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Same Diagnosis, Different Bodies: The Four PMOS Phenotypes · 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.
• 0:10
  Dr. Komal Patil-Sisodia: I'm Dr.
• 0:10
  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.
• 0:22
  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.
• 0:38
  Dr. Komal Patil-Sisodia: This podcast is my answer to that gap.
• 0:40
  Dr. Komal Patil-Sisodia: We'll cover menopause, metabolism, hormones, and everything in between with real evidence, not trends, and without the overwhelm.
• 0:48
  Dr. Komal Patil-Sisodia: A quick disclaimer.
• 0:49
  Dr. Komal Patil-Sisodia: I'm a physician, but this is education, not personalized medical advice.
• 0:53
  Dr. Komal Patil-Sisodia: Take what resonates and discuss it with your own healthcare team.
• 0:57
  Dr. Komal Patil-Sisodia: Now, let's get into it and talk about what's clearly hormonal and what's not.
• 1:04
  Dr. Komal Patil-Sisodia: Picture two women.
• 1:05
  Dr. Komal Patil-Sisodia: They're both in their late twenties, and within a few months of each other, they both get the same diagnosis, PMOS, polyendocrine metabolic ovarian syndrome, which was previously known as PCOS, which is the name you still may hear more often.
• 1:20
  Dr. Komal Patil-Sisodia: The first woman has many of the symptoms people usually connect with PMOS.
• 1:24
  Dr. Komal Patil-Sisodia: Her periods are irregular.
• 1:26
  Dr. Komal Patil-Sisodia: She has stubborn acne along her jawline.
• 1:29
  Dr. Komal Patil-Sisodia: She has unwanted facial or body hair, and her blood work shows higher levels of androgens like testosterone and DHEAS.
• 1:37
  Dr. Komal Patil-Sisodia: The second woman looks completely different.
• 1:40
  Dr. Komal Patil-Sisodia: Maybe her periods are pretty regular.
• 1:42
  Dr. Komal Patil-Sisodia: She doesn't have acne or unwanted hair.
• 1:44
  Dr. Komal Patil-Sisodia: Her androgen levels are normal, and she may have only found out something was going on because an ultrasound showed that her ovaries had a polycystic appearance.
• 1:54
  Dr. Komal Patil-Sisodia: The same diagnosis, very different bodies.
• 1:58
  Dr. Komal Patil-Sisodia: And this is one of the most confusing things about PMOS.
• 2:02
  Dr. Komal Patil-Sisodia: If you have PMOS, and you've ever compared symptoms with a friend and thought,"Wait, how can we possibly have the same condition?" There's a reason for that.
• 2:13
  Dr. Komal Patil-Sisodia: PMOS does not look the same in everyone.
• 2:16
  Dr. Komal Patil-Sisodia: In fact, there are four recognized phenotypes or types of PMOS, and knowing which type you have can help explain your symptoms, your health risks, and what your medical care may need to focus on.
• 2:28
  Dr. Komal Patil-Sisodia: Today, we're breaking down all four types.
• 2:31
  Dr. Komal Patil-Sisodia: What makes them different?
• 2:32
  Dr. Komal Patil-Sisodia: Why does your phenotype matter?
• 2:34
  Dr. Komal Patil-Sisodia: And what should you actually do with this information?
• 2:38
  Dr. Komal Patil-Sisodia: I'm Dr.
• 2:39
  Dr. Komal Patil-Sisodia: Komal Patil-Sisodia, and this is Clearly Hormonal.
• 2:43
  Dr. Komal Patil-Sisodia: Before we talk about the four subtypes, we need to talk about three things they're built from.
• 2:47
  Dr. Komal Patil-Sisodia: Think of them as three ingredients.
• 2:49
  Dr. Komal Patil-Sisodia: Doctors commonly use a system called the Rotterdam criteria to diagnose PMOS.
• 2:56
  Dr. Komal Patil-Sisodia: There are three possible features.
• 2:58
  Dr. Komal Patil-Sisodia: Ingredient one is hyperandrogenism.
• 3:01
  Dr. Komal Patil-Sisodia: That's a long word, so let's make it simple.
• 3:03
  Dr. Komal Patil-Sisodia: Hyperandrogenism means higher androgen levels or signs that androgens are having a stronger effect on your body.
• 3:10
  Dr. Komal Patil-Sisodia: Androgens are hormones that everyone has, regardless of gender.
• 3:14
  Dr. Komal Patil-Sisodia: But higher levels or stronger effects can cause symptoms like acne, unwanted facial or body hair, or thinning hair on the scalp.
• 3:23
  Dr. Komal Patil-Sisodia: Sometimes we see high androgen levels on a blood test, like high testosterone or high DHEAS.
• 3:29
  Dr. Komal Patil-Sisodia: Other times, the blood work may not tell the whole story, but the symptoms are there.
• 3:34
  Dr. Komal Patil-Sisodia: So this isn't only about a number on a lab report.
• 3:37
  Dr. Komal Patil-Sisodia: It's also about what these hormones are doing in your body.
• 3:41
  Dr. Komal Patil-Sisodia: Ingredient number two is ovulatory dysfunction.
• 3:45
  Dr. Komal Patil-Sisodia: This means you aren't ovulating regularly.
• 3:47
  Dr. Komal Patil-Sisodia: Ovulation is when an ovary releases an egg.
• 3:50
  Dr. Komal Patil-Sisodia: When that doesn't happen regularly, your periods may become unpredictable, very far apart, or disappear completely.
• 3:57
  Dr. Komal Patil-Sisodia: But this can be tricky.
• 3:58
  Dr. Komal Patil-Sisodia: Some people have cycles that look fairly normal and still aren't ovulating regularly.
• 4:03
  Dr. Komal Patil-Sisodia: So having a period doesn't always tell us the whole story.
• 4:07
  Dr. Komal Patil-Sisodia: Ingredient three: polycystic ovarian morphology This is something we can see on an ultrasound, and here's an important myth to clear up.
• 4:18
  Dr. Komal Patil-Sisodia: We're not actually talking about a bunch of ovarian cysts.
• 4:21
  Dr. Komal Patil-Sisodia: What doctors are usually seeing is a higher number of small follicles, or sometimes ovaries that are larger than expected.
• 4:29
  Dr. Komal Patil-Sisodia: That old word, polycystic, has caused a lot of confusion.
• 4:33
  Dr. Komal Patil-Sisodia: Now, here's the most important part.
• 4:35
  Dr. Komal Patil-Sisodia: You only need two of these three ingredients or features to meet the diagnostic criteria for PMOS.
• 4:43
  Dr. Komal Patil-Sisodia: Two out of three.
• 4:44
  Dr. Komal Patil-Sisodia: You do not need all three.
• 4:46
  Dr. Komal Patil-Sisodia: And that one fact explains why two people with PMOS can look so different.
• 4:52
  Dr. Komal Patil-Sisodia: Different combinations of these three ingredients create different types of PMOS.
• 4:57
  Dr. Komal Patil-Sisodia: And here's one more myth before we move on.
• 4:59
  Dr. Komal Patil-Sisodia: Having polycystic-looking ovaries on an ultrasound by itself does not mean you have PMOS.
• 5:06
  Dr. Komal Patil-Sisodia: That's only one of the three ingredients.
• 5:09
  Dr. Komal Patil-Sisodia: So now that we know our ingredients, let's put them together There are four phenotypes There are four phenotypes, A, B, C, and D.
• 5:19
  Dr. Komal Patil-Sisodia: Those letters aren't very memorable, so I'm gonna give each one a nickname.
• 5:23
  Dr. Komal Patil-Sisodia: Phenotype A is the full house.
• 5:26
  Dr. Komal Patil-Sisodia: It has all three ingredients, hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology.
• 5:34
  Dr. Komal Patil-Sisodia: All three.
• 5:35
  Dr. Komal Patil-Sisodia: That's why I call it the full house.
• 5:37
  Dr. Komal Patil-Sisodia: This is probably the version that comes closest to what many people picture when they hear PMOS.
• 5:43
  Dr. Komal Patil-Sisodia: Someone may have irregular periods, acne, or unwanted hair growth, higher androgen levels, and the typical ovarian appearance on an ultrasound.
• 5:52
  Dr. Komal Patil-Sisodia: This group also tends to have the highest level of metabolic risk, meaning high risk for developing metabolic syndrome, which increases your lifetime risk for diabetes, heart disease, and stroke.
• 6:04
  Dr. Komal Patil-Sisodia: Phenotype B is hormonal and irregular without the ultrasound finding.
• 6:09
  Dr. Komal Patil-Sisodia: It has two ingredients, hyperandrogenism plus ovulatory dysfunction.
• 6:15
  Dr. Komal Patil-Sisodia: But the ovaries don't have that typical polycystic appearance on ultrasound.
• 6:20
  Dr. Komal Patil-Sisodia: This surprises a lot of people.
• 6:22
  Dr. Komal Patil-Sisodia: You can have PMOS even when your ovaries look completely normal on an ultrasound.
• 6:28
  Dr. Komal Patil-Sisodia: You may have acne, unwanted hair growth, higher androgen levels, and irregular periods, But no polycystic ovarian morphology.
• 6:36
  Dr. Komal Patil-Sisodia: And here's something important.
• 6:38
  Dr. Komal Patil-Sisodia: The metabolic risk for phenotype B can look a lot like the risk for phenotype A.
• 6:43
  Dr. Komal Patil-Sisodia: That tells us that the ultrasound appearance isn't necessarily what's driving that risk.
• 6:50
  Dr. Komal Patil-Sisodia: Phenotype C is the ovulatory type.
• 6:50
  Dr. Komal Patil-Sisodia: Phenotype C has hyperandrogenism plus polycystic ovarian morphology.
• 6:57
  Dr. Komal Patil-Sisodia: But ovulation is still happening regularly, so this person may have fairly regular periods.
• 7:02
  Dr. Komal Patil-Sisodia: They may not think anything is wrong with ovulation at all.
• 7:06
  Dr. Komal Patil-Sisodia: Instead, acne, unwanted hair growth, scalp hair thinning, or abnormal hormone testing may be what leads them to a doctor.
• 7:14
  Dr. Komal Patil-Sisodia: This group still has metabolic risk, but it generally falls somewhere between phenotypes A and B and the milder phenotype D.
• 7:23
  Dr. Komal Patil-Sisodia: And then we have phenotype D, which is the non-hyperandrogenic type.
• 7:28
  Dr. Komal Patil-Sisodia: This type has ovulatory dysfunction plus polycystic ovarian morphology, but there's no hyperandrogenism.
• 7:35
  Dr. Komal Patil-Sisodia: So androgen levels may be totally normal.
• 7:38
  Dr. Komal Patil-Sisodia: There may be no unwanted hair growth, no androgen-related acne, and this tends to be the mildest of the four when we're talking about hormone and metabolic problems.
• 7:48
  Dr. Komal Patil-Sisodia: But, and this is important, milder does not mean the risk doesn't exist.
• 7:54
  Dr. Komal Patil-Sisodia: So we're gonna come back to that.
• 7:56
  Dr. Komal Patil-Sisodia: So let's review.
• 7:57
  Dr. Komal Patil-Sisodia: A is all three criteria.
• 7:59
  Dr. Komal Patil-Sisodia: B is androgens plus ovulation problems.
• 8:03
  Dr. Komal Patil-Sisodia: C is elevated androgens plus the ovarian appearance.
• 8:08
  Dr. Komal Patil-Sisodia: And D is ovulation problems plus the ovarian appearance without the high androgens.
• 8:14
  Dr. Komal Patil-Sisodia: Four combinations, four different ways PMOS can show up, one diagnosis.
• 8:20
  Dr. Komal Patil-Sisodia: And suddenly, it makes so much more sense why comparing your PMOS to someone else's can be so frustrating.
• 8:27
  Dr. Komal Patil-Sisodia: Let's talk about why your phenotype actually matters.
• 8:30
  Dr. Komal Patil-Sisodia: You may be thinking,"Okay, interesting.
• 8:33
  Dr. Komal Patil-Sisodia: I'm an A, B, C, or D.
• 8:34
  Dr. Komal Patil-Sisodia: Is that like getting my colors done and I'm a winter, spring, summer, fall?" But does that letter actually change anything?
• 8:43
  Dr. Komal Patil-Sisodia: Yes, because your phenotype isn't just an interesting label.
• 8:47
  Dr. Komal Patil-Sisodia: It can act like a risk map.
• 8:49
  Dr. Komal Patil-Sisodia: One of the biggest things we're watching for in PMOS is insulin resistance.
• 8:54
  Dr. Komal Patil-Sisodia: Insulin is a hormone that can help move glucose or sugar from your blood into your cells, where your body can use it for energy.
• 9:02
  Dr. Komal Patil-Sisodia: With insulin resistance, your cells don't respond to insulin as well as they should, so your body may need to produce more and more insulin to get the same job done.
• 9:12
  Dr. Komal Patil-Sisodia: Over time, that can affect much more than your blood sugar, and here's where this gets really important.
• 9:19
  Dr. Komal Patil-Sisodia: We sometimes assume that body weight tells us who is at metabolic risk, but the research tells us the picture is much more complicated.
• 9:27
  Dr. Komal Patil-Sisodia: A twenty twenty-five study looked directly at insulin resistance and found that insulin resistance helped predict which PMOS phenotype a person had.
• 9:38
  Dr. Komal Patil-Sisodia: Once researchers accounted for insulin resistance, bMI or body mass index was no longer a significant predictor.
• 9:44
  Dr. Komal Patil-Sisodia: In plain English, two people can have the same BMI and carry very different metabolic risks, and someone in a thinner body can still have pretty significant insulin resistance.
• 9:55
  Dr. Komal Patil-Sisodia: That matters especially for people with phenotype A or B.
• 9:59
  Dr. Komal Patil-Sisodia: If you have a lower BMI, you should not be automatically told you're thin, so we don't have to worry about metabolic problems.
• 10:06
  Dr. Komal Patil-Sisodia: Your body size doesn't give us enough information.
• 10:09
  Dr. Komal Patil-Sisodia: Your actual metabolic health matters.
• 10:12
  Dr. Komal Patil-Sisodia: Researchers are starting to look beyond these four phenotypes.
• 10:15
  Dr. Komal Patil-Sisodia: Newer studies are asking whether we can group PMOS based more directly on patterns involving insulin, androgens, and other reproductive hormones.
• 10:23
  Dr. Komal Patil-Sisodia: We're not quite at the point where everyone needs to memorize all of those newer categories, but the direction of the science is exciting.
• 10:30
  Dr. Komal Patil-Sisodia: We're moving towards a future where we may be able to say,"This is the exact pattern happening in your body, and these are the risks we need to pay most attention to." For now, the practical lesson is this.
• 10:43
  Dr. Komal Patil-Sisodia: Your phenotype may help guide how closely your clinician watches things like insulin resistance, cholesterol, other lipids, and blood pressure, especially if you're phenotype A or B.
• 10:55
  Dr. Komal Patil-Sisodia: And your weight should never be the only thing deciding whether you get screening I want to talk directly to people with phenotype D for a minute because I've heard versions of these questions from patients.
• 11:06
  Dr. Komal Patil-Sisodia: I don't have the acne.
• 11:07
  Dr. Komal Patil-Sisodia: I don't have the hair growth.
• 11:08
  Dr. Komal Patil-Sisodia: My androgens are normal.
• 11:10
  Dr. Komal Patil-Sisodia: Does my diagnosis really count?
• 11:12
  Dr. Komal Patil-Sisodia: Yes.
• 11:13
  Dr. Komal Patil-Sisodia: Phenotype D is still PMOS.
• 11:15
  Dr. Komal Patil-Sisodia: It meets the diagnostic criteria.
• 11:18
  Dr. Komal Patil-Sisodia: Your symptoms may not match the version of PMOS that gets talked about most often, but that doesn't mean your experience doesn't matter.
• 11:26
  Dr. Komal Patil-Sisodia: And this can become a real problem.
• 11:28
  Dr. Komal Patil-Sisodia: When symptoms are less obvious, people may be more likely to delay care.
• 11:33
  Dr. Komal Patil-Sisodia: Sometimes patients start wondering whether follow-up appointments are even worth it.
• 11:37
  Dr. Komal Patil-Sisodia: Sometimes clinicians may not pay as much attention because the patient doesn't fit the classic picture.
• 11:43
  Dr. Komal Patil-Sisodia: But ovulatory dysfunction, meaning irregular periods, is still ovulatory dysfunction.
• 11:49
  Dr. Komal Patil-Sisodia: And if you're not ovulating regularly, that can still affect your menstrual cycle and your fertility plans if fertility matters to you.
• 11:57
  Dr. Komal Patil-Sisodia: Now, there's another side to all of this, and I don't wanna scare you unnecessarily.
• 12:01
  Dr. Komal Patil-Sisodia: Phenotype D really does tend to have the mildest metabolic risk of the four phenotypes.
• 12:06
  Dr. Komal Patil-Sisodia: That's good news.
• 12:08
  Dr. Komal Patil-Sisodia: Lower risk is lower risk, but lower risk does not mean zero risk, and it doesn't mean that your diagnosis should simply be ignored.
• 12:15
  Dr. Komal Patil-Sisodia: It means your medical plan may look more different, and that's the entire point about talking about phenotypes.
• 12:21
  Dr. Komal Patil-Sisodia: And here's one more thing I want you to remember.
• 12:23
  Dr. Komal Patil-Sisodia: Your phenotype may not stay exactly the same forever.
• 12:26
  Dr. Komal Patil-Sisodia: Hormones change over time, your symptoms can change with age, and treatment can change with what we're seeing.
• 12:33
  Dr. Komal Patil-Sisodia: Your body at twenty-two may not look like your body at thirty-two or forty-two.
• 12:37
  Dr. Komal Patil-Sisodia: So think of your phenotype as a snapshot of what's happening in your body, not a permanent label stamped on you for life.
• 12:45
  Dr. Komal Patil-Sisodia: So what do you do with this information now that you know that there are four phenotypes?
• 12:50
  Dr. Komal Patil-Sisodia: I have three things I want you to take away from this episode.
• 12:53
  Dr. Komal Patil-Sisodia: Number one, ask which phenotype you have.
• 12:56
  Dr. Komal Patil-Sisodia: At your next appointment, ask,"Which PMOS phenotype do I have?" And if your clinician doesn't normally use the letters, ask this instead:"Which of the three Rotterdam criteria did I meet when I was diagnosed?
• 13:10
  Dr. Komal Patil-Sisodia: Was it hyperandrogenism, ovulatory dysfunction, polycystic ovarian morphology, or all three?" You may have had this diagnosis for years without anybody ever explaining that part to you.
• 13:22
  Dr. Komal Patil-Sisodia: Number two, ask what your phenotype means for screening.
• 13:26
  Dr. Komal Patil-Sisodia: Once you know your phenotype, ask,"Does this change how often I should be screened for metabolic problems?" Ask about insulin resistance, ask about cholesterol and your overall lipid panel, ask about blood pressure, and ask about how often those things should be checked based on your individual risk.
• 13:44
  Dr. Komal Patil-Sisodia: The goal isn't to collect another letter for your medical chart.
• 13:47
  Dr. Komal Patil-Sisodia: The goal is to use that information to make your care more specific to you.
• 13:52
  Dr. Komal Patil-Sisodia: Number three, don't let BMI end the conversation.
• 13:57
  Dr. Komal Patil-Sisodia: This is especially important if you're in a thinner body.
• 14:00
  Dr. Komal Patil-Sisodia: If you have phenotype A or B, don't assume you're protected from insulin resistance because of your size, and don't let someone else assume that either.
• 14:08
  Dr. Komal Patil-Sisodia: You deserve appropriate metabolic screening based on what's happening inside your body, not just what your body looks like from the outside.
• 14:15
  Dr. Komal Patil-Sisodia: And this connects to a bigger idea we talk about often on Clearly Hormonal.
• 14:19
  Dr. Komal Patil-Sisodia: PMOS isn't only about periods, and it isn't only about fertility.
• 14:24
  Dr. Komal Patil-Sisodia: The reproductive symptoms may be what gets your attention when you're younger, but your long-term metabolic health matters too.
• 14:32
  Dr. Komal Patil-Sisodia: Knowing your phenotype gives you one more piece of information that can help you ask better questions and get more individualized care.
• 14:39
  Dr. Komal Patil-Sisodia: Now, let's bring it all together.
• 14:41
  Dr. Komal Patil-Sisodia: PMOS is diagnosed using three main features: hyperandrogenism, so signs that your testosterone is elevated either clinically or on a lab test; ovulatory dysfunction, where your periods are not irregular or may be absent; and polycystic ovarian morphology, where you appear to have a lot of little small follicles in your ovaries or your ovaries appear larger than the average population.
• 15:07
  Dr. Komal Patil-Sisodia: You generally need two out of those three.
• 15:10
  Dr. Komal Patil-Sisodia: And because those features can show up in different combinations, we get four different phenotypes: A, B, C, and D.
• 15:17
  Dr. Komal Patil-Sisodia: Phenotype A has all three criteria.
• 15:20
  Dr. Komal Patil-Sisodia: Phenotype B has hyperandrogenism and ovulatory dysfunction.
• 15:24
  Dr. Komal Patil-Sisodia: Phenotype C has hyperandrogenism and polycystic ovarian morphology.
• 15:29
  Dr. Komal Patil-Sisodia: And phenotype D has ovulatory dysfunction and polycystic ovarian morphology without the hyperandrogenism.
• 15:36
  Dr. Komal Patil-Sisodia: Same diagnosis, different bodies, different symptoms, and different levels of risk.
• 15:41
  Dr. Komal Patil-Sisodia: And maybe the most important thing I want you to remember from this episode is you cannot tell someone's metabolic health just by looking at their body.
• 15:51
  Dr. Komal Patil-Sisodia: BMI is one piece of information.
• 15:53
  Dr. Komal Patil-Sisodia: It's not the whole story.
• 15:56
  Dr. Komal Patil-Sisodia: If this episode gave you language you didn't have before, screenshot the phenotype breakdown and send it to someone who's been told you have PMOS but was never told what type.
• 16:05
  Dr. Komal Patil-Sisodia: And maybe save those three questions for your next appointment.
• 16:08
  Dr. Komal Patil-Sisodia: Which phenotype do I have?
• 16:10
  Dr. Komal Patil-Sisodia: Which diagnostic criteria did I meet?
• 16:13
  Dr. Komal Patil-Sisodia: And what does that mean for my screening and care?
• 16:16
  Dr. Komal Patil-Sisodia: Better information gives you better questions, and better questions can lead to better care.
• 16:21
  Dr. Komal Patil-Sisodia: Thank you so much for joining me today.
• 16:24
  Dr. Komal Patil-Sisodia: Until next time, take care of your very specific, very individual hormonal body, and I'll see you on the next episode