PMOS – Polyendocrine Metabolic Ovarian Syndrome (formerly PCOS, polycystic ovary syndrome)

Overview: What Is PMOS?

PMOS occurs in about 6 to 18 percent of all women of childbearing age. Nevertheless, the disease is often not recognized because it does not present itself in a clear and uniform way. To diagnose polyendocrine metabolic ovarian syndrome, various symptoms are assessed or examined. A diagnosis of PMOS may be made only if at least two of the following three characteristics are present—provided that other conditions associated with similar symptoms (so-called differential diagnoses) have been previously ruled out:

• Disturbed menstrual cycle: This means either missing periods or irregular (i.e. more than 35 days between periods) or, more rarely, significantly shortened cycles (i.e. less than 21 days between periods).
• Excess male hormones (androgens) in the blood and/or increased hair growth in areas of the body not typical for women (so-called male-pattern hair growth / hirsutism), severe acne, or severe hair loss.
• Polycystic ovaries (ovaries). This means that in at least one of the two ovaries, more than 20 fluid-filled follicles with a diameter of up to 9 millimeters can be counted. Another ultrasound criterion for the diagnosis is at least one ovary with a volume greater than 10 milliliters. An elevated AMH (Anti-Müller-Hormone) level is now also a diagnostic criterion for adult women. This reflects the typically increased egg reserve in women with PMOS.

Important to know: The term “polycystic ovaries” is actually misleading, because these are not true ovarian cysts, but rather many small follicles that have stopped developing. It was precisely this lack of precision that was one of the main reasons for renaming polycystic ovary syndrome (PCOS) to polyendocrine metabolic ovary syndrome (PMOS).

Although PMOS often goes undiagnosed, the opposite—a misdiagnosis—is also not uncommon. Careful diagnostics with recording of the cycle duration, ultrasound examination of the ovaries, physical examination with a special focus on the hair and blood tests are therefore important. Before a definitive diagnosis of PMOS can be made, other causes must be ruled out. For example, irregular periods or an increased androgen level, which are caused by other disorders. It must also be ensured that no disease of the pituitary gland, adrenal cortex or other ovarian disease is responsible for the symptoms.

PMOS: What are the causes?

The exact cause of polyendocrine metabolic ovarian syndrome has not yet been fully elucidated. As the disease occurs more frequently in some families, genetic factors probably play a role in its development. Studies have shown that a higher-than-average number of women are affected if their mothers were also diagnosed with PMOS. The affected women often have fathers who developed hormone-induced baldness at an early age. It is also possible that hormonal factors in the womb play a role in a newborn girl later developing PMOS.

The disease is triggered by a disruption in the body’s own regulatory mechanisms. It is currently unclear whether the cause is primarily the ovary or the sugar metabolism, or both. The central regulation of the pituitary gland (hypophysis) also shows abnormalities in the secretion of the hormones that control the menstrual cycle: the so-called luteinizing hormone (LH) is secreted more in relation to the follicle stimulating hormone (FSH). FSH is crucially responsible for the healthy development of egg cells in the female organism.

Studies show that a large proportion of women with PMOS—regardless of whether they are overweight or of normal weight—have impaired insulin metabolism. Increased insulin secretion can increase the production of male hormones, as well as the release of luteinizing hormone from the pituitary gland and promote the development of obesity.

Symptoms: What are the signs and symptoms of PMOS?

The symptoms of PMOS are very diverse and often vary greatly from person to person. You may only feel a few physical changes, but the symptoms can also be very pronounced. This makes it difficult to reliably diagnose the disease.

• The majority of affected women experience irregular or absent periods. Since the balance of female hormones is disrupted and women with PMOS ovulate less frequently or not at all, it may be more difficult to become pregnant, or PMOS may lead to (easily treatable) infertility due to the lack of ovulation.
• Due to cycle disorders, affected women often need support to make their wish for a child come true.
• During an ultrasound examination, your doctor will usually detect an increased number of follicles and/or an enlarged ovary. The so-called AMH (anti-Müllerian hormone) can also be measured. A value that is higher than average may be associated with a PMOS.
• Furthermore, a high proportion of women with PMOS are insulin-resistant. This means that your body cells do not react sensitively enough to the hormone insulin. The cells therefore absorb less sugar (glucose) from the blood, causing the blood sugar level to rise. In order to regulate blood sugar, the high glucose level signals the pancreas to produce even more insulin. The risk of developing diabetes (type 2) also increases. Impaired glucose metabolism is found particularly—though not exclusively—in overweight PMOS patients.
• The chronically elevated insulin level promotes the production of male hormones (androgens), which is already increased by the high number of small follicles. A common consequence is that affected women develop more hair on their face, stomach, back or pubic area. Acne, hair loss, and oily skin are also among the common symptoms.
• The majority of women with this condition are overweight or have difficulty preventing their body weight from increasing. Obesity exacerbates the hormonal changes associated with PMOS. Many women with PMOS develop nonalcoholic fatty liver disease.
• Many women affected by PMOS find their condition psychologically distressing. It is not uncommon for anxiety and emotional upsets or even depression to occur.
• If the patient wishes to have children, delayed pregnancy is often an additional burden. However, there are very effective aids that also make pregnancy possible. Fertility specialists know best about support options.

To offer you the most advanced and effective treatment options for these symptoms, the University Hospital of Zurich has established a Center for PMOS where specialists in internal medicine, reproductive medicine, nutritionists, sports medicine specialists, physical therapists, dermatologists, and psychiatrists work together to develop a treatment plan tailored to your needs. Through various research projects at this center, we are also working to further improve the methods for diagnosing and treating PMOS.

Diagnosis of PMOS

Diagnosing polyendocrine metabolic syndrome requires a comprehensive evaluation, as the symptoms are varied and can differ from person to person. The following methods are used:

• Medical history: recording of menstrual cycle, unfulfilled desire to have children (sterility), so-called androgenization signs (hirsutism (increased body hair), acne or hair loss) and weight history.
• Ultrasound examination: visualization of the ovaries to check for the presence of polycystic ovaries or to measure the volume of the ovaries.
• Physical examination: hirsutism score (evaluation and assessment of physical hairiness), acne, hair loss, measurement of blood pressure and BMI.
• Blood test: analysis of hormones (including male and female hormones, thyroid hormones, hormones of the adrenal cortex and pituitary gland), testing for diabetes and lipometabolic disorders.

A clear diagnosis requires at least two of the three Rotterdam criteria to be met: a disturbed menstrual cycle, polycystic ovaries or an elevated AMH level as well as an elevated androgen level or increased visible signs of androgenization (especially hirsutism, acne).

Forecast: How will the PMOS perform?

PMOS is one of the most common hormonal disorders in women. PMOS usually occurs between the ages of 20 and 30 (and sometimes earlier). In addition to menstrual irregularities, unwanted hair growth and acne often lead to a visit to the doctor. However, the disease may not be diagnosed until an expected pregnancy fails to materialize. At the same time, however, PMOS also has the advantage that, due to the above-average egg reserve in women with PMOS, fertility is maintained slightly longer than would be expected based on their biological age.

Treatment: How is PMOS treated?

A polyendocrine metabolic ovarian syndrome cannot be cured; instead, it affects those with the condition for their entire lives. However, your doctor can treat symptoms and sequelae well:

Treating PMOS with the Birth Control Pill

The hormonal imbalance in women with PMOS can often be regulated by taking the birth control pill . It can also reduce the production of male hormones and the resulting changes (acne, strong body hair). However, be sure to ask your doctor about the right preparation and whether it is safe to take. If the pill alone is not enough, there are additional medications that can further reduce male hormones. These are also often the method of choice if you are unable or unwilling to take pills for health reasons.

Other Medications for PMOS

The active ingredient metformin has the effect of increasing sensitivity to insulin and lowering blood sugar levels. Metformin can also help with weight loss and the reduction of male hormones. The active ingredients letrozole and clomiphene promote the maturation of follicles and ovulation; this increases fertility and therefore the chance of pregnancy. Studies have shown that combined therapy with metformin and letrozole is particularly effective. However, both medications must be prescribed by a doctor and regular ultrasound checks must be carried out, especially when taking ovulation-promoting medication. The natural active ingredient inositol can also help by regulating the hormone balance. The current study situation promises a similarly good effect as metformin. However, more studies are needed for widespread use.

Laparoscopic Ovarian Drilling

The removal of excess follicles is intended to normalize the menstrual cycle, which is out of sync, and the overproduction of male hormones. With the help of an electric needle or laser, they can usually be reduced in a targeted manner during a laparoscopy. The normalization of the follicle count achieved in this way should also lead to a normalization of the cycle and ovulation. This procedure is called drilling (internationally often: laparoscopic ovarian drilling, LOD for short). It is usually used as a PMOS therapy only after treatment of the hormonal disorder has proven unsuccessful, and is necessary in only the rarest of cases.

A healthy lifestyle can reduce PMOS symptoms

Regular exercise and sport can help to reduce excess weight. Adequate nutrition is another important factor. Female patients who suffer from PMOS often experience a reduction in their symptoms as a result of weight loss. The likelihood of conceiving despite PMOS also increases: Even a five percent weight loss leads to improved fertility and more regular cycles.

A healthy diet leads to a lower release of insulin. This normalization of the blood sugar level often noticeably reduces the symptoms of the disease. It is important to have your sugar metabolism checked regularly, usually once a year.

Through successful treatment of polyendocrine metabolic ovarian syndrome

• the balance of hormones is restored.
• menstrual cycles become more frequent and regular.
• the body’s cells react more sensitively to insulin. This also allows the pancreas to recover and reduce insulin production to a normal level. This in turn reduces the likelihood of developing diabetes.
• blood lipid levels and blood pressure also improve.
• a fatty liver that may have developed can regress.

Despite the PMOS diagnosis, all of this also increases fertility and the chances of pregnancy.

PMOS and the Desire to Have Children

If you are a PMOS patient with menstrual irregularities and would like to become pregnant, you should discuss this with your doctor as soon as possible. The goal of bringing about egg maturation in the natural cycle can be well supported medically, but often takes some time. It therefore makes sense to start medical support sooner rather than later. Sometimes it is not possible to bring a single egg to maturity without other eggs also starting the maturation process. As there is no wish to run the risk of a higher-grade multiple pregnancy, such treatment cycles are discontinued and a new attempt is made.

If it is not possible to bring a maximum of 2 eggs to maturity at the same time, artificial insemination may be an alternative. In this case, the possibility is used to bring a larger number of eggs to maturity in parallel, thus creating a reserve for several attempts to become pregnant or, in the best case, to create the conditions for the entire family planning with one treatment.

Artificial insemination – technically known as in vitro fertilization (IVF) or – if the sperm must be injected directly into the egg due to limited sperm quality – intracytoplasmic sperm injection (ICSI) should be carried out in a fertility clinic with many years of experience. This is the case at the Fertility Center of the University Hospital Zurich – here you can expect not only state-of-the-art technology, but also constant personal care that is precisely tailored to your needs.

Many young women who suffer from polyendocrine metabolic ovarian syndrome fear that they may no longer be able to have children—and this thought causes them stress. Here, a consultation can help you learn about PMOS and its effects on health, including Help fertility.

To put your mind at ease: Even with PMOS, you have an excellent chance of fulfilling your wish to have a child—even if you might need a little help along the way. A large Swedish study involving more than 45,000 women with PMOS found that, on average, they were one year older than women without PMOS when they gave birth to their first child. But they had a baby just as often.