Evo Terra (Host): Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. I'm Evo Terra. And I'm joined today by Dr. Leen Wehbeh, endocrinologist and Medical Director of the University of Maryland St. Joseph Medical Group's Diabetes and Endocrinology Center. We'll be discussing P-C-O-S or PCOS becoming P-M-O-S or maybe PMOS and what that diagnosis really means, how it affects the whole body, and what patients should know about the symptoms and the risks and treatments. Dr. Wehbeh, welcome.

Leen Wehbeh, MD: Thank you so much, Evo. Thank you for having me. I'm excited to be here and to talk about this change that is well overdue.

Host: Wonderful. So, those were—in case you couldn't tell—brand new acronyms to me. But I went ahead and looked them up. I know that the old PCOS is polycystic ovarian syndrome, and the new PMOS is polyendocrine metabolic ovarian syndrome. So, other than the fact that you decided to add five more syllables to it, what's really changed here?

Leen Wehbeh, MD: Polycystic ovary syndrome, kind of from the name you feel like, "Oh, it's an ovarian disorder, it's ovarian cysts, which is kind of not very accurate to describe really what the syndrome encompassed. It's not just ovarian disorder. The cysts on the ovary are really not cysts. They are just small immature follicles. And when you use this name, polycystic ovary syndrome, you hide very important aspects of the syndrome, which are metabolic and endocrine or hormonal disorders that are also included. So, that's why changing the name to polyendocrine metabolic ovarian syndrome better describes the true wide range of presentations or involvement of the syndrome. So, this was really well overdue.

Host: So, what exactly is PMOS—which you pronounce well, I don't. So, I'm just going to stick with PMOS. And what are some common symptoms that people may not realize are connected to this?

Leen Wehbeh, MD: Metabolic ovarian syndrome or PMOS, the new name, is what we used to call PCOS. And basically, it's a very common endocrine metabolic disorder. It affects about one in eight to one in 10 women in reproductive ages. But basically, what it entails is, again, various presentations.

Women can have evidence of excess male sex hormone like, for example, acne, that persists beyond the teenage years or starts in adulthood or increased hair that is thick and terminal hair in unwanted areas in women. Or they might have irregular periods, so periods that are either too long between two periods, like more than thirty-five days, or too short between periods, or not having enough periods in a year. It also includes having increased risk of metabolic complications, which is mainly driven by insulin resistance. Those are increased risk of impaired glucose or diabetes and prediabetes, increased risk of weight gain or difficulty losing weight. On the long run, that would carry increased risk of fatty liver disease or increased risk of cardiovascular disease.

So, it's a wide range. And of course, infertility occasionally because irregular periods basically entails also that there's no ovulation happening sometimes, and that can make fertility or getting pregnant difficult. So, infertility sometimes can be one of the presenting symptoms.

Host: So, you mentioned a lot of condition there. So clearly, people might have PMOS even though they have regular menstrual cycles, they don't have ovarian cysts, and some other typical conditions. Do I have that right?

Leen Wehbeh, MD: Absolutely. Absolutely. So based on the guidelines, to really make a diagnosis of PMOS or polyendocrine metabolic ovarian syndrome, you have to have two out of three criteria satisfied. So, the three criteria are either having evidence of excess testosterone or androgen, which is the male sex hormone that you see. So, mainly acne or excess hair in unwanted areas or sometimes hair thinning in the scalp, in what we call androgenic alopecia, or having evidence of high testosterone or androgen levels on blood tests. So, either/or. That's criteria number one.

Criteria number two is having irregular periods. Again, those are periods that are not occurring every month or by having more than 35 days between periods or having less than eight periods per year. And this is criteria number two.

Then, criteria number three is having cysts seen on ovarian ultrasound. There are certain to satisfy to call it, which is the number of cysts and the size of the cysts and the ovaries. In the last few years, they added an alternative to the ovary seen on ultrasound, which is measuring a blood test called anti-Müllerian hormone or AMH. So, ultrasound cysts or AMH level that is elevated would form the third criteria.

So to have a diagnosis, you have to satisfy two out of three criteria. So yes, you could have PCOS when you get an ultrasound and there's no ovaries. And honestly, if you have the first two criteria, you don't even need to go and get an ultrasound necessarily.

Host: So, that makes it sound to me like, well, the first two of those criteria might be something someone could notice on their own. The other one's going to require a doctor visit. So when should someone talk to their doctor about their symptoms?

Leen Wehbeh, MD: Because of the wide range of presentation, basically irregular periods should prompt a woman to seek a doctor's opinion. So basically, if the periods again are more than 35 days between periods or they are too short, like less than 20 days, between periods or having less than eight periods per year, that should prompt a consideration of visiting a doctor.

If the woman is having acne that persists beyond the teenage years or starts in adulthood or having evidence of excess hair that is thick terminal hair in unwanted areas, if the woman is having difficulty losing weight or having weight gain that is unexplained by diet or activity and exercise level, that should prompt evaluation as well. Infertility, of course, that should prompt evaluation in general. So, those would be reasons to consider getting a doctor's opinion.

Host: You ended there on obviously reproductive health, clearly important, but you've touched on other ideas, the insulin resistance, skin and hair changes. Let's talk about what else is happening in the body when PMOS is diagnosed?

Leen Wehbeh, MD: So basically, it's two main hormonal disturbances basically that drive this. There's androgen excess. Again, androgen is the male sex hormone in the body, and there is insulin resistance. So, they both kind of feed into each other and reinforce each other. So when you have androgen excess, that would increase insulin resistance. When you have insulin resistance, that causes more androgen excess. So, it's kind of like they feed and reinforce each other. And these two conditions or abnormalities lead also to weight gain and difficulty losing weight. They also lead to, again, all the manifestations we see, like the irregular periods and, as a result, infertility associated with it.

Androgen excess with all the skin changes, acne, skin tags. Sometimes people can have evidence of the, skin becoming a little thickened, a little darker in color, kind of velvety. That's a sign of insulin resistance as well. There could be sleep disturbances. Patients can be at increased risk of having obstructive sleep apnea. And the metabolic changes, increased risk of diabetes or high blood pressure or high cholesterol. And this is even when the BMI or body mass index or body's weight might not be very elevated. So, these are important things to consider.

Host: In a moment, I'm going to ask about treatment. But before I do that, you've touched on them a bit. Let's talk about the long-term health risks that people with PMOS should be aware of.

Leen Wehbeh, MD: Right. So basically, long-term risks, a big part of it would be metabolic. Again, increased risk of weight gain and obesity, difficulty losing weight, increased risk associated with increased risk of diabetes, high blood pressure, cholesterol. On the long run, that increases the risk of fatty liver and cardiovascular disease. So, those would be metabolic complications that are very important to be mindful of on the long run. The other very important long-term risk that can be seen is increased risk of endometrial or uterine cancer. The reason for that is when you have irregular periods, what happens is there is unopposed estrogen, we call it, which means the uterine lining is getting exposed to estrogen. And because there's no ovulation, there's not enough progesterone, and that uterine lining can grow thicker. That can increase the risk of hyperplasia, which means, again, increased thickness or increased production of uterine lining and increased risk of uterine cancer as well.

Now, although there is statistically increased risk, like it's about two and a half fold higher than people without PCOS for uterine cancer, it's still not necessarily recommended to do certain screening per se. But it's important to treat the irregular periods and make sure the woman is having appropriate periods. So, those would be two major categories for long-term risks of the condition.

Host: Excellent. So, you are reminding us all that this, human body is a complicated process. So, let's talk about treatments. Let's get people better. How do doctors decide what is the right treatment option for a patient, and what are those options?

Leen Wehbeh, MD: Yeah. That's a great question. And because of how heterogeneous or various the presentation can be, the treatment is directed towards what is the most important thing that's bothering the patient or that is the main presentation of PCOS. As I said, some people might have regular periods. So, regulating their period might not be the most important step. Some people have the irregular period as the main problem, so regulating the period would be the focus. Metabolic complications, it would be very important to target those. So, let's talk about each one of them one by one. I think that would be easier.

So, metabolic complications, if the patient is having weight gain or difficulty losing weight, lifestyle would be very, very important of course. So having healthy diet, avoiding very high carb or fat content in food having regular exercise. We usually recommend a minimum of 150 minutes per week of moderate intensity exercise and trying to be healthy and choosing food options in a healthy way. If diabetes is there, metformin should be considered. We treat this as if it is diabetes, even if it's not associated with PCOS. Same thing for the high blood pressure and high cholesterol. So, screening for them is very important, and then treating them if they are present is very important.

Let's talk about irregular periods. Usually, birth control pills is the mainstay if the woman is not desiring pregnancy. So, that would be a very d- like differentiating factor. If the woman is planning or desiring pregnancy in the near future, obviously, we're not going to use birth control pills. But if the woman is not desiring pregnancy, that would be the first-line treatment. Obviously, if there is pregnancy desire, a lot of these women can conceive naturally. It doesn't mean that infertility is absolutely there. So, that is important to know as well. But if there is difficulty there, usually, there are medications that can help improve fertility. And frequently, we do recommend seeking the care of a fertility doctor or GYN doctor specializing in fertility or what we call reproductive endocrinology.

A first-line medication for infertility in PCOS would be a medication called letrozole. There are other options like clomiphene or Clomid and with or without metformin, and there are other options as well, but those would be kind of like the most common ones or first-line drugs to be used.

Then for excess hair, this is kind of a harder one. Birth control pills would still be first line if the woman is not desiring pregnancy for excess hair or the androgen excess that we see, because birth control pills can lower the amount of the androgens and they can bind it so it is less active. Also, we usually recommend like mechanical hair removal and laser therapy. Those are very effective as well. There is a medication called spironolactone, which is kind of an androgen blocker that can be used however, not super successful. And really, hair changes, in any case, It's very slow. To see a change on the hair, it's very slow. So usually, I do tell my patients you have to wait, give it at least six to twelve months to really know if one modality we're trying, like birth control pills or spironolactone, is effective. And spironolactone effectiveness is really not that great, but sometimes could be considered. But very important to note, it should be used with reliable contraceptive method because it can cause teratogenic effects on the baby if there's unwanted pregnancy. So, this is a very important aspect.

And metabolic complications and weight gain, again, we treat it the same as any, weight gain or weight loss drug. We can consider weight loss medications. We could consider weight loss surgeries in the right patient. So, it's basically treatment is directed towards the main issue that is the main concern of the patient.

Host: Wow. This has been a wide-ranging and information-filled conversation. I want to thank you very much for your time today, Dr. Wehbeh.

Leen Wehbeh, MD: Thank you so much. Thank you for having me.

Host: And thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again, and please share this on your social media. For more podcasts, articles, and to sign up for our emails, visit our Health Hub at health.umms.org. Thanks for watching.