Revisiting ESR in PCOS: an easily obtainable link to immune and metabolic dysregulation

Polycystic ovary syndrome (PCOS) is closely associated with systemic low-grade inflammation, yet evidence regarding erythrocyte sedimentation rate (ESR), a cost-effective and stable inflammatory marker, in reproductive-aged women without comorbidities remains limited, particularly its relationships with metabolic-endocrine parameters. This study aimed to characterize ESR dynamics in reproductive-aged women with PCOS who have no systemic comorbidities versus normo-ovulatory controls, and to evaluate its associations with endocrine and metabolic disturbances while controlling for systemic confounders.

In this retrospective analysis, we enrolled a total of 2,006 women diagnosed with PCOS and 10,038 normo-ovulatory women as controls. ESR was measured using an automated ESR analyzer, and metabolic-endocrine parameters (lipid profile, hepatic/renal function, and reproductive hormones) were quantified using automated immunoassays. The alterations in ESR levels and their associations with endocrine and metabolic conditions were assessed.

PCOS women exhibited significantly elevated ESR levels across all age/BMI strata, with a higher hyper-ESR (ESR > 20 mm/h) prevalence. ESR was positively correlated with atherogenic lipids and renal/hepatic function. LH/FSH ratio, TT, and atherogenic lipids contributd to hyper-ESR in both PCOS and control groups, indicating neuroendocrine/metabolism-inflammation crosstalk. Despite associations, ESR demonstrated low discriminative performance for incident PCOS and suboptimal predictive value for dyslipidemia/hyperandrogenemia across distinct populations.

This large-scale study suggests ESR may serve as an accessible biomarker of chronic inflammation associated with PCOS, which is linked to metabolic-endocrine dysregulation. The findings offer new insights into the pathophysiology of PCOS and may support the clinical utility of ESR in monitoring disease severity and guiding anti-inflammatory interventions in PCOS women.