Body mass index outperforms the Rotterdam criteria in defining phenotypic heterogeneity in polycystic ovary syndrome: a multicenter study from the Italian PCOS registry (PCOSOUTCOME.net)
Year: 2026
Type: article
Study design: Observational Study
Abstract: PURPOSE: Polycystic ovary syndrome (PCOS) is a common and highly heterogeneous endocrine-metabolic disorder. The Rotterdam criteria identify four diagnostic phenotypes; however, it remains unclear whether these phenotypes or body mass index (BMI) better predict metabolic risk. The PCOSOUTCOME.net registry collects data from multiple Italian centers and provides an opportunity to compare the effectiveness of Rotterdam phenotypes versus BMI in characterizing the clinical, metabolic, and psychological heterogeneity of women with PCOS. METHODS: We included 1,314 Caucasian women of reproductive age with PCOS. Participants were stratified according to Rotterdam phenotypes and BMI categories (normal weight, overweight, and obesity; and BMI < 27 kg/m² vs. ≥ 27 kg/m²). Clinical, hormonal, metabolic, gynecological, and psychological parameters were assessed and compared across subgroups. RESULTS: No significant differences in BMI or in the prevalence of metabolic complications (dyslipidemia, glucose intolerance, hypertension, and metabolic syndrome) were observed among the four Rotterdam phenotypes, although anxiety scores were highest in phenotype A. In contrast, BMI-based stratification identified clear differences in metabolic markers: women with obesity or a BMI ≥ 27 kg/m² showed a higher prevalence of all metabolic complications, as well as higher free androgen index (FAI) and hirsutism scores. CONCLUSIONS: In this multicenter cohort, Rotterdam phenotypes failed to discriminate metabolic risk, whereas BMI-based stratification proved more informative in identifying cardiometabolic complications. Moreover, obesity in PCOS identifies a distinct hyperandrogenic phenotype. These findings underscore the need to integrate BMI into the classification of PCOS to better capture patient heterogeneity, with potential implications for metabolic assessment and risk stratification.
Authors: Alessandra Gambineri, Silvia Federici, Elisa Maseroli, Laura Guccione, Marco Bonomi, Anna Maria Fulghesu, Roberta Giordano, Roberto Mioni, Rosario Pivonello, Laura Rotolo, Chiara Sabbadin, Carla Scaroni, Massimo Tonacchera, Herbert Valensise, Nunzia Verde, Linda Vignozzi, Paolo Moghetti, Costanzo Moretti
Institutions: IRCCS Azienda Ospedliero-Universitaria di Bologna Policlinico di Sant'Orsola, University of Bologna, University of Milan, IRCCS Istituto Auxologico Italiano, Azienda Ospedaliero-Universitaria Careggi, University of Rome Tor Vergata, University of Cagliari, University of Turin, University of Padua, Azienda Ospedale - Università Padova, University of Naples Federico II, Ospedale Cisanello, Azienda Ospedaliera Universitaria Pisana, Policlinico Casilino, University of Florence, University of Verona
Language: English
Subfield: Reproductive Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $4,790
OpenAlex ID: W7204573425