Your Guide to Navigating PMOS (formerly PCOS)

What is PMOS?

Until recently, this condition was known as Polycystic Ovary Syndrome (PCOS). However, an international group of experts has proposed renaming it Polyendocrine Metabolic Ovarian Syndrome (PMOS) because the old name doesn't accurately reflect the condition.

The term polycystic ovaries is misleading because many people diagnosed with the condition don't actually have polycystic-appearing ovaries, while many people without the condition do. More importantly, the old name overlooks the significant hormonal (endocrine) and metabolic features that are central to the condition for many people, such as insulin resistance.

You'll still hear the term PCOS used frequently because the name change is still being adopted, but throughout this article I'll refer to it as Polyendocrine Metabolic Ovarian Syndrome (PMOS).

PMOS is characterised by three overlapping features: endocrine dysfunction, metabolic dysfunction and ovarian dysfunction. Different people experience these to varying degrees, which is why the condition can look quite different from one person to another. People often discover they have PMOS after visiting their doctor because of symptoms such as irregular periods, facial hair growth, acne or hair loss. These symptoms may also occur alongside difficulty losing weight, although not everyone experiences this.

Androgen hormones and PMOS

Androgens are hormones produced by the ovaries and adrenal glands. When present in excess, they can cause acne, hair loss on the crown of the head, hirsutism (dark, coarse hair growth on the chin, upper lip, chest and back), insulin resistance (more on this below) and delayed ovulation (which also means delayed or absent periods because you need to ovulate to have a period).

Ovarian dysfunction and PMOS

When you ovulate, you always get a period about two weeks later (unless you are pregnant).

Those with PMOS often experience irregular periods or lose their period altogether because their ovaries are having trouble ovulating regularly. On ultrasound, the ovaries may appear enlarged and contain many small follicles (often previously referred to as "cysts"). These are actually immature follicles where an egg started to develop but didn't mature enough to be released.

Many people think polycystic ovaries are the defining feature of PMOS, but it's important to remember that people without PMOS can have polycystic-appearing ovaries and ovulate normally without excess androgen symptoms. Conversely, not everyone with PMOS will have polycystic ovaries on ultrasound. They may simply have androgen excess and irregular ovulation, which can be sufficient for diagnosis. Current diagnosis is still based on the Rotterdam criteria, which require two of the following three features after excluding other causes: irregular or absent ovulation, clinical or biochemical signs of androgen excess, and polycystic ovarian morphology on ultrasound.

Metabolic dysfunction in PMOS

Insulin resistance is very common in people with PMOS. Insulin resistance means the body's cells don't respond efficiently to insulin, so the pancreas needs to produce more insulin to keep blood glucose within a healthy range.

Chronically elevated insulin levels don't just regulate blood sugar—they also stimulate the ovaries to produce more androgens and can interfere with normal ovulation. Over time, insulin resistance increases the risk of metabolic syndrome, type 2 diabetes and cardiovascular disease.

In some people it also contributes to increased fat storage and makes weight regulation more difficult. People of all body sizes can have PMOS and insulin resistance. Having a lean body type does not rule out significant metabolic dysfunction.

What causes PMOS?

It is not yet known exactly what causes PMOS, although genetic factors clearly play an important role. This helps explain why, although insulin resistance drives the condition in many cases, not everyone with insulin resistance develops PMOS.

Is it PMOS?

Sometimes PMOS is misdiagnosed, so make sure you've had a thorough assessment and seek a second opinion if necessary.

Several other conditions can cause similar symptoms, including hypothyroidism, hyperprolactinaemia (very high prolactin levels), hypothalamic amenorrhoea (where periods stop due to low energy availability or intensive exercise), perimenopause and adrenal disorders.

Here are some hormone tests to discuss with your healthcare practitioner to ensure you've been thoroughly assessed:

• Free testosterone

• LH

• FSH

• Prolactin

• Oestradiol

• Progesterone

• DHEAS

• Thyroid function

Am I insulin resistant?

Unfortunately, there isn't a single perfect test for insulin resistance, which means it often goes undetected. People with PMOS who have abdominal weight gain, elevated triglycerides, low HDL cholesterol, high fasting insulin or blood glucose, or a family history of type 2 diabetes are more likely to have insulin resistance.

Whether you're lean or overweight, it's worth assessing your metabolic health because insulin resistance can exist without obvious symptoms and contributes to many of the hormonal features of PMOS. This should include blood pressure, waist circumference (under 80 cm is generally considered a healthy target for most women), and blood tests including:

• HOMA-IR (fasting insulin and glucose)

• HbA1c

• Fasting lipid profile (cholesterol and triglycerides)
  

PMOS and fertility

The irregular or absent ovulation associated with PMOS can make it more difficult to conceive because there are fewer opportunities for fertilisation over time, and it's difficult to predict when ovulation will occur.

There are other factors that may make conception with PMOS more challenging, such as an increased risk of miscarriage. However, having PMOS doesn't necessarily mean you will struggle to conceive—it simply means you may need a little more time or support.

What you can do to help your PMOS

Step number one: ensure healthy blood sugar levels after eating.

This is because insulin is our blood sugar regulation hormone and the higher our blood sugar (also known as blood glucose) spikes after eating, the more insulin we need to make to get it back down. Repeated blood glucose spikes can cause insulin resistance and stimulate the ovaries to make androgens (explained above).

Here are my top 3 tips to start making a huge difference to your post-meal glucose and insulin levels today. You’ll notice you’ll have way better energy too!

1. Choose mostly savoury foods. Keep any sweet tasting food, whether natural or not, to a minimum and eat it only after a meal as a dessert, rather than as part of the main meal or as a snack. This includes fruit and naturally derived syrups such as maple syrup and honey.

2. Eat 1-2 cups of veggies before your lunch and dinner regardless of whether the meal already contains veggies. This could mean a simple salad, veggie crudites (e.g. celery, carrot, green beans, snow peas, red capsicum, radish), or roasted veggies such as broccoli, cauliflower, asparagus, eggplant, zucchini or fennel. Avoid using potato, sweet potato and beetroot as your pre-meal veggies as these contain starches and sugars that will spike your blood sugar. The aforementioned veggies are low in starches and sugars, and high in fibre. The fibre slows stomach emptying and reduces the rate at which glucose enters the bloodstream. This strategy is excellent to reduce sugar cravings too.

3. Include quality sources of protein with every meal & snack. Protein has a much smaller effect on blood glucose than refined carbohydrates and helps slow digestion, making it an excellent addition to every meal and snack. Choose from: fish, chicken, lean beef & lamb, ricotta, natural yoghurt, goats cheese, raw nuts (brazil, almond, walnut, cashew, hazelnut, coconut), seeds (pumpkin, sunflower, sesame, flaxseed, soaked chia seed), eggs, tofu, tempeh, chickpeas, beans, lentils.

Step number 2: exercise.

Exercise that builds muscle mass is one of the most effective ways to improve insulin sensitivity. Muscle acts as a major storage site for glucose, so increasing muscle mass helps your body dispose of glucose more efficiently and reduces the amount of insulin required after meals. This benefits both the metabolic and hormonal features of PMOS.

Resistance exercise increases muscle tissue. If you don’t know how to do this already, you can start at home with a free 10-minute Youtube workout for beginners and work your way up to 30 mins, a few times a week. If you aren’t sure if you are doing it correctly, it’s a good idea to have at least one session with a personal trainer to get your technique right and avoid injury.

Once you have your resistance routine in place, try to add some exercise that gets your heart rate up a few times a week. Again, start with 5-10 mins and increase length as you can. These two types of exercise are very beneficial for everyone with PMOS, whether you are trying to shift weight or not.

Step number 3: get further help.

You don’t have to wait until you have mastered the above to get further help. Assemble a team that can help you achieve your goals. This may include a naturopath (see below for how naturopathy can help manage PMOS), your GP and/or relevant specialists.

Medical treatment for PMOS

First-line treatment for PMOS is diet and lifestyle modification. You may have been told to lose weight or increase exercise but sometimes it can be less obvious to know how to do that. If you are struggling follow the above tips and consider seeing a naturopath (read more below).

If you are not trying to conceive, chances are you will be offered the oral contraceptive pill to control your symptoms. It is important to realise that this doesn’t prevent your symptoms from coming back later if you come off the pill and it doesn’t treat insulin resistance, weight gain or prevent type 2 diabetes. The pill suppresses ovulation and alters your body's natural hormone production, which can improve symptoms while you're taking it. However, it doesn't address the underlying metabolic or hormonal drivers of PMOS.

If insulin resistance or metabolic dysfunction is contributing to your PMOS, or if you're trying to conceive, you may be offered metformin. This medication can help some people with PMOS, although it may not be enough on its own. Many patients who turn up in my office have tried metformin but cannot tolerate the digestive side effects (bloating and diarrhoea) and are looking for a different option.

If you are trying to conceive, your specialist may recommend ovulation induction medications such as clomifene or letrozole. These medications stimulate ovulation but don't work for everyone with PMOS.

How a naturopath can help with PMOS

Diet and lifestyle education is one area where naturopathy can play a valuable role in supporting people with PMOS. We can guide you through exactly what to eat in a way that suits your lifestyle, preferences and goals while helping you make sustainable changes over the long term.

Naturopaths can also prescribe high-quality practitioner-only nutritional and herbal medicines to improve insulin sensitivity, support ovulation and help regulate hormones. Our goal is to address the underlying hormonal and metabolic drivers rather than simply masking symptoms.

I'd love to list my favourite herbs and nutrients for PMOS, but there are so many options and not every treatment is appropriate for every person. Remember at the beginning of this article when I explained that PMOS is a syndrome with a wide range of presentations? That's why an individualised assessment is so important when deciding which herbal and nutritional medicines are most appropriate and what doses are likely to be effective.

In Summary

Although being diagnosed with Polyendocrine Metabolic Ovarian Syndrome (PMOS) can feel confusing and overwhelming, understanding what's happening in your body empowers you to make meaningful changes that can improve your symptoms and long-term health.

Remember that PMOS is highly individual. While the underlying hormonal and metabolic changes differ from person to person, diet, lifestyle and targeted treatment can make a significant difference for many people. I hope the strategies in this article provide a helpful starting point, and if you'd like personalised guidance, don't hesitate to reach out for support.

If you're wondering whether you have PMOS, aren't getting the results you hoped for with your current treatment, or would like a personalised plan, I'd love to help. Book in for a free 10 minute discovery call here.

Josephine Cabrall - BHSc (Nat)

She/Her

Naturopath & Nutritionist

RH: Reproductive Health