Research
Subclinical Cardiovascular Disease in PCOS: Facts
Women with PCOS face elevated cardiovascular risks due to metabolic issues, requiring early detection and proactive management strategies.
August 6, 2025
·
13
Women with PCOS face elevated cardiovascular risks due to metabolic issues, requiring early detection and proactive management strategies.
Subclinical cardiovascular disease (CVD) is an early, silent stage of heart disease. Women with polycystic ovary syndrome (PCOS) are at a much higher risk due to metabolic issues like insulin resistance, high androgen levels, and inflammation. Early detection is key to preventing severe complications like heart attacks or strokes.
Even women with normal weight and PCOS face these risks. Early screening for blood pressure, cholesterol, glucose levels, and arterial health can help manage these dangers. Lifestyle changes like a healthy diet, regular exercise, and medical treatments (e.g., metformin) are critical to reducing long-term risks.
Takeaway: If you have PCOS, talk to your doctor about cardiovascular screenings - even if you feel fine. Early prevention can save lives.
Identifying subclinical cardiovascular disease (CVD) in women with PCOS involves specialized diagnostic tools that detect vascular changes before symptoms emerge. In the United States, healthcare providers rely on several methods to evaluate cardiovascular health, focusing on early signs of arterial dysfunction, vascular responsiveness, and fat deposits. These techniques offer a critical window into understanding and managing arterial health in PCOS.
Flow-mediated dilation (FMD) testing measures how well blood vessels expand in response to increased blood flow. This noninvasive procedure involves briefly restricting blood flow in the arm with a cuff, followed by ultrasound imaging to assess the arterial response. A 2013 meta-analysis found that FMD was 3.4% lower in reproductive-aged women with PCOS compared to controls, highlighting reduced vascular function in this group. Obesity and metabolic syndrome further exacerbate this issue, emphasizing the importance of managing weight and metabolic health. Since FMD primarily evaluates larger blood vessels, it provides valuable insights into early atherosclerotic changes.
To complement FMD, imaging techniques like CIMT and CAC scoring offer additional perspectives on arterial health.
CAC scoring and CIMT are widely used to assess arterial health. CIMT involves using ultrasound to measure the thickness of the carotid artery walls in the neck. According to a 2007 meta-analysis, even a 0.10-mm increase in CIMT is linked to a 15% higher risk of heart attacks and an 18% higher risk of stroke. Women with PCOS often exhibit increased CIMT values during their reproductive years, though results across studies vary.
CAC scoring, on the other hand, uses CT scans to detect calcium deposits in coronary arteries. Findings from the Multi-Ethnic Study of Atherosclerosis (MESA) revealed that each standard deviation increase in CAC corresponds to a 2.5-fold higher risk of cardiovascular events, compared to a 1.2-fold increase with CIMT. However, research on CAC in PCOS patients has been inconsistent. While smaller studies have noted a link between PCOS and higher calcium deposits, larger studies have found no connection between irregular menstrual cycles and increased CAC. This variability suggests that CAC scoring might be more useful for specific PCOS subgroups or when combined with other risk factors.
Beyond arterial function tests, imaging fat deposits offers additional insights into cardiovascular risk. Advanced imaging now allows for the assessment of visceral fat (around internal organs) and epicardial fat (between the heart muscle and its outer lining). These fat deposits are metabolically active and can contribute to inflammation and vascular damage.
A 2017 study found that women with PCOS had greater visceral fat thickness than age- and BMI-matched controls, with visceral fat emerging as the strongest independent predictor of CIMT. Epicardial fat, which mirrors visceral fat, provides a more accessible alternative to costly MRI scans. Echocardiography, for instance, is a simple and reliable method for measuring epicardial fat thickness. Research shows that obese women with PCOS have greater epicardial fat thickness compared to obese controls, while this difference is not seen in normal-weight women. This suggests that obesity amplifies cardiovascular risks in PCOS.
Polycystic Ovary Syndrome (PCOS) significantly raises cardiovascular risks, surpassing those of the general population and even aligning with other well-recognized high-risk groups. In the United States, healthcare professionals are increasingly acknowledging these patterns, emphasizing the importance of early intervention. Let's break down the cardiovascular risks associated with PCOS and how they compare to other high-risk groups.
Women with PCOS face double the risk of experiencing future cardiovascular events, such as heart attacks and strokes, compared to the general population. This elevated risk places them in a high-risk category similar to other groups already recognized for their cardiovascular vulnerability.
For example, impaired glucose tolerance - a precursor to diabetes - affects 31.3% of women with PCOS, compared to just 14% of age- and weight-matched controls. Additionally, 7.5% of PCOS patients have type 2 diabetes, while none of the control group in the same study developed the condition. The Office on Women's Health reports that nearly half of women with PCOS go on to develop either diabetes or prediabetes before the age of 40.
Insulin resistance, a key driver of these complications, is present in 50–80% of women with PCOS. A 2017 study highlighted that women with PCOS are four times more likely to develop type 2 diabetes compared to their peers without the condition.
A large meta-analysis, involving 2,256 women with PCOS and 4,130 controls, revealed that the odds of having metabolic syndrome were nearly three times higher for those with PCOS (odds ratio: 2.88).
The cardiovascular risks tied to PCOS become even clearer when compared to other high-risk populations. For instance, under the 2017 American College of Cardiology/American Heart Association hypertension guidelines, 65% of women with PCOS were found to have high blood pressure, compared to 41% of women without PCOS.
A population-based study from 2005 showed that individuals with impaired glucose tolerance had a mortality rate of 5.5% over five years, compared to 1.9% for those without glucose intolerance. Since up to 65% of cardiovascular disease deaths occur in individuals with impaired glucose tolerance - and these risks are significantly higher in PCOS - the cardiovascular burden becomes undeniable.
| Risk Factor | PCOS Patients | Control Groups | Risk Comparison |
|---|---|---|---|
| Impaired Glucose Tolerance | 31.3% | 14% | 2.2x higher |
| Type 2 Diabetes | 7.5% | 0% | Elevated |
| Hypertension (2017 criteria) | 65% | 41% | 1.6x higher |
| Metabolic Syndrome | OR 2.88 | Baseline | 2.9x higher odds |
| Future CVD Events | 2x risk | Baseline | Double the risk |
Dr. Erin Michos, associate director of preventive cardiology at the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, highlights the broader health concerns:
"Women worry about infertility, acne and weight gain but might not be thinking of high blood pressure and type 2 diabetes. It's important to know that they're at an increased risk and how important diet and exercise is".
Interestingly, the heightened cardiovascular risk in PCOS often exists independently of body mass index (BMI). While obesity can amplify these risks, even lean women with PCOS face elevated chances of developing diabetes and cardiovascular issues. Research indicates that up to 80% of women with PCOS are overweight or obese, yet metabolic complications persist even in those with normal weight.
When looking at actual cardiovascular events, women with PCOS experienced rates of 22.6 events per 1,000 patient-years, compared to 13.2 events in control groups. This highlights not just an increase in risk factors but also a significantly higher occurrence of cardiovascular events.
In response to these findings, the 2023 International Evidence-Based PCOS Guideline - developed with input from 39 organizations across 71 countries - has called for universal cardiovascular risk assessments in all women with PCOS, regardless of their age or BMI. This shift in clinical practice underscores the importance of treating PCOS as an independent risk factor for cardiovascular disease, comparable to other well-established high-risk conditions. These insights set the stage for discussing proactive monitoring and intervention strategies in the next section.
The elevated cardiovascular risk associated with PCOS becomes clearer when we examine the underlying biological processes. These mechanisms reveal how silent vascular damage develops in women with PCOS, driven by a mix of metabolic disruptions and hormonal imbalances that strain the cardiovascular system over time.
Insulin resistance is one of the main culprits behind cardiovascular issues in PCOS. When cells fail to respond to insulin properly, the pancreas compensates by producing more insulin. This excess insulin not only disrupts metabolic balance but also stimulates the ovaries to produce more androgens, fueling a cycle of hormonal and metabolic dysfunction.
On a cellular level, insulin resistance in PCOS interferes with insulin signaling by altering phosphorylation pathways, reducing GLUT4 expression, and impairing mitochondrial function. These changes lead to dyslipidemia, characterized by increased secretion of non-esterified fatty acids, higher hepatic triglyceride production, overproduction of VLDL cholesterol, and reduced lipoprotein lipase activity. As a result, women with PCOS often show an atherogenic lipid profile, with 12.6 mg/dL higher LDL cholesterol, 26.4 mg/dL higher triglycerides, and 6.4 mg/dL lower HDL cholesterol compared to women without the condition.
Additionally, around 35% of women with PCOS have impaired glucose tolerance, and 7.5–10% eventually develop type 2 diabetes. This combination of abnormal lipid and glucose metabolism significantly heightens cardiovascular risk.
Beyond metabolic disturbances, hyperandrogenism - the hallmark of PCOS - plays a pivotal role in cardiovascular health. Affecting 80–90% of women with PCOS, elevated androgen levels contribute to an unfavorable lipid profile, arterial stiffness, and endothelial dysfunction, all of which can raise blood pressure.
High androgen levels also lead to increased abdominal fat, which worsens insulin resistance and triggers secondary hyperinsulinemia. This cascade promotes sodium retention, higher blood pressure, and chronic low-grade inflammation. Hypertension in PCOS is further linked to mechanisms like hyperaldosteronism, autonomic imbalances, increased renal sodium reabsorption, and reduced nitric oxide production.
According to the 2017 American College of Cardiology guidelines, 65% of women with PCOS have hypertension, compared to 41% of women without the condition. Additionally, metabolic syndrome - which includes dyslipidemia, hypertension, and glucose irregularities - occurs 2.88 times more often in women with PCOS than in those without.
These interconnected mechanisms highlight how subclinical cardiovascular damage often develops unnoticed in women with PCOS. Understanding these processes emphasizes the need for early detection and proactive intervention to reduce the likelihood of future cardiovascular complications in this high-risk group.
Effective monitoring and timely intervention are crucial for managing cardiovascular risks in women with PCOS. Since the mechanisms behind subclinical cardiovascular disease (CVD) in PCOS are complex, a thorough approach to monitoring and treatment is necessary. Although no specific guidelines for cardiovascular screening in PCOS exist, the 2023 International Evidence-Based Guideline recommends assessing cardiovascular risk factors universally in women with PCOS, regardless of their age or body mass index. It's important to note that traditional risk assessment methods may underestimate cardiovascular risk in this population. For instance, a study of premenopausal women aged 30 to 45 found that coronary calcium was significantly more common in women with PCOS (39%) compared to weight- and age-matched controls (21%) and community-dwelling women (9.9%). Regular risk assessments followed by proactive management can help reduce long-term cardiovascular complications.
Blood Pressure Monitoring
Blood pressure checks are essential and should be performed at every clinic visit using proper techniques. Annual assessments are recommended, with a normal 24-hour mean blood pressure defined as less than 130/80 mm Hg.
Lipid Profile Screening
Screening for lipid abnormalities - focusing on HDL-C, LDL-C, VLDL cholesterol, and triglycerides - should begin at age 30. If results are normal, testing every 3 to 5 years is sufficient. However, lipid profiles should also be evaluated at the time of PCOS diagnosis and then revisited based on individual cardiovascular risk.
Imaging Techniques
Imaging can provide additional insights during the reproductive years. To minimize radiation exposure, carotid intima-media thickness (cIMT) assessments are recommended starting at age 30, with follow-ups every 3 to 5 years if results are normal. CT coronary calcium evaluations may be considered starting at age 45. These imaging tools can help identify early signs of atherosclerosis, such as carotid thickening or coronary calcium, which should trigger aggressive management of all modifiable risk factors.
Glucose Metabolism Monitoring
Given the high prevalence of insulin resistance in PCOS, glucose metabolism should be closely monitored. An oral glucose tolerance test is recommended at diagnosis and up to three times a year if other risk factors persist.
Identifying these risk factors through careful monitoring sets the stage for targeted interventions to prevent or manage cardiovascular complications.
Lifestyle changes and medical treatments are essential for reducing cardiovascular risks in PCOS. These strategies focus on addressing modifiable risk factors like insulin resistance, dyslipidemia, and high blood pressure.
Dietary Changes
A low-glycemic index, fiber-rich diet that incorporates omega-3 fatty acids and anti-inflammatory foods can help manage multiple risk factors simultaneously, including insulin resistance and abnormal lipid levels.
Physical Activity
Regular exercise is critical. Aim for at least 30 minutes of daily aerobic and resistance exercises, such as brisk walking, Pilates, or yoga, on most days. Moderate-intensity activities are preferred to avoid excessive cortisol production.
"Daily activity is important in glycaemic control and vigorous aerobic exercise can help to also increase insulin sensitivity. Adding in some resistance training per week will also help as this increases metabolic activity which also improves insulin sensitivity." - Olivia Tyler, Clinical Regional Fitness Lead
Medical Treatments
Medical interventions may include metformin, myo-inositol, anti-androgen therapies, and combined oral contraceptives to address underlying issues like insulin resistance, hyperandrogenism, and overall cardiometabolic risk. For women with established atherosclerosis, treatment should follow secondary prevention guidelines, such as targeting an LDL-C below 100 mg/dL and non-HDL-C below 130 mg/dL, as outlined in prior recommendations.
Healthcare providers should remain vigilant about the elevated cardiovascular risk in women with PCOS. Weight monitoring should be done in a sensitive and nonjudgmental manner, emphasizing preventive strategies to improve long-term outcomes. For more detailed, evidence-based information on managing PCOS and cardiovascular health, visit PCOSHelp.
Studies reveal that PCOS significantly increases the risk of cardiovascular issues. A meta-analysis involving over 1 million women found that PCOS is linked to higher rates of ischemic events, heart attacks, and strokes, affecting about 1 in 8 women. These statistics highlight a pressing concern for women's health.
Addressing this risk requires early detection and proactive care. The complex mechanisms of PCOS - such as insulin resistance, high androgen levels, inflammation, and oxidative stress - often go unnoticed in traditional cardiovascular risk evaluations. This underscores the importance of tailored management strategies.
The 2023 International Evidence-Based PCOS Guideline now recommends universal cardiovascular risk assessments for all women with PCOS, regardless of their age or BMI. Additionally, research has shown that maternal PCOS can increase cardiovascular risks in children, further stressing the importance of early prevention efforts.
For women living with PCOS and its potential cardiovascular effects, access to reliable, evidence-backed resources is essential. Support groups and educational platforms play a vital role in providing information and emotional support. These resources empower women to advocate for themselves, work closely with healthcare providers, and manage their condition effectively. The 2018 International Evidence-Based Guideline for PCOS also highlights the value of support groups in addressing gaps in available information.
Women with PCOS can take steps to keep their heart health in check and lower the risk of cardiovascular issues. The focus should be on regular health evaluations and adopting healthier habits. Here’s how:
By staying informed and making these changes, women with PCOS can reduce their risk of cardiovascular disease and support their long-term well-being.
To help lower the cardiovascular risks tied to PCOS, make regular physical activity a priority. Aim for at least 150 minutes of moderate exercise or 75 minutes of vigorous activity each week. Pair this with maintaining a healthy weight through a combination of balanced eating habits and consistent exercise.
Focus on a diet packed with whole, unprocessed foods - think plenty of fruits, vegetables, lean proteins, and healthy fats. Also, managing stress effectively, getting 7–9 hours of quality sleep every night, and steering clear of smoking and excessive alcohol can make a big difference. These lifestyle adjustments can go a long way in improving heart health and reducing the cardiometabolic risks associated with PCOS.
Standard cardiovascular risk assessments often miss the specific challenges women with PCOS face. These assessments typically focus on general factors like blood pressure, cholesterol levels, and age, but they may not account for PCOS-related issues like insulin resistance, hormonal imbalances, and metabolic disturbances - all of which can significantly raise the risk of heart problems.
To address these gaps, more targeted evaluations are essential. This includes checking markers of insulin resistance, conducting hormonal tests, and using advanced imaging tools like coronary artery calcium scoring. These methods are particularly helpful in spotting early signs of subclinical atherosclerosis, a condition that appears more frequently in women with PCOS. By tailoring cardiovascular assessments to include these factors, healthcare providers can gain a more accurate understanding of long-term heart health risks.
