Bridging the Practice Gap: Polycystic Ovary Syndrome as an Under-Recognised Risk State for Ischaemic Stroke and...

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive-aged women. Epidemiologic evidence increasingly indicates that women with PCOS exhibit elevated risk of ischaemic stroke. Unlike prior reviews that have focused predominantly on general cardiovascular risk in PCOS, this review specifically examines ischaemic stroke risk, its mechanistic links, and the extent to which current stroke and cardiovascular frameworks fail to account for PCOS. We conducted a narrative review examining the association of PCOS on ischaemic stroke and cardiovascular disease (CVD). Large-scale cohort studies and meta-analyses from 2000 to 2025 were identified from Medline, Embase, PubMed, and Google Scholar, with specific emphasis on ischaemic stroke in women with PCOS. Case reports and case series were excluded. There is substantial evidence supporting the relationship between PCOS and increased vascular risk. Large-scale cohort studies and meta-analyses report higher rates of cerebrovascular events among women with PCOS. A recent 2025 meta-analysis pooling 11 studies reported a statistically significantly increased risk of stroke in women with PCOS (OR = 1.89, 95% CI = 1.22-2.55), although heterogeneity was high (I² = 97.7%), indicating important variation in study design, populations, and confounder adjustment. Other meta-analyses report more modest associations, and some studies did not demonstrate significant associations with myocardial infarction or all-cause mortality. Several analyses also showed attenuation of risk following adjustment for body mass index and metabolic factors. The observed association between PCOS and vascular risk should be interpreted with caution, given substantial heterogeneity and potential confounding by cardiometabolic factors. These findings raise the possibility that increased risk may be mediated through established pathways such as obesity, insulin resistance, and dyslipidaemia rather than representing a consistently independent effect. Despite this, PCOS remains inconsistently recognised within clinical frameworks. Current stroke guidelines and widely used risk prediction tools, including QRISK3 and the Essen Stroke Risk Score, do not incorporate PCOS, highlighting a potential gap in sex-specific risk assessment. Evidence demonstrating that inclusion of PCOS improves risk prediction or clinical outcomes remains limited. However, under-recognition of vascular risk in women with PCOS may limit timely risk assessment and intervention. This review highlights a number of implementation gaps globally, including gaps in research and inter-disciplinary communication. Priority next steps include prospective studies to clarify whether PCOS independently contributes to vascular risk, and predictive modelling studies to determine whether including PCOS improves risk stratification. In parallel, multidisciplinary care pathways may support earlier identification and prevention in higher-risk women.