Why Is September PCOS Awareness Month? A Complete PCOS Guide

The Origin of September as PCOS Awareness Month

September became PCOS Awareness Month after the PCOS Awareness Association (PCOSAA) launched its first annual campaign in September 2011. The organization chose the month to align with the back-to-school calendar, when patients and clinicians are most likely to schedule annual check-ins and address health concerns that were deferred over summer. Since then, patient advocacy groups, endocrinology societies, and fertility clinics around the world have joined the campaign each September to share screening information, fund research, and reduce the diagnostic delay that still affects millions of people.

The teal ribbon was adopted as the PCOS symbol around the same time, giving the condition a visible identity alongside other awareness campaigns. September has no formal federal designation for PCOS in the United States as of mid-2025, but the month has achieved enough cultural momentum that major health systems now publish PCOS content, run free screening events, and offer discounted lab panels throughout September.

Why Awareness Still Matters in 2025

Polycystic ovary syndrome affects between 6% and 13% of women of reproductive age globally, according to the World Health Organization, yet awareness remains low even among those who have the condition. A 2023 survey-based analysis found that fewer than half of women with confirmed PCOS could accurately name all three Rotterdam diagnostic criteria. That knowledge gap translates directly into delayed treatment, prolonged subfertility, and avoidable metabolic complications.

The Role of Patient Advocacy

The PCOSAA, the PCOS Challenge nonprofit, and endocrinology advocacy arms of groups such as the Endocrine Society publish updated clinical summaries and patient toolkits each September. Those resources have helped shift PCOS from a largely gynecology-only conversation to a multidisciplinary one that includes endocrinologists, dietitians, mental health clinicians, and primary care providers.

What Is Polycystic Ovary Syndrome?

PCOS is a heterogeneous hormonal disorder defined by at least two of three Rotterdam criteria: oligo- or anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology on ultrasound. It is not a single disease but a spectrum, which partly explains why diagnosis takes an average of two or more years even after a woman first presents with symptoms.

The WHO fact sheet on PCOS states directly: "Polycystic ovary syndrome (PCOS) is a common hormonal condition that affects women of reproductive age. It usually starts during adolescence, but symptoms may fluctuate over time."

The Rotterdam Criteria Explained

The 2003 Rotterdam consensus, later refined by the Endocrine Society's 2013 Clinical Practice Guideline, requires two of the following three features for diagnosis:

1. Irregular or absent menstrual cycles (fewer than 8 cycles per year or cycles longer than 35 days)
2. Elevated total or free testosterone, or clinical signs such as hirsutism (Ferriman-Gallwey score > 4 to 6) or acne
3. Polycystic ovarian morphology: 12 or more follicles measuring 2 to 9 mm in one ovary, or ovarian volume above 10 mL on transvaginal ultrasound

Other causes of androgen excess, such as congenital adrenal hyperplasia, Cushing syndrome, and androgen-secreting tumors, must be excluded before a PCOS diagnosis is confirmed.

PCOS Phenotypes

Four phenotypes emerge from the Rotterdam criteria:

• Phenotype A (classic): hyperandrogenism plus anovulation plus polycystic ovaries. Carries the highest metabolic risk.
• Phenotype B: hyperandrogenism plus anovulation, normal ovarian morphology.
• Phenotype C: hyperandrogenism plus polycystic ovaries, regular cycles.
• Phenotype D (ovulatory PCOS): anovulation plus polycystic ovaries, no clinical or biochemical hyperandrogenism. Lowest metabolic risk phenotype.

Phenotype affects treatment priority. A woman with phenotype A who wants to delay pregnancy will likely need both cycle regulation and metabolic management, while someone with phenotype D and normal metabolic markers may focus primarily on cycle support.

How Common Is PCOS and Who Does It Affect?

PCOS is the most common endocrine disorder of reproductive-age women worldwide. Prevalence estimates range from 6% to 13% depending on the diagnostic criteria used, per the WHO. Using the broader Rotterdam criteria rather than the older NIH 1990 criteria consistently produces higher prevalence figures.

Age of Onset

Symptoms often begin around the time of the first menstrual period (menarche), though diagnosis during adolescence is complicated by the fact that irregular cycles and mild acne are common in the first two years after menarche in all adolescents. The Endocrine Society guideline recommends waiting at least two years post-menarche before applying Rotterdam criteria to adolescents.

PCOS does not disappear at menopause. Androgen levels may normalize with age, but the metabolic sequelae, including type 2 diabetes risk, dyslipidemia, and cardiovascular risk, persist into the postmenopausal years.

Racial and Ethnic Differences

Prevalence and clinical expression vary across populations. South Asian women with PCOS show higher rates of insulin resistance at lower body mass index compared with White European women. Black women are more likely to have hyperandrogenism as a presenting feature. These differences have implications for screening thresholds and treatment targets, though current US guidelines do not yet specify race-stratified cutoffs.

PCOS Symptoms: What to Watch For

Symptoms span reproductive, metabolic, and psychological domains. No single symptom is pathognomonic for PCOS, which is one reason the average diagnostic delay stretches past two years.

Reproductive Symptoms

• Infrequent, irregular, or absent periods
• Anovulatory cycles (periods that occur without ovulation)
• Subfertility or difficulty conceiving
• Recurrent early pregnancy loss (miscarriage rates are modestly elevated, approximately 30 to 50% higher than the general population in some cohort studies)

Androgenic Symptoms

• Hirsutism: excess hair on the face, chest, abdomen, or thighs
• Acne, particularly along the jawline and chin
• Androgenic alopecia (thinning at the crown)
• Oily skin

Metabolic Symptoms

Up to 70% of women with PCOS have some degree of insulin resistance, according to a widely cited review in Diabetes Care. That insulin resistance drives weight gain, fatigue, carbohydrate cravings, and acanthosis nigricans (darkened skin patches at the neck and underarms).

Psychological Symptoms

Depression and anxiety affect women with PCOS at roughly three times the rate seen in age-matched controls, per a meta-analysis published in Human Reproduction. Sleep apnea, which occurs at higher rates in PCOS independent of body weight, compounds fatigue and mood disruption.

How Is PCOS Diagnosed?

Diagnosis requires a clinical history, physical examination, serum hormone panel, and pelvic ultrasound. No single blood test confirms PCOS.

Laboratory Workup

A standard PCOS hormone panel includes:

• Total and free testosterone (elevated in 60 to 80% of classic PCOS)
• Sex hormone-binding globulin (SHBG), often low
• LH and FSH (LH:FSH ratio > 2:1 in roughly 60% of cases, though not a diagnostic criterion)
• Anti-Müllerian hormone (AMH): elevated in PCOS, correlates with antral follicle count
• Fasting glucose and insulin, or a 2-hour oral glucose tolerance test
• HbA1c
• Fasting lipid panel
• TSH (to exclude thyroid dysfunction as a cause of cycle irregularity)
• 17-hydroxyprogesterone to exclude late-onset congenital adrenal hyperplasia

The Endocrine Society recommends against using LH:FSH ratio or AMH as standalone diagnostic tools, given their sensitivity limitations.

Ultrasound Findings

Transvaginal ultrasound is preferred over transabdominal in adult women. The updated 2018 threshold (from the International Guidelines for PCOS) raised the follicle count criterion to 20 or more follicles per ovary using modern high-frequency transducers, replacing the older 12-follicle threshold. Ovarian volume above 10 mL remains a valid alternative criterion.

PCOS and Insulin Resistance: The Metabolic Connection

Insulin resistance sits at the center of PCOS pathophysiology for most women. Elevated insulin stimulates ovarian theca cells to produce excess androgens, suppresses SHBG production in the liver (raising free androgen levels), and disrupts the LH surge needed for ovulation. The result is a self-reinforcing cycle of hyperandrogenism and anovulation driven by metabolic dysfunction.

Long-Term Metabolic Risks

Women with PCOS have approximately:

• 2 to 4 times the risk of developing type 2 diabetes compared with age-matched controls, per a cohort study in JAMA
• 2-fold higher risk of cardiovascular events in some observational datasets, though this association is not fully adjusted for BMI in all studies
• Higher rates of non-alcoholic fatty liver disease (NAFLD), estimated at 35 to 70% prevalence in PCOS vs. 15 to 25% in the general female population

The American Diabetes Association Standards of Medical Care recommends screening women with PCOS for prediabetes and type 2 diabetes at least every three years, or more frequently if additional risk factors are present.

Metformin's Role

Metformin (typically 500 to 2,000 mg/day) reduces hepatic glucose output and improves peripheral insulin sensitivity. A Cochrane review (Cochrane Database Syst Rev, 2017) found metformin improved menstrual frequency and reduced androgen levels compared with placebo, though it was less effective than letrozole for ovulation induction. Metformin remains a first-line agent for metabolic management in PCOS, particularly in women who cannot tolerate or do not want hormonal contraceptives.

PCOS Treatment Options

No single treatment addresses all PCOS features simultaneously. Treatment is individualized based on the patient's primary concern (cycle regulation, fertility, hyperandrogenism, or metabolic health) and phenotype.

Hormonal Contraceptives for Cycle Regulation

Combined oral contraceptives (COCs) are the first-line treatment for irregular periods and hirsutism in women with PCOS who are not trying to conceive. COCs suppress LH, reduce ovarian androgen production, and raise SHBG, lowering free testosterone. Preparations containing anti-androgenic progestins such as drospirenone or cyproterone acetate (where available) show modestly greater improvement in hirsutism scores compared with levonorgestrel-containing pills in head-to-head trials.

Ovulation Induction for Fertility

Women with PCOS who want to conceive have three primary ovulation-induction options:

1. Letrozole (2.5 to 7.5 mg on cycle days 3 to 7): The NEJM PPCOS II trial (N=750) found letrozole produced a live-birth rate of 27.5% vs. 19.1% for clomiphene citrate (P<0.001), making letrozole the preferred first-line agent per current guidelines.
2. Clomiphene citrate (50 to 150 mg/day): Effective but carries a higher multiple-pregnancy risk than letrozole and a lower live-birth rate in the PPCOS II comparison.
3. Gonadotropins with IUI or IVF: Reserved for women who fail oral agents or have additional infertility factors.

GLP-1 Receptor Agonists in PCOS

Semaglutide (Ozempic, Wegovy) and liraglutide (Saxenda, Victoza) are gaining traction as adjuncts for PCOS management in women with obesity or significant insulin resistance. In the STEP-1 trial (N=1,961), semaglutide 2.4 mg produced 14.9% mean weight loss at 68 weeks vs. 2.4% with placebo NEJM, 2021. Observational data and small RCTs suggest that weight loss of this magnitude can restore spontaneous ovulation in a meaningful proportion of anovulatory women with PCOS. GLP-1 agonists are not FDA-approved specifically for PCOS as of mid-2025, but their use in PCOS with metabolic comorbidity is supported by the Endocrine Society's 2023 obesity pharmacotherapy guideline.

Spironolactone for Androgen Excess

Spironolactone (50 to 200 mg/day) blocks androgen receptors and reduces adrenal androgen production. It is frequently combined with a COC to prevent pregnancy (spironolactone is teratogenic in male fetuses) and to counteract its potassium-sparing effect. Clinical improvement in hirsutism takes 6 months or longer due to the hair growth cycle.

Lifestyle Interventions

A meta-analysis in Human Reproduction Update (2011) found that a 5 to 10% reduction in body weight restored ovulation in 55 to 100% of overweight women with PCOS. The intervention did not need to be extreme: a caloric deficit of 500 kcal/day combined with 150 minutes of moderate-intensity aerobic exercise per week produced clinically meaningful hormonal changes within 12 weeks in multiple trials.

The HealthRX clinical team uses a structured "PCOS Priority Triage" framework to sequence treatment. The first step is identifying the patient's primary concern (fertility vs. Symptom management vs. Metabolic risk reduction). The second step is metabolic phenotyping using fasting insulin, HOMA-IR, and AMH. The third step is selecting agents in order of evidence strength for the identified concern, then reassessing at 3 months. This approach reduces the common error of defaulting to a COC for every PCOS patient regardless of their actual treatment goals.

PCOS and Mental Health: The Overlooked Dimension

Psychological burden in PCOS is disproportionate to the condition's "benign" label in older literature. A 2011 systematic review and meta-analysis in Human Reproduction (k=17 studies) found odds ratios of 3.78 for depression and 5.62 for anxiety in women with PCOS compared with controls.

Body image concerns, androgenic symptoms such as hirsutism and acne, and the chronic uncertainty of an irregular menstrual cycle all contribute to this burden. Fertility anxiety adds another layer for women in their late 20s and 30s.

Screening Recommendations

The International Evidence-Based Guideline for PCOS (2018), developed jointly by Monash University, the European Society of Human Reproduction and Embryology (ESHRE), and the American Society for Reproductive Medicine (ASRM), recommends routine screening for anxiety and depression at the time of PCOS diagnosis using validated tools such as the PHQ-9 and GAD-7.

Cognitive behavioral therapy (CBT) has the strongest evidence base for anxiety management in PCOS. Mindfulness-based stress reduction shows benefit for quality-of-life scores in small RCTs but lacks long-term data.

PCOS During Pregnancy and Postpartum

Women with PCOS who conceive face modestly higher rates of gestational diabetes mellitus (GDM), pregnancy-induced hypertension, and preterm birth compared with the general population. A 2011 systematic review in BJOG found the odds ratio for GDM in PCOS pregnancies was 2.94 (95% CI 1.70 to 5.08).

Metformin is sometimes continued through the first trimester in women with PCOS to reduce miscarriage risk, though evidence from the MPreg trial showed no significant reduction in miscarriage rates compared with placebo. Decisions about metformin continuation in pregnancy should involve shared decision-making with an obstetrician.

PCOS in Adolescents: Special Diagnostic Considerations

Diagnosing PCOS in adolescents requires caution. Per the Endocrine Society guideline, polycystic ovarian morphology on ultrasound should not be used as a diagnostic criterion in adolescents within 8 years of menarche because multicystic ovaries are common in early puberty. Both hyperandrogenism AND irregular cycles must be present for an adolescent diagnosis.

Treatment for adolescents focuses on the lowest-effective-dose COC, lifestyle counseling, and metabolic monitoring rather than aggressive pharmacotherapy.

How to Participate in PCOS Awareness Month

September offers concrete opportunities to act on PCOS awareness beyond social media ribbon-sharing.

For Patients

• Request a full PCOS hormone panel if you have irregular periods, persistent acne, or unexplained weight gain.
• Use the PCOSAA's free symptom checklist to document symptom history before a clinical appointment.
• Ask your provider specifically about HOMA-IR testing, since standard fasting glucose alone may miss insulin resistance in lean women with PCOS.

For Clinicians

• Review your practice's average time from first PCOS-related complaint to confirmed diagnosis. A gap longer than 12 months warrants a protocol review.
• Screen all patients with PCOS for depression and anxiety at annual visits using PHQ-9 and GAD-7.
• Offer a referral to a registered dietitian experienced in insulin resistance with every new PCOS diagnosis.

For Advocates

• The PCOS Challenge and PCOSAA both accept donations in September that fund research grants and patient education materials.
• Sharing accurate clinical information, rather than anecdotal supplement recommendations, on social media during September reduces the misinformation burden that often delays diagnosis further.

Emerging Research: What the Next Five Years May Bring

Several areas of PCOS research are advancing toward clinical translation.

Gut Microbiome and PCOS

Multiple cohort studies have identified distinct gut microbiome signatures in women with PCOS, characterized by reduced microbial diversity and lower abundance of short-chain fatty acid-producing genera such as Lactobacillus and Bifidobacterium. A 2019 study in Journal of Clinical Endocrinology and Metabolism found microbiome differences correlated with androgen levels and insulin resistance scores. Probiotic and prebiotic interventions are in early-phase trials.

Anti-Müllerian Hormone as a Diagnostic Biomarker

AMH levels are 2 to 3 times higher in women with PCOS than in age-matched controls. The 2018 international guideline stopped short of approving AMH as a standalone diagnostic criterion because assay standardization across laboratories is incomplete. That standardization work is ongoing, and AMH may replace the follicle-count ultrasound criterion in the next guideline revision, reducing the need for transvaginal ultrasound in diagnosis.

Novel Pharmacotherapy

Inositol compounds, particularly myo-inositol and D-chiro-inositol in a 40:1 ratio, have shown modest benefits for insulin sensitivity and menstrual regularity in multiple small RCTs. The European Medicines Agency has not approved inositol as a PCOS treatment, and the FDA classifies it as a dietary supplement, but the evidence base is growing. A well-powered multicenter RCT is needed before clinical guidelines can recommend it as a pharmacological agent.