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Anti-Müllerian hormone identified PCOS in small study

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Cutoff is probably too low

"I think AMH will diagnose women with an increased number of follicles, irrespective of their androgens. If in addition they have elevated androgen levels, they will be most probably have PCOS," said Dr. Rodolfo Rey.

But the value proposed in this study "is quite low. Many apparently normal girls have values over 3.4 ng/mL. The range of AMH is quite large" in teenagers and young women – perhaps up to 6-7 ng/mL. "This study needs more controls [to capture] the whole range of normal," he said.

Several investigators have proposed replacing ultrasound with AMH to diagnose PCOS in adult women, but "the problem is always the cutoff level. I haven’t seen studies that give cutoff values that could replace ultrasound. We don’t have enough data," he said.

Also, not all PCOS patients have polycystic ovaries. "AMH is reflecting the number of follicles rather than the levels of androgens." By relying on it too heavily, it’s possible to miss hyperandrogenism without polycystic ovaries.

Dr. Rey is a pediatric endocrinologist at Children’s Hospital in Buenos Aires, Argentina. He has received honoraria from Beckman Coulter for his work on AMH assays.


AT ENDO 2013

SAN FRANCISCO – An anti-Müllerian hormone level of 3.4 ng/mL or greater identified polycystic ovary syndrome in a study of 31 nonobese adolescents.

That cutoff was determined to best discriminate between PCOS and controls, with a positive predictive value of 75% and a negative predictive value of 61% in a study of 15 nonobese adolescents with PCOS aged 13-21 years, and 16 controls, reported Dr. Aviva Sopher at the Endocrine Society’s Annual Meeting.

The goal of the study wasn’t to define a definitive anti-Müllerian hormone (AMH) cutoff; that may come later as Dr. Sopher’s group and others continue to investigate the matter. Instead, the project was a preliminary proof-of-concept effort to gauge the utility of AMH in adolescent PCOS diagnosis.

Dr. Aviva Sopher

For now, because there was "overlap in AMH values between PCOS and controls" and "a normal adolescent girl with polyfollicular ovaries and no other symptoms can have an AMH in the range that we think of [as signifying] PCOS, I wouldn’t use AMH on its own. I am suggesting the use of AMH in conjunction with clinical presentation and lab work," said Dr. Sopher, a pediatric endocrinologist at Columbia University in New York.

The hope, however, is that AMH will eventually replace the need for ultrasound; the transabdominal approach is "suboptimal" in adolescents, and transvaginal ultrasound is "overly invasive in this age group," she said.

The hormone is produced by growing follicles and is a marker of their number. Blood levels were assessed in the study by enzyme-linked immunosorbent assay (ELISA). PCOS was diagnosed by National Institutes of Health criteria (Fertil. Steril. 2010; 93:1938-41).

AMH was significantly higher in subjects with PCOS (4.4 ng/mL) than in controls (2.4 ng/mL), and correlated significantly with average ovarian size, the appearance of polycystic ovaries, free testosterone, and androstenedione.

The PCOS participants were 1.5-fold more likely to have an AMH level of more that 3.4 ng/mL than were the healthy controls, and that cutoff had a positive predictive value for PCOS of 75% and a negative predictive value of non-PCOS of 61%.

Mean ovarian size was similar in both groups (7.1 cc in subjects with PCOS versus 6.7 cc in controls), as were body mass index z-scores (0.45 vs. 0.19) and percent body fat (36.6% vs. 34.2%). The differences were not significant.

The subjects were at least 2 years post menarche. Exclusion criteria included premature birth; other potential causes of hirsutism and irregular menses; and birth control pill use within 3 months of enrollment. Normal-weight girls were selected "to exclude the confounding factor of obesity," Dr. Sopher said.

AMH is a useful adjunct to diagnose adolescent PCOS, and it has the potential to replace ultrasound as a marker of follicle count, she concluded.

The authors said they had nothing to disclose. The study was funded by the National Institutes of Health.

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