Polyendocrine metabolic ovarian syndrome (PMOS), formerly PCOS, is more than a question of ovarian appearance or fertility. How do insulin signalling, ovulation, sleep, breathing and physical health fit together in the care of one person?

Gerry at The Health Equation

For many years I have explored the links between symptoms and wider health in my Health Equation articles. I also discuss these questions on Gerry at The Health Equation on Spotify: https://creators.spotify.com/pod/profile/gerrygaj/

Please follow this show on Spotify. It really helps!

Gerry Gajadharsingh writes:

A new name, a wider conversation

In May 2026, an international consensus adopted polyendocrine metabolic ovarian syndrome (PMOS) as the name for the condition long called polycystic ovary syndrome (PCOS). Many people will understandably continue to know it as PCOS while terminology changes. The new name does not mean that an established diagnosis has suddenly become a different disease. It corrects the misleading impression that ovarian cysts define the condition. What ultrasound may show is a pattern of numerous small follicles, not necessarily pathological cysts. A woman can have PMOS without that ultrasound appearance.

What does a diagnosis actually require?

In adults, the established framework looks for two of three features after other causes have been considered: irregular or absent ovulation, clinical or biochemical androgen excess, and polycystic ovarian morphology. Anti-Müllerian hormone may substitute for ultrasound in a suitable adult diagnostic pathway, but neither is a stand-alone diagnosis. When irregular cycles and androgen excess are already established, ultrasound is not needed just to complete a checklist. Adolescents need a more cautious approach: both persistent ovulatory dysfunction, interpreted against time since menarche, and hyperandrogenism are required; ultrasound and AMH should not be used to diagnose them. Pregnancy, thyroid dysfunction, raised prolactin and other causes of androgen excess may need exclusion according to the presentation.

The endocrine and metabolic connection

Insulin resistance is common in PMOS, though it is not universal and cannot be diagnosed from body size alone. Higher insulin levels can stimulate ovarian androgen production and lower sex hormone-binding globulin, increasing biologically available androgen. This can contribute to acne, excess facial or body hair and disrupted ovulation. Conversely, androgen activity, adipose tissue, genetics and environment may affect metabolic health. This feedback is clinically useful, but it is not a complete explanation for every patient. Women with PMOS may be lean, may have different cycle patterns and may seek help for very different concerns.

How I would use the IRSF TM

My Integrated Regulatory Systems Framework (IRSF) considers seven interacting systems. It helps me ask which mechanisms matter for this particular person; it is not a diagnostic test or a claim that every system causes PMOS.

The endocrine system examines ovulation, androgen activity and thyroid or other disorders that can mimic PMOS. The metabolic system considers glucose tolerance, insulin signalling, eating pattern, movement, lipids and liver health. The circulatory system prompts blood pressure and longer-term cardiovascular assessment, including pregnancy-related risks. The neural system considers sleep, stress, mood, pain, body image and how symptoms affect daily life. The respiratory system considers sleep apnoea and observable breathing behaviour, including whether symptoms coincide with altered breathing. The immune and inflammatory system asks whether another inflammatory condition needs separate investigation, while avoiding the notion that a single inflammatory marker explains PMOS. The musculoskeletal system looks at strength, movement, pelvic and back symptoms and barriers to exercise. The seven domains provide a structured history, not seven mandatory treatments.

Glucose regulation in everyday life

My clinical suspicion is that glucose dysregulation and excessive insulin signalling are especially important in a substantial proportion of people with PMOS. Insulin is a normal response to eating, but sustained insulin resistance may increase circulating insulin and amplify androgen activity. This is why I explore the whole dietary pattern rather than treating a single fasting result as the answer. A 75 g oral glucose tolerance test is the most accurate recommended assessment of glycaemic status in PMOS, while routine insulin assays have limited clinical value.

In practice, I discuss sufficient protein across meals, fibre-rich vegetables, pulses and less refined, lower glycaemic load carbohydrate choices, adapted to preference, energy needs and activity. For someone who grazes on refined carbohydrate throughout the day, replacing habitual snacking with satisfying, balanced meals may be a reasonable experiment. It may help appetite and food quality, but we cannot promise that avoiding snacks lowers overall insulin exposure or improves PMOS outcomes. The international guideline recommends sustainable healthy eating and finds no one superior diet composition. Meal timing should be individualised, particularly where pregnancy, medication, high training demands or disordered eating are relevant.

Breathing, HRV and the neural response

In my consultations, observing breathing behaviour alongside heart rate variability (HRV) can be enlightening. I ask about breathing during rest, speech, exertion and sleep, and whether symptoms such as palpitations, dizziness or anxiety track with a change in pattern. If indicated, capnometry can add information about ventilation. Research suggests that some groups with PMOS have lower HRV than controls, but results vary and an individual HRV reading cannot diagnose PMOS or pinpoint its cause.

When a patient shows a problematic breathing pattern, gentle guided breathing and retraining can provide a practical way to address that pattern and related distress. HRV can help us observe a response over time if conditions of measurement are consistent. I regard this as an individualised adjunct for symptoms and self-regulation, not an established way to correct androgen excess, restore ovulation or treat insulin resistance. Snoring and daytime sleepiness also deserve separate assessment for obstructive sleep apnoea; breathing exercises must not delay that assessment.

Where osteopathic manual treatment fits

Osteopathic examination may uncover pelvic, lumbar, thoracic or diaphragmatic restrictions, pain and movement limitations that deserve care in their own right. Manual treatment may help comfort and mobility and may make activity more achievable. I also consider how movement and tissue mechanics could affect local circulation, but it would be premature to claim that manipulation improves ovarian blood flow, restores ovulation or treats the endocrine disorder. A small randomised pilot of osteopathic treatment found improvement in a post-exercise blood pressure measure, but no significant metabolic, endocrine or reproductive improvements. I would therefore use manual care as a person-centred adjunct with defined symptom and function goals, alongside appropriate medical management.

What should be assessed over time?

The initial consultation should ask what matters most to the patient: bleeding pattern, skin and hair changes, fertility, metabolic health, sleep, mood or something else. Blood pressure, glycaemic status and a lipid profile help identify longer-term risk. The international guideline regards an oral glucose tolerance test as the most accurate assessment of glycaemic status across body sizes; other tests may be used when it is impractical. A fasting insulin result is not routinely helpful as a diagnostic shortcut. Prolonged infrequent periods warrant attention to endometrial protection. Psychological distress and disordered eating should be approached sensitively, without weight stigma. A rapidly deepening voice, new virilisation or a marked and sudden rise in androgen symptoms needs prompt specialist assessment rather than an automatic PMOS label.

Treatment is guided by priorities

There is no single PMOS treatment for everyone. Sustainable physical activity, food quality and sleep support health even without weight loss. Depending on individual goals and contraindications, medical options can include hormonal contraception or progestogen for cycle management and endometrial protection, metformin for selected metabolic indications, and fertility assessment and ovulation induction when pregnancy is desired. Letrozole is generally first-line pharmacological ovulation induction for anovulatory infertility where no other infertility factor is present. Acne and hirsutism may need their own treatment plan. Supplements can be discussed, but a systems approach must not become a long list of unsupported tests or products. Each proposed intervention should have a clear purpose and a way to review its benefit.

Why the name matters in practice

A scan alone does not tell the whole story; neither does a glucose result or an HRV trace. The new name asks us to recognise the endocrine and metabolic pattern while attending to the person who lives with it. My guiding question is: Why has this particular person developed these particular symptoms at this particular time?

Clinical disclaimer

This article is for educational purposes and does not replace individual assessment. Sudden virilisation, severe or unusual bleeding, acute pelvic pain, or pregnancy-related concerns require prompt medical advice.

References

Davis SE et al. Weekly osteopathic manipulative treatment in women with PCOS: a randomised controlled pilot study. J Am Osteopath Assoc. 2020. https://pubmed.ncbi.nlm.nih.gov/32337566/

Mirzohreh ST et al. Exploring heart rate variability in PCOS: a systematic review and meta-analysis. Syst Rev. 2024. https://pubmed.ncbi.nlm.nih.gov/39049099/

Papakonstantinou E et al. Effect of meal frequency on glucose and insulin levels in women with PCOS: a randomised trial. Eur J Clin Nutr. 2016. https://doi.org/10.1038/ejcn.2015.225

International PCOS Guideline (2023), dietary and metabolic recommendations: https://pmc.ncbi.nlm.nih.gov/articles/PMC10477934/

Teede HJ et al. Polyendocrine metabolic ovarian syndrome, the new name for polycystic ovary syndrome: a multistep global consensus process. The Lancet (2026). https://pubmed.ncbi.nlm.nih.gov/42119588/

International Evidence-based Guideline for the Assessment and Management of PMOS, based on the 2023 guideline. Monash University. https://www.monash.edu/medicine/mchri/pcos/guideline

NICE. Draft guideline on polyendocrine metabolic ovarian syndrome (July 2026); final guidance pending at time of writing. https://www.nice.org.uk/guidance/gid-ng10436/documents/450