Background: Polycystic Ovarian Disease (PCOS) is a common endocrine disorder associated with significant metabolic complications, including insulin resistance, obesity, dyslipidemia, and increased cardiovascular risk. While biochemical markers are traditionally used to assess metabolic dysfunction, radiological imaging, particularly ultrasound, has emerged as a valuable tool for identifying high-risk phenotypes through evaluation of ovarian morphology and fat distribution.

Objective: To review current evidence on radiological predictors of metabolic risk in women with PCOS and to summarize imaging parameters associated with insulin resistance and cardiometabolic abnormalities.

Methods: A narrative review of literature published between 2000 and 2024 was conducted using PubMed, Scopus, and Google Scholar. Studies evaluating ultrasound and magnetic resonance imaging parameters in adult women diagnosed with PCOS were included. Key radiological markers such as follicle number per ovary, ovarian volume, stromal echogenicity, ovarian vascularity, and visceral adiposity were analyzed in relation to metabolic outcomes.

Results: Increased follicle number per ovary and enlarged ovarian volume were consistently associated with insulin resistance and hyperandrogenism. Prominent ovarian stromal hypertrophy and increased stromal vascularity demonstrated strong correlations with adverse lipid profiles and elevated fasting insulin levels. Magnetic resonance imaging revealed disproportionate visceral fat accumulation in women with PCOS, even in those with normal body mass index, highlighting a hidden metabolic risk. Advanced ultrasound techniques improved assessment accuracy but remain limited in routine clinical practice.

Conclusion: Radiological markers provide important insight into metabolic risk in PCOS and serve as useful adjuncts to clinical and biochemical evaluation. Ultrasound-derived ovarian morphology and MRI-assessed visceral adiposity help identify high-risk phenotypes, supporting early intervention and personalized management. However, imaging findings should be interpreted within a comprehensive diagnostic framework. Standardized protocols and integrated diagnostic models are needed to enhance clinical utility.

Keywords: Polycystic Ovarian Disease; Ultrasound Imaging; Metabolic Risk; Ovarian Morphology