Proposed section structure
1. Highlights. 2. Clinical background and unmet need. 3. Study design and methods. 4. Key results. 5. Mechanistic and clinical interpretation. 6. Strengths and limitations. 7. Implications for practice and research. 8. Funding, registration, and citation.
Highlights
Adolescents with coexisting metabolic dysfunction-associated steatotic liver disease (MASLD) and polycystic ovary syndrome (PCOS) had a more adverse metabolic phenotype than those with either disorder alone.
In this longitudinal cohort, the combined PCOS plus MASLD phenotype in adolescence predicted greater insulin resistance, higher remnant lipoprotein cholesterol, and a higher triglyceride to high-density lipoprotein cholesterol ratio by age 27 years.
PCOS alone, in the absence of adolescent MASLD or obesity, did not predict future insulin resistance, suggesting that hepatic steatosis may help identify the metabolically highest-risk subgroup within PCOS.
The findings support a more integrated liver-endocrine-cardiometabolic approach to risk stratification in adolescent girls and young women.
Background and clinical context
MASLD and PCOS are among the most common chronic metabolic disorders affecting young women. MASLD, the updated nomenclature for what was previously termed nonalcoholic fatty liver disease when linked to metabolic dysfunction, is increasingly recognized as a multisystem disease rather than an isolated hepatic condition. PCOS, likewise, is no longer viewed solely as a reproductive disorder; it is strongly associated with insulin resistance, central adiposity, dyslipidemia, and long-term risk of type 2 diabetes and cardiovascular disease.
Although both conditions frequently cluster around obesity and insulin resistance, an important clinical question is whether their coexistence identifies a subgroup with risk that is meaningfully greater than either diagnosis alone. This matters particularly in adolescence, when overt cardiometabolic disease has usually not yet developed, but early risk trajectories are already being established. If dual pathology during the teenage years predicts worse metabolic outcomes in adulthood, it could justify earlier and more intensive screening, counseling, and potentially targeted intervention.
The study by Ayonrinde and colleagues addresses this issue using data from the Raine Study, a well-known Australian longitudinal cohort. Their central message is clinically important: in adolescent girls, MASLD coexisting with PCOS appears to mark a particularly unfavorable cardiometabolic phenotype, whereas PCOS alone did not confer the same long-term metabolic signal in this cohort.
Study design and methods
Design and population
This was a longitudinal observational cohort analysis nested within the Raine Study. The investigators evaluated 199 community-based female adolescents who had sufficient data to retrospectively determine PCOS status at age 14 years and MASLD status at age 17 years. Follow-up data at age 27 years were available in 148 participants.
Exposure definitions
The study used updated diagnostic criteria to retrospectively classify PCOS and MASLD. PCOS was determined at age 14 years, incorporating clinical, biochemical, and pelvic ultrasound data. MASLD was assessed at age 17 years using abdominal ultrasound together with metabolic context. The key exposure groups were those with both PCOS and MASLD, PCOS without MASLD, MASLD without PCOS, and neither condition.
Assessments
Participants underwent anthropometric evaluation, blood testing, and imaging. The adolescent dataset included obesity-related measures, lipid parameters, sex hormone indices, and liver ultrasound findings. At age 27 years, follow-up assessments included anthropometry, fasting blood studies, and cardiovascular risk markers. The outcomes of greatest interest were insulin resistance and adverse lipid-related parameters, particularly remnant lipoprotein cholesterol and the triglyceride to HDL-cholesterol ratio, both of which are clinically relevant markers of atherogenic dysmetabolism.
Endpoints
The primary aim was to determine whether the coexistence of PCOS and MASLD during adolescence predicted worse future cardiometabolic parameters than either condition alone. The analysis focused on metabolic risk phenotyping rather than hard clinical events, which is appropriate given the participants’ young adult age at follow-up.
Key findings
Baseline prevalence and overlap
Among the 199 female adolescents, 37 participants, or 18.6%, had MASLD at age 17 years, and 32, or 16.1%, had PCOS. Of the adolescents with PCOS, 12 of 32, or 37.5%, also had MASLD. Twenty participants, or 10.1% of the cohort, had PCOS without MASLD, while 142, or 71.4%, had neither disorder. These figures underscore that MASLD is not a marginal comorbidity within PCOS; rather, it affected more than one-third of adolescents with PCOS in this sample.
Adolescent metabolic phenotype
The combination of PCOS and MASLD was associated with a clearly worse metabolic and hormonal profile during adolescence than that seen in peers with MASLD alone, PCOS alone, or neither condition. Specifically, adolescents with the combined phenotype were more likely to have obesity and showed higher serum remnant lipoprotein cholesterol, higher free testosterone, higher total testosterone, and lower sex hormone-binding globulin (SHBG), with reported P values below .05 for these comparisons.
This pattern is biologically coherent. Low SHBG and elevated androgens are characteristic of hyperandrogenic PCOS, while remnant lipoprotein elevation reflects atherogenic dyslipidemia linked to hepatic insulin resistance and increased very-low-density lipoprotein metabolism. The convergence of these findings suggests that combined PCOS and MASLD may represent a more severe systemic insulin-resistant state rather than simply two parallel diagnoses.
Longitudinal outcomes at age 27 years
The most clinically relevant finding emerged at the 10-year follow-up. Women who had PCOS plus MASLD in adolescence, numbering 10 among the 148 with adult follow-up, were more insulin resistant at age 27 years than those with PCOS alone, MASLD alone, or neither condition. They also had higher serum remnant lipoprotein cholesterol and a higher triglyceride to HDL-cholesterol ratio, again with P values below .05.
These markers matter. Insulin resistance is central to future risk of type 2 diabetes, while remnant cholesterol and the triglyceride to HDL-cholesterol ratio track with atherogenic dyslipidemia, hepatic overproduction of triglyceride-rich lipoproteins, and elevated cardiovascular risk. Although the cohort was too young to assess myocardial infarction, stroke, or liver-related complications, the biomarker trajectory is consistent with a less favorable cardiometabolic course.
One of the most notable negative findings was that PCOS without MASLD or obesity in adolescence did not predict future insulin resistance. This point may have substantial clinical significance. It suggests that not all adolescents with PCOS carry the same metabolic risk, and that liver fat status may help distinguish those with reproductive-predominant disease from those with a broader and more hazardous metabolic phenotype.
Clinical and mechanistic interpretation
The study supports the concept that MASLD is an informative metabolic risk amplifier within PCOS. Several mechanisms could explain this interaction. First, insulin resistance is a common driver of both conditions. In PCOS, hyperinsulinemia exacerbates ovarian androgen production and suppresses SHBG, increasing free androgen levels. In MASLD, insulin resistance promotes hepatic de novo lipogenesis, impaired lipid oxidation, and accumulation of intrahepatic fat. When both disorders coexist, they may reflect a more entrenched, multisystem insulin-resistant state.
Second, hyperandrogenism itself may worsen metabolic dysfunction. Prior literature suggests that androgen excess in females is associated with visceral adiposity, hepatic steatosis, and adverse lipid metabolism. Thus, higher testosterone and lower SHBG in the combined phenotype may be markers not just of reproductive dysfunction but of a more severe metabolic disturbance.
Third, remnant lipoprotein cholesterol may be a particularly useful translational biomarker in this setting. Remnant particles are increasingly implicated in residual cardiovascular risk beyond low-density lipoprotein cholesterol. Their elevation in adolescents and adults with combined PCOS and MASLD raises the possibility that conventional lipid screening alone may underestimate risk in these patients.
From a practical standpoint, the findings argue against viewing PCOS as metabolically homogeneous. Young women with PCOS and coexisting hepatic steatosis may require closer surveillance for insulin resistance, dyslipidemia, and weight gain than those without evidence of MASLD.
How these findings fit with existing evidence
The results align with a growing body of evidence linking PCOS to steatotic liver disease and to cardiometabolic dysfunction. Multiple prior studies and meta-analyses have shown a higher prevalence of hepatic steatosis in women with PCOS, particularly in those with obesity and hyperandrogenism. International PCOS guidance already recommends metabolic risk assessment, and hepatology societies increasingly emphasize the extrahepatic implications of MASLD. What this study adds is the longitudinal adolescent-to-adult perspective, suggesting that the coexistence of these disorders during formative years may have prognostic value over a decade.
The observation that PCOS alone did not predict later insulin resistance in the absence of adolescent obesity or MASLD also complements recent efforts to phenotype PCOS more precisely. It supports a shift from one-size-fits-all labeling toward risk stratification based on metabolic comorbidity, body composition, liver status, and biochemical severity.
Strengths and limitations
Strengths
The study has several strengths. It uses a community-based longitudinal cohort rather than a highly selected referral population, improving relevance to real-world adolescent care. It includes imaging-based assessment of hepatic steatosis and detailed biochemical profiling. Most importantly, it examines long-term metabolic outcomes across a 10-year interval, which is valuable in a field where many studies are cross-sectional.
Limitations
Interpretation should still be cautious. The sample size was modest, and the subgroup with both PCOS and MASLD was small, especially at age 27 years, where only 10 participants with the combined phenotype were available for follow-up. This limits statistical precision and the ability to perform more granular multivariable analyses.
PCOS and MASLD classifications were retrospectively determined using updated criteria. While methodologically reasonable, retrospective phenotyping can introduce misclassification, particularly in adolescence where normal pubertal physiology may overlap with PCOS features. In addition, liver ultrasound, although practical and widely used, has limited sensitivity for mild steatosis and cannot stage inflammation or fibrosis. Therefore, the study addresses steatosis-associated metabolic risk but not the full spectrum of liver injury severity.
The outcomes were surrogate cardiometabolic markers rather than clinical events. That is expected in a young cohort, but it means the study cannot directly quantify future diabetes incidence, cardiovascular events, or progressive liver disease. Residual confounding by lifestyle, ethnicity, socioeconomic factors, or change in body weight over time is also possible.
Implications for clinical practice
For clinicians caring for adolescents and young women, the main message is that the presence of MASLD may help identify a higher-risk metabolic subset within PCOS. In practical terms, when a patient with PCOS also has obesity, dyslipidemia, elevated triglycerides, low HDL-cholesterol, or evidence of hepatic steatosis, the threshold for comprehensive metabolic evaluation should be low.
Reasonable care considerations include measurement of body mass index and waist-related adiposity, fasting glucose or hemoglobin A1c as appropriate, lipid profiling, and assessment of liver enzymes, recognizing that normal aminotransferases do not exclude steatotic liver disease. Where clinically indicated, liver imaging may refine risk assessment. Lifestyle intervention remains foundational, but these data suggest that a liver-inclusive risk discussion may improve early preventive care.
The study does not establish a treatment algorithm, nor does it justify universal liver imaging in every adolescent with PCOS. However, it does support a multidisciplinary perspective in which endocrinology, adolescent medicine, primary care, and hepatology consider PCOS and MASLD as intersecting manifestations of cardiometabolic disease rather than isolated organ-specific problems.
Research implications
Future work should validate these findings in larger and more diverse cohorts, ideally with prospective phenotyping from adolescence onward. More precise liver assessment using elastography or magnetic resonance-based techniques could determine whether liver fat burden, fibrosis risk, or both drive long-term metabolic outcomes. It would also be useful to know whether interventions that reduce liver fat in adolescents with PCOS translate into improved insulin sensitivity and lipid profiles over time.
Another priority is refining risk markers. Remnant cholesterol emerged as a notable signal in this study and may deserve broader evaluation in PCOS-MASLD populations. Whether this biomarker adds predictive value beyond traditional lipids and anthropometric measures remains an open but clinically relevant question.
Conclusion
This longitudinal Raine Study analysis suggests that the coexistence of MASLD and PCOS in adolescence identifies a subgroup of young women with a substantially worse cardiometabolic trajectory into adulthood. Compared with PCOS or MASLD alone, the combined phenotype was associated with obesity, androgenic and lipid abnormalities in adolescence and with greater insulin resistance and atherogenic dyslipidemia by age 27 years. Equally important, PCOS alone without MASLD or obesity did not predict future insulin resistance in this cohort.
For clinicians, the implication is straightforward: in adolescents with PCOS, concomitant steatotic liver disease should not be considered incidental. It may be a clinically useful marker of amplified metabolic vulnerability and a signal to intensify long-term cardiometabolic surveillance and prevention.
Funding and ClinicalTrials.gov
The abstract provided does not report specific funding details or a ClinicalTrials.gov registration number. The Raine Study is an established longitudinal cohort, but no trial registration is cited in the source abstract.
References
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