WEBVTT - 203. Why is PCOS now called PMOS?

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<v Speaker 1>Welcome to the kick Your Expert led podcast, helping you

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<v Speaker 1>Well, welcome everyone. I'm Bridget Maloney.

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<v Speaker 2>And I'm obstetrician doctor Patrick.

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<v Speaker 1>Maloney, and we're recording this in the middle of winter

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<v Speaker 1>and it's a.

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<v Speaker 2>Bit cults past cold in the studio and we've had

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<v Speaker 2>to turn the heater off so that you.

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<v Speaker 1>Can't so we don't have a buzzying in the background.

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<v Speaker 1>But we've got a very exciting, I hope podcast to do.

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<v Speaker 1>And that's another update to a name or guideline, and

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<v Speaker 1>we're going to be talking about PCO or as it's

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<v Speaker 1>known now, p m OS.

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<v Speaker 2>Yeah. So changing the name to PMS has been pretty

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<v Speaker 2>well received because it probably much better describes the condition,

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<v Speaker 2>makes sense of the treatments, and respects the reality of

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<v Speaker 2>people who've got it.

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<v Speaker 1>Yeah, because you know, in the name polycystic, everyone sort

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<v Speaker 1>of just goes straight to the ovaries, don't they, and

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<v Speaker 1>sort of look at the ovaries and look at the

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<v Speaker 1>cysts on the ovaries. It's much more than.

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<v Speaker 2>That, that's right, I think that was the problem. So

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<v Speaker 2>polycystic ovarian syndrome or PCOS or p cost of people

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<v Speaker 2>called it. It really described one small feature of the condition,

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<v Speaker 2>and even that it described incorrectly. So the cysts that

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<v Speaker 2>we can see on the ovary in women with PCOS

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<v Speaker 2>aren't sists according to the traditional definition of an ovarian cyst.

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<v Speaker 2>So their little follicles where the eggs come from. And

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<v Speaker 2>those follicles, of course start off deep in the ovary,

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<v Speaker 2>and in an normal cycle, the ovary picks one and

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<v Speaker 2>says you are the chosen one for this month, and

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<v Speaker 2>it matures it up. The follicle gets bigger, it moves

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<v Speaker 2>to the edge of the ovary, and in the middle

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<v Speaker 2>of the month, at the end of a hormonal cascade

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<v Speaker 2>of hormonal signals, the follical eruptions and the egg pops out,

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<v Speaker 2>and then that egg's got a fighting chance of being

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<v Speaker 2>picked up by the little fingers on the end of

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<v Speaker 2>the Filippian tubes and maybe even meet up with some

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<v Speaker 2>sperms coming down the tube in the other direction. And

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<v Speaker 2>so that's normal of varian physiology. And one of the

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<v Speaker 2>things that happens in PCs is that you get a

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<v Speaker 2>large number of semi mature follicles that have reached a

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<v Speaker 2>certain size, but not an ovulatory size, and they're sort

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<v Speaker 2>of around the periphery of the ovary, suggesting that they've

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<v Speaker 2>been partially matured, but none of them have got to

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<v Speaker 2>the point where they can pop out. And so a

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<v Speaker 2>lot of the problems with PCs as it used to

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<v Speaker 2>be called, followed from the fact that because there was

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<v Speaker 2>no ovulation, there was little or no natural progesterone secretion

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<v Speaker 2>from the ovary in the second half of the cycle,

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<v Speaker 2>and a number of different metabolic problems flowed from that.

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<v Speaker 2>But the original observation that there's seemed to be a

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<v Speaker 2>bunch of cysts within the ovary wasn't even a correct observation,

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<v Speaker 2>let alone the basis of the disease.

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<v Speaker 1>And I did read that because we're getting better at

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<v Speaker 1>doing ultrasounds, or there are more that people have more

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<v Speaker 1>access to ultrasounds, that there's a lot of people that

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<v Speaker 1>look like they've got lots of cysts on their ovaries,

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<v Speaker 1>but don't necessarily have PCOS. So it was sort of

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<v Speaker 1>leading to an over diagnosis.

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<v Speaker 2>Yes, because just seeing that picture didn't mean that the

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<v Speaker 2>person had PCOS. For example, if you saw that picture

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<v Speaker 2>in a woman who was who had regular of ovulation,

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<v Speaker 2>normal menstrual cycles, no acne, no hers utism, no endocrine disturbance,

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<v Speaker 2>and was thin, then they clearly don't have PCOS despite

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<v Speaker 2>having the typical ivarian features of Now the.

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<v Speaker 1>Big drive to change the name, you know, obviously because

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<v Speaker 1>the PCOS wasn't describing it well. But it was led

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<v Speaker 1>by an Australian researcher, wasn't it.

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<v Speaker 2>Yeah, that's exciting, so that a team from a Monash

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<v Speaker 2>really pushed for the this to change. And I don't

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<v Speaker 2>know exactly what the impetus was within that team, but

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<v Speaker 2>I suspect it's because by calling it a polymetabolic avarian syndrome,

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<v Speaker 2>I think the ovaries was still lucky to get into

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<v Speaker 2>the new title. I think by calling it a poly

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<v Speaker 2>metabolic syndrome, it's probably put the management of this condition

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<v Speaker 2>and back where it really belongs, which is in the

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<v Speaker 2>hands of the endocrinologists. There's medical specialists involved in our bodies,

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<v Speaker 2>glands and physiology associated with glandular function, rather than the gynecologist,

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<v Speaker 2>where it's a common thing to be sent to us.

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<v Speaker 2>But it's not a common thing in my experience for

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<v Speaker 2>Australian trained gynecologists to be particularly expert at the management

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<v Speaker 2>of this condition, or certainly expert at the non gynecological manifestations.

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<v Speaker 1>Of this condition. Yeah, that's fascinating, isn't it. And listeners

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<v Speaker 1>from places outside of Australia, your practitioners still might call

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<v Speaker 1>it PCOS because it's going to be a gradual change.

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<v Speaker 2>Yeah, it got published in the Lancet, which is quite

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<v Speaker 2>a big deal. But the change that's proposed will happen

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<v Speaker 2>over a few years. Medical world's not you know, we

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<v Speaker 2>fear change.

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<v Speaker 1>It famous for moving fast.

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<v Speaker 2>It won't happen overnight, that's right. But what we hope

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<v Speaker 2>is it's part of a of a developing approach to

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<v Speaker 2>this problem where it's seen as not purely or in

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<v Speaker 2>some cases not at all a gynecological problem. For example,

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<v Speaker 2>I consider myself an expert on the management of PCOS

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<v Speaker 2>when it comes to in fertility, so I am the

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<v Speaker 2>right person to see somebody who has got significant p

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<v Speaker 2>I just said PCs, significant p mos and they're not

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<v Speaker 2>ovulating and they want to be pregnant. Send them along.

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<v Speaker 2>But am I the ideal person to manage that person's

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<v Speaker 2>difficulty losing weight there they're acne, their purseudism, their risk

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<v Speaker 2>of diabetes, and their coexisting non gynecological metabolic problems like

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<v Speaker 2>thyroid disease. Absolutely not.

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<v Speaker 1>That's such a good point, and it's very common. That's

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<v Speaker 1>why we're talking about it.

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<v Speaker 2>That's why we're talking about it because this is not rare.

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<v Speaker 2>So I think something like twelve percent do we gear

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<v Speaker 2>twelve percent? We looked this up of adult women meet

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<v Speaker 2>the current diagnostic criteria, which is an awful lot of

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<v Speaker 2>women in the world. This is millions and millions of

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<v Speaker 2>people who meet the criteria. Now, some would have relatively

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<v Speaker 2>minor manifestations, but most could probably do with a high level,

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<v Speaker 2>multi disciplinary assessment of their PMOS problem.

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<v Speaker 1>So, Pat, let's give a very succinct answer to what

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<v Speaker 1>are the features that are in PMO?

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<v Speaker 2>Okay, so this is a the new name respects. It's

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<v Speaker 2>the reality that this is a multi system condition. So

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<v Speaker 2>there's the reproductive gynecological ones which are quite well described.

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<v Speaker 2>There can be a disturbance to the menstrual cycle and

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<v Speaker 2>a degree of subfertility. Then there's the dermatological ones, so

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<v Speaker 2>that's the acne and the excess body hair.

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<v Speaker 1>Which you said the term before hersietism.

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<v Speaker 2>Yeah, yeah, hersteutism is excess body hair. Yeah yeah, yeah,

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<v Speaker 2>what's the definition? Well, there are some places you definitely

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<v Speaker 2>shouldn't have here. There are you know, racial and cultural

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<v Speaker 2>differences in how much hair people have or consider normal.

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<v Speaker 2>But the people what I ask people is you have

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<v Speaker 2>you got more heare than you want to have? Yeah,

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<v Speaker 2>or you can easily control. There are indocrine or glandular manifestations.

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<v Speaker 2>There is a sort of more loosely defined cardio metabolic

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<v Speaker 2>aspect to it, and a body weight issue to it.

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<v Speaker 2>And then there's psychological manifestations as well, particularly in severe cases.

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<v Speaker 1>And the people who have well who were diagnosed with

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<v Speaker 1>PCOS might have heard about the Rotterdam criteria. Can you

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<v Speaker 1>just talk about that?

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<v Speaker 2>Those were the well known criteria which made up the

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<v Speaker 2>diagnosis and the idea that you would have two out

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<v Speaker 2>of three of irregular cycles and ovulatory dysfunction. So that's

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<v Speaker 2>the guyiny stuff, hyper androgenism, which is too much testosterone,

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<v Speaker 2>which was responsible for the acne and the excess body hair,

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<v Speaker 2>and then an ultrasound appearance where the ovaries had an

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<v Speaker 2>appearance consistent with that.

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<v Speaker 1>Condition, and we talked about how that sort of being

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<v Speaker 1>challenged a little bit. Say, let's just take the ultrasound

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<v Speaker 1>a bit, because the polycystic is a bit misleading. But

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<v Speaker 1>there's other reasons why that's being challenged, isn't there.

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<v Speaker 2>Yeah, Well, I think that that original criteria doesn't take

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<v Speaker 2>into consideration the broader metabolic and the broader endocrine disturbance

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<v Speaker 2>that this condition involves and is increasingly recognized as involving,

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<v Speaker 2>and therefore a new set of diagnostic criteria might be

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<v Speaker 2>coming a And.

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<v Speaker 1>We've talked about the other things like having an ultrasound

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<v Speaker 1>or somebody noticing excess body hair, but the cardio metabolic,

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<v Speaker 1>how would somebody be tested, Well, what's their cardio system

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<v Speaker 1>being tested with?

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<v Speaker 2>Yeah, So, remembering for a moment that I'm a gynecologist

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<v Speaker 2>and we're straying outside my area of expertise a little bit,

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<v Speaker 2>I think that the gynecological investigations are well described, but

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<v Speaker 2>the management of this condition as its definition and understanding

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<v Speaker 2>broadens is likely to then involve management guidelines that take

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<v Speaker 2>into consideration its broader implications. So, for example, when we

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<v Speaker 2>look at cardio cardiovascular metabolic risk assessment, then it might

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<v Speaker 2>be reasonable that every few years someone with PMOS would

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<v Speaker 2>have perhaps a fasting glucose test he mu globin a

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<v Speaker 2>one C testing to try and find the diabetes before

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<v Speaker 2>its clinical clinically apparent cholesterol blood pressure something we're not

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<v Speaker 2>measuring tons of times in young women, well in non

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<v Speaker 2>pregnant young women, and then perhaps fasting insulin levels. These

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<v Speaker 2>thought to be marcus of the sort of cardiovascular metabolic

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<v Speaker 2>dysfunction that starts young in these in these patients.

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<v Speaker 1>Yep, and you mentioned like a multidisciplinary approach. Who else

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<v Speaker 1>would be involved in a person's care?

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<v Speaker 2>Well, this is the thing, right, I think you know,

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<v Speaker 2>a bigger team. So we might have involved in the

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<v Speaker 2>in the care of somebody with with you know, significant

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<v Speaker 2>or severe pm OS. Perhaps an endochronologist, a physician skilled

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<v Speaker 2>in the management of glangular problems, perhaps as the team leader,

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<v Speaker 2>and then GP family doctor of course GP managing you know,

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<v Speaker 2>most of this on a day to day basis, but

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<v Speaker 2>perhaps the indecronologists involved once a year a gynecologist when

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<v Speaker 2>it's gynecologically or obstetrically relevant, but perhaps not the rest

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<v Speaker 2>of the time. People. The availability of the various weight

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<v Speaker 2>loss medications that we've got now that actually work means

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<v Speaker 2>that there's this growing area of doctors involved in the

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<v Speaker 2>management and treatment of obesity and the downstream issues related

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<v Speaker 2>to obesity, and the downsdoing issues related to the treatments

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<v Speaker 2>for obesity. So if obesity was part of the PMOS

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<v Speaker 2>patient's profile, then obesity specific management and then psychological support

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<v Speaker 2>when we touched on before.

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<v Speaker 1>So because people listening to this podcast would have picked

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<v Speaker 1>this episode up because perhaps they do have PMOS and

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<v Speaker 1>are trying to get pregnant. What going to a gynocologist

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<v Speaker 1>or an obstrician. What's the management there?

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<v Speaker 2>Yes, it's probably it's almost a podcast in itself, but

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<v Speaker 2>the idea is from our specific trying to get pregnant

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<v Speaker 2>point of view, not to downplay the importance of all

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<v Speaker 2>the rest, but if we've got someone who's got this

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<v Speaker 2>condition is trying to get pregnant, we're trying to re

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<v Speaker 2>establish ovulation. That's the bottom line. And if the patient's

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<v Speaker 2>clearly not ovulating. That will be clear from an analysis

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<v Speaker 2>of their cycle, and they might go a year without

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<v Speaker 2>a period. Those are that's a clearly an ovulatory time.

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<v Speaker 2>They're not ovulating and so there's no subsequent period two

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<v Speaker 2>weeks later, and re establishing that is the name of

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<v Speaker 2>the game. We tend to examine the couple more broadly

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<v Speaker 2>rather than just focus on the no period that's the

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<v Speaker 2>whole problem. Maybe not, Maybe there's also male factor. There's

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<v Speaker 2>also a problem with pelvic pain and ametriosis. But re

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<v Speaker 2>establishing ovulation is the name of the game from that

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<v Speaker 2>PMOS point of view. Now, there are various ways to

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<v Speaker 2>do that. Sometimes people respond to weight reduction and a

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<v Speaker 2>lot of the p p m o S symptoms get

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<v Speaker 2>better at lower body weights. Now that can be easier

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<v Speaker 2>said than done. But if we if we've got someone

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<v Speaker 2>who's an ovulation responds well to weight reduction, the patient

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<v Speaker 2>will often tell you that that's happened to her in

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<v Speaker 2>the past, So she's dropped some weight, particularly quickly, and

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<v Speaker 2>the periods start up again. Great news. We can we can,

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<v Speaker 2>we can try that. Sometimes that's not appropriate, can't be done.

0:15:36.520 --> 0:15:39.560
<v Speaker 2>There is no weight problem women's woman's already in normal

0:15:39.760 --> 0:15:42.880
<v Speaker 2>normal weight range. So there's no role for weight reduction

0:15:44.240 --> 0:15:46.160
<v Speaker 2>or it's been tried in it didn't work. So then

0:15:46.200 --> 0:15:50.360
<v Speaker 2>we look at medications and there's some very effective medications

0:15:50.720 --> 0:15:53.200
<v Speaker 2>that can in a sense, trick the ovary to say

0:15:53.200 --> 0:15:56.720
<v Speaker 2>that you you don't have PMS anymore, and then the

0:15:56.760 --> 0:16:01.480
<v Speaker 2>ovary will will reawaken, pick a fie and start opulating.

0:16:01.720 --> 0:16:03.400
<v Speaker 1>And people might know that term, and in fact, I

0:16:03.400 --> 0:16:05.040
<v Speaker 1>hope they do because we've talked about it a lot. That's

0:16:05.080 --> 0:16:05.920
<v Speaker 1>ovulation induction.

0:16:06.040 --> 0:16:10.200
<v Speaker 2>That's ovulation induction. Yeah, so it's it's a it's a

0:16:10.240 --> 0:16:15.200
<v Speaker 2>reproductive intervention, well short of big invasive, expensive things like IVF,

0:16:16.920 --> 0:16:23.000
<v Speaker 2>but very successful when the primary problem is not male factor,

0:16:23.040 --> 0:16:25.480
<v Speaker 2>it's not block tubs, it's not in themetriosis, it's just

0:16:25.480 --> 0:16:26.479
<v Speaker 2>that we're not ovulating.

0:16:28.240 --> 0:16:32.080
<v Speaker 1>You've touched a couple of times on the obesity management medication.

0:16:34.000 --> 0:16:35.760
<v Speaker 1>Can we talk a little bit about that. I know

0:16:35.760 --> 0:16:38.880
<v Speaker 1>we've got a clinician in the practice that likes to

0:16:38.880 --> 0:16:40.000
<v Speaker 1>call them ozembic bases.

0:16:41.720 --> 0:16:45.640
<v Speaker 2>Yeah, so I think these g l P one receptor

0:16:45.680 --> 0:16:48.600
<v Speaker 2>agness that that that have have come out now there's

0:16:48.680 --> 0:16:53.920
<v Speaker 2>various different brand names. They really they really work and

0:16:54.320 --> 0:16:59.960
<v Speaker 2>they're probably particularly useful to help people. If what if

0:17:00.080 --> 0:17:04.119
<v Speaker 2>the way we're trying to treat the PMOS, regardless of

0:17:04.160 --> 0:17:08.560
<v Speaker 2>which symptom we're looking at, is through weight reduction, then

0:17:09.040 --> 0:17:14.359
<v Speaker 2>you know, it's very unhelpful to most people carrying extra

0:17:14.359 --> 0:17:16.800
<v Speaker 2>body weight to say the key to this is weight reduction.

0:17:16.840 --> 0:17:20.480
<v Speaker 2>Good luck, it's been recognized for a long time. You

0:17:20.480 --> 0:17:23.040
<v Speaker 2>need to give people a plan and a recipe for

0:17:23.080 --> 0:17:26.960
<v Speaker 2>that weight reduction. Now, some people can just manage that

0:17:27.040 --> 0:17:30.440
<v Speaker 2>through dietary alteration and increasing exercise, but lots and lots

0:17:30.480 --> 0:17:33.600
<v Speaker 2>and lots can't. And if we're going to hang our

0:17:33.640 --> 0:17:37.320
<v Speaker 2>hat on weight reduction as the answer, then it may

0:17:37.359 --> 0:17:38.959
<v Speaker 2>well involve the use of these medications.

0:17:39.560 --> 0:17:42.520
<v Speaker 1>And is it safe to get pregnant on these medications?

0:17:43.200 --> 0:17:46.960
<v Speaker 2>The simil answer is no, they're not sort of ratified

0:17:47.000 --> 0:17:51.760
<v Speaker 2>for use in pregnancy. If our main treatment goal with

0:17:51.840 --> 0:17:54.639
<v Speaker 2>the PMOS patient is to get her ovulating again, and

0:17:54.680 --> 0:17:58.199
<v Speaker 2>she's ovulated and conceived, then bingo, we've got there. She

0:17:58.280 --> 0:18:01.360
<v Speaker 2>may still have some weight issues, but in pregnancy they

0:18:01.400 --> 0:18:06.200
<v Speaker 2>need to be managed through dietary modifications and exercise. Because

0:18:06.240 --> 0:18:12.000
<v Speaker 2>the medications probably unsuitable and certainly not proven to be suitable.

0:18:12.200 --> 0:18:17.000
<v Speaker 1>And so would somebody on a GLP one if they

0:18:17.080 --> 0:18:20.679
<v Speaker 1>got pregnant. Is the conception is that a problem?

0:18:20.800 --> 0:18:22.720
<v Speaker 2>No, you just stop it when you know you're pregnant. Okay,

0:18:22.800 --> 0:18:25.679
<v Speaker 2>yeah right, yeah, Like much things, it's quite fine just

0:18:25.720 --> 0:18:26.520
<v Speaker 2>to stop it when you know.

0:18:27.040 --> 0:18:28.760
<v Speaker 1>I know what people will say, is it better for

0:18:28.760 --> 0:18:31.320
<v Speaker 1>me to be on a GLP one and lose the

0:18:31.320 --> 0:18:35.800
<v Speaker 1>weight and perhaps have another contraception method while I'm doing that,

0:18:36.160 --> 0:18:38.080
<v Speaker 1>and then once I've lost the weight, go off all

0:18:38.119 --> 0:18:41.159
<v Speaker 1>of it, take the contraception out if it's a marina,

0:18:41.320 --> 0:18:42.280
<v Speaker 1>and then get pregnant.

0:18:43.359 --> 0:18:45.080
<v Speaker 2>I don't think so. You could just be on it

0:18:45.119 --> 0:18:46.640
<v Speaker 2>and then lose the weight and then if you get

0:18:46.640 --> 0:18:47.439
<v Speaker 2>pregnant to stop it.

0:18:47.560 --> 0:18:52.560
<v Speaker 1>Great. That sounds like a solution then, okay, good, all right, Well,

0:18:53.080 --> 0:18:57.280
<v Speaker 1>is there anything that a patient should be aware of

0:18:57.320 --> 0:18:59.720
<v Speaker 1>what they need to ask their practitioner. So if they're

0:18:59.720 --> 0:19:02.880
<v Speaker 1>saying an endochronologist and the NDO chronologist is really sort

0:19:02.880 --> 0:19:06.800
<v Speaker 1>of focused on their metabolic problem, how do they talk

0:19:06.800 --> 0:19:09.359
<v Speaker 1>to that endo chronologist about that the fact is that

0:19:09.400 --> 0:19:10.320
<v Speaker 1>they want to be pregnant.

0:19:10.760 --> 0:19:14.440
<v Speaker 2>Well, I think that the you know, we're a big

0:19:14.480 --> 0:19:17.719
<v Speaker 2>fan of the family doctor here on our podcast, And

0:19:17.800 --> 0:19:21.159
<v Speaker 2>I think that the family doctor GP probably should be

0:19:21.320 --> 0:19:27.520
<v Speaker 2>the coordinating person in terms of the everyday needs of

0:19:27.600 --> 0:19:31.360
<v Speaker 2>the patient and really should be aware of what that

0:19:31.520 --> 0:19:36.120
<v Speaker 2>woman's goals are for the next five years maybe, and

0:19:36.240 --> 0:19:41.040
<v Speaker 2>so involving the right people at the right time. Very

0:19:41.040 --> 0:19:46.040
<v Speaker 2>comfortable with the endochronologist being the sort of scientific team leader.

0:19:47.040 --> 0:19:50.400
<v Speaker 2>But nobody knows you like your family doctor should, and

0:19:50.520 --> 0:19:54.600
<v Speaker 2>that person really should be aware of what your upcoming

0:19:54.800 --> 0:19:56.919
<v Speaker 2>goals are and think, oh, you want to be pregnant

0:19:56.920 --> 0:19:58.359
<v Speaker 2>next year. All right, Well, why don't we go off

0:19:58.400 --> 0:20:03.600
<v Speaker 2>and see the productive team just to find out for

0:20:03.680 --> 0:20:07.280
<v Speaker 2>your just to find out how what their approach to

0:20:07.320 --> 0:20:09.520
<v Speaker 2>this would be excellent.

0:20:09.840 --> 0:20:11.919
<v Speaker 1>All right, Well, we'd love to get your feedback on

0:20:12.040 --> 0:20:16.000
<v Speaker 1>how your PMOS is being managed and how you're traveling

0:20:16.160 --> 0:20:18.640
<v Speaker 1>with it, and if you're in a different country, we'd

0:20:18.680 --> 0:20:21.320
<v Speaker 1>love to hear what those different countries and what you

0:20:21.320 --> 0:20:24.320
<v Speaker 1>know the process is for you as somebody that has PMOS,

0:20:24.359 --> 0:20:26.159
<v Speaker 1>because it's a lifelong condition, isn't it.

0:20:26.200 --> 0:20:28.919
<v Speaker 2>Well it is, yeah, and there are points in your

0:20:28.960 --> 0:20:32.000
<v Speaker 2>life where it's more important than others around the baby

0:20:32.000 --> 0:20:35.480
<v Speaker 2>time and so forth. But I'm hoping that this name

0:20:35.640 --> 0:20:42.679
<v Speaker 2>change gives the patience with the condition more confidence to

0:20:43.040 --> 0:20:47.520
<v Speaker 2>expect and demand a better level of a better level

0:20:47.560 --> 0:20:50.360
<v Speaker 2>of multi disciplinary care for this condition.

0:20:51.640 --> 0:20:54.080
<v Speaker 1>All right, Well we'll put the new guidelines. Well they're

0:20:54.080 --> 0:20:56.320
<v Speaker 1>not new, they're twenty twenty three, but it's taken this

0:20:56.400 --> 0:21:01.240
<v Speaker 1>long for the world to accept it. We'll put them

0:21:01.400 --> 0:21:03.840
<v Speaker 1>as a link to the show notes for everybody out

0:21:03.840 --> 0:21:08.560
<v Speaker 1>there that has PMOS and we are hoping that this helps.

0:21:09.480 --> 0:21:11.840
<v Speaker 1>All Right, everybody, thanks for listening.

0:21:12.200 --> 0:21:12.920
<v Speaker 2>If you really.

0:21:12.800 --> 0:21:16.160
<v Speaker 1>Enjoyed this podcast, please share it with a friend. We've

0:21:16.200 --> 0:21:19.560
<v Speaker 1>got some really great topics coming up and we know

0:21:19.640 --> 0:21:24.000
<v Speaker 1>that you'll be fully informed. So until next week, we'll.

0:21:23.880 --> 0:21:25.480
<v Speaker 2>See you then. Thanks for listening, everybody.

0:21:25.560 --> 0:21:31.800
<v Speaker 1>Okay, bye for now. Hey, even though doctor pat is

0:21:31.880 --> 0:21:34.280
<v Speaker 1>well a doctor and we get lots of other doctors

0:21:34.280 --> 0:21:37.119
<v Speaker 1>and other experts on our podcast, I just need to

0:21:37.160 --> 0:21:41.280
<v Speaker 1>remind you that this podcast is for informational purposes only.

0:21:41.880 --> 0:21:45.400
<v Speaker 1>We share lots of medical insights and experience, but everything

0:21:45.440 --> 0:21:48.439
<v Speaker 1>we talk about is general in nature and may not

0:21:48.480 --> 0:21:52.679
<v Speaker 1>apply to your specific situation. Please always consult with your

0:21:52.760 --> 0:21:56.679
<v Speaker 1>own healthcare provider for your individual medical advice. When you

0:21:56.720 --> 0:21:57.479
<v Speaker 1>grow your baby,