Ep. 14: PMOS, GDM and Pregnancy with Dr Chelsea Watt

September is PMOS Awareness Month, though depending on when you last checked in, you might still know the condition as PCOS. Yep, it got a name change, and there's a really good reason behind it that we get into in this episode.

To help us make sense of it all, Celia sat down with Dr Chelsea Watt, a specialist obstetrician, gynaecologist and sonologist who heads up Redefine Women's Health on the Gold Coast. Chelsea's the kind of guest who makes a genuinely complex topic feel manageable, she walks through what PMOS actually is, why it so often goes undiagnosed for years, and what it means if you're pregnant, trying to conceive, or newly facing a gestational diabetes diagnosis alongside it.

From the sneaky, easy to miss symptoms, to the extra glucose tolerance testing recommended for women with PMOS, to the very real mental load of managing two diagnoses at once, Chelsea covers it with the kind of warmth and honesty you wish every appointment came with. She's also refreshingly upfront about the parts nobody really warns you about, like insulin resistance creeping up in the third trimester, or the possibility of a delay in your milk coming in.

If you've ever felt like gestational diabetes came out of nowhere, or you're wondering whether your PMOS diagnosis changes anything about how your pregnancy will be monitored, this conversation is for you.

What you'll hear in this episode

• What PMOS actually is, why the name changed from PCOS, and what the new name reflects about the condition.
• The subtle, often-missed symptoms of PMOS and why they can take years to piece together into a diagnosis.
• How PMOS is actually diagnosed, and why it can feel like a long process of ruling things out.
• What PMOS means for fertility and conception, and the support options available if you're trying to conceive.
• Why women with PMOS face a higher risk of gestational diabetes, up to three times more likely, plus other pregnancy risks to be aware of.
• Whether gestational diabetes is harder to manage when you also have PMOS, and why medication like metformin or insulin may come into the picture sooner.
• The extra glucose tolerance testing recommended for women with PMOS, both before conception and in the first trimester.
• Why insulin resistance tends to climb through the second and third trimester, and how to navigate the shifting goalposts.
• The less talked about challenges, like delayed milk supply and the mental health load of managing two diagnoses at once.
• How to prepare for a future pregnancy if you already know you have PMOS, including the six to twelve month preconception window.

Resources and links mentioned

• Redefine Women's Health → redefinewomenshealth.com.au
• Redefine Women's Health on Instagram → @redefinewomenshealth
• Dr Chelsea Watt on Instagram → @dr_chelsea_watt
• Antenatal expressing and colostrum collection, covered in more detail on a previous Gestie episode → Listen here
  
  

About the guest

Dr Chelsea Watt is a specialist obstetrician, gynaecologist and sonologist based on the Gold Coast, where she heads up Redefine Women's Health, a multidisciplinary women's care collective spanning preconception, pregnancy, postpartum and lifelong gynaecological health. Find her at redefinewomenshealth.com.au, or follow along on Instagram at @redefinewomenshealth and @dr_chelsea_watt.

Transcript

This transcript was auto-generated and lightly edited for clarity.

Celia (00:00) September is PMOS Awareness Month, though you might know it by its old name, PCOS. In this episode, we're taking a closer look at what PMOS is, its connection with gestational diabetes, and what that might mean for your care during pregnancy. To help us unpack it all, I'm joined by Dr Chelsea Watt, a specialist obstetrician, gynaecologist and sonologist, who heads up Redefine Women's Health on the Gold Coast. Hi Chelsea, thanks for joining us.

Dr Chelsea Watt (00:26) You're so welcome. It's a delight to be here.

Celia (00:29) So maybe we start at the very beginning. What is PMOS?

Dr Chelsea Watt (00:33) Of course. So PMOS now stands for polyendocrine metabolic ovarian syndrome, and it's revised from its previous name, PCOS, which was simply polycystic ovarian syndrome.

The name change has come about, rightly so, because the original name PCOS focused solely on the ovarian portion of the condition. We now know so much more about it, and it really is a condition of both endocrine and metabolic dysfunction. So the name PMOS is more true to the actual pathophysiology of the condition.

Celia (01:08) Okay.

Dr Chelsea Watt (01:09) So we now know that it involves insulin resistance, high cholesterol and cardiovascular risk, which the focus on ovaries in the initial name just didn't quite account for.

Celia (01:20) Yeah, and as I was looking into it, the symptoms seem like they can be quite varied.

Dr Chelsea Watt (01:25) So varied.

Celia (01:26) Can you speak to what that might look like for somebody?

Dr Chelsea Watt (01:28) Yeah, absolutely. It can show up quite subtly, and that's why it's a little bit difficult. It's usually just a couple of symptoms here or there, which traditionally is why it isn't diagnosed until that time of fertility or reproductive age, which is where the ovaries became a big focus.

Celia (01:41) Mm.

Dr Chelsea Watt (01:42) But actually it can show up as difficulty maintaining a stable weight, difficulty losing weight. It can show up as acne, a male pattern of hair growth across the chin and chest, or even male patterns of hair loss, which we call androgenic alopecia. So yeah, it shows up as quite subtle things, and women often seek help for one of those things at a time, which doesn't really allow the woman or their care provider to piece it all together in a meaningful way. The other big way it shows up, apart from those clinical features, is menstrual cycle irregularities.

Celia (02:23) Mm. If you're kind of piecing the puzzle together over time, how does it eventually get diagnosed?

Dr Chelsea Watt (02:30) So PMOS is diagnosed still based on the Rotterdam criteria, which is the same way we used to diagnose PCOS. It's a criteria that requires two of three features of the condition: one of them being menstrual irregularities, such as oligo or anovulation. Then there's clinical and blood biochemical changes consistent with increased male pattern hormones. And then there's the other piece of the puzzle, which is the polycystic ovarian morphology that we see on ultrasound. And then, obviously, with an individualised approach to everything, we want to make sure the other causes of hyperandrogenism or menstrual irregularities are really ruled out in the process before coming up with a diagnosis of PMOS.

Celia (03:16) So it doesn't sound like it's easy to come to that conclusion. It's a bit of investigative work. Yeah.

Dr Chelsea Watt (03:20) Like so much in women's health, there's just no easy path through it. So not necessarily unique to PMOS, but classic

Celia (03:28) Mm-hmm.

Dr Chelsea Watt (03:29) for women's health conditions. We're delicate, we are. And so yeah, it's just finding a trusted healthcare professional that you can talk to about those symptoms you're feeling, to help you piece it together.

Celia (03:40) Okay. When it comes to PMOS and pregnancy, what's helpful to be aware of, either leading up to wanting to be pregnant or once you are pregnant?

Dr Chelsea Watt (03:49) Yeah.

Dr Chelsea Watt (03:50) I always recommend women have a preconception appointment to discuss all of the things related to pregnancy, fertility and their reproductive journey. For PMOS specifically, it's a leading cause of anovulatory infertility, meaning the eggs aren't being released and therefore you're unable to fall pregnant. So conception can be affected, although the majority of women with PMOS do conceive, often with just some lifestyle modifications, or potentially some ovulation induction help with various medications, or in some cases assisted reproduction may be indicated.

Celia (04:27) Okay.

Dr Chelsea Watt (04:28) Once pregnant, the evidence does consistently show some increased risk for the pregnancy, particularly in relation to development of gestational diabetes, development of blood pressure conditions, as well as pre-eclampsia, preterm birth, and even caesarean section delivery.

So it's always important to get as much information as possible leading into the pregnancy, because we know that improving insulin resistance leading into the pregnancy can reduce some of those risks. And empowering yourself with the knowledge can really take away some of that uncertainty in a time that you're already so vulnerable during pregnancy.

So adding new information, new diagnoses, women are very quick to blame themselves, even though we know in PMOS there's no individual factor that led to this. It's a natural way to process that information, so if you can do that processing before leading into a pregnancy, it can be quite empowering. And then if the diagnosis of gestational diabetes does show up, which women with PMOS are up to three times more likely to receive, studies show, then having done that groundwork leading into it, understanding what insulin resistance is can really help manage the mental load that gestational diabetes presents.

Celia (05:42) Baby brain is real. That was half my struggle, trying to understand the carbs and, you know, insulin resistance.

Dr Chelsea Watt (05:43) 100%. Yeah.

Celia (05:48) So that would be great going in.

Dr Chelsea Watt (05:51) Yeah, absolutely. And then just having those links to, say, an endocrinologist if that's someone you need on your team, or a dietitian or nutritionist that you trust. Having that care team and support around you can also help, A, destigmatise it, but B, just knowing where you can seek help quickly.

Celia (06:10) So if you were to have PMOS and get gestational diabetes, is it harder to manage than someone with just gestational diabetes?

Dr Chelsea Watt (06:19) So this is a really interesting point, and I think gestational diabetes is hard to manage, full stop. For the reasons you just alluded to, it can be a real challenge and can really increase the mental load for our mums. So whilst I don't think it's necessarily harder to manage, I think it is, full stop, hard.

For PMOS, there is an increased likelihood of needing to use medications to help manage the insulin resistance in the pregnancy, over someone with simply a gestational diabetes diagnosis without PMOS. Because with a baseline insulin resistance being brought into the pregnancy, there's more likelihood of needing something like metformin or insulin to help manage those sugar levels during the pregnancy. But all in all, managing gestational diabetes is hard. We're not perfect at predicting

Celia (07:13) Yeah, we're not having that.

Dr Chelsea Watt (07:16) who will need medication, who won't need medication, who will respond well to the medication and who won't. Ultimately, having a diagnosis of gestational diabetes is truly difficult to navigate. Then, adding PMOS on top of it just gives you a few extra time points to check in on that insulin resistance in the pregnancy, which we can touch on a bit more. But yeah, there is an increased risk of needing those kinds of aids to help manage it.

Celia (07:45) Okay. So how would it change how your pregnancy is monitored or treated?

Dr Chelsea Watt (07:51) So we currently recommend anyone with a diagnosis of PMOS, during that preconception phase, do a glucose tolerance test to really understand what that resistance looks like, because there may be a role for dietary changes, lifestyle modifications and potentially metformin, even leading into the pregnancy, which has been shown to improve pregnancy outcomes as well.

And then with a diagnosis of PMOS, we also recommend a first trimester glucose tolerance test, usually around that 10 to 12 week mark, to understand again what that insulin resistance is looking like in the first trimester, to either make a clear diagnosis or have a baseline level to work towards. But a normal first trimester glucose tolerance test for someone with PMOS, we'd still be recommending that 24 to 28 week one too. You don't get out of that altogether, so

Celia (08:45) Damn it.

Dr Chelsea Watt (08:46) you might get an early one, but it doesn't replace the routine screening at 24 to 28 weeks.

Celia (08:52) Something that definitely caught me out, I've heard from many other mums that it caught them out as well: the insulin resistance generally increases from that point onwards, till about thirty-six weeks, I think it is.

Dr Chelsea Watt (09:03) That's exactly right.

Celia (09:05) That gradual incline, you know, meals that were working okay suddenly stop working, you stop getting numbers you're happy with. Is that

Dr Chelsea Watt (09:12) Yeah.

Celia (09:13) even more pronounced if you have PMOS?

Dr Chelsea Watt (09:16) It's pretty similar. So that increase you're mentioning throughout the second and third trimester is there, and that's pretty similar whether it's gestational diabetes, type one diabetes or type two diabetes, that kind of trajectory happens with insulin resistance across the course of the pregnancy. But it's really just making sure that through those times you're engaging with your care team and your providers to help you shift and change and navigate that as best you can. I think it's similar to having a newborn, you've got to shift and change and adjust to whatever new thing is coming

Celia (09:50) Yeah.

Dr Chelsea Watt (09:52) each week. So it's similar with a diagnosis such as gestational diabetes, it can be constantly shifting. But knowing your care team, trusting your care team to help guide you through that, can be a real sense of safety in it.

Celia (10:07) Yeah, absolutely. I wish there was a bit more of a warning up front about needing to

Dr Chelsea Watt (10:11) Yeah.

Celia (10:12) be flexible. So that's

Dr Chelsea Watt (10:14) Yeah.

Celia (10:14) really good to call out.

Dr Chelsea Watt (10:16) And I think striving for perfection can sometimes set us up for failure too. With gestational diabetes, we're wanting you to empower yourself with the knowledge, make the actionable changes, reach out if your go-tos aren't working.

Celia (10:32) Mm.

Dr Chelsea Watt (10:32) But ultimately there needs to be a sense of kindness towards yourself. This is a big thing to be managing during a very transitional time in your life. Being really generous with yourself in that time, I think, is really important. It's

Celia (10:48) Mm.

Dr Chelsea Watt (10:49) not about who to blame, or what am I doing, or I can't get it. It's about rolling through those good days and those more challenging days, with the goal of remembering that this is an intensified period of monitoring, but it's not a permanent state forever.

Celia (11:06) Absolutely. Those are wise words.

Dr Chelsea Watt (11:09) You

Celia (11:11) Are there any other unique challenges or surprises in the PMOS/GDM combination journey that people should be aware of?

Dr Chelsea Watt (11:20) There are a couple of things worth noting. There can be a delay in lactogenesis, so milk production, for some women due to that elevated androgen exposure. So early lactation support is something I always recommend. And, as you've touched on in some of your other episodes, things like antenatal expressing and colostrum collection, those sorts of things, but really just engaging with a lactation support team early, to help set you up to succeed if you're choosing to breastfeed.

And then the only other thing, which I think is always important to touch on and is paramount in the provision of maternity care, is that link with mental health. As we've touched on, pregnancy is such a vulnerable time. One in five women have a perinatal mental health diagnosis concurrent with their pregnancy, so those numbers are huge. And I think if we add in what can sometimes be the burden of gestational diabetes, I know we're not meant to talk about things negatively, but it can be a real burden for women.

Celia (12:22) Yeah.

Dr Chelsea Watt (12:23) So if we add in the diagnosis of PMOS and the burden of gestational diabetes, it can be enough to really trigger a deterioration in mental health that, yes, we think is self-limiting because it's just during the pregnancy, but that can really carry through into challenges transitioning to motherhood after birth as well. So always a shout out for prioritising maternal mental health in this space.

Celia (12:47) I actually appreciate you calling it what it is. I know, like you said, we don't want to talk about it in a negative lens, but I

Dr Chelsea Watt (12:52) Yeah.

Celia (12:52) think it's important to acknowledge that is one of the potential realities.

Dr Chelsea Watt (12:55) Absolutely. Those feelings are normal, and whether they're fleeting feelings or whether that's the overwhelming experience you took away from it, gestational diabetes is a lot. Yeah, it's a lot. And yeah, exactly.

Celia (13:06) Yes. TLDR, yeah. So can the gestational diabetes diagnosis ever be what leads someone to discover they had underlying PMOS? Can it work the other way too?

Dr Chelsea Watt (13:20) Absolutely, quite regularly. For most women, pregnancy is really the first time they're regularly seeing healthcare providers, regularly getting blood tests, and regularly looking at their preventative and ongoing health. So it's not uncommon that the diagnosis of gestational diabetes is the first time it clicks that there's an element of insulin resistance there, is that just going to be during the pregnancy, or will this carry on and persist? What we educate women about, with that new diagnosis of gestational diabetes, is let's focus on now, and how we can reduce maternal and infant risk now, but that it's something we double back to in the postpartum period to understand if this is an underlying insulin resistance that may carry through, or

Celia (14:07) Mm-hmm.

Dr Chelsea Watt (14:08) whether it will resolve completely with the pregnancy.

Celia (14:11) And is that something that's kind of caught by, well, I think it's around six weeks that you're recommended to do the follow-up glucose test, or is there more to it than that?

Dr Chelsea Watt (14:20) Yeah, so gestational diabetes is an independent risk factor for insulin resistance, lifelong. The goal of the six week check is to see if it's all resolved at the moment, or whether women would benefit from metformin being initiated at that time and continued on. But truly, the underlying features of PMOS, and the shift in hormones that happens so rapidly in that postpartum phase, often mask the underlying features of PMOS, so they don't really get uncovered until that six to nine month mark, when all those hormones recalibrate, the menstrual cycle recalibrates, and we can really assess that after that time.

And that glucose tolerance test at six weeks postpartum, it's not really to diagnose necessarily, because we'd need to wait for all of those hormones to recalibrate before doing the formal testing, to check where those endocrine levels are up to, where the metabolic side of things are up to, and then, from an ultrasound point of view, reassessing those ovaries.

Celia (15:23) Yeah, okay. Still worth doing though, the six week glucose test, just for understanding a general baseline. Yeah. Yeah, I was like, I don't know many women who've done it, at least not in that timeframe.

Dr Chelsea Watt (15:30) Yeah, that is the current guideline and recommendation. I always think it's a bit hard getting out of the house, I know. No, I think that's exactly right. And so, yes, current evidence suggests that. I'm a bit more of a realist, that six weeks is a wild time. Absolutely. And

Celia (15:47) Mm-hmm. Especially if you have other kids to look after, that's not happening till, yeah.

Dr Chelsea Watt (15:52) So I know that signing up to do three hours in a pathology clinic at six weeks postpartum is not top of anyone's to-do list. And so, yes, that's what current guidelines recommend. I just recommend women being aware that a diagnosis of gestational diabetes is something to take forward into their future appointments with a healthcare professional. So

Celia (16:13) Hm.

Dr Chelsea Watt (16:13) if someone's saying, "Do you have any past medical history?", gestational diabetes is one of them. Don't just forget about it like the pregnancy's over, it's in the past. Flag it as something you went through, and ideally do the follow-up. But I know anecdotally most women don't quite get there at that six week mark, for sure.

Celia (16:30) Yeah. Okay, if somebody's listening and already knows she has PMOS, and she wants to have a baby in the next year or two, I mean

Dr Chelsea Watt (16:38) Mm-hmm.

Celia (16:39) you kind of mentioned a few of these points earlier, but what conversations would you encourage her to have with her GP, or should she be engaging specialists ahead

Dr Chelsea Watt (16:47) Yeah.

Celia (16:47) of trying to conceive?

Dr Chelsea Watt (16:49) So I think preconception appointments are so valuable. You want to find the care team that's going to help see you through this time, whether that's a primary care GP, an obstetrician, a gynaecologist, an endocrinologist, it's about finding the people who will help you through this next really transitional phase. I think there's power in that, power in knowing your people who are going to be there, whether that's because you have a diagnosis of PMOS, or you're wondering whether you do or don't have any diagnosis at all.

I think having a sit down, having that appointment to unpack all of the aspects that are so important in preconception care, is so valid. And then for PMOS in particular, we'd ideally initiate a conversation six to twelve months before attempting conception. This is really to undertake metabolic assessments, to understand what those baseline blood tests look like, attempting to optimise insulin resistance through lifestyle interventions and modifications where indicated, perhaps metformin if there's value in that depending on individual circumstances, and then also folate, iodine and other preconception supplements that are recommended as well.

We can also start ovulation tracking, to understand whether you're actually ovulating. That can be a mix of LH surge strips that you're weeing on, blood tests to check progesterone throughout the cycle, and then also, in my rooms, I do ultrasounds to assess if there's that dominant follicle that's ovulating that month. So we can just gather a bit of information before you have that mental tick-over into actively trying, because

Celia (18:31) Mm.

Dr Chelsea Watt (18:32) I think once that starts, even our most chill patients who aren't trying, but trying, it can still really take a toll. And so if you've been trying for six, twelve months without all of that information, it can sometimes feel like a couple of backwards steps by the time you have an appointment to discuss some of these things with your healthcare provider. So I think a proactive approach can be really beneficial, not because there has to be change, but let's find out if there does or doesn't, so you have that information as part of your timeframe for trying.

Celia (19:08) I was on top of that before I got pregnant with my first daughter, and then I fell pregnant quite easily with her. And then I thought, "This'll work just as easily again second time around," and I didn't think to go and check all of my vitamins and that

Dr Chelsea Watt (19:23) Yeah, of course.

Celia (19:24) and it was about six months after we started trying that I was like, I might just get some blood work done, and it

Dr Chelsea Watt (19:28) Yeah.

Celia (19:30) was my iron and folate that were all very low. I just thought I was a tired toddler parent. So yeah, I think it's, yeah, totally, yeah, so I think not

Dr Chelsea Watt (19:35) Yeah, this is classic, normalising the struggles of parenting when there's an actual underlying condition. Yeah, yeah.

Celia (19:44) just for the initial pregnancy, but yeah, I learned my lesson there, every pregnancy, really, go back and get that understanding.

Dr Chelsea Watt (19:51) Absolutely, yeah.

Celia (19:53) You recently opened a women's care collective on the Gold Coast called Redefine Women's Health. Can you tell me a little bit about what you offer women there?

Dr Chelsea Watt (20:02) So Redefine Women's Health is based on the southern Gold Coast, to service all of the Gold Coast, but also northern New South Wales and surrounds. We have women travelling quite a long way to see us so far, but the goal is to really integrate everyone's specialties. So I'm great at what I do, which is providing obstetric care, gynaecological care, and also, as a sonologist, ultrasound care as well. But a woman needs to be looked after in a 360 degree way, is how I feel.

So Redefine Women's Health has been able to bring together a wonderful group of specialist practitioners to really wrap around women at every stage of their health journey. In the rooms we have obstetrician gynaecologists, a women's health specialist GP, psychology, physiotherapy and acupuncture, with a real emphasis on continuity of care across preconception, pregnancy, postpartum and lifelong gynaecological health. It really is about long appointments, being cared for by a multidisciplinary team, and us really working together to set women up for success in their own healthcare journey, whatever that may look like. It's a really lovely place to work, and to come to as well. Yeah. Yeah, yeah, no, it's truly

Celia (21:16) You might have a Brisbane customer, you had me at long appointments.

Dr Chelsea Watt (21:23) It's just, we can't be putting a number on how many things women can come to see us about. You know, you

Celia (21:29) Mm-hmm.

Dr Chelsea Watt (21:30) can only bring up one issue, women's healthcare isn't isolated like that. It needs to be integrated. Often women will come with one issue, but by the time the consult is finished, we've unravelled a couple of different things that really deserve attention, that are impacting our patient's quality of life.

Celia (21:47) Mm.

Dr Chelsea Watt (21:48) So I think putting a number on how many issues can be brought up just isn't it. What we are in control of is the time that we have

Celia (21:55) Hm.

Dr Chelsea Watt (21:56) and yeah, our women are seeing such value in it so far, so I'm feeling

Celia (22:01) Yeah.

Dr Chelsea Watt (22:01) very, very lucky to have been part of starting something that really values what women's healthcare should look like.

Celia (22:09) Well, okay, finally, what would you say to the woman listening now who's managing both PMOS and gestational diabetes? What would you want her to hear?

Dr Chelsea Watt (22:19) I would want you to hear: hang in there. Honestly, pregnancy can be so hard, and adding new diagnoses such as PMOS and gestational diabetes can make it really hard. Engaging with your care team, focusing on the small steps you can take to make change, but doing it all with kindness towards yourself, is really important. And just trying to keep a little bit of perspective, which I know is really challenging, but that this is a temporary intensification of care, rather than what will become your new normal. Just keeping the big picture in mind as best you can.

Celia (23:00) Love that, and I'm sure it will resonate with others listening too. Thank you so much, Dr Chelsea, I've learnt so much through this conversation, about PMOS and women's health in general. If others were wanting to connect with you, how can they do that?

Dr Chelsea Watt (23:15) Yeah, I'm a true advocate for women's health, and I truly think it should be done differently. I think women deserve better in this space. Absolutely, I'd be delighted if you followed along at Redefine Women's Health, or my personal account, which is Dr Chelsea Watt, or booked an appointment, come see me. And for sure, come check out the rooms, they're absolutely divine. Thanks for your time today.

Celia (23:34) I'd love to. Come check out the new digs too, amazing.