Anti-Müllerian hormone measurement for the diagnosis of polycystic ovary syndrome

Pigment epithelium-derived factor expression and role in follicular development

RESEARCH QUESTION

What is the involvement of pigment epithelium-derived factor (PEDF), expressed in granulosa cells, in folliculogenesis?

DESIGN

mRNA expression of PEDF and other key factors [Cyp19, anti-Müllerian hormone receptor (AMHR) and vascular endothelial growth factor (VEGF)] in mice follicles was examined in order to typify the expression of PEDF in growing follicles and in human primary granulosa cells (hpGC), and to follow the interplay between PEDF and the other main players in folliculogenesis: FSH and AMH.

RESULTS

mRNA expression of PEDF increased through folliculogenesis, although the pattern differed from that of the other examined genes, affecting the follicular angiogenic and oxidative balance. In hpGC, prolonged exposure to FSH stimulated the up-regulation of PEDF mRNA. Furthermore, a negative correlation between AMH and PEDF was observed: AMH stimulation reduced the expression of PEDF mRNA and PEDF stimulation reduced the expression of AMHR mRNA.

CONCLUSIONS

Folliculogenesis, an intricate process that requires close dialogue between the oocyte and its supporting granulosa cells, is mediated by various endocrine and paracrine factors. The current findings suggest that PEDF, expressed in granulosa cells, is a pro-folliculogenesis player that interacts with FSH and AMH in the process of follicular growth. However, the mechanism of this process is yet to be determined.

A Cross-Sectional Study of Alzheimer-Related Proteins in Women with Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine condition in women of reproductive age, and several risk factors found in PCOS are associated with an increased risk of Alzheimer's disease (AD). Proteins increased in AD have been reported to include fibronectin (FN) fragments 3 and 4 (FN1.3 and FN1.4, respectively) and ApoE. We hypothesized that Alzheimer-related proteins would be dysregulated in PCOS because of associated insulin resistance and obesity. In this comparative cross-sectional analysis, aptamer-based SomaScan proteomic analysis for the detection of plasma Alzheimer-related proteins was undertaken in a PCOS biobank of 143 women with PCOS and 97 control women. Amyloid precursor protein (APP) (p < 0.05) and amyloid P-component (APCS) (p < 0.001) were elevated in PCOS, while alpha-synuclein (SNCA) (p < 0.05) was reduced in PCOS. Associations with protective heat shock proteins (HSPs) showed that SNCA positively correlated with HSP90 (p < 0.0001) and HSP60 (p < 0.0001) in both the PCOS and control women. Correlations with markers of inflammation showed that APCS correlated with interleukin 6 (IL6) (p = 0.04), while Apolipoprotein (Apo) E3 correlated with TNF-alpha (p = 0.02). FN, FN1.3, FN1.4 and ApoE were all elevated significantly (p < 0.05). An AD-associated protein pattern with elevated FN, FN1.3, FN1.4 and ApoE was found in PCOS, in addition to elevated APP and reduced SNCA, which was the same as reported for type 2 diabetes (T2D) with, additionally, an elevation in APCS. With the AD biomarker pattern in PCOS being very similar to that in T2D, where there is an association between AD and T2D, this suggests that larger prospective cohort studies are needed in women with PCOS to determine if there is a causal association with AD.

Complement Dysregulation in Obese Versus Nonobese Polycystic Ovary Syndrome Patients

INTRODUCTION

Upregulation of complement system factors are reported to be increased in polycystic ovary syndrome (PCOS) and may be due to obesity and insulin resistance rather than inherently due to PCOS. We directly compared complement factors from an obese, insulin-resistant PCOS population to a nonobese, non-insulin-resistant PCOS population in a proteomic analysis to investigate this.

METHODS

Plasma was collected from 234 women (137 with PCOS and 97 controls) from a biobank cohort and compared to a nonobese, non-insulin-resistant population (24 with PCOS and 24 controls). Slow off-rate modified aptamer (SOMA) scan plasma protein measurement was undertaken for the following complement system proteins: C1q, C1r, C2, C3, C3a, iC3b, C3b, C3d, C3adesArg, C4, C4a, C4b, C5, C5a, C5b-6 complex, C8, properdin, factor B, factor D, factor H, factor I, Mannose-binding protein C (MBL), complement decay-accelerating factor (DAF) and complement factor H-related protein 5 (CFHR5).

RESULTS

The alternative pathway of the complement system was overexpressed in both obese and nonobese PCOS, with increased C3 (p < 0.05) and properdin (p < 0.01); additionally, factor B increased in obese PCOS (p < 0.01). For inhibitors of this pathway, factor I was increased (p < 0.01) in both slim and obese PCOS, with an increase in CFHR5 and factor H in obese PCOS (p < 0.01). Complement factors iC3b, C3d and C5a, associated with an enhanced B cell response and inflammatory cytokine release, were increased in both slim and obese PCOS (p < 0.05). C3a and its product, C3adesArg, were both significantly elevated in nonobese PCOS (<0.01) but not altered in obese PCOS. Hyperandrogenemia correlated positively with properdin and iC3b in obese PCOS (p < 0.05) but not in nonobese PCOS. There was no association with insulin resistance. BMI correlated positively in both groups with factor B, factor H and C5a. Additionally, in obese PCOS, BMI correlated with C3d, factor D, factor I, CFHR5 and C5a (p < 0.05), and in nonobese PCOS, BMI correlated with properdin, iC3b, C3, C3adesArg, C3a, C4, C5, C5a and C1q. In obese controls, BMI correlated with C3, C3desArg, C3a, C3d, C4, factor I, factor B, C5a and C5, whilst in nonobese controls, BMI only correlated negatively with C1q. Comparison of nonobese and obese PCOS showed that properdin, C3b, iC3b, C4A, factor D, factor H and MBL differed.

CONCLUSION

The upregulation of the alternative complement pathway was seen in nonobese PCOS and was further exacerbated in obese PCOS, indicating that this is an inherent feature of the pathophysiology of PCOS that is worsened by obesity and is reflected in the differences between the nonobese and obese PCOS phenotypes. However, the increase in the complement proteins associated with activation was counterbalanced by upregulation of complement inhibitors; this was evident in both PCOS groups, suggesting that insults, such as a cardiovascular event or infection, that cause activation of complement pathways may be amplified in PCOS.

Diagnostic Performance of Anti-Müllerian Hormone, Luteinizing Hormone to Follicle-Stimulating Hormone Ratio, Testosterone, and Prolactin to Predict Polycystic Ovary Syndrome Among Sudanese Women

Background

Polycystic ovary syndrome (PCOS) is one of the most important contributing factors to infertility. The diagnosis of PCOS is not an easy procedure, as the signs and symptoms are heterogeneous and of undefined etiology. There are only a few published studies that address the diagnostic performance of anti-Müllerian hormone in diagnosis of PCOS in sub-Saharan Africa including Sudan.

Objective

This study aims to assess anti-Müllerian hormone (AMH), luteinizing to follicle-stimulating hormone ratio (LH: FSH), total testosterone (TT), and prolactin (PRL) levels among PCOS. In addition, we determine if AMH can be used as a predictor of PCOS among Sudanese women.

Methods

There were 600 women enrolled in this observational cross-sectional study, 300 of whom had PCOS, and 300 of whom healthy women; PCOS was diagnosed using the Rotterdam criteria. On days 2-4 of the menstrual cycle, serum LH, FSH, AMH, TT, and PRL levels were measured for all participants. Diagnostic performance of these parameters for PCOS was determined by receiver operating characteristic (ROC) curve.

Results

Significantly higher means among PCOS regarding their BMI, AMH; LH: FSH ratio; TT; PRL, whereas significantly inverse in FSH compared with normal ovulatory women. On ROC analysis, AMH had the largest operating characteristic curve at cut-off >3.95 ng/mL; AUC = 0.999 with Youden's index 0.99%, followed by LH: FSH ratio at cut-off 0.749; AUC=0.932; Youden's index 0.813%, TT cut-off 0.82 mIU/L, AUC=0.852 with Youden's index 0.58, while PRL showed the lowest AUC=0.627 with cut-off 15.3 ng/mL, Youden's index was 0.18%, P. value<0.001.

Conclusions

Sudanese women with PCOS had higher serum AMH level, LH:FSH ratio, and TT level. Moreover, AMH level has better discriminative power and good diagnostic potency for the diagnosis of PCOS among Sudanese.

HDL-Associated Proteins in Subjects with Polycystic Ovary Syndrome: A Proteomic Study

Introduction. Serum lipoproteins, with the exception of high-density lipoprotein cholesterol (HDL-C), are increased in polycystic ovary syndrome (PCOS) and their levels may reflect the associated obesity and insulin resistance, but the nature of this association is not fully explained. Therefore, proteomic analysis of key proteins in lipoprotein metabolism was performed. Methods. In this cohort study, plasma was collected from 234 women (137 with PCOS and 97 controls without PCOS). Somalogic proteomic analysis was undertaken for the following 19 proteins involved in lipoprotein, and particularly HDL, metabolism: alpha-1-antichymotrypsin; alpha-1-antitrypsin; apolipoproteins A-1, B, D, E, E2, E3, E4, L1, and M; clusterin; complement C3; hemopexin; heparin cofactor II; kininogen-1; serum amyloid A-1; amyloid beta A-4; and paraoxonase-1. Results. The levels of apolipoprotein E were higher in PCOS (p = 0.012). However, the other isoforms of ApoE, ApoE2, E3, and E4, did not differ when compared with controls. ApoM was lower in PCOS (p = 0.000002). Complement C3 was higher in PCOS (p = 0.037), as was heparin cofactor II (HCFII) (p = 0.0004). The levels of the other proteins associated with lipoprotein metabolism did not differ between PCOS and controls. Conclusions. These data contribute to the concern of the deleterious dyslipidemia found in PCOS, with the novel combination reported here of higher levels of ApoE, C3 and HCFII together with lower ApoM. The dysregulation of these proteins could circumvent the protective effect of HDL-C and contribute to a more atherogenic profile that may increase cardiovascular risk.

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.

Assessing the androgenic and metabolic heterogeneity in polycystic ovary syndrome using cluster analysis

INTRODUCTION

Some but not all women with polycystic ovary syndrome (PCOS) develop the metabolic syndrome (MS). The objective of this study was to determine if a subset of women with PCOS had higher androgen levels predisposing them to MS and whether routinely measured hormonal parameters impacted the metabolic syndrome score (siMS).

METHODS

We included data from a discovery (PCOS clinic data) and a replication cohort (Hull PCOS Biobank) and utilized eight routinely measured hormonal parameters in our clinics (free androgen index [FAI], sex hormone-binding globulin, dehydroepiandrosterone sulphate (DHEAS), androstenedione, luteinizing hormone [LH], follicular stimulating hormone, anti-Müllerian hormone and 17 hydroxyprogesterone [17-OHP]) to perform a K-means clustering (an unsupervised machine learning algorithm). We used NbClust Package in R to determine the best number of clusters. We estimated the siMS in each cluster and used regression analysis to evaluate the effect of hormonal parameters on SiMS.

RESULTS

The study consisted of 310 women with PCOS (discovery cohort: n = 199, replication cohort: n = 111). The cluster analysis identified two clusters in both the discovery and replication cohorts. The discovery cohort identified a larger cluster (n = 137) and a smaller cluster (n = 62), with 31% of the study participants. Similarly, the replication cohort identified a larger cluster (n = 74) and a smaller cluster (n = 37) with 33% of the study participants. The smaller cluster in the discovery cohort had significantly higher levels of LH (7.26 vs. 16.1 IU/L, p < .001), FAI (5.21 vs. 9.22, p < .001), androstenedione (3.93 vs. 7.56 nmol/L, p < .001) and 17-OHP (1.59 vs. 3.12 nmol/L, p < .001). These findings were replicated in the replication cohort. The mean (±SD) siMS score was higher in the smaller cluster, 3.1 (±1.1) versus 2.8 (±0.8); however, this was not statistically significant (p = .20). In the regression analysis, higher FAI (β = .05, p = .003) and androstenedione (β = .03, p = .02) were independently associated with a higher risk of SiMS score, while higher DHEAS levels were associated with a lower siMS score (β = -.07, p = .03) CONCLUSION: We identified a subset of women in our PCOS cohort with significantly higher LH, FAI, and androstenedione levels. We show that higher levels of androstenedione and FAI are associated with a higher siMS, while higher DHEAS levels were associated with lower siMS.

The Role of Serum Anti-Mullerian Hormone Measurement in the Diagnosis of Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common endocrinological disorder in women with significant reproductive, metabolic, and psychological health implications. The lack of a specific diagnostic test poses challenges in making the diagnosis of PCOS, resulting in underdiagnosis and undertreatment. Anti-Mullerian hormone (AMH) synthesized by the pre-antral and small antral ovarian follicles appears to play an important role in the pathophysiology of PCOS, and serum AMH levels are often elevated in women with PCOS. The aim of this review is to inform the possibility of utilizing anti-Mullerian hormone either as a diagnostic test for PCOS or as an alternative diagnostic criterion in place of polycystic ovarian morphology, hyperandrogenism, and oligo-anovulation. Increased levels of serum AMH correlate highly with PCOS, polycystic ovarian morphology, hyperandrogenism, and oligo/amenorrhea. Additionally, serum AMH has high diagnostic accuracy as an isolated marker for PCOS or as a replacement for polycystic ovarian morphology.

Multiomics Analysis-Based Biomarkers in Diagnosis of Polycystic Ovary Syndrome

Polycystic ovarian syndrome is an utmost communal endocrine, psychological, reproductive, and metabolic disorder that occurs in women of reproductive age with extensive range of clinical manifestations. This may even lead to long-term multiple morbidities including obesity, diabetes mellitus, insulin resistance, cardiovascular disease, infertility, cerebrovascular diseases, and ovarian and endometrial cancer. Women affliction from PCOS in midst assemblage of manifestations allied with menstrual dysfunction and androgen exorbitance, which considerably affects eminence of life. PCOS is recognized as a multifactorial disorder and systemic syndrome in first-degree family members; therefore, the etiology of PCOS syndrome has not been copiously interpreted. The disorder of PCOS comprehends numerous allied health conditions and has influenced various metabolic processes. Due to multifaceted pathophysiology engaging several pathways and proteins, single genetic diagnostic tests cannot be supportive to determine in straight way. Clarification of cellular and biochemical pathways and various genetic players underlying PCOS could upsurge our consideration of pathophysiology of this syndrome. It is requisite to know pathophysiological relationship between biomarker and their reflection towards PCOS disease. Biomarkers deliver vibrantly and potent ways to apprehend the spectrum of PCOS with applications in screening, diagnosis, characterization, and monitoring. This paper relies on the endeavor to point out many candidates as potential biomarkers based on omics technologies, thus highlighting correlation between PCOS disease with innovative technologies. Therefore, the objective of existing review is to encapsulate more findings towards cutting-edge advances in prospective use of biomarkers for PCOS disease. Discussed biomarkers may be fruitful in guiding therapies, addressing disease risk, and predicting clinical outcomes in future.

Components of the Complement Cascade Differ in Polycystic Ovary Syndrome

Complement pathway proteins are reported to be increased in polycystic ovary syndrome (PCOS) and may be affected by obesity and insulin resistance. To investigate this, a proteomic analysis of the complement system was undertaken, including inhibitory proteins. In this cohort study, plasma was collected from 234 women (137 with PCOS and 97 controls). SOMALogic proteomic analysis was undertaken for the following complement system proteins: C1q, C1r, C2, C3, C3a, iC3b, C3b, C3d, C3adesArg, C4, C4a, C4b, C5, C5a, C5b-6 complex, C8, properdin, factor B, factor D, factor H, factor I, mannose-binding protein C (MBL), complement decay-accelerating factor (DAF) and complement factor H-related protein 5 (CFHR5). The alternative pathway of the complement system was primarily overexpressed in PCOS, with increased C3 (p < 0.05), properdin and factor B (p < 0.01). In addition, inhibition of this pathway was also seen in PCOS, with an increase in CFHR5, factor H and factor I (p < 0.01). Downstream complement factors iC3b and C3d, associated with an enhanced B cell response, and C5a, associated with an inflammatory cytokine release, were increased (p < 0.01). Hyperandrogenemia correlated positively with properdin and iC3b, whilst insulin resistance (HOMA-IR) correlated with iC3b and factor H (p < 0.05) in PCOS. BMI correlated positively with C3d, factor B, factor D, factor I, CFHR5 and C5a (p < 0.05). This comprehensive evaluation of the complement system in PCOS revealed the upregulation of components of the complement system, which appears to be offset by the concurrent upregulation of its inhibitors, with these changes accounted for in part by BMI, hyperandrogenemia and insulin resistance.

Updated meta-analysis on the diagnostic accuracy of serum anti-Mullerian hormone in poly cystic ovary syndrome involving 13 509 subjects

AIM

To determine the diagnostic accuracy of anti-Mullerian hormone (AMH) in the diagnosis of polycystic ovary syndrome (PCOS).

METHODS

Two independent reviewers searched the electronic databases and search engines using PubMed, Cochrane library, and Google Scholar systematically to retrieve relevant articles published from inception to September 2021. The diagnostic efficacy of AMH was computed using the random-effects model in terms of pooled sensitivity, specificity, and diagnostic odds ratio (DOR) with 95% confidence interval (CI). A meta-regression and subgroup analysis were performed to check for any source which could explain possible heterogeneity. Risk of bias assessment was conducted using the QUADAS-2 tool recommended by Cochrane Library.

RESULTS

This meta-analysis included a total of 41 studies involving 13 509 subjects. We observed promising pooled sensitivity 0.78 (95% CI 0.74 to 0.81), specificity 0.87 (95% CI 0.84 to 0.90), and diagnostic odds ratio (DOR) 24 (95% CI 15 to 37), for AMH in detecting PCOS and discriminatory power (summary receiver operating characteristic [SROC] curves, 0.89 [95% CI 0.86-0.92]). The most prominent bias was noted in the patient selection and index test assessment.

CONCLUSIONS

With the findings of this current meta-analysis, we conclude serum AMH to be a promising biomarker for the diagnosis of PCOS, however, substantial heterogeneity among studies needs individual patient data analysis in order to identify an optimal cut-off value and homogenous findings.

REGISTRATION NUMBER AND GUIDELINES

This meta-analysis was performed according to constructed protocol registered in the PROSPERO database with registration number CRD42021246910.

Association of microRNAs With Embryo Development and Fertilization in Women Undergoing Subfertility Treatments: A Pilot Study

Objective: Small non-coding RNAs, known as microRNAs (miRNAs), have emerging regulatory functions within the ovary that have been related to fertility. This study was undertaken to determine if circulating miRNAs reflect the changes associated with the parameters of embryo development and fertilization.

Methods: In this cross-sectional pilot study. Plasma miRNAs were collected from 48 sequentially presenting women in the follicular phase prior to commencing in vitro fertilization (IVF). Circulating miRNAs were measured using locked nucleic acid (LNA)-based quantitative PCR (qPCR), while an updated miRNA data set was used to determine their level of expression.

Results: Body mass index and weight were associated with the miRNAs let7b-3p and miR-375, respectively (p &lt; 0.05), with the same relationship being found between endometrium thickness at oocyte retrieval and miR-885-5p and miR-34a-5p (p &lt; 0.05). In contrast, miR-1260a was found to be inversely associated with anti-Mullerian hormone (AMH; p = 0.007), while miR-365a-3p, miR122-5p, and miR-34a-5p correlated with embryo fertilization rates (p &lt; 0.05). However, when omitting cases of male infertility (n = 15), miR122-5p remained significant (p &lt; 0.05), while miR-365a-3p and miR-34a-5p no longer differed; interestingly, however, miR1260a and mir93.3p became significant (p = 0.0087/0.02, respectively). Furthermore, age was negatively associated with miR-335-3p, miR-28-5p, miR-155-5p, miR-501-3p, and miR-497-5p (p &lt; 0.05). Live birth rate was negatively associated with miR-335-3p, miR-100-5p, miR-497-5p, let-7d, and miR-574-3p (p &lt; 0.05), but these were not significant when age was accounted for.However, with the exclusion of male factor infertility, all those miRNAs were no longer significant, though miR.150.5p emerged as significant (p = 0.042). A beta-regression model identified miR-1260a, miR-486-5p, and miR-132-3p (p &lt; 0.03, p = 0.0003, p &lt; 0.00001, respectively) as the most predictive for fertilization rate. Notably, changes in detectable miRNAs were not linked to cleavage rate, top quality embryos (G3D3), and blastocyst or antral follicle count. An ingenuity pathway analysis showed that miRNAs associated with age were also associated with the variables found in reproductive system diseases.

Conclusion: Plasma miRNAs prior to the IVF cycle were associated with differing demographic and IVF parameters, including age, and may be predictive biomarkers of fertilization rate.

Metabolic consequences of obesity on the hypercoagulable state of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) women have a hypercoagulable state; however, whether this is intrinsically due to PCOS or, alternatively, a consequence of its metabolic complications is unclear. We determined plasma coagulation pathway protein levels in PCOS (n = 146) and control (n = 97) women recruited to a PCOS biobank. Circulating levels of a panel of 18 clotting pathway proteins were determined by Slow Off-rate Modified Aptamer-scan plasma protein measurement. Cohorts were age matched, though PCOS had elevated body mass index (p < 0.001), insulin (p < 0.001) and C-reactive protein (CRP) (p < 0.0001). Eight pro-coagulation proteins were elevated in PCOS: plasminogen activator inhibitor-1 (p < 0.0001), fibrinogen (p < 0.01), fibrinogen gamma chain (p < 0.0001), fibronectin (p < 0.01), von Willebrand factor (p < 0.05), D-dimer (p < 0.0001), P-selectin (p < 0.05), and plasma kallikrein (p < 0.001). However, two anticoagulant proteins, vitamin K-dependent protein-S (p < 0.0001) and heparin cofactor-II (p < 0.001) were elevated and prothrombin was decreased (p < 0.05). CRP, as a marker of inflammation, and insulin resistance (HOMA-IR) correlated with 11 and 6 of the clotting proteins, respectively (p < 0.05). When matched for BMI < 25 (16 PCOS, 53 controls) HOMA-IR remained elevated (p < 0.05) and heparin cofactor-II was increased (p < 0.05). In a multivariate analysis accounting for inflammation, insulin resistance and BMI, there was no correlation of PCOS with any of the coagulation proteins. The hypercoagulable state in PCOS is not intrinsic to the disease as it can be fully accounted for by BMI, inflammation and insulin resistance.

Vitamin D Association With Macrophage-Derived Cytokines in Polycystic Ovary Syndrome: An Enhanced Risk of COVID-19 Infection?

BACKGROUND

Women with polycystic ovary syndrome (PCOS) often have vitamin D deficiency, a known risk factor for severe COVID-19 disease. Alveolar macrophage-derived cytokines contribute to the inflammation underlying pulmonary disease in COVID-19. We sought to determine if basal macrophage activation, as a risk factor for COVID-19 infection, was present in PCOS and, if so, was further enhanced by vitamin D deficiency.

METHODS

A cross-sectional study in 99 PCOS and 68 control women who presented sequentially. Plasma levels of a macrophage-derived cytokine panel were determined by Slow Off-rate Modified Aptamer (SOMA)-scan plasma protein measurement. Vitamin D was measured by tandem mass spectroscopy.

RESULTS

Vitamin D was lower in PCOS women (p<0.0001) and correlated negatively with body mass index (BMI) in PCOS (r=0.28, p=0.0046). Basal macrophage activation markers CXCL5, CD163 and MMP9 were elevated, whilst protective CD200 was decreased (p<0.05); changes in these variables were related to, and fully accounted for, by BMI. PCOS and control women were then stratified according to vitamin D concentration. Vitamin D deficiency was associated with decreased CD80 and IFN-γ in PCOS and IL-12 in both groups (p<0.05). These factors, important in initiating and maintaining the immune response, were again accounted for by BMI.

CONCLUSION

Basal macrophage activation was higher in PCOS with macrophage changes related with increased infection risk associating with vitamin D; all changes were BMI dependent, suggesting that obese PCOS with vitamin D deficiency may be at greater risk of more severe COVID-19 infection, but that it is obesity-related rather than an independent PCOS factor.

A prospective study of anti-mullerian hormone and other ovarian and adrenal hormones in adult female acne

Polycystic ovarian syndrome (PCOS) diagnosis in adult female acne (AFA) is tough owing to unreliable ultrasonography in virgins or obese females and inconsistent hyperandrogenemia. We analyzed hormones in AFA and established a diagnostic cut-off value of anti-mullerian hormone (AMH) for PCOS. Female acne patients aged ≥25 years were assessed with total testosterone (TT), sex hormone binding globulin (SHBG), free androgen index (FAI), AMH, 17-hydroxyprogesterone (17-OHP), dehydroepiandrosterone sulfate (DHEAS), follicle stimulating hormone (FSH), and luteinizing hormone (LH). Rotterdam's criteria defined PCOS. AMH was measured (Access AMH assay) to calculate the diagnostic cut off value using receiver operating characteristic (ROC) curve. Of 120 cases, 25.83% had PCOS. This group had significant clinical hyperandrogenism, truncal and adolescent acne, polycystic ovarian morphology (PCOM), and raised hormones (AMH, TT, FAI, LH, and LH/FSH). AMH levels were significantly higher in the PCOS group (6.91 ± 3.85 ng/mL) and positively correlated with TT, FAI, 17OHP, LH, and LH/FSH ratio. AMH at >5.1 ng/mL (sensitivity-70.97% and specificity-82.02%) predicted PCOS and correlated with PCOM. AMH (>5.1 ng/mL) is useful for diagnosing PCOS and surrogate for hyperandrogenemia and PCOM. Its correlation with hormones in non PCOS AFA highlights its sensitivity to diagnose endocrinological derangements.

A Systematic Review of the Effects of Exercise on Hormones in Women with Polycystic Ovary Syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common endocrine disorder that is characterized by menstrual irregularity and elevated serum androgens, and is often accompanied by insulin resistance. The etiology of PCOS is unknown. Lifestyle interventions and weight loss, where appropriate, remain first-line treatments for women with PCOS. Regular physical activity is recommended for women with PCOS to maintain a healthy weight and cardiovascular fitness.

PURPOSE

To review the evidence for the impact of various exercise interventions on hormone levels in women with PCOS.

METHODS

A systematic review of original studies indexed in PubMed that utilized an exercise intervention in women with PCOS and reported hormone values pre- and post-intervention. Studies in which the effects of the exercise intervention could be determined were included.

RESULTS

Vigorous aerobic exercise improves insulin measures in women with PCOS. Resistance or strength training may improve androgen levels, though additional studies are warranted. Studies with yoga are limited but suggest improvements in androgens. Limited information is available on the impact of exercise on adipokines and anti-Müllerian hormone, warranting further investigation.

CONCLUSIONS

Recommended guidelines for women with PCOS include vigorous aerobic exercise and resistance training to improve measures of insulin sensitivity and androgen levels.

Increased MicroRNA Levels in Women With Polycystic Ovarian Syndrome but Without Insulin Resistance: A Pilot Prospective Study

BACKGROUND

Small noncoding microRNA (miRNA) have regulatory functions in polycystic ovary syndrome (PCOS) that differ to those in women without PCOS. However, little is known about miRNA expression in women with PCOS who are not insulin resistant (IR).

METHODS

Circulating miRNAs were measured using quantitative polymerase chain reaction (qPCR) in 24 non-obese BMI and age matched women with PCOS and 24 control women. A miRNA data set was used to determine miRNA levels.

RESULTS

Women with PCOS showed a higher free androgen index (FAI) and anti-mullerian hormone (AMH) but IR did not differ. Four miRNAs (miR-1260a, miR-18b-5p, miR-424-5p, and miR let-7b-3p) differed between control and PCOS women that passed the false discovery rate (FDR) out of a total of 177 circulating miRNAs that were detected. MiRNA let-7b-3p correlated with AMH in PCOS (p < 0.05). When the groups were combined, miR-1260a correlated with FAI and let-7b-3p correlated with body mass index (BMI) (p < 0.05). There was no correlation to androgen levels. Ingenuity pathway analysis showed that nine of the top 10 miRNAs reported were associated with inflammatory pathways.

CONCLUSION

When IR did not differ between PCOS and control women, only four miRNA differed significantly suggesting that IR may be a driver for many of the miRNA changes reported. Let-7b-3p was related to AMH in PCOS, and to BMI as a group, whilst miR-1260a correlated with FAI. Androgen levels, however, had no effect upon circulating miRNA profiles. The expressed miRNAs were associated with the inflammatory pathway involving TNF and IL6.

Advantages of Serum Anti-Müllerian Hormone as a Marker for Polycystic Ovarian Syndrome

OBJECTIVE

To evaluate the advantages of using anti-Müllerian hormone (AMH) in the diagnosis of polycystic ovary syndrome (PCOS).

METHODS

We compared data from 56 Han Chinese patients with PCOS and 52 female control Han Chinese individuals in terms of biochemical markers and the antral follicle count (AFC). Then, the correlation between serum AMH levels and various endocrine and metabolic factors was analyzed. We generated receiver operating characteristic (ROC) curves to assess the usefulness of AMH, AFC, the luteinizing hormone/follicle-stimulating hormone (LH/FSH) ratio, and testosterone (T), to discriminate between the PCOS and control groups.

RESULTS

The LH/FSH ratio, homeostatis model assessment of insulin resistance (HOMA-IR), testosterone (T), blood glucose (Glu), triglyceride (TG), body mass index (BMI), AFC and, in particular, serum AMH level were significantly higher in the PCOS group than in the control group (P <.05; P <.001). The serum AMH level had a significant positive effect on the likelihood of AFC changes in patients with PCOS and control-group women. The areas under the ROC curve (AUC) of AMH, AFC, LH/FSH ratio, and T were 0.952, 0.778, 0.760, and 0.665, respectively. The best cutoff point for AMH was 6.09 ng per mL, with sensitivity of 88% and specificity of 88%.

Serum Anti-Müllerian Hormone in the Diagnosis of Polycystic Ovary Syndrome in Association with Clinical Symptoms

Polycystic ovary syndrome (PCOS) is one of the most prevalent endocrine diseases affecting women of reproductive age. The pathogeny of PCOS is still not completely understood, but one contributing factor that has been proposed is anti-Müllerian hormone (AMH). There is currently no clear correlation between levels of AMH and incidence of PCOS in Saudi Arabian patients. The goal of this study was to determine the threshold of AMH and correlate it with PCOS clinical features to facilitate a proper diagnosis for PCOS. In this case-control study, we recruited 79 PCOS women and 69 normal ovulatory women; PCOS patients were diagnosed according to the Rotterdam criterion. On days 2–4 of the menstrual cycle, transvaginal/abdominal ultrasound was performed and serum levels of AMH, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were measured for all participants. The receiver operating characteristic curve (ROC) was used to determine the AMH diagnostic cut-off at 3.19 ng/mL, with 72% sensitivity and 70% specificity; AMH > 3.19 ng/mL was significantly correlated with PCOS. High AMH levels were correlated with age at menarche, polycystic ovarian morphology (PCOM), and oligo/amenorrhea. Serum AMH is a promising diagnostic marker of ovarian dysfunction in PCOS patients especially in cases in which the evaluation of PCOM was complicated.

Development of a novel risk prediction and risk stratification score for polycystic ovary syndrome

OBJECTIVE

The aim of this study was to develop a simple phenotypic algorithm that can capture the underlying clinical and hormonal abnormalities to help in the diagnosis and risk stratification of polycystic ovary syndrome (PCOS).

METHODS

The study consisted of 111 women with PCOS fulfilling the Rotterdam diagnostic criteria and 67 women without PCOS. A Firth's penalized logistic regression model was used for independent variable section. Model optimism, discrimination and calibration were assessed using bootstrapping, area under the curve (AUC) and Hosmer-Lemeshow statistics, respectively. The prognostic index (PI) and risk score for developing PCOS were calculated using independent variables from the regression model.

RESULTS

Firth penalized logistic regression model with backward selection identified four independent predictors of PCOS namely free androgen index [β 0.30 (0.12), P = 0.008], 17-OHP [β = 0.20 (0.01), P = 0.026], anti-mullerian hormone [AMH; β = 0.04 (0.01) P < 0.0001] and waist circumference [β = 0.08 (0.02), P < 0.0001]. The model estimates indicated high internal validity (minimal optimism on 1000-fold bootstrapping), good discrimination ability (bias corrected c-statistic = 0.90) and good calibration (Hosmer-Lemeshow χ²  = 3.7865). PCOS women with a high-risk score (q1 + q2 + q3 vs q4) presented with a worse metabolic profile characterized by a higher 2-hour glucose (P = 0.01), insulin (P = 0.0003), triglycerides (P = 0.0005), C-reactive protein (P < 0.0001) and low HDL-cholesterol (P = 0.02) as compared to those with lower risk score for PCOS.

CONCLUSIONS

We propose a simple four-variable model, which captures the underlying clinical and hormonal abnormalities in PCOS and can be used for diagnosis and metabolic risk stratification in women with PCOS.

Can we use serum Anti-Mullerian hormone to differentiate the diagnosis between polycystic ovary syndrome patients and healthy women with polycystic ovarian morphology and regular menstrual cycles

Objectives:

To compare Anti-Mullerian hormone (AMH) concentrations between polycystic ovary syndrome (PCOS) patients and healthy women who have polycystic ovarian morphology (PCOM) with regular menstrual cycles, and to determine a diagnostic cutoff value for PCOS women during reproductive period.

Methods:

This study was carried out between February 2013 and October 2017 at the Department of Obstetrics and Gynecology, İzmir Katip Çelebi University Atatürk Training and Research Hospital, Izmir, Turkey. Seventy PCOS patients and 70 PCOM women with normal menstrual cycles were included in the study. Blood samples of the subjects were obtained following an 8-hour fast for AMH and biochemical assessments, serum gonadotropin, and androgen measurements.

Results:

The mean serum AMH levels of PCOS patients were found to be higher than PCOM women with normal menstrual cycles (p<0.01). The optimal serum AMH cutoff value for PCOS diagnosis was determined as 3.51 ng/ml (sensitivity 72.8%, specificity 75.7%).

Conclusion:

Serum AMH concentrations are significantly higher in PCOS patients independent from the ovarian morphology and number of follicles per ovary. Positive and negative predictive values of AMH in PCOS diagnosis were found to be 75% and 73.6%, respectively, with a cutoff value of 3.51 ng/mL.

Simplified 4-item criteria for polycystic ovary syndrome: A bridge too far?

OBJECTIVES

Although the Rotterdam 2003 polycystic ovarian syndrome (PCOS) diagnostic criteria is widely used, the need to consider multiple variables makes it unwieldy in clinical practice. We propose a simplified PCOS criteria wherein diagnosis is made if two of the following three items were present: (i) oligomenorrhoea, (ii) anti-mullerian hormone (AMH) above threshold and/or (iii) hyperandrogenism defined as either testosterone above threshold and/or the presence of hirsutism.

DESIGN SETTING AND PARTICIPANTS

This prospective cross-sectional study consists of healthy women (n = 157) recruited at an annual hospital health screen for staff and volunteers from the university community, and a patient cohort (n = 174) comprising women referred for suspected PCOS.

MAIN OUTCOME MEASURES

We used the healthy cohort to establish threshold values for serum testosterone, antral follicle counts (AFC), ovarian volume (OV) and AMH. Women from the patient cohort, classified as PCOS by simplified PCOS criteria, AMH alone and Rotterdam 2003, were compared with respect to prevalence of oligomenorrhoea, hyperandrogenism and metabolic indices.

RESULTS

In healthy women, testosterone ≥1.89 nmol/L, AFC ≥22 follicles and OV ≥8.44 mL, best predicted oligomenorrhoea and were used as threshold values for PCOS criteria. An AMH level ≥37.0 pmol/L best predicted polycystic ovarian morphology. AMH alone as a single biomarker demonstrated poor specificity (58.9%) for PCOS compared to Rotterdam 2003. In contrast, there was a 94% overlap in women selected as PCOS by the simplified PCOS criteria and Rotterdam 2003. The population characteristics of these two groups of PCOS women showed no significant mean differences in androgenic, ovarian, AMH and metabolic (BMI, HOMA-IR) variables.

CONCLUSIONS

Our data recommend the simplified PCOS criteria with population-specific thresholds for diagnosis of PCOS. Its ability to replace ovarian ultrasound biometry with the highly correlated variable AMH, and use of testosterone as a single marker for hyperandrogenaemia alongside the key symptoms of oligomenorrhoea and hirsutism confers significant clinical potential for the diagnosis of PCOS.