Metformin and Combined Oral Contraceptive Pills in the Management of Polycystic Ovary Syndrome: A Systematic Review and Meta-analysis

J Clin Endocrinol Metab. 2024 Jan 18;109(2):e817-e836. doi: 10.1210/clinem/dgad465.


Context: Polycystic ovary syndrome (PCOS) affects more than 1 in 10 women.

Objective: As part of the 2023 International PCOS Guidelines update, comparisons between combined oral contraceptive pills (COCP), metformin, and combination treatment were evaluated.

Data sources: Ovid Medline, Embase, PsycINFO, All EBM, and CINAHL were searched.

Study selection: Women with PCOS included in randomized controlled trials (RCTs).

Data extraction: We calculated mean differences and 95% CIs regarding anthropometrics, metabolic, and hyperandrogenic outcomes. Meta-analyses and quality assessment using GRADE were performed.

Data synthesis: The search identified 1660 publications; 36 RCTs were included. For hirsutism, no differences were seen when comparing metformin vs COCP, nor when comparing COCP vs combination treatment with metformin and COCP. Metformin was inferior on free androgen index (FAI) (7.08; 95% CI 4.81, 9.36), sex hormone binding globulin (SHBG) (-118.61 nmol/L; 95% CI -174.46, -62.75) and testosterone (0.48 nmol/L; 95% CI 0.32, 0.64) compared with COCP. COCP was inferior for FAI (0.58; 95% CI 0.36, 0.80) and SHBG (-16.61 nmol/L; 95% CI -28.51, -4.71) compared with combination treatment, whereas testosterone did not differ. Metformin lowered insulin (-27.12 pmol/L; 95% CI -40.65, -13.59) and triglycerides (-0.15 mmol/L; 95% CI -0.29, -0.01) compared with COCP. COCP was inferior for insulin (17.03 pmol/L; 95% CI 7.79, 26.26) and insulin resistance (0.44; 95% CI 0.17, 0.70) compared with combination treatment.

Conclusions: The choice of metformin or COCP treatment should be based on symptoms, noting some biochemical benefits from combination treatment targeting both major endocrine disturbances seen in PCOS (hyperinsulinemia and hyperandrogenism).

Keywords: combined oral contraceptive pill; hirsutism; meta-analysis; metformin; polycystic ovary syndrome; weight.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Contraceptives, Oral, Combined / therapeutic use
  • Female
  • Humans
  • Hypoglycemic Agents / therapeutic use
  • Insulins*
  • Metformin* / therapeutic use
  • Polycystic Ovary Syndrome* / drug therapy
  • Testosterone


  • Metformin
  • Contraceptives, Oral, Combined
  • Hypoglycemic Agents
  • Testosterone
  • Insulins