The traditional therapeutic approach to polycystic ovary syndrome (PCOS) is symptomatic. However, PCOS women often show several metabolic abnormalities, and there is growing evidence that these women may have increased cardiovascular risk and other major medical outcomes later in life. Insulin resistance with associated hyperinsulinemia and androgen excess seem to play a central role in the pathogenesis of PCOS. Consistently, attenuation of insulin resistance may affect the entire spectrum of endocrine, metabolic and reproductive abnormalities of PCOS in many subjects. Furthermore, antiandrogen drugs seem to be not only an effective tool in the symptomatic treatment of PCOS, but also a potential pathogenetic therapy, as suggested by the favourable changes of body composition and metabolic features reported using these drugs in PCOS women.