Understanding PCOS: Part 1 – What is Polycystic Ovarian Syndrome?

It’s a term you may have heard before, but with the amount of information swirling around the internet, it can be hard to define. And it’s understandable that you feel confused, overwhelmed, or downright lost when trying to understand it. 

It’s polycystic ovarian syndrome, or PCOS, and it affects nearly one in every ten women of child bearing age. 

Understanding PCOS is the first step in getting control of your condition, and that can mean learning a lot about things like cysts, insulin resistance, and the right nutrition and supplement options for you and your PCOS. In this four part series, we cover it all, from what PCOS is and the different types, to the relationship between PCOS and insulin, and how they’re all supported by your choices you make about your nutrition. 

What is PCOS?

Polycystic ovarian syndrome is a “common health problem caused by an imbalance of reproductive hormones” that can lead to the development of cysts on the ovaries and potential infertility in women. PCOS, though, is so much more than having cysts on your ovaries and in my opinion (and the opinion of many!), is a disease that needs a new name. As we’ve continued to learn more about this condition, we now know you can no longer diagnose PCOS simply by seeing cysts in an ultrasound.

There are actually 3 criteria that were created by leading experts in 2003. This is typically known as the Rotterdam criteria and, in order to meet the criteria for PCOS, you actually only have to have two out of the three. ⁣⁣⁣This is what created the types of PCOS that we’ll cover later, but is great for understanding why PCOS for one woman isn’t the same as another. 

Here are the criteria: 

  1. Delayed ovulation or menstrual cycles: Anovulation is defined as fewer than 10 menstrual cycles per year or cycles that are longer than 35 days. ⁣⁣⁣
  2. High androgens. This could be high androgens on labs (testosterone, DHEA, DHT, androstenedione) or the presence of acne, hair growth (chin, upper lip, chest, belly, nipples), or male pattern baldness. 
  3. ⁣⁣Polycystic ovaries: In order to meet the criteria of ‘polycystic’, an ovary has to have 12 or more follicles measuring from 2-9mm OR an ovarian volume larger than 10cm in one ovary. ⁣⁣⁣ This can be tricky because polycystic ovaries can occur with PCOS, but they don’t mean you have it. Research has shown that healthy women have polycystic ovaries about 25% of the time. ⁣⁣That’s why ⁣it’s important to remember that polycystic literally means multiple follicles. Each month we grow new follicles and then one becomes dominant. With elevated androgen levels, like in PCOS, the follicles don’t develop properly and ovulation doesn’t occur. This leads to hormone imbalances and a lot of unwanted symptoms. ⁣⁣

When it comes to cysts, there can also be a great deal of confusion surrounding the presence of cysts found on an ultrasound. Not all cysts found on an ultrasound are ‘true’ ovarian cysts, and many otherwise healthy women will develop cysts separate from PCOS. 

Just like PCOS, there are different types of cysts that may be found on ultrasound. 

  • Functional cysts are one of the most common types of cysts. These large, fluid-filled sacs normally resolve on their own. They are common and can happy in healthy women as well as those with PCOS. There are typically only one or two present, unlike the many cysts that occur when they are true PCOS cysts. 
  • Complex ovarian cysts are large cysts that can contain a number of different types of cells. They may even contain blood or other tissue, and are often benign. Unfortunately, they can become painful when they grow too large, but there are typically only one to two present, as well. 
  • PCOS cysts aren’t true cysts like functional or complex cysts. Instead, the cysts in PCOS are really follicles that were unable to develop fully due to high levels of androgens and insulin. Instead of one of the follicles becoming the dominant follicle and leading to ovulation, all of the development of the follicles stalls and you get the appearance of cysts. This also prevents ovulation. 

What Causes PCOS?

There are a number of things that contribute to PCOS, but when it comes down to it, Polycystic Ovarian Syndrome has a few main contributing factors, including high androgens and elevated insulin. High androgens are what stalls the growth of the follicles and delays ovulation. Anovulatory cycles are what then lead to hormonal imbalances and, subsequently, symptoms of PCOS. 

Chronic low grade inflammation that occurs with PCOS causes the body to be less sensitive to insulin. This means we need to release more insulin in order to get the same amount of energy in our cells, which can be damaging not only to our ovaries but also to the rest of our body. 

These two factors are also connected. High insulin levels irritate our ovaries and cause them to release more androgens. Then, the androgens cause the anovulatory cycles, making the process cyclical and tough to beat. 

PCOS is truly a condition of high androgens. Just like with any disease, it’s important to rule out other conditions that may be causing your symptoms. For PCOS, that means ruling out other conditions that can cause hormonal imbalances such as high androgens or other symptoms in polycystic ovarian syndrome. 

Conditions that also cause high androgen include high prolactin, hypothyroidism, and pituitary or adrenal diseases, though this is rare. Androgens can also be high after getting off of birth control, known as ‘Post Pill PCOS’, or when coming off of certain psychiatric medications. 

Outside of the medical conditions that can cause high androgens, there are also other reasons you may have higher than normal androgens outside of (or in conjunction with!) PCOS. These include chronic stress, inflammation, nutrient deficiencies, sluggish liver, low stress hormone binding globulin, poor diet, and kidney issues.

Types of PCOS

One of the biggest challenges when it comes to understanding PCOS is knowing that no two women are exactly alike and, because of that, neither are their diseases. While everyone experiences PCOS differently, there are four main types of polycystic ovarian syndrome that most women fall into. 

  1. Type A: Also known as “Classic PCOS”, this is the most severe type of PCOS and is often driven by insulin resistance. ⁣⁣⁣⁣⁣⁣⁣⁣⁣Many women with this type carry weight around the midsection and may be overweight, but you can still have this type of PCOS and be lean. Most women with this type of PCOS have irregular periods, often low progesterone, and may have acne/hair growth or loss. ⁣⁣⁣⁣⁣
  2. ⁣⁣⁣Type B:⁣⁣⁣⁣⁣ ⁣⁣⁣⁣⁣This type is similar to type A, but there are no cysts on the ovaries. ⁣⁣⁣⁣⁣⁣⁣⁣⁣Cycles are still irregular and women that have this type often have acne/hair growth or loss. ⁣⁣⁣⁣⁣
  3. ⁣⁣⁣⁣Type C: With “Non Classic PCOS”⁣⁣⁣⁣⁣, ⁣⁣⁣women tend to have moderate values of androgens, be less overweight than type A, & have a moderately-high waist circumference. ⁣⁣⁣⁣⁣⁣⁣⁣⁣But remember, that’s not always the case. Lean women can also have this type. ⁣⁣⁣⁣⁣⁣⁣⁣⁣The big difference with this type is regular cycles, however women with this type should be cautious in assuming they are ovulating and it’s highly recommended to confirm ovulation with BBT, as research has shown that this type only ovulates a percentage of the time. ⁣⁣⁣⁣⁣
  4. ⁣⁣⁣⁣Type D: ⁣⁣⁣⁣⁣⁣⁣⁣⁣This is where the controversy starts. Type D is when you have polycystic ovaries and irregular cycles, but you don’t have high androgens. ⁣⁣⁣⁣⁣⁣⁣⁣⁣⁣This is when you have to rule out other possibilities in order to confirm you have PCOS.⁣⁣⁣ Typically lean women without high androgens or signs of high androgens fit into this type. ⁣⁣⁣⁣⁣⁣⁣⁣⁣Some practitioners do not recognize this type of PCOS, but if you compare their levels of androgens to women without PCOS they are still higher. ⁣⁣⁣⁣⁣

Wrapping It Up

It’s easy to see why there is so much confusion surrounding polycystic ovarian syndrome, and why women can feel lost when looking for answers for their symptoms. The good news is that, with understanding, there are options for managing PCOS along with the help of a qualified provider. 

The first step in figuring out how to control your symptoms is understanding the root cause of your condition, and functional lab tests can help you do just that. My Functional Lab Testing packages do just that! This comprehensive dried urine at home hormone test measures all sex hormones, stress hormones and cortisol pattern, B vitamins, and more. Order yours on my website at https://www.hormonehealingrd.com/functional-lab-testing and get not only your test but also a video results review from me!

In our next part, we’ll talk about insulin and its effect on PCOS. Find the link to the next post here.

Amanda Montalvo

Amanda Montalvo is a women's health dietitian who helps women find the root cause of hormone imbalances and regain healthy menstrual cycles.

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