Managing PMOS and insulin resistance: From primary care to specialist

Welcome back to this Contemporary OB/GYN, Contemporary Pediatrics, and Patient Care Online Special Report series, exploring the global consensus on renaming polycystic ovary syndrome (PCOS) to polyendocrine metabolic ovarian syndrome (PMOS). Across 5 episodes, our host and experts examine what this shift means for diagnosis, management, and patient care across the reproductive lifespan.

Our Experts:

• Heather Appelbaum, MD, FACOG, is director of Pediatric and Adolescent Gynecology at K. Hovnanian Children's Hospital at Hackensack Meridian Jersey Shore University Medical Center. She is an associate professor of Obstetrics and Gynecology at Hackensack Meridian School of Medicine and director of the PMOS Multidisciplinary Program at Jersey Shore University Medical Center.
• Melanie Cree, MD, PhD, is a professor of Pediatric Endocrinology at the University of Colorado Anschutz Campus and founder and director of the PMOS Multi-disciplinary Clinic at Children's Hospital Colorado. She serves on the board of the Androgen Excess PMOS Society.
• Michelle M. Maresca, MD, is medical director for pediatric obesity medicine at Joseph M. Sanzari Children's Hospital at Hackensack Meridian Hackensack University Medical Center in New Jersey. She is a member of the pediatric and advocacy committees of the Obesity Medicine Association.

In this episode, the panel maps out when primary care should manage PMOS versus refer, and why insulin resistance deserves as much attention as androgens.

Michelle M. Maresca, MD, opened by describing menstrual cycles as a vital sign: irregular periods paired with signs of hyperandrogenism, such as hirsutism, severe acne, or androgenic alopecia, or with insulin-resistance markers such as acanthosis nigricans, difficulty maintaining a healthy BMI, hypertriglyceridemia, low HDL cholesterol, or metabolic dysfunction-associated steatotic liver disease, should prompt evaluation for PMOS. She said referral decisions ultimately hinge on an individual primary care provider's comfort with diagnosis, treatment, or both. Heather Appelbaum, MD, FACOG, agreed that primary care providers are well positioned to lead lifestyle interventions, including cardiovascular activity, reduced processed sugar intake, and appropriate caloric intake, and that referral makes sense once a provider reaches the limit of their comfort managing the condition.

Melanie Cree, MD, PhD, drawing on her experience in a rural Idaho practice where pediatric endocrinologists are scarce, said PMOS is not a one-visit condition and that patients should expect frequent follow-up over an extended period. She holds 2 firm lines regardless of practice setting: protecting endometrial health by some method, and requiring medication rather than lifestyle changes alone for any adolescent with type 2 diabetes. Otherwise, she said, treatment remains patient-centered.

Cree noted she has grown more aggressive with metformin and other insulin sensitizers, reasoning that PMOS-related insulin resistance compounds the insulin resistance that accompanies puberty itself, citing her own research on the topic. She described 3 stacked drivers of elevated insulin: testosterone, pubertal insulin resistance, and PMOS itself, plus a fourth driver, cortisol, shaped by sleep and stress. Poor sleep and obstructive sleep apnea blunt the normal overnight cortisol drop and worsen both insulin resistance and cravings for high-sugar, high-fat foods, she said, meaning that improving sleep and managing stress often must precede changes to diet or activity.