Polycystic ovary syndrome (PCOS) is usually discussed as a period and fertility condition, but it is also a metabolic one. Women with PCOS are more likely to develop high blood pressure and type 2 diabetes, and pooled studies point to higher rates of heart disease and stroke as well.
The risk of a heart attack before menopause remains low for most women, with or without PCOS. The practical point is that PCOS is a reason to have blood pressure, cholesterol and blood sugar checked earlier and more regularly than you otherwise might.
Key takeaways
- PCOS raises the likelihood of high blood pressure and type 2 diabetes, including in women who are not overweight.
- Studies link PCOS to more heart disease and stroke, though the evidence is observational and uneven.
- International guidance now asks clinicians to treat PCOS as a cardiovascular risk factor and to assess the standard risk factors.
- Blood pressure, a lipid profile and blood sugar are the core checks, starting at diagnosis.
Why a hormone condition affects the heart
PCOS is common. The 2023 international guideline puts its prevalence at 10% to 13% of women of reproductive age.1 It is defined by some combination of irregular ovulation, higher androgen levels and a characteristic appearance of the ovaries.
Underneath those features, many women with PCOS have insulin resistance, which the guideline describes as part of how the condition develops. Insulin resistance is the bridge to the heart: it pushes blood sugar, blood pressure and blood fats in an unfavorable direction over time.
This is why PCOS does not end when periods become regular or when pregnancy is no longer a goal. The metabolic side continues.
The metabolic features
A 2020 meta-analysis brought together 23 long-term cohort studies comparing women with and without PCOS. Women with PCOS were 75% more likely to develop high blood pressure and three times as likely to develop type 2 diabetes.2
Cholesterol differences were smaller. Total cholesterol ran slightly higher and HDL cholesterol slightly lower in women with PCOS, while LDL cholesterol and triglycerides were not clearly different in that analysis.2
Weight explains part of this, but not all of it. The 2023 guideline states that women with PCOS have a higher risk of impaired glucose tolerance and type 2 diabetes regardless of age and body mass index.1 A normal weight does not rule the risk out.
Heart attack and stroke: what studies show
The review carried out for the 2023 guideline pooled 20 studies covering 1.06 million women. PCOS was associated with higher odds of cardiovascular disease overall, of ischemic heart disease, of heart attack and of stroke. The link with death from cardiovascular causes was less clear.3
The earlier 2020 meta-analysis was more cautious. It found a 41% higher risk of non-fatal stroke, but its result for coronary events did not reach statistical significance.2
Two limits apply to all of this research. The studies are observational, and their results vary widely from one to the next. Many of the women were also young, an age at which heart attacks and strokes are rare in any group.
What is still uncertain
It is not settled how much of the added risk comes from PCOS itself and how much from the weight gain, blood pressure and diabetes that often accompany it. It is also unknown whether screening women with PCOS and treating what is found leads to fewer heart attacks later. The authors of the 2020 meta-analysis called for trials to answer that question.
The guideline reflects this balance. It says women with PCOS should be considered at increased risk of cardiovascular disease, while acknowledging that the overall risk in premenopausal women is low.1
The picture may change at midlife, when the changes of menopause are added on top. Our guide to menopause and heart disease risk covers that stage.
What to monitor
The 2023 guideline recommends that all women with PCOS be assessed for cardiovascular risk factors.1 Its specific advice is summarized below.
| Check | What the 2023 guideline advises |
|---|---|
| Blood pressure | Every year, and when planning a pregnancy |
| Lipid profile | At diagnosis, whatever your age or weight, then as often as your results and overall risk call for |
| Blood sugar status | At diagnosis, then every one to three years depending on your other diabetes risk factors |
| Sleep apnea symptoms | Ask about snoring, unrefreshing sleep and daytime sleepiness |
The sleep question is there because the guideline reports that obstructive sleep apnea is significantly more common in women with PCOS, independent of body mass index.1 Sleep apnea has its own links to blood pressure and heart rhythm, described in our guide to sleep apnea and heart risk.
Smoking status, family history and waist measurement round out the picture. None of these checks is unusual. What PCOS changes is when they start and how consistently they are repeated.
Your next step
If you have PCOS and cannot remember your last blood pressure reading, lipid profile or blood sugar test, that is the place to begin. Our guide to a heart disease risk assessment explains how these results are combined into an overall estimate.
You can also answer the three quick questions in the screener on the Cardio Res-Q program page. Insulin resistance is among the risk factors listed on that page.
Are You a Candidate for Cardio Res-Q?
Three quick questions about the risk factors we screen for. Your answers stay between you and the clinic.
Frequently asked questions
Does PCOS cause heart disease?
PCOS is associated with more heart disease and stroke in pooled studies, but those studies cannot show cause. What is well established is that PCOS raises the chance of high blood pressure and type 2 diabetes, and both of those damage arteries over time. That is why the standard risk factors are the focus of monitoring.
I have PCOS and a normal weight. Does this apply to me?
Yes. International guidance says the higher risk of blood sugar problems in PCOS holds regardless of body mass index, and it advises a lipid profile at diagnosis for all women with PCOS whatever their weight. Being lean lowers some risks but does not remove the reason to check.
When should heart risk checks start?
At diagnosis, according to the 2023 international guideline. It advises a lipid profile and a blood sugar assessment when PCOS is diagnosed and a blood pressure reading every year after that. How often lipids and blood sugar are repeated depends on your results.
Do I need a heart scan because I have PCOS?
PCOS alone is not a standard reason for heart imaging, and the international guideline does not call for it. Its advice centers on blood pressure, lipids, blood sugar and lifestyle factors. Whether any further testing makes sense depends on your age and overall risk, and is a decision to make with your clinician.
Related reading
This article is for general education and is not medical advice. Decisions about testing and medication should be made with your clinician. If you have chest pain or other symptoms of a heart attack, call 911.
