PMOS
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PMOS - The New Name for PCOS
PMOS stands for Polyendocrine Metabolic Ovarian Syndrome, and it is the newly proposed replacement name for what has historically been called Polycystic Ovary Syndrome (PCOS).
The Lancet Consensus (May 2026)
A landmark global consensus paper was published in The Lancet on May 12, 2026 (just 10 days ago):
Teede HJ et al. "Polyendocrine metabolic ovarian syndrome, the new name for polycystic ovary syndrome: a multistep global consensus process." Lancet. 2026. [DOI: 10.1016/S0140-6736(26)00717-8] [PMID: 42119588]
The process involved 56 leading academic, clinical, and patient organisations, iterative global surveys with responses from 14,360 people with PCOS, modified Delphi methods, nominal group technique workshops, and marketing/implementation analyses.
Why Rename It?
The term "polycystic ovary syndrome" is considered inaccurate and harmful for several reasons:
- Misleading pathology: The name implies pathological ovarian cysts - but the ovaries have follicles, not true cysts. This is a longstanding misnomer (noted even in older textbooks like Tietz Laboratory Medicine).
- Obscures the real disease: It hides the condition's diverse endocrine and metabolic features - hyperandrogenism, insulin resistance, metabolic syndrome, cardiovascular risk.
- Delays diagnosis: The cyst-centric framing causes clinicians and patients to focus on ovarian morphology rather than systemic dysfunction.
- Contributes to stigma: The name has contributed to fragmented care and stigma, and curtails research and policy framing.
- Affects 1 in 8 women: Given the prevalence, the real-world impact of the misnomer is substantial.
Why "Polyendocrine Metabolic Ovarian Syndrome"?
The new name was chosen because its three core terms accurately reflect the condition's multisystem pathophysiology:
| Term | What it captures |
|---|---|
| Polyendocrine | Multiple endocrine disruptions (androgens, insulin, LH/FSH axis) |
| Metabolic | Insulin resistance, dyslipidemia, cardiovascular risk, obesity |
| Ovarian | Ovarian dysfunction, irregular cycles, anovulation, altered folliculogenesis |
The word "cysts" is deliberately omitted from the new name.
What Hasn't Changed
The underlying condition and its management remain the same. Per Harrison's 22e, treatment still includes:
- Combined hormonal contraceptives (first-line for cycle regulation and androgen suppression)
- Antiandrogens (spironolactone, flutamide) for refractory hyperandrogenism
- Letrozole (first-line for ovulation induction); clomiphene citrate as alternative
- Metformin for cardiometabolic risk in overweight/obese patients
- Lifestyle management for all patients, with screening for obesity, hypertension, glycemic control, depression, and anxiety
Implementation
A co-designed global implementation strategy is underway, including:
- A transition period (the PCOS acronym won't vanish overnight)
- Education of health professionals and patients
- Alignment with health systems and disease classification bodies (ICD, etc.)
The abbreviation PMOS replaces PCOS.
clinical guidelines for GERD'
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GERD clinical guidelines 2024 2025 ACG AGA management recommendations
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Clinical Guidelines for GERD
Definition and Pathophysiology
Gastroesophageal reflux disease (GERD) occurs due to an imbalance between the transdiaphragmatic pressure gradient and the valve mechanism at the esophagogastric junction (EGJ). The antireflux barrier has five components: (1) the lower esophageal sphincter (LES), (2) the diaphragmatic crus, (3) the angle of His, (4) the Gubaroff valve (mucosal cushion), and (5) the intra-abdominal esophageal segment. GERD develops when any of these fail - most commonly due to hiatal hernia, defective LES, obesity (increased abdominal pressure), or excessive transient LES relaxations (TLESRs).
- Sabiston Textbook of Surgery, p. 1699-1700
Symptoms
Typical:
- Heartburn (substernal warmth moving toward neck, worsened by meals, may awaken patient)
- Regurgitation of acid or nonacidic fluid
- Water brash (reflex salivation)
Atypical (Extraesophageal):
- Chronic cough, asthma, bronchitis
- Hoarseness, pharyngitis
- Dental erosions
- Chest pain (non-cardiac)
Alarm features requiring urgent evaluation: odynophagia, dysphagia, unexplained weight loss, recurrent vomiting, GI bleeding, jaundice, palpable mass or adenopathy, family history of GI malignancy.
- Harrison's Principles of Internal Medicine 22e, p. 716-728
Diagnosis
Step 1: Clinical Assessment
- Typical GERD symptoms (heartburn, regurgitation) without alarm features: empiric PPI therapy for 4-8 weeks - no further testing required initially.
- Alarm features present: upper endoscopy first.
Step 2: Endoscopy - Indications (ASGE 2025 Guideline)
- Alarm symptoms present
- Multiple risk factors for Barrett's esophagus (age >50, male sex, obesity, >5 years of heartburn, White race, smoking)
- History of sleeve gastrectomy (GERD is common post-sleeve)
- Symptoms persisting despite 4-8 weeks of PPI therapy
- Heartburn duration >5 years, especially in patients >50 years old (Barrett's screening)
Endoscopy is NOT needed in low-risk patients who respond to acid suppressants.
- ASGE Guideline 2025 [PMID: 39692638]
Step 3: Ambulatory Reflux Testing
- For PPI non-responders: 48-96 hour wireless pH capsule (off PPI) - gold standard for confirming pathologic reflux
- Combined pH-impedance testing (on PPI) - identifies esophageal hypersensitivity or non-acid reflux in patients with persistent/atypical symptoms on therapy
- High-resolution esophageal manometry - mandatory when surgical fundoplication is being considered; poor esophageal peristalsis predicts post-op dysphagia
The 24-hour esophageal pH probe remains the gold standard for diagnosing pathologic GER (in both adults and children).
- Sabiston Textbook of Surgery; Current Surgical Therapy 14e
Treatment: Step-Up Approach
1. Lifestyle Modifications (All Patients - First Line)
Recommended by ASGE 2025 and all major guidelines:
- Weight loss (obesity is a primary driver via increased abdominal pressure)
- Elevate head of bed
- Avoid meals within 3 hours of bedtime
- Avoid trigger foods: caffeine, alcohol, fatty/spicy foods, chocolate, mint
- Avoid tight clothing
- Smoking cessation
- Reduce exercise intensity if exercise-induced
2. Medical Management
Proton Pump Inhibitors (PPIs) - First-Line Pharmacotherapy
- Recommended at the lowest effective dose for the shortest duration needed
- Single daily dose before meals; escalate to twice daily if insufficient response
- Effective for symptom relief and healing of erosive esophagitis
- Up to one-third of patients do not fully respond to PPI monotherapy
H2 Receptor Antagonists (H2RAs)
- Second-line or adjunct (e.g., nighttime dosing for nocturnal symptoms)
- Less potent acid suppression than PPIs
Antacids / Alginates
- Useful for on-demand mild symptom relief
Potassium-Competitive Acid Blockers (P-CABs) - AGA 2024 Update
A new drug class (e.g., vonoprazan) with faster onset and more potent acid suppression than PPIs:
- Do NOT use as first-line for uninvestigated heartburn or non-erosive reflux disease
- May use for severe erosive esophagitis (LA Grade C/D) where PPIs have failed
- Do NOT use for mild erosive esophagitis (LA Grade A/B) as first-line
- Use P-CABs in H. pylori eradication regimens (superior to PPIs)
- Higher cost limits routine use in the US
- AGA Clinical Practice Update 2024 [PMID: 39269391]
3. Endoscopic Antireflux Therapy (ASGE 2025)
For patients with confirmed GERD who wish to avoid lifelong medication:
| Hiatal Hernia Size | Hill Grade | Recommended Approach |
|---|---|---|
| Small (≤2 cm) | Grade I-II | Transoral incisionless fundoplication (TIF) - alternative to chronic PPI |
| Large (>2 cm) | Grade III-IV | Combined TIF + hiatal hernia repair (cTIF) or surgical fundoplication |
Radiofrequency energy (Stretta) is another endoscopic option with a more modest evidence base.
4. Surgical Management
Laparoscopic Nissen fundoplication (360° wrap) is the gold standard surgical treatment:
- Highly effective for confirmed GERD with mechanical defect
- Requires pre-operative manometry (to exclude poor esophageal motility, which predicts post-op dysphagia)
- Alternatives: partial wraps (Toupet 270°, Thal) for patients with poor peristalsis
- Indications: patients who fail or refuse long-term medical therapy, have large hiatal hernia with poor valve integrity, or have documented aspiration/respiratory complications of GERD
- Anti-reflux surgery also effectively alleviates GERD symptoms in Barrett's esophagus patients
- Sabiston Textbook of Surgery; Goldman-Cecil Medicine
Complications and Management
| Complication | Prevalence | Management |
|---|---|---|
| Erosive esophagitis | Common | PPI; LA grade C/D may need P-CABs or surgery |
| Peptic stricture | Less common | Endoscopic balloon dilation + PPI (triamcinolone injection for recalcitrant cases) |
| Barrett's esophagus | 5-15% of GERD patients on endoscopy | Surveillance endoscopy; PPI + high-dose aspirin may reduce progression; endoscopic eradication therapy for dysplasia |
| Esophageal adenocarcinoma | Barrett's complication | Endoscopic resection for early cancer; surgical for advanced |
- Goldman-Cecil Medicine, p. 3215-3230
Extraesophageal GERD - AGA 2023 Guidelines
Key points from the AGA Clinical Practice Update 2023 [PMID: 37061897]:
- No single test can confirm GERD as the cause of extraesophageal symptoms (cough, asthma, hoarseness)
- Multidisciplinary approach required (gastroenterology + pulmonology/ENT/otolaryngology)
- Initial PPI trial (single dose, up to BID with typical symptoms) is reasonable
- Symptom improvement on PPI does not confirm GERD (other mechanisms possible)
- If one PPI trial (up to 12 weeks) fails, objective reflux testing before further PPI escalation
- pH-impedance on PPI can assess role of ongoing acid or non-acid reflux
- Alternatives: alginate antacids, external UES compression devices, cognitive-behavioral therapy, neuromodulators
Special Populations
Pregnancy: Lifestyle modifications first; PPIs are generally safe but use at lowest effective dose.
Post-sleeve gastrectomy: GERD is common and often severe after sleeve gastrectomy. Upper endoscopy is recommended. Conversion to Roux-en-Y gastric bypass may be required for refractory cases.
Pediatrics: Conservative measures first (formula thickening, positional changes), then PPIs. Nissen fundoplication (laparoscopic) is the gold standard surgery for children with life-threatening events, failure to thrive, or esophageal stricture.
- Schwartz's Principles of Surgery 11e; Current Surgical Therapy 14e
Key Guideline Sources (2023-2026)
- ASGE 2025 Guideline on diagnosis and management of GERD [PMID: 39692638] - most recent and comprehensive
- AGA 2024 Update on P-CABs [PMID: 39269391]
- AGA 2023 Update on Extraesophageal GERD [PMID: 37061897]
- San Diego Consensus 2026 on laryngopharyngeal reflux [PMID: 40197644]
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