PMOS not PCOS: A matter far beyond just eggs.

What is PCOS?

Quite often in our daily practice as health care professionals, we come across women who are diagnosed with polycystic ovarian syndrome (PCOS).

It is one of the most common hormonal and metabolic disorders affecting women of reproductive age and is now increasingly being referred to as Polyendocrine Metabolic Ovarian Syndrome (PMOS).

PMOS affects about 10% of women and its incidence is evidently rising. For most women, PCOS is a much more familiar term than PMOS. For that reason, the nomenclature PCOS is used across the article for the sake of familiarity. With this, readers should keep in mind the long-term problems that may be associated with PCOS, which led to its name change to PMOS.

It’s the word "PCOS" that catches the attention of most women, as more often than not, the term is heard across friends, mothers, and sisters. The first question and concern that comes to the mind of most women is whether she will be able to conceive, as maternal instinct is natural and paramount for any woman.

While myths may persistently be ingrained in women with PCOS that they may not get pregnant, the reality is different, as infertility associated with PCOS is highly treatable and can result in pregnancy in most women who have it. While PCOS in pregnancy can present certain challenges, many women can actually increase their fertility through lifestyle changes and modest weight loss. In other women, pregnancy can be achieved successfully with basic infertility treatments. Some women do, however, need additional help in conceiving in the form of in vitro fertilization (IVF), which is a highly effective form of treatment of infertility in women with PCOS.

Most women with PCOS often think losing weight is an almost impossible task and question if diet and exercise can actually help them conceive. The benefits of weight reduction are much more effective than they seem and include improved ovulatory function, improved chances of conception, a safer pregnancy for both the mother and baby, and if the woman needs it, a better response to fertility medications.  By losing around 5 percent of body weight, a woman can actually restore her menstrual cycle and ovulate on her own with this fact having been proven by several studies. Weight loss has also been shown to reduce other symptoms such as excessive and abnormal hair growth, acne and balding. In essence, all women truly need is a strong inclination and desire to help themselves.

When discussing PCOS causes, insulin resistance is considered one of the primary drivers of the condition in the majority of women. As a result of this, the cells do not get appropriate signals to perform a multitude of important tasks. In the absence of coordinated signals, the entire body then goes through a roller coaster of hormonal imbalances and distress, which leads to an excess of male hormones. This ultimately leads to weight gain, central obesity, ovulation problems, mood disorders and skin and hair problems. The relationship between insulin resistance and PCOS is now widely recognised and is considered one of the major drivers of the condition.

As gynaecologists, we also meet women with PCOS whose usual concerns are either cosmetic or reproductive. As part of our job, we cater to their reproductive goal, however it’s important to keep in mind that our role does not end there. Looking beyond, there are more serious concerns that are likely to happen beyond the reproductive age, which is precisely why the name has now rightly been changed from PCOS to PMOS. Many studies confirm that the insulin resistance associated with PCOS can expose women to a higher risk of metabolic syndrome, including hypertension, hyperlipidaemia, diabetes and cardiovascular disease. By the age of 40, almost 40% of women with PCOS develop pre-diabetes or diabetes.

The increased cardiovascular risk in PCOS women is owed to two mechanisms. The first mechanism is the direct atherogenic action due to insulin resistance and the other mechanism is an adverse effect of the lipoprotein profile seen in PCOS. The risk of heart attack is also increased four to seven times in these women. It appears that in PCOS women risk factors for the development of atherosclerotic conditions, hypertension and myocardial infarction are present at an earlier age than in women without PCOS. Obstructive Sleep Apnoea [OSA] and daytime somnolence are also found to be three times more common in PCOS patients.

A worldwide survey conducted by healthcare professionals led to the suggestion that the name PCOS can be misleading as it indicates involvement only of ovaries, which is far from reality.  This is precisely why the name has now been changed to PMOS, which acknowledges the long-term metabolic risks associated with the condition.

Apart from metabolic disorders, women with PCOS are also more at risk of developing uterine, ovarian, and possibly also breast cancer in later life. Chronic anovulation predisposes women to endometrial cancer and this risk is reported to be three times higher compared to women without PCOS. This calls for the need for more frequent evaluations.

Keeping in mind the long-term implications of PCOS, there is a need for a holistic approach to the disease process. Every responsible gynaecologist should utilise every potential opportunity to evaluate and educate patients about ways to prevent long-term and potentially threatening metabolic disorders by intervening at the earliest. Long-term follow-ups and yearly blood screenings are recommended, particularly for those beyond reproductive age, to prevent the co-morbidities.

PCOS treatment can also involve diet and women with PCOS are advised to reduce their overall carbohydrate intake and should particularly avoid sugars and refined carbohydrates. For example, white bread, white rice and anything that has been stripped of its natural fibre or made with refined white flour should be avoided. It’s advised to consume foods high in fibre or those that are made from whole grains and are as unprocessed as possible. For women with PCOS, it’s advisable to consume four or more small meals instead of fewer large ones so that insulin levels do not spike. Apart from dietary advice, regular moderate or vigorous exercise five or more times a week is also encouraged. This not only improves weight loss, regularity of menses, improved fertility but also reduces long term metabolic implications associated with PCOS.

Many women find themselves asking how to cure PCOS permanently. While there is currently no permanent cure for PCOS, symptoms can often be effectively managed through lifestyle changes, weight management, medical treatment, and ongoing monitoring.

Conclusion:

Polycystic ovarian syndrome that was once considered to be purely related to sex organs should no longer be considered a purely gynaecological disorder. There needs to be widespread awareness about the metabolic complications associated with PCOS and education that sex hormones do not affect only the reproductive organs but many other organs in the body, which can lead to long-term and potentially serious complications. As healthcare workers, it is our mission to disseminate information about the new nomenclature of PMOS and its long-term metabolic complications.