Maggie McKay (Host): Welcome to The Fertile Edge, a podcast from the Reproductive Science Center of the San Francisco Bay Area. I'm your host, Maggie McKay. Joining us today is surgical director, Dr. Evan Rosenbluth, to discuss PMOS or polyendocrine metabolic ovarian syndrome. Thank you so much for being here today and making the time, Dr. Rosenbluth.

Evan Rosenbluth, MD: Thanks so much for having me.

Host: So, let's start with why is the name changing now and what took so long to get here and what did it used to be called?

Evan Rosenbluth, MD: It's a good question. PMOS used to be called forever PCOS or polycystic ovarian syndrome. And the problem was is that PCOS is kind of a misnomer, and it confused lots of people. not just patients, but doctors as well. Because PCOS or polycystic ovarian syndrome is not really true. The ovaries are not filled with cysts. They're actually filled with follicles, which is a totally different thing. And so, I think the impetus to change the name was to kind of create less confusion and more understanding about the syndrome.

Host: Any reason it took so long?

Evan Rosenbluth, MD: I don't know. Doctors are stubborn people, I think, and maybe that's part of the reason. But it's hard to get a group of physicians together and come up with a consensus. But they finally did.

Host: for patients who have already been diagnosed with PCOS, what does the renaming actually mean for their care?

Evan Rosenbluth, MD: As of now, nothing really has changed with the name change, meaning that the criteria to diagnose PMOS is the same as it was for PCOS. And different groups have different criteria to diagnose PMOS.

Typically, American reproductive endocrinologists use what we call the Rotterdam criteria. And the Rotterdam criteria was invented a few decades ago, where both the European Society and the American Society of Reproductive Endocrinologists met in Rotterdam and says, "Okay, this is what constitutes, back in the day, PCOS and now PMOS."

And the three main criteria, it said you need two out of these three things in order to get the diagnosis. And the first is having irregular periods. So, periods really typically greater than every 35 days. The second is having any evidence of extra androgens, or what's typically thought of extra male hormones.

And the third criteria was using ultrasound to actually look at the ovaries. And the original criteria was either having big ovaries, so greater than 10 mLs in volume, or counting 12 or more follicles in either one of those ovaries. Back a few years ago in 2018, they revised that antral follicle count requirement to say 20 or more follicles using newer technology, high-resolution ultrasound.

Host: How does framing this as a metabolic syndrome change the treatment conversation, if at all? Like, do you talk to your patients differently now that it has a new name?

Evan Rosenbluth, MD: Well, really, PMOS is really the same as PCOS. And so, nothing changes as far as diagnosis or treatment. And so, we treat patients the same.

Host: And so, what are the most common misconceptions patients bring into the consultation room, and how do you address them?

Evan Rosenbluth, MD: I think the first thing as far as PMOS is that patients oftentimes are misdiagnosed, or it's taken years for them to get a diagnosis, or potentially in the community when their regular doctor has diagnosed it but doesn't give any other information and people get freaked out saying, "Okay, my chances of having a kid are ruined," or, "It's never going to happen for me." I think those are some of the most common misconceptions. And the truth is PMOS is one of the most common ovulation disorders. In fact, I think it affects one in eight or one in 10 women. And it's usually very treatable actually.

Host: What does a fertility workup look like for someone who's been newly diagnosed with PMOS?

Evan Rosenbluth, MD: So when people come in with PCOS, usually they have ovulation disorders or irregular periods. And so, before we diagnose PCOS, we have to check other things to make sure we're not missing any other reasons for ovulation disorders. So, oftentimes we'll do other endocrine or hormonal panels looking at both pituitary hormones, sex hormones, and potentially other metabolic problems like insulin resistance or diabetes

Host: This has been so informative, Dr. Rosenbluth. In closing, is there anything else you'd like to add that you think would be helpful for women to know who are being diagnosed with this?

Evan Rosenbluth, MD: I'm going to add something because when I talk to patients that come in with PMOS, I kind of go into a little spiel and we talk first of all what's supposed to happen during a normal menstrual cycle. That makes it easier to understand ovulation disorder or PMOS. So, I'm going to explain that real quickly. Now, typically, ovaries are filled with thousands of eggs which you can't see, and they're microscopic, and most of those eggs have been sleeping or resting, and they've been that way since you were born.

Now, independent of a period, so whether people have regular menstrual cycles or not, some of those eggs start to mature. And when that happens, they turn into follicles, and follicles are fluid-filled sacs we can actually see on an ultrasound. Now, assuming people have regular cycles early in the menstrual cycle, estrogen levels are low.

And because they're low, the brain at that point is saying, "I need to make more," and it does that by increasing a hormone from the brain called FSH or follicle-stimulating hormone. That increase of FSH gets the follicles to start growing. And as the follicles grow, they make estrogen, which makes the lining of the uterus nice and thick.

And for humans, one follicle gets bigger than the other ones. And that big follicle actually prevents the other ones from growing. Eventually, the follicle gets big enough where you ovulate, you release an egg. That's why we have one baby at a time. But also, the cells that line that follicle where you ovulate from after you ovulate start making progesterone, and that progesterone's important for supporting an early pregnancy.

But if you don't get pregnant, the cells that make the progesterone start to die. And after about two weeks, the progesterone level gets down to zero. That's when you slough the lining of your uterus and get a period. And so, the only way to truly get a true period is by getting a thick enough lining that eventually gets exposed to progesterone. And the only way to get exposed to progesterone other than taking it as a medication is by ovulating. And so, people that have PMOS or delayed periods oftentimes either have delayed ovulation or no ovulation whatsoever.

Now, for people with PMOS, a good chunk of the time, the majority of the times, there's probably metabolic problems or insulin resistance. And what happens are the receptors in the ovaries that can accept insulin, and when they get hit really hard with high levels of insulin, there's a shift from more female hormones to more androgen production. And those follicles that were supposed to grow and release one egg, they get either stuck or delayed, and then you get delayed or missing periods. And so that's the very simple way of looking at PMOS.

The nice thing is that typically we have fairly simple, straightforward treatment options for people that are trying to conceive or ovulate. Oftentimes, that'll involve oral medications that typically work by lowering estrogen levels. And when you lower estrogen levels, your brain goes, "I really need to make more." It does that by increasing follicle-stimulating hormone, and the vast majority of the time, those follicles that were delayed or stuck eventually start growing again and you ovulate. So usually, treatment for PCOS or PMOS is very straightforward and easy.

Host: Well, that's all encouraging. And earlier you said that it's very common, and like you said, you have straightforward treatment. So if someone's diagnosed, maybe they don't have to be as scared as they are.

Evan Rosenbluth, MD: Absolutely. In fact, most patients that come in with PMOS, they're freaked out and scared. Oftentimes very emotional. And then usually after the conversation it's like, "Oh, it's not necessarily a terrible problem to have because there's lots of eggs in the ovaries. We just have to coax them to come out. And it's usually very straightforward. Most people leave here relieved.

Host: I bet. Well, thank you so much for sharing your expertise. This has been very educational and helpful. We appreciate it.

Evan Rosenbluth, MD: Thank you so much for having me

Host: Again, that's Dr. Evan Rosenbluth. And if you'd like to find out more, please visit rscbayarea.com. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay. Thanks for listening to Fertile Edge.