These recommendations are based on guidelines from the Royal College of Obstetricians and Gynaecologists [RCOG, 2007].

Risk factors for cardiovascular disease

• Limited evidence from a non-systematic review, a small cross-sectional study, and a case-control study suggests that women with polycystic ovary syndrome (PCOS) have more risk factors for cardiovascular disease than other women of the same age. In particular, they may have central obesity, hypertriglyceridaemia, and reduced high-density lipoprotein (HDL) cholesterol levels.
• There is evidence from a non-systematic review and case-control studies that women with PCOS frequently have abnormal lipid profiles, with increased triglyceride and total and low-density lipoprotein cholesterol levels. However the effect of PCOS on HDL cholesterol is controversial [RCOG, 2007].
• A systematic review found that evidence linking PCOS and hypertension was conflicting.
• Central obesity is observed in 35–60% of women with PCOS [Balen and Glass, 2005].
• Hyperandrogenism is associated with a preponderance of fat localized to truncal abdominal sites, and women with PCOS have greater truncal abdominal fat distribution (demonstrated by a higher waist-to-hip ratio).
• This central distribution of fat is independent of body mass index and is associated with higher plasma insulin and triglyceride concentrations and lower HDL cholesterol concentrations.
• Limited evidence from a small cross-sectional study indicates that women with PCOS have elevated concentrations of plasminogen activator inhibitor 1, which is a potent inhibitor of fibrinolysis, and has been linked to insulin resistance and an increased risk of thrombotic vascular events [Hopkinson et al, 1998; Kelly et al, 2000].
• Hyperhomocysteinaemia is a recognized risk factor for atherosclerosis. Limited evidence from a small case-control study suggests that plasma homocysteine levels are higher in women with PCOS than in an ethnically matched control group.

Risk of cardiovascular disease

• It is not known whether women with PCOS are at greater risk of cardiovascular disease.
• Limited evidence from epidemiological studies shows that morbidity and mortality from coronary heart disease in middle-aged women with a history of PCOS is not as high as predicted, despite their increased cardiovascular risk factors [Wild, 2002b; Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, 2004].
• However, the cohorts of women studied so far have been relatively young (around 55 years) [Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, 2004].
• Unknown factors in PCOS may protect the heart despite the presence of other risk factors [Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, 2004].
• Limited evidence suggests an increased risk of stroke.
• It is not clear whether PCOS is an independent risk factor for cardiovascular disease [Wild, 2002b].

Recommendations for screening for cardiovascular risk factors

• At present, it is unclear which women should be screened for cardiovascular risk and when this should occur. These recommendations are based on expert opinion and consensus.
• Guidelines from the Royal College of Obstetricians and Gynaecologists [RCOG, 2007] suggest that it is prudent to screen women with PCOS for cardiovascular risk factors.
• It has been suggested that only women 35 years of age or older with PCOS should be screened [Lobo and Carmina, 2000] because abnormal lipid levels in younger women usually do not require treatment [Harborne et al, 2003].

Recommendations for treatment

• Although women with PCOS are more likely to have abnormal lipid profiles, which may put them at higher risk of cardiovascular disease, it is not known whether modifying the risk factors in women with PCOS reduces cardiovascular events. No studies have been sufficiently powered to assess the effects of preventive therapy on cardiovascular morbidity and mortality in women with PCOS [Wild, 2002b].
• Although conventional cardiovascular risk calculators have not been validated in women with PCOS, guidelines from the Royal College of Obstetricians and Gynaecologists recommend that clinicians should continue to identify cardiovascular risk factors in women with PCOS and treat them according to current guidance [RCOG, 2007].
• CKS recommends that, in view of the possible increased risk of cardiovascular events, clinicians should give advice on measures to reduce cardiovascular risk.