Polycystic ovary syndrome (PCOS) is a common condition in reproductive-aged women, with reproductive, cardiometabolic, and psychological features. The heterogeneity in insulin resistance, obesity, and cardiometabolic features has led to controversy on the independent contributions of PCOS status, diagnostic criteria, phenotype, and adiposity. It now appears that women with PCOS have an increased risk of insulin resistance and cardiometabolic features, which is independent of, but worsened by, adiposity and central adiposity, and is unrelated to reproductive phenotype. Obesity may be more prevalent in the more severe phenotypes, which suggests either an exacerbation of the reproductive features or a more likely diagnosis in overweight women with PCOS. Therefore, all women with PCOS should be targeted for prevention, screening, and management of cardiometabolic features.