Polyendocrine metabolic ovarian syndrome (PMOS), previously called polycystic ovary syndrome (PCOS), is the most common hormonal disorder in women of reproductive age.
PMOS is diagnosed when a woman has at least two of the following three features: irregular menstrual periods, high testosterone or related symptoms (like excess facial hair), or an excess of antral ovarian follicles on ultrasound. Persons with PMOS are not more likely than those without to have true ovarian cysts. A blood test for high levels of anti-Müllerian hormone can replace the ultrasound in the diagnosis. Other symptoms associated with PMOS are heavy periods, acne, difficulty getting pregnant, and patches of darker skin.
The exact cause of PMOS remains uncertain. There is a clear genetic component, but environmental factors are also thought to contribute. PMOS occurs in between 5% and 18% of women. The disorder is linked to insulin resistance, which is made worse by obesity. Insulin resistance and related excess insulin levels increase the risk of complications such as type 2 diabetes and liver disease. Those living with PMOS also have higher risk of endometrial cancer.
Management focuses on relieving symptoms and reducing long-term risks. A healthy lifestyle and weight control are recommended for general management. In addition, hormonal contraception can help regulate menstrual cycles and reduce acne and excess hair growth. Metformin, a common antidiabetic drug, increases insulin sensitivity. For fertility, ovulation can be induced with letrozole, among other methods. In addition, those affected can be monitored for cardiometabolic risks, and during pregnancy.
Signs and symptoms PMOS has a wide variety of signs and symptoms. They include issues with ovulation (such as irregular periods), excess levels of androgens (hormones that trigger male characteristics, such as facial hair growth), and metabolism (such as weight gain). Symptoms usually start in puberty, but may be masked if oral contraceptives are started early.
Common signs and symptoms of PMOS are: Irregular periods: periods may stop completely or may be less frequent. When they do happen, periods can be very heavy. There may be menstrual bleeding without ovulation, too; around 40% of women with PMOS who have a regular cycle have periods without ovulation. Infertility: PMOS is one of the leading causes of infertility in women. A "male" pattern of hair growth, including hair on the chin, upper lip, chest, upper thighs, and on the belly. This growth pattern, called hirsutism, is present in about 60% of women with PMOS. Acne: Acne is typically severe, persists beyond adolescence, or continues despite standard treatment. Pattern hair loss (androgenic alopecia), at the top of the scalp Skin issues, such as oily skin or a condition where dark, thick, and "velvety" patches can form (acanthosis nigricans) The ovaries might be larger than normal, with many small fluid-filled sacs that surround eggs ("follicles"). Testosterone levels are usually elevated: one meta-analysis showed testosterone levels to be 1.5 times higher in women with PMOS compared to women without PMOS.
Associated conditions Women with PMOS have an increased risk of a range of metabolic, cardiovascular, reproductive and mental health conditions. The likelihood of developing metabolic disorders is about three to seven times higher than in women without PMOS. Insulin resistance is common, even in lean women with PMOS. Overweight or obese women with PMOS are at higher risk of type 2 diabetes than women without PMOS at the same BMI. Lean women with PMOS do not appear to be at higher risk of developing diabetes. Other metabolic and cardiovascular complications commonly associated with PMOS include: Obesity: Across different cultures and ancestries, between 30% and 80% of women with PMOS are overweight or obese. There is marked weight gain between adolescence and adulthood, compared to those without PMOS. Dyslipidemia: disorders of fat (lipid) metabolism such as cholesterol and triglycerides: in PMOS, levels of low-density lipoprotein cholesterol are often high, while high-density cholesterol levels are low. Metabolic dysfunction–associated steatotic liver disease (MASLD; a chronic liver disease), particularly if androgen levels are high High blood pressure Metabolic syndrome, which occurs in about 40% of women with PMOS Cardiovascular disease: women with PMOS have about a two-fold increased risk of strokes and coronary heart disease compared to women without PMOS who have similar BMI.
PMOS increases the risk of pregnancy complications, such as gestational diabetes, high blood pressure, low blood sugar levels, and pre-eclampsia. Miscarriages are more likely, and when a baby is delivered, they are more likely to require admission to the neonatal intensive care unit.
PMOS is associated with mental health-related conditions including depression, anxiety, bipolar disorder, and obsessive–compulsive disorder. Those with PMOS often report reduced quality of life due to excess body weight, and to a lesser extent due to hirsutism, infertility and menstrual cycles. In regions where infertility or hirsutism are stigmatised, the impact on mental health is more severe. Body image can be negatively affected and PMOS increases the risk of eating disorders, such as binge eating. In addition, sexual wellbeing is often lower in women with PMOS.
Women with PMOS are about three times more likely to develop endometrial cancer. This is linked to lack of periods and lower levels of sex hormone-binding globulin (SHBG) and progesterone. Women with PMOS more often have sleep apnea, particularly if obesity is present.
Cause PMOS's root cause is unknown. Risk factors include a family history of PMOS, early development of pubic hair and sweat gland development (adrenarche), and obesity. Low birth weight, exposure to androgens in the womb, and exposure to hormone disruptors may also predispose people to PMOS.
Genetics PMOS has a clear genetic component and high heritability. Evidence of the genetic basis comes from family and twin studies, as well as from large genome-wide association studies. The correlation in PMOS occurrence between identical twin sisters was found to be twice as high as that between non-identical twins, suggesting a significant genetic influence. Twenty-five different genetic loci have been found to correlate with PMOS in genome-wide association studies, of which thirteen were replicated in at least one other study. Variants in genes involved in insulin signaling and androgen synthesis, including those affecting ovarian steroidogenesis, have also been associated with increased susceptibility to PMOS. Genes near some of these loci imply neuroendocrine and metabolic dysfunction, but the role of other genes is not yet clear.
Men with a family history of PMOS also display some of the symptoms associated with it. For instance, brothers of women with PMOS show a higher likelihood of high AMH levels, insulin resistance, and abnormal lipid levels in the blood. Men with the genetic risk factors associated with PMOS also have higher levels of obesity, type-2 diabetes, male pattern hair loss, and cardiovascular disease. Not all similarities between family members are likely due to genetics, as PMOS and obesity in mothers can have an impact on fetal development, making it more likely for men to get metabolic disorders with age.
Mendelian randomization is a method in genetic epidemiology that seeks to identify causal relationships between risk factors and diseases. It uses the randomness of inheriting different genes to do so. Using Mendelian randomization, it was found that PMOS has causal links to sex hormone-binding globulin level, anti-Müllerian hormone (AMH) level, menopause age, body fat percentage, insulin resistance, depression, breast cancer, ovarian cancer, obsessive-compulsive disorder, and lung capacity. Other factors do not seem causally linked: anxiety disorder, schizophrenia, type 2 diabetes, coronary heart disease, stroke, or birth weight.
Environment PMOS may also be impacted by epigenetics, which regulates how active genes are. High levels of androgens and AMH during pregnancy and early weight gain can hinder the fetal environment. In studies of PMOS in mice, exposure to AMH or the androgen dihydrotestosterone still has an effect three generations later. If that is so in humans, it implies that PMOS can be inherited via epigenetic changes. Blood in the umbilical cord of babies whose mothers have PMOS shows specific epigenetic changes suggestive of PMOS.
There is little evidence on the effect of environmental pollutants on PMOS risk. Hormone disruptors are chemicals that disturb the hormonal system by blocking or mimicking natural hormones. Of these, bisphenol A and phthalates (both used in plastics), and possibly octocrylene exposure may raise the risks of PMOS.
Obesity is implicated in PMOS development. As fat tissue can produce androgens, obesity leads to increased androgen levels. It also leads to suppression of the SHBG hormone, increased insulin resistance, and abnormally increased insulin levels. Some of the effects go both ways: PMOS might impact appetite, so that weight gain becomes more likely. Weight loss using diet is equally effective in people with and without PMOS.
Mechanism
PMOS involves both hormonal and metabolic changes. Women with PMOS often have higher levels of androgens, mainly produced by the ovaries, as part of a disrupted hypothalamus–pituitary–ovarian axis. In the brain, the hypothalamus sends out gonadotropin-releasing hormone (GnRH) pulses with higher frequency. This raises luteinising hormone (LH), while follicle-stimulating hormone (FSH) stays the same or is slightly lower. The higher LH stimulates theca cells in the ovary to produce more androgens.
The disrupted hormonal environment, including high levels of androgens, suppresses the growth and development of ovarian follicles ("cysts"). This leads to an accumulation of many small follicles, a feature referred to as polycystic ovarian morphology. The lack of ovarian follicle development also leads to a reduction in ovulation. Granulosa cells in these small follicles produce high levels of anti-Müllerian hormone, which reduces the conversion of testosterone to oestradiol (oestrogen).
Metabolic changes are common in PMOS. Many women develop insulin resistance, which causes the pancreas to produce extra insulin. High insulin levels reduce liver production of sex hormone-binding globulin (SHBG), increasing free circulating androgens. Low-grade inflammation can worsen insulin resistance, creating a reinforcing loop between metabolic and reproductive disturbances. Insulin resistance is not present only in overweight women with PMOS, but obesity makes it worse.
PMOS is associated with cardiovascular and liver dysfunction. For instance, women with PMOS can have coronary and aortic calcification. Obesity, impaired glucose metabolism, and excess androgens are all risk factors for liver dysfunction (MASLD).
Diagnosis Diagnostic criteria Different criteria are used for diagnosing PMOS, but the (revised) Rotterdam criteria are recommended by clinical guidelines. According to these criteria, an adult woman is diagnosed with PMOS if she meets two out of the following three:
Signs of androgen excess, either clinical (visible signs such as facial hair or acne) or biochemical (detected through a blood test). Androgens are "male" hormones like testosterone. Irregular or absent menstrual cycles Polycystic ovaries on ultrasound or high levels of anti-Müllerian hormone (AMH)