OBJECTIVE: To compare the efficacy of exercise modalities for simultaneously improving homeostasis model assessment for insulin resistance (HOMA-IR) and total testosterone in women with polycystic ovary syndrome (PCOS). METHODS: We conducted a Bayesian network meta-analysis of 19 randomized controlled trials (n = 808) to evaluate six exercise interventions: yoga, moderate-intensity continuous training (MICT), high-intensity interval training (HIIT), resistance training (RT), combined aerobic-resistance training (CT), and control (CG). Primary outcomes were changes in HOMA-IR and total testosterone, with interventions ranked via surface under the cumulative ranking curve (SUCRA). RESULTS: For HOMA-IR reduction, yoga (SUCRA 90.73%; SMD -0.73, 95% CrI -1.3 to -0.086) and HIIT (SUCRA 74.12%; SMD -0.47, 95% CrI -0.75 to -0.15) demonstrated superior efficacy versus MICT (SUCRA 50.56%) and CT (SUCRA 42.29%), while RT was the least effective (SUCRA 32.53%). For testosterone lowering, yoga was ranked the highest again (SUCRA 92.46%; SMD -0.85, 95% CrI -1.7 to -0.12), followed by MICT (SUCRA 75.72%; SMD -0.56, 95% CrI -0.97 to -0.25) and HIIT (SUCRA 61.12%; SMD -0.42, CrI -0.88 to -0.12). CT and RT showed non-significant effects for both outcomes (p > 0.05). CONCLUSIONS: Yoga is the optimal intervention for dual-pathway improvement in PCOS. HIIT and MICT provide outcome-specific benefits (metabolicversus endocrine), whereas CT and RT necessitate protocol refinement. SYSTEMATIC REVIEW REGISTRATION: This systematic review and network meta-analysis study was registered in PROSPERO (CRD420251011979).

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