PCOS isn't one condition — it's at least four different patterns that happen to share irregular cycles and androgen excess. Treating all of them the same way is why so many women cycle through the pill, metformin and spironolactone without lasting change. The right protocol starts with identifying your subtype.
The four PCOS subtypes
Most women have one dominant pattern with a contribution from the others.
- •Insulin-driven (most common) — high fasting insulin, low SHBG, often weight gain
- •Adrenal — high DHEA-S, often lean, stress-driven
- •Post-pill — temporary rebound after stopping hormonal contraception
- •Inflammatory — driven by gut, food sensitivities or chronic stress
The panel that identifies subtype
This is the minimum that lets us actually distinguish them:
- •LH and FSH on day 3 (ratio matters)
- •Total testosterone, free testosterone, SHBG
- •DHEA-S
- •AMH (often elevated in PCOS)
- •Fasting insulin and HbA1c
- •Thyroid (TSH, free T4, free T3, TPO antibodies)
- •Prolactin and 17-OH progesterone to rule out look-alikes
What changes when you know the subtype
Insulin-driven PCOS responds to nutrition, strength training, sleep and sometimes inositol or metformin. Adrenal PCOS needs stress recovery and sleep — not blood-sugar protocols. Post-pill usually self-resolves with support. Inflammatory PCOS needs gut and diet work. Same diagnosis, completely different protocols.
Frequently asked
Yes. The diagnostic criteria require two of three: irregular cycles, signs of androgen excess (physical or lab), and polycystic ovaries on ultrasound. Two-out-of-three is enough.
Ideally yes — the pill suppresses LH, FSH and free testosterone, and changes SHBG dramatically. Three months off gives a true picture.