From primary care to specialist: Managing PMOS and insulin resistance

Maresca opens by describing periods as a vital sign: irregular cycles paired with hyperandrogenism signs such as hirsutism, severe acne, or androgenic alopecia, or with insulin-resistance markers like acanthosis nigricans, difficulty maintaining a healthy BMI, hypertriglyceridemia, low HDL, or MASLD (formerly NAFLD), should prompt evaluation for PMOS. She says referral decisions ultimately hinge on an individual primary care provider's comfort with diagnosis, treatment, or both. Appelbaum agrees that PCPs are well positioned to lead lifestyle interventions — cardiovascular activity, reduced processed sugar, appropriate caloric intake — and that referral makes sense once a provider reaches the limit of their comfort with diagnosis or management.

Cree, describing her rural Idaho practice where pediatric endocrinologists are scarce, tells PCPs that PMOS is not a one-visit condition; she tells patients to expect visits every two to three months for up to a year. She holds two firm lines regardless of setting: protecting endometrial health by some method, and requiring medication — not lifestyle alone — for any adolescent with type 2 diabetes. Otherwise, treatment stays patient-centered. Cree has grown more aggressive with metformin and other insulin sensitizers, reasoning that PMOS-related insulin resistance compounds the insulin resistance of puberty itself; her research shows girls with PMOS run 20–30 mg/dL higher than peers at each oral glucose tolerance test point despite technically normal values. She frames her model as three stacked drivers of high insulin — testosterone, pubertal insulin resistance, and PMOS itself — plus a fourth, cortisol, shaped by sleep and stress. Poor sleep and obstructive sleep apnea blunt the normal overnight cortisol drop and worsen insulin resistance and hunger for high-sugar, high-fat foods, she says, so fixing sleep and managing stress often has to come before food or activity changes can succeed.

In the next episode, "The PMOS Diagnostic Workup: Labs, Rule-Outs, and Timing Tips," Maresca and Cree detail the labs that actually change management, from ruling out Cushing's to the LH-to-FSH trick for ambiguous cases