The value of ultrasonographic features in diagnosis and prediction of reproductive-metabolic dysfunctions in polycystic ovary syndrome: a narrative review

Polycystic ovary syndrome (PCOS) is a prevalent endocrine disorder with variable clinical presentations, posing diagnostic challenges. This article presents a narrative review of the pertinent literature regarding the ultrasound parameters for the diagnosis and prediction of reproductive-metabolic dysfunctions in PCOS. A comprehensive search was conducted in PubMed and Embase databases for articles published in English from inception until 2025 using keywords and phrases including ‘polycystic ovary syndrome,’ ‘ultrasound,’ ‘ovarian volume,’ ‘antral follicle count,’ ‘follicle distribution pattern,’ ‘ovarian stroma,’ and ‘Doppler indices.’ Inclusion criteria comprised studies addressing diagnostic ultrasound markers for PCOS and their association with reproductive and metabolic outcomes. A review of the existing studies in this area showed that follicle number per ovary (FNPO) remains a core diagnostic marker for PCOS. The Rotterdam criteria define PCOM as ≥ 12 antral follicles per ovary; however, updated guidelines recommend thresholds of ≥ 20–25 to accommodate higher-resolution imaging. FNPO correlates strongly with hyperandrogenism and metabolic disturbances but requires consideration of ultrasound technology and operator proficiency for interpretation. Ovarian volume (OV) > 10 mL has been classically used, though ethnicity- and age-specific cutoffs have been proposed. OV correlates variably with reproductive and metabolic features. Follicle Distribution Pattern (FDP): Two main patterns—peripheral cystic pattern (or “string of pearls”) and general cystic pattern —reflect differences in follicle arrangement that are linked to endocrine profiles. FDP is not yet formally included in diagnostic criteria due to heterogeneity in associations and classification. Ovarian stromal area/ovarian area (SAOA) ratio: a higher SAOA ratio (> 0.32) suggests increased stroma proportion seen in PCOS and is associated with androgen excess. Doppler Indices (RI and PI) reveal changes in vascular resistance and pulsatility in ovarian and uterine arteries in PCOS. Lower RI and PI values typically indicate increased stromal vascularization, aiding diagnosis, though not yet routine clinically. Future research should prioritize prospective, multiethnic studies to establish age- and race-specific diagnostic and predictive thresholds. It is suggested that in future studies, the power of various sonographic markers for detecting and predicting metabolic disorders associated with PCOS be evaluated using artificial intelligence-equipped devices.