Comparative cardiometabolic effects of high, moderate, and low intensity exercise in polycystic ovary syndrome: a systematic review and network meta-analysis of randomized controlled trials

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BACKGROUND: Polycystic ovarian syndrome (PCOS) affects up to 13% of reproductive-aged women and is associated with increased cardiometabolic risk due to insulin resistance, dyslipidemia, and obesity. While exercise is recommended for lifestyle management, specific guidance is lacking. This study compares high-intensity interval training (HIIT), moderate-intensity continuous training (MICT), and low-intensity training (LIT) to evaluate their metabolic effects in women with PCOS and support tailored lifestyle recommendations. METHODS: A systematic review and network meta-analysis (NMA) of randomized controlled trials compared HIIT, MICT, LIT, and no exercise in women with PCOS, following PRISMA guidelines. Primary outcomes were body mass index (BMI), homeostatic model assessment of insulin resistance (HOMA-IR), and maximal oxygen uptake (VO2max). Secondary outcomes included fasting insulin levels, lipid profile, glucose, glycated hemoglobin (HbA1c), and blood pressure. Random-effects models estimated mean differences with 95% confidence intervals (CIs). Surface under the cumulative ranking curve (SUCRA) values were used to identify the most effective interventions. The review protocol was prospectively registered in PROSPERO (CRD420251030439). RESULTS: Twenty-three randomized controlled trials (1,192 participants) were included. In the network meta-analysis, moderate-intensity continuous training (MICT) significantly reduced HOMA-IR (mean difference [MD], − 0.25; 95% confidence interval [CI], − 0.42 to − 0.08), whereas high-intensity interval training (HIIT) did not (MD, − 0.18; 95% CI, − 0.42 to 0.05). HIIT significantly increased VO2max (MD, 5.56; 95% CI, 3.54–7.58; I²=68.8%). Both HIIT and MICT significantly reduced fasting insulin (HIIT: MD, − 1.89; 95% CI, − 2.70 to − 1.08; MICT: MD, − 0.92; 95% CI, − 1.46 to − 0.37) and LDL cholesterol (HIIT: MD, − 6.92; 95% CI, − 10.81 to − 3.02; MICT: MD, − 5.42; 95% CI, − 8.05 to − 2.79). No significant effects were observed for BMI, HDL cholesterol, triglycerides, glucose, HbA1c, or blood pressure. Surface under the cumulative ranking curve (SUCRA) rankings favored HIIT for VO2max (0.84), fasting insulin (0.99), and LDL cholesterol (0.87), and MICT for HOMA-IR (0.89). The certainty of evidence ranged from low to moderate across outcomes. CONCLUSION: In women with polycystic ovary syndrome, moderate-intensity continuous training improved insulin resistance, while high-intensity interval training enhanced VO2max and reduced insulin and LDL levels. No significant effects were observed for BMI, glucose, triglycerides, HDL, or blood pressure. The certainty of evidence ranged from low to moderate. These findings suggest that different exercise intensities may influence distinct metabolic outcomes, highlighting the need for individualized approaches in future research and clinical practice.

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