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PMOS After the Reproductive Years: Why It Doesn't Go Away · 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.
• 0:10
  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.
• 0:21
  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.
• 0:40
  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, 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.
• 0:56
  Dr. Komal Patil-Sisodia: Now, let's get into it and talk about what's clearly hormonal and what's not.
• 1:03
  Dr. Komal Patil-Sisodia: This month is PMOS Awareness Month, and over the next four episodes, I want to take PMOS somewhere it doesn't usually get talked about, past the fertility years.
• 1:14
  Dr. Komal Patil-Sisodia: Most of what you hear about PMOS centers on periods, ovulation, and getting pregnant.
• 1:20
  Dr. Komal Patil-Sisodia: Ask someone what PMOS is, and you'll probably hear something about irregular cycles or trouble conceiving.
• 1:27
  Dr. Komal Patil-Sisodia: That's not wrong, but it's incomplete, and that incompleteness has consequences.
• 1:34
  Dr. Komal Patil-Sisodia: Here's the thing that nobody tells patients.
• 1:38
  Dr. Komal Patil-Sisodia: PMOS doesn't resolve when your cycles change.
• 1:41
  Dr. Komal Patil-Sisodia: It doesn't quietly retire once you're done having kids or once you hit perimenopause.
• 1:46
  Dr. Komal Patil-Sisodia: In fact, we actually used to tell people that it did.
• 1:49
  Dr. Komal Patil-Sisodia: But here's the thing we're missing.
• 1:50
  Dr. Komal Patil-Sisodia: The metabolic and cardiovascular risk that comes with PMOS doesn't just take a pause just because the reproductive story does.
• 1:59
  Dr. Komal Patil-Sisodia: So today, we're starting with what happens to PMOS at perimenopause and beyond.
• 2:05
  Dr. Komal Patil-Sisodia: This is the conversation I wish more of my patients had 10 years earlier Let's start with how I want you to think about PMOS.
• 2:18
  Dr. Komal Patil-Sisodia: It's not just a reproductive years condition.
• 2:21
  Dr. Komal Patil-Sisodia: It's a lifelong condition that affects your metabolism and your heart health.
• 2:25
  Dr. Komal Patil-Sisodia: It just happens to show up first through period related symptoms.
• 2:30
  Dr. Komal Patil-Sisodia: Doctors will diagnose PMOS, and I know we've talked about this in other podcast episodes, using three main signs: irregular periods, high androgen hormones like testosterone and DHEAS, and a certain pattern that we see on ovarian ultrasound that we call polycystic ovarian morphology or PCOM.
• 2:49
  Dr. Komal Patil-Sisodia: Those three signs are how we make the diagnosis, but they're not the whole disease.
• 2:53
  Dr. Komal Patil-Sisodia: Underneath those signs, there's something else, a body that tends towards insulin resistance, extra fat around the belly, and a less healthy cholesterol pattern.
• 3:04
  Dr. Komal Patil-Sisodia: Insulin resistance means your body doesn't respond well to insulin, so it has to work harder to keep your blood sugar steady.
• 3:11
  Dr. Komal Patil-Sisodia: This pattern will often start as early as the teenage years.
• 3:15
  Dr. Komal Patil-Sisodia: So what happens when a patient's periods become regular, either on their own or because the patient stopped trying to conceive and is not tracking their cycle anymore?
• 3:26
  Dr. Komal Patil-Sisodia: The visible sign goes away, but the underlying biology doesn't.
• 3:30
  Dr. Komal Patil-Sisodia: It's still there.
• 3:31
  Dr. Komal Patil-Sisodia: It's just not something that you're paying attention to anymore, and that's the main problem I want you to think about today.
• 3:37
  Dr. Komal Patil-Sisodia: We built our whole system for diagnosing and following PMOS around these three symptoms, and irregular periods is one of them.
• 3:46
  Dr. Komal Patil-Sisodia: But that symptom actually stops being useful once somebody reaches perimenopause, and perimenopause is exactly when the metabolic risks tend to get worse.
• 3:56
  Dr. Komal Patil-Sisodia: So it's this false sense of security that people feel like,"Oh, my periods are regular now," or,"They've gone away and I don't have PMOS anymore." That's not the case.
• 4:05
  Dr. Komal Patil-Sisodia: Let's talk about what actually changes at perimenopause, and let's get specific about the shifts during this time.
• 4:12
  Dr. Komal Patil-Sisodia: The first thing that happens is that insulin resistance gets worse.
• 4:16
  Dr. Komal Patil-Sisodia: Women with PMOS will often start out with some degree of insulin resistance, no matter their weight.
• 4:21
  Dr. Komal Patil-Sisodia: And perimenopause brings on its own wave of insulin resistance as the estrogen levels fluctuate and then drop.
• 4:28
  Dr. Komal Patil-Sisodia: So you're stacking a menopause-related shift on top of a PMOS starting point that was already tilting in that direction.
• 4:37
  Dr. Komal Patil-Sisodia: For a lot of my patients, this means that insulin resistance is rising faster and earlier than it does for people who don't have a PMOS history.
• 4:46
  Dr. Komal Patil-Sisodia: Second, cholesterol.
• 4:48
  Dr. Komal Patil-Sisodia: Perimenopause is known for raising LDL cholesterol, sometimes called the bad cholesterol, and triglycerides, especially as estrogen's protective effects start fading.
• 4:58
  Dr. Komal Patil-Sisodia: In patients with PMOS, these numbers will often start off from a less favorable place.
• 5:03
  Dr. Komal Patil-Sisodia: So LDL may be higher than the average person, or triglycerides may be higher than the average person's.
• 5:08
  Dr. Komal Patil-Sisodia: So the shift during perimenopause tends to land somewhere worse, not just similar to where it started.
• 5:16
  Dr. Komal Patil-Sisodia: So the shift that happens in perimenopause to women with PMOS actually ends up being a little bit worse than to women who don't have PMOS.
• 5:25
  Dr. Komal Patil-Sisodia: Lastly, we have body composition or body shape.
• 5:28
  Dr. Komal Patil-Sisodia: Even in patients who never struggled with their weight during their reproductive years, perimenopause will cause a change in body composition.
• 5:36
  Dr. Komal Patil-Sisodia: The estrogen levels drop.
• 5:37
  Dr. Komal Patil-Sisodia: We tend to lose muscle mass and hold onto fat mass or gain fat mass, and a lot of that fat accumulation happens in the belly.
• 5:46
  Dr. Komal Patil-Sisodia: In PMOS, this pattern is often already present to some degree, so the increase in belly fat that many midlife patients notice can be more pronounced in patients who have PMOS.
• 5:56
  Dr. Komal Patil-Sisodia: And belly fat specifically, which is also known as visceral fat, is the kind that's most closely linked to heart and metabolic risk.
• 6:04
  Dr. Komal Patil-Sisodia: None of this is meant to scare you.
• 6:06
  Dr. Komal Patil-Sisodia: It's just meant to explain why the conversation can't stop at,"Your periods are regular now, so you're fine." Here's where things get tricky for doctors, and this is the part I really want other clinicians to think about.
• 6:17
  Dr. Komal Patil-Sisodia: Picture a patient with a PMOS history whose periods were finally regular for ten years.
• 6:22
  Dr. Komal Patil-Sisodia: Now she's in her forties, and they've gone irregular again.
• 6:26
  Dr. Komal Patil-Sisodia: This time, it's not PMOS causing it.
• 6:28
  Dr. Komal Patil-Sisodia: It's perimenopause, and that part is normal, and it's the right explanation for why the cycles have changed.
• 6:34
  Dr. Komal Patil-Sisodia: But here's what gets missed.
• 6:35
  Dr. Komal Patil-Sisodia: Patient-- the patient sees irregular periods and thinks,"I've been here before with PMOS." The doctor thinks irregular periods and says,"This is just perimenopause," and moves on.
• 6:46
  Dr. Komal Patil-Sisodia: And both of them are so focused on explaining how and why the cycles are irregular that nobody stops to ask a different question.
• 6:52
  Dr. Komal Patil-Sisodia: Does this patient's PMOS history change how we should manage her heart and metabolic health during this transition, regardless of what's causing her periods to be irregular right now?
• 7:05
  Dr. Komal Patil-Sisodia: That second question is the one that matters the most, and it's the one that almost never gets asked.
• 7:10
  Dr. Komal Patil-Sisodia: I see this happen a lot.
• 7:11
  Dr. Komal Patil-Sisodia: A patient's chart says PMOS resolved, or the diagnosis quietly falls off the list of active problems because it's not showing up in the way we've trained ourselves to look for.
• 7:21
  Dr. Komal Patil-Sisodia: Nobody asks,"Could this be connected to PMOS?" Because the way we think about PMOS is built entirely around reproduction and fertility.
• 7:31
  Dr. Komal Patil-Sisodia: Once someone moves past that stage of life, they move PMOS out of the conversation too, and that's a blind spot.
• 7:37
  Dr. Komal Patil-Sisodia: But it's one that's easy to fix.
• 7:39
  Dr. Komal Patil-Sisodia: We just need to ask one question at every midlife visit for a patient with a PMOS history.
• 7:44
  Dr. Komal Patil-Sisodia: Given this patient's metabolic starting point, what should we be watching for now at this stage in her life?
• 7:52
  Dr. Komal Patil-Sisodia: Next, I wanna talk about heart health risk that carries forward.
• 7:56
  Dr. Komal Patil-Sisodia: This is the part of the story that matters the most to me.
• 7:58
  Dr. Komal Patil-Sisodia: It's the thread that runs through almost everything I talk about on this show.
• 8:01
  Dr. Komal Patil-Sisodia: I've been very candid about sharing my mom's history and how it's affected me personally.
• 8:07
  Dr. Komal Patil-Sisodia: The insulin resistance and cholesterol changes that show up early in PMOS are not just inconveniences during the reproductive years.
• 8:14
  Dr. Komal Patil-Sisodia: They are the first chapters of a heart health story that keeps being written for decades.
• 8:19
  Dr. Komal Patil-Sisodia: And by the time a patient with PMOS reaches perimenopause, she's often had twenty-plus years of a less favorable metabolic starting point than her peers, even if no one flagged it as urgent because it didn't cause obvious symptoms.
• 8:34
  Dr. Komal Patil-Sisodia: Then perimenopause arrives and speeds things up even more.
• 8:38
  Dr. Komal Patil-Sisodia: As the estrogen drops, it affects blood vessel function, cholesterol, and fat storage in ways that raise heart disease risk for every woman going through this transition.
• 8:49
  Dr. Komal Patil-Sisodia: For a patient with PMOS, that speed up is happening on a steeper curve, one that starts decades earlier.
• 8:56
  Dr. Komal Patil-Sisodia: This is exactly why I keep saying PMOS is a condition that affects your metabolism and heart health across your whole life.
• 9:04
  Dr. Komal Patil-Sisodia: It's not just a reproductive diagnosis with a start and end date.
• 9:08
  Dr. Komal Patil-Sisodia: If we treat it like the second one, we miss our chance to step in early.
• 9:14
  Dr. Komal Patil-Sisodia: If we treat it like a reproductive diagnosis only, we're actually missing our chance to step in early on the one thing that matters most in the long run, heart health So here's what we actually do about it So what does this mean in practice, whether you're a patient listening right now or a doctor that's thinking about your own patients?
• 9:38
  Dr. Komal Patil-Sisodia: For patients with PMOS who are entering perimenopause, I approach a few things differently than I would for someone without that history.
• 9:46
  Dr. Komal Patil-Sisodia: Monitoring will start earlier and get more specific.
• 9:48
  Dr. Komal Patil-Sisodia: I want cholesterol and metabolic blood work checked with a lower bar for concern.
• 9:53
  Dr. Komal Patil-Sisodia: I am looking at trends over time, not just waiting for one number to cross a line.
• 9:58
  Dr. Komal Patil-Sisodia: So for example, if your fasting glucose five years ago was seventy and now it's eighty, and then next year it's ninety, and then it's ninety-nine, you are developing insulin resistance because your body's ability to keep your fasting glucose lower is getting impaired because that number is rising over time.
• 10:17
  Dr. Komal Patil-Sisodia: It still hasn't hit prediabetes or diabetes levels, but we're seeing that trend.
• 10:23
  Dr. Komal Patil-Sisodia: The same thing happens with cholesterol levels.
• 10:25
  Dr. Komal Patil-Sisodia: They will start rising even within the normal range and eventually pop out of the normal range.
• 10:30
  Dr. Komal Patil-Sisodia: But we have several years of data that we can look at that shows that trend, and we can probably intervene a little bit earlier than we normally do.
• 10:39
  Dr. Komal Patil-Sisodia: The treatment goals will also shift for me.
• 10:41
  Dr. Komal Patil-Sisodia: During the reproductive years, a lot of PMOS care is built around ovulation and regular cycles and fertility.
• 10:48
  Dr. Komal Patil-Sisodia: Once those goals aren't a priority anymore, the care plan should shift fully towards protecting long-term metabolic and heart health.
• 10:56
  Dr. Komal Patil-Sisodia: That means a different approach to insulin-sensitizing medications like metformin or GLP-1s.
• 11:03
  Dr. Komal Patil-Sisodia: It means a closer look at a cholesterol treatment or a more proactive conversation about weight management tools, which is its own episode later in the series.
• 11:13
  Dr. Komal Patil-Sisodia: And then there's hormone therapy.
• 11:14
  Dr. Komal Patil-Sisodia: This one is a little bit more complex and deserves its own deeper conversation.
• 11:19
  Dr. Komal Patil-Sisodia: But broadly, having a PMOS history doesn't automatically rule hormone therapy in or out.
• 11:24
  Dr. Komal Patil-Sisodia: It does mean that a patient's metabolic and heart health history should shape decisions about what type of hormone therapy, how it's taken, and how closely we monitor it.
• 11:34
  Dr. Komal Patil-Sisodia: And here's the bottom line I want you to walk away with.
• 11:37
  Dr. Komal Patil-Sisodia: A PMOS history doesn't stop mattering at perimenopause.
• 11:42
  Dr. Komal Patil-Sisodia: If anything, it matters more because this is the window where heart health risk that's been quietly building starts to show up clinically That's episode one of our PMOS Awareness Month series.
• 11:56
  Dr. Komal Patil-Sisodia: And if you take one thing from today, let it be this: stop thinking of PMO-- stop thinking of PMOS as something that only happens during your reproductive years and then goes away.
• 12:07
  Dr. Komal Patil-Sisodia: It is a condition that travels with you for life, and perimenopause is one of the most important checkpoints along that path.
• 12:15
  Dr. Komal Patil-Sisodia: Over the next three weeks, we'll keep building on this.
• 12:18
  Dr. Komal Patil-Sisodia: We'll talk about lean PMOS, sometimes referred to as skinny PMOS, and why it gets missed so often.
• 12:24
  Dr. Komal Patil-Sisodia: We'll talk about where GLP-1 medications and other weight management tools fit into PMOS care.
• 12:30
  Dr. Komal Patil-Sisodia: And then we'll talk about the long road to diagnosis that many patients face, along with the toll it takes on mental health.
• 12:36
  Dr. Komal Patil-Sisodia: Thank you for listening, and if this episode gave you something to think about, share it with someone who needs to hear it.
• 12:43
  Dr. Komal Patil-Sisodia: I'll see you on the next episode.
• 12:46
  Dr. Komal Patil-Sisodia: Before I let you go, I want to make sure you walk away with something more than just this episode.
• 12:51
  Dr. Komal Patil-Sisodia: As you know, September is PMOS Awareness Month, and I'm building something that I'm really excited about, a mini course on PMOS.
• 12:58
  Dr. Komal Patil-Sisodia: It will be videos plus a workbook that walks you through it as exactly what it is, not just a reproductive diagnosis, but a cardiometabolic one that shows up differently for every person and changes as you move through different stages of life.
• 13:12
  Dr. Komal Patil-Sisodia: You'll figure out your phenotype, understand your real risk factors, and walk into your next doctor's appointment with the right questions instead of just a diagnosis and a shrug.
• 13:21
  Dr. Komal Patil-Sisodia: Here's the thing.
• 13:22
  Dr. Komal Patil-Sisodia: The course isn't out yet, and I want you to be the first to know when it drops.
• 13:25
  Dr. Komal Patil-Sisodia: So head over to eastsidemm.com/newsletter and get on my email list.
• 13:30
  Dr. Komal Patil-Sisodia: That's where I'll share it first, along with everything else I'm putting together for PMOS Awareness Month.
• 13:35
  Dr. Komal Patil-Sisodia: The link's in the show notes.
• 13:37
  Dr. Komal Patil-Sisodia: Go sign up, and I'll see you again next week.