If you have PCOS and you have ever been told you are “too young” to think about heart health, think again.

PCOS is often framed as a fertility or period issue, but it is actually a lifelong metabolic and inflammatory condition. This is important to understand, as the metabolic drivers that sit underneath PCOS, particularly insulin resistance, abdominal weight, and chronic low-grade inflammation, can affect cardiovascular health over time. 

The good news is that you can do a lot to support your long-term risk, especially when you understand which markers matter and what your results actually mean.

In this blog, I will cover:

• Why cardiovascular risk is higher in PCOS
• How insulin resistance and inflammation fit into the picture
• What cholesterol is and how to interpret the main lipid markers
• Two lesser-known markers, apolipoprotein B (ApoB) and lipoprotein(a) (Lp(a))
• What this means for you in real life and how to access testing in the UK

Why cardiovascular risk is higher in PCOS

Over the past few years, higher-quality research has strengthened the evidence that women with PCOS have a higher risk of cardiovascular disease over the long term compared with women without PCOS (by a staggering 47-68% depending on the study). 

It is important to say this clearly and calmly. Higher risk does not mean heart disease is inevitable. It means PCOS is a reason to take prevention seriously, earlier, and with a focus on the underlying drivers rather than quick fixes.

The 2023 International Guidelines for PCOS reflect this – they recommend awareness of cardiovascular risk in PCOS and highlights the importance of regular assessment of cardiometabolic risk factors such as blood pressure and lipids. 

So, what is driving that increased risk?

The role of insulin resistance and inflammation

For many women, insulin resistance is one of the central features of PCOS. When insulin levels remain higher for longer, this can influence cardiovascular risk in several ways, including changes in lipid metabolism (cholesterol levels), higher triglycerides, lower HDL cholesterol, and a tendency towards a more atherogenic lipid profile – meaning a higher risk of cardiovascular disease.

Chronic low-grade inflammation is also common in PCOS, particularly when insulin resistance, poor sleep, chronic stress or central weight gain are present. Inflammation can damage the lining of blood vessels which can lead to a greater risk of heart disease. This is one reason heart health is about more than cholesterol alone.

Cholesterol, blood pressure and PCOS

In practice, the most common cardiovascular markers that come up in PCOS include:

• Dyslipidaemia (high cholesterol levels)
• Higher blood pressure
• Higher fasting insulin or glucose dysregulation
• Raised inflammatory markers in some people

The PCOS guidelines recommend that all women with PCOS have blood pressure measured at least annually. Cholesterol testing is also recommended, with follow-up frequency based on results and overall risk. 

Cholesterol explained: what it is and what the markers mean

Cholesterol is a waxy, fat-like substance that your body uses to build cell membranes, make vitamin D, and produce hormones and bile acids. It is super important for your wellbeing! Your liver makes most of the cholesterol you need, and you also get a small amount from food.

Cholesterol only becomes a problem when cholesterol-containing particles build up in artery walls over time, contributing to atherosclerosis (narrowing and hardening of the arteries). This process is influenced by many things - including blood pressure, blood sugar balance, inflammation, smoking, genetics, hormone balance, stress, sleep and how much exercise you do.

What is a lipid profile actually measuring?

A standard lipid profile usually includes:

• Total cholesterol
  • This is the overall amount of cholesterol in your blood. It is a broad measure and does not tell you how cholesterol is being carried.
• LDL cholesterol (often called “bad cholesterol”)
  • LDL stands for low-density lipoprotein. LDL particles carry cholesterol from the liver out to tissues. When LDL particles are present in higher numbers, or are circulating for longer, the risk of cholesterol being deposited in artery walls may be increased.
• HDL cholesterol (often called “good cholesterol”)
  • HDL stands for high-density lipoprotein. HDL particles are involved in reverse cholesterol transport, moving cholesterol away from tissues back towards the liver – they are like the rubbish truck coming and taking away the waste. HDL is not a simple “the higher the better” marker, but in general, low HDL can be a sign of metabolic risk.
• Triglycerides
  • Triglycerides are a type of fat used for energy storage. They often rise with insulin resistance (when blood sugar isn’t under control), excess alcohol intake, high intakes of ultra-processed foods, and low activity levels. They can also rise if the blood test is taken soon after eating, which is why your GP may request a fasting test.
• Non-HDL cholesterol
  • This is not always reported, but it is easy to calculate: total cholesterol minus HDL cholesterol. It represents the cholesterol carried by all potentially atherogenic particles (not just LDL), ie the particles that are linked to potential heart disease. In UK practice, non-HDL cholesterol is often used in risk assessment and monitoring. 

Why “LDL cholesterol” is not the whole story

LDL cholesterol tells you how much cholesterol is being carried inside LDL particles. But it does not tell you how many particles are carrying it.

This matters because atherosclerosis is driven by the number of atherogenic particles entering the artery wall. Two people can have the same LDL cholesterol but a very different number of LDL particles. This is one reason why measuring something called ApoB can actually be more helpful in ascertaining your risk of heart disease.

ApoB: the marker that helps you understand what’s going on

Apolipoprotein B (ApoB) is a protein found on the surface of atherogenic lipoproteins (including LDL, VLDL and remnants), ie the cholesterol carriers that may lead to heart disease. Each particle carries one ApoB, so ApoB is effectively a count of the number of “risk-carrying” particles.

Recent reviews and expert consensus documents have highlighted ApoB as a strong predictor of cardiovascular risk, particularly in people with insulin resistance, obesity, metabolic syndrome or higher triglycerides. 

How is ApoB linked to PCOS?

PCOS is commonly associated with insulin resistance and altered lipid metabolism. Emerging research suggests ApoB-related particle patterns may be relevant in PCOS, especially where triglycerides are higher or weight gain is present, although larger studies are still needed. 

The practical take-home is that ApoB can sometimes help clarify risk when standard cholesterol results do not match the rest of the clinical picture.

ApoB levels can be measured in a simple blood test. It is not always part of routine NHS lipid testing, but it can be requested in some settings. This is something you can request from your GP, or there are many private labs that offer this measurement. If this is something that you’d like to look at, please do get in touch as this is something that I can potentially help with.

Lp(a): a genetic risk factor worth knowing about

Lipoprotein(a), written as Lp(a), is an LDL-like particle with an additional protein attached (apolipoprotein(a)). Lp(a) is largely genetic and remains fairly stable across your lifetime.

However, elevated Lp(a) is now recognised as an independent risk factor for cardiovascular disease. It can contribute to risk even when other cholesterol markers look “fine”. European guidance and consensus documents support measuring Lp(a) at least once in adulthood, to identify inherited elevation and refine risk assessment. 

Research shows that high Lp(a) increases heart disease risk by acting like "sticky" LDL cholesterol, promoting plaque buildup (atherosclerosis) and blood clots in arteries, potentially leading to heart attacks and strokes, even with normal cholesterol. This is because its unique protein (Apo(a)) hinders plaque breakdown and encourages clot formation. This genetic factor causes more aggressive plaque, calcification, and inflammation, independently raising cardiovascular danger, especially with other risk factors present. 

A 2023 systematic review and meta-analysis found that women with PCOS had higher Lp(a) levels compared with controls, including in both overweight and non-overweight women. 

This does not mean every woman with PCOS will have high Lp(a). It means Lp(a) is one of the markers that may be relevant for some women, particularly those with a family history of early cardiovascular disease.

How do you test Lp(a)?

Lp(a) is also tested with a simple blood test. Like ApoB, it is not routinely included in standard lipid panels.

A helpful approach is to ask your GP whether Lp(a) testing is appropriate for you, especially if you have:

• A family history of heart disease or stroke at a younger age
• Raised cholesterol that does not fully explain the family pattern
• Other risk factors alongside PCOS

Lp(a) can be reported in different units (mg/dL or nmol/L), and results should be interpreted accordingly. Many clinical sources use approximately 50 mg/dL or 125 nmol/L as a threshold associated with higher risk, but your overall clinical picture matters. 

Because Lp(a) is genetic, lifestyle changes tend not to shift the number very much. The focus is usually on lowering overall risk by improving other modifiable factors (LDL cholesterol, blood pressure, blood sugar, inflammation, smoking status, fitness, sleep). 

Specialist medications specifically targeting Lp(a) are under investigation, but lifestyle still matters because it reduces the total risk burden. 

Blood pressure and PCOS: an often-overlooked risk factor

Blood pressure is one of the most important and modifiable cardiovascular risk factors, yet it is often under-discussed in PCOS, particularly in younger women.

Evidence from large observational studies and recent systematic reviews shows that women with PCOS have a higher prevalence of elevated blood pressure and hypertension compared with women without PCOS, even after adjusting for body weight. This suggests that PCOS itself, not just weight, contributes to blood pressure dysregulation.

Several mechanisms appear to be involved. Insulin resistance plays a central role, as higher circulating insulin levels promote sodium retention in the kidneys and increase sympathetic nervous system activity, both of which raise blood pressure. Chronic low-grade inflammation and endothelial dysfunction, which are common in PCOS, also reduce the ability of blood vessels to relax appropriately.

Hormonal factors may contribute as well. Elevated androgens have been associated with higher blood pressure in women with PCOS, and emerging research suggests that altered renin–angiotensin signalling may further influence vascular tone in this population.

Importantly, raised blood pressure in PCOS can occur even when readings are only mildly elevated or fluctuate between normal and borderline ranges. These early changes still matter. Long-term data show that cumulative exposure to higher blood pressure over time is strongly associated with cardiovascular risk later in life.

What this means in practice

The current international PCOS guideline recommends that all women with PCOS have their blood pressure checked at least annually, regardless of age. This is a key prevention step, not an indication that something is already wrong.

From a nutrition and lifestyle perspective, blood pressure in PCOS often responds well to the same foundations that support insulin sensitivity and inflammation balance. Dietary patterns rich in vegetables, fruit, legumes, wholegrains, nuts and seeds are consistently associated with lower blood pressure, while high intakes of ultra-processed foods are linked to higher readings.