Ep 338: What to know about PMOS

0:00You're listening to the Fertility Docs Uncensored Podcast, featuring insight on all things fertility from some of the top-rated doctors around America. Whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.

0:21Dr. Susan Hudson: This episode is brought to you by Receptiva DX. What if unexplained infertility isn't actually unexplained? For many women, hidden inflammation associated with endometriosis and other uterine conditions can go undetected for years, even when everything else appears normal. For more than a decade, fertility specialists have trusted Receptiva DX to provide deeper insight into the uterine environment, helping women and their physicians uncover answers and make more informed treatment decisions.

0:52Dr. Carrie Bedient: Hello, and welcome to another episode of Fertility Docs Uncensored. I am one of your co-hosts, Dr. Keri Bedian from the Fertility Center of Las Vegas, and I am joined by my candid and charismatic co-host, Dr. Susan Hudson from Texas Fertility Center. And we are joined today by Dr. Stephanie Brownridge, who is at RMA New York. And Stephanie, we are so glad that you are here with us today. How is everything going? Everything is going great. Thank you so much for having me. I'm so happy to be here and talk to you and talk about this topic and I'm excited. Fabulous. Have you gone on any wild and crazy trips this summer or what did you normally do as a kid for vacations?

1:38Yeah, that's a good question. Actually this summer I did go to Portugal, which was a bit uncharacteristic. Yes, I typically don't travel and I typically don't travel internationally. But I did that this summer and that was great and that was very fun and ended up being relaxing and I enjoyed Europe and that was great. Historically, I'm from Michigan. As a kid, I went to camp and I went on a lot of camping trips. This was a far cry from that. That was adventurous in its own right.

2:14Dr. Carrie Bedient: Were these all camping trips going to a camp or was it camping with family where there were as many episodes of trying to avoid being eaten by siblings or other family members as there were trying to run away from bears? So it's funny you mentioned bears. That's exactly what I was going to say. And it's not a metaphor. So this was a camping trip with my peers, but one of them was more rugged and involved a lot of hiking and sleeping in a tent and packing and bringing your food with you and things like that and then hanging it outside the tent. And there was an instance where a bear did eat our food.

2:56So we had to hike back very quickly the next day, probably about seven, eight hours. This was in my teen years. I think I was much less stressed about it at that time than I would be if it happened now. But it is. Now I have this exciting story to share. That was an interesting one for sure.

3:12Dr. Susan Hudson: I always think of in the movie The Parent Trap, the original with Hayley Mills. They put the honey on the feet and the little baby bear calves are licking. And, you know, nobody would actually want that to happen. But it's funny. But not when it's actually happening to you. I know. That should have been me. Should have been with the sticks and trying to fend off the predator.

3:34Dr. Carrie Bedient: I think that I would have gone out, discovered that the bears ate the food and just called it a day and said, I guess we're going home now. No camping. That would have been a good time to call it for sure.

3:45Dr. Susan Hudson: So y 'all went back and got food and then went and continued your camping trip? We went back and then we were actually based on a bus. And so we hiked back the seven, eight hours and then I got food and then back on the bus into the next location, the next adventure. Okay. So it helped you migrate through your camping adventure. Exactly. Yeah. That's an interesting way of doing it. Mm-hmm. Yes. Expect to be unexpected. So that's what we did. I am not a camper. I've been camping one time. Like real camping one time. Carrie? Yeah.

4:25Dr. Carrie Bedient: Are we counting car camping? Because that's the only type of camping I've ever done.

4:29Dr. Susan Hudson: No, in a tent on the ground.

4:32Dr. Carrie Bedient: No, no. That's how we do car camping. We get all this stuff. We never put everything on our back and then hike several miles to a remote. Oh, yeah.

4:40Dr. Susan Hudson: Yeah. Okay. Yeah, that counts. That counts.

4:43Dr. Carrie Bedient: I've done lots of tent camping back in the days when that was the only thing I could afford was the tent. And the pay per use ended up being excellent because we used it a fair amount. And my now husband had a little transportable grill that we would take everywhere with us. And we did okay. I don't think I have been camping in the better part of 10, 15 plus years. But back in the day, it was very helpful. Now you're inspired.

5:13Dr. Susan Hudson: I got a question about Portugal because that's actually somewhere we really want to go soon. And my husband has a friend who lives in Portugal. And so there's a secondary benefit to going and visiting somebody. What was your number one thing you enjoyed there? So we went to an area called Comporta, which is a beach town. And I would recommend, I would highly recommend. Honestly, it was kind of like the relaxed attitude of the locals. It was just such a nice environment. And yeah, it was kind of like, okay. In this instance, maybe it felt like I was camping. where the house lost power. And I was prepared.

5:54The house lost power. And so we're trying to figure out with the box and the switch and we don't want to mess anything up. Then someone came to help us and we were so panicked. And the lights went out. It was pitch black. And it's like kind of a language barrier. And he's like, it's okay. Relax. Like you're Portugal. It's all good. I was like, you know what? That's a good, it's a good attitude. I'm going to try. I'm going to try in times of stress. Just control what you can. Take a deep breath. A little more chill than Manhattan. A little bit. Yes. Excellent.

6:50Dr. Susan Hudson: This isn't another fertility book filled with opinions or miracle cures. It's an evidence-based guide that walks you through every stage of IVF, from understanding your fertility evaluation and choosing a treatment plan, to medications, egg retrieval, embryos, genetic testing, transfers, and the two-week wait, and beyond. Because the last thing you need during IVF is more noise. Close the tabs, put down your phone, open the IVF Blueprint instead. available now wherever books are sold.

7:25Dr. Carrie Bedient: All right. So before we dive into PMOS, what used to be PCOS, Susan, do we have a question?

7:31Dr. Susan Hudson: We do have a question for today. All right. Our question is, my husband and I have been trying for almost two years. He's 31 and I'm 32, tried seven months of Femara. And in January, I had laparoscopic surgery to diagnose and remove endo. My OB-GYN diagnosed me with stage 3-4 endo and adeno. I've had an HSG, saline ultrasound, and hysteroscopy, which removed fibroids on the uterus. Also was diagnosed with complete blockage of my right fallopian tube. We have gone through two IUIs, however, both have been on my right side, the block side. I am wondering what are your thoughts with continuing to try IUI if slash when my left side, the open tube, is producing the follicle or going straight to IVF and not doing IUI or if there is any other treatment?

8:24It's a matter of preference, I would say. So treating the endo and the adeno is going to help any and all of the above. It's going to help spontaneous pregnancies. It's going to help ovulation induction IUI cycles. It's going to help IVF and transfer. That's already checked off the list. Now, continuing to try ovulation induction, maybe you'll get a follicle on the appropriate side. Maybe the tube will pick up an egg from the other side. But it requires persistence. And she wanted to be pregnant yesterday. You've been through a lot when it's really a matter of preference, being a good candidate for any of the above.

9:03And so where IVF would maybe have some benefit would be to control, we can control, get eggs from both sides, fertilize them, make presumably some euploid chromosomally normal embryos. Everything's been optimized in terms of the imaging, the surgery, so transfer back a euploid, hopefully quality embryo with a very high chance of success, positive pregnancy test, and potentially probably have more embryos from that round to use in the future. Hopefully you don't face this again, but if you're facing this again, difficulty conceiving the next baby should that be what you want to do. You have the embryos from this cycle, which is sometimes a benefit of going through IVF, especially at a younger age.

9:51Really any of the above, there are options, but it wouldn't be wrong to continue ovulation induction, but it's not easy and it requires persistence. It might be worth discussing IVF at this point.

10:02Dr. Carrie Bedient: How do you approach it when someone's got a blocked tube on one side, but not the other side. And they're only ovulating on the blocked side. What do you guys do with your patients when that happens? It's so frustrating. We put in the ultrasound problem. We just both know what we're going to see. And it's so frustrating. It's exactly this conversation. And it's more nuanced. Is there insurance coverage? And what are we thinking about building our family? That's a conversation that we have. It's worth a few rounds to see may be a situation, if there's ever a situation, to try the injectable gonadotropins, depending on, again, number of follicles, number of eggs that will release, age.

10:46But if you really have gone through several rounds and just for whatever reason can't control, can't get an egg to ovulate from the side that you want it to ovulate from, it would be a reason to move on to IVF.

10:56Dr. Susan Hudson: Now, it is important for people to know that you can ovulate on one side and get pregnant through the opposite fallopian tube. No question. No question. There is a physical misconception that people, and for those of you who are watching us on YouTube, you can see me like making motions with my body and my hands, is people think about their uterus being their body and their fallopian tubes sticking out at the sides, whereas they're more like kind of draped down. And when you ovulate, it's not like the egg hops immediately from the follicle. So when you ovulate, the hormonal signals tell the follicle to create a hole and then the ovary kind of contracts.

11:43Dr. Susan Hudson: That's the reason why sometimes people have pain in their ovary. And that fluid ends up in the base of your pelvis and it's sloshing around there as you're walking around having your day. And ideally the fimbria, both fallopian tubes, the end of the fallopian tubes are looking for the little signals trying to find that egg. So just because you're not ovulating on that side, and I know there's a lot of REIs that'll just cancel cycles. I'm not really of that mindset and I do get a reasonable number of these people pregnant. For this couple, I would say a lot of it has to do with where are you emotionally and how many kiddos do you want to have.

12:21Dr. Susan Hudson: If you're sitting here at 31, 32 and you want one, maybe two, then I think you could do some more ovulation induction with IUI. Maybe do some intratubal insemination if your doctor has that available. Again, remember if you do more than two, it doesn't increase your odds. So it's either going to happen in the first or second time. If you're sitting there and you're like, I really want to have two children or I really want to have four children, that's when you really need to start considering, let's bypass the tubes, let's get those eggs, let's create a great environment, and let's make a home run.

13:00Dr. Carrie Bedient: Completely agree. Yeah, we agree with all of that. All right, so let's dive into our topic of the day, which is PCOS went through a name change, and now it's PMOS. So Stephanie, can you walk us through the alphabet soup and tell us what PCOS stands for and what PMOS stands for. Yes. Okay. So this was an interesting one. We were ready for this change. I didn't even know I was ready for this change, but I was definitely ready for this change. So PCOS, polycystic ovary syndrome, has undergone a name change to now PMOS, polyendocrine metabolic ovarian syndrome. PCOS, if we're asking why the name change after all these years, after decades, PCOS, polycystic ovary syndrome, is misleading.

13:54And if we break it down, polycystic, people are hearing this and they're thinking and they're picturing, do I have cysts on my ovaries? Well, I think I have this condition. I think I have this syndrome, but I don't know if I have an ovarian cyst or if I have cysts on my ovaries. And it's misleading and it's inaccurate because it's really not referring to a cyst.

14:15Dr. Carrie Bedient: So I was going to say, Susan, interjection here, because I don't want to deprive you of the opportunity to get on your soapbox and hopefully the last time that we will ever let you get on this particular soapbox. What's the difference between a cyst and a follicle?

14:30Dr. Susan Hudson: So a cyst is something greater than two centimeters that's not supposed to be there at a particular point in time. So follicles are the little fluid-filled sacs that contain your eggs. Now those follicles do ideally get big and then you ovulate from them and then they regress and go through that whole process. But people with this condition, PMOS, they tend, not always, but they tend to have lots and lots of follicles and not cysts. I can't even tell you how many people will come in and they're like, oh, I had a ruptured cyst. I know I have, at that time, PCOS. And it's like, that's not even the same.

15:16Dr. Susan Hudson: Like, we are at least talking about the right organ, but we're not talking about the right part of the organ. So thank you, Carrie.

15:23Dr. Carrie Bedient: Okay. I knew that we had to give you that opportunity today to talk about how PCOS is a creptacularly named condition. All right, so Stephanie, what's the polyendocrine component of this? Because the endocrine part was not included in any of the PCOS title before. So what does that refer to in PMOS? So now this term is more all-encompassing. So what's really happening with this condition, with this syndrome, is a few things. Irregular periods, no menstrual periods. Yes, the polycystic or the many follicles seen on an ultrasound, which usually goes hand in hand with a high AMH level antimullerian hormone.

16:10And what we call hyperandrogenism, meaning high androgens, whether this is determined through a blood test or are there clinical signs of this. And many people with PCOS, PMOS know what this means. Frustrating cystic acne. This is hair loss on your head where you want hair growth. This is hair growth where you don't want it on your chin. Kind of this frustrating clinical sequela of high androgens. When we're really thinking about the endocrine component, it's these androgens, it's going hand in hand with what we'll get to with the metabolic component with high insulin levels and insulin resistance, and really the interplay between the two.

17:03And this is really the pathophysiology of the condition and how it manifests as these frustrating symptoms that many or all people with PMOS know and understand. Let's go through the metabolic component of it. So the metabolic component, they're all frustrating components, but the metabolic component, this is difficulty with weight loss. This is what we call central adiposity, carrying a lot of weight in the midsection. This is other chronic conditions, high blood pressure, high cholesterol, sleep apnea, needing to see a cardiologist at a younger age. And these are chronic conditions that are really important components of PMOS because, again, patients living with this condition understand, okay, these are things that I'm dealing with.

18:00These are conditions that I need to go see a doctor for. And going hand-in-hand with the usually a higher weight with PMOS, it's extraordinarily difficult to lose that weight because of this metabolic pathophysiology, despite diet, exercise, all of the above. And so this is really where we see the metabolic component.

18:25Dr. Susan Hudson: So one thing that I learned when I was in fellowship, I worked with a gentleman, Dr. Frank Gonzalez. And one thing that he was really passionate about is understanding that the mitochondria in people with PMOS, they don't function the same as they do in other people. And so when you come into your doctor and you're like, oh, my goodness, I have all these things and I can't lose weight. I'm working out with my husband. I'm working out with my girlfriend. I am not eating or I'm eating exactly what I should be eating. and I'm doing all the right things and they lose 20 pounds and I lose two. And it is not that you are failing at anything.

19:08Dr. Susan Hudson: That is one of the most important things for you to understand is you are not failing at something. Your body is not communicating effectively with the other parts of your body and you need help. And it is okay to get that help. Now, another thing to know about is these metabolic things Stephanie was talking about. Stephanie, if you have lean PCOS, so you're a normal weight individual, but you don't ovulate, you have polycystic ovaries, all those types of things, do you still have to be worried about those other metabolic issues? If I'm thin, am I good to go? Sometimes we see it. Sometimes we see it, yes.

19:51We can see this insulin resistance. We can see a higher, how are we testing for this hemoglobin A1C? we can sometimes see high blood pressure, not as much, not as much with a higher weight. And another way to answer the question is patients who are in a higher weight category with this condition, with PMOS, if they lose a certain percentage of their body weight, we can see that it starts to correct some of the clinical sequela. Maybe the periods become more regular. Maybe some of these abnormal markers in the blood, they start to improve. They start to normalize. Not easy to lose weight. Sometimes it requires medication, but we can see that there's some improvement in these parameters.

20:37And patients, the phrase was called lean PCOS, weight loss will not be effective in restoring the normal ovulatory function in these cases and maintaining a normal, healthy BMI will really be the focus. That's where that conversation can differ based on the metabolic category and based on the BMI.

20:58Dr. Susan Hudson: RMA of New York is a global leader in state-of-the-art reproductive medicine, serving as Division of Reproductive Endocrinology and Infertility at the Icahn School of Medicine at Mount Sinai. Led by an integrated team of physicians and scientists, RMA of New York is renowned for its pioneering research in the field and for delivering high IVF success rates. With locations across Manhattan, Brooklyn, Westchester, and Long Island, RMA of New York has helped thousands to build the families of their dreams for more than two decades and counting.

21:28Dr. Carrie Bedient: Do you recommend any particular diet or nutrition plan for these patients? Because everybody comes in and weight loss is almost universally or weight management is almost universally one of the topics to discuss. Are there any nutrition tips for patients who have PMOS, lean PMOS that you both rely on? In general, I don't think any diet, any nutritional plan is going to, it's not one size fits all. Now, sure, in this category, we can say a lower glycemic index diet, but I think we're going to keep it back to basics. A relatively healthy diet, nothing extreme. Certainly if you're having a snack or whatever it is, something with carbs, it's okay.

22:19It's all okay. Focus on high nutritional value, fruits, vegetables, whole grains, sometimes for fertility for that reason. We say a Mediterranean diet with PMOS, low glycemic index, trying to avoid some of those carbohydrates. It's not easy. It's not easy for me. It's not easy for anyone. And so again, we don't have to get extreme why the name change was so important. There is a lot of stigma. And again, people really can commit to the change where they're not seeing the results and it can be very frustrating. I just say focus on what you can. Healthy diet, healthy lifestyle, if you can lower that inflammation, which is a big part of the condition.

22:58And so if someone's asking me, that's what I would recommend. And just do what you can. For some people, it's easy to eliminate one thing or one category. For some people, they want to do a whole overhaul. I think with a lot of the newer medications, that's been very helpful. But typically focusing on nutrition, whole foods, things like that. That's what I would recommend.

23:18Dr. Susan Hudson: What are your thoughts for people who are wanting to lose weight using some of the newer medications like the GLP ones, like Ozempic, Monjaro, Chiris Appetite, those types of things? Whether depending on what phase of life are they in? Are we in a reproductive phase or are we in a we want to just be healthy phase? Yeah, I'm a huge fan of these medications. I think they're really finally now we have an option. There have been certain we would say lose weight before you get pregnant, lose weight to help restore your fertility. It's really not so easy, especially with PMOS. And really all you're doing is losing time.

23:57And so now these medications are highly effective. And we can actually, in a matter of months, accomplish this goal or at least bring down the BMI to a level where we think, okay, we're going to decrease some of these risks in pregnancy. And also, pregnancy complications are a part of this condition. What I'm doing as a fertility doctor is not only focusing on the fertility, but really optimizing what we can for a healthy pregnancy, healthy delivery, healthy baby, healthy mom. I think these medications, while yes, they will cause a temporary delay in trying to conceive because we need to pause that to focus on this and then go back to that, it's effective.

24:39And anytime we have something in medicine that's so effective, I am a huge advocate of that. I think we've seen a lot of success with these medications.

24:46Dr. Susan Hudson: You mentioned pregnancy risks. For people who have PMOS, what are some of the biggest pregnancy risks that we have concerns about? And it really goes hand in hand with the chronic conditions that we worry about. So same thing with diabetes, which would be diabetes and pregnancy, gestational diabetes with high blood pressure, gestational hypertension. And when these things happen, it leads to increased monitoring and pregnancy. It leads to a potential hospitalization, potential preterms, delivery, NICU admission, complications postpartum. And these are things we have to take very seriously, especially after a fertility journey.

25:29Nobody ever wants a pregnancy complication, but if we have the opportunity to prevent this, I think that's an important focus for the patient and the physician working together as a team. Those are some of the pregnancy complications that we can see. It's having to do with the general health and then what the implications can be. Again, more monitoring, early delivery, things like that.

25:51Dr. Carrie Bedient: I really hope that with the renaming of PCOS to polyendocrine metabolics ovarian syndrome, that there are more subtypes of doctors that are able to claim ownership over this, because historically, it's been the gynecologists and the reproductive endocrinologists who handle all of this, and everybody else is, shoo, shoo, be gone, this is a woman's problem, which that's a whole other episode in and of itself. But what I'm very hopeful is that It will increase the uptake of physicians from the internal medicine doctors, the family practice physicians, the medical endocrinologists. They already grabbed this.

26:32Dr. Carrie Bedient: They already see a lot of these patients. But I'm hoping that it really helps with the uptick of doctors who are willing to manage it because all of a sudden it goes from being an ovarian problem to diabetes, blood pressure, things that are very much in their wheelhouse kind of issue. This was part of the reason for the name change is for this access to care, the advocacy, the research. It's really multifactorial. And that's now reflected in the name. And that's reflected now in hopefully the care team for these patients. I completely agree.

27:06Dr. Susan Hudson: The one part of the name that's really the biggest change is the polyendocrine part of it. And part of that has to do with things like insulin, insulin sensitivity. How do those things interact with either some of those symptoms you're talking about or having to do with reproduction itself? So this is really the interplay. So with insulin, which is important for our glucose metabolism and using the sugar appropriately in the cells in our body, If we have a dysregulation with this, then we have our blood sugar too elevated. This is a problem that can lead to conditions such as prediabetes or diabetes.

27:46And what's happening at the level of the ovary itself with the high androgens and the high insulin, this interplay between the two is causing a dysfunction and a dysregulation and how it's called folliculogenesis, so how those follicles can develop. And this now brings us to the ovarian component. So I actually think it's very appropriately named. So what's happening with the ovarian component and the reproduction category and the irregular cycles and I'm not getting my period and I don't know when I ovulate and am I ovulating and now I'm trying to conceive and this is very frustrating because when am I ovulating if I am?

28:30So what's happening is, back to the original name, the misnomer, polycystic, there are many follicles in the ovary. If we're to do an ultrasound, we would see that and we do see that. I like to say, if you have to have a condition in my office, I don't mind this one because a lot of eggs, this is a good problem to work with. Yes, it's frustrating. You even have to come see me at all, but I like having a lot of eggs. So this is the silver lining. So we're seeing a lot of resting follicles. They're all small. None of them are growing and developing and reaching the point and maturing and reaching the point of ovulation where they're going to release an egg.

29:08And this is because of really the pathophysiology and the dysfunction. Again, the androgens, the insulin acting at the level of the ovary. back to the endocrine component coming from a gland in our brain that's really secreting these signals to other glands and ultimately to the ovary where this dysfunction is happening. So there's an impaired folliculogenesis. We're not growing a follicle every month and releasing a follicle and then either getting a period or hopefully getting pregnant if that's what the goal is. And so months go by with no ovulation. And that's really what's happening. And so it really does involve all these systems.

29:44And that's why this name change is so important because now we can really focus on, okay, where do we need to intervene so that we know how to best treat this?

29:52Dr. Carrie Bedient: I am very curious about what practical tip each one of you would give a PMOS patient in your office. So from the perspective of an REI, what is the most practical tip that you can come up with that you wish your patients either already knew or actually listened when you told them? Not that they're not listening, but more because we just give a fire hose of information. But what's the one thing that both of you want your patients to remember about PMOS that is a practical, helpful tip? I like to say with this condition, we have to treat the problem that it's causing. And a lot of patients will say to me, understandably, they really want to get to the root cause of this condition in particular because they just want to know.

30:42I was on birth control for years. It kind of helped. That's not aligned with my goals. Now I'd like to be off this medication. My one-liner is we know what the root cause is. It's everything we're discussing now, and that's reflected in the name change. However, we have to treat the problem it's causing. If it's the cystic acne, we're working with a dermatologist. Back to this approach with it's multidisciplinary. If it's infertility or irregular ovulation, we need to restore ovulation. If it's prediabetes, we need to work with an endocrinologist. So it's very frustrating, but there are treatments for all of the clinical sopala for all of the symptoms.

31:22And so we have to treat the problem that it's causing.

31:24Dr. Susan Hudson: And mine is very similar in that I like people to understand that this is the way you are wired. PMOS is not something that we can get to a point and fix everything. We have to know what your priorities are and what are the things in you that need modification, assistance, whatever it is to help you be the healthiest that you can be. And that's going to vary at different points in your life. When you're wanting to baby make, there's a very specific goal. When you're not wanting to baby make, there's a lot of things that can have serious implications for your longevity. And it's not something to be, don't be mad at yourself.

32:16Dr. Susan Hudson: There's nothing you did or didn't do to make this happen. I have celiac. It sucks. Like I totally, totally get it. And I understand after many years that no, even with me doing gluten-free and doing all the things I need to, there are some things that just aren't going to be the same as everybody else, But I can be pretty darn close and I can be healthy. The same goals go for people with PMOS. You may not be exactly the same as your sister or your best friend, but we can help you have a healthy, long, happy life.

32:52Dr. Carrie Bedient: I'd say that my practical tip is with respect to patients with PMOS who are in the baby making phase, let the ovulation predictor kits go. Let it slide, let it ride. This is one thing where it is very helpful to be working with an REI or a gynecologist who's got an interest in this because ovulation predictor kits are notoriously unreliable in PMOS patients. They're either They're always positive because your LH is just high enough to trip them. They're always negative because your LH never goes high enough to trip them. Or the most obnoxious out of all of these, I think, is they surf the line.

33:29Dr. Carrie Bedient: And it's just high enough to go positive and then go negative. So it looks like you ovulated, but you really didn't. And then a couple of days later, it goes positive again. And people will drive themselves to absolute distraction trying to keep up with these ovulation predictor kits. And many of the apps and the kits that are now out there at least give more direction than just the straight blue line, positive or negative. But even so, it can be very, very helpful to say, okay, I am going to give up this particular headache. I'm going to hand this one over to the doc so that we can worry about it because I guarantee you, we're not going to worry about it for very long.

34:10Dr. Carrie Bedient: We're going to give you the medication, then we're going to give you a trigger shot, and this is going to be the least of both your and our problems. We're going to spend all of our time on everything else because getting you to ovulate with the meds that we have available, in the grand scheme of things, is fairly easy. Don't hold on to the problems you don't have to hold on to. And in many cases for PMOS, that problem comes in the form of an ovulation predictor.

34:33Dr. Susan Hudson: I thought of another one. Another one is when you're working with your doctor and if you're trying to do things with either timed intercourse or IUIs, intrauterine insemination, go in there with a little bit of patience because women with PMOS walk a very fine line between not recruiting a follicle and recruiting too many follicles. We have some very good, effective supplements, medications, techniques that will help us get you where you need to be. But sometimes it takes a little bit of time to figure out the special combination that your particular body needs, especially if you're one of those people who have lots and lots and lots of those follicles on your ovaries.

35:28Dr. Susan Hudson: Now, the qualification for polycystic appearing ovaries has historically been about 11 or 12 follicles. I'm talking about those people who have like 25 follicles on both of your ovaries. It may take a little bit longer, but your doctor is probably going to be able to get you where you want to be.

35:47Dr. Carrie Bedient: So here's another practical question. What are your favorite medications for PMOS patients? What are the ones that seem to come out of our toolbox most often with this group of patients? This is what we call ovulation induction. If what we're doing in my office is we're trying to induce ovulation and this is cycle to cycle. So it's medication, it's pills that you take at the beginning of the cycle, and we may have to define when that is, and it's really cycle to cycle. So it will restore ovulation, presumably for that one cycle, and we'll time intercourse or we'll decide to move forward with an intrauterine insemination, and then if that works, that's what works, and if not, two weeks later, you'll get a period, and we start again.

36:33There are fertility medications that we can use for this. There are medications such as Clomid, such as Letrozol. They have brand names. They have generic names. I usually call it Femar Letrozol. And this is the medication that I like to use for PMOS patients because it does a pretty good job of not only restoring ovulation, but usually the goal is it recruits one follicle or one egg to release as opposed to many. And when we're first starting out and just trying to restore ovulation, we really only want the one egg to release to reduce that chance or risk of multiples. So for me, that's one I like to use.

37:12If now we're thinking of prediabetes, now we're focusing on the whole condition, there are other medications that we might want to consider using, which now again, we're back to multifactorial, a gynecologist or somebody else prescribing these medications, potentially metformin. Metformin, this isn't necessarily the number one benefit, the number one goal, but it could restore ovulation. But if we're improving the glycemic profile and reducing the insulin resistance, then that may be a secondary benefit. So these are some of the medication in my toolbox.

37:44Dr. Susan Hudson: I would say one of my favorite supplements is ovacetol, which is a combination of myoinositol and D-chiroinositol in a very specific proportion. I think there's some reasonable evidence that it can even help people restore normal ovulation as an independent factor. It does a pretty good job with people who have some borderline glycemic control. So if you're on the edge of prediabetes or in that prediabetes range and you're like, I really need to get that down so I don't increase my risk of diabetes and pregnancy, some pretty good evidence that's coming out that that can help us on our journey.

38:30Dr. Susan Hudson: I think it's a little bit better tolerated than sometimes things like metformin. But if you need some of the bigger guns like metformin, then we absolutely use them. Carrie, what do you tend to use?

38:44Dr. Carrie Bedient: I agree with everything that you all have said. I default to letrozole as the first ovulation induction agent of choice. I'm pretty liberal with who I give metformin to in this group of people, but always with the caution that metformin can have some GI side effects, nausea, diarrhea, upset, all of those things can be more common. So ideally, you want to go slow and increase it, take it with food, take it in the evening, maybe one of the extended release versions so that you experience some of those side effects less. I think the Myo-inositol is a great way to go because you can start it whenever you want.

39:19Dr. Carrie Bedient: You don't need a doctor's prescription for that. And it's a great little second messenger system. So it replaces the mechanics in the cells that help make things happen. So it's the ropes and the pulley is behind the big set pieces moving around. And if you can make those easier to work with, then you can affect everything down the line. So I would say that those are my three big medications as well.

39:46Dr. Susan Hudson: Vitamin D as well. People with PMOS, although most of us are vitamin D deficient, people with PMOS have an even higher risk of being vitamin D deficient. So making sure you're getting a good vitamin D supplement. That's another one.

40:00Dr. Carrie Bedient: So has anything changed about the diagnostic criteria at all between PCOS and PMOS? It's very similar. We list again the three criteria, the irregular cycles and the high androgens and the appearance on the ultrasound of these many follicles. And different governing bodies have had different definitions and diagnoses and sometimes it depends on if you're in the teenage years. But now really we're still thinking about those three criteria. two of the three. We're adding AMH, now antimullarian hormone, which again usually goes hand in hand with the number of antral follicles that we're seeing on the ultrasound.

40:39So that being elevated, a little nuanced with again the number of follicles seen in each ovary. I think it's important and it's always important to meet the criteria to know if you have a syndrome or a disease or whatever it is. But really part of this change in nomenclature is just to be more inclusive, to have a broader approach. And so some people exist somewhere on the spectrum with PCOS, PMOS, and you don't necessarily have to fully have the diagnosis to take the same therapeutic approach and the same treatment approach. So yes, there are some subtle differences, but I think that the concept is the same.

41:19And hopefully with the name change, it will be more comprehensive in terms of the diagnosis and the treatment. Absolutely.

41:26Dr. Carrie Bedient: Well, all set. Thank you so much for spending your time with us, Stephanie. This has been Dr. Stephanie Brownridge at RMA New York, and she's in the Manhattan office. So go see her, especially if you are struggling with PCOS slash PMOS. And keep in mind that any of the prior information you see published on PCOS, it all still applies. It's not like it goes into obscurity just because there's been a name change. But we're very appreciative that you joined us for this episode, Stephanie. Thank you. Thank you so much for having me. For anybody who happens to be watching the video, the sun has literally set on our conversation.

42:04Thank you so much to our audience for spending part of your day with us.

42:07Dr. Susan Hudson: If you enjoyed this episode, subscribe, leave a review, and send us your questions at fertilitydocsandsensored.com.

42:14Dr. Carrie Bedient: And if you want even more fertility information, pick up a copy of the IVF Blueprint, which is our practical guide to understanding fertility treatment, IVF, and the decisions you face along the way.

42:23Dr. Susan Hudson: Before we go, remember, this podcast is for education and entertainment only.

42:28Dr. Carrie Bedient: While we are fertility doctors, we are not your fertility doctors.

42:33Dr. Susan Hudson: Nothing we discuss should replace medical advice from your own physician who knows your individual history and circumstances. Thanks for listening. Bye. This podcast is sponsored by Receptiva DX. When fertility questions remain unanswered, Receptiva DX helps reveal why. Trusted by fertility specialists for over a decade, Receptiva DX identifies inflammatory changes in the uterine lining associated with endometriosis and other conditions that may interfere with implantation and pregnancy. From unexplained infertility, recurrent pregnancy loss, or simply undiagnosed pain, Receptiva DX helps women and their physicians make more informed treatment decisions and move forward with confidence.

43:16We'll be right back.