue as PCOS, all the different types of PCOS, all those things you just mentioned, that multifactorial approach is the point, right? All those things have to be addressed. The lifestyle, the diet, the supplementation, possibly prescriptions, all those things have to be looked at. That’s how we create treatment plans around those types of things because you can’t just take Metformin or birth control pills and expect these kinds of complicated issues to be able to either be reversed or improved or whatever the case might be.
Dr. Davidson: Exactly. When you do the bloodwork with a classic presentation here is you see– like we had talked about in the previous podcast, all those labs and testing that we talked about, they have it all. They definitely have it all. That LH, FSH ratio, the luteinizing hormone to follicles stimulating hormone ratio, you’ll see that two to one. Their LH might be at 14 and their FSH is at seven or their LH is at 20 and their FSH is at 10. You see that classic two to one ratio. With the testosterone levels like we had talked about before is they definitely have well above normal levels of testosterone. They’re anywhere 45 to 90, maybe even more.
Dr. Maki: Yes. Right. I’ve seen plenty of testosterone levels in the– the high 90’s to even over 100. I’ve seen DHA levels in the 500 range before. Those are– I wouldn’t say, like you said, I wouldn’t call them necessarily that common to see numbers quite that high. But they can certainly get up there fairly easily. Usually when they have those type of androgen numbers, like you said, those other tests, the triglycerides, the fasting insulins, the cholesterol, all those things are going to also be abnormal as well. So, when you look at the entire blood panel, it’s going to really point you in one particular direction fairly easily.
Dr. Davidson: Exactly. You’ll see the low to no progesterone levels. Then one thing that we love to test on all women, not just PCOS, but all women is checking for the thyroid function. You always see hypothyroid or low thyroid function in that classic type. So, it’s really important to keep an eye on their thyroid all the time.
Dr. Maki: Yes. Right. Granted, thyroid is not a female hormone. But as we talked about on the last episode, thyroid function– improving thyroid function has a dramatic impact on the female cycle. So, you can use a different hormone to have an impact on the female hormones and that can be– we kind of look at them as you have your primary metabolic hormones, the hormones your body can’t live without, right? You have your insulin, your cortisol, your thyroid. There’s a few other ones. But those are the ones that most people know. Then you have your secondary hormones, which are the female hormones and some other ones. Usually in most instances, the primary metabolic hormones always influence the secondary sex hormones. But not necessarily so much the other direction. Sometimes, like you said, you’re giving a woman some estrogen, you’re giving her some progesterone. Maybe a little– men giving them some testosterone. But it’s usually the influence of those primary metabolic hormones having the impact on the female hormones. That’s why PCOS, as we’ve been talking, it’s really an insulin issue but it manifests as a female hormone problem. That’s why it gets– that’s why the treatment aspect of it gets kind of convoluted or is just really ineffective because they’re focusing on the wrong part.
Dr. Davidson: Exactly. So kind of think of it, like the thyroid and the adrenal glands are upstream from the female reproductive hormones. So, instead of chasing your tail with trying to correct these female reproductive hormones, you definitely want to go upstream, balance those hormones first and then later, I kind of call, like the reproductive hormones kind of like the frosting on the cake. You got to correct that thyroid. You got to work on those adrenal glands, so then you’ll have your base. You have your cake and then you can add a little– the frosting on top with balancing up that estrogen, raising up that progesterone. But definitely always working upstream is where we want to start.
Dr. Maki: Yes. Now, the thyroid part is fairly easy to implement whether we’re doing supplementation or prescription. But the insulin, the cortisol, that’s the hard part. That is the really the essence of not just PCOS but a lot of conditions are, we could blame them on insulin and cortisol dysfunction. But there really isn’t a lot of– there’s– one, there’s no prescriptions for them specifically that manipulate them in a good way. Metformin, as we talked about, that has an impact on insulin sensitivity. But even that falls short very quickly, even in diabetes treatment. It works but it doesn’t– I think Metformin in general is a fairly– I think it’s a good medication. I think– we prescribe it ourselves. But I think when you just focus on that one thing, I think that’s where– there’s lot to be desired with that. There’s so much more of that that can and should be done to help a patient like this.
Dr. Davidson: So, while I mentioned, you don’t see the classic, a full Monty here are the classic PCOS that often. But when you do, I really think that they are underserved because there really isn’t a good conventional treatment model for them. Which is why we’re so passionate about it.
Dr. Maki: Yes. That’s why we treat the things we treat because we’ve seen, over the years, people come to us for these types of reasons or these types of complaints. Our job is to help our patients achieve whatever it is they’re trying to achieve. Whether it’s weight loss, whether it’s pregnancy, whether it’s just to feel better, all those things and they’ve already been down that conventional route and they just haven’t gotten anywhere. Whether they haven’t gotten a diagnosis or not. So now, it’s our turn to step in there and hopefully get things turned in the right direction. So, if you’d like more information about us and our approach, you can visit our website progressyourhealth.com.
You can enter in an email. You can actually get access to our free hormone video course, where we go through a few of these profiles. One on PCOS, one on hypothyroid. I think there’s another one on perimenopause and menopause. It’s Dr. Davidson on videos, so you get a chance to see and listen to her, have some very good information, things that you might have either heard before but kind of condense down into a very easily digestible way. The videos are relatively pretty short but packed full of good information.
Dr. Davidson: Now, I’m blushing. Yes, you get to see me on the video, talking away. But it’s a good course. We’re proud of it. Definitely go to the website and you can download it. It’s free. But for this podcast, we talked about the classic PCOS. For the next two, we’re going to talk about the two types which is common and concealed.
Dr. Maki: Yes. So, I think that wraps up this one. The next episode we’re going to talk about the common PCOS. Common and classic might seem fairly similar. But we’ll kind of hash those out and hopefully you’ll have a better understanding of the difference between the two. So for this one, I’m Dr. Maki.
Dr. Davidson: I’m Dr. Davidson.
Dr. Maki: Take care. Bye-bye.
Dr. Davidson: Bye.