PCOS Becomes PMOS: What's Changing?

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things reproductive health. I'm your host, Dr. Erica Newlin. This podcast is intended to help you better understand your health, leaving you feeling empowered to live your best. On each episode, you'll hear from our experts on topics such as pregnancy, fertility, menopause, and everything in between.

On today's episode, we're highlighting an important change in women's healthcare, the renaming of PCOS or polycystic ovarian syndrome, to PMOS, which stands for polyendocrine metabolic ovarian syndrome. This change reflects a growing understanding that this condition is about much more than the ovaries. It affects multiple hormone systems, metabolism, and long-term health. I'm joined by Dr. Mindy Christanson, Chief of Reproductive Endocrinology and Infertility at Cleveland Clinic, to discuss what PMOS is, why experts felt a name change was needed, and what this means for patients living with the condition. Thank you so much for joining me on the podcast, Dr. Christianson.

Mindy Christianson, MD:

Thank you so much for having me.

Erica Newlin, MD:

Before we start, can you tell our listeners a little bit about your role in the Cleveland Clinic and your background?

Mindy Christianson, MD:

Absolutely. So I'm a reproductive endocrinologist, so that means I did a residency in obstetrics and gynecology and then specialized training in reproductive endocrinology and infertility. So I am the medical director of the Cleveland Clinic Fertility Center, so I help a lot of patients with their family building goals. And I'm also the section head of reproductive endocrinology and infertility here at Cleveland Clinic.

Erica Newlin, MD:

And then let's start with the basics and unpack why this change is happening in the first place. Why was there a push to rename PCOS?

Mindy Christianson, MD:

There had been talk for many years about changing the name of PCOS and really because it was confusing for patients and it really did focus so much on the ovaries when it is so much more than just the ovaries. So for instance, a lot of patients may have an ultrasound and it may show a good egg supply. It may show a lot of follicles, which means that someone has a good egg supply, but then the report says polycystic ovaries and then patients automatically think they have polycystic ovary syndrome. So that was one example of how it can be confusing. And a lot of patients with polycystic ovary syndrome would think that they had cysts on their ovaries that needed to have surgery. So it really focused so much on the cysts on the ovaries and the follicles on the ovaries that that caused a lot of confusion when in essence, when someone's diagnosed with PMOS, it really is a lifelong disease and it's not just about the ovaries, it's about an increased risk of cardiovascular disease, it's about an increased risk of obesity, of insulin resistance and type two diabetes.

It has so many more long-term health consequences. That's really one of the main reasons for the name change.

Erica Newlin, MD:

For sure. I, as a general gynecologist, am very happy to see this name change. And I mentioned it earlier, but what does PMOS stand for? And you've alluded to it previously as well, but how does this new name better reflect the condition?

Mindy Christianson, MD:

So PMOS stands for polyendocrine metabolic ovarian syndrome. And so it's still referring to the ovaries, but it's referring to polyendocrine or multiple hormone systems within the body involved. So for instance, having insulin resistance and increased insulin levels and increased risk of diabetes is just one example. And also some patients may have increased androgen levels, that's very common, and have symptoms such as hirsutism or hair on the face or chin or in a male pattern. And so that's just examples of how other endocrine systems are involved.

Erica Newlin, MD:

And why is the name change considered significant for patient care?

Mindy Christianson, MD:

It's considered significant because how often do we have a very common disorder, a very common disease, polyendocrine metabolic ovarian syndrome or PCOS, I'm still stumbling with the name, affects five to 10% of women. And so it affects a lot of people, but then to change the actual name of a medical condition is a big deal. And so it was taken very seriously. There were multiple focus groups of multiple subspecialties, including medical endocrinology, reproductive endocrinology, obstetrics and gynecology, dermatology, cardiology. Multiple focus groups were held and patients were also involved. And so I think it really shows that there was a lot of thought put into this new name.

Erica Newlin, MD:

Now that we understand why the name is changing, let's talk about what PMOS actually is and how it affects the body. What are some of the most common symptoms that patients might experience?

Mindy Christianson, MD:

One of the interesting things about PMOS is it can affect people in different ways. For instance, a lot of times I will diagnose someone with PMOS because they're having infertility. They may have had irregular cycles their entire life and didn't think much of it, or they'd been on birth control pills for a long time due to having irregular cycles and were never officially diagnosed. So sometimes fertility is a main issue. Other times patients have very distressing symptoms such as hirsutism, as I discussed before, having hair in a male pattern or having hair on their face or chin that they need to have removed, that can be very distressing. A lot of patients may have challenges with obesity, really having trouble losing weight. So there's a lot of different ways it could impact patients.

Erica Newlin, MD:

And then many people associate PCOS with ovarian cyst. Does someone need to have cysts to be diagnosed with PMOS?

Mindy Christianson, MD:

Well, the diagnostic criteria for PMOS is currently the same as it was for PCOS. And so that's having two out of three things. So one is polycystic ovaries on ultrasound. The second is irregular cycles or not having periods, and so really having issues with the menstrual cycle. And then the third is having increased androgens. And so those can either be symptomatic increased androgens, so actually having the symptoms of increased testosterone or other androgens such as acne or hair on the face or chin, or having lab values reflective of that.

Erica Newlin, MD:

What are some common misconceptions that can delay diagnosis?

Mindy Christianson, MD:

Well, some things that can delay diagnosis, if someone had irregular cycles when they were very young and they were on birth control pills for many years, that's actually one of the main line treatments we use for PMOS. And so if someone had been on birth control pills, they were actually being treated for many, many years and that was masking the symptoms and also preventing the diagnosis. And so that's actually a very common scenario that may delay the diagnosis.

Erica Newlin, MD:

One thing many women think about when they're diagnosed with PMOS is how it might affect their ability to have children. Let's spend a few minutes talking about fertility and family planning. How does PMOS affect fertility?

Mindy Christianson, MD:

The primary way that PMOS can impact fertility is really by delaying ovulation or the patient just not ovulating at all or very frequently. And when most people are trying to conceive, they're trying to time intercourse around the time of ovulation. And so if someone's not ovulating regularly, if they have very long cycles or if they're very sporadic, that can make it very challenging.

Erica Newlin, MD:

We don't have to delve too much into the nitty-gritty, but why do people who have PMOS have difficulties with ovulation?

Mindy Christianson, MD:

Well, that really comes down to all of the different hormones that are into play, but basically if someone has PMOS, it's really a hormone imbalance. And so there's imbalance of the hormones that control the menstrual cycle. So because of that, the tiny little follicles on the ovary that are just sitting there, once every cycle, usually one of them is selected, one of those follicles grows and is the one that will have an egg grow and then release an egg at ovulation. But when people have PMOS because of that hormone imbalance, they're not able to have that follicle develop on a regular basis.

Erica Newlin, MD:

Does having PMOS automatically mean you'll have difficulty getting pregnant?

Mindy Christianson, MD:

Well, it really depends. There are patients that may have a very mild form where they may just have longer cycles or they may skip a couple cycles. And so these patients may conceive, it just may take longer. Other patients though, if they're not having periods at all, that obviously would make it very difficult for them to get pregnant since they're not ovulating.

Erica Newlin, MD:

Can women with PMOS have healthy pregnancies?

Mindy Christianson, MD:

For the most part, they can, and they do. Some of the issues though associated with PMOS, such as insulin resistance and having an increased risk of type two diabetes can carry over into pregnancy. And so when they are pregnant, they will have more screening for gestational diabetes.

Erica Newlin, MD:

When should someone with PMOS seek a fertility evaluation?

Mindy Christianson, MD:

In general, if someone is not having regular periods, that would be a good reason to either first see their OB/GYN or see a fertility specialist since that's really going to be a core issue. And that is one of the things that we evaluate on a regular basis.

Erica Newlin, MD:

What fertility treatment options are available for people with PMOS who are struggling to conceive?

Mindy Christianson, MD:

The good news is that for the most part, patients with PMOS are able to conceive with oral medications. We have oral ovulation induction medications such as letrozole or clomiphene citrate that will help people ovulate regularly. So I often tell people with PMOS that they actually are secretly very fertile because they have a good egg supply and we just need to help them ovulate more regularly.

Erica Newlin, MD:

What do you wish more women understood about PMOS and fertility?

Mindy Christianson, MD:

I think it's important for women to understand that having a diagnosis of PMOS is not just about the reproductive years, but it's really a lifelong condition. And the earlier someone is diagnosed, the more they can focus on these long-term health consequences and just being as healthy as possible to address those.

Erica Newlin, MD:

Are there any misconceptions about PMOS that might cause unnecessary fear or anxiety?

Mindy Christianson, MD:

I think that with the former name, there was a lot of misconceptions about having ovarian cysts and people would associate ovarian cysts with ovarian tumors. People would often tell me, "Well, I have ovarian cysts and that's because of my PCOS." But having a large ovarian cyst is very different than having the diagnosis of PMOS.

Erica Newlin, MD:

Because PMOS affects so many aspects of health, getting the right diagnosis and understanding potential risk is incredibly important. So let's explore that next. You mentioned the diagnostic criteria for PMOS, but how is PMOS diagnosed?

Mindy Christianson, MD:

So generally someone will present with some of the core symptoms such as irregular cycles and then they'll have a full workup for that symptom. So if someone's presenting with irregular cycles, we have certain labs that we check, and it's important to know that PMOS is going to be a diagnosis of exclusion. And so if someone had a thyroid disorder, for instance, if they were hypo or hyperthyroid, that can cause irregular cycles. So that would have to be normalized first before giving someone the diagnosis of PMOS. Other patients may present with hirsutism or acne and also have irregular cycles, but their main complaint may be a different symptom altogether.

Erica Newlin, MD:

And then what role does weight play in PMOS?

Mindy Christianson, MD:

Typically, about 50% of women with PMOS have struggles with weight gain and obesity, and it can be harder to lose weight, and that's really tied to the insulin resistance or the body being less sensitive to insulin, the hormone that's so important for keeping the blood sugar low. And so when people have PMOS, it's really important to have regular screening for insulin resistance and for type two diabetes.

Erica Newlin, MD:

And why is it important for patients to think beyond reproductive symptoms when they're managing their PMOS?

Mindy Christianson, MD:

It's really important to think beyond the reproductive years because patients with PMOS can be at increased risk for cardiovascular disease, hypertension, hyperlipidemia, and many other conditions really tied to cardiovascular and endocrine health.

Erica Newlin, MD:

What health screenings or monitoring should patients discuss with their providers?

Mindy Christianson, MD:

In general, if someone has PMOS, they should be screened at least annually for insulin resistance or type two diabetes. They also should have a fasted lipid panel once a year, and then they should have regular weight screenings if they're not following their weight. I think those are some of the most important aspects.

Erica Newlin, MD:

And then the good news is that there are many ways patients can manage PMOS and support their overall health. So let's talk about treatment and lifestyle strategies. Other than ovulation induction medications, what treatment options are available for PMOS?

Mindy Christianson, MD:

For patients with PMOS, and so if they're looking just at fertility, we have options available, and I think it should be important to note that when we're seeing a patient with PMOS, we're going to look at them and kind of put them into a group as to whether they're trying to conceive right now and whether fertility is their goal or whether they're not actively trying to conceive and it's really just long-term health maintenance. I mean, those are two different things. And so if someone's trying to get pregnant, we have our oral ovulation induction agents, and if those are not successful, and sometimes we'll have patients who are clomiphene citrate resistant or letrozole resistant, then we have much stronger injectable medications that they can take to help them ovulate or produce a follicle. And then there's also, if they don't conceive over time, we may need to do a full complete fertility evaluation because there may be more than one issue occurring.

So for fertility, that's kind of one whole area, but for patients we're seeing with symptomatic PMOS, it really depends on if their main concern is weight gain or obesity or whether it's more of the increased androgen symptoms, and so really kind of narrowing in. It's really important though that we counsel patients that have PMOS, that it's important that they do have regular withdrawal bleeds or regular periods. If a patient does not have a regular period, they can develop endometrial hyperplasia, which is a precursor or a risk factor for endometrial cancer, which is preventable. So I've unfortunately seen many patients with a new diagnosis of endometrial cancer that were patients with PMOS who didn't know that it was important that they have regular periods.

Erica Newlin, MD:

What role do nutrition, exercise, and lifestyle changes play in managing PMOS?

Mindy Christianson, MD:

So it's really important that a patient have specialized counseling for diet and lifestyle. Often a diet that will work for a patient with PMOS is going to be a lower carbohydrate, more complex carbohydrate diet. And so really seeing a nutritionist who can help them make the right choices because a very modest weight loss if someone has obesity with PMOS can really help normalize their cycles.

Erica Newlin, MD:

What are some realistic first steps a patient can take?

Mindy Christianson, MD:

I think if someone has a new diagnosis of PMOS and they really want to move forward with optimizing their health, I think a nutrition consultation is key and it's possible to have a nutrition consultation really focusing on PMOS because there are specific dietary strategies such as a lower carbohydrate diet that can really help patients. So I think that is one strategy. The second is really identifying what your goal healthy weight is and doing what you can to achieve it and identifying if there's any metabolic factors such as insulin resistance that is making it harder for someone to lose weight. If there is, there are medications such as metformin that we can also use that are making the body more sensitive to insulin and helping blood sugar in general, but they also can aid a bit in weight loss. So I think that identifying your healthy weight and a diet are important, and then also really building in that habit of regular exercising and finding an exercise that you enjoy that you can keep doing consistently.

Erica Newlin, MD:

Do you think that the name change will lead more to moving away from PMOS or PCOS as a gynecologic disorder and more as a team approach with endocrine?

Mindy Christianson, MD:

I absolutely do. I think that one of the reasons for the name change is to really identify it as a multidisciplinary disorder and there are multiple subspecialists that can help a patient with PMOS. And so I think that is really key.

Erica Newlin, MD:

This has been such an interesting conversation about how our understanding of this condition continues to evolve. Before we wrap up, let's leave our listeners with one final takeaway. What's one step someone can take today if they think they have PMOS?

Mindy Christianson, MD:

I think if someone thinks they have PMOS, it's really important that they either make an appointment with their OB/GYN or with a reproductive endocrinologist to really have a full evaluation. We do have specific criteria we use to diagnose someone with PMOS, and it really does involve having an ultrasound and having labs and having an exam. So all of that together can really help someone confirm that they have the diagnosis so then they can move forward and make those positive lifestyle changes.

Erica Newlin, MD:

Dr. Christensen, thank you so much for joining me on the podcast today. For more information and helpful resources on PMOS, visit clevelandclinic.org/pmos. That's clevelandclinic.org/pmos. If you found this episode helpful, subscribe and share it with a friend. Remember, understanding the full picture of your health is an important step toward getting the care and support you deserve.

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.