Metabolic dysfunction in women with PCOS is more closely linked to BMI than to hyperandrogenism

Polycystic ovary syndrome (PCOS) is frequently conceptualized as a hyperandrogenic disorder, yet cardiometabolic risk may be driven primarily by obesity and insulin resistance. We characterized glucose-insulin dynamics in women with PCOS and examined whether metabolic dysfunction was more closely associated with obesity status than with androgen-related parameters.

In this retrospective cross-sectional study, 71 women with PCOS underwent a standardized 3-hour oral glucose tolerance test (OGTT, 0-180 min) and were stratified by obesity status (BMI <30 kg/m², n=37; BMI ≥30 kg/m², n=34). OGTT-derived indices included the Matsuda index, HOMA-IR and AUCglucose_(0-180). Associations were assessed using Pearson correlations and parsimonious multivariable linear regression models for log(Matsuda), log(HOMA-IR), and AUCglucose_(0-180) including BMI, age and total testosterone as predictors.

Obese women were older and had higher fasting glucose than non-obese women, whereas HbA1c was only numerically higher. During the OGTT, they showed higher glucose and insulin concentrations, lower insulin sensitivity, higher fasting insulin resistance, greater glucose exposure, and a higher insulin response relative to glucose exposure. PCOM prevalence, Rotterdam phenotype distribution, moderate-to-severe hirsutism and menstrual grades were similar between groups. Total testosterone and adrenal androgens were comparable. Across the parsimonious model, BMI was the only consistent independent predictor of log(Matsuda), log(HOMA-IR), and AUCglucose_(0-180).

Within this PCOS cohort, metabolic impairment was more closely associated with BMI and obesity status than with the androgen-related parameters assessed. These findings support metabolic risk stratification in PCOS focused on obesity and insulin resistance rather than broader androgen-related markers.