What are the common four phenotypes of PCOS? This is important at least for treatment purpose because till date the treatment of PCOS is mostly empirical and symptom-based As such scientist and reproductive biologists have classified PCOS into four broad phenotypes, though there are many other phenotypes of PCOS. Total 43 phenotypes have been classified by some International Organizations and also by “Androgen Excess and PCO society”. However for day to day clinical practice the following classification seems to be more meaningful.

What are the common four phenotypes of PCOS? This is important at least for treatment purpose because till date the treatment of PCOS is mostly empirical and symptom-based As such scientist and reproductive biologists have classified PCOS into four broad phenotypes, though there are many other phenotypes of PCOS. Total 43 phenotypes have been classified by some International Organizations and also by “Androgen Excess and PCO society”. However for day to day clinical practice the following classification seems to be more meaningful.

a) Phenotype-I PCOS -> Characteristic will be i) Oligomenorrhea/sometimes Secondary Amenorrhea; ii) USG will show evidence of PCOS or PCOM, iii) evidence of hyperandrogenism, iv) Hyperinsulinaemia woman / Normo-insulinoma woman. In 37.5% of such type-I cases there will be clinical and laboratory metabolic syndrome. In fact this is the commonest phenotypes of PCOS as high as 65.6% of PCOS women. If there is documented hyperinsulinaemia then the doctor should seriously consider the Insulin sensitizer has the first or initial drug of choice like i) Metformin, ii) Myoinositol & other isomers, iii) Chr. Pico ate, iv) NAC, v) Vit-D à preferred initial agent will be drugs to combat IR not the Ovulogen).

b) Phenotype-II: This comprises i) Oligomenorrhea,  ii) USG evidence polycystic ovary or PCOM, iii) usually Normo-androgenic women  and 10% will have associated metabolic syndrome (they will need judicious administration of lipid lowering agents) – If at all hyperandrogenaemia then it’ll be better to treat them by OCP as an initial drug. If they seek fertility treatment then it will be prudent to prescribe Pre Tr. with Inj Agonist in previous mid luteal phase or pre tr. with Progesterone, Inj. Progesterone for consecutive five days followed by gonadotrophin Inj. and IUI. All these information’s are mentioned so that many of us don’t unnecessarily carry on with Clomiphene or Letrozole for months together which will be futile induction. Therefore before we prescribe CC or Letrozole it will be again good clinical gesture if some phenotypic classification is made well ahead and a planning a type of induction is rationally designed. These type-II cases are most likely to be CC resistance due to high insulin level. However the prevalence of type-II PCOS in India is about 22.2%.

c) Phenotype-III PCOS: Usually there is i) no Oligomenorrhea (Eumneirrhoic) or very rarely there can be oligomenorrhoea, ii) USG evidence of PCOS, iii) Moderate hyperandrogenism, iv) Minimal number of such PCOS women will have metabolic syndrome. The prevalence of phenotype-III will be only about 1% of PCOS women. –If history is Oligomenorrheaà  Primary agent of Ry will be CC/Anastrazole/ Gonadotrophins in cases who are oligomenorrheic.

d) Phenotype-IV: i) Oligomenorrhea+, b) Ovaries in USG usually normal pattern with normal echogenicity and volume, iii) hyperandrogenism+, iv) metabolic syndrome will be associated in 50% of phenotype-IV PCOS. In fact the prevalence of these phenotypes is 11.2% of all PCOS.

Tips-1: PCOS women seeking fertility restoration – tips for drug selection seeking women. At first one has to assess TSH, Purl. DHESO4. Now after estimating all these three hormones we have to supplement or suppress the hormone milieu. Suppose in there is isolated rise of prolactin hormone, dopamine agonist (cabergoline or bromocripitine) will suffice. But, who demonstrate unusual raise of DHEASO4 and/or T4 then my dear members it will be prudent to find out source of Testosterone by special tests like ACTH stimulation tests, Serum cortisol etc, 17-OH P etc.

Tips-2: If there is abnormal hair growth then she should ideally refer to an Endocrinologist and Cosmetic Surgeon if necessary. In these cases COC alone or in combination with Aldactone will hopefully suffice.

Tips-3: To note that most Obese PCOS, even average weight PCOS women will mandate Lifestyle modification, Exercise, Dietary Modification, Vit-D supplementation if serum level is low, Anti-oxidant to prevent onward vascular damage and only on few occasion some PCOS women will have to take Orlistat (if obesity but overweight women) and lipid lowering agents particularly if triglyceride levels are high.

Tips-4: For instance if LH is high and Ovarian Volume is > 12 CC³à then LOD (laparoscopic Drilling of ovaries) may be given priority to maximize the efficacy of Tr of ovulation   induction..

By contras if there is predominate hyperinsulinaemia in a clinically suspected PCOS then one should can allow fair trial with insulin sensitizers for couple of months without resorting Clomiphene /Anastrazole or gonadotrophin inj-not to speak of ART.

The beauty of insulin sensitizers is those such drugs but not all insulin sensitizers in addition to controlling plasma glucose but also reduce circulating serum   androgens. We should keep in mind that Letrozole reduces or should I say normalizes the ovarian bio synthesis of androgens—in the cortical tissue of ovaries).