PMOS (PCOS): Not Just Irregular Periods (Bongato, 9/16/26)

A recording of this presentation is available HERE.

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Thanks to Dr. Charlene Bongato for an excellent update on Polyendocrine Metabolic Ovarian Syndrome (PMOS), formerly known as Polycstic Ovarian Syndrome (PCOS). It was recently renamed to capture the reality that the disease, as we now understand it, is not a primary ovarian problem but rather a multifactorial syndrome with environmental influences and characterized by: 

1) hyperandrogenism 

2) ovulatory dysfunction 

3) polycystic ovarian morphologic features

***it is important to note that while insulin resistance is closely associated, it is NOT a defining feature

5-13% of female patients meet criteria for PMOS (by Rotterdam criteria, see below)

it is the most common cause of anovulatory fertility

~70% of patients remain undiagnosed

PMOS is caused by dysregulated ovarian androgen excretion or increased extra ovarian androgen production, characterized by excess LH and decreased FSH.

"Atypical PMOS" is obesity-related

Rotterdam criteria (must meet at least 2/3)

• oligo- or an- ovulation
• clinical or biochemical signs of hyperandrogenism
• polycystic ovaries by ultrasound

Additionally, per ACOG, Anti-Mullerian hormone (AMH) can serve as a diagnostic marker of PMOS when factors such as age, phenotype, BMI, etc are taken into account. 

How to assess for excess androgen?

1) Clinical assessment for hirsutism, using the modified Ferrimen Gallwey Score

additional manifestations of hyperandrogenism include acne (2.8x more prevalent in adolescents with PMOS), androgenic alopecia, seborrhea, hyperhidrosis, hydranitis suppurativa

***note: virilization is abnormal in PMOS and should prompt investigation for other causes of hyperandrogenism

2) Laboratory assessment: total and free testosterone (can consider DHEA, androstenedione if testosterone is normal)

Take care NOT to diagnose PMOS in teens. You need both irregular cycles and hyper-androgenism. Should not assess cycles until at least 2 years of menarched, AND polycystic ovarian morphology (PCOM) should NOT be used within 8 years of menarche. Additionally AMH should not be used.

Typical vs. Atypical

• In functionally typical PMOS, overexpression of DENND1A.V2 leads to hypersecretion of testosterone precursors from the theca cells. Plus 20-30% of the time, there is adrenal contribution with also elevated DHEA.
• In functionally atypical PMOS, obesity mediated insulin resistance and excess leads to stimulation of steroidogenesis and overproduction of androgens within adipocytes

Additional evaluation after diagnosing PMOS should include: 

1. Cardio-metabolic risk assessment: HbA1c, lipids, STOP-BANG (for OSA) 
2. MASLD
3. Depression and anxiety
4. Anovulatory infertility
5. (there is an elevated risk for endometrial cancer but screening is generally NOT recommended)

Management

management of PMOS depends primarily on desire for fertility

goals include: management of hyperandrogenic features, management of underlying metabolic abnormalities, prevention of endometrial hyperplasia and cancer, contraception (for those not desiring pregnancy) and ovulation induction (for those who desire pregnancy)

For those who do NOT want to pursue pregnancy:

Endometrial protection with pills/patch/ring (combined contraceptives) are first line to manage hyperandrogenism, cycle regularity and contraception. Progestin only products are acceptable but do not manage hyperandrogen. Metformin can help with menstrual regularity.

Certain progestins have less androgenic activity (see image)

You can add spironolactone after 6 months for additional anti-androgen effect PRN

For those who DO want to pursue pregnancy:

Ovulation induction is the goal with either letrozole (now first line) or clomiphene

Metformin does not help with ovulation dysfunction except for patients with insulin resistance who have failed lifestyle interventions (diet, weight loss)

Addition of a supplement called inositol has increasing evidence for ovulation induction

Additional dietary supplements to consider: Vitamin D, Omega 3, NAC, berberine