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 puberty and 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 reduced estradiol (E2) levels Dewailly, D., et al., Hum Reprod Update, 2014
Two Cell Two Gonadotropin Theory
AMH: Clinical Utility Diagnostic Marker Ovarian Reserve Predictive Marker For OHSS Tumor Marker For Granulosa Cell Tumors 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 Prognostic Marker For predicting ovarian response in COH Upcoming Diagnostic Marker For PCOS Follicular Fluid Levels Correlate with Pregnancy rate
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 in PCOS Serum and follicular AMH levels are higher in PCOS ** Serum AMH values could be useful particularly in cases in which the transvaginal 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 Biochemical Ultrasound FSH FBS USG pelvis for PCOS and endometrial thickness LH PGBS (post 75g) USG abdomen for Non Alcoholic Fatty Hormonal Liver (NAFL) and cholelithiasis TSH, Free T4 PRL Lipid profile S. Testosterone Calcium SHBG LFT (only in NAFLD) Hb CBC (routine) 17-OHP Insulin fasting Insulin post glucose 25(OH)D AMH CRP Free Androgen Index & HOMAIR were calculated
Percent PCOS: NIRRH Data 70 60 50 40 30 20 10 0 64 PCOS at NIRRH Infertility Clinic (n=383) 9.92 6 4 4 6 6 6.53 Body Mass Index (n=100 PCOS Women) Waist Hip Ratio (n=100 PCOS women) 60 55.2 More than 0.8 less than 0.8 50 40 less than 0.8, 30% 30 27 20 10 0 6.3 11.6 < 19 19.1-23 23.1-24.9 Obese 25 and above More than 0.8, 70%
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
AMH value 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 20 18 16 14 12 10 8 6 4 2 0 10 15 20 25 30 35 40 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 Hip Circumference 88.69 12.51-0.21 0.11 101.71 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
AMH value 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) 20 18 16 14 12 10 8 6 4 2 0 10 15 20 25 30 35 40 45 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 Normal IR Moderate IR HOMAIR n % Mean AMH ng/ml SD <3 17 30.9 8.6 3.45 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 of cyproterone acetate cause a significant suppression of gonadotropins and testosterone levels, a reduction in the number of ovarian small follicles as well as a significant reduction in AMH levels Treatment of obese PCOS women with metformin resulted in the reduction of androgens and AMH levels, without any significant decrease in follicle number On the other hand, gonadotropin-releasing hormone (GnRH) agonists do not seem to affect AMH concentrations Panidis D et al, 2010 Gynecol Endocrinol 2010. Fleming R, Fertil Steril 2005 Piltonen HumReprod 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
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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,