The Cardiometabolic Risk in Women with Polycystic Ovarian Syndrome (PCOS): From Pathophysiology to Diagnosis and Treatment

Abstract

Polycystic Ovarian Syndrome (PCOS) is a prevalent endocrine disorder affecting women of reproductive age, with significant variations in presentation characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology. Beyond reproductive health, it may also pose crucial long-term cardiometabolic risks, especially for women with specific types of PCOS, contributing to early subclinical cardiovascular atherosclerotic alterations such as endothelial dysfunction, increased arterial stiffness, and coronary artery calcium levels, respectively. Moreover, the precise relationship between clinical cardiovascular disease (CVD) and PCOS remains debated, with studies demonstrating an elevated risk while others report no significant association. This review investigates the pathophysiology of PCOS, focusing on insulin resistance and its link to subclinical and clinical cardiovascular disease. Diagnostic challenges and novel management strategies, including lifestyle interventions, medications like metformin and glucagon-like peptide-1 receptor agonists (GLP-1RAs), hormonal contraceptives, and bariatric surgery, are further discussed. Recognizing the cardiometabolic risks associated with PCOS, a comprehensive approach and early intervention should address both the reproductive and cardiometabolic dimensions of the syndrome.

Keywords: cardiovascular disease; metabolic syndrome; polycystic ovarian syndrome; risk factors; treatment.

Figure 1

Diagnostic criteria for polycystic ovarian syndrome (PCOS). The key criteria used for diagnosing PCOS, including hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology, based on the Rotterdam criteria and other relevant clinical guidelines. Parts of the figure were drawn using pictures from Servier Medical Art. Servier Medical Art by Servier is licensed under a Creative Commons Attribution 3.0 Unported License (https://creativecommons.org/licenses/by/3.0/ (accessed on 26 August 2024)).

Figure 2

Polycystic ovarian syndrome (PCOS) phenotypes. PCOS is characterized by different variations of clinical features such as hyperandrogenism, ovulatory dysfunction, and polycystic ovarian morphology, as classified by the Rotterdam criteria.

Figure 3

Cardiometabolic risk in patients with polycystic ovarian syndrome (PCOS). The key cardiometabolic risks associated with PCOS, including insulin resistance, hyperandrogenism, obesity, dyslipidemia, hypertension, increased risk of type 2 diabetes mellitus (DM), chronic low-grade inflammation, metabolic syndrome, subclinical cardiovascular disease (CVD), and clinical CVD. ↑: higher.

Figure 4

Subclinical cardiovascular disease (CVD) outcomes in patients with polycystic ovarian syndrome (PCOS). Subclinical CVD outcomes in women with PCOS, including impaired endothelial function, increased arterial stiffness, elevated coronary artery calcium levels, an increased carotid intima–media thickness, and the presence of carotid plaques.

Figure 5

Cardiometabolic management in patients with polycystic ovarian syndrome (PCOS). Primary individualized interventions focusing on dietary changes are administered as the [Mediterranean diet (Med Diet), ketogenic diet (Keto Diet) or low-glycemic index (Low G.I.) diet] and secondary non-dietary interventions, depending on the body mass index. The non-dietary interventions are distinguished between obese and non-obese individuals: (i) non-obese—metformin and/or myo-inositol and/or oral contraceptives; and (ii) obese—glucagon-like peptide-1 receptor agonists (GLP-1RAs) and/or bariatric surgery. ±: combined treatment or separate treatment, individually per patient medical history.