Women with polycystic ovary syndrome (PCOS) and insulin resistance have an increased risk of developing many of the consequences of the metabolic syndrome. Obesity, but in particular metabolic syndrome seems to be the main cause of nonalcoholic fatty liver disease (NAFLD) so, it is not surprising that NAFLD is very common in patients with PCOS. We present the case of a 23-year-old woman diagnosed with PCOS and insulin resistance in our Endocrinology Clinic (irregular menses, hyperandrogenemia, polycystic ovary morphology and increased ovarian volume on pelvic ultrasound, high levels of fasting insulin and after glucose administration). The clinical approach revealed a body mass index (BMI) of 34 kg/m2 with waist circumference of 108 cm, no evidence of hirsutism and a blood pressure of 180/120 mmHg. The lab tests showed elevated serum aminotrasferase levels (ALT=203 U/l, AST=145 U/l), normal alkaline phosphatase and a high level of fibrinogen (525 mg/dl). She had no risk factors for viral hepatitis and denied having any history of alcohol use. Further work-up of the abnormal liver enzymes revealed negative serologic studies for hepatitis B and C, negative test results for antimicrosomal and antinuclear antibodies, and a normal plasma ferritin level. The abdominal ultrasound showed hepatic steatosis. We excluded other possible causes for secondary hypertension. We suggest that evaluation for liver disease should be considered at a much earlier age in women with PCOS and components of the metabolic syndrome.