From PCOS to PMOS: What does it all mean?
The Name Change: PCOS to PMOS
The landmark decision to rename Polycystic Ovarian Syndrom (PCOS) to Polyendocrine Metabolic Syndrome (PMOS) reflects a global push for better understanding and care. (Teede PhD et al. #) Broadening the name from PCOS - a name that emphasizes the involvement and importance of ovarian cysts in the condition, to PMOS, which underscores the whole-body reality of the syndrome, aims to both better represent the condition to the public, but also emphasize the multi-system implications within a clinical context - that is, for patients and care providers.
The new name validates the experiences of folks with PCOS / PMOS which can be diverse and represent a variety of signs and symptoms. Varying symptom presentations demand different treatment approaches, whereas anyone with a PCOS diagnosis is most commonly given 2 recommendations: go on oral contraceptive (i.e. hormonal birth control) and lose weight (see my take on these recommendations here). It corrects the misleading focus on ovarian pathology, which is NOT a feature of the syndrome. It also emphasizes the need for clinicians and clinical research to move beyond a focus on the ovaries, and take into account the variety of systems implicated in the syndrome’s manifestations. At the root of the change, is the recognition that in order to improve accurate diagnosis, remove stigma and best mitigate the far-reaching secondary risks PCOS / PMOS can bring, we need to take into account its metabolic, endocrine, cardiovascular and reproductive implications.
Polyendocrine Metabolic vs Polycystic
Although the presence of multiple ovarian cysts has been considered a hallmark symptom of PCOS, these cysts are not pathogenic. They are simply an abundance of immature follicles, which are not harmful in themselves. The cysts are just one of many possible clinical manifestations of the syndrome, borne of the upstream endocrine and metabolic dysfunction that actually drives PMOS. Since the issue is with the maturation of these follicles, which is driven by hormones released from the hypothalamus (a gland in the brain), the new name acknowledges the root of that issue in the term ‘polyendocrine’ (i.e. multi-hormone).
Then again, there is not just one hormonal pathway that leads to PCOS / PMOS symptoms. The hypothalamic-pituitary-ovarian axis (HPO axis), adrenal androgen production, the pancreatic insulin-signaling pathway, and gut-hormone interactions are all implicated in the variety of pathological manifestations of PCOS / PMOS. Hormone, metabolic and organ interactions matter - not just what the ovaries look like.
PCOS has always been more than just irregular periods and cystic ovaries. Differences in hormone signalling along the HPO axis, involving the adrenal glands, impacting androgen hormones, and very commonly altering insulin signaling pathways all coalesce to create PCOS / PMOS symptoms.
Just talking about cysts misses the great majority of what this syndrome can impact in a human body. Moreover, even if we focus on cysts and ovulation or period regulation, the multi-hormone pathways that are behaving differently in a PCOS / PMOS body are driving the proliferation of benign follicular cysts on the ovaries, and causing skipped periods / anovulatory menstrual cycles. So these ‘polyendocrine metabolic’ factors must be acknowledged and addressed in order to make any possible impact on cyst development, ovulation and period regularity.
What do we miss when we focus on the ovaries?
Rather than being an ovarian problem, reproductive hormone differences start in the hypothalamus (in the brain, not the reproductive organs). The interaction of these multiple hormone pathways results in the symptomatic presentation of PCOS / PMOS. When we only look for the presence of ovarian cysts, we do patients a major disservice. Not only is this likely to result in mediocre clinical outcomes (in terms of accurate diagnosis, management of symptoms, and patient satisfaction), but it also means that we would miss screening for and supporting endocrine dysfunction that can increase risk of heart disease, dyslipidemia (high cholesterol), metabolic dysfunction-associated steatotic liver disease (MASLD, formerly NAFLD, aka fatty liver disease), endometrial cancer and more.
How does the change from polycystic ovarian syndrome to polyendocrine metabolic syndrome change patient care?
The new name has been a global undertaking, and was driven by the collaboration of medical care providers, advocacy groups, and over 14,000 patients affected by PCOS / PMOS worldwide. It is an important change that will hopefully have rippling effects in improving screening and assessment guidelines, reducing stigma and improving treatment options for patients.
Broadening the scope of what clinicians are looking for will help more patients get a diagnosis sooner. Emphasizing the whole-body operations of PCOS / PMOS should underscore the need for full body assessments and treatments that treat the endocrine and metabolic drivers of symptoms. And de-emphasizing the ovarian cysts may help to reduce the stigma that the condition has in contexts where pressures and emphasis placed on fertility can make navigating what is often perceived as a gynecological pathology a fraught experience.
Hopefully, we will also see that there are many contexts in which the gynecological health aspects of the syndrome are not the primary concern, and yet addressing the whole body considerations are nonetheless paramount to supporting overall health outcomes. For example, in non-binary and transgender folks who may have desired outcomes outside the classic treatment paradigm (for example, not concerned with irregular periods due to menstrual suppression with HRT, or who welcome the enhanced facial hair growth), the metabolic and endocrine implications of the syndrome are still important to address. Moreover, for those who do not include fertility in their treatment goals, there are many considerations for care that are important to account for in order to improve quality of life and reduce the risk of comorbidities such as type 2 diabetes, hypertension, elevated cholesterol, acne, hair loss rather than just focusing on regulating periods and enhancing fertility.
How does the change from polycystic to polyendocrine metabolic change your naturopathic assessment and treatment?
From a functional medicine and naturopathic perspective, there is no change to how we approach the assessment and treatment of PCOS / PMOS.
We will continue to use a full systems, whole body approach to care. When we consider the possibility of a PCOS / PMOS diagnosis, we have always looked beyond the ovaries.
We consider the following:
What are your symptoms, pain points, and goals?
For example, are you hoping to regulate periods, investigate hair loss/acne/unwanted hair growth?
Are experiencing unexplained weight gain or weight loss resistance? Fatigue? Brain fog?
Is fertility a consideration?
Are you wondering how to navigate a PCOS diagnosis while exploring gender affirming care?
We assess multiple endocrine systems
We look at menstrual signs & symptoms
We assess signs of androgen excess and/or measure hormone levels
We may measure a variety of hormone levels - including reproductive hormones, stress hormones and insulin
We assess insulin signaling pathways
We never make blanket recommendations regarding weight loss, or use BMI as a surrogate marker for metabolic health
We individualize treatment based on the above symptoms, goals and assessments
We monitor and screen for possible comorbidities based on your individualized assessment, and integrate these considerations into your treatment plan accordingly
At the end of the day, your diagnosis, be it PCOS, PMOS or unconfirmed, is not the most important aspect of care. The critical thing is to evaluate your signs, symptoms and physiological functioning accurately, and to tailor a treatment program that keeps in mind your primary goals, your short, medium and long term well-being, alongside the individualized assessment results.
What should I do if I think I have PCOS / PMOS?
If you think you have PCOS / PMOS, or if you have been diagnosed by another health care provider, please reach out to get an individualized assessment and treatment protocol. I’ll review your health history, and discuss how we assess PCOS / PMOS - this includes consideration of signs & symptoms, possible referral for bloodwork and/or imaging. We’ll break down what is showing up in your assessment, and what that tells us about which endocrine or metabolic pathways are in need of attention and support. And we’ll tailor a treatment plan that takes into account your health history, assessment and specific goals. We’ll be able to identify which elevated risk factors typically associated with PCOS / PMOS are most relevant for you, and determine how we can best mitigate those risks.
PCOS to PMOS: key take aways
The shift in name from polycystic ovarian syndrome (PCOS) to polyendocrine metabolic syndrome (PMOS) is a huge change, and one that certainly better represents the realities of a condition that affects over 170 million people worldwide. I’m hopeful that this change in language will help to support an improvement in clinical care and support offered globally as well.
As a naturopathic doctor, the name change has not altered my approach to care, since none of the information about this syndrome is new. However, it is uplifting to see that health care providers, researchers, patients and patient advocates can collaborate across the world to successfully enact change to improve patient diagnosis, care and treatment that will surely have wide reaching effects around the world and well into the future. I am curious to see if this collaborative approach will serve as a model to update and improve the classification of other often misrepresented or under-diagnosed conditions such as endometriosis.