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Past Article of the Month Originally Published 11/03/2008
PCOS: Serum AMH Levels as Diagnostic and Treatment Markers

By Steven R. Lindheim, M.D., M.M.M
<i>Polycystic Ovarian Syndrome (PCOS) is not just a medical problem. The psychological ramifications in dealing with it can be enormous. One of the most frustrating aspects of PCOS is that it is so difficult to diagnose. This article, by Dr. Steven Lindheim, discusses new methods for its diagnosis and new hope for women suffering from PCOS.</i> Polycystic ovary syndrome (PCOS) is a disorder characterized by excessive androgens (male producing hormones) and anovulation (not releasing an egg) . It the most common endocrine disorder in reproductive age women with at least 1 in 15 women having PCOS. Health related complications associated with PCOS include obesity, insulin resistance, dyslipidemia, pancreatic beta-cell dysfunction, type 2 diabetes, cardiovascular disease (labile hypertension), endometrial cancer, sleep apnea, inflammation, and infertility. Frustrating to the medical community and patients alike, the exact cause of PCOS remains largely unknown and its diagnosis essentially is one of exclusion from disorders that mimic PCOS including congenital adrenal hyperplasia, hyperprolactinemia, and thyroid disease. Because there is no universal test that is diagnostic for PCOS, the diagnosis requires two of the following three criteria: 1) intermittent or absent menstrual cycles; 2) clinical (abnormal hair growth or excessive acne) and/or biochemical (serum testosterone or elevated LH to FSH ratios) signs of hyperandrogenism; or 3) polycystic ovaries seen on ultrasound. PCOS is an enigma in that it presents as a disorder with mild to extreme amounts of hyperandrogensim and menstrual problems which can be quite variable. Up to 40% of women will not expressing the classic signs of hyperandrogenism, which makes the diagnosis exceedingly challenging. Women who are lean in physical appearance with PCOS may represent an unexpressed form of PCOS or may be a prelude to individuals who will later present with the classic signs of obesity/overweight PCOS. What further confuses the picture is the fact that the appearance of polycystic appearing ovaries (multiple tiny cysts) on ultrasound are seen in up to 20% of women without evidence of androgen excess. The significance as an isolated finding of polycystic appearing ovaries in an otherwise normal female is unclear. AMH as a Marker of Ovarian Reserve in Ageing Women In recent years there has been an increasing interest in the role of anti-Mllerian hormone or Mllerian-inhibiting substance (AMH) which comes from the ovary and appears and to reduce preantral and antral (baby) follicle responsiveness to FSH. Many physicians are using this as a marker of ovarian reserve and egg function. Currently what is known about serum AMH levels is there is a reduction with increasing age and a decline as there is a reduction in the ovarian follicle pool (what is left in the tank) and thus may correlate with ones quality of remaining eggs. In the past decades, blood FSH and estradiol seem to be the most reliable markers of ovarian reserve and successful outcomes in those undergoing IUI and IVF cycles. Even better for the patient, serum AMH levels can be drawn at any time of the menstrual cycle in contrast to the required day 3 sampling for FSH. AMH production has also been reported to be increased in women with PCOS compared to controls and this may be the result of abnormalities in follicles of women with PCOS. Increased ovarian AMH levels may turn out to be the best marker for PCOS and remove this disease as one of exclusion. Therapy for PCOS including metformin administration to improve insulin resistance in women affected by PCOS is associated with a reduction in serum AMH levels, suggesting that the measurement of AMH could be used to evaluate treatment efficacy. In addition, AMH may also find application in preventing, diagnosing, and monitoring for ovarian hyperstimulation syndrome (OHSS) which occurs much more frequently in women with PCOS who use ovulation induction medications for infertility. There seems to be little doubt that research on AMH will continue in the years to come. A clearer understanding of its role in ovarian function may help physicians to find a role for AMH measurement in the field of reproductive medicine and may simplify the diagnosis and efficacy of treatment in women with Polycystic Ovarian Syndrome. <i>Steven R. Lindheim, M.D., M.M.M.,is the Scientific Director at Fertility Specialists Medical Group, San Diego Center For Reproductive Surgery, in San Diego, CA. He can be reached at [email protected]. </i> * Back
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