Polyendocrine metabolic ovarian syndrome (PMOS) is a common endocrine condition with a prevalence of 10-13% in reproductive-aged women associated with reproductive, metabolic and psychological dysfunction (1).Higher rates of weight gain and obesity have been observed in women with PMOS (2). While the mechanistic reason for this is yet unclear, this may be related to intrinsic factors including dysregulation of appetite and energy homeostasis. This systematic review and meta-analysis aims to evaluate the physiological factors influencing energy intake and expenditure in women with PMOS compared to those without. MEDLINE, EMBASE, PsycInfo, AMED, CINAHL and the Cochrane Central Register of Controlled Trials were searched up to 8 September 2025. Papers comparing outcomes of energy intake (postprandial appetite hormones, subjective appetite) or expenditure (resting energy expenditure (REE), total energy expenditure, meal induced thermogenesis (MIT)) between women with and without PMOS were included. Risk of bias assessment was based on the Newcastle Ottawa and Joanna Briggs Institute scales, certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation and meta-analysis undertaken as appropriate. Thirty-two papers were included (n = 22 energy intake, n = 10 energy expenditure). Studies reporting multiple outcomes were included as separate comparisons, resulting in n = 44 studies. Sample sizes of women with PMOS ranged from seven to 244. Overall, findings were inconsistent; 52% of studies reported no between-group differences and 47% reporting altered physiological responses. Six of ten studies demonstrated smaller postprandial decreases in ghrelin in women with PMOS. Postprandial glucagon-like peptide-1 (GLP-1) was inconsistent: four studies reported lower responses, five found no differences and one reported higher response. Three out of four studies found no differences in postprandial peptide YY (PYY) and one a smaller rise. One study showed that within women with PMOS, those with insulin resistance (IR) had greater energy intake than those without IR. Two studies assessed MIT; one demonstrated reduced MIT in women with PMOS as well as greater IR, while the other found no between-group differences. Meta-analysis of six studies (n = 605 PMOS, n = 231 controls) saw no significant difference in REE (weighted mean difference −40.09 kcal/day, 95% CI −264.14 to 183.96; p = 0.73), although heterogeneity was substantial (I² = 98%). Overall certainty of evidence was very low. There is limited evidence for consistent alterations in physiological factors affecting energy homeostasis in women with PMOS. Heterogeneity including in study design, meal tolerance test protocols and clinical characteristics of participants, in addition to low-certainty evidence and small sample sizes limit firm conclusions. This review highlights the need for standardised methodologies and consistent study designs. Future studies should also consider characterising women with PMOS according to clinically relevant metabolic characteristics when investigating physiological determinants of energy balance.