S. AMH in PCOS

Research Insights beyond a Diagnostic Marker

Dr. Anushree D. Patil, MD. DGO

Scientist - D

National Institute for Research in Reproductive Health

(Indian Council of Medical Research) (Dr. Anushree Patil, Dr. Shahina Begum, Dr. Beena Joshi)

Multidisciplinary PCOS Clinic at NIRRH

Gynaecologist Consultation Community Activities

Counseling on Nutrition and PCOS Yoga Session

Anti Mullerian Hormone

Anti-Müllerian hormone (AMH) is a

homodimeric glycoprotein linked by disulfide

bonds and a molecular weight of 140kDa.

The hormone belongs to the Transforming

Growth Factor-β (TGF-β) superfamily

The gene encoding AMH is located in the short

arm of chromosome 19

AMH plays an important role in male sex

differentiation as its production by the

embryonic testes induces the regression of

Mullerian ducts

AMH action is exerted through two receptors:

type I receptor (AMHRI) and type II receptor

(AMHRII) which are present on the AMH

target-organs (gonads and Mullerιan ducts)

Specific Actions of AMH in Human Ovary

AMH is produced by the granulosa cells of small growing follicles

In female neonates, AMH is virtually undetectable but increases gradually until pubertyand remains relatively stable thereafter and throughout the reproductive period

Inhibits initial follicle recruitment

Inhibits FSH-dependent growth and selection of pre antral and small antral follicles.

AMH remains highly expressed in cumulus cells of mature follicles.

AMH has inhibitory effect on FSH-induced CYP19a1 expression leading to reducedestradiol (E2) levels

Dewailly, D., et al., Hum Reprod Update, 2014

Two Cell Two Gonadotropin Theory

AMH: Clinical Utility

Interpretation AMH Range (ng/ml)

High Above 4.0

Normal 1.5 -4.0

Low Normal 1.0-1.5

Low 0.5-1.0

Diagnostic Marker

Ovarian Reserve

Follicular Fluid Levels

Correlate

with Pregnancy rate

Upcoming Diagnostic

Marker

For PCOS

Prognostic Marker

For predicting ovarian

response in COH

Tumor Marker

For Granulosa Cell

Tumors

Predictive Marker

For OHSS

AMH in PCOS AMH production in PCOS granulosa cells is increased by 75%*

AMH excess has an essential role in the process of follicular arrest

AMH may be used as a marker of ovarian follicle impairment inPCOS

Serum and follicular AMH levels are higher in PCOS**

Serum AMH values could be useful particularly in cases in which thetransvaginal ultrasound examination is not feasible***

Though values are higher in adolescents, not a predictor of PCOS

Age related decline has slower reduction rate of s. AMH

Levels lower in obese women with PCOS

*Pellat et al.; 2007. J Clin Endocrinol Metab 2007

**Fallat ME et al.; Fertil Steril 1997

***Pigny P et al.; J Clin Endocrinol Metab 2006

AMH in PCOS

AMH independently and positively correlated with LH,

testosterone, androstendione and free androgen index (FAI)

values and the number of small follicles*

Differences in AMH concentrations between four phenotypic

groups of PCOS reflected the severity of the syndrome

A correlation between AMH levels and HOMA-IR values has

not been confirmed in studies

Significant positive correlation between AMH levels and AGEs

in normal weight women with PCOS**

* Laven JS et al.; J Clin Endocrinol Metab 2004

**Diamanti-Kandarakis E et al.; Eur J Endocrinol 2009

Objective

To study the correlation of AMH among PCOS women with

Hormonal profile

Biochemical parameters

Anthropometric measurements

Body mass composition

Materials and Methods

Study design: Clinic based observational cross sectional study

Study sites: NIRRH Multidisciplinary PCOS Clinic

Study Population: Women diagnosed with PCOS using Rotterdam criteria

Selection Criteria

Inclusion criteria (2 out of 3)

Anovulation

Hyperandrogenism, clinical or biochemical

USG evidence of PCO

Exclusion criteria

Not willing for blood collection

On oral contraceptive pills

Study Duration: One Year

Investigations

• Hormonal

Hormonal Biochemical Ultrasound

FSH FBS USG pelvis for PCOS and endometrial

thickness

LH PGBS (post 75g) USG abdomen for Non Alcoholic Fatty

Liver (NAFL) and cholelithiasis

TSH, Free T4 Lipid profile

PRL LFT (only in NAFLD)

S. Testosterone Calcium

SHBG Hb CBC (routine)

17-OHP CRP

Insulin fasting

Insulin post

glucose

25(OH)D

AMH

Free Androgen Index & HOMAIR were calculated

64

9.926 4 4 6 6 6.53

0

10

20

30

40

50

60

70

6.3

27

11.6

55.2

0

10

20

30

40

50

60

< 19 19.1-23 23.1-24.9 Obese 25 and above

Per

cen

t

More than 0.8, 70%

less than 0.8,30%

More than 0.8 less than 0.8

Body Mass Index (n=100 PCOS Women) Waist Hip Ratio (n=100 PCOS women)

PCOS at NIRRH Infertility Clinic (n=383)

PCOS: NIRRH Data

Mean Age Hormonal and Biochemical parameters

(n=55)

Mean (±SD)

Age 26.33 years 5.088

LH 10.28 mIU /ml 6.28

FSH 06.63 mIU /ml 1.34

S. Testosterone 50.77 ng/dl 20.33

SHBG 33.63 nmol/ 18.02

FAI 06.59 04.45

HOMAIR 04.13 02.25

25(OH)D 12.77 ng/ml 07.96

AMH 07.96 ng/ml 04.70

Correlation between AMH and Age

Age Group n Mean AMH (±SD)

15-20 8 9.1 (5.4)

20-30 37 8.4 (4.8)

30-40 17 6.5 (4.8)

No significant difference was found

in mean AMH levels among age

groups

ANOVA, p= 0.35

0

2

4

6

8

10

12

14

16

18

20

10 15 20 25 30 35 40A

MH

val

ue

Age

Inverse relationship

between age and AMH

Correlation (r)= -0.14, p=0.27

Cut off Values of AMH for Diagnosis of PCOS

Author Year Cut off

level

pmol/ml

Sensitivity

(%)

Specificity

(%)

Iliodromiti 2016 33.6 82 79

Saikumar 2013 23.8 98 93

Casadei 2013 33 95 95

Dewailley 2011 35.7 92 97

Correlation of AMH

with Anthropometry and Body Mass Composition

Parameter Mean SD r p

Waist

Circumference

88.69 12.51 -0.21 0.11

Hip

Circumference

101.71 11.44 -0.12 0.36

Waist: Hip ratio 0.86 0.12 -0.15 0.28

Total fat% 34.7 4.70 -0.21 0.15

Visceral fat % 8.87 6.64 -0.14 0.92

Skeletal Muscle % 23.7 1.9 0.18 0.2

BMR 1288 177.41 -0.20 0.16

Correlation between AMH and BMI

BMI Category n Mean AMH (SD)

<18 Underweight 1 6

18-23 Normal 13 9.9 (5.2)

23-25 Overweight 7 10.2 (5.3)

>25 Obese 34 7.2 (3.9)0

2

4

6

8

10

12

14

16

18

20

10 15 20 25 30 35 40 45

AM

H v

alu

e

BMI

r= -0.23, p=0.09

Difference was not statistically significant with BMI

Correlation of AMH

with Hormonal Biochemical Parameters

Variable r p value

LH 268 0.03*

FSH -0.14 0.24

s. Testosterone 0.28 0.02*

SHBG 0.8 0.52

FAI 0.147 0.293

HOMAIR -0.33 0.016*

25(OH)D 0.265 0.03*

Pearson Correlation applied

S. AMH and HOMAIR

Category

of Insulin

Resistance

HOMAIR n % Mean

AMH

ng/ml

SD

Normal

IR

<3 17 30.9 8.6 3.45

Moderate

IR

3-5 25 45.5 9.66 5.37

Severe IR >5 13 23.6 5.11 2.09

Limitations

Small sample size

Comparison with healthy controls required

Results

Inverse correlation with age

Positive correlation with LH and s. Testosterone

Negative correlation with HOMAIR

Conclusion

Beyond a diagnostic marker, AMH may have a

significant role in the hyperandrogenemia of PCOS

Clinical Implication: Monitoring Treatment Response

Contraceptives containing 35mg of ethynylestradiol and 2mg ofcyproterone acetate cause a significant suppression of gonadotropins andtestosterone levels, a reduction in the number of ovarian small follicles aswell as a significant reduction in AMH levels

Treatment of obese PCOS women with metformin resulted in thereduction of androgens and AMH levels, without any significant decreasein follicle number

On the other hand, gonadotropin-releasing hormone (GnRH) agonists donot seem to affect AMH concentrations

Panidis D et al, 2010 Gynecol Endocrinol 2010. Fleming R, Fertil Steril 2005

Piltonen Hum Reprod 2005

Novel Role of AMH in GnRH neuron excitability

AMH-dependent regulation of GnRH release could be involved in the pathophysiology of

fertility and could hold therapeutic potential for treating PCOS.

Irene Cimino, Nature Communications, Jan 2016

Future Directions

Standard cut off level for AMH level for

diagnosing PCOS needs to be established

Threshold for PCOS diagnosis may need to be

modified through the life span

Studies with large sample size for use of AMH

levels to diagnose PCOS in adolescents

Thank You!

• Finally, the• 2013 Endocrine Society guidelines• do not include a recommendation• for using AMH measurement as a• routine diagnostic tool for PCOS.3• Although AMH level and oligoanovulation• are correlated, • AMH• has not been proven to be an acceptable• indicator of ovulatory• dysfunction or hyper andro -• genism.23 Hence, • AMH level, if• used, should be combined with• other laboratory or clinical measures• of hyperandrogenism and/or• ovulatory dysfunction to maximize• its diagnostic sensitivity and specificity.• Furthermore, the role of• AMH is unclear in diagnosing subtypes• of PCOS,