Heart rate dynamics in polyendocrine metabolic ovarian syndrome: from heterogeneity to wearable digital phenotyping

Polyendocrine metabolic ovarian syndrome (PMOS) is the new consensus name for polycystic ovary syndrome (PCOS), emphasizing the broader multisystem nature of the condition. Altered autonomic nervous system (ANS) regulation may provide an integrative physiological perspective on the reproductive, metabolic, and cardiovascular alterations associated with PMOS/PCOS. Heart rate variability (HRV) provides a non-invasive approach for assessing autonomic regulation; however, conventional HRV indices primarily characterize the magnitude and spectral distribution of variability. We therefore propose a multidimensional framework for investigating autonomic alterations in PMOS/PCOS. It integrates conventional HRV with heart rate fragmentation, nonlinear complexity, and deceleration and acceleration capacities derived from phase-rectified signal averaging. This Review evaluates the evidence supporting these dimensions and discusses how validated wearable monitoring, standardized preprocessing, and digital phenotyping may support future context-aware autonomic research. Prospective PMOS/PCOS-specific validation is required before these approaches can inform metabolic risk stratification, treatment monitoring, or clinical decision-making.