By Dr. Alexsia Priolo

Between 8-13% of women live with polycystic ovary syndrome (PCOS). This is a complex condition involving reproductive, metabolic and psychological features.

PCOS is considered a syndrome, because it doesn’t always present the same among all individuals – there are multiple types. In fact, in order to be ‘diagnosed’ with PCOS, you must have at least two out of three symptoms as laid out by the Rotterdam criteria:

1. Delayed ovulation or irregular menstrual cycles (anovulation)
2. High androgenic hormones such as testosterone
3. Polycystic ovaries identified by ultrasound testing

Taking a deeper look at the Rotterdam criteria:

Delayed ovulation or irregular menstrual cycles
The truth is, we don’t always ovulate – even if your period app says you do. Rather than relying on information from your phone, you can pay attention to cues that your body is sending you. Being mindful of cervical fluid and basal body temperature during your period will help you understand if you are ovulating. Or, testing your serum progesterone levels 7 days after you ovulate will indicate if you’ve ovulated.

Irregular menstrual cycles can be identified as:

• Normal in the first year of having your period

• In the first 1-3 years of having your period: Less that  21 or greater than 45 days

• After having your period for 3 years: Less that 21 or greater than 35 days

• After having your period for 3 years: Less than 8 menstrual cycles per year

High Androgens
All women have male hormones, just like all men have female hormones. However, higher levels of male hormones may be problematic. High testosterone may contribute to acne along the jawline or back, growth of facial and body hair, alopecia (hair loss) in specific patterns.

A tool you can use to determine if you are experiencing changes in hair growth is the Ferriman Gallway score. The Ludwig visual score helps to assess the degree of alopecia. You don’t need to be exhibiting signs of high male hormones in order to have them. To determine if you have high androgens, you must get them tested!

Here’s what you should be asking your (Medical or Naturopathic) doctor to test:

• Free testosterone

• Total testosterone

• Androstnedione

• DHEAS

Polycystic Ovaries
As mentioned earlier, you don’t need to have ovarian cysts to have PCOS. That said, to determine if you have cysts, a transvaginal ultrasound needs to be done. While criteria continue to change as technology advances, currently you need 12+ follicles that are between 2-9 mm or an ovarian volume bigger that 10cm in a single ovary.

An ultrasound should not be used for the diagnosis of PCOS in people who have only had their periods for less that 8 years. This is because, at this life stage, you may have many follicles in your ovaries.

The 4 Types of PCOS

Now that you have a better understanding of the diagnostic criteria you might be wondering about the types of PCOS I alluded to earlier:

Type A
Classified as:

• Hyperandrogenism

• Anovulation/irregular periods

• Polycystic Ovaries

Signs and symptoms include: increased BMI and weight circumference, highest androgen values, polycystic ovaries, increased LH/FSH, AMH, low progesterone, and menstrual irregularity. The Type A person may also be insulin resistant, potentially leading to an increased risk of diabetes and heart disease.

Type B
Classified as:

• Hyperandrogenism

• Anovulation/irregular periods

Signs and symptoms include: increased BMI, abdominal weight gain menstrual irregularity, physical signs of high androgens (eg. hirsutism, acne and alopecia). Insulin resistance is also a factor.

Type C
Classified as:

• Hyperandrogenism

• Poylcystic ovaries

Signs and symptoms include: medium BMI score, abdominal weight gain, increased androgens (eg. testosterone) and polycystic ovaries. While periods may be regular, ovulation may not be occurring.

Type D
Classified as:

• Anovulation/irregular periods

• Polycystic ovaries

Signs and symptoms include: menstrual irregularities, polycystic ovaries, androgen levels are normal (no physical signs of androgen excess), normal BMI, normal waist circumference may be signs of insulin resistance. This type is thought of as ‘lean’ PCOS.

Other considerations

Beyond looking at male hormone levels and figuring out if you’re ovulating, there are a couple of things to keep in mind if you have PCOS.

Type 2 diabetes/impaired glucose tolerance/gestational diabetes is increased in women with PCOS. Therefore, when you’re getting your male testosterone levels measured, you should also be asking for the following tests:

• Fasting insulin

• Fasting glucose

• These two tests will determine if you have insulin resistance, which is a key feature of PCOS. In addition, all women with PCOS are at higher risk for cardiovascular disease. Screening should include:

• Fasting lipid profile

• Blood pressure measurement

• Weight, height and waist circumference

Next Steps

Knowing the criteria for PCOS and the four types is a great start in determining if you might be living with PCOS. Although first line treatment is the combined oral contraceptive (eg. the birth control pill), there are dietary and lifestyle interventions that can make a difference.

Nevertheless, getting more information is key in understanding how to approach your specific PCOS type. Here are some ideas on how to move ahead:

• Track your period

• Find out if your body is ovulating (use your period app as a suggestion)

• Get your blood work done (Naturopathic Doctors can requisition blood work too!)

• Talk to your medical doctor about an ultrasound if either the first 2 criteria may not be an issue (ie. blood work is optimal)

For more information about PCOS or to learn if dietary and lifestyle interventions are right for you, consider speaking to a Naturopathic Doctor today!

References:

Teede, H., Misso, M., Costello, M., Dokras, A., Laven, J., Moran, L., Piltonen, T., Norman, R., Andersen, M., Azziz, R., Balen, A., Baye, E., Boyle, J., Brennan, L., Broekmans, F., Dabadghao, P., Devoto, L., Dewailly, D., Downes, L., Fauser, B., Franks, S., Garad, R., Gibson-Helm, M., Harrison, C., Hart, R., Hawkes, R., Hirschberg, A., Hoeger, K., Hohmann, F., Hutchison, S., Joham, A., Johnson, L., Jordan, C., Kulkarni, J., Legro, R., Li, R., Lujan, M., Malhotra, J., Mansfield, D., Marsh, K., McAllister, V., Mocanu, E., Mol, B., Ng, E., Oberfield, S., Ottey, S., Peña, A., Qiao, J., Redman, L., Rodgers, R., Rombauts, L., Romualdi, D., Shah, D., Speight, J., Spritzer, P., Stener-Victorin, E., Stepto, N., Tapanainen, J., Tassone, E., Thangaratinam, S., Thondan, M., Tzeng, C., van der Spuy, Z., Vanky, E., Vogiatzi, M., Wan, A., Wijeyaratne, C., Witchel, S., Woolcock, J. and Yildiz, B. (2018). Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertility and Sterility, 110(3), pp.364-379.