The renaming of Polycystic Ovary Syndrome (PCOS) to Polyendocrine Metabolic Ovarian Syndrome (PMOS) represents a fundamental shift in understanding this condition as a multi-system endocrine disorder rather than a primarily ovarian condition. This change reflects the recognition that PMOS affects 170 million women globally with reproductive, metabolic, dermatological, and psychological features, and requires a holistic, interdisciplinary approach to diagnosis and management that addresses the full spectrum of the condition's impact on women's health across the lifespan.
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Then PCOS, Now PMOSAdded:
Hello Madre.
Do you want to share your slides once?
Madre quick check.
>> Good afternoon ma'am.
You can see now.
>> Yeah. Yeah, we can see.
Yeah, perfect.
Um I will introduce you Madi one one speaker at a time.
And this Mad, you want to message her or something?
Uh hello Madi.
>> Huh? Yeah. Yeah. Messaging her.
>> Huh? And by chance if she doesn't, we'll put your lecture first.
Shall they call?
You want me to call her him?
>> I think so now because we are almost going live now and also I've just emailed her 2 minutes to go and we waiting call I'm calling She's not picking up.
Yeah, I was just calling you to tell you to join.
>> We're trying to breathe in and breathe out.
Hi, Helina.
>> Hello.
I just saw your call Maduri but I thought I would just finish getting >> I was just calling you that's why so that we can shall we start Helena?
>> Yes absolutely.
>> Okay good.
>> You let me know when you want me to share the screen.
>> Sure. Sure. Um tech team are we going live?
>> Yes ma'am.
>> Yeah. Can we start?
>> We live. Yeah.
The brilliance of the light does not diminish despite it being repeatedly used to light many more lamps. So too knowledge does not lessen when shared with or imparted to others. It becomes benefits both the receiver and the giver. A very good afternoon to all of you and a warm welcome to all participants joining us from across India and around the world. On behalf of artist for her, the Asian research and training institute for skill transfer, it is my privilege to welcome you to this landmark webinar, PCOS then versus PMOS now, straight from the experts behind the movement. Today is not just another academic discussion. We are going to witness a historic moment in women's health where evolving science is challenging long-held assumptions and encouraging us to rethink how we understand, diagnose, and manage one of the most common conditions affecting women globally. Today, we have the unique opportunity to hear directly from the thought leaders who have helped shape this global conversation.
It is my pleasure to introduce our moderator for today's session, Dr. Hma Dvakar, an internationally respected gynecologist, women's health advocate, educator, and champion of innovation in healthcare delivery. Through her leadership in capacity building, digital health, public health initiatives, and women's wellness across the life course, Dr. Dwakar has consistently worked to bridge the gap between evidence and practice ensuring that advances in science reach women everywhere including the last mind. Today she will guide us through this important conversation with two distinguished global experts over to Dr. Thank you so much PNI and on my own behalf and on behalf of team artist we extend a very heartfelt welcome to two of our very distinguished guests and experts for today's webinar and all our beloved delegates who have joined us from across the globe.
We accept that change is constant and we also often allude to the fact that oh what's in a name yes ladies and gentlemen the PCOS then and PMOS now let's see what is the story behind it and it is indeed now my great honor to introduce the first expert who would be deliberating in this session on PCOS then and PMOS now at the knowledge cafe hosted by artist professor Dr. Helena Ted is a globally recognized worldleading authorities in reproductive endocrinology and women's health. She is the president of international society of endocrinology, a renowned clinical scientist, a lead author of international evidence-based guidelines for PCOS then. And we also had her in one of our previous session which was titled the changing guidelines in PCOS then and now. And now we present her back to you with Dr. Maduri on yet another insightful deliberation on PCOS then and PMOS now. She is one of the foremost voices driving global efforts to improve care for women with this condition and her work has transformed how clinicians understand and manage this issue across the world placing patient centered care and evidence-based practice at the heart of the management.
Today she'll help us understand the scientific journey that has led us to the proposal for PMOS and what this means for the future of women's health.
Ladies and gentlemen, please join me in welcoming Professor Helena Ted who will unlock and unravel the mysteries of PMOS for the clinicians. Over to you Helena.
>> Thank you Hemer. If you can stop sharing I will share my screen.
Thank you very much.
Okay, just going to make sure that you can Sorry, just go back to the start slide.
Okay, can you all see that slide?
>> Yes.
>> Excellent. Thank you. So, we're here to talk about polyindocrine metabolic ovarian syndrome or PMOS, the new name for what was previously termed polycystic ovary syndrome or PCOS. I'm going to take you through the definitive global rename, the history, rationale, process, and very rapidly advancing implementation.
In terms of disclosures, I'm the president of the International Society of Endocrinology. I'm the lead on the PMOS name change process and on the international guidelines and I have no other disclosures and receive no funding from farmer. All my funding comes from government competitive grants.
That's um both as a clinician and as an academic. So I'm going to first talk about the name change, why we needed to change it, how we did it and what it now is. So we all know that this is a condition caused by genetics, epigenetics and environmental factors.
It is endocrine or a chemical messenger disorder including disruption of androgens, insulin and neuroindocrine pathways but also many other endocrine pathways are disrupted.
The clinical features are reproductive, metabolic, dermatological and psychological. The reproductive are not only arrest of ovulatory processes um and an increase in the number of developing follicles that we see on ultrasound but they're also significant fertility implications and less commonly recognized major pregnancy implications as well as an increase in endometrial cancer. The metabolic features are diverse. The dermatological features are quite significant especially in regions such as India and South Asia including aanthosis, excess body and facial hair, scalp hair loss and acne. But importantly, the psychological features include eight times the rate of suicide attempts, major prevalence of anxiety and depression, disordered eating and equivalent, if not greater impact on quality of life than type 1 diabetes.
These are yet only some of the endocrine disruptions we see in this condition. So endocrine is a a fundamental disruptor here. But androgen excess, LHFSH or gonadotrophen imbalance and kissepin changes in the hypothalamic gonadotrophic axis, GABA and serotonin pathways which are involved in psychological features, elevated antimmalarial hormone from an endocrine perspective, significant atypine dysregulation and alteration in the IGF-1 signaling. All of these pathways and more are disrupted in this condition.
And yet this is what we think of the condition as and what we used to call it. Remembering that there are no increase in abnormal ovarian cysts in this condition. There is an increase in disrupted follicle development and as such it looks like cysts on ultrasound but there are no increase in abnormal cysts in what was called polycystic ovarian syndrome. In fact, it's a diverse condition with many significant clinical features. So why does this matter if we only focus the name on one particular part of the condition? First of all, the name is incorrect. There are no increase in abnormal cysts. Secondly, it is not a primarily ovarian disorder.
But again, does that really matter?
Turns out in medicine and healthcare, it is critical.
If you designate a condition as we have as primarily an ovarian disorder, the access to research funding for this condition comes from a very very very small and incorrect box. Not only is it within women's health and women's reproductive health, which is a relatively small funding source, but it's within the ovary. And so what we see is a condition that's been known about for a hundred years with not a single approved specific medication to treat the condition.
In fact, only recently with guidelines have we seen uh acknowledgement that some of the existing medications such as metformin for treatment of insulin resistance and diabetes are now approved specifically for this condition. But fundamentally there are so many opportunities for us to address this.
But it's never been funded in research.
So if we don't fund research, we don't get new evidence. If we don't get new evidence, we tend to not be able to focus on updating guidelines, which is why the process has been so slow. We also tend to educate in very narrow bands. I had very comprehensive medical training and in six years as an undergraduate I had one hour of education on a condition that affects one in eight reproductive age women and beyond and it was under infertility and gynecology. When you classify a disorder as a gynecological disorder only then there are implications of that. the cardiologists, dermatologists, psychologists, um allied health clinicians, midwives and even obstitricians as opposed to infertility doctors do not tend to think it's their problem and do not uh tend to think of the broader features. So in fact our education is narrow the framing of the condition is narrow the clinical ownership is narrow and we don't think about the broader implications that leads to really really high levels of dissatisfaction and in fact throughout the world our research has shown this is one of the most underdiagnosed um conditions. It often takes three clinicians to actually get diagnosed.
And once diagnosed, the dissatisfaction with care rates are really high. Not because each individual clinician is poor at their job, but because we actually have that whole process of mclassification as a problem. This process was not just about changing the name to fix the um incorrect or inaccurate characterization of an ovarian disorder or of increased abnormal cyst but actually to break out of that classification that has caused all of these problems. So this affects 170 million women globally during the reproductive years and many beyond and in South Asia even more. greater than 70% remain undiagnosed. And in 2012, the NIH in the US had a a major evidence-based workshop and recommended at that time that the name should be changed because it was inaccurate and it was causing harm. However, it wasn't clear what it should be changed to. It's since evolved in science that the polycystic description is a misnomer that the single organ frailing framing as a primary um effect of this condition is incorrect and that has had major downstream harm. This condition spans predominantly endocrine driven metabolic reproductive psychological and dermatological features. We have done the patient population a great disservice by keeping it framed as it has been for so long. So why didn't we do this earlier if the recommendation was 2012? There's been a lack of global leadership. Whose job is it? Whose right is it who has the authority to lead a name change? Is it the endocrinologist, the gynecologist, the dieticians, the cardiologist? Whose job when there are so many people who need to be at the table? There was a lack of patient alignment. Some countries, especially in the US where advocacy was strong, felt that they'd spent so much time and effort on advocacy that a name change would be detrimental. But that is but 4% of the world's population. And for most of the world's population, that advocacy was seriously lacking. There was a lack of agreed alternative name. This is probably the biggest barrier.
And there was a lack of implementation resources and strategy. This initiative we're about to describe understood that and addressed all four.
So the mandate for change came from a large global survey that was published last year but undertaken in 2024 after the 2023 guideline. It looked at the perspectives from patients and health professionals including in India and South Asia but across the world on what the clinical features were, what the problem with the current name was, should it be renamed and what the core things to consider would be. It did not ask what the name should be and most important this built on patient advocacy and also built on the international consortium for the evidence-based guidelines that are now used in 195 countries that sorry I should say that survey of around 8,000 people universally endorsed the need for a name change and validated that the benefits would outweigh the risks. So we then went on um a pathway if you like to engage even more partners than we had involved in the guideline which was around 40 and increased that to 56 and since then have increased even further and that included patient groups in all world regions as well as diverse health professional groups and we built on the coalition and governments in the guidelines. These are a list of the international and national societies and indeed you can see that Aspire and many other groups have been involved.
The first question we asked people once we had a mandate for change was what are the principles we should adhere to and the surveys provided us with that information. Essentially we developed those principles and best practice. We engaged patient groups including the lead group the governance process that had shared value and power including with patient representatives. We engaged and involved all groups to determine the principles the approach we would take the ultimate terms and the name and we considered cultural appropriateness and had a strong focus on dissemination and implementation.
So that process was very rigorous and unprecedented and is now being used for multiple other similar initiatives.
We got the governance and funding. We did the major first round of surveys. So this is after the mandate. We then had an international workshop which others including Maduri Patel who we'll speak shortly were involved in and then had a second survey and input from marketing experts and then finally came to a consensus which then kicked off the implementation strategy. Patients or consumer and community involvement were critical at every step of the way because ultimately they're the ones that live with this condition. So in a condition with 170 million affected in reproductive age, we ended up engaging around 22,000 people from the mandate stage into the name change. 56 societies and patient groups and they generated 90 nominated representatives from all world regions to actually participate in the final stage.
The first thing we asked them is what principles we should apply. So we've already got a mandate to change this.
What are our principles? The most important was scientific accuracy and avoiding stigma. Patient outcomes being forefront, clarity and communication, culturally appropriateness and implementation feasibility. These principles guided every decision that was subsequently made. The next thing we asked them is what approach should we take? Should we come up with a new accurate name? Should we use what's called a generic name? asthma, diabetes doesn't mean anything, but it also isn't incorrect and doesn't bring stigma. Or should we retain the P, the C, the O, and the S from a history point of view, but come up with new words that align with those? Well, we got a very clear message on this. Less than 50% actually supported the last two and 82% wanted an accurate name which was based on the symptoms they experienced. they were second tired in essence of being given a name for this their condition that they didn't relate to and that was a really important message for us. So from there we went through a very rigorous multi-stage process looking at all the different terms. So the key terms that emerged were polyendocrine or potentially endocrine poly meaning many endocrine meaning hormones metabolic the alternative was cardioabolic. ovarian.
The alternative is reproductive. Now that was the most controversial but in essence there was about 85% support for either polyendocrine or endocrine. The majority of support was for metabolic over cardioabolic and the most controversial was on ovarian versus reproductive. One of the critical factors that came from input from cultural groups was that labeling a woman as having a reproductive disorder implying that she could not reproduce would have potentially major harmful um implications around the world when in fact the majority of people with this condition with treatment can have the family size they aspire to especially if they're diagnosed properly and treated appropriately. So for that reason with very compelling patient stories and strong advocacy the preference in multiple rounds of voting and surveys was to choose ovarian over reproductive and ovarian moves away from the gland ovary and implies function secondary to endocrine disturbance such as ovulation effects hormonal um impacts and fertility impacts. Once these terms were agreed and that sentence really simplified a very complex process, then they were combined into a name, different um orders and combinations with an acronym, making sure that the acronym didn't duplicate anything else, considering language and cultural implications, and getting input from major marketing experts. The marketing expertise was quite important because their advice was this is not a new condition. The diagnostic criteria have not changed. the science has just caught up to kick out the old inaccurate name and bring in a new one. So you need some continuity. POS was actually not that similar to PCOS but it was quite different. It was different enough to be important. In the end in the workshops we had 97% consensus to approve the new name and this was published then in the Lancet as the most prominent medical journal globally and that was really important for credibility.
I'll go on to the other publications we've had since then but this was fundamentally important and I have to say I was incredibly nervous that we would have broken the embargo because of all the engagement we had with journalists before. But it does show you that the embargo system can still work globally. I've just before this talk finished my 205th interview with the media about this condition. And the fascinating thing is that those that interest was driven by female journalists, the majority of whom had the condition or who had friends or siblings with the condition.
So why is this name more accurate? How does it align with the clinical features of the condition? We've already talked about all of these pathways that we know are primarily disrupted in this condition. This is not because of an ovarian disorder.
We've already talked about the clinical features and here we've just elaborated on the reproductive disorders which are broad, the metabolic disorders including cardiovascular risk factors, diabetes, pregnancy complications, um uh metabolic liver disease and cardiovascular disease and the dermatological implications which in um South Asia really do include um aanthosis and other quite significant manifestations as well as those psychological ical features.
Those clinical features change across the lifespan and the symptoms actually are most prominent or the classic symptoms are most prominent in adolescence and then change through to being less prominent uh after menopause.
But the BMI increase occurs over time.
The psychological burden persists and the metabolic features become more prominent as people become older. It's now been agreed and included in the guideline that this is a lifelong disorder but the diagnostic criteria predominantly apply earlier in life.
So this all became clear with the international evidence-based guidelines and India uh and many in fact involved uh in the Indian PCOS society previously PCOS society of India um were involved in these guidelines. In fact, of all countries have probably been most enthusiastically adopted within India and within many Asian regions. The diagnostic criteria are unchanged. The way we frame these criteria are different. These are not primary ovarian criteria. They are in fact endocrine criteria. that for adults you require oligo or anovvulation clinical or biochemical hyperandrogenism what's currently called polycystic ovarian morphology on ultrasound but is in the process of being changed again with a consensus process or antimmalarian hormone levels and exclusion of other eiology. So two of those three are required. The international guidelines have specified um more detail around those which you can reference their guidelines for but they've also separated out that in adolescence you require both one and two and in fact you are advised not to look at the ovarian morphology or AMH levels because they overlap with pubertal physiology and do risk over diagnosis.
These diagnostic criteria have not changed but in fact they are actually seen differently as endocrine mediated.
And one of the other things we recognized was the critical need to have improved care from pediatric care onwards to make sure that we get the diagnosis right that we um empower uh care across the lifespan.
some of the neglected clinical areas including in adolescence. The adolescent um doctors or pediatricians who are involved in this process said the number of times they sit with a young woman who's just been diagnosed often with her mother in present in present at the consultation and they have to say you have a disorder called polycystic ovarian syndrome. You don't have increased abnormal cysts. It's not an ovary disorder. We're not going to assess your ovaries, but this is the name of your condition. And now I'm going to explain to you what it really is and how harmful and confusing that diagnosis was. Even more so than actually in adults. And yet in our adolescence, we see major metabolic risk. We do see ovarian manifestations.
Um but often the dermatological and psychological features are paramount and they're simply more often than not from the evidence we have around the world told they have this polycystic um syndrome and put on birth control pills which often the parents not that um supportive of rather than recognizing that what they're actually being treated with is hormonal regulating medications that will overcome these problems. And that has been a really significant change for the adolescent community. The other area that's very neglected is pregnancy outcomes. PMOS has the same adverse pregnancy outcomes as type 1 diabetes. And if you think of all the preconception counseling and all the attention we give people with type 1 diabetes in pregnancy and yet this has the same complications. This is our analysis of 17 million pregnancies around the world. The first thing to note is only 2 to 4% so one in six maybe one in five with the condition are even recognized or identified in pregnancy.
They have up to two-fold miscarriage rate two to threefold gestational diabetes especially in South Asian populations. They have much higher gestational hypertension. They have preeclampsia rates that are much higher and pre-term birth. Those risks are independent of age, independent of BMI, and of mode of conception and are present even if you remove the use of assisted reproductive technology. And the offspring have fetal growth restriction, premature birth, low birth weight, and higher rates of admission to neonatal intensive care units. This is not a benign condition in pregnancy and yet it is not mentioned in the abstetric textbooks and midwives have absolutely no training on PMOS.
The other key neglected feature is that of cardiovascular risk. This is a UK study of 174,000 women showing increased risk of almost all um the cardiovascular outcomes. And more importantly, this is the data on those with a BMI under 25 and in Asian populations, we would argue under 23 showing an increase in all cardiovascular outcomes and also in thrombosis. This is really important to understand that it its effects are broad. So in this case the best models of care don't focus on the ovary and don't just focus on inaccurate cyst but are actually interdisciplinary involve primary care involve gynecologists and others recognizing the broader features of the condition and are patient centered depending on the life stage and the features that they present with. It has to involve patient empowerment and accurate education over the inaccurate misinformation on social media and be around what the patient priorities are and it also needs to be countenanced as a chronic disorder with lifelong care.
So having changed the name to PMOS, having recognized it aligns with clinical features and that there are some areas we need to address the neglect, the most important thing here is how we implement this name change. It would be irresponsible to change the name and not drive implementation. And as an implementation scientist, this has been the area that I've been probably most passionate about. So we have 86% of patients who supported name change alongside the majority of health professionals. We have 22,000 surveyed that are involved and we had 56 organizations including many throughout Asia and 97% consensus on workshop business. We have had individuals who've attempted to perhaps increase their own prominence by being critics of this process and by suggesting we should not change the name. I would challenge each one of them to think carefully about the fact that they are prioritizing their own opinion over what is the most unprecedented global engagement to bypass individual opinion transcend that space and actually come up with global consensus.
But we have had a rigorous inclus inclusive medical naming process. All of those that I've outlined have been involved. We've used implementation science including the consolidated framework for implementation research and the um expert consensus on strategies and we've em embedded evaluation.
We've um work towards better understanding aiming to reduce less stigma by having a more accurate name and by recognizing the broader features of this condition for clinical practice. Framing this outside one discipline and framing it outside one organ is really important to work towards reducing diagnostic delay better um align with diagnostic criteria aiming to improve patient and health professional education and have much more holistic patient centered care in research moving outside that incorrect classification box to increase our research our funding and our diversity and a focus on treatment. um changing the codes to optimize um uh the way we frame the condition and to have much broader research programs. Whilst we do plan to have a three-year transition, the implementation has been so rapid so far that we may actually not need that whole time. In fact, the principles that underpinned our implementation process have been the same principles. accuracy, improving patient outcomes, avoiding stigma, being clear in communication, being culturally appropriate, and being implementable.
We are using the architecture we've used for the international guideline translation. PCOS is definitively now PMOS. We are not going back and indeed I'll show you why. And the implementation is led by implementation scientists. It involves changing the policy, not just the name, but reclassifying the disorder as an endocrine disorder with reproductive, metabolic, psychological, and dermatological complications, accelerating more diverse research, generating more evidence, broadening education and ownership, and improving care and outcomes.
In fact, these are the the eight stages.
So, publication and dissemination. We started with the Lancet. We've now been in Lancet child um and adolescent health, nature medicine. There's an upcoming paper in New England Journal of Medicine, Nature Metabolism, and 24 other major leading journals across the different specialties.
The resources and global communication, I'll show you some of that. These were all developed before the release of the guideline in 20 different languages and went out to the 56 part societies who then disseminated them further. The reach of those communication and resources have been unprecedented. The media and social media was better than we could have anticipated. The reach is currently 1 billion from conventional media and 75 million from social media.
New York Times, Times Magazine, BBC, CNN, Reddit, um the online platform and media across the world have engaged health information systems. Snow Med, which is the medical terminology system used in 80 countries, has decided that the response and the request from their member countries has been so enthusiastic, they are going to rename and reclassify in one step rather than waiting for WH ICD codes that will then allow us to change it from medical record and billing systems. We are notifying research funders. We have already changed uh gone through the process to change the terms. PCOS will not disappear. All the history that's there will be retained. But the new term from moving forward will be PMOS. That includes across all the research databases. And we are just writing to the top 100 journals and their editors to make sure all future publications use the new name. The WH international code of diseases is a slower process but is underway. Not just the name change but the reclassification.
In terms of global conferences, we have already presented globally at many different forums um including this one and it's a great opportunity. We have a series of um uh presentations across all relevant fields and globally over the next 18 months. We have also written to or are writing to the top 400 universities globally recommending the name change and the reclassification actually providing curriculum content in multiple languages that can be adapted for use instantly in their not only medical but also allied health and nursing curricula and we've already made changes to the major textbooks such as Harrison's in the online version international guidelines already used in 195 countries. POS, formerly PCOS, has been changed as of today and will be re-released at the end of this week. And the National Institute of Clinical Excellence in the UK, which is adapting the international guidelines, has already changed the name definitively to PMOS due to overwhelming health professional and public support. And the 2028 guideline will only use the term PMOS.
In essence, this is now unstoppable and even better than we had anticipated.
These are some of the recent publications in nature medicine focusing on why the name is important and reclassification. Lancet adolescent and child health, why this is so important for adolescence and the other ones you can see are actually coming forward at the moment.
This is some of the the media content that was actually released and these are some of the resources that were developed. They were based on the resources from the guideline and the network and the ask PCOS app which is free and used in 195 countries has now converted to ask Pam OS and that QR code gives you free access to the resources in 20 different languages.
The app itself is outlined here and resources such as 10 things to know about the condition is now reverted to 10 things to know about PMOS.
These are some of the resources in the 20 different languages and I believe as of this week we're now up to 25 different languages.
But the interesting thing has been that media and social media response. As I said, there will be at least 25 publications. Mainstream media has reached a billion and there has been 6,000 segments um on the condition. The social media sentiment has been 80% factual, neutral or positive, 20% negative. But that has not necessarily been about the name change. It's been about the neglect. So you've changed the name, but what are you going to do to improve my care? And this is a a wordle or a word diagram of the key um things that were mentioned, including significant frustration about the fact that there are no increase in abnormal cysts despite the fact that that's what so many understood. And indeed this is the global um engagement around media and with the exception of small areas in Asia and in northern Africa there was social media and media activity around the world.
So in terms of those steps we have already completed or are well underway in our publication program. Our resources are already disseminated and used globally. Our media and social media reach has been far more than we expected. We have already started the process with Snowmed and then we'll move on to the electronic health records. In research, we've already um worked through the meth changes for terms and research databases and are working with the editors. In the international classification, the application is already submitted. And in education, we've already um got the conference program and now are working on the university changes and textbooks and the guidelines. We've changed the 2023 guidelines and the nice guidelines and the 2028 will be the final step here.
But this has progressed in less than 4 weeks since the name change has been released because of all of the background work that was done before. So remember 170 million women globally of reproductive age and many more postmenopause. This is too common and too important to be misdiagnosed, misnamed and underserved. And this is now the most comprehensive, rigorous and inclusive medical renaming process ever undertaken. And it the implementation has been unprecedented.
The process is now being applied in multiple other name changes and actually to assist in land commission implementation where they've been unable to achieve a consensus.
It's a pathway. We may have changed the name, but the transition is needed because not every clinician is going to know about this overnight. I've just come back from Japan and the International Congress of Endocrinology where we had a lot of strong representation from experts across Asia in about four and a half 5,000 strong contingent and the number of clinicians who came up to me and said 1 2 3 days after the name was changed my patients came to me in rural Pakistan and in India and in Sri Lanka and in the region and said they've changed the name of my condition. What does this now mean? So, not only the clinicians, but the patients know that things have changed.
So, we're on a journey to get to better care and better outcomes. It won't change overnight, but it will change.
And the era of individual expert opinion fighting against the strong current of international consensus is now over. I wanted to acknowledge all the people who are involved uh and which includes Maduri and others and also to uh to thank the people who are involved in this process and I will leave you on that point. Over to you Maduri.
Yeah. Thank you so much Helena. I think uh you should be rightly coined as the unstoppable Helena because the last slide which you show last one of the few slides that you showed about the implementation strategy and the road continues the lot has been done before but quite clearly you're determined to do a lot more and many things are underway. So you have really laid the fresh thinking foundation amidst thousands of clinicians who are watching this program today as to what was the science behind this change. the implications for diagnosis, research, communications, patient care and what it means for all of us as clinicians, researchers, policy makers and the women themselves, whether from Asia or the west, whether from rural or the urban.
It just has touched about everybody. So, thank you so very much. 97% consensus in a workshop. Congratulations for that.
especially at 205 plus interviews. You are something so special and we are so privileged to have you with us today.
Thank you. Thank you so very much. And thanks to the connect through Dr. Maduri who had promised us that she will bring you on earlier sooner than later to present it to our audience in India. And next it is my proud privilege to introduce my very beloved friend and colleague Dr. Maduri who really needs no introduction to the Indian audience and um uh she is one of India's most respected reproductive medicine specialists and a leading voice in infertility and reproductive endocrinology. from the post of vice president of ISAR. She's stepping uh into the post of president in just the next two years and now she's currently the presidentelect officer and uh she's also the PCOS society lead for the country and her voice is well respected well heard she's a clinical director of the part fertility and endoscopic clinic a working encyclopedia as we call her an educator a researcher a mentor to countless clinicians across the country.
Maduri will be switching us over now to the response in India for this change of terminology PCOS then and POS now. So over to you Maduri for your experience of the things going on in India and how we as clinicians are in for a new era to handle this condition for millions of women in our own country.
>> Uh thank you HA. So, professor Helina has already set the stage as to why and how the name change happened and I will speak on how it is important in the Indian context.
So, we know that this consensus has taken almost more than 14 years and she's already described that the global burden is almost 170 million and in India we know about 19.6% uh of the women are affected with PCOS.
So why does it bear then a disproportionate burden? One, it is because of genetic predisposition where the beta cell dysfunction and insulin resistance are seen even at a lower BMI as compared to the Caucasians. There's a dietary transition where high refined carbohydrate diet, low protein and low fiber diet has been used. Physical activity especially because of rapid urbanization and sedentary occupation.
There's also a double malnutrition that is there is intrauterine under nutrition resulting in insulin resistance in the baby and then it results in postnatal overnutrition. There's epigenetic epigenetic programming with intergenerational insulin resistance and diabetes cycle through the girl child in India. There's also a BMI paradox because Indian adults of BMI 23 had has the same uh type 2 diabetes melatus risk as a Caucasian at BMI of 27 and the also it has been seen that there's an earlier onset of type 2 diabetes melatus which happens at anywhere between the age of 25 and 34 uh as compared to uh as compared to the uh Caucasians and uh it is about uh it is the incidence is about 24 to 39% abnormal BMI in Indians versus 9.3% in the white population.
So we know the different phenotypes and we know the the phenotype A the prevalence is around about 34% 34% of phenotype B it's about 15 to 21% and the maximum uh cases what we see in India are basic basically belong to phenotype C and the uh prevalence is almost about 41 uh 41% uh in these patients and phenotype D basically the again the prevalence rate is around 20 to 32% person and the presence of phenotype C basically challenges the glo global assumption that classic hyper hyperandrogenic phenotype is most common necessitate therefore it necessates that we have a Indian specific diagnostic threshold as well as guidelines and then why does POS fit the Indian phenotype better because we know that it is predominantly metabolic and Indian women with PMOS frequently demonstr ate early insulin resistance, central adyposity despite a normal BMI, high visceral fat and low muscle mass, metabolic syndrome, dysipidemia and non-alcoholic uh fatty liver has a high incidence. There's also a higher incidence of pre-diabetes and type 2 diabetes at a younger age and increased cardiovascular risk and this has a clinical implication in that the BMI underreads the risk and as in the west and therefore we must use the waist circumference and the waist to height ratio uh hip ratio and for the Asian cutoffs. So if you look at the Indian national data according to the NIH the prevalence is only 7.2 to according to the roto criteria it's 19.6% whereas according to the AO a PCOS society criteria it's 13.6% but if you look at the most prevalence we see that the incidence is as high as 40%. And if you look at the co-orbidities, dysipidemia is seen in about 92% of the patients, obesity in 43%, uh fatty liver in about 33%, metabolic syndrome in 25%, hypertension in 8.3% and diabetes in 3.4%.
We also know that India carries a disproportionate metabolic burden and prevalence varies regionally and PMOS reframes a condition already at the epicenter of India's non-communicable disease crisis. It has been seen that one in three Indian adults have metabolic syndrome. 35% of women have as against 26% of the men and the prevalence is 32% in urban areas as against 22% in rural areas and 50% of the PMS women in South India uh witness metabolic syndrome. So therefore you can see in some states of south India like Kerala the incidence of metabolic syndrome is as high as 61% whereas it is lower in northeast India which is about 35%.
So we know that India already has the a world's large highest burden of type 2 uh diabetes and also a rapidly rising cardiovascular disease risk and adding PMOS which independently ripples the type 2 diabetes risk and raises the cardiovascular risk by 1.5 by 1.5.
So if you look at the Indian data for metabolic crisis about 11.4% 4% have diabetes melatus. 15.3% have pre-diabetes. 35.5% have hypertension.
81.2% have dysipidemia. 39.5% have abdominal obesity. And 28.6% have general obesity. And as you can see this is significantly higher than the global population. And as you can see over here about 1 136 million uh Indians have pre-diabetes. And this is the largest prevention window uh in history we can get and therefore labeling it as PMOS and will help us in preventing type 2 diabetes.
So basically the Indian phenotype is a thin fat Indian and uh usually the metabolic risk is hidden in this and the PMOS is going to help us in unmasking this risk because we know that the South Asian phenotype has higher visceral fat lower muscle mass insulin resistance at normal BMI and the defining biology behind India's metabolic epidemic in India normal BMI does not mean metabolically metabolic safety. PMS as a diagnost diagnosis legally and clinically obligates the physician to investigate metabolic risk irrespective of the bo body weight and the name change enforces this.
So if you look at the uh look at the metabolic risk so uh as compared to the Caucasians it starts with a BMI of 23 because the visceral fat is almost 10 to 20% higher than the Caucasian position muscle mass is 15 to 20% lower the BMI at 23 has the same risk at a BMI of 27 of the Caucasians the risk of type 2 diabetes and metabolic risk is significantly higher than the Caucasian population. The beta cell reserve also rapidly declines as compared to the Caucas Caucasians and the age adapt to uh of type 2 diabetes malacid onset is between 30s and 40s as compared to 50s in the Caucasian population. It's also been seen that in the Asia-Pacific the BMI cut offs the body fat percentage is about 3 to five points higher at the same BMI in South Asians versus Caucasians.
Therefore, the metabolic component is often the most clinically dangerous aspect and the name PMO shifts attention towards prevention, lifestyle intervention, long-term cardabolic health rather than only fertility and menstrual symptoms. Therefore, cardium metabolic screening for lipids, glucose, liver and uh hypertension is core of management for the f from the first visit and it is not an add-on later.
Coming to the fertility perspective, many Indian patients seek care for infertility. The term PCOS unintentionally narrows the condition to ovelation, cyst and fertility treatment.
Whereas PMOS broadens clinician and patient thinking towards usite quality, endometrial dysfunction, inflammation, obesity as well as metabolic optimization before art. This is especially relevant in those patients who have recurrent implantation failure and poor ART outcome.
We also need to look at the psychological and social importance because the term cystic ovaries creates fear. the patient feels do I have a tumor? Will I need surgery or can I conceive naturally or I would not conceive. So in India where reproductive stigma remains significant terminology matters socially. Pom may therefore reduce fear associated with cyst improve patient understanding encourage lifestyle ownership and also reduce ultra ultrasounddriven anxiety. It's also important in adolescent because in India about one in five girls aged between 14 and 19 years have a pool prevalence of about 17.7%.
There was a study which was conducted in Delhi where they uh they diagnosed PCO uh POS in about 17.4% uh percent of the girls the onset is typically 2 years after minarchy.
So in India basically irregular cycles we know can often be normalized. Acne and herocidism are cosmetically treated only. Weight gain is culturally minimized. Young girls are labeled PCOS casually after one ultrasound. Therefore reframing to PMOS could help avoid premature labeling based solely on the scan appearance. Encourage holistic evaluation and early metabolic screening. reduce over medication abnormal ovaries and also increase screening from insulin resistance and mental health before full-fledged metabolic uh syndrome is established.
How can the name change then transfer from the investigations as well as the management? So we know that each word of PMO unlocks a new investigation axis beyond the old ultrasound and the tesron approach. AMH not yet routinely used as well as 17 hydroxy progesterone and DHES are also often omitted and therefore may be required as it is a polyendocrine condition. We also need to do a full metabolic pan panel which should not be negotiable or optional. the of FN uh FNPO threshold which changed from TW 12 to 20 has rec classified almost 37.7 uh 75% of Indian phenotype and added functional assessment of the ovarian axis the PCOS framing basically what we did was to treat the menstrual cycle the skin and the fertility whereas the PMOS framing will allow us to treat the whole person and across a a lifetime line of uh of the woman. So if you look at the diagnostic criteria then and now and what uh what is the Indian uh uh implication uh we can see that hypoandrogenmia was hypoandrogenmia oligo anovilation was mandatory in the NIH9 uh 90 criteria where the ultrasound AMH and metabolic screening and psychology screening was not included in Rotterdam criteria we we had to have I one uh uh two of the three criteria between the hypoandrogenism oligo ovulation and PCOM morphology. AMH was not used but metabolic screening was recommended and psychological screening again was not used but as in 2023 after the publication of the guidelines they said that hypoandrogenmia either clinical or biochemical is required.
Olivvelation also is required and presence of polycystic ovarian morphology where we have more than 20 follicles per ovary is necessary. AMH could be used as an alternative to ultrasound in the adults to diagnose uh polycystic ovarian morphology. Uh metabolic screening is strongly recommended. Psychological screening was also recommended and adolescent uh specific criteria were added in but changing the name from P uh to POS in 2026 the core endocrine access evaluation is important we have to look at the ovarian features uh and therefore we have because of the presence of polycystic ovarian morphology the term ovarian has been retained there's also uh AMH is also supported as a biomarker metab Metabolic is screening is central to the framework. Psychological screening also is a integral compon is a component as well as in adolescent a full lifestyle uh life cycle approach should be adopted.
Coming to the mana uh management basically now we have to look at uh at it holistically and and toward the entire life where we have to look at the reproductive metabolic as well as the psychological uh psychological symptoms and from adolescent to menopause.
Initially chromophene citrate was the first line of drug for ovelation induction but today we know that letter is superior. Metabolic screening for fasting glucose lipids O GTT is mandatory uh in all whereas initially what we uh what we monitored was only the fasting glucose or the O GTT today inositols also are emerging therapy especially in improving the insulin sensitivity and resistance in Indian trials there's also been structural lifestyle implementation which should include both diet and exercise as the first line of therapy and We should also have Indian specific guidelines for the same. Mental health should be integral and therefore screening for anxiety, depression, quality of life should be a part of the standard care and long-term monitoring is most important and it mandates screening for type 2 diabetes, cardiovascular disease risk, endometrial car and endometrial carcinoma.
Counseling also has changed because basically at that point of time uh we uh we just uh thought about fertility and more of hormonal balance and therefore these patients were just offer offered ovarian uh oral contraceptive pills. The mental health was never addressed and there was no long-term monitoring plan which was given to the patient. But today with the name change we know we have to uh explain the diagnosis and in the Indian specific uh where the family also is present at the time of consultation we have to address to the mother-in-law and her other family members the fear of infertility directly and reframe as a manageable condition.
The metabolic risk counseling also uh should should be prioritized in India as we know that 92% have this lipidmia and every patient leaves with uh leaves the consulting with awareness of lipids and not just periods and therefore we need to show them their lab values and explain targets so that they are convinced for the lifestyle modification. We also need counseling for fertility and reproduction because we know that marriage and fertility pressure is intense in India. Proactive fertility counseling from diagnosis is important and it's not only when the couple uh presence to us but at the time of diagnosis as pre as prevents years of anxiety and late referral. lifestyle, mental health and long-term uh long-term surveillance is also very important because in India we know that mental health stigma is a great barrier.
There's also a barrier of body shaming and weight blame are rampant and the PMOS name change will focus on metabolic system and not on body appearance and therefore it allows a non-shaming clinical conversation.
It's also it is also of great relevance for public health in India because the Indian burden according to the IC ICMR uh which looked at about 9,800 women across five zones of the country uh concluded that obesity incidents is almost about 40% in the urban population. There's also a regional variation in the in the real where in the northeast northeast India prevalence is the least and is about 9.18% with different phenotype mixes. The pool meta analysis prevalence is about 11.3% uh and it varies by the criteria as well as by the setting. So we know that India is the diabetic capital of the world facing rising obesity in younger women seeing increasing infertility rates and experiencing earlier cardioabolic disease onset and therefore reframing PCOS as PMS aligns the condition with non-communicable disease prevention preventive women's health and lifelong metabolic surveillance. This has implications for the national screening program, fertility counseling, preconception care as well as pregnancy risk reduction. So then what are the challenges and unmet needs in India. So we do not have any India specific guidelines uh which is evidence-based that there's a lot of diagnostic ambiguity because the population specific FNPO and AMS threshold remain unvalidated for Indian women. We also do not have access to multi-disiplinary care in most uh tertiary as well as primary health settings. This under diagnosis and diagnostic delay in India basically because of social economic barriers. The rural urban divide and low health literacy comp uh compounds this further. Mental health gap is large because mental health screening is rarely integrated in the India PCOS clinics. Adolescent PMOS is overdiagnosed and early oral contraceptive pill prescriptions are very common in India. So I would like to conclude by saying that transition from PCOS to PMS is conceptional and strategic. It shifts the focus from ovaries to the whole body health, emphasizes prevention over symptom treatment, aligns with the Indian metabolic risk phenotype and encourages multidisciplinary care. Most importantly, it reframes this disorder from a fertility problem to a lifelong woman's health condition. That conceptual shift may significantly improve overall health outcome in women.
Therefore, the overall goals include greater awareness, enhanced diagnosis, improved care quality and patient satisfaction and optimized outcomes across the broad features of the condition. I thank you all for the patient hearing and this is a link to the article published by professor Helen in Lancet on 12th of May uh 2026. Thank you.
>> Thank you very much Dr. Maduri Patel for your insightful presentations. Uh we now move on to the interactive discussion segment uh moderated by Dr. Dma Dwakar where we will explore the key questions from the audience. Over to you Dr. Can I just again >> sorry I was just going to Can I just acknowledge that Dr. Mar Patil was one of the authors on that Lancet paper.
>> Thank you. Yeah, and we are very very proud of that and therefore we thought we'll put two great people together and it's been a shared delight uh hearing from yourselves about the entire evolution of this which has taken humongous amount of efforts. So there are as expected a barrage of questions.
Um Helena very nicely put the whole spectrum of life course approach from adolescent to reproductive to the menopause. So the ultrasound is now called a six sense. Most of the obgians will send adolescence for an ultrasound examination and that's where the trigger starts. Should ultrasound findings still be central to the diagnosis? And if we find the ultrasound last line impression as they usually write, it's PCOS, should we step up into complete metabolic screening for such a patient?
>> So perhaps I'll kick off and then M can um can comment. So the problem with ultrasound is that traditional polycystic ovarian morphology and I can tell you that name will change shortly will no longer be called polycystic but we're just finalizing that process >> um is a normal pubertal physiological change and labeling a young woman as having PMOS based only on ovarian morphology is fundamentally incorrect and does not relate to their long-term reproductive let alone metabolic and other clinical outcomes. Uh so in fact AMH and PMOS morphology is not recommended at present. One of the biggest questions here is the noise or we call it noise created because of the relationship between age chronological age and the inability to set a cut off for what is abnormal. So Maria has quite clearly outlined the change in cut offs and that was because of the increased sensitivity of ultrasound from 12 to 20 and that's very important but in fact the the big problem is that it's very difficult to get an accurate age and cut off as as girls go through adolescence. The reason for that is menarchy is so different.
Menarchi can occur from 9 to 18 and and it's a normal distribution. So, we're actually just in the process of finalizing a global analysis of AMH and and um polyfolicular ovarian morphology or follicle number per ovary based on gynecological age. And that looks like it's going to be far more accurate. But in the interim, it does more harm than good. So, an adolescent girl, especially they're not sexually active, should not have an in pervaginal ultrasound.
um abdominal approaches or rectal approaches are not accurate enough and we are almost certainly going to be likely to mislead so that AMH and ovarian morphology should not be used in the adolescent especially if we have no concerns about increased abnormal ovarian cysts. Now if a young woman presents with pelvic pain that's a completely different issue but for the diagnosis of this condition we should not be doing this test either AMH or the AV morphology once they're 20 and hopefully very soon when we get the um gynecological age we'll be able to define that better. That's very different and it's actually important to be able to do the ultrasound. But I will also say that it is increasingly becoming clear that AMH levels are more cost effective than ovarian ultrasounds.
And if you ask patients, they would far prefer an AMH level over when they're having the rather blood done over an invasive gynecological procedure. So we just need to keep that in mind and that may actually be a recommendation in the upcoming guidelines depending on the evidence. But the the uh evidence around cost effectiveness is strong. Major do you want to comment from an Indian perspective?
>> What what I feel is in the adolescent group basically all those girls who have irregular menstrual cycle as well as signs of hyperendrogenmia we should just mark them as they are at risk of developing PMS and not diagnose them PMS. But if they have obesity probably we should do some metabolic screening where we should do a OGTT because uh many times we see that they do have abnormal glucose tolerance and if they already have insulin resistance if even these young girls you can see that they would have aanthosis nigricans. So basically that would again uh probably alert you that probably she could have insulin resistance uh in this patient and uh we know that having more number of follicles or a polycystic coarian morphology is very common in the adolescent group because it's one of the pubertal changes which happens and usually as she crosses her 18 years they come back to normal. So we have to reserve a diagnosis but keep uh label them as at risk uh till she reaches her adulthood that is after the age of 18 years. Yeah. So Badri again back to you on the Indian scenario as it is the PCOS as it was called overdiagnosed in adolescence too many things are being you know added on to their so-called unnecessary treatment. In addition to that, if we say just report it as multifolicular ovaries, do the metabolic test, will we be increasing the cost at the cost of excess of investigations and the obesity factor which you mentioned urban or rural? Many are just used to taking the BMI and the cut off you have emphasized is 23. So we will have plenty of them uh in our clinics and the waist uh hip circumference the waist height ratio all the other things and the new kid on the block the semaglutide also to reduce the obesity. So will those things start featuring in an overdiagnostic and an overt treatment way is a concern.
>> Yeah. So basically I feel that an ultrasound should not be done in these girls. we we just label them as risk and probably most of them clinically show the uh show signs of hyperendogenmia and they have irregular cycles which may normalize later as I've already uh told in my talk. uh so and I'm not very sure about using semiglutides in the adolescent age because it has been seen that uh I mean you as long as you're taking it basically your weight is under control once you stop it uh your weight increases again so I'm not sure I mean if they start in the adolescent whether they should be continue all throughout their life uh so I think lifestyle modification in the form of exercise and diet is the most important and probably apart from us counseling uh the girls we also should have coun uh counselors and we also should have group uh you know the patient groups and I think this uh helps a lot in Mumbai I think there are three or four patient groups and they regularly meet in Bangalore I'm not very sure but as I'm I do talks for the Mumbai group so I know that they have four groups of these patient groups and uh they do meet and uh there's a lot of exchange which happens And that has really helped them in living with the condition. Uh what I have seen and what they uh talk to us when we have a meeting together.
Sure.
because there are both pros and cons because as it is you know people jump into conclusion with one or two findings and then start doing this that and the other. So the complexity should not be enhanced and we have to be um very well aware and therefore these deliberations today were so very important as to exercising the right amount of caution.
Back to you Helena. The question is about integrating mental well-being or a quick check on the mental status which has been highlighted again and again and again that it's an integral part of this. So how do you see that the clinicians in their busy busy busy practice are empowered doing this on their own or does this add another dimension to the multispeciality one more person uh into the group where none are available. So how do you see that coming forth?
>> Yeah. So the guideline was intended to be very practical >> and had input from people around the world including low resource settings and high demand settings.
>> Uh there are two very simple questions.
For example, you can ask to screen for depression and they're not difficult.
They take 20 seconds >> and anxiety is very similar. Yes, you can use quite complex or or you know moderately complex screening tools, but actually there's some really simple questions that are outlined in the guideline that give you a very good idea about whether you need to be worried about this young woman or not.
>> With eight times the suicide rate that we see in the background population and 80% prevalence of anxiety and depressive symptoms. And I don't know about you, but as a clinician, I've never had a condition where so many people go through so many boxes of tissues when we make the diagnosis and talk about the condition.
>> There is a profound psychological impact of this condition and we ignore it at our peril. And just putting someone on the hormonal regulatory therapy, which is the pill, but is framed as only being oral contraceptive pill is fine, but it really does not do them any service at all. You can very briefly and very simply ask very very brief questions which don't increase your consultation time but flag those who are at most risk. And then the most important thing is just to acknowledge that this is a tough road and that here's an information resource such as the ask PMOS app. It's free. It's available around the world. It has evidence-based information. It explains the condition and trying to get >> young women off social media. The support groups I agree with with Madura are really important but it's really important they collaborate with experts because often they get a lot of misinformation on the support groups.
You see these I join many of them so I can counter that misinformation and you'll see a a story that supposedly is from a patient about their difficulties and at the end and I found inositol supplements and they cured me even though the evidence is that inositol does not make a clinically meaningful difference or I've tried bourberine or I've tried this that or the other or I've tried the miracle diet and the reality is and and then they tell people not to use hormonal contraceptive or metformin or conventional therapy.
therapy and the fundamental similarity there is it always comes back to personal financial gain for the messenger. So consumer groups are really important, but be careful about the information they send. And absolutely, as a clinician, it can take you under one minute to ask the critical questions about psychological features. And you can either get them to come back for another consultation or you can send them to a primary care doctor or you can send them to reputable information online. But not asking and dismissing is worse, much worse than not even acknowledging those features.
>> Absolutely. I would underline and underscore these sentences from Helena because even for pregnancy and postpartum we are shifting this task to the frontline healthcare providers that they must ask the minimal two to four questions flag it and bring it to the notice of the consultant and from there we go. So this has to be extended across the life course because mental well-being is such an integral part and it's coming as a center stage for many many issues that we are dealing with and it's high time that we acknowledge that and bring it to the forefront. Pri you were going to say something.
>> Uh no no I was just going to ask Helina whether all of us should use the PHQ the other eight which has got minimal questions >> when the patient comes to us and uh we diagnose so that at least we have some idea about her mental status. I think uh that's uh I feel that's a very good thing and that which I've been following. Uh so I feel that uh it really gives us some amount of idea about her mental status. I also wanted to ask Helina about the GLP1 agonist. I mean what what do you say would you use them in adolescent? I mean I would not use them. So I want your opinion on that whether you would use them or uh in infertility practice.
>> Yeah. So challenging. So as I said very disappointingly there are almost no trials in this condition and indeed there a big trial that will be published soon and semiglutide in adolescence but in the American population where the obesity is really skewed. So there's a very severe morbid obesity in that population and and the features that we see are just not representative in most of much of the rest of the world. But but it it definitely has efficacy. The I think the bottom line is rather than drawing a line of we would not use um for example adolescence that might be 19 with with severe diabetes and metabolic implications and in a multiple piled attempt at at lifestyle implementation.
I think it's fair to say that obesity is understood as a broad metabolic disorder on its own and POS is one of the exacerbating clinical features or exacerbated clinical features of this condition. And when you have multiple factors contributing, the reality is that lifestyle alone will not manage it.
If you've got established obesity and especially arguably in the Indian population, but in so many ways this reflects our failure of policy. We would not run around treating smoking predominantly through nicotine, you know, through other nicotine administrative um uh pharmacological preparations. we would use policy. We would use, you know, um the the classic public health triad of incentivize, regulate, and educate. But for some reason with obesity, we just think it's all about education. We don't manage the the broader implications. We don't manage the ultrarocessed foods. We don't manage the environment. And then we blame and stigmatize people who were subject to the the complications. It is an abject failure of our public health policy around the world. And it's so sad to see that big food learned from big tobacco and has managed to skirt around their implications when we know things like a sugar tax not so much modulate public behavior but actually dramatically change the way um corporate entities formulate their product. So they're just much healthier and they just make things so much easier. But there was just such a reluctance and such a incipid and insidious infiltration of all public health and and policy groups around the world around food. So I think the answer has to be policy. It's not hard. We know the answers. We just have to be brave enough. But having said that, if someone has established obesity just and they wish to lose weight and there has to be their intention, denying them access to efficacious treatment on a basis of stigma is challenging. And the other thing I would say is as these agents come off patent for example in India where where they're available in oral formulations and it's a chronic disorder one would wonder whether we're justified in our objections and in this condition it's primarily because we don't have enough evidence. So my biggest um response to that is policy policy policy policy and abject failure up to date. And then my next one is farmer responsibility about non-sexist and appropriate approaches to high-risisk groups in their research agenda which they have failed to do to date. And then the next one is that where it's warranted medical therapy is justified especially if there are multiple complications.
Um and then finally with the newer agents and the long-term maintenance that's the concern we have because in fact you want to remove these medications before conception and the problem is the moment you do that a rapid gestational weight gain is really quite concerning. So we still don't have a good what we know that we can step down the GLP-1 agents and they can be given given at lower dose and less frequently for a chronic you know treatment and that works but what we don't know is how we manage them when we stop them in pregnancy and whether metformin and other agents can actually help mitigate because we know metformin is fairly safe in pregnancy whether they can help mitigate that really dramatic increase in weight we see for pregnancy which is concerning. So at the moment the answer to me is not so much whether it's adolescence or not. The concern is what we do about preconception and pregnancy.
>> Yeah.
>> Yeah. Thanks Elena. And then your point about the policy and the public health initiatives amidst the NCDs, the hypertension and the diabetes tsunami is already there in low middle- inome countries like ours. And now obesity and mental uh health is also emerging as two other major non-communicable diseases which need to be tackled with persistent and consistent efforts from very very strong lobbies from within the country as well and uh it's uh definitely I would agree with you that it's not an easy task but it needs to be done because it's one of the urgent uh and a burning issue that is facing us as on today. U Maduri the question to you is would you change the infertility treatment protocols based on the PMOS and their further progression into the risks in pregnancy that were alluded to in the talk I think now whatever protocols we are using in this group of patients basically the lowd dose protocols the antagonist along with the antagonist and if there's a high risk of uh osiss then we are using the agonist trigger I don't think uh I mean we would really change the policy but in many patients we see that they already are metabolically compromise. So in these patients would definitely we would add metform into this uh group and it has also been I mean I have still not started using and I don't think I intend also using the GLP-1 agonist for my infertility patients because uh anyway once they stop the treat I mean they have to stop the treatment where before they want to conceive and therefore uh probably uh many a times they don't want to do that and if uh and we really do not know what effects it has on pregnancy because there are no studies been conducted on that. So I think uh my lifestyle modification would be the first thing and my treatment will more so depend upon the age of the patient because today the patients who are coming to us are almost more sometimes more than 35 36 7 years and therefore uh at this stage I would you know not that much less stress on uh lifestyle modification and especially go with the treatment but if they are younger I would definitely advise them lifestyle modification and then go in for the treatment.
>> Sure, that was a question from Rumina Bachi. I hope she's happy with the answer. There was another question by Vijay Lakmi which I think she's now you know trying to withdraw that question from the Q&A box because that question was alluding to what Helina said about the supports group uh giving uh misinformation about my how it helped them etc. So she has asked the question are these drugs of any proven efficacy?
No.
>> Yeah.
>> But it's really important. So when you look at a lot of these studies, they're very poor quality >> and they they're often not randomized control trials or they use the same population. When you exclude those trustworthy or untrustworthy trials, >> there's some minor hormonal benefit, but there's no clinical benefit whatsoever.
And compared to metformin, they are less effective. So let's just think about that for a moment. Metformin came from lavender. It is a natural product. But we did what we always do. If it works, we turn it into a medication and we put quality control. And yes, there's a patent for a while. But metformin is so cheap. It's much cheaper than inositol in most cases. And here we have a scenario where inositol is promoted largely by influencers and others and often quite expensive but it is not proven to generate a benefit other than selective very poor quality trial. So the the real issue here is rely on the good quality evidence which the guideline went to extensive evidence to to extract and the conclusion we came to is if you want to try it try it but there's no evidence will give you any benefit and whatever you do don't exclude the efficacious therapies >> um and I would agree with Maduri when if someone is younger if you make the diagnosis early and we've proven this if a young woman comes in with features of this condition is put on the combined oral contraceptive pill and not diagnosed as many of our pediatric colleagues used to do because they were worried about labeling them. They will not be aware that they need to plan their reproductive lifespan. They won't be aware of prevention. They won't understand the psychological features or other features that they have and they'll largely feel you know um mistreated or undertreated. Then they come off at an older age often so in India but in general older age than they would have if they'd known. Our evidence is with a diagnosis. They come off contraception and plan to conceive four years earlier >> that if they don't have a diagnosis, >> then they come off the contraceptive pill or their contraception older. They don't know they've got this condition.
So, they then go through that process.
Then they go through the process of accessing infertility care. And by the time they've done that, they are much more likely to be lipous. They're much more likely to have a lower than aspirational family size. and they're more likely to have an advanced maternal age pregnancy. All of which are suboptimal outcomes. But if they're diagnosed in adolescence, they understand the condition, they have more prevention, they plan their their fertility journey earlier, they are more likely, in fact, very likely to reach their aspirational family size and less likely to be nipprous. We cannot not diagnose these young women in adolescence or we are causing harm. We cannot suggest that they use ineffective treatments such as inositol which effectively is expensive urine >> because that's where it goes. We need to make sure we're focusing on evidence-based information. And the reason so many young women are vulnerable to misinformation is because of that whole cascade about policy, education, and inadequate care. Not asking them about psychological features. Even just asking is therapeutic. Even just asking shows we care and we recognize. If we don't do that, we leave the door open for misinformation.
more in India also ha I'm finding that so many of the companies are coming with combination of metformin and inostol I don't know how it how it really works and I think each drug I mean I don't prefer using any combination drugs because the pharmaccoinetics of each drug is different and when you put them together I'm not sure really whether one also is effective so I think uh um I mean we should probably encourage the I mean these women with PCOS that they go on metformin I mean it's much better than unless they cannot tolerate the metformin because there are many who have a lot of GI symptoms and they cannot uh tolerate metformin so I think uh that is probably a small group where these drugs could be helpful but uh if you remember we had done a very small trial I mean of about I with you I had done about 50 patients where we use vitamin D as a control And we use anosis. Uh so at least there was no effect on the fertility.
>> Yeah.
>> And there was nothing uh I mean which was uh >> Yeah. Yeah. Sure.
>> We said that you know there was >> say it a little more loudly and clearly I guess. So that so the last three minutes and one quick question to Maduri and one last question to Helena. Shri Son asks if urine test is positive when the patient has taken the semiclutide can we continue the pregnancy.
>> So in my opinion based on the evidence we have which is observational and I agree with Maduri there is not enough but there is increasing numbers of women who are taking these agents when they conceive. There is currently no evidence of adverse outcomes. Yeah. So I would counsel the patient that whilst we have no studies of randomized control trials, the current observational evidence is at least reassuring. But I would never use that to encourage people to take it when they're trying to conceive. I would use that to reassure them that if they're pregnant while they're on it, they need to stop immediately.
>> They need to really be careful about gestational weight gain because we know gestational weight gain. So I chair the WHO task force on gestational weight gain and adverse effects. Gestational weight gain has independent and quite marked effects on adverse pregnancy outcomes over and above BMI and it is really rapid. They're up to 30 or more kilograms of weight loss and weight gain in pregnancy. So the emphasis should be when they stop metformin again not the evidence in this context but we know it doesn't do harm and really stringent lifestyle support for that pregnancy monitoring gestational weight gain so we don't do harm >> absolutely because even on this count Helena all the frontline providers and the OBG bands have been sensitized enough to make a note of gestational weight gain which until very recent past they used to not really pay attention they used to just okay you've gained good weight and that so but what is the comprehensive weight gain where they need to restrict and all that that's because of the tsunami of diabetes and pregnancy in our country so you know they've been doubly guided towards that so that is one thing that is happening and then one last question the question is about what happens to PMOS in the menopausal age group and all of these women who go through their reproductive age and transit they're just left loose in the population without specifically spotlighting that they may be at more risk.
>> Medie, do you want to answer that one?
>> Yeah, I mean uh so basically we know that these women uh if you look if you look at the uh uh hormone metabolic we know that they are at the higher risk of developing type 2 diabetes as well as cardiovas they also have higher cardiovascular disease risk. Plus apart from that they also have a higher risk of developing endometrial hyperplasia and endometrial carcinoma. So basically they should be under surveillance for metabolic syndrome for sure. And uh I mean there's we really do not screen uh for endometrial hyperlasia or for endometrial carcinoma I mean regularly just because they are pmos but if they do have symptoms we have to probably investigate them earlier than giving them empirical treatment to uh to I mean decrease the bleeding if they are having menorasia or if they having shorter cycles uh probably to uh regularize the cycle. So at this stage it's best to uh do an endometrial biopsy in these uh patients and uh we prefer doing nowadays a hyroscopic biopsy because we can probably identify the hypoplastic areas and we do not miss by just doing a endometrial pipel biopsy wherein we just take uh some tissue from the endometrial cavity.
That's my >> Yeah. So besides that maduri you know what again it's all about the policies in countries like ours there's no policy for that age group after the reproductive aid when they're in the system with the pregnancy then they let loose we have not connecting the dots about the life course approach and therefore our wellness um wheel of wellness clinics which we have now floated across the country have brought to light that so many of these women have never ever seen any specialist gynecologist ologist or whomsoever after their last child birth and they just you know let loose in the population like that but 78% of them said nobody told us that you know they were not not even aware that they needed this kind of a care because this could you know impact the uh menopausal age group so I think there is a lot that >> one thing to remember on that that's really important is the prevalence of metabolic associated fatty liver disease in in the post-menopausal population and the implications of that are becoming incredibly >> yes >> uh important. So it's not just diabetes and heart disease, it's actually screening and being aware of that >> and the one thing the guidelines have said is that a diagnosis historically or retrospectively is a diagnosis for life.
>> Yes. Yes. I think you know again you the points brought home was about asking simple questions about the mental well-being guiding them for the possible risks beyond uh you know at every uh span of their life course very very important and I think all of us as OBJ vans have more to do because it's not just a quick fix in that point in time that she's coming to us at a particular age group that we let her go. we have to think of the continuum of care in the true sense and uh guide her across the life course. So with that very very valuable time spent with uh the experts here and I can't really thank them enough for uh the kind of insights that they have given. We started with the terminology change but we know that we have to change our attitudes. We have to implement many things in our practice and we have to do better than what we have already been doing for every girl, every women everywhere, every time. So for a formal thank you note uh I hand over to Dr. Pune again and my heartfelt thanks to Helena and Maduri. We know how busy you are but this was incredibly important for the last phase of what Helena said. The journey continues and we are uh the feet on street implementers of what the uh force behind this whole terminology change has bought uh to highlight uh not only in today's celebration but for all times to come.
As we come to the close of this enlightening session, it is clear that today's discussion was about much more than just a name change. It was about advancing science, improving communication, reducing the stigma, enhancing patient understanding, and ultimately delivering better outcomes for our women. We extend our heartfelt gratitude to Professor Dr. Helena Tid and Dr. Dr. Matrial for sharing their expertise and perspectives. Our sincere thanks to Dr. Hadi Diwak for moderating this important conversation and to all participants for joining us and contributing to this global dialogue.
The future of women's health depends on our willingness to continually question, learn, adapt and innovate. And today's discussion has been a wonderful example of exactly that. Thank you for being a part of this journey. Stay connected with artist for her for more educational initiatives and capacity building programs. Have a wonderful day and a good >> Thank you.
>> Thank you so much. Thank you.
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