PMOS vs PCOS: New Diagnosis Criteria Explained

A 34-year-old woman walks into an OBGYN's office. She has just gotten married. She has spent twenty years with painful periods that seven or eight doctors called normal. An ultrasound finally tells her the truth: she has zero eggs left. "The only thing I wanted in life was to have a child," she tells Dr. Thais Aliabadi, the Los Angeles OBGYN known online as Dr. A, who has practiced for three decades and performs surgeries at an outcome level reached by fewer than 1% of gynecologic surgeons in the country (04:26). No one had ever diagnosed her endometriosis. No one had ever checked her egg count (08:14).

That story is the engine of this episode, and it explains why Aliabadi says the current name for one of the most common hormone disorders in women is wrong. Polycystic ovary syndrome, PCOS, implies cysts on the ovaries. There usually aren't any. She prefers PMOS, polyendocrine metabolic ovarian syndrome, a name that points at the actual problem: metabolism (10:35). PMOS affects about 15% of women, and 75% of them never get diagnosed (10:55, 00:29). The diagnosis itself is not complicated. A patient needs to meet two of three criteria: irregular ovulation, meaning cycles longer than 35 days or fewer than eight periods a year; a high egg count on ultrasound or an elevated AMH blood test; and physical signs of excess testosterone such as acne, facial hair, or hair thinning (10:55, 11:42). A normal blood testosterone level does not rule it out.

The mechanism Aliabadi describes is almost mechanical. Eat carbohydrates, the body makes glucose, the pancreas releases insulin to push that sugar into cells. In PMOS, the cells resist the insulin's signal. Sugar bounces around in the blood instead of being absorbed, so insulin keeps climbing. That high insulin tells the liver to store the unused sugar as visceral fat, the inflammatory kind packed around organs rather than under skin (14:59). It also does something stranger: even though the rest of the body has gone insulin resistant, the ovaries stay insulin sensitive. The excess insulin stimulates cells in the ovary called theca cells to pump out testosterone, and that testosterone is toxic to the small follicles waiting to mature each month. They freeze halfway, which is what produces the "string of pearls" appearance on an ultrasound that used to get this condition named for cysts that were never really there (15:28, 16:32).

The consequence that struck me most is what this does to mood. Aliabadi describes the brain's limbic system, the seat of emotion, as needing calm conditions to stay calm: steady estrogen, normal testosterone, low inflammation, and progesterone, which has a soothing effect on the brain. PMOS wrecks all four. Frozen follicles secrete estrogen erratically. Without ovulation, progesterone drops. Inflammation climbs. Meanwhile the prefrontal cortex, which is supposed to act as a brake on emotional reactivity, needs the same steady chemistry and doesn't get it either.

"You have a car going 100 miles an hour down the street, and the brake doesn't work." — Dr. Thais Aliabadi [19:01]

Where do these patients end up, she asks. A dermatologist for the acne. A psychiatrist for the anxiety or the eating disorder. A fertility clinic when they can't get pregnant. Rarely does anyone connect the dots back to the original, treatable problem, which is metabolic. "If you address their metabolic dysfunction," she says, "you lift that first puzzle, and the domino gets fixed" (19:41). Her first-line approach is not exotic: cut processed carbohydrates, walk for 15 minutes after meals to blunt the insulin spike, try an inositol supplement, and, depending on the patient, metformin or a GLP-1 medication, the same drug class behind Ozempic, used here specifically to correct insulin resistance rather than just to suppress appetite (25:31, 26:19).

The Diagnosis Nobody Has

Endometriosis gets a harsher verdict. The published rate is about 10% of women, but Aliabadi believes the real number is 20% or higher, because so many cases go unfound (27:27). It takes nine to eleven years, on average, for a diagnosis (27:27, 00:29). The condition starts when endometrial cells, the kind that normally line the uterus and shed as a period, travel out through the fallopian tubes. In most women the immune system clears these stray cells out. In endometriosis, the immune system fails to do that, and the cells attach instead, to the bladder, the bowel, behind the uterus, sometimes as high as the diaphragm (28:47). Each implant then builds its own blood supply, grows nerve fibers, and produces an enzyme called aromatase that lets it manufacture its own estrogen to keep growing (29:12). Over years, the constant nerve firing rewires how the brain and spinal cord process pain, a phenomenon called central sensitization, so a sensation that would register as mild in someone else becomes unbearable (30:28).

"I tell my staff and my children that the standard of care for women's health is in the sewer system." — Dr. Thais Aliabadi [09:08]

Part of the dismissal problem is structural: half of U.S. counties have no gynecologist at all (09:33). Part of it is diagnostic difficulty. Aliabadi estimates that fewer than 1% of gynecologists are trained to properly diagnose or operate on advanced endometriosis, and that if 100 gynecologists performed laparoscopic surgery on 100 suspected cases, roughly 40 would wake the patient up and report finding nothing, simply because the lesions are small and easy to miss (33:33). A newer blood test called Her Resolve catches about 80% of true cases; a positive result is meaningful, but a negative one does not clear a patient, so she recommends pairing it with a pelvic ultrasound (35:49). The gold-standard treatment is still laparoscopic excision, cutting out the implants directly, though hormonal IUDs and a drug class called GnRH antagonists, which suppress estrogen and can make patients pain-free within about two months, are often used alongside or before surgery (32:57, 34:16).

What to Ask For

PMDD, premenstrual dysphoric disorder, is a separate condition, a severe form of PMS affecting 3 to 5% of women in which mood crashes for 10 to 14 days a month and then lifts almost overnight once the period starts (42:04, 42:39). Aliabadi's treatment is precise rather than constant. She often starts patients on the birth control pill Yaz to stop ovulation, which removes the hormonal swing that triggers the crash (43:33). For SSRIs, she avoids treating the whole month. Patients take Prozac at 20 milligrams once a day, or Zoloft at 25 milligrams, only during the window before their period, then stop (44:48). "The PMDD brain is extremely responsive to SSRIs," she says, "during that window," which is why continuous dosing usually is not necessary (44:48).

She is also direct about a myth she sees spreading online: that birth control pills cause infertility. They don't. Women who stop the pill after years of use and then struggle to conceive are usually uncovering an underlying condition, often PMOS or endometriosis, that the pill had been masking rather than causing (48:51). The pill raises a protein called sex hormone binding globulin, which mops up free testosterone and is part of why skin, hair, and cycle regularity often improve on it (47:20). Off the pill, those symptoms can resurface, not because the pill damaged anything, but because nothing underneath was ever treated.

The numbers on egg count are sobering on their own terms. A fetus has six to seven million eggs at 20 weeks; by birth that drops to one to two million; by age 30 it's roughly 100,000 to 150,000; by menopause it is around 1,000 (49:41). Endometriosis and PMOS both accelerate that decline, through inflammation and scarring in the first case and through poor egg quality despite high counts in the second. Aliabadi says 61% of her PMOS patients also have endometriosis, so finding one condition should prompt a search for the other (50:55).

What ties PMOS, endometriosis, and PMDD together in this conversation is not biology so much as the pattern of being disbelieved. Aliabadi's closing instruction has nothing to do with lab values. Get a second opinion. If that fails, get a third.

"No one on this planet cares about your body or your health as much as you do." — Dr. Thais Aliabadi [52:46]