Speaker 1: Welcome to the kick Your Expert led podcast, helping you
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Speaker 1: a parent.
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Speaker 1: Well, welcome everyone. I'm Bridget Maloney.
Speaker 2: And I'm obstetrician doctor Patrick.
Speaker 1: Maloney, and we're recording this in the middle of winter
Speaker 1: and it's a.
Speaker 2: Bit cults past cold in the studio and we've had
Speaker 2: to turn the heater off so that you.
Speaker 1: Can't so we don't have a buzzying in the background.
Speaker 1: But we've got a very exciting, I hope podcast to do.
Speaker 1: And that's another update to a name or guideline, and
Speaker 1: we're going to be talking about PCO or as it's
Speaker 1: known now, p m OS.
Speaker 2: Yeah. So changing the name to PMS has been pretty
Speaker 2: well received because it probably much better describes the condition,
Speaker 2: makes sense of the treatments, and respects the reality of
Speaker 2: people who've got it.
Speaker 1: Yeah, because you know, in the name polycystic, everyone sort
Speaker 1: of just goes straight to the ovaries, don't they, and
Speaker 1: sort of look at the ovaries and look at the
Speaker 1: cysts on the ovaries. It's much more than.
Speaker 2: That, that's right, I think that was the problem. So
Speaker 2: polycystic ovarian syndrome or PCOS or p cost of people
Speaker 2: called it. It really described one small feature of the condition,
Speaker 2: and even that it described incorrectly. So the cysts that
Speaker 2: we can see on the ovary in women with PCOS
Speaker 2: aren't sists according to the traditional definition of an ovarian cyst.
Speaker 2: So their little follicles where the eggs come from. And
Speaker 2: those follicles, of course start off deep in the ovary,
Speaker 2: and in an normal cycle, the ovary picks one and
Speaker 2: says you are the chosen one for this month, and
Speaker 2: it matures it up. The follicle gets bigger, it moves
Speaker 2: to the edge of the ovary, and in the middle
Speaker 2: of the month, at the end of a hormonal cascade
Speaker 2: of hormonal signals, the follical eruptions and the egg pops out,
Speaker 2: and then that egg's got a fighting chance of being
Speaker 2: picked up by the little fingers on the end of
Speaker 2: the Filippian tubes and maybe even meet up with some
Speaker 2: sperms coming down the tube in the other direction. And
Speaker 2: so that's normal of varian physiology. And one of the
Speaker 2: things that happens in PCs is that you get a
Speaker 2: large number of semi mature follicles that have reached a
Speaker 2: certain size, but not an ovulatory size, and they're sort
Speaker 2: of around the periphery of the ovary, suggesting that they've
Speaker 2: been partially matured, but none of them have got to
Speaker 2: the point where they can pop out. And so a
Speaker 2: lot of the problems with PCs as it used to
Speaker 2: be called, followed from the fact that because there was
Speaker 2: no ovulation, there was little or no natural progesterone secretion
Speaker 2: from the ovary in the second half of the cycle,
Speaker 2: and a number of different metabolic problems flowed from that.
Speaker 2: But the original observation that there's seemed to be a
Speaker 2: bunch of cysts within the ovary wasn't even a correct observation,
Speaker 2: let alone the basis of the disease.
Speaker 1: And I did read that because we're getting better at
Speaker 1: doing ultrasounds, or there are more that people have more
Speaker 1: access to ultrasounds, that there's a lot of people that
Speaker 1: look like they've got lots of cysts on their ovaries,
Speaker 1: but don't necessarily have PCOS. So it was sort of
Speaker 1: leading to an over diagnosis.
Speaker 2: Yes, because just seeing that picture didn't mean that the
Speaker 2: person had PCOS. For example, if you saw that picture
Speaker 2: in a woman who was who had regular of ovulation,
Speaker 2: normal menstrual cycles, no acne, no hers utism, no endocrine disturbance,
Speaker 2: and was thin, then they clearly don't have PCOS despite
Speaker 2: having the typical ivarian features of Now the.
Speaker 1: Big drive to change the name, you know, obviously because
Speaker 1: the PCOS wasn't describing it well. But it was led
Speaker 1: by an Australian researcher, wasn't it.
Speaker 2: Yeah, that's exciting, so that a team from a Monash
Speaker 2: really pushed for the this to change. And I don't
Speaker 2: know exactly what the impetus was within that team, but
Speaker 2: I suspect it's because by calling it a polymetabolic avarian syndrome,
Speaker 2: I think the ovaries was still lucky to get into
Speaker 2: the new title. I think by calling it a poly
Speaker 2: metabolic syndrome, it's probably put the management of this condition
Speaker 2: and back where it really belongs, which is in the
Speaker 2: hands of the endocrinologists. There's medical specialists involved in our bodies,
Speaker 2: glands and physiology associated with glandular function, rather than the gynecologist,
Speaker 2: where it's a common thing to be sent to us.
Speaker 2: But it's not a common thing in my experience for
Speaker 2: Australian trained gynecologists to be particularly expert at the management
Speaker 2: of this condition, or certainly expert at the non gynecological manifestations.
Speaker 1: Of this condition. Yeah, that's fascinating, isn't it. And listeners
Speaker 1: from places outside of Australia, your practitioners still might call
Speaker 1: it PCOS because it's going to be a gradual change.
Speaker 2: Yeah, it got published in the Lancet, which is quite
Speaker 2: a big deal. But the change that's proposed will happen
Speaker 2: over a few years. Medical world's not you know, we
Speaker 2: fear change.
Speaker 1: It famous for moving fast.
Speaker 2: It won't happen overnight, that's right. But what we hope
Speaker 2: is it's part of a of a developing approach to
Speaker 2: this problem where it's seen as not purely or in
Speaker 2: some cases not at all a gynecological problem. For example,
Speaker 2: I consider myself an expert on the management of PCOS
Speaker 2: when it comes to in fertility, so I am the
Speaker 2: right person to see somebody who has got significant p
Speaker 2: I just said PCs, significant p mos and they're not
Speaker 2: ovulating and they want to be pregnant. Send them along.
Speaker 2: But am I the ideal person to manage that person's
Speaker 2: difficulty losing weight there they're acne, their purseudism, their risk
Speaker 2: of diabetes, and their coexisting non gynecological metabolic problems like
Speaker 2: thyroid disease. Absolutely not.
Speaker 1: That's such a good point, and it's very common. That's
Speaker 1: why we're talking about it.
Speaker 2: That's why we're talking about it because this is not rare.
Speaker 2: So I think something like twelve percent do we gear
Speaker 2: twelve percent? We looked this up of adult women meet
Speaker 2: the current diagnostic criteria, which is an awful lot of
Speaker 2: women in the world. This is millions and millions of
Speaker 2: people who meet the criteria. Now, some would have relatively
Speaker 2: minor manifestations, but most could probably do with a high level,
Speaker 2: multi disciplinary assessment of their PMOS problem.
Speaker 1: So, Pat, let's give a very succinct answer to what
Speaker 1: are the features that are in PMO?
Speaker 2: Okay, so this is a the new name respects. It's
Speaker 2: the reality that this is a multi system condition. So
Speaker 2: there's the reproductive gynecological ones which are quite well described.
Speaker 2: There can be a disturbance to the menstrual cycle and
Speaker 2: a degree of subfertility. Then there's the dermatological ones, so
Speaker 2: that's the acne and the excess body hair.
Speaker 1: Which you said the term before hersietism.
Speaker 2: Yeah, yeah, hersteutism is excess body hair. Yeah yeah, yeah,
Speaker 2: what's the definition? Well, there are some places you definitely
Speaker 2: shouldn't have here. There are you know, racial and cultural
Speaker 2: differences in how much hair people have or consider normal.
Speaker 2: But the people what I ask people is you have
Speaker 2: you got more heare than you want to have? Yeah,
Speaker 2: or you can easily control. There are indocrine or glandular manifestations.
Speaker 2: There is a sort of more loosely defined cardio metabolic
Speaker 2: aspect to it, and a body weight issue to it.
Speaker 2: And then there's psychological manifestations as well, particularly in severe cases.
Speaker 1: And the people who have well who were diagnosed with
Speaker 1: PCOS might have heard about the Rotterdam criteria. Can you
Speaker 1: just talk about that?
Speaker 2: Those were the well known criteria which made up the
Speaker 2: diagnosis and the idea that you would have two out
Speaker 2: of three of irregular cycles and ovulatory dysfunction. So that's
Speaker 2: the guyiny stuff, hyper androgenism, which is too much testosterone,
Speaker 2: which was responsible for the acne and the excess body hair,
Speaker 2: and then an ultrasound appearance where the ovaries had an
Speaker 2: appearance consistent with that.
Speaker 1: Condition, and we talked about how that sort of being
Speaker 1: challenged a little bit. Say, let's just take the ultrasound
Speaker 1: a bit, because the polycystic is a bit misleading. But
Speaker 1: there's other reasons why that's being challenged, isn't there.
Speaker 2: Yeah, Well, I think that that original criteria doesn't take
Speaker 2: into consideration the broader metabolic and the broader endocrine disturbance
Speaker 2: that this condition involves and is increasingly recognized as involving,
Speaker 2: and therefore a new set of diagnostic criteria might be
Speaker 2: coming a And.
Speaker 1: We've talked about the other things like having an ultrasound
Speaker 1: or somebody noticing excess body hair, but the cardio metabolic,
Speaker 1: how would somebody be tested, Well, what's their cardio system
Speaker 1: being tested with?
Speaker 2: Yeah, So, remembering for a moment that I'm a gynecologist
Speaker 2: and we're straying outside my area of expertise a little bit,
Speaker 2: I think that the gynecological investigations are well described, but
Speaker 2: the management of this condition as its definition and understanding
Speaker 2: broadens is likely to then involve management guidelines that take
Speaker 2: into consideration its broader implications. So, for example, when we
Speaker 2: look at cardio cardiovascular metabolic risk assessment, then it might
Speaker 2: be reasonable that every few years someone with PMOS would
Speaker 2: have perhaps a fasting glucose test he mu globin a
Speaker 2: one C testing to try and find the diabetes before
Speaker 2: its clinical clinically apparent cholesterol blood pressure something we're not
Speaker 2: measuring tons of times in young women, well in non
Speaker 2: pregnant young women, and then perhaps fasting insulin levels. These
Speaker 2: thought to be marcus of the sort of cardiovascular metabolic
Speaker 2: dysfunction that starts young in these in these patients.
Speaker 1: Yep, and you mentioned like a multidisciplinary approach. Who else
Speaker 1: would be involved in a person's care?
Speaker 2: Well, this is the thing, right, I think you know,
Speaker 2: a bigger team. So we might have involved in the
Speaker 2: in the care of somebody with with you know, significant
Speaker 2: or severe pm OS. Perhaps an endochronologist, a physician skilled
Speaker 2: in the management of glangular problems, perhaps as the team leader,
Speaker 2: and then GP family doctor of course GP managing you know,
Speaker 2: most of this on a day to day basis, but
Speaker 2: perhaps the indecronologists involved once a year a gynecologist when
Speaker 2: it's gynecologically or obstetrically relevant, but perhaps not the rest
Speaker 2: of the time. People. The availability of the various weight
Speaker 2: loss medications that we've got now that actually work means
Speaker 2: that there's this growing area of doctors involved in the
Speaker 2: management and treatment of obesity and the downstream issues related
Speaker 2: to obesity, and the downsdoing issues related to the treatments
Speaker 2: for obesity. So if obesity was part of the PMOS
Speaker 2: patient's profile, then obesity specific management and then psychological support
Speaker 2: when we touched on before.
Speaker 1: So because people listening to this podcast would have picked
Speaker 1: this episode up because perhaps they do have PMOS and
Speaker 1: are trying to get pregnant. What going to a gynocologist
Speaker 1: or an obstrician. What's the management there?
Speaker 2: Yes, it's probably it's almost a podcast in itself, but
Speaker 2: the idea is from our specific trying to get pregnant
Speaker 2: point of view, not to downplay the importance of all
Speaker 2: the rest, but if we've got someone who's got this
Speaker 2: condition is trying to get pregnant, we're trying to re
Speaker 2: establish ovulation. That's the bottom line. And if the patient's
Speaker 2: clearly not ovulating. That will be clear from an analysis
Speaker 2: of their cycle, and they might go a year without
Speaker 2: a period. Those are that's a clearly an ovulatory time.
Speaker 2: They're not ovulating and so there's no subsequent period two
Speaker 2: weeks later, and re establishing that is the name of
Speaker 2: the game. We tend to examine the couple more broadly
Speaker 2: rather than just focus on the no period that's the
Speaker 2: whole problem. Maybe not, Maybe there's also male factor. There's
Speaker 2: also a problem with pelvic pain and ametriosis. But re
Speaker 2: establishing ovulation is the name of the game from that
Speaker 2: PMOS point of view. Now, there are various ways to
Speaker 2: do that. Sometimes people respond to weight reduction and a
Speaker 2: lot of the p p m o S symptoms get
Speaker 2: better at lower body weights. Now that can be easier
Speaker 2: said than done. But if we if we've got someone
Speaker 2: who's an ovulation responds well to weight reduction, the patient
Speaker 2: will often tell you that that's happened to her in
Speaker 2: the past, So she's dropped some weight, particularly quickly, and
Speaker 2: the periods start up again. Great news. We can we can,
Speaker 2: we can try that. Sometimes that's not appropriate, can't be done.
Speaker 2: There is no weight problem women's woman's already in normal
Speaker 2: normal weight range. So there's no role for weight reduction
Speaker 2: or it's been tried in it didn't work. So then
Speaker 2: we look at medications and there's some very effective medications
Speaker 2: that can in a sense, trick the ovary to say
Speaker 2: that you you don't have PMS anymore, and then the
Speaker 2: ovary will will reawaken, pick a fie and start opulating.
Speaker 1: And people might know that term, and in fact, I
Speaker 1: hope they do because we've talked about it a lot. That's
Speaker 1: ovulation induction.
Speaker 2: That's ovulation induction. Yeah, so it's it's a it's a
Speaker 2: reproductive intervention, well short of big invasive, expensive things like IVF,
Speaker 2: but very successful when the primary problem is not male factor,
Speaker 2: it's not block tubs, it's not in themetriosis, it's just
Speaker 2: that we're not ovulating.
Speaker 1: You've touched a couple of times on the obesity management medication.
Speaker 1: Can we talk a little bit about that. I know
Speaker 1: we've got a clinician in the practice that likes to
Speaker 1: call them ozembic bases.
Speaker 2: Yeah, so I think these g l P one receptor
Speaker 2: agness that that that have have come out now there's
Speaker 2: various different brand names. They really they really work and
Speaker 2: they're probably particularly useful to help people. If what if
Speaker 2: the way we're trying to treat the PMOS, regardless of
Speaker 2: which symptom we're looking at, is through weight reduction, then
Speaker 2: you know, it's very unhelpful to most people carrying extra
Speaker 2: body weight to say the key to this is weight reduction.
Speaker 2: Good luck, it's been recognized for a long time. You
Speaker 2: need to give people a plan and a recipe for
Speaker 2: that weight reduction. Now, some people can just manage that
Speaker 2: through dietary alteration and increasing exercise, but lots and lots
Speaker 2: and lots can't. And if we're going to hang our
Speaker 2: hat on weight reduction as the answer, then it may
Speaker 2: well involve the use of these medications.
Speaker 1: And is it safe to get pregnant on these medications?
Speaker 2: The simil answer is no, they're not sort of ratified
Speaker 2: for use in pregnancy. If our main treatment goal with
Speaker 2: the PMOS patient is to get her ovulating again, and
Speaker 2: she's ovulated and conceived, then bingo, we've got there. She
Speaker 2: may still have some weight issues, but in pregnancy they
Speaker 2: need to be managed through dietary modifications and exercise. Because
Speaker 2: the medications probably unsuitable and certainly not proven to be suitable.
Speaker 1: And so would somebody on a GLP one if they
Speaker 1: got pregnant. Is the conception is that a problem?
Speaker 2: No, you just stop it when you know you're pregnant. Okay,
Speaker 2: yeah right, yeah, Like much things, it's quite fine just
Speaker 2: to stop it when you know.
Speaker 1: I know what people will say, is it better for
Speaker 1: me to be on a GLP one and lose the
Speaker 1: weight and perhaps have another contraception method while I'm doing that,
Speaker 1: and then once I've lost the weight, go off all
Speaker 1: of it, take the contraception out if it's a marina,
Speaker 1: and then get pregnant.
Speaker 2: I don't think so. You could just be on it
Speaker 2: and then lose the weight and then if you get
Speaker 2: pregnant to stop it.
Speaker 1: Great. That sounds like a solution then, okay, good, all right, Well,
Speaker 1: is there anything that a patient should be aware of
Speaker 1: what they need to ask their practitioner. So if they're
Speaker 1: saying an endochronologist and the NDO chronologist is really sort
Speaker 1: of focused on their metabolic problem, how do they talk
Speaker 1: to that endo chronologist about that the fact is that
Speaker 1: they want to be pregnant.
Speaker 2: Well, I think that the you know, we're a big
Speaker 2: fan of the family doctor here on our podcast, And
Speaker 2: I think that the family doctor GP probably should be
Speaker 2: the coordinating person in terms of the everyday needs of
Speaker 2: the patient and really should be aware of what that
Speaker 2: woman's goals are for the next five years maybe, and
Speaker 2: so involving the right people at the right time. Very
Speaker 2: comfortable with the endochronologist being the sort of scientific team leader.
Speaker 2: But nobody knows you like your family doctor should, and
Speaker 2: that person really should be aware of what your upcoming
Speaker 2: goals are and think, oh, you want to be pregnant
Speaker 2: next year. All right, Well, why don't we go off
Speaker 2: and see the productive team just to find out for
Speaker 2: your just to find out how what their approach to
Speaker 2: this would be excellent.
Speaker 1: All right, Well, we'd love to get your feedback on
Speaker 1: how your PMOS is being managed and how you're traveling
Speaker 1: with it, and if you're in a different country, we'd
Speaker 1: love to hear what those different countries and what you
Speaker 1: know the process is for you as somebody that has PMOS,
Speaker 1: because it's a lifelong condition, isn't it.
Speaker 2: Well it is, yeah, and there are points in your
Speaker 2: life where it's more important than others around the baby
Speaker 2: time and so forth. But I'm hoping that this name
Speaker 2: change gives the patience with the condition more confidence to
Speaker 2: expect and demand a better level of a better level
Speaker 2: of multi disciplinary care for this condition.
Speaker 1: All right, Well we'll put the new guidelines. Well they're
Speaker 1: not new, they're twenty twenty three, but it's taken this
Speaker 1: long for the world to accept it. We'll put them
Speaker 1: as a link to the show notes for everybody out
Speaker 1: there that has PMOS and we are hoping that this helps.
Speaker 1: All Right, everybody, thanks for listening.
Speaker 2: If you really.
Speaker 1: Enjoyed this podcast, please share it with a friend. We've
Speaker 1: got some really great topics coming up and we know
Speaker 1: that you'll be fully informed. So until next week, we'll.
Speaker 2: See you then. Thanks for listening, everybody.
Speaker 1: Okay, bye for now. Hey, even though doctor pat is
Speaker 1: well a doctor and we get lots of other doctors
Speaker 1: and other experts on our podcast, I just need to
Speaker 1: remind you that this podcast is for informational purposes only.
Speaker 1: We share lots of medical insights and experience, but everything
Speaker 1: we talk about is general in nature and may not
Speaker 1: apply to your specific situation. Please always consult with your
Speaker 1: own healthcare provider for your individual medical advice. When you
Speaker 1: grow your baby,