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Lean PMOS: Why the Diagnosis Gets Missed Without Weight Gain · Clearly Hormonal

• 0:01
  Dr. Komal Patil-Sisodia: Welcome to Clearly Hormonal, the podcast where we stop googling our symptoms at midnight and actually start understanding what's going on in our bodies.
• 0:09
  Dr. Komal Patil-Sisodia: I'm Dr.
• 0:09
  Dr. Komal Patil-Sisodia: Komal Patil-Sisodia, an endocrinologist, internist, obesity medicine specialist, and a Menopause Society certified practitioner, which is really just a whole lot of words to say hormones are kind of my jam.
• 0:21
  Dr. Komal Patil-Sisodia: I've spent 17 years watching women try to navigate their hormonal health without ever having been taught the language for what's happening in their own bodies, and then meeting clinicians who want nothing more than to help them figure it out, but are up against 10-minute appointments and a system that just wasn't built for it.
• 0:37
  Dr. Komal Patil-Sisodia: This podcast is my answer to that gap.
• 0:39
  Dr. Komal Patil-Sisodia: We'll cover menopause, metabolism, hormones, and everything in between with real evidence, not trends, and without the overwhelm.
• 0:47
  Dr. Komal Patil-Sisodia: A quick disclaimer: I'm a physician, but this is education, not personalized medical advice.
• 0:52
  Dr. Komal Patil-Sisodia: Take what resonates and discuss it with your own healthcare team.
• 0:56
  Dr. Komal Patil-Sisodia: Now, let's get into it and talk about what's clearly hormonal and what's not.
• 1:01
  Dr. Komal Patil-Sisodia: Hi, everyone.
• 1:02
  Dr. Komal Patil-Sisodia: Welcome back to the PMOS awareness series on Clearly Hormonal this month.
• 1:06
  Dr. Komal Patil-Sisodia: This is episode two in our four-part series.
• 1:10
  Dr. Komal Patil-Sisodia: Last week, we talked about what happens in PMOS, otherwise known as polyendocrine metabolic ovarian syndrome, after your reproductive years end, at perimenopause and beyond.
• 1:21
  Dr. Komal Patil-Sisodia: And today, we're going back to the diagnosis, but from an angle that gets almost no attention: PMOS in patients who are not struggling with overweight or obesity.
• 1:34
  Dr. Komal Patil-Sisodia: If you picture PMOS, you probably picture someone struggling with their weight.
• 1:38
  Dr. Komal Patil-Sisodia: That picture is so common that it shapes who gets tested, who gets believed, and who gets sent home without answers.
• 1:47
  Dr. Komal Patil-Sisodia: But a significant number of people who have PMOS are actually a normal body weight, and because they don't fit the picture, they often wait years for a diagnosis, if they ever get one at all.
• 2:00
  Dr. Komal Patil-Sisodia: Today, we're talking about lean PMOS, what it looks like, why it gets missed, and what it means for how we should be screening.
• 2:09
  Dr. Komal Patil-Sisodia: Let's talk a bit about where the idea of the PMOS body comes from and why that picture exists in the first place.
• 2:18
  Dr. Komal Patil-Sisodia: PMOS is closely linked to insulin resistance, and insulin resistance often shows up alongside weight gain, especially around the middle.
• 2:26
  Dr. Komal Patil-Sisodia: And because that pattern is common, it became the default image of PMOS in medical training, in patient education, and in the culture at large.
• 2:37
  Dr. Komal Patil-Sisodia: Ask most people to describe PMOS, and weight comes up almost immediately.
• 2:42
  Dr. Komal Patil-Sisodia: But here's the problem.
• 2:43
  Dr. Komal Patil-Sisodia: The picture describes a common presentation.
• 2:47
  Dr. Komal Patil-Sisodia: It doesn't really describe the diagnosis itself.
• 2:50
  Dr. Komal Patil-Sisodia: PMOS is defined by three things: irregular periods, or anovulatory cycles, high androgen hormones like DHEAS and testosterone, and a certain pattern on ovarian ultrasound that we call polycystic ovarian morphology.
• 3:06
  Dr. Komal Patil-Sisodia: Body weight is not one of the three criteria for diagnosis.
• 3:10
  Dr. Komal Patil-Sisodia: A lean patient can meet every single one of those criteria.
• 3:14
  Dr. Komal Patil-Sisodia: A patient with a normal BMI can meet every single one of those criteria just as clearly as a patient who is living in a larger body.
• 3:23
  Dr. Komal Patil-Sisodia: So when we let one common presentation stand in for a whole diagnosis, we set up a system that is built to miss people who don't really match the picture we've painted in our heads Let's talk a bit about what lean PMOS actually looks like.
• 3:39
  Dr. Komal Patil-Sisodia: The reproductive symptoms are often the same.
• 3:42
  Dr. Komal Patil-Sisodia: Irregular or missing periods, acne that shows up in teen years and in adulthood, increased facial hair growth on the face, the chest, or the back, and hair thinning at the scalp.
• 3:54
  Dr. Komal Patil-Sisodia: These symptoms show up whether someone is carrying extra weight.
• 3:58
  Dr. Komal Patil-Sisodia: These symptoms show up regardless of whether someone's carrying extra weight because they come from androgen hormones, not from body size.
• 4:05
  Dr. Komal Patil-Sisodia: And the metabolic picture can also look different on the surface, but it's not necessarily healthier underneath.
• 4:12
  Dr. Komal Patil-Sisodia: Lean patients with PMOS can still have insulin resistance.
• 4:17
  Dr. Komal Patil-Sisodia: Their bodies just handle it a little bit differently.
• 4:19
  Dr. Komal Patil-Sisodia: Instead of storing the extra insulin's effects as visible weight gain, they may store fat in less visible places, like around the organs in the abdomen, and externally, they can look like they have a normal BMI everywhere else.
• 4:36
  Dr. Komal Patil-Sisodia: This is sometimes called normal weight obesity, and it's exactly the kind of thing a scale or a quick look in an exam room will never catch.
• 4:45
  Dr. Komal Patil-Sisodia: So a patient with a normal BMI can walk into an office with textbook PMOS symptoms and an insulin resistance pattern that's kind of bringing underneath the surface and still walk out without a diagnosis because nothing about their appearance raised a flag It's no surprise why the diagnosis gets missed.
• 5:05
  Dr. Komal Patil-Sisodia: This is where I wanna slow down a bit, because there's a few different ways this diagnosis slips through the cracks, and they all compound on each other.
• 5:13
  Dr. Komal Patil-Sisodia: First, patients don't often bring up their symptoms as a pattern.
• 5:17
  Dr. Komal Patil-Sisodia: Someone might mention irregular periods to their gynecologist, unwanted facial hair to their esthetician, and adult acne to their dermatologist.
• 5:27
  Dr. Komal Patil-Sisodia: Each provider sees one piece, and nobody sees all three together, which is what would clearly point towards PMOS.
• 5:36
  Dr. Komal Patil-Sisodia: Second, when a patient with a normal BMI brings these symptoms to a doctor, weight is often used as an informal filter for who, quote,"looks like" they might have PMOS.
• 5:49
  Dr. Komal Patil-Sisodia: A doctor who has trained on the idea that PMOS equals weight gain may reach for other explanations first.
• 5:57
  Dr. Komal Patil-Sisodia: Common things I hear in my office are,"I was told it was stress,""side effects to birth control," or,"Some women are just irregular." That is not a failure of caring.
• 6:08
  Dr. Komal Patil-Sisodia: It's a failure of the mental picture we've been trained to use.
• 6:13
  Dr. Komal Patil-Sisodia: Third, patients often don't think to raise PMOS as a possibility if they're not struggling with their weight.
• 6:21
  Dr. Komal Patil-Sisodia: If everything they've ever heard about PMOS ties it to weight and they've never struggled with that, PMOS may never even cross their mind as an explanation for what they're experiencing.
• 6:32
  Dr. Komal Patil-Sisodia: And you put all those three things together, and you get exactly what we see in practice: longer delays to diagnosis for patients who have PMOS and a normal BMI, more specialist visits before actually getting an answer, and more time spent being told nothing is wrong.
• 6:51
  Dr. Komal Patil-Sisodia: So why does this matter?
• 6:53
  Dr. Komal Patil-Sisodia: Here's why.
• 6:55
  Dr. Komal Patil-Sisodia: It connects directly to what we- So why does this matter?
• 6:59
  Dr. Komal Patil-Sisodia: So why does closing this gap matter?
• 7:02
  Dr. Komal Patil-Sisodia: I want to talk about how it connects directly to what we talked about in the last episode.
• 7:06
  Dr. Komal Patil-Sisodia: PMOS is a cardiometabolic condition, meaning it affects your heart and your metabolism, not just your reproductive system.
• 7:15
  Dr. Komal Patil-Sisodia: That's true no matter what a patient's body looks like.
• 7:18
  Dr. Komal Patil-Sisodia: A lean patient with undiagnosed PMOS is still building that same insulin resistance and cholesterol changes we talked about last week.
• 7:25
  Dr. Komal Patil-Sisodia: They're just doing it without anyone watching because nothing about their appearance triggered the screening conversation.
• 7:32
  Dr. Komal Patil-Sisodia: That means a lean patient with PMOS may actually be at a specific kind of disadvantage.
• 7:38
  Dr. Komal Patil-Sisodia: Their metabolic risk is real, but it's invisible to the usual visual cues doctors are trained to notice.
• 7:45
  Dr. Komal Patil-Sisodia: Without a diagnosis, they're not getting the blood work, the monitoring, or the conversation about long-term heart health that a diagnosis would normally trigger.
• 7:54
  Dr. Komal Patil-Sisodia: The cost of missing lean PMOS isn't just a delayed answer to why my periods are irregular.
• 8:01
  Dr. Komal Patil-Sisodia: It's a delayed start on protecting metabolic and heart health for decades ahead.
• 8:06
  Dr. Komal Patil-Sisodia: Here's what I think should change, and I want to put forth what I want all of the listeners, patients and clinicians both, to take from this episode.
• 8:16
  Dr. Komal Patil-Sisodia: For clinicians, stop using body size as a filter for who gets worked up for PMOS.
• 8:22
  Dr. Komal Patil-Sisodia: If a patient has irregular cycles, signs of high testosterone or DHEAS, or both, that's the signal to evaluate regardless of what the patient weighs.
• 8:33
  Dr. Komal Patil-Sisodia: A normal weight does not rule anything out.
• 8:36
  Dr. Komal Patil-Sisodia: And for patients, if you have irregular periods, adult acne, increased hair growth on your face or on your body, or thinning of your scalp hair, and you've been told it's just stress or just genetics without actually getting a real workup, it's reasonable to ask specifically about PMOS, even if you've never thought of yourself as someone who would have it.
• 8:58
  Dr. Komal Patil-Sisodia: Bring the symptoms together as a pattern rather than mentioning them one at a time to different providers.
• 9:04
  Dr. Komal Patil-Sisodia: And for anyone who's already been diagnosed with lean PMOS, don't let your body size convince you that the metabolic risk doesn't apply to you.
• 9:13
  Dr. Komal Patil-Sisodia: It does.
• 9:14
  Dr. Komal Patil-Sisodia: The monitoring and the long-term thinking we talked about in the last episode applies just as much to you as it does to anyone else with the diagnosis.
• 9:24
  Dr. Komal Patil-Sisodia: That's episode two of our PMOS Awareness Month series.
• 9:28
  Dr. Komal Patil-Sisodia: The takeaway today, PMOS does not have one body type.
• 9:34
  Dr. Komal Patil-Sisodia: If we keep diagnosing it like it does, we will keep missing people who need answers, and more importantly, need the long-term monitoring that comes with those answers.
• 9:44
  Dr. Komal Patil-Sisodia: Next week, we're going to talk a bit about treatment.
• 9:46
  Dr. Komal Patil-Sisodia: We'll talk about where GLP-1 medications and other weight management tools fit into PMOS care and who they actually make sense for.
• 9:54
  Dr. Komal Patil-Sisodia: Thank you all for listening, and if this episode helped you see PMOS differently, share it with someone who needs to hear it.
• 10:01
  Dr. Komal Patil-Sisodia: I'll see you on the next episode.
• 10:04
  Dr. Komal Patil-Sisodia: Before you sign off, I wanted to tell you about a project that I have that's coming up that I'm very excited about.
• 10:09
  Dr. Komal Patil-Sisodia: I'm putting out a PMOS mini course to help you get a better understanding of your PMOS phenotype and how to advocate for yourself when you go into a doctor's office and you're not getting answers or help.
• 10:21
  Dr. Komal Patil-Sisodia: If you want more information, sign up for my newsletter, which you can find at eastsidemm.com/newsletter or follow me on social@drpatilsisodia on Instagram or TikTok.