Interestingly, the meta-analysis found, in good and fair quality studies, that women with PCOS have had obesity related metabolic abnormalities associated with significantly lower SHBG levels but not with indices of hyperandrogenism [81], which highlights the possibility that decreased SHBG occurs prior to increased androgens in PCOS. Here, SHBG is linked to obesity due to melanocortin 4 receptor deficiency.