What are the common four phenotypes of PCOS?

Phenotypes of PCO women :: This is important 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) Type-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-insulinmic 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. Piconate, iv) Nac, v) Vit-D à preferred initial agent will be drugs to combat IR not the Ovulogens).

b) hyperandrogenaemia /Normo-androgenic women –If hyperandrogenaemic: -- TR by OCP / Pre Tr. With Inj Agonist in mid luteal phase/ Progesterone

c) Eumneirrhoic or oligomenorrhoea woman –If history is oligomenorrheicà  Primary agent of Ry will be CC/Anastrazole/ Gonadotrophins in cases who are oligomenorrheic.

d) Fertility restoration seeking women --who demonstrate unusual raise value of DHEASO4/ T4:- to find out source of Testosterone by special tests-ACTH stimulation tests, Serum cortisol etc, 17-OH P etc.

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. Etc.

Therefore my proposition to Forum members is to diagnose or pinpoint the exact pathology the candidate is suffering from instead of putting her in a broad category of PCOS which encompasses any many many metabolic/ hormonal abnormalities, for example a woman may be designated as a) normo insulinaemic, b) hyperandrogenic, c) oligomenorrheic d) normal weight e) anovulatory woman instead if labelling her PCOS. What is the view f Forum members about such stratifying in initial diag work up? The limitations are initial high cost of Lab tests and difficult to interpret the Lab values of insulin / Testosterone. Unfortunately the Lb methodology of these two hormonal parameters (Insulin/ T4) has not been standardized.