Back to overview

PCOS / PMOS

PCOS and the heart

Blood pressure, blood lipids and long-term prevention

Heart and blood vessel disease is the most common cause of death in women. In women with polycystic ovary syndrome (PCOS/PMOS), many risk factors for these diseases start at a young age. The consequences often appear only decades later, but the course is set early.

For a long time it was unclear whether the more frequent risk factors in PCOS really lead to more heart attacks and strokes. Most studies had examined young women, in whom such events are still rare. Newer studies with older women and longer follow-up give clearer answers today.

What are the risk factors?

Women with PCOS more often have changed blood lipids, especially raised triglycerides, low HDL cholesterol and often raised LDL cholesterol. In addition, high blood pressure, a build-up of abdominal fat, insulin resistance, disturbed blood sugar and mild chronic inflammation are more common. Even in young women with PCOS, studies show early changes in the blood vessels, such as less elastic arteries and a thicker vessel wall.

Another complication of the syndrome is fatty liver (MASLD). It affects about 40% of women with PCOS. Fatty liver is linked to a higher cardiovascular risk. A 2021 meta-analysis of about 5.8 million people showed an about 45% higher risk of heart attack, stroke and other cardiovascular events. People with MASLD die more often from heart disease than from liver disease. More about fatty liver in the article PCOS, diabetes and metabolic syndrome.

To assess risk, the Androgen Excess and PCOS Society proposed in 2010 to divide women with PCOS into two groups. The first group has a moderate risk. It includes women with one of the following factors: a higher weight, smoking, changed blood lipids, high blood pressure, impaired glucose tolerance or early heart disease in the family. The second group has a high risk. It includes women with metabolic syndrome, type 2 diabetes or known disease of the blood vessels or the kidneys. This classification is still used today and helps the doctor decide how often check-ups are needed.

What do studies show about heart attack and stroke?

A review from 2020 summarized the available long-term data. It shows a clearly higher risk of type 2 diabetes, high blood pressure and changed blood lipids in women with PCOS. For heart attack and stroke, however, the studies do not agree.

This disagreement comes from the complexity of the syndrome. The syndrome has different clinical forms: with or without raised androgens, with or without cycle disorders, with or without a higher weight. The studies also use different diagnostic criteria and look at women of different ages. For this reason, it is not possible to study a uniform group of women, and the results differ.

Some studies find a higher risk. A large 2025 study from the UK Biobank compared women with PCOS, with a median age of about 61, with women of the same age and the same weight. The risk of heart and blood vessel disease was about 76% higher in PCOS. Remarkably, the higher risk was found mainly in women without raised androgens. This shows that every form of the syndrome needs its own assessment and that the risk does not depend on weight alone.

A 2023 meta-analysis looked at women during the menopausal transition and after the menopause. The overall cardiovascular risk was not clearly different, but heart attacks were about 2.5 times and strokes about 1.7 times more common. The authors conclude that these complications are mainly due to the higher weight that often comes with the syndrome.

Other studies find no higher risk. A Swedish study followed women with PCOS for 32 years, up to the age of 72 to 91. Overall mortality and cardiovascular disease were not higher than in women of the same age. An American study of women after the menopause (WISE) showed a similar result.

These data give a clear picture. The risk is highest in the reproductive years and in the perimenopause. After the menopause, androgens fall and the features of the syndrome fade. A woman who reaches the menopause without a major metabolic burden does not seem to have a higher risk than other women. In women with an increased risk at the menopause, the situation has already been shaped by the course of the syndrome during the reproductive years: by weight, blood sugar, blood pressure and blood lipids. For this reason, prevention in the reproductive years determines heart health after the menopause. More in the article Menopause.

The 2023 international guideline sums up: risk factors are clearly more common in PCOS, and this justifies regular checks in all women with the syndrome. The absolute risk for a young woman is still low. The aim of prevention is that it stays low in later life as well.

Why is pregnancy a warning sign?

Women with PCOS more often have high blood pressure, pre-eclampsia and gestational diabetes in pregnancy. These complications do not matter only for the pregnancy. The major cardiology societies see them as a sign of a higher risk of heart and blood vessel disease later in life. A woman with PCOS and such a pregnancy in her history therefore needs particularly careful prevention. More about PCOS and pregnancy in the article PCOS and reproduction.

How does hormonal treatment affect the heart?

The pill is a common treatment in PCOS. It contains estrogen, which increases the risk of thrombosis and raises blood pressure in some women. The guideline therefore recommends the lowest effective dose of estrogen and a choice based on the general rules of the World Health Organization. Higher-risk preparations, such as the combination with cyproterone acetate, are not the first choice.

In women over 35 who smoke, and in women with high blood pressure, migraine with aura or a history of thrombosis, a preparation with estrogen is usually not suitable. For these women there are treatments with a progestin only. The choice of any hormonal treatment therefore always takes the heart and blood vessels into account.

What does prevention include?

The guideline recommends an assessment of cardiovascular risk in all women with PCOS at diagnosis. The doctor measures blood pressure every year and also before pregnancy or fertility treatment. Blood lipids are tested at diagnosis, regardless of age and weight. After that, the doctor checks them depending on the result and the overall risk.

This also includes regular blood sugar checks, measuring weight and waist circumference, and asking about smoking. Ethnic background and family history, such as an early heart attack in parents or siblings, are also part of the assessment.

What protects the heart?

The most effective measures are simple, but they need consistency: not smoking, regular exercise, a balanced diet, enough sleep and a stable weight. The doctor treats raised blood pressure and raised blood lipids according to the general guidelines, with medication if needed. In women who wish to become pregnant, the doctor adapts the choice of these medicines to a possible pregnancy.

The practice's approach

Sources: International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome (Monash University, ESHRE, ASRM, 2023); Teede HJ et al., Human Reproduction 2023. Wild RA et al., Assessment of cardiovascular risk and prevention of cardiovascular disease in women with PCOS: a consensus statement by the Androgen Excess and PCOS Society, Journal of Clinical Endocrinology and Metabolism 2010. Wekker V et al., Long-term cardiometabolic disease risk in women with PCOS, Human Reproduction Update 2020. Henney AE et al., Journal of Clinical Endocrinology and Metabolism 2025 (UK Biobank). European Society of Endocrinology – The polycystic ovary syndrome: a position statement, European Journal of Endocrinology 2014. WHO – Medical eligibility criteria for contraceptive use (2015). Forslund M et al., Morbidity and mortality in PCOS: a prospective follow-up up to a mean age above 80 years, European Journal of Obstetrics & Gynecology and Reproductive Biology 2022. Bairey Merz CN et al., Cardiovascular disease and 10-year mortality in postmenopausal women with clinical features of polycystic ovary syndrome (WISE), Journal of Women’s Health 2016. Millán-de-Meer M et al., PCOS during the menopausal transition and after menopause: a systematic review and meta-analysis, Human Reproduction Update 2023. Mantovani A et al., Non-alcoholic fatty liver disease and risk of fatal and non-fatal cardiovascular events: an updated systematic review and meta-analysis, The Lancet Gastroenterology & Hepatology 2021.