Michael Abrahams | What is PMOS/PCOS?

Recently, there have been many discussions in public spaces, including social media platforms, about polyendocrine metabolic ovarian syndrome, or PMOS (formerly known as polycystic ovary syndrome, or PCOS). It is a common disorder but, because of its complexity, it is poorly understood by many, including some who are afflicted with it. For the sake of those who wish to understand it, I will attempt to break it down.

PMOS affects roughly one in eight women of reproductive age (over 170 million people) worldwide. The primary risk factor for the condition is a family history, reflecting a strong genetic component. In utero exposure to androgens, certain medications, diets high in processed and calorie-dense foods, environmental toxins, chronic low-grade inflammation, and chronic childhood trauma also increase the risk.

Following exclusion of other disorders, the condition is diagnosed in adults (age ≥20 years) who meet at least two of three criteria. The first criterion is oligo-anovulation. Ovulation refers to the part of the menstrual cycle when a mature egg is released from one of the ovaries. The prefix “oligo-” means “few”. So oligoovulation refers to the ovaries releasing an egg only occasionally, resulting in typically eight or fewer menstrual periods per year. The prefix “an-” means “without”. So anovulation refers to not releasing an egg at all during a cycle. Oligo-anovulation is manifested by irregular cycles. Sometimes periods go missing for months, only to reappear heavy and prolonged. Ovulation is necessary for pregnancy, so PMOS is a common cause of impaired fertility. However, having PMOS does not mean that a woman with the condition cannot conceive, as many do, even without assistance. Because women with PMOS are used to having unpredictable cycles, when they do conceive, they may discover they are pregnant when they are months into the pregnancy.

The second criterion is clinical or biochemical evidence of hyperandrogenism. The prefix “hyper-” means “excessive”. Androgens are steroid hormones that regulate the development and maintenance of male characteristics, the most well-known one being testosterone. Hyperandrogenism therefore refers to a state in which excessive amounts of these hormones are present. This is often manifested by dermatological (skin) conditions such as hirsutism, which is excess coarse male-pattern hair growth on the face, chest, or back. Conversely, on the scalp, there may be hair thinning or male-pattern baldness. Acne and oily skin can also result. Excessive amounts of androgens can also interfere with ovulation, resulting in menstrual irregularities and impairment of fertility. Adolescents (ages 10-19 years) must meet these first two criteria.

The third criterion is polycystic ovaries on ultrasound or elevated levels of anti-Müllerian hormone (AMH). The condition was previously called polycystic ovary syndrome (PCOS) because this appearance of the ovaries is a common feature of the disorder, although it does not have to be present. Polycystic ovaries differ from normal ovaries by being larger, rounder, and containing 20 or more small fluid-filled sacs called follicles, usually lined up tightly along the periphery (outer edge) of the organ, giving a “string of pearls” appearance. Normal ovaries are almond-shaped, smaller, and contain only a few scattered follicles. In the ovaries, each egg develops inside its own protective follicle, which makes oestrogen and other hormones that control the menstrual cycle. Anti-Müllerian hormone is a protein made by reproductive tissues that helps measure a woman’s egg supply.

There is no single sign (observable physical finding) or symptom (reported feeling) that is used to diagnose the condition. This is why it is referred to as a syndrome. The word syndrome comes from Greek roots meaning “running together” and, in medicine, the word is used to describe disorders characterised by a collection of signs and symptoms.

And it is the diversity of signs and symptoms that influenced the changing of the name of the condition from PCOS to PMOS. The “PM” stands for “polyendocrine metabolic”. The prefix “poly-” means “many”, and multiple endocrine (hormonal) and metabolic (chemical processes that change food into energy or build and repair tissues) abnormalities are found in persons with the condition. Also, polycystic ovaries are not necessary to make the diagnosis, and polycystic ovaries also appear in women with no endocrinological problems. Disturbances in multiple hormones, including insulin (a hormone that helps move sugar from your blood into your cells for energy), androgens, neuroendocrine (relating to the nervous and endocrine systems) and ovarian hormones, are found in women with PMOS, and features can be metabolic, endocrinological, reproductive, dermatological and psychological. Being overweight or obese is another feature of PMOS, and excess fat contributes to the severity of the disorder.

So, although PMOS is usually seen as a gynaecological disorder, it is really a multisystem condition, and its management requires a holistic approach often involving other physicians and healthcare workers such as internists, endocrinologists, dietitians and mental health professionals. Lifestyle strategies are important. If overweight, losing as little as 5 per cent of body weight can improve metabolic function, lower androgen levels, and help regulate menstrual cycles. Appropriate physical activity, a healthy diet and supplements can help stabilise blood sugar, prevent insulin resistance and reduce inflammation.

Drug treatments vary depending on signs, symptoms and reproductive ambitions, and include hormonal birth control and other hormonal preparations to regulate menstrual cycles and protect the endometrium (uterine lining), anti-androgens to counteract the effects of elevated androgens, drugs that increase insulin sensitivity to stabilise blood glucose, and drugs that enhance fertility for those who wish to conceive.

I hope those reading this summary will find it useful. Ladies, if you have any of the above-mentioned signs and symptoms and have not been evaluated, visit your physician and ask whether PMOS is a possibility. If so, have them investigate and treat you accordingly.

Michael Abrahams is an obstetrician and gynaecologist, social commentator, and human-rights advocate. Send feedback to columns@gleanerjm.com and michabe_1999@hotmail.com, or follow him on X @mikeyabrahams.