Polyendocrine Metabolic Ovarian Syndrome (PMOS)

What are the signs and symptoms of polyendocrine metabolic ovarian syndrome (PMOS)?

Some symptoms of PMOS are very noticeable and others are not quite as obvious. Sometimes teens keep the less obvious symptoms hidden because they are embarrassed to discuss them with parents and caregivers. We understand this at Children’s Colorado, which is why our PMOS specialists take extra time to listen to you or your child when providing care for them and offer a safe and friendly environment in which they feel comfortable sharing.

Common symptoms associated with PMOS include:

• Fewer than eight periods per year or 3 months between periods
• Not starting periods by age 15
• Weight gain
• Thick, dark hair in places where men tend to grow hair —including the upper lip, chin, sideburn area, chest and belly (called hirsutism)
• Hair loss on the top of the head or around the forehead
• Severe acne on the face, back or chest
• Dark skin on the back of the neck, in the armpits or at the waist
• Infections in the armpits, under the breasts and at the groin

High insulin and PMOS symptoms

Insulin is the hormone that helps our body use sugar. Insulin resistance with high insulin happens during puberty, PMOS, weight gain, decreased physical activity, mental health struggles, not enough sleep, sleep apnea and certain medications. As a result of high insulin, the ovaries release more testosterone. The extra testosterone causes the physical symptoms of PMOS, like excess hair growth on the face and body and periods that are not monthly.

How do we diagnose polyendocrine metabolic ovarian syndrome (PMOS)?

PCOS is a complex condition to diagnose and explain because it affects everyone differently. To be diagnosed with PMOS, a patient must have all of the following:

• Abnormal periods: This can mean skipped periods, no periods at all or periods that come more often than every three weeks.
• Skin findings or laboratory tests indicating hyperandrogenism: This means that a person has acne, hirsutism (extra hair on their face and body) and balding. If they do not have these signs, we can also make a PMOS diagnosis by testing for high levels of androgen (usually the hormone testosterone) with a blood test.
• No other cause for the symptoms.

If a patient only has one of the symptoms, they are considered "at-risk" for PMOS.

Several other laboratory measurements must be performed to rule out other causes of irregular periods. Problems with thyroid hormones (TSH, T4), prolactin (a hormone needed for making breast milk), brain hormones that talk to the ovary (LH, FSH), pregnancy and adrenal gland hormones (DHEAS, 17-OH Progesterone) produce similar symptoms, so testing for these conditions is needed as well. We rarely order a pelvic ultrasound of the ovaries as it is not indicated in teens, and we also don’t need to perform a pelvic exam. Guidelines state to diagnose PMOS in teens with physical exams and laboratory findings only.

What other conditions can PMOS be associated with?

Other conditions besides PMOS are linked to the hormones that cause higher levels of insulin and testosterone, and this can affect the entire body. Once we diagnose someone with PMOS, we also recommend they be tested for Type 2 diabetes, high cholesterol, high blood pressure, liver inflammation and obstructive sleep apnea. PMOS can also be associated with mood issues such as depression, anxiety, disordered eating and sleep problems.

Why choose Children's Hospital Colorado to test for PMOS?

Children’s Colorado has a team of experts in PMOS in multiple departments, including gynecology, endocrinology and adolescent medicine as well as psychologists, dermatologists and nutritionists with extra PMOS knowledge. An accurate diagnosis of PMOS can be made by providers in gynecology, endocrinology or adolescent medicine.

For those girls with several different medical problems related to their PMOS, Children's Colorado has the only multidisciplinary adolescent PMOS Clinic in the region. Doctors from all specialties impacted by PMOS work together in one clinic to provide you or your child with the most accurate and efficient care.

PMOS Clinic care team includes:

• Endocrinologists: doctors who manage weight gain and diabetes risk
• Gynecologists: doctors who manage irregular periods and other reproductive issues
• Dermatologists: doctors who can help with acne and unwanted hair growth
• Psychologists: doctors who can help with the mental stress of dealing with the condition
• Lifestyle experts: specialists to help with nutrition and exercise

What to expect from polyendocrine metabolic ovarian syndrome (PMOS) testing

Blood test results generally take 1 to 2 weeks. The only discomfort is from a quick needle-stick to draw blood. The blood tests are most accurate when taken in the morning before you eat.

How do we treat polyendocrine metabolic ovarian syndrome (PMOS)?

We have three main goals when treating PMOS:

• Keep the lining of the uterus (also known as the endometrium) healthy to prevent uterus cancer.
• Screen for health issues related to PMOS, including high blood pressure, fatty liver disease, high cholesterol, diabetes, sleep disorders and mood struggles.
• Treat what is bothering the patient the most first. This may be concerns about extra hair and acne, having periods every month or making lifestyle change to lower insulin levels

At Children's Colorado, our professionals provide patients with different treatment options for PMOS, including healthy lifestyle changes that teens can manage on their own. However, when lifestyle changes aren't enough, we can also prescribe medication that can be helpful.

Lifestyle changes

Anyone with PMOS should try to make healthy lifestyle choices.

• Decreasing insulin: You can do this by avoiding foods with a lot of simple carbohydrates and drinks with sugar or calories (soda, juice, coffee drinks).
• Increasing activity and exercise: This can also lower insulin and treat metabolic conditions.
• Improving sleep quality: Poor sleep, loud snoring and excess stress can all increase the stress hormone cortisol and this also makes insulin higher and increases appetite.

For those who are overweight, or who are not overweight but are not exercising, the most important treatment is making lifestyle changes in diet and exercise. A 5% to 7% reduction of total body weight can improve periods in many teens with PMOS. Patients and their families using this treatment method have access to lifestyle specialists including dieticians in our multidisciplinary clinic to help make these changes.

Medication options

Our experts will discuss which medicines might be best suited for you or your child.

Birth control with estrogen 

For girls with severe hair growth or acne, irregular periods or those who are sexually active, birth control can help. There are several options that contain estrogen such as a pill, patch or ring.

These medicines work by decreasing the amount of free testosterone in the body. Regular periods may start within the first month. It’s also normal to have some irregular bleeding at first, but this will improve with time. It usually takes 3 months to notice an improvement in acne and 6 months to notice a decrease in hair growth.

Metformin

Metformin is a pill that helps the body use insulin better and lowers insulin levels. In 6 to 12 months, metformin can help control periods, clear up acne and reduce hair growth. The most common side effect is nausea (upset stomach), but patients generally tolerate the drug well. Metformin improves the health of the ovaries and makes it easier to get pregnant. All young women who are sexually active should use birth control while taking metformin.

Learn more about Metformin:

• English (.pdf)
• Español (.pdf)

Provera

Patients take this progesterone-only pill for 10 days to cause a period and keep the uterus healthy. It’s best for teens who have not had a period in more than 3 to 6 months, or do not want to take a hormone medication every day.

Spironolactone

Spironolactone blocks the action of testosterone in the skin. This medication minimizes hair growth and acne in 6 to 12 months. Using birth control with estrogen while taking spironolactone is often recommended because spironolactone can cause birth defects. The combination may also improve skin results.

Learn more about Spironolactone:

• English (.pdf)
• Español (.pdf)

Laser hair removal

Girls with dark hair growth often seek laser hair removal. Laser therapy works best if you are also taking a medicine or making lifestyle changes to lower testosterone.

Minoxidil

This over-the-counter product blocks the hair follicle from "seeing" testosterone and slows hair loss.

It's used for balding and the loss of hair at the front of the scalp. It takes 3 to 9 months to work, and you can buy it at drug stores or grocery stores.

Long-acting, progestin-only methods

Intrauterine devices (IUDs) with progesterone (such as Mirena, Skyra or Kylina), and the under-the-skin implant, Implanon, provide a steady, low-dose of progestin. Progestin is a hormonal medication that keeps the lining of the uterus healthy and reduces menstrual bleeding. IUD are effective for 3-8 years and the implant works for 3 years. We can remove either method at any time. These methods do not help with extra hair growth, balding or acne.

Learn more about IUDs

Why choose Children's Colorado for polyendocrine metabolic ovarian syndrome (PMOS) care?

The experts in the Department of Pediatric and Adolescent Gynecology, Endocrinology and Adolescent Medicine place a strong emphasis on communicating with patients in a caring and sensitive way, whether you are a teen coming or the parent of a patient we are treating. We recognize that the teenage years can be a difficult time in a young woman's life and struggling with irregular periods and obesity as a result of PMOS can be very challenging. We not only provide expert medical treatment and considerate care, but we can also help with the added stress that PMOS can cause.

Although PMOS is a common condition, the diagnosis and management of adolescents with PMOS is very different from adults. It requires the unique expertise and medical training in pediatric healthcare that all our doctors have. By combining the efforts of health professionals from different departments like gynecology, endocrinology, dermatology, psychology, lifestyle medicine and nutrition, we can help you or your child effectively manage this condition and move on to a healthier, happier life.

The multidisciplinary PMOS Clinic at Children's Colorado provides you or your child direct access to all these medical specialists at one location to ensure the best care possible and provide treatment tailored for you or your child’s individual needs.

Managing periods with polyendocrine metabolic ovarian syndrome (PMOS)

When someone has PMOS, they don’t ovulate each month (the process of the ovaries releasing an egg). Without regular ovulation, there may be no periods, skipped periods, irregular periods, or very heavy and long bleeding. For people who have irregular periods, we recommend treatment to prevent excessive bleeding and keep the lining of the uterus healthy.

Treatment to help manage periods with PMOS

You have many options for managing periods with PMOS. All the treatments contain progestin, which keeps the lining of the uterus thin and protects it from future problems. The best treatment for you or your child will depend on several factors. Our team considers the following questions:

• Is acne an issue?
• Do you have extra hair on the face and body, or thinning hair on the head?
• Is there any issue with taking medication each day?
• When someone is using hormonal therapy, the lining of the uterus stays thin and healthy. Because of this, it’s very safe to have fewer periods or none at all. Would an option that means fewer or no menstrual periods be better?
• What else is important about keeping the uterus healthy?

Learn more about options for managing periods with PMOS and what treatments can help with acne, extra body or facial hair and thinning hair:

• English (.pdf)
• Español (.pdf)  

More information about polyendocrine metabolic ovarian syndrome (PMOS) is available from the following resources:

The Office of Women’s Health is a branch of the U.S. Department of Health and Human Services that coordinates women's health efforts and addresses critical women's health issues by informing and advancing government policies, educating health care professionals and consumers, and supporting innovative programs.

Download this information on PMOS:

• English (.pdf)