28/07/2016 Role of Anti­Mullerian Hormone (AMH) in Polycystic Ovary Syndrome (PCOS)?

 A Mini Review | Open Access | OMICS International
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Mini Review Open Access

Role of An椀爀‐Mullerian Hormone (AMH) in Polycys椀爀c Ovary Syndrome (PCOS)?
A Mini Review
Nida Zahid*

Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan

Corresponding Nida Zahid
Author : MBBS, MSc Epidemiology and Biostatistics
Instructor at Department of Community Health Sciences
Aga Khan University, 48­A,31st street 
Off Khayabane Mujahid DHA­5, Karachi, Pakistan 
Tel: +92213002331924 
E­mail: nida.zahid@aku.edu
Received July 25, 2014; Accepted August 25, 2014; Published September 01, 2014

Citation: Zahid N (2014) Role of Anti­Mullerian Hormone (AMH) in Polycystic Ovary Syndrome (PCOS)? A Mini Review. Reprod Syst Sex Disord 3:143. doi:
10.4172/2161­038X.1000143

Copyright:  ©2013  Zahid  N.  This  is  an  open­access  article  distributed  under  the  terms  of  the  Creative  Commons  Attribution  License,  which  permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abbreviations
PCOS:  Polycystic  Ovary  Syndrome;  LH:  Luteinizing  Hormone;  FSH:  Follicular  Stimulating  Hormone;  U/S:  Ultrasound;  ESHRE/ASRM:  European  Society
for  Human  Reproduction/American  Society  of  Reproductive  Medicine  (http://www.omicsonline.org/searchresult.php?keyword=reproductive­medicine);
FNPO: Follicle Number Per Ovary; AMH: Anti­Mullerian Hormone

Mini­review
Polycystic Ovary Syndrome (PCOS) is the one most common cause of infertility (http://www.omicsonline.org/searchresult.php?keyword=infertility)  due  to
an  ovulation  and  it  is  often  diagnosed  for  the  first  time  in  the  fertility  clinics.  The  traits  of  the  syndrome  that  female  with  an  ovulatory  or  oligo­ovulatory
PCOS exhibit include; hyperandrogenism, whether clinical and/or biochemical, and ultrasonic polycystic ovaries [1].
PCO  affects  about  10%  of  females.  Increase  in  the  burden  of  PCOS  has  led  to  a  considerable  amount  of  research  into  its  risk  factors,  pathophysiology
and the management [2]. There have been numerous theories that have been put forward for describing the etiology for an ovulation in PCO including; an
excess of small antral follicles, hyperandrogenaemia, hyperinsulinaemia and dysfunctional feedback mechanisms [3].

Although  PCOS  is  the  most  frequent  endocrine  disorder  in  women  of  reproductive  age  but  its  diagnosis  remains  one  of  the  most  challenging  issues  in
endocrinology  (http://www.omicsonline.org/searchresult.php?keyword=endocrinology),  gynecology  (http://www.omicsonline.org/searchresult.php?
keyword=gynecology), and reproductive medicine. It has been observed that for many years, different combinations of clinical (irregular menstrual cycles,
http://www.omicsonline.org/open­access/role­of­antimullerian­hormone­amh­in­polycystic­ovary­syndrome­pcos­a­mini­review­2161­038X­3­143.php?ai… 1/8
28/07/2016 Role of Anti­Mullerian Hormone (AMH) in Polycystic Ovary Syndrome (PCOS)? A Mini Review | Open Access | OMICS International
keyword=gynecology), and reproductive medicine. It has been observed that for many years, different combinations of clinical (irregular menstrual cycles,
hirsutism,  and  acne),  biological  (elevated  serum  testosterone  (http://www.omicsonline.org/searchresult.php?keyword=testosterone)  or  androstenedione
levels  or  increased  LH/FSH  ratio),  and  Ultrasound  (U/S)  criteria  have  been  proposed,  with  very  little  international  consensus.  In  2003  the  Rotterdam
European  Society  for  Human  Reproduction/American  Society  of  Reproductive  Medicine  (ESHRE/ASRM)­sponsored  PCOS  consensus  workshop  group
proposed  that  the  diagnosis  of  PCOS  should  include  two  of  the  following  three  criteria:  1)  oligo­  and/or  an  ovulation
(http://www.omicsonline.org/searchresult.php?keyword=ovulation), 2) clinical and/or biochemical hyperandrogenism and 3) polycystic ovaries on ultrasound
[4]. It was proposed to include the Ultrasound (U/S) criteria in the definition of PCOS that is considered at the present time as the most specific, namely
an increased ovarian volume (10 ml) and/or the presence of 12 or more follicles in each ovary measuring 2–9 mm [5]. But indeed, using a threshold of 12
for the Follicle Number Per Ovary (FNPO) showed that only 75% of PCOS patients were diagnosed whereas 99% of the normal women were under this cut
off  value  [5].  Therefore  this  suggest  that  counting  of  the  FNPO  may  not  be  easy  to  obtain  with  sufficient  reliability  by  every  group,  moreover  it  is  still
debated whether a FNPO greater than 12 is specific of Polycystic Ovaries (PCO) [6].

Hence based on the recent research there are some new concepts which may help to coordinate past theories. Anti­Mullerian Hormone (AMH) is a member
of  the  transforming  growth  factor  ß  family  of  growth  and  differentiation  factors  [7].  It  has  an  integral  role  in  the  intrauterine  development  and  sex
differentiation of the male fetus. It is secreted from the Sertoli cells of the developing testes inhibiting ipsilateral mullerian duct development and thereby
allowing  the  Wolffian  duct  system  to  prevail  [8].  However,  the  role  of  AMH  across  the  female  (http://www.omicsonline.org/searchresult.php?
keyword=female)reproductive life­span has only more recently come to light [2]. In the ovary, AMH has an inhibitory effect on primordial follicle recruitment
as  well  as  on  the  responsiveness  of  growing  follicles  to  Follicle­Stimulating  Hormone  (FSH).  The  ovary­specific  expression  pattern  in  granulosa  cells  of
growing non selected follicles makes AMH an ideal marker for the size of the ovarian follicle pool and also a prognostic factor for fertility potential [7].
Women  with  PCOS  have  an  increased  number  of  small  follicles  in  the  pre­antral  and  antral  stage,  and  therefore  it  is  observed  that  their  AMH  serum
concentrations  are  higher  than  their  counterpart  [2].  Since,  Fallat  et  al.  first  reported  this  in  1997,  there  have  been  several  clinical  studies  that  have
confirmed the increased levels of serum AMH levels i.e. two to three times higher in PCOS compared with the levels in women with normal ovaries [9­11].
Another  study  reported  significantly  elevated  levels  of  AMH  in  normogonadotrophic,  normoestrogenic,  an­ovulatory  patients  compared  with  controls  [12].
Moreover,  female  sufferings  with  PCO  have  higher  levels  of  AMH  whether  obese  or  lean  as  compared  to  a  female  with  no  PCOS  [13].  This  has  been
reported  in  a  study  that  recruited  sample  from  a  community  that  included  both  lean  and  overweight  women.  Elevated  circulating  AMH  levels  were  found
among  PCOS  females  versus  non­PCOS  women,  regardless  of  Insulin  (http://www.omicsonline.org/searchresult.php?keyword=insulin)  resistance  and
adiposity status [13].  Similarly  another  study  suggested  that  non  obese  adolescents  with  Polycystic  Ovary  Syndrome  (PCOS)  had  higher  levels  of  Anti­
Mullerian Hormone (AMH) i.e. 1.49 times as compared to the controls [14].
Furthermore, AMH levels are positively correlated with individual features of PCOS, including LH concentrations, testosterone, mean ovarian volume and
the number of ovarian follicles as reported by Laven et al. [10]. A recent study supports the finding that the level of AMH can help to demarcate between
women  with  PCOS  compared  with  women  with  polycystic  ovarian  morphology  alone  compared  with  controls  [15].  Thus,  not  only  is  AMH  elevated  in
women with PCOS but it also correlates with the severity of PCOS. It was reported in a recent study that the strongest group difference for AMH levels
was found in the group with severe PCOS patients versus controls with age­adjusted odds ratio of 2.56 (95% Confidence Interval (CI) 2.00­3.27; p<0.0001)
[16]. Therefore, it is not just the mere increase in the number of these follicles that produce raised AMH levels but it is also the individual’s follicles from a
polycystic ovary that produces more AMH than their size­matched counterparts from a normal ovary. Findings from study by Pelatt et al. suggests that the
AMH  production  from  the  granulosa  (http://www.omicsonline.org/searchresult.php?keyword=granulosa)cells  of  a  patient  with  ovulatory  PCOS  was  three
times higher compared with granulosa cells from normal ovaries and surprisingly , the AMH production from sized matched granulosa cells of a patient with
an ovulatory PCOS was up to 75 times higher [17].
Hence as a diagnostic marker, AMH measurement has been found to offer a relatively high specificity and sensitivity (92 and 67%, respectively) for PCOS
[11].  Thus  in  situations  where  accurate  ultrasound  data  are  not  available  or  where  there  is  lack  of  adequate  quality  of  equipment  used  for  sinology  [18]
AMH could be used instead of the follicle count as a diagnostic criterion for PCOS [11]. There was a study that suggested no association between AMH
and  PCOS  but  they  believed  that  the  study  results  may  have  been  influenced  by  use  of  transabdominal  U/S  instead  of  trans­vaginal  approach  which
usually tends to under estimate the prevalence of polycystic ovaries [19].  Hence  in  cases  where  vaginal  scans  are  not  feasible  AMH  may  be  used  as  a
surrogate parameter in PCOS diagnosis [16].

In addition the use of AMH may also be useful in the therapeutic approach of PCOS patients. Indeed overweight women with PCOS who respond to weight
loss  (http://www.omicsonline.org/searchresult.php?keyword=weight­loss)  with  menstrual  improvements  have  significantly  reduced  pre  weight­loss  AMH
levels, indicating that baseline AMH may provide a potential clinical predictor of menstrual improvements with weight loss in PCOS [20]. Similarly, basal
AMH  level  evaluation  may  be  useful  in  the  prediction  of  ovarian  response  to  clomiphene  citrate  [21].  Finally  it  has  been  shown  that  metformin
administration in women affected by PCOS is associated with a reduction in both AMH serum levels and antral follicles, suggesting that the measurement
of AMH could be used to evaluate the treatment efficacy with insulin sensitizers [22].
Therefore  through  review  we  can  propose  the  potential  application  of  AMH  as  a  diagnostic  marker  for  PCOS.  Moreover  it  will  also  be  significant  to
clinicians for making their therapeutic decision.

Conflict of Interest
There is no conflict of interest.

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http://www.omicsonline.org/open­access/role­of­antimullerian­hormone­amh­in­polycystic­ovary­syndrome­pcos­a­mini­review­2161­038X­3­143.php?ai… 2/8
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 2nd Pregnancy (http://pregnancy.omicsgroup.com/) and Child Health (http://pregnancy.omicsgroup.com/) 
Aug 29­31, 2016 ,Sao Paulo, Brazil

 Reproductive (http://reproductivehealth.conferenceseries.com/) Health (http://reproductivehealth.conferenceseries.com/) Summit
(http://reproductivehealth.conferenceseries.com/)
Aug 29­ 31, 2016 Atlanta, USA

 2nd World Congress on Polycystic Ovarian Syndrome (http://pcosaa.conferenceseries.com/) 
Oct 5­7, 2016, Orlando, USA

 3rd Gynecology (http://gynecology.conferenceseries.com/) and Obstetrics (http://gynecology.conferenceseries.com/) 
Oct 17­19, 2016, Dubai, UAE

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