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The gut microbiota profoundly engages in the pathophysiology of PCOS-IR through multiple pathways and networked interactions. This review provides a comprehensive narrative synthesis of the latest evidence on gut microbiota dysbiosis in PCOS-IR, with a particular focus on its molecular mechanisms, and evaluates therapeutic strategies based on gut microbiota modulation. It seeks to provide theoretical foundations and forward-looking perspectives for precision microbiome therapies. 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