Polycystic ovary syndrome: antimüllerian hormone and its role in the pathophysiology of the syndrome.

Not all women diagnosed with PCOS share the same cardiovascular risk profiles

What prevents the fall in anti-Müllerian hormone (AMH) levels in polycystic ovary syndrome (PCOS) and what are the consequences of this for follicle progression in these ovaries? Exposure of granulosa cells (GCs) to high levels of androgens, equivalent to that found in PCOS, prevented the fall in AMH and was associated with dysregulated AMH-SMAD signalling leading to stalled follicle progression in PCOS. In normal ovaries, AMH exerts an inhibitory role on antral follicle development and a fall in AMH levels is a prerequisite for ovulation. Levels of AMH are high in PCOS, contributing to the dysregulated follicle growth that is a common cause of anovulatory infertility in these women. Human KGN-GC (the cell line that corresponds to immature GC from smaller antral follicles (AF)) were cultured with a range of doses of various androgens to determine the effects on AMH production. KGN-GC were also treated with PHTPP (an oestrogen receptor β (ERβ) antagonist) to examine the relationship between AMH expression and the ratio of ERα:ERβ. The differential dose-related effect of AMH on gene expression and SMAD signalling was investigated in human granulosa-luteal cells (hGLC) from women with normal ovaries, with polycystic ovarian morphology (PCOM) and with PCOS. KGN-GC were also cultured for a prolonged period with AMH at different doses to assess the effect on cell proliferation and viability. AMH protein production by cells exposed to androgens was measured by ELISA. The effect of PHTPP on the mRNA expression levels of AMH, ERα and ERβ was assessed by real-time quantitative PCR (qPCR). The influence of AMH on the relative mRNA expression levels of aromatase, AMH and its receptor AMHRII, and the FSH and LH receptor (FSHR and LHR) in control, PCOM and PCOS hGLCs was quantified by qPCR. Western blotting was used to assess changes in levels of SMAD proteins (pSMAD-1/5/8; SMAD-4; SMAD-6 and SMAD-7) after exposure of hGLCs from healthy women and women with PCOS to AMH. The ApoTox-Glo Triplex assay was used to evaluate the effect of AMH on cell viability, cytotoxicity and apoptosis. Testosterone reduced AMH protein secreted from KGN-GC at 10-9-10-7M (P< 0.05; P< 0.005, multiple uncorrected comparisons Fishers least squares difference), but at equivalent hyperandrogenemic levels no change was seen in AMH levels. 5α-DHT produced a significant dose-related increase in AMH protein secreted into the media (P= 0.022, ANOVA). Increasing the mRNA ratio of ERα:ERβ produced a corresponding increase in AMH mRNA expression (P= 0.015, two-way ANOVA). AMH increased mRNA levels of aromatase (P< 0.05, one-way ANOVA) and FSHR (P< 0.0001, one-way ANOVA) in hGLCs from women with PCOM, but not from normal cells or PCOS (normal n= 7, PCOM n= 5, PCOS n= 4). In contrast to hGLCs from ovulatory ovaries, in PCOS AMH reduced protein levels (cell content) of stimulatory pSMAD-1/5/8 and SMAD-4 but increased inhibitory SMAD-6 and -7 (P< 0.05, normal n= 6, PCOS n= 3). AMH at 20 and 50ng/ml decreased KGN-GC cell proliferation but not viability after 8days of treatment (P< 0.005, two-way ANOVA). N/A. Luteinised GC from women undergoing IVF have a relatively low expression of AMH/AMHRII but advantageously continue to display responses inherent to the ovarian morphology from which they are collected. To compensate, we also utilised the KGN cell line which has been characterised to be at a developmental stage close to that of immature GC. The lack of flutamide influence on testosterone effects is not in itself sufficient evidence to conclude that the effect on AMH is mediated via conversion to oestrogen, and the effect of aromatase inhibitors or oestrogen-specific inhibitors should be tested. The effect of flutamide was tested on testosterone but not DHT. Normal folliculogenesis and ovulation are dependent on the timely reduction in AMH production from GC at the time of follicle selection. Our findings reveal for the first time that theca-derived androgens may play a role in this model but that this inhibitory action is lost at levels of androgens equivalent to those seen in PCOS. The AMH decline may either be a direct effect of androgens or an indirect one via conversion to oestradiol and acting through the upregulation of ERα, which is known to stimulate the AMH promoter. Interestingly, the ability of GCs to respond to this continually elevated AMH level appears to be reduced in cells from women with PCOS due to an adaptive alteration in the SMAD signalling pathway and lower expression of AMHRII, indicating a form of 'AMH resistance'. This study was funded by the Thomas Addison Scholarship, St Georges Hospital Trust. The authors report no conflict of interest in this work and have nothing to disclose. N/A.

A variant in the fibrillin-3 gene is associated with TGF-β and inhibin B levels in women with polycystic ovary syndrome

Can serum anti-Müllerian hormone (AMH) replace polycystic ovary morphology (PCOM) determined by ultrasound as a diagnostic component of polycystic ovary syndrome (PCOS)? Despite good correlations between serum AMH and PCOM, the use of a high serum AMH as a proxy for PCOM resulted in the reclassification of PCOS in 5% of study participants, with the main effect being more women identified, although some women previously classified as having PCOS were no longer classified as such. AMH has been proposed as an alternative to PCOM as a diagnostic component of PCOS. Previous studies are limited by poorly defining PCOS, use of infertile women as comparators, measurement of hormones by immunoassay that lack precision in the female range, low-resolution ovarian ultrasound and inconsistent handling and storage of serum samples. This is an Australian cross-sectional study of 163 non-healthcare-seeking women. Serum AMH was measured by both the Ansh picoAMH assay and the Beckman Coulter Access 2 (BA2) assay, in parallel with androgens measured by liquid chromatography-tandem mass spectrometry, in blood samples of women, not pregnant, breast feeding or using systemic steroids, who also underwent high-resolution ovarian ultrasound. PCOS was determined by the Rotterdam criteria with PCOM defined by the Androgen Excess-PCOS Taskforce recommendation of ≥25 follicles in at least one ovary. Cut-off serum concentrations that best identified women as having PCOM were identified by receiver operator characteristic (ROC) curves. A total of 163 women, mean (SD) age 32.5 (5.5) years, who provided a blood sample and had both ovaries visualized on ultrasound were included in the analysis. Women with isolated PCOM had higher median (range) Ansh AMH and BA2 AMH concentrations than those with no PCOS characteristics [56.9 pmol/l (34.6, 104.2) versus 18.7 (3.2, 50.9), P = 0.002 and 38.5 pmol/l (22.2, 100.2) versus 16.7 (3.5, 38.9), P = 0.002, respectively]. An AMH ≥ 44.0 pmol/l, suggested by the ROC curve, identified 80.6% of women with PCOM, falsely identified 15.2% of women without PCOM as having PCOS and had a positive predictive value of 55.6%. The negative predictive value was 94.9%. An AMH BA2 assay cut-off of ≥33.2 pmol/l provided a sensitivity of 80.6%, a specificity of 79.5% and a positive predictive value for PCOM of 48.1%. The negative predictive value was 94.6% for PCOM. When serum AMH was used in the place of PCOM as a diagnostic criterion for PCOS, the Ansh assay resulted in an additional seven women classified as having PCOS and no longer classified one woman as having PCOS. For the BA2 assay, eight additional and two fewer women were classified as having PCOS. Overall, both assays resulted in six more women being classified as having PCOS. Women with functional hypogonadotrophic hypogonadism were not excluded and may have been misclassified as having an oligo-amenorrhoea-PCOM phenotype. As study participants were predominantly Caucasian/White, our findings cannot be generalized to women of other ethnicities. Although serum AMH reflects the number of developing ovarian follicles, the absolute values vary between assays and specific reference ranges for individual assays are required. Irrespective of the assay used, replacing PCOM with serum AMH to diagnose PCOS in a community-based sample altered the number of women classified as having or not having PCOS. Consequently, although overall the risk of women being identified as having PCOS would be increased, some women would no longer be classified as having this condition. The study was supported by the Norman Beischer Research Foundation and the Grollo-Ruzzene Foundation. S.R.D. is an NHMRC Senior Principal Research Fellow (Grant No. 1135843). S.R.D. reports unrelated support that includes grants from the NHMRC Australia, personal fees for educational activities from Besins Healthcare, Abbott Chile, BioFemme and Pfizer Australia, personal Advisory Board/consultancy fees from Theramex, Abbott Laboratories, Astellas, Mayne Pharmaceuticals, Roche Diagnostics, Lawley Pharmaceuticals and Que Oncology and has received institutional grant funding from Que Oncology and Ovoca research. The other authors declare no conflicts of interest. N/A.

BackgroundThis study aimed to evaluate the cut-off value of anti-Müllerian hormone (AMH) combined with body mass index (BMI) in the diagnosis of polycystic ovary syndrome (PCOS) and polycystic ovary morphology (PCOM).MethodsThis retrospective study included 15,970 patients: 3775 women with PCOS, 2879 women with PCOM, and 9316 patients as controls. Multivariate logistic regression analysis was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for AMH. We randomly divided the patients into two data sets. In dataset 1, a receiver operating characteristic (ROC) curve was generated to analyze the accuracy of basic AMH levels in diagnosing PCOS and PCOM. The optimal cut-off value was calculated in dataset 1 and validated in dataset 2, expressed as sensitivity and specificity.ResultsIn the PCOS group, obese patients had the lowest AMH levels, while underweight patients had the highest AMH level (P < 0.001). After adjusting for age, the ratio of luteinizing hormone (LH) and follicle stimulating hormone (FSH), serum testosterone level, and BMI, AMH was an independent predictor of PCOS and PCOM. In the group with BMI < 18.5 kg/m2, the optimistic AMH cut-off value was 5.145 ng/mL with a sensitivity of 84.3% and specificity of 89.1%, whereas in the BMI ≥ 28 kg/m2 group, the optimistic AMH cut-off value was 3.165 ng/mL with a sensitivity of 88.7% and specificity of 74.6%. For the BMI range categories of 18.5–24, 24.0–28 kg/m2, the optimistic AMH cut-off values were 4.345 ng/mL and 4.115 ng/mL, respectively. The tendency that the group with lower weight corresponded to higher AMH cut-off values was also applicable to PCOM. In the same BMI category, patients with PCOM had a lower AMH diagnosis threshold than those with PCOS (< 18.5 kg/m2, 5.145 vs. 4.3 ng/mL; 18.5–24 kg/m2, 4.345 vs. 3.635 ng/mL; 24.0–28 kg/m2, 4.115 vs. 3.73 ng/mL; ≥ 28 kg /m2, 3.165 vs. 3.155 ng/mL). These cut-off values had a good diagnostic efficacy in the validation dataset. Based on different phenotypes and severity of ovulation disorders, the distribution of AMH in PCOS were also significantly different (P < 0.001).ConclusionsAMH is a potential diagnostic indicator of PCOS and is adversely associated with BMI. The AMH cut-off value for diagnosing PCOS was significantly higher than that for PCOM.

Anti-Müllerian hormone (AMH) is produced by granulosa cells of pre-antral and small antral ovarian follicles. In polycystic ovary syndrome (PCOS), higher levels of serum AMH are usually encountered due to the ample presence of small antral follicles and a high AMH production per follicular unit which have led to the proposal of AMH as a serum diagnostic marker for PCOS or as a surrogate for polycystic ovarian morphology (PCOM). However, heterozygous coding mutations of the AMH gene with decreased in vitro bioactivity have been described in some women with PCOS. Such mutation carriers have a trend toward reduced serum AMH levels compared to noncarriers, although both types of women with PCOS have similar circulating gonadotropin and testosterone (T) levels. This report describes a normal-weight woman with PCOS by NIH criteria with severely reduced AMH levels (index woman with PCOS). Our objective was to examine the molecular basis for her reduced serum AMH levels and to compare her endocrine characteristics to similar-weight women with PCOS and detectable AMH levels. Twenty normoandrogenic ovulatory (control) and 13 age- and BMI-matched women with PCOS (19-35 years; 19-25 kg/m2) underwent transvaginal sonography and serum hormone measures including gonadotropins, sex hormone-binding globulin, total and free T, androstenedione, dehydroepiandrosterone sulfate, estrone, estradiol and AMH. The latter was measured by ELISA (Pico-AMH: Ansh Labs, Webster, TX, USA). Women with PCOS and detectable AMH had higher serum AMH (10.82 (6.74-13.40) ng/ml, median (interquartile range)), total and free T (total T: 55.5 (49.5-62.5) ng/dl; free T: 5.65 (4.75-6.6) pg/ml) levels and greater total antral follicle count (AFC) (46 (39-59) follicles) than controls (AMH: 4.03 (2.47-6.11) ng/ml; total T: 30 (24.5-34.5) ng/dl; free T: 2.2 (1.8-2.45) pg/ml; AFC 16 (14.5-21.5) follicles, P < 0.05, all values), along with a trend toward LH hypersecretion (P = 0.06). The index woman with PCOS had severely reduced serum AMH levels (∼0.1 ng/ml), although she also had a typical NIH-defined PCOS phenotype resembling that of the other women with PCOS and elevated AMH levels. All women with PCOS, including the index woman with PCOS, exhibited LH hypersecretion, hyperandrogenism, reduced serum estrogen/androgen ratios and PCOM. A homozygous Ala515Val variant (rs10417628) in the mature region of AMH was identified in the index woman with PCOS. Recombinant hAMH-515Val displayed normal processing and bioactivity, yet had severely reduced immunoactivity when measured by the commercial pico-AMH ELISA assay by Ansh Labs. In conclusion, homozygous AMH variant rs10417628 may severely impair serum AMH immunoactivity without affecting its bioactivity or PCOS phenotypic expression. Variants in AMH can interfere with serum AMH immunoactivity without affecting the phenotype in PCOS. This observation can be accompanied by discordance between AMH immunoactivity and bioactivity.

Can cluster analysis be used to differentiate between normo-ovulatory women with normal ovaries and normo-ovulatory women with polycystic ovarian morphology (PCOM) in a non-subjective manner? Cluster analysis can be used to accurately and non-subjectively differentiate between normo-ovulatory women with normal ovaries and normo-ovulatory women with PCOM. Currently, PCOM is diagnosed using a fixed threshold level, i.e. 12 or more follicles per ovary, and is one of the diagnostic criteria of polycystic ovary syndrome (PCOS). However, PCOM is also encountered in normo-ovulatory women, suggesting that it could just represent a normal variant. On the other hand, recent studies have shown subtle endocrine abnormalities in women with isolated PCOM that resemble those found in women with PCOS. Because of the strong correlation between anti-Müllerian hormone (AMH) and follicle number, a high serum AMH level has been proposed as a surrogate marker for PCOM and could, therefore, be integrated in the diagnostic classifications for PCOS. This was a retrospective observational cohort study. Original cohorts had been recruited for previous studies between 1998 and 2010. Two hundred ninety-seven regularly cycling women and 700 women with PCOS were eligible for inclusion. Cluster analysis was performed in 297 regularly cycling women. After exclusion of 'PCOM' clusters, each 'non-PCOM' cluster (young, n = 118 and old, n = 100) was included in the construction of a receiver operating characteristics curve to test the diagnostic performance of follicle number per ovary (FNPO) and serum AMH in discriminating similarly aged full-blown PCOS patients (n = 411 and 237, respectively) from normal regularly cycling non-PCOM women. The optimal number of clusters was four; age was the most important classifying variable, followed by the FNPO and serum AMH. Two distinct clusters of normo-ovulatory women with PCOM were isolated and differed solely by age, i.e. 'young' and 'old'. Both 'PCOM' clusters had their similarly aged counterpart of 'non-PCOM' clusters. Likewise, two clusters comprised women younger than 30 years, with (n = 28, 'PCOM regularly cycling women') or without (n = 118, 'normal regularly cycling women') features of PCOM (increased FNPO and/or serum AMH). The two other clusters in older women could be labelled 'normal regularly cycling women' or 'PCOM regularly cycling women' (n = 100 and 51, respectively). The prevalence of PCOM was significantly greater in old than in young regularly cycling women controls. In the young population, after exclusion of the 'PCOM regularly cycling women', the diagnostic performance of AMH, expressed by area under the curve (AUC) (AUC = 0.903; CI (0.876-0.930)) to differentiate PCOS women from normal regularly cycling women was similar to that using the FNPO (AUC = 0.915, CI (0.891-0.940)) (P = 0.25), confirming results from earlier studies. In the old population, the diagnostic performance of AMH was greater than that of FNPO (AUCs = 0.948 (0.927-0.970) vs 0.874 (0.836-0.912), respectively, P = 0.00035). Cut-off levels of AMH and antral follicle count distinguishing regularly cycling non-PCOM women from PCOS women were higher in young women than in older women. Data of normal women were obtained from earlier studies, aiming to measure normal endocrine values. Apparently, the strong effect of age in cluster analysis revealed a dichotomy in the age distribution among the cohort of regularly cycling women included. This was involuntary since in none of the original studies, eligibility was limited by age and there was considerable overlap in age ranges of the cohorts. Transvaginal ultrasound was performed using a 6.5-8 mHz probe and our data confirm that this threshold level for FNPO is still valid if using such probe frequencies, although the use of devices with a maximum frequency lower than 8 mHz has become obsolete. Obviously, newer ultrasound scanner using higher transducer frequency will facilitate the detection of more follicles. Our data support the use of AMH as a surrogate for ultrasound to define PCOM, which is one of the three items of the Rotterdam classification. They also show that age should be taken into account to define the optimal threshold. The fact that the prevalence of PCOM was increased in the older regularly cycling women, may be due to 'attenuated' PCOS, a phenomenon that has been described in ageing women with PCOS. These women might have had anovulatory cycles in the past and have become ovulatory with increasing age, and were, therefore, eligible for this study. However, since most women included at older age have had spontaneous pregnancies in the past, PCOM at older age may be associated with a subclinical form of PCOS, which may also be present in young regularly cycling women. No funding was received for this study. J.S.E.L. has received grants and support from Ferring, MSD, Organon, Merck-Serono, Schering Plough and Serono during recruitment and analysis of data for this study. S.L.F., A.D. and D.D. do not have any conflict of interest.

This observational study compares the ratio of serum anti-Mullerian hormone (AMH) to the total antral follicle count (AFC) (as a marker of AMH production per follicle) in the various phenotypes of women with polycystic ovary syndrome (PCOS) and isolated polycystic ovarian morphology (PCOM). Two hundred and sixty-two women were recruited. Women with PCOS were divided into four phenotypes based on the diagnostic inclusion criteria of oligo-anovulation (OA), hyperandrogenism (HA) and polycystic ovarian morphology (PCOM). These included Group A (OA + HA + PCOM), Group B (OA + HA), Group C (HA + PCOM) and Group D (OA + PCOM). A ratio of serum AMH to total AFC was calculated and expressed as the AMH/AFC ratio which was compared in the phenotypes of PCOS and isolated PCOM. The median AMH/AFC ratios in PCOS-A, PCOS-D, PCOS-C and PCOM were 1.5, 1.6, 1.2 and 1.1, respectively. There were significant differences in the groups compared [F(3, 238) = 6.14, p = 0.000)]. The ratios were significantly higher in the oligo-anovulatory phenotypes PCOS-A and PCOS-D than the PCOM (p = 0.004 and 0.002, respectively). There was no significant difference in the ratio between ovulatory phenotype PCOS-C and PCOM (p = 0.59). The role of androgens and LH in per-follicle AMH production remains limited. The findings support the hypothesis of a key role for AMH in the mechanism of anovulation in PCOS.

Study question How does the anti-Müllerian hormone (AMH) cutoff of 3.2 ng/mL perform in diagnosing polycystic ovarian morphology (PCOM) in young adult women 18-24 years of age? Summary answer At the cutoff of 3.2 ng/mL using Elecsys AMH Plus immunoassay, AMH shows a high sensitivity and specificity in identifying PCOM in young adult women. What is known already Polycystic ovary syndrome (PCOS) is diagnosed using the Rotterdam criteria with at least two out of three criteria being met: oligo-anovulation (OA), hyperandrogenism (HA) and PCOM. The diagnosis of PCOM is using either antral follicle count (AFC) or AMH. The Roche Elecsys AMH Plus immunoassay was validated at a cutoff of 3.2 ng/mL for detecting PCOM as part of the PCOS diagnosis in 25-45 year old women. Study design, size, duration This was a retrospective case-control study conducted between October 2024 and December 2024. The study used banked samples from 136 women with PCOS and 85 controls in the age range 18-24 years. The PCOS cases were defined by Rotterdam criteria fulfilling at least 2 out of 3 diagnostic criteria (OA, HA and PCOM), and the control women were healthy subjects with an AFC of &amp;lt; 20 antral follicles/ovary. Participants/materials, setting, methods Serum levels of AMH were measured using the Roche Elecsys® AMH Plus immunoassay, AFC was determined using transvaginal ultrasound. The performance of the AMH cutoff of 3.2 ng/mL to distinguish between PCOM cases using PCOS phenotype A (OA+HA+PCOM) and strict controls (primary population) was assessed. As sensitivity analysis the performance of the cutoff was assessed in a cohort consisting of the PCOS phenotypes with PCOM (OA+HA+PCOM, OA+PCOM, HA+PCOM) and strict controls. Main results and the role of chance In the primary population, women with PCOS (cases) and healthy women (controls) were similar in age (median age 21.0 vs 22.0 years) and body mass index (median BMI 23.8 vs 22.0 kg/m2). At the previously established cut off of 3.2 ng/mL the Elecsys AMH Plus immunoassay showed 85.0 % sensitivity (95% confidence interval [CI]: 76.5–91.4%) and 68.2% specificity (95% CI: 57.2–77.9%) for detecting PCOM in the primary population that consisted of women aged 18-24 years with the full blown PCOS (OA+HA+PCOM) and healthy controls. The overall percentage agreement (OPA) in this population was 77.3% (95% CI: 70.6-83.1%) and the area under the receiver operating characteristic curve (AUC-ROC) for the prediction of case-control status by serum AMH was 85.8% (95% CI: 80.5–91.0%). When all phenotypes with PCOM (OA+HA+PCOM; OA+PCOM; HA+PCOM) were included the sensitivity was 83.5% (95% CI: 76.0-89.3%) and the specificity 68.2% (95% CI 57.2-77.9%). OPA was 77.5% (95% CI 71.4-82.9%) and AUC-ROC was found to be 84.6% (95% CI 79.5-89.6%) including all phenotypes with PCOM. The Spearman correlation coefficient between AMH and AFC found in the full study population, was 0.70. Limitations, reasons for caution The study design was a case-control study in a cohort with control women being healthy without any symptoms of PCOS. Therefore, the AMH cutoff of 3.2 ng/mL needs to be further validated in independent cohort study in young adult women with suspected PCOS. Wider implications of the findings The Roche Elecsys AMH Plus immunoassay is a useful and robust method for identifying PCOM as part of the PCOS diagnosis in conjunction with other clinical characteristics defined by the Rotterdam criteria in young women in the age range from 18 to 24 years. Trial registration number No

Purpose: Women with PCOS have higher levels of AMH than matched controls; however, the feasibility of using elevated serum AMH value as a criterion, in the diagnosis of PCOS, is still debatable. The goal of this study was to examine a population of women with elevated AMH (&gt;5.0 ng/mL) and evaluate whether high serum AMH value can be predictive of four different clinical PCOS phenotypes (phenotype A (AOM, amenorrhea/oligomenorrhea + HA, hyperandrogenism + PCO, polycystic ovaries); Phenotype B: AOM + HA; Phenotype C: HA + PCO; and phenotype D: AOM + PCO, as defined by the Rotterdam criteria. Methods: This retrospective study included 227 women with one or more diagnoses of PCOS (ICD-9 256.4, ICD-10 E28.2) and 103 women without PCOS. All serum AMH levels were measured using Beckman Access-2 automated chemiluminescence assay and the age, BMI and AMH levels were analyzed using univariate analysis of covariance. Received operator curves were used to determine the AMH thresholds for predicting PCOS features and phenotypes. Results: Mean serum AMH levels were 9.96, 6.84, 6.43, 6.03, and 1.98 ng/ml in women with PCOS phenotype A, B, C, D, and control respectively. 101 (44.5%) patients were oligo/amenorrheic PCOS, 98 (43.2%) were hyperandrogenic PCOS, and 103 (45.4%) were PCO. Women with all three PCOS features had a significantly higher mean serum AMH compared to those with less of these features. The area under the curve (AUC) estimates of AMH showed high value ranging from 0.76 (95% CI, 0.71-0.81) in AOM group to 0.82 (95% CI, 0.79-0.88) in the PCO group. Conclusion: This study confirms the diagnostic opportunity of AMH test for discriminating between patients with PCOS phenotype and controls. High AMH accurately predicted PCOS in 92% (209 out of 227) patients diagnosed with PCOS. AMH value can predict PCOS in 78% women with oligo/amenorrheic PCOS, 77% with hyperandrogenic PCOS, and 79% with PCO. In keeping with the view that women with PCOS have a variety of phenotypic presentation that can be challenging to diagnose, using AMH test in combination with oligo/ amenorrhea or hyperandrogenism offers a non-invasive objective tool to screen patients with clinical features of PCOS.

Study question To develop an age-specific percentile distribution of anti-Müllerian hormone (AMH) in patients with polycystic ovary syndrome (PCOS) measured by three different assays. Summary answer Our age-related normograms may help to interpret AMH levels in PCOS patients and facilitate the use of AMH as a diagnostic tool across age ranges. What is known already In the last years, AMH assessment has gained widespread use in the clinical settings of several conditions. However, several challenges still exist to adopt the AMH as a marker of polycystic ovary morphology (PCOM), as included in the recently updated international guideline. Although different evaluations of age- and assay-specific reference ranges have been published in the last years, these studies have mainly been conducted in normo-ovulatory or infertile women and little is known about the higher range of AMH levels, especially in women with PCOS. Study design, size, duration Retrospective single-center cross-sectional study, including 2,725 women with PCOS who consulted the Reproductive Endocrinology and Infertility Clinic of the Erasmus University Medical Center, Rotterdam, The Netherlands. Participants/materials, setting, methods A total of 2,725 women aged 20 to 40 years with PCOS were included. PCOS was diagnosed according to the Rotterdam Criteria. Serum AMH levels were measured using the following AMH assays: (1) Gen II AMH ELISA, 2) picoAMH assay, and 3) Elecsys AMH plus assay. Age-specific centile curves were constructed using the LMS method. The correlations between AMH with clinical, endocrine, and ultrasound features were also evaluated. Main results and the role of chance To our knowledge, this is the first study with real-world data reporting AMH age-specific percentile nomograms in a large population of PCOS women using three different assays. The 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles were calculated according to a population/based approach per age (years) for the Gen II, the picoAMH, and the Elecsys assays. We also considered the age-percentile values of AMH in PCOS patients for the Gen II, the picoAMH and the Elecsys assays according to the cut-offs previously proposed in literature for each specific assay. Interestingly, in our population, a high percentage of women with polycystic ovarian morphology (PCOM) showed AMH levels lower than the cut-offs proposed. Serum AMH levels were significantly higher in patients with phenotype A compared to all other phenotypes for all three assays. For all three assays, we found a statistically significant positive correlation between AMH levels and LH, LH/FSH ratio, testosterone, androstenedione, FAI, mean follicular number, and mean ovarian volume. In contrast, AMH levels were negatively correlated with BMI in all groups. Limitations, reasons for caution This is a retrospective cross-sectional study. Longitudinal studies with a large cohort of women that could be followed for many years are needed to validate our nomogram. Wider implications of the findings AMH threshold levels can be influenced by several variables, making it difficult to identify a general cut-off to diagnose PCOM. Further research should overcome the concept of a single cut-off value. The results of the present study may help clinicians interpret AMH levels in PCOS patients across age ranges. Trial registration number In this retrospective cross-sectional study, 2,725 women who consulted the Reproductive Endocrinology and Infertility Clinic of the Erasmus University Medical Center, Rotterdam, The Netherlands, were included. The Medical Ethical Review Board of the Erasmus University Medical Center Rotterdam approved retrospective studies within this patient population, which includes women with ovulatory dysfunction (MEC-2020-0534).

What is the relationship of serum anti-Mullerian hormone (AMH) with polycystic ovarian morphology (PCOM) and polycystic ovary syndrome (PCOS)? Serum AMH concentrations are capable of differentiating between normal ovaries, PCOM and PCOS. Serum AMH levels are high in PCOS reflecting the number of small antral follicles and an intrinsic defect of individual granulosa cells. Data were collected prospectively and analysed from three groups of women: those with PCOS according to Rotterdam criteria, those with PCOM but no symptoms and those with normal ovaries. Women with PCOS (n = 90), with PCOM (n = 35) and with normal ovaries (controls, n = 90), matched for age and body mass index, were all being treated for infertility at Homerton University Hospital, a tertiary referral centre. Using adequate numbers and statistical methods for demographically similar groups, there were significant differences in the mean serum AMH concentrations between women with PCOS [77.6 pmol/l (95% CI 64.8-90.3)], those with PCOM [52.2 pmol/l (95% CI 40.1-64.2)] and controls [23.6 pmol/l (95% CI 20.5-26.7)] (P < 0.001). The combination of AMH >48 pmol/l and LH > 6 IU/l diagnosed 82.6% of women with PCOS. The mean serum FSH was lower in both PCOS and PCOM compared with controls, whereas LH was higher in PCOS compared with PCOM and controls and correlated positively with AMH (r = 0.321, P < 0.01). Further research is needed to determine the relationship of AMH, PCOS and PCOM. The study was restricted to women who sought out treatment for infertility. The study suggests that the severity of symptoms of PCOS is positively related to the number of small follicles and that AMH may play an important part in the pathophysiology of anovulation. None.

Study question What is the optimal serum anti-Mullerian hormone (AMH) cut-off for diagnosing PCOS, and what factors influence AMH value variations in women with PCOS? Summary answer AMH cut-off for PCOS diagnosis was 5.055 ng/mL (sensitivity=85.4%,specificity=75.8%). In PCOS women, AMH levels declined more slowly with age and correlated with serum testosterone concentrations. What is known already Elevated serum AMH levels are a hallmark of PCOS, yet a widely accepted diagnostic cut-off remains controversial. PCOS is characterized by diverse endocrine and metabolic disorders, which can influence AMH concentrations. Study design, size, duration This case-control study included comprehensive sampling from medical records of women who visited our fertility clinics over the past five years (2019–2024) and underwent AMH testing (n = 8233). Participants were allocated into PCOS (n = 1200) and non-PCOS groups (n = 7233). PCOS was diagnosed following the Rotterdam criteria. Age and BMI were recorded for all patients. For women with PCOS, additional data on clinical characteristics, serum hormonal profiles, metabolic parameters, and polycystic ovarian morphology on ultrasound were routinely collected. Participants/materials, setting, methods Propensity score matching (PSM) in a 1:1 ratio was performed using age and BMI as covariates. Receiver operating characteristic (ROC) curve analysis and the Youden Index were used to determine the optimal cut-off point of AMH for the diagnosis of PCOS. Age-specific AMH values were compared between the two groups by analyzing difference in slope changes. Multiple linear regression analysis was conducted to identify factors associated with AMH distribution among PCOS women. Main results and the role of chance After PSM, 1162 PCOS patients and 1162 controls were included in the final analysis. Serum AMH levels demonstrated diagnostic relevance for PCOS (AUC=0.88, p &amp;lt; 0.05), with 5.055 ng/dL identified as the optimal cut-off (sensitivity=85.4%, specificity=75.8%). AMH levels decreased progressively with age in the study cohort, with a slope coefficient of -0.053 (95%CI: -0.103 to -0.003, p &amp;lt; 0.001). There were differences in age-specific AMH distribution between the two groups. The age-related decline in AMH levels was less pronounced in PCOS women compared to controls, as evidenced by a significant difference in slope coefficients (0.125, 95%CI: 0.044 to 0.205, p = 0.003). Multiple linear regression analysis was performed to identify factors influencing AMH levels in women with PCOS, using clinical characteristics, laboratory tests, and ultrasound findings as covariates. Serum AMH levels were positively associated with total serum testosterone levels (B-value=0.46, 95%CI: 0.07–0.85, p = 0.02). Prolactin concentrations (B-value=0.04, 95%CI: -0.07–0.85, p = 0.09) and the presence of polycystic ovarian morphology on ultrasound (B-value=1.16, 95%CI: -0.09–2.42, p = 0.07) showed a trend toward influencing AMH levels, albeit not statistically significant. Limitations, reasons for caution Older women constituted a small proportion of the PCOS population (n = 103 aged ≥35 years; n = 21 aged ≥38 years), potentially limiting the analysis of AMH-age correlations in this study. Wider implications of the findings These findings provide an AMH cut-off for PCOS diagnosis and suggest that endocrine disorders play a critical role in regulating AMH activity in women suffering from this condition. With advancing age, serum AMH levels appear to be better preserved in women with PCOS compared to their non-PCOS counterparts. Trial registration number No

Polycystic ovary syndrome (PCOS) is the most common gynecological endocrine disorders affecting up to 10% of all females in their reproductive age, and its cause of onset is still elusive. A spectrum of recent research reflected diverse associations between increased plasma level of anti-Mullerian hormone (AMH) and different clinical features of PCOS. Since AMH levels reflect the pool of growing follicles that potentially can ovulate, it can be stated that serum AMH levels can be used to assess the “functional ovarian reserve,” rather mentioning it as the “ovarian reserve.” AMH also appears to be a premier endocrine parameter for the assessment of atrophied ovarian follicular pool in response to age of individuals. AMH hinders the follicular development as well as the follicular recruitment and ultimately resulting in follicular arrest which is the key pathophysiologic condition for the onset of PCOS. Furthermore, FSH-induced aromatase activity remains inhibited by AMH that aids emergence of other associated clinical signs of PCOS, such as excess androgen, followed by insulin resistance among the PCOS individuals. Given the versatile association of AMH with PCOS and scarcity in literature explaining the underling mechanisms how AMH relates with PCOS, this review article will discuss the roles of AMH in the pathogenesis of PCOS which may introduce a new era in treatment approach of PCOS.

ContextIncreased Anti-Mullerian Hormone in polycystic ovary syndrome, may be due to overactive follicles rather than reflect antral follicle count.ObjectiveDoes Anti-Mullerian Hormone reflect antral follicle count similarly in women with or without polycystic ovary syndrome or polycystic ovarian morphology?DesignCross-sectional, case-control.SettingWomen who delivered preterm in 1999–2006. For each index woman, a woman with a term delivery was identified.PatientsParticipation rate was 69%. Between 2006–2008, 262 women were included, and diagnosed to have polycystic ovary syndrome, polycystic ovarian morphology or to be normal controls.Intervention(s)Blood tests, a clinical examination and vaginal ultrasound.Main Outcome Measure(s)Anti-Mullerian Hormone / antral follicle count -ratio, SHBG, androstenedione and insulin, to test potential influence on the Anti-Mullerian Hormone / antral follicle count -ratio.ResultsMean Anti-Mullerian Hormone / antral follicle count ratio in women with polycystic ovary syndrome or polycystic ovarian morphology was similar to that of the controls (polycystic ovary syndrome: 1,2 p = 0,10 polycystic ovarian morphology: 1,2, p = 0,27 Controls 1,3). Anti-Mullerian Hormone showed a positive linear correlation to antral follicle count in all groups. Multivariate analysis did not change the results.ConclusionsWe confirmed the positive correlation between AMH and follicle count. Anti-Mullerian Hormone seems to be a reliable predictor of antral follicle count, independent of polycystic ovary syndrome diagnosis or ovarian morphology.