Substituting serum anti-Müllerian hormone for polycystic ovary morphology increases the number of women diagnosed with polycystic ovary syndrome: a community-based cross-sectional study

Anti-müllerian hormone as a diagnostic biomarker for polycystic ovary syndrome and polycystic ovarian morphology: a systematic review and meta-analysis

IMPORTANCE

As part of the 2023 international evidence-based polycystic ovary syndrome (PCOS) guideline, this meta-analysis investigated the inclusion of Anti-Müllerian hormone (AMH) levels in the diagnostic criteria for PCOS.

OBJECTIVE

To answer the following three questions: 1) Are AMH levels effective in diagnosing PCOS in adult women? 2) Are AMH levels effective in diagnosing PCOS in adolescents? Are AMH levels effective in diagnosing polycystic ovarian morphology (PCOM)?

DATA SOURCES

Searches were conducted in six databases until July 31, 2023.

STUDY SELECTION AND SYNTHESIS

Eligible studies were those conducted in humans, published in English, and reporting sensitivity, specificity, and/or area under the curve values. Extracted data included study population, age, body mass index, AMH assay, cut-off value of AMH levels, sensitivity, specificity, and area under the curve values. The risk of bias was assessed using the quality assessment of diagnostic accuracy studies tool. A random effects model was used to test diagnostic accuracy.

MAIN OUTCOMES

Pooled sensitivity and specificity to use AMH levels for PCOS diagnosis in adults as well as adolescents and for detecting PCOM in adults.

RESULTS

Eighty-two studies were included. The adult AMH-PCOS meta-analyses (n = 68) showed a pooled sensitivity and specificity of 0.79 (95% confidence interval [CI], 0.76-0.82; I2 = 86%) and 0.87 (95% CI, 0.84-0.89; I2 = 91%). The adolescent AMH-PCOS meta-analysis (n = 11) showed a pooled sensitivity and specificity of 0.66 (95% CI, 0.58-0.73; I2 = 74%) and 0.78 (95% CI, 0.71-0.83; I2 = 45%). The adult AMH-PCOM meta-analysis (n = 7) showed a pooled sensitivity and specificity of 0.79 (95% CI, 0.72-0.85; I2 = 94%) and 0.87 (95% CI, 0.78-0.93; I2 = 94%). CONCLUSION AND RELEVANCE: This study investigated the most profound change in the 2023 international evidence-based PCOS guideline, which now recommends AMH levels for defining PCOM in adults in accordance with the diagnostic algorithm. Antimüllerian hormone levels alone are insufficient for PCOS diagnosis and are nonspecific for PCOM in adolescents. Multiple factors influence AMH levels and cause heterogeneity as well as limitations in this study. Consequently, no international cut-off value could be recommended, emphasizing the need for research on more individualized cut-off values.

Age-related Curves of AMH Using the Gen II, the picoAMH, and the Elecsys Assays in Women With Polycystic Ovary Syndrome

CONTEXT

Several challenges still exist to adopt the anti-müllerian hormone (AMH) as a marker of polycystic ovary morphology, as included in the recently updated international guideline. Although different evaluations of age- and assay-specific reference ranges have been published in the past few years, these studies have mainly been conducted in normo-ovulatory or infertile women.

OBJECTIVE

To develop an age-specific percentile distribution of AMH in patients with polycystic ovary syndrome (PCOS) measured by 3 different assays.

DESIGN

Retrospective cross-sectional study.

PATIENTS

A total of 2725 women aged 20 to 40 years with PCOS diagnosis were included.

INTERVENTIONS

Serum AMH measurement by the Gen II (Beckman Coulter), the picoAMH (Ansh Labs), and the Elecsys (Roche) assays.

MAIN OUTCOME MEASURES

Age-specific percentile curves for all the assays and correlations between AMH, clinical, hormonal, and ultrasound characteristics.

RESULTS

Age-related nomograms for the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles of AMH were calculated using the Lambda-Mu-Sigma method for all the assays. AMH levels were significantly different between PCOS phenotypes. AMH levels were positively correlated to LH, LH/FSH ratio, testosterone, androstenedione, free androgen index, mean follicular number, and mean ovarian volume.

CONCLUSION

To our knowledge, this is the first study reporting age-specific percentile nomograms of serum AMH levels measured by the Gen II, the picoAMH, and the Elecsys assays in a large population of women with PCOS. These findings may help to interpret AMH levels in patients with PCOS and facilitate the use of AMH as a diagnostic tool across age ranges.

Utility of Serum Anti-Müllerian Hormone Measurement as Part of Polycystic Ovary Syndrome Diagnosis

The 2023 international evidence-based guideline update for the assessment and management of polycystic ovary syndrome (PCOS) recommends using the Rotterdam criteria for the diagnosis of PCOS. The updated guideline has evidence-based recommendation for the diagnosis, and it now also includes serum anti-Müllerian hormone (AMH) measurement as an alternative tool for gynecological ultrasound to diagnose polycystic ovary morphology (PCOM). The aim of this new recommendation was to facilitate PCOS diagnostic workup in primary care and other disciplines, as currently most diagnosing is done in gynecology and infertility clinics. Here, we review factors affecting AMH levels as well as the utility of AMH in PCOS diagnosis. We identified relevant studies that report different cut-offs for AMH to diagnose PCOM as part of PCOS diagnosis. There are, however, some limitations when using AMH that should be acknowledged. These include physiological aspects like age, ethnicity, and obesity and iatrogenic causes like hormonal medication and ovarian surgery. Also reference ranges are different depending on AMH assay used. As a summary, we conclude that AMH is a usable tool in PCOM diagnostics, but it does not have a single cut-off. Therefore, further studies are needed to establish age and assay-based reference ranges.

Validation of an Anti-Müllerian Hormone Cutoff for Polycystic Ovarian Morphology in the Diagnosis of Polycystic Ovary Syndrome in the HARMONIA Study: Protocol for a Prospective, Noninterventional Study

BACKGROUND

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in women and is diagnosed using the Rotterdam criteria, including diagnosis of polycystic ovarian morphology (PCOM) by transvaginal ultrasound (TVUS). Due to high cost, availability, and the impact of the operator and ultrasound equipment on the reliability of the antral follicle count (AFC) by TVUS, an unmet need exists for a diagnostic test to determine PCOM without TVUS. A strong positive correlation between elevated anti-Müllerian hormone (AMH) levels and AFCs has been demonstrated in women with PCOS. In addition, recent updates to the international evidence-based PCOS guidelines state that serum AMH can be used as an alternative to TVUS-determined AFC, in the diagnosis of PCOM. The retrospective APHRODITE study derived and validated an AMH cutoff of 3.2 ng/mL for the Elecsys AMH Plus or Elecsys AMH assays (Roche) to diagnose PCOM in patients with PCOS.

OBJECTIVE

This study aims to further validate, in an independent prospective cohort, the AMH cutoff (3.2 ng/mL) for PCOM determination, which was previously derived and validated in the APHRODITE study.

METHODS

This large, prospective, multicenter, population-based, noninterventional study will evaluate the previously established AMH cutoff for the determination of PCOM during the diagnosis of PCOS using the Elecsys AMH Plus immunoassay in an independent population. Participants were women born between July 1985 and December 1987 in Northern Finland; the study partially links to the Northern Finland Birth Cohort 1986. We assessed the enrolled women, determined with the 2023 PCOS Guidelines, for current PCOS status and divided them by phenotype if positive. Each participant had 1 study visit to collect serum samples, record clinical data, and undergo a gynecological examination including TVUS. All data were collected by highly trained midwives or trained gynecologists. Sensitivity, specificity, and agreement measures were used to validate the previously determined cutoff in the whole population and in subpopulations based on phenotype and relevant demographic or clinical factors. The minimum target sample size was approximately 1800 women, including approximately 10% with PCOS.

RESULTS

At the time of manuscript submission, participant recruitment had concluded, and 1803 women were enrolled into the study. Data collection is complete and biostatistical analysis is planned for 2023.

CONCLUSIONS

To limit variability, there were few TVUS operators and only 2 TVUS machines of the same type. Additionally, all women who were taking oral contraceptives were excluded from the primary analysis population. Selection bias was limited as this was a population-based study and participants were not seeking treatment for PCOS symptoms. Validating the AMH cutoff in a large, population-based study will provide further evidence on the utility of the Elecsys AMH Plus or Elecsys AMH assays in PCOM diagnosis as an alternative to TVUS. Measuring AMH for PCOM diagnosis could reduce delayed or missed diagnoses due to operator-dependent TVUS examinations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05527353; http://tinyurl.com/2f3ffbdz.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48854.

Biomarkers in Polycystic Ovary Syndrome

Polycystic Ovary Syndrome (PCOS) is the most common endocrine disorder in reproductive-age women. PCOS is diagnosed by the presence of two of the following three characteristics: hyperandrogenemia and/or hyperandrogenism, oligo/amenorrhea, and polycystic ovarian morphology. PCOS is associated with reproductive and non-reproductive complications, including obesity, insulin resistance and diabetes, dyslipidemia, and increased blood pressure. There is an urgent need for biomarkers that address both the reproductive and non-reproductive aspects of this complex syndrome. This review focuses on biomarkers, or potential ones, associated with the reproductive and non-reproductive aspects of PCOS, including anthropometric and clinical biomarkers, insulin and the IGF-1 system, lipids, anti-Müllerian hormone and gonadotropins, steroids, inflammatory and renal injury biomarkers, oxidative stress, and non-coding RNAs. We expect that this review will bring some light on the recent updates in the field and encourage researchers to join the exciting and promising field of PCOS biomarkers.

Serum Anti-Mullerian Hormone (AMH) Levels Among Different PCOS Phenotypes and Its Correlation with Clinical, Endocrine, and Metabolic Markers of PCOS

Anti-Mullerian hormone (AMH) is one of the direct indicators of follicular pool but no standard cutoff has been defined for diagnosis of polycystic ovary syndrome (PCOS). The present study evaluated the serum AMH levels among different PCOS phenotypes and correlated the AMH levels with clinical, hormonal, and metabolic parameters among Indian PCOS women. Mean serum AMH was 12.39 ± 5.3ng/mL in PCOS cohort and 3.83 ± 1.5 ng/mL in non-PCOS cohort (P < 0.01). Out of 608 PCOS women, 273 (44.9%) women belonged to phenotype A, 230 (37.8%) women were phenotype D. Phenotypes C and B were 12.17% and 5.10% respectively. Among those with the highest AMH group (AMH>20ng/ml; 8.05%), majority belonged to phenotype A. Menstrual cycle length, serum testosterone, fasting total cholesterol levels, and follicle number per ovary had positive correlation with serum anti-Mullerian levels (P < 0.05). AMH cutoff for the diagnosis of PCOS was calculated as ≥ 6.06 ng/mL on ROC analysis with sensitivity and specificity of 91.45% and 90.71% respectively. The study shows high serum AMH levels in PCOS are associated with worse clinical, endocrinological, and metabolic parameters. These levels may be used to counsel patients regarding treatment response, help in individualized management and prediction of reproductive and long-term metabolic outcomes.

AMH as part of the diagnostic PCOS workup in large epidemiological studies

OBJECTIVES

Previous studies have shown good correlation between polycystic ovarian morphology (PCOM) and serum anti-Müllerian hormone (AMH) levels. We evaluated the utility of AMH as a surrogate for PCOM as a part of the polycystic ovary syndrome (PCOS) diagnosis by describing how the use of different AMH cut-off values would change the prevalence of PCOS.

METHODS

A general population-based birth cohort study. Anti-Müllerian hormone concentrations were measured from serum samples taken at age 31 years (n = 2917) using the electrochemiluminescence immunoassay (Elecsys). Anti-Müllerian hormone data were combined with data on oligo/amenorrhoea and hyperandrogenism to identify women with PCOS.

RESULTS

The addition of AMH as a surrogate marker for PCOM increased the number of women fulfilling at least two PCOS features in accordance with the Rotterdam criteria. The prevalence of PCOS was 5.9% when using the AMH cut-off based on the 97.5% quartile (10.35 ng/mL) and 13.6% when using the recently proposed cut-off of 3.2 ng/mL. When using the latter cut-off value, the distribution of PCOS phenotypes A, B, C, and D was 23.9%, 4.7%, 36.6%, and 34.8%, respectively. Compared with the controls, all PCOS groups with different AMH concentration cut-offs showed significantly elevated testosterone (T), free androgen index (FAI), luteinizing hormone (LH), LH/follicle-stimulating hormone (FSH) ratio, body mass index (BMI), waist circumference, and homoeostatic model assessment of insulin resistance (HOMA-IR) values, as well as significantly decreased sex hormone-binding globulin (SHBG) values.

CONCLUSIONS

Anti-Müllerian hormone could be useful surrogate for PCOM in large data sets, where transvaginal ultrasound is not feasible, to aid the capturing of women with typical PCOS characteristics. Anti-Müllerian hormone measurement from archived samples enables retrospective PCOS diagnosis when combined with oligo/amenorrhoea or hyperandrogenism.

Determining the age group-based cut-off values of serum anti-Mullerian hormone concentrations to diagnose polycystic ovary syndrome

OBJECTIVE

To determine the cut-off values of the serum anti-Müllerian hormone (AMH) concentration for different age groups (21-25, 26-30, 31-35 years) to diagnose polycystic ovary syndrome (PCOS).

METHODS

In total, 187 women aged 21-35 years were included in this descriptive study. Patients diagnosed with PCOS according to the Rotterdam Criteria formed the PCOS group (n = 93), whereas those without symptoms related to PCOS formed the control group (n = 94). Follicular phase serum hormone concentrations were evaluated during the endocrinological assessment of patients with PCOS. Serum levels of estradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, total testosterone, dehydroepiandrosterone sulfate, sex hormone-binding globulin, androstenedione, and AMH were measured. The free androgen index and LH/FSH ratio were calculated. Cut-off values of serum AMH concentrations for the age groups were measured using receiver operating characteristic curve analysis.

RESULTS

The prevalence rates of frank, ovulatory, normoandrogenic, and non-polycystic ovary PCOS were 69.9, 10.8, 10.8, and 8.6%, respectively. Serum AMH concentrations >5.56 ng/mL were associated with PCOS in the 21-25-year-old group. The cut-off value was 4.01 ng/mL in the 26-30-year-old group, whereas it was 3.42 ng/mL in the oldest age group. The correlation between the antral follicle count (AFC) and serum AMH level was strong for each age group.

CONCLUSIONS

The serum AMH concentration is a valuable parameter for assessing patients with symptoms indicative of PCOS. We recommend measuring serum AMH levels to support the diagnosis or to use them instead of the AFC for the Rotterdam criteria.

The Relationship Between Insulin Resistance and Obesity and Serum Anti-Mullerian Hormone Level in Chinese Women with Polycystic Ovary Syndrome: A Retrospective, Single-Center Cohort Study

Background

Anti-Mullerian hormone (AMH) is vital in the pathophysiological process of polycystic ovary syndrome (PCOS). The exact relationship between obesity and insulin resistance (IR) with AMH levels remains unclear.

Methods

A retrospective, single-center cohort study of 220 women with PCOS who underwent physical, endocrine, and metabolic assessments were performed. Patients were grouped by age, body mass indices (BMI), Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), and different phenotypes. Pearson correlation analysis assessed the correlation between AMH and HOMA-IR, BMI, and other PCOS indicators, and multiple linear regression analysis was performed to determine factors influencing AMH.

Results

In 220 patients with PCOS, serum AMH levels decreased with age and were significantly higher in the IR group than in the non-IR group (P < 0.01). AMH increased significantly in anovulatory patients with hyperandrogenemia and/or polycystic ovary, with no significant difference between obese and non-obese individuals. AMH levels correlated positively with luteinizing hormone (LH), LH/follicular stimulating hormone (FSH), testosterone, fasting insulin (FINS), and HOMA-IR levels; negatively with age and BMI levels (P < 0.05) and weakly with fasting plasma glucose in the classical PCOS phenotype (r=0.148, P < 0.05). Regression analysis showed that age, testosterone, FINS, LH, LH/FSH, and BMI influenced AMH levels (P < 0.05).

Conclusion

Chinese women with PCOS-IR showed associations with greater AMH levels. AMH levels correlated positively with HOMA-IR levels and negatively with BMI. AMH combined with BMI and HOMA-IR levels may help determine PCOS severity.

Anti-Müllerian hormone for the diagnosis and prediction of menopause: a systematic review

BACKGROUND

The early onset of menopause is associated with increased risks of cardiovascular disease and osteoporosis. As a woman's circulating anti-Müllerian hormone (AMH) concentration reflects the number of follicles remaining in the ovary and declines towards the menopause, serum AMH may be of value in the early diagnosis and prediction of age at menopause.

OBJECTIVE AND RATIONALE

This systematic review was undertaken to determine whether there is evidence to support the use of AMH alone, or in conjunction with other markers, to diagnose menopause, to predict menopause, or to predict and/or diagnose premature ovarian insufficiency (POI).

SEARCH METHODS

A systematic literature search for publications reporting on AMH in relation to menopause or POI was conducted in PubMed®, Embase®, and the Cochrane Central Register of Controlled Trials up to 31 May 2022. Data were extracted and synthesized using the Synthesis Without Meta-analysis for diagnosis of menopause, prediction of menopause, prediction of menopause with a single/repeat measurement of AMH, validation of prediction models, short-term prediction in perimenopausal women, and diagnosis and prediction of POI. Risk-of-bias was evaluated using the Tool to Assess Risk of Bias in Cohort Studies protocol and studies at high risk of bias were excluded.

OUTCOMES

A total of 3207 studies were identified, and 41, including 28 858 women, were deemed relevant and included. Of the three studies that assessed AMH for the diagnosis of menopause, one showed that undetectable AMH had equivalent diagnostic accuracy to elevated FSH (>22.3 mIU/ml). No study assessed whether AMH could be used to shorten the 12 months of amenorrhoea required for a formal diagnosis of menopause. Studies assessing AMH with the onset of menopause (27 publications [n = 23 835 women]) generally indicated that lower age-specific AMH concentrations are associated with an earlier age at menopause. However, AMH alone could not be used to predict age at menopause with precision (with estimates and CIs ranging from 2 to 12 years for women aged <40 years). The predictive value of AMH increased with age, as the interval of prediction (time to menopause) shortened. There was evidence that undetectable, or extremely low AMH, may aid early diagnosis of POI in young women with a family history of POI, and women presenting with primary or secondary amenorrhoea (11 studies [n = 4537]).

WIDER IMPLICATIONS

The findings of this systematic review support the use of serum AMH to study the age of menopause in population studies. The increased sensitivity of current AMH assays provides improved accuracy for the prediction of imminent menopause, but diagnostic use for individual patients has not been rigorously examined. Prediction of age at menopause remains imprecise when it is not imminent, although the finding of very low AMH values in young women is both of clinical value in indicating an increased risk of developing POI and may facilitate timely diagnosis.

Comparison of 3 Different AMH Assays With AMH Levels and Follicle Count in Women With Polycystic Ovary Syndrome

CONTEXT

Anti-Müllerian hormone (AMH) levels strongly correlate with the number of antral follicles (total follicle count, TFC) in the ovary. In women with polycystic ovary syndrome (PCOS), this is reflected by significantly increased serum AMH levels. Different assays have been developed to measure AMH. However, little is known about the interassay correlation in women with increased AMH levels.

OBJECTIVE

To investigate the correlation of AMH values between different AMH assays and with TFC in PCOS patients.

METHODS

AMH levels were measured in 1660 PCOS patients, using 3 different AMH assays: Gen II (Beckman Coulter); picoAMH (Ansh Labs); and Elecsys (Roche). Passing Bablok regression was used to compare assay methods. Spearman's correlation was used to correlate AMH levels and TFC.

RESULTS

Strong interassay correlations were present over the total range of AMH levels (0.81-0.94). Stratification in subgroups, revealed an AMH level-dependent interassay correlation with strong interassay correlations in the low (<2.80 ng/mL) and high (>7.04 ng/mL) subgroups (0.62-0.86). However, the correlation in the mid-AMH subgroup (2.80-7.04 ng/mL) was only moderate (0.28-0.56). A strong correlation was present between the total range of AMH levels and TFC (0.57-0.62). However, in all 3 AMH subgroups the correlation became moderate at best, independently of assay method (0.11-0.45).

CONCLUSION

In conclusion, both the interassay correlation and the correlation between AMH level and follicle count depend on the range of serum AMH levels. This once more emphasizes the need of a standardization of AMH measurement for an accurate interpretation of AMH in clinical practice.