help button home button Endocrine Society JCEM
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Journal of Clinical Endocrinology & Metabolism , doi:10.1210/jc.2007-1188
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Submit a related Letter to the Editor
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Copyright Permission
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Moran, L. J.
Right arrow Articles by Norman, R. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Moran, L. J.
Right arrow Articles by Norman, R. J.
Related Collections
Right arrow Female Endocrinology
Right arrow Obesity
The Journal of Clinical Endocrinology & Metabolism Vol. 92, No. 10 3796-3802
Copyright © 2007 by The Endocrine Society

The Use of Anti-Müllerian Hormone in Predicting Menstrual Response after Weight Loss in Overweight Women with Polycystic Ovary Syndrome

Lisa J. Moran, Manny Noakes, Peter M. Clifton and Robert J. Norman

Research Centre for Reproductive Health (L.J.M., R.J.N.), Discipline of Obstetrics and Gynaecology, University of Adelaide, Adelaide SA 5005, Australia; and Commonwealth Scientific and Industrial Research Organisation Human Nutrition (L.J.M., M.N., P.M.C.), Adelaide 5000, Australia

Address all correspondence and requests for reprints to: Robert Norman, Discipline of Obstetrics and Gynaecology, University of Adelaide, 6th Floor, Medical School North, Adelaide SA 5005, Australia. E-mail: Robert.norman{at}adelaide.edu.au.


   Abstract
Top
 Abstract
Introduction
 Subjects and Methods
 Results
 Discussion
 References
 
Background: Polycystic ovary syndrome (PCOS) is associated with reproductive and metabolic abnormalities, specifically menstrual dysfunction and anovulation in conjunction with elevated pre-antral follicle number and arrested follicular maturation. Although anti-müllerian hormone (AMH), an inhibitor of follicle recruitment and maturation, is increased in women with PCOS, the usefulness of circulating AMH levels as a clinical predictor of menstrual response to weight loss in PCOS is not known.

Methods: Overweight women with PCOS (n = 26, age 32.9 ± 5.8 yr, weight 98.9 ± 20.8 kg, body mass index 36.1 ± 7.0 kg/m2, mean ± SD) followed an 8-wk weight loss and 6-month weight maintenance program.

Results: Net reductions in weight (4.6 ± 4.8 kg), waist circumference (6.0 ± 5.3 cm), testosterone (0.3 ± 0.6 nmol/liter), fasting insulin (3.7 ± 7.6 mU/liter), and the homeostasis model assessment of insulin sensitivity (0.7 ± 1.3) occurred for all subjects over the entire study duration. Of 26 subjects, 15 (57.7%) responded to the intervention with improvements in menstrual cyclicity (responders). Compared to nonresponders, responders had lower AMH levels at baseline (23.6 ± 12.0 vs. 37.9 ± 17.8 pmol/liter; P = 0.021). Only responders had reductions in fasting insulin (6.1 ± 5.9 mU/liter; P = 0.001) and homeostasis model assessment (1.3 ± 5.9; P = 0.002) with acute weight loss (wk 0–8). Baseline AMH was most strongly predicted by baseline ghrelin, free testosterone, and insulin (r2 = 0.528; P = 0.002).

Conclusions: Overweight women with PCOS who respond to weight loss with menstrual improvements have significantly reduced preweight loss AMH and demonstrate improvements in surrogate measures of insulin resistance with weight loss. Pretreatment AMH is a potential clinical predictor of menstrual improvements with weight loss in PCOS.


   Introduction
Top
 Abstract
 Introduction
Subjects and Methods
 Results
 Discussion
 References
 
POLYCYSTIC OVARY SYNDROME (PCOS) is a common endocrine condition in women of reproductive age with prevalence estimated at 5–10%. Its clinical manifestation includes insulin resistance, hyperandrogenism, an increased prevalence of obesity and abdominal obesity, the metabolic syndrome, impaired glucose tolerance, and type 2 diabetes mellitus (1, 2, 3). Weight loss is a key initial treatment strategy in obese women with PCOS, and improves insulin sensitivity, hyperandrogenism, metabolic risk factors, menstrual function and ovulation (4, 5, 6), fertility and reproductive outcomes (6), and reduces ovarian volume and follicle number (4).

In PCOS, anovulation and menstrual irregularity are characterized by excessive early follicular growth with significantly greater amounts of primary and pre-antral follicles (7), likely caused by elevated intraovarian androgens augmenting thecal and granulosa cell growth (8). Furthermore, antral follicle development is arrested at the 4- to 7-mm stage, and dominant follicle selection is disturbed. This is proposed to be due to factors including reduced sensitivity to FSH caused by excessive production of local inhibitors of its action such as anti-müllerian hormone (AMH), inhibin or estradiol (9, 10), or increased LH action due to early LH receptor gain or excessive LH production (11). AMH is a member of the TGF-ß family and is produced in the granulosa cells of early developing follicles (12). AMH strongly correlates with the number of antral follicles (13), and is proposed to play a role in follicle development and function, specifically the inhibition of initial recruitment of primordial follicles (14) and the inhibition of pre-antral and small antral follicle growth and selection (15). Furthermore, a number of studies have demonstrated that AMH is a more useful marker of ovarian responsiveness, embryo number, or assisted reproductive technology outcomes than other factors such as antral follicle count, inhibin, estradiol, or FSH (16, 17).

Women with PCOS display elevated circulating AMH levels compared with age and body mass index (BMI)-matched controls with normal menstrual regularity (18, 19, 20). Furthermore, AMH levels are higher in amenorrheic women with PCOS compared with oligomenorrhea women with PCOS in conjunction with significantly elevated 2- to 9-mm follicle number per ovary, and AMH has been proposed as a surrogate marker for antral follicle count in PCOS (21). Although a number of studies have demonstrated improvements in menstrual function and reductions in AMH after metformin therapy in women with PCOS (20, 22, 23), the relationship of AMH to menstrual improvements after weight loss is unknown. Therefore, the aim of this study was to test the hypothesis that elevated preweight loss AMH levels are higher in women with PCOS who do not respond to weight loss with menstrual improvements compared with women with PCOS who display menstrual improvements after weight loss.


   Subjects and Methods
Top
 Abstract
 Introduction
 Subjects and Methods
Results
 Discussion
 References
 
Subjects and recruitment

Overweight women (European Caucasian) with PCOS (n = 26) were recruited through public advertisement. This comprises a subset of a population of overweight women with PCOS studied with a dietary weight loss intervention (24) who either responded to weight loss with menstrual improvements (responders, n = 15) or responded to weight loss with no menstrual improvements (nonresponders, n = 11). These women were chosen from the previous cohort because they were the subjects for whom data on menstrual cyclicity were available. The study was approved by the Human Ethics committees of the Commonwealth Scientific and Industrial Research Organisation Division of Health Sciences and Nutrition, The Royal Adelaide Hospital, and the Womens and Childrens Hospital of South Australia, and all subjects gave informed written consent. PCOS was diagnosed according to the Rotterdam consensus group as previously described (24, 25). Inclusion and exclusion criteria have been previously described (24). The use of endocrine hormonal treatment or insulin-sensitizing agents was not permitted during both phases of the study, and the use of oral contraceptives was not permitted during phase 1 of the study. Subjects were required to cease oral contraceptives 4 wk and hormonal treatment/insulin-sensitizing agents 2 wk before commencement of the short-term study phase. From wk 8–32 (phase 2), subjects were allowed to take oral contraceptives with ethinyl estradiol less than 35 µg.

Study design

The study was conducted over 32 wk with 8-wk energy restriction, whereby two meals daily were replaced with commercially available meal replacements (Slim·Fast; Unilever Australasia, Epping, New South Wales, Australia) with all subjects after the same dietary protocol (phase 1) and 24-wk weight maintenance with subjects after either a carbohydrate-counting (CC) (n = 15) or fat-counting (FC) (n = 11) protocol (phase 2). The dietary protocol is described in detail elsewhere (24). Subjects were stratified to ensure equal distribution for age, BMI, smoking status, and use of oral contraceptives, and then the two groups were randomized by an independent observer using the computer program Clinstat (Clinstat Inc., Kingston, Ontario, Canada) to the CC or FC protocol before study commencement.

Clinical and biochemical measurements

In phases 1 and 2, subjects attended the clinic fortnightly and monthly, respectively, for dietary counseling and assessment. All clinical measurements were taken at wk 0, 8, and 32. Weight, waist circumference, and total fat free mass (by bioelectrical impedance) were measured, and overnight fasting venous blood samples were taken for assessment of plasma glucose, insulin and ghrelin, and serum testosterone and SHBG, as previously described (24). A 2-hour oral glucose tolerance test (OGTT) (75 g load) was conducted with assessment of venous glucose and insulin at 0 and 120 min. Plasma AMH was measured using an Immunotech immunoenzymatric assay (Beckman Coulter, Marseille, France) with an intraassay coefficient of 3.5% and an analytical sensitivity of 0.7 pM. The homeostasis model assessment (HOMA) was used as a surrogate measure of insulin sensitivity and was calculated as [fasting serum insulin (mU/liter) x fasting plasma glucose (mmol/liter)/22.5] (26). The free androgen index (FAI) (testosterone/SHBG x 100) and equilibrium binding equations for determination of free testosterone (27) were used as surrogate estimates of free testosterone. Biochemical assays were performed in a single assay at the completion of the study, and all samples for individuals were analyzed in the same assay.

Subjects documented their menstrual cycles for the study duration and for 6 months before study commencement. During phase 1, first morning urine samples were collected twice weekly and assessed for total urinary pregnanediol-3-glucuronide (28) to determine ovulation status. Results were compared with the menses calendars to qualitatively determine ovulation. Improvements in menstrual cyclicity were defined as a change from nonovulatory to ovulatory cycles or from irregular cycles (defined as cycle length <26 d or >31 d, or variation between consecutive cycles of >3 d) to regular cycles, or an improvement in consecutive intercycle variation for either phase 1 or 2. At least 8 wk was required to assess if a patient responded to the treatment to measure ovulation over the short-term study phase.

Statistics

Data were presented as means ± SD. Normality was assessed using the Kolmogorov-Smirnoff test. Where data were nonnormally distributed, data were log transformed for analysis. Two subjects with PCOS had impaired glucose tolerance defined as 2-h OGGT 7.8–11.1 mmol/liter and were excluded from the glucose analysis. Five subjects recommenced oral contraceptive/hormonal treatment in phase 2, and their data were excluded from reproductive hormone analysis. Results are presented for 26 subjects except fasting glucose and HOMA (n = 24), 2-h glucose (n = 23) and ghrelin (n = 19). Subjects who responded to weight loss with improved menstrual cyclicity (responders) were assessed separately from those who responded to weight loss with no improved menstrual cyclicity (nonresponders), with cyclicity as the between-subject factor. Two-tailed statistical analysis was performed using SPSS for Windows 10.0 software (SPSS, Inc., Chicago, IL), with statistical significance set at {alpha} level of P ≤ 0.05. Baseline data were assessed using a one-way ANOVA. Comparisons between time points were assessed using two-factor ANOVA, with time as the within-subject factor and menstrual cyclicity improvement as the between-subject factor. In the event of an interaction, post hoc pairwise comparisons (Bonferroni) were performed. Relationships between variables were examined using bivariate and partial correlations, analysis of covariance, and multiple linear regression.


   Results
Top
 Abstract
 Introduction
 Subjects and Methods
 Results
Discussion
 References
 
Subjects and dietary intake

There were no significant differences among the baseline characteristics for subjects included and excluded from this study: age 32.9 ± 5.8 vs. 31.1 ± 4.1 yr; weight 98.9 ± 20.9 vs. 92.0 ± 13.3 yr; BMI 36.1 ± 7.0 vs. 33.6 ± 5.2 kg/m2; waist circumference 102.5 ± 13.3 vs. 100.6 ± 11.3 cm; FAI 12.2 ± 9.8 vs. 15.3 ± 8.5; and fasting insulin 13.4 ± 8.0 vs. 14.4 ± 7.7 mU/liter.

For this subset of the study, 26 subjects commenced the weight loss phase (age 32.9 ± 5.8 yr, weight 98.9 ± 20.8 kg, and BMI 36.1 ± 7.0 kg/m2), 25 completed phase 1, and 21 completed phase 2. Baseline characteristics at wk 0 are presented in Table 1Go. Dietary intake data are described in detail elsewhere (24). The mean daily dietary intake for phase 1 was 4832.1 ± 597.0 kJ, 20.6 ± 4.5% fat, 53.2 ± 5.6% carbohydrate, and 24.3 ± 2.1% protein, and the mean daily dietary intake for phase 2 was 6036.7 ± 1959.0 kJ, 33.8 ± 5.6% fat, 41.3 ± 3.2% carbohydrate, and 21.6 ± 3.2% protein.


View this table:
[in this window]
[in a new window]

  		TABLE 1. Baseline characteristics for overweight women with PCOS who responded to a 32-wk weight loss intervention with improvements (responders) or no improvements (nonresponders) in menstrual cyclicity

 
Changes in weight, body composition, reproductive hormones, insulin and glucose homeostasis, lipid profile, and CRP with weight loss

As previously reported (24), there was no difference between the subjects after the CC or FC protocol at baseline, or over phase 1 or 2 for changes in weight, metabolic, or reproductive outcomes. Therefore, combined results are presented for both dietary treatments. Reductions in weight (6.3 ± 2.1 kg), BMI (2.2 ± 0.7 kg/m2), waist circumference (6.4 ± 2.7 cm), total fat mass (4.32 ± 2.2 kg), total fat free mass (1.9 ± 1.9 kg), testosterone (0.2 ± 0.5 nmol/liter), FAI (2.4 ± 4.0), free testosterone (7.8 ± 13.7 pmol/liter), 2-h OGTT glucose (0.3 ± 1.1 mmol/liter), HOMA (0.8 ± 1.3 mU/liter), fasting insulin (4.0 ± 6.2 mU/liter), and OGTT insulin (31.1 ± 52.2 mU/liter) occurred with acute weight loss (phase 1). These were maintained over the entire study duration for weight (4.6 ± 4.8 kg), BMI (1.7 ± 1.7 kg/m2), waist circumference (6.0 ± 5.3 cm), total fat mass (2.8 ± 3.3 kg), total fat free mass (1.8 ± 2.8 kg), testosterone (0.3 ± 0.6 nmol/liter), fasting insulin (3.7 ± 7.6 mU/liter), and HOMA (0.7 ± 1.3 mU/liter).

Menstrual cyclicity responders’ analysis

Of the 26 subjects analyzed, improvements in menstrual cyclicity occurred for 15 (57.7%): one was previously amenorrheic and recommenced menses, two pregnancies (one from a previously amenorrheic women), six women whose cycle length improved, five whose cycle length improved from an irregular cycle to a regular cycle, and one women who was previously an irregular ovulator and ovulated regularly after weight loss. There were 10 subjects who displayed improvements in menstrual cyclicity in phase 1, and five subjects displayed improvements in menstrual cyclicity in phase 2.

There were no differences in weight loss over the short term (5.9 ± 1.9 vs. 6.4 ± 2.4 kg or 6.1 ± 1.8 vs. 6.5 ± 2.2%; P = 0.379) or over the entire study (4.7 ± 5.9 vs. 4.6 ± 3.1 kg or 5.0 ± 5.6 vs. 4.7 ± 3.4%; P = 0.940) for responders compared with nonresponders.

After acute weight loss in phase 1, there was a cyclicity-by-weight loss effect for fasting insulin (P = 0.005) and HOMA (P = 0.011) such that responders demonstrated a decrease in fasting insulin (6.1 ± 5.9 mU/liter; P = 0.001) and HOMA (1.3 ± 5.9; P = 0.002) compared with no changes for nonresponders for fasting insulin (1.3 ± 5.9; P = 0.492) and HOMA (0.3 ± 1.4; P = 0.509) (Fig. 1Go). There was no difference in changes in fasting insulin or HOMA over phase 2 or for the study as a whole between responders and nonresponders. These relationships remained after adjusting for age and changes in weight.


Figure 1
View larger version (12K):
[in this window]
[in a new window]

  		FIG. 1. Changes in fasting insulin (A) and HOMA (B) for subjects who responded to a 32-wk weight loss intervention with improvements (responders, n = 15) or no improvement (nonresponders, n = 11) in menstrual cyclicity. Data are presented as mean ± SD. For conversion from mU/liter to pmol/liter for insulin, multiply by 6.95. Data were assessed using repeated-measures ANOVA, with time as the within-subject factor and diet as the between-subject factor. There was no significant time x diet interaction for any variables. *, Cyclicity-by-weight loss effect (P = 0.005) and reduction in fasting insulin for responders only (P = 0.001). **, Cyclicity-by-weight loss effect (P = 0.011) and reduction in HOMA for responders only (P = 0.002).

 
AMH

Baseline AMH levels were significantly lower for subjects who responded to weight loss with menstrual improvements compared with subjects who responded to weight loss with no menstrual improvements (23.6 ± 12.0 vs. 37.9 ± 17.8 pmol/liter; P = 0.021) (Fig. 2Go). This relationship remained after controlling for all baseline variables with the exception of fasting ghrelin and was removed after adjusting for the change in insulin, HOMA, free testosterone, FAI, and ghrelin over the study (wk 0–8 and 0–32). In this study we had 99.9% power to detect the observed difference of 12.3 pmol/liter in AMH to P < 0.05 between responders and nonresponders.


Figure 2
View larger version (11K):
[in this window]
[in a new window]

  		FIG. 2. AMH levels at baseline (wk 0) for subjects who responded to a 32-wk weight loss intervention with improvements (responders, n = 15) or no improvement (nonresponders, n = 11) in menstrual cyclicity. A, Data are presented as individual subject values. B, Data are presented as combined mean ± SD values. For conversion from pmol/liter to pg/ml for AMH, multiply by 0.014. **, Significant differences (P = 0.021) between responders and nonresponders. Data were assessed using one-way ANOVA with menstrual cyclicity as the between-subject factor.

 
Correlations and multiple regression

We attempted to explore the relationship between AMH and other hormonal variables through correlation and multiple regression analysis. Baseline AMH correlated with age (r = –0.489; P = 0.015), testosterone (r = 0.573; P = 0.002), FAI (r = 0.399; P = 0.043), free testosterone (r = 0.449; P = 0.021), ghrelin (r = –0.544; P = 0.016), the change in FAI from wk 0–8 (r = –0.453; P = 0.023), and the change in insulin from wk 0–32 (r = 0.511; P = 0.018). After adjustment for weight, all these relationships remained. On adjustment for age, only the relationship with baseline testosterone remained.

The best predictor of AMH was baseline ghrelin (r2 = 0.254; P = 0.016). The model was further improved by addition of free testosterone (r2 = 0.358; P = 0.011) and insulin together (r2 = 0.528; P = 0.002), and remained significant on adjusting for age. The best predictor of the change in insulin from wk 0–8 was fasting insulin (explaining 45.8% of the variance; P < 0.001), fasting insulin, and free testosterone (together explaining 60.2% of the variance; P < 0.001). This model was significant on controlling for age and weight, and was not altered by incorporating AMH (r2 = 0.576; P = 0.001) or fasting ghrelin (r2 = 0.611; P < 0.001) into the model.


   Discussion
Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
References
 
We report for the first time that pretreatment AMH is a clinical predictor of reproductive responsiveness to weight loss in overweight women with PCOS. Women with PCOS who respond to weight loss with improvements in menstrual cyclicity display significantly lower baseline AMH levels compared with women who have no menstrual improvements after weight loss. We have additionally confirmed our previous observations that responders to weight loss programs have significantly greater reductions in surrogate measures of insulin sensitivity (fasting insulin and HOMA) (28).

The severity of reproductive dysfunction in PCOS is influenced by a range of factors, including adiposity, abdominal adiposity, insulin resistance, and hyperinsulinemia and hyperandrogenism. However, there has been little research on clinical or biochemical measures that predict reproductive outcomes after pharmaceutical or lifestyle treatment in PCOS. In overweight women with PCOS, predictors of poor ovulatory response (29, 30, 31, 32), conception (33), or live birth (34) after ovulation induction with FSH or clomiphene citrate included elevated OGTT glucose and insulin (32), upper body fat distribution (29), BMI, age (34), androgens (30, 31, 34), leptin (30), or follicle number or ovarian volumes (30). However, there has been no work as yet examining pretreatment characteristics that could assist in identifying subjects who would maximally benefit from weight loss. Previously, subjects with PCOS who show menstrual improvements after weight loss (4–6 months) have been documented as having no metabolic differences (35), greater decreases in fasting insulin, HOMA or insulin sensitivity (5, 28), greater decreases in LH (5), greater decreases in central fat (5), or greater increases in LH and reductions in estradiol (36) after weight loss. This current study is the first to provide a simple clinical test to assess reproductive responsiveness to weight loss before commencement of treatment. Furthermore, AMH values remain relatively constant over the menstrual cycle (37) and during oral contraceptive pill use (18), which further increase its use as a clinical diagnostic marker of treatment outcome.

Women with PCOS display elevated AMH levels (18, 19, 20), which is proposed to be a direct consequence of the increased number of preantral follicles in PCOS. Furthermore, increased follicular AMH levels are reported in PCOS, and a recent report additionally demonstrated elevated AMH production per granulosa cell in women with PCOS compared with controls and in anovulatory compared with ovulatory women with PCOS (38). It is not known if this elevated production is an intrinsic feature of PCOS or due to altered levels of regulatory factors. We and other investigators have observed positive correlations between circulating AMH and androgens (19, 23), supported by elevated AMH in hyperandrogenic women with PCOS compared with normoandrogenic women with PCOS (19, 21). In male rats AMH reduces androgens, and androgens reduce AMH (39), supporting a potential regulatory role of AMH on androgens, although it is not possible to determine the direction of this effect. Furthermore, AMH positively correlates with LH (19) and negatively correlates with FSH (19, 40, 41), estradiol (42, 43) and SHBG (43), and insulin in PCOS. In in vitro studies, FSH and/or estradiol inhibited AMH mRNA and AMH type II receptor expression and production in rat ovarian follicle cells (12). This demonstrates a potential mechanism for altered AMH production in women with PCOS.

However, AMH may not be primarily regulated by gonadotropins or steroids because AMH levels do not change during the menstrual cycle (37), or after oral contraceptive use or FSH administration in women with PCOS (18, 44), despite changes in testosterone, LH, FSH, progesterone, estradiol, or inhibin. Conversely, AMH levels decreased after acute controlled ovarian stimulation with FSH in women without PCOS, although it is possible that this affected AMH levels through follicular development rather than through a role on the synthesis or expression of AMH (45). Furthermore, in our subjects we did not perform our blood sample measures at one defined stage of the menstrual cycle. This excludes assessment of other potential regulators of AMH production or measures of ovarian reserve such as inhibin, FSH, and LH, and incorporation of these into the current study would have assisted the assessment of the relative contribution of these gonadotropins to menstrual dysfunction and AMH regulation in PCOS.

Despite no differences in baseline ghrelin or differential changes in ghrelin after weight loss between responders and nonresponders, we report for the first time a positive association between ghrelin and AMH. Ghrelin and ghrelin receptors have been localized in the human or rodent ovary, embryo, endometrium, and placenta (reviewed in Ref. 46); ghrelin mRNA expression fluctuates throughout the rat estrous cycle and pregnancy (47), and in rodent models ghrelin decreases LH and GnRH secretion and LH responsiveness to GnRH in vivo (48). In the human ovary (PCOS and non-PCOS), ghrelin expression is localized to ovarian interstitial cells, which possess LH-controlled steroidogenic activity, and the corpus luteum (49, 50), whereas the ghrelin receptor has a more widespread localization to areas, including the interstitial hilus cells, corpus luteum, oocytes, and follicular cells (49), suggesting a potential role in follicular or luteal growth or function. In addition, ghrelin mRNA expression is reduced in polycystic ovaries, suggesting a potential contribution of ghrelin to the reproductive function and the presentation of PCOS (51). Therefore, it is possible that the lower levels of ghrelin commonly observed in PCOS are either related to the elevated AMH, albeit in an as yet unidentified manner, or are an unrelated effect of a different state (hyperandrogenism, hyperinsulinemia, or obesity), as demonstrated by relationships between ghrelin, insulin resistance, hyperandrogenism, and obesity (52, 53, 54). The potential role of ghrelin in the regulation of human folliculogenesis thus remains to be elucidated.

We confirm previous findings by our group (5, 28) of greater improvements in surrogate measures of insulin sensitivity after weight loss for women with PCOS demonstrating improvements in menstrual cyclicity. In these previous studies, we were not able to determine any baseline differences between the responders and nonresponders, although we did not measure any ovarian inhibitors such as AMH. However, it is not clear in this current study if the reduced pretreatment AMH levels and greater reductions in insulin resistance after weight loss represent similar mechanisms of action for menstrual dysfunction. Women with PCOS and higher surrogate measures of insulin resistance had similar levels of AMH compared with those with lower surrogate measures of insulin resistance (20), and no association (22) or a positive correlation (43) was reported between insulin and AMH. Furthermore, although short-term metformin administration (1 wk to 4 months) resulted in improvements in hyperandrogenism, menstrual cyclicity (22), surrogate measures of insulin sensitivity, and reductions in antral follicle number (20), long-term metformin administration (6–8 months) was required for reductions in AMH (22, 23). Therefore, menstrual improvements after weight loss may be due to reductions in factors, including insulin-stimulated androgen production, although it has not yet been examined if these are related to changes in AMH.

Insulin resistance, abnormalities in gonadotropin or androgen regulation, and menstrual dysfunction can occur independent of obesity in some women with PCOS (3). Obesity further worsens menstrual and metabolic abnormalities in PCOS (55), and in overweight women with PCOS, weight loss reduces insulin resistance and hyperinsulinemia (5) with consequent effects on reducing ovarian androgen production (56). Where insulin resistance and obesity are the main contributors to hyperandrogenism and menstrual dysfunction in PCOS, weight loss will likely have a greater effect on the clinical and metabolic presentation of PCOS. Thus, it is possible that reduced AMH levels in overweight women with PCOS indicate a lesser contribution of gonadotrophic or steroidogenic abnormalities, and a greater contribution of obesity and insulin resistance to menstrual dysfunction. This is consistent with subjects with reduced baseline AMH levels being more responsive to weight loss with regards to improvements in insulin sensitivity. This is a particularly useful clinical marker given the similar baseline metabolic profile between responders and nonresponders for waist circumference, hyperandrogenism, and surrogate measures of insulin resistance. However, it is possible that we were not able to detect baseline clinical differences between responders and nonresponders due to the small sample size and use of surrogate measures of body composition and insulin sensitivity. The use of more precise measures would have assisted detailed comparisons between responders and nonresponders. In women with PCOS and elevated baseline AMH, a greater degree of weight loss may be required to observe clinical improvements, or pharmacological therapy may be necessary. This is preferable in conjunction with lifestyle management to optimize improvement of other metabolic risk factors commonly present in PCOS (2).

Identification of baseline AMH thresholds for use in determining women with PCOS who are responsive to weight loss with regards to menstrual dysfunction would be a useful expansion of this study. AMH levels appear to be highly variable with considerable overlapping values reported between responders and nonresponders in this study and between women with and without PCOS in other studies (40), and larger studies are required to determine accurately specific thresholds for classification of menstrual responders. Furthermore, the effect of weight loss on circulating AMH levels has not been examined, and reductions in AMH may be required for menstrual improvements to occur. This was not measured in this study. Thus, we report for the first time that pretreatment AMH level is the best marker of responsiveness in menstrual cyclicity after weight loss therapy. This has important clinical implications for the pretreatment identification of women with PCOS who will benefit from lifestyle intervention and subjects who may require more intensive pharmacological intervention.


   Acknowledgments
 
We thank Unilever for assistance with study supplies. We also thank Anne McGuffin, Kathryn Bastiaans, and Julia Weaver for coordinating the trial; Jennifer Keogh and Gemma Williams for assisting in the dietary intervention; Rosemary McArthur, Ruth Pinches, Sue Davies, and Deborah Roffe for their nursing expertise; and Brenton Bennett, Alan Gilmore, Mark Mano, Cherie Keatch, and Candita Sullivan for assisting with the biochemical assays.


   Footnotes
 
This work was supported by a National Health and Medical Research Council Program grant (to R.J.N.), The University of Adelaide Faculty of Health Sciences Small Research Grants Scheme, and Colin Matthews Research Grants for Clinically Based Research.

Disclosure Statement: L.J.M. and P.M.C. have nothing to declare. M.N. consults for the Egg Nutrition Advisory Board and has received lecture fees from Meat and Livestock Australia, and R.J.N. consults for Novartis, Organon, and has received lecture fees from Organon, Institute Biochimique SA.

First Published Online July 24, 2007

Abbreviations: AMH, Anti-müllerian hormone; BMI, body mass index; CC, carbohydrate counting; FAI, free androgen index; FC, fat counting; HOMA, homeostasis model assessment; OGTT, oral glucose tolerance test; PCOS, polycystic ovary syndrome.

Received May 30, 2007.

Accepted July 16, 2007.


   References
Top
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 References
 

  1. Hart R, Hickey M, Franks S 2004 Definitions, prevalence and symptoms of polycystic ovaries and polycystic ovary syndrome. Best Pract Res Clin Obstet Gynaecol 18:671–683[CrossRef][Medline]
  2. Norman RJ, Masters L, Milner CR, Wang JX, Davies MJ 2001 Relative risk of conversion from normoglycaemia to impaired glucose tolerance or non-insulin dependent diabetes mellitus in polycystic ovarian syndrome. Hum Reprod 16:1995–1998[Abstract/Free Full Text]
  3. Dunaif A, Segal KR, Futterweit W, Dobrjansky A 1989 Profound peripheral insulin resistance, independent of obesity, in polycystic ovary syndrome. Diabetes 38:1165–1174[Abstract]
  4. Crosignani PG, Colombo M, Vegetti W, Somigliana E, Gessati A, Ragni G 2003 Overweight and obese anovulatory patients with polycystic ovaries: parallel improvements in anthropometric indices, ovarian physiology and fertility rate induced by diet. Hum Reprod 18:1928–1932[Abstract/Free Full Text]
  5. Huber-Buchholz MM, Carey DG, Norman RJ 1999 Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: role of insulin sensitivity and luteinizing hormone. J Clin Endocrinol Metab 84:1470–1474[Abstract/Free Full Text]
  6. Clark AM, Thornley B, Tomlinson L, Galletley C, Norman RJ 1998 Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment. Hum Reprod 13:1502–1505[Abstract/Free Full Text]
  7. Webber LJ, Stubbs S, Stark J, Trew GH, Margara R, Hardy K, Franks S 2003 Formation and early development of follicles in the polycystic ovary. Lancet 362:1017–1021[CrossRef][Medline]
  8. Vendola KA, Zhou J, Adesanya OO, Weil SJ, Bondy CA 1998 Androgens stimulate early stages of follicular growth in the primate ovary. J Clin Invest 101:2622–2629[Medline]
  9. Lockwood GM, Muttukrishna S, Groome NP, Matthews DR, Ledger WL 1998 Mid-follicular phase pulses of inhibin B are absent in polycystic ovarian syndrome and are initiated by successful laparoscopic ovarian diathermy: a possible mechanism regulating emergence of the dominant follicle. J Clin Endocrinol Metab 83:1730–1735[Abstract/Free Full Text]
  10. Chavez-Ross A, Franks S, Mason HD, Hardy K, Stark J 1997 Modelling the control of ovulation and polycystic ovary syndrome. J Math Biol 36:95–118[CrossRef][Medline]
  11. Jakimiuk AJ, Weitsman SR, Navab A, Magoffin DA 2001 Luteinizing hormone receptor, steroidogenesis acute regulatory protein, and steroidogenic enzyme messenger ribonucleic acids are overexpressed in thecal and granulosa cells from polycystic ovaries. J Clin Endocrinol Metab 86:1318–1323[Abstract/Free Full Text]
  12. Baarends WM, Uilenbroek JT, Kramer P, Hoogerbrugge JW, van Leeuwen EC, Themmen AP, Grootegoed JA 1995 Anti-müllerian hormone and anti-müllerian hormone type II receptor messenger ribonucleic acid expression in rat ovaries during postnatal development, the estrous cycle, and gonadotropin-induced follicle growth. Endocrinology 136:4951–4962[Abstract]
  13. van Rooij IA, Broekmans FJ, te Velde ER, Fauser BC, Bancsi LF, de Jong FH, Themmen AP 2002 Serum anti-Mullerian hormone levels: a novel measure of ovarian reserve. Hum Reprod 17:3065–3071[Abstract/Free Full Text]
  14. Carlsson IB, Scott JE, Visser JA, Ritvos O, Themmen AP, Hovatta O 2006 Anti-Mullerian hormone inhibits initiation of growth of human primordial ovarian follicles in vitro. Hum Reprod 21:2223–2227[Abstract/Free Full Text]
  15. Durlinger AL, Gruijters MJ, Kramer P, Karels B, Kumar TR, Matzuk MM, Rose UM, de Jong FH, Uilenbroek JT, Grootegoed JA, Themmen AP 2001 Anti-Müllerian hormone attenuates the effects of FSH on follicle development in the mouse ovary. Endocrinology 142:4891–4899[Abstract/Free Full Text]
  16. Muttukrishna S, McGarrigle H, Wakim R, Khadum I, Ranieri DM, Serhal P 2005 Antral follicle count, anti-mullerian hormone and inhibin B: predictors of ovarian response in assisted reproductive technology? BJOG 112:1384–1390[Medline]
  17. McIlveen M, Skull JD, Ledger WL 2007 Evaluation of the utility of multiple endocrine and ultrasound measures of ovarian reserve in the prediction of cycle cancellation in a high-risk IVF population. Hum Reprod 22:778–785[Abstract/Free Full Text]
  18. Somunkiran A, Yavuz T, Yucel O, Ozdemir I 28 Feb 2007 Anti-Mullerian hormone levels during hormonal contraception in women with polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol
  19. Eldar-Geva T, Margalioth EJ, Gal M, Ben-Chetrit A, Algur N, Zylber-Haran E, Brooks B, Huerta M, Spitz IM 2005 Serum anti-Mullerian hormone levels during controlled ovarian hyperstimulation in women with polycystic ovaries with and without hyperandrogenism. Hum Reprod 20:1814–1819[Abstract/Free Full Text]
  20. Bayrak A, Terbell H, Urwitz-Lane R, Mor E, Stanczyk FZ, Paulson RJ 2007 Acute effects of metformin therapy include improvement of insulin resistance and ovarian morphology. Fertil Steril 87:870–875[CrossRef][Medline]
  21. Pigny P, Jonard S, Robert Y, Dewailly D 2006 Serum anti-Müllerian hormone as a surrogate for antral follicle count for definition of the polycystic ovary syndrome. J Clin Endocrinol Metab 91:941–945[Abstract/Free Full Text]
  22. Fleming R, Harborne L, MacLaughlin DT, Ling D, Norman J, Sattar N, Seifer DB 2005 Metformin reduces serum mullerian-inhibiting substance levels in women with polycystic ovary syndrome after protracted treatment. Fertil Steril 83:130–136[CrossRef][Medline]
  23. Piltonen T, Morin-Papunen L, Koivunen R, Perheentupa A, Ruokonen A, Tapanainen JS 2005 Serum anti-Mullerian hormone levels remain high until late reproductive age and decrease during metformin therapy in women with polycystic ovary syndrome. Hum Reprod 20:1820–1826[Abstract/Free Full Text]
  24. Moran LJ, Noakes M, Clifton PM, Wittert GA, Williams G, Norman RJ 2006 Short-term meal replacements followed by dietary macronutrient restriction enhance weight loss in polycystic ovary syndrome. Am J Clin Nutr 84:77–87[Abstract/Free Full Text]
  25. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group 2004 Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 81:19–25[Medline]
  26. Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC 1985 Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia 28:412–419[CrossRef][Medline]
  27. Vermeulen A, Verdonck L, Kaufman JM 1999 A critical evaluation of simple methods for the estimation of free testosterone in serum. J Clin Endocrinol Metab 84:3666–3672[Abstract/Free Full Text]
  28. Moran LJ, Noakes M, Clifton PM, Tomlinson L, Norman RJ 2003 Dietary composition in restoring reproductive and metabolic physiology in overweight women with polycystic ovary syndrome. J Clin Endocrinol Metab 88:812–819[Abstract/Free Full Text]
  29. Douchi T, Oki T, Yamasaki H, Nakae M, Imabayashi A, Nagata Y 2004 Body fat patterning in polycystic ovary syndrome women as a predictor of the response to clomiphene. Acta Obstet Gynecol Scand 83:838–841[CrossRef][Medline]
  30. Imani B, Eijkemans MJ, de Jong FH, Payne NN, Bouchard P, Giudice LC, Fauser BC 2000 Free androgen index and leptin are the most prominent endocrine predictors of ovarian response during clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility. J Clin Endocrinol Metab 85:676–682[Abstract/Free Full Text]
  31. Imani B, Eijkemans MJ, te Velde ER, Habbema JD, Fauser BC 1998 Predictors of patients remaining anovulatory during clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility. J Clin Endocrinol Metab 83:2361–2365[Abstract/Free Full Text]
  32. Kurabayashi T, Suzuki M, Fujita K, Murakawa H, Hasegawa I, Tanaka K 2006 Prognostic factors for ovulatory response with clomiphene citrate in polycystic ovary syndrome. Eur J Obstet Gynecol Reprod Biol 126:201–205[CrossRef][Medline]
  33. Imani B, Eijkemans MJ, te Velde ER, Habbema JD, Fauser BC 1999 Predictors of chances to conceive in ovulatory patients during clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility. J Clin Endocrinol Metab 84:1617–1622[Abstract/Free Full Text]
  34. Imani B, Eijkemans MJ, te Velde ER, Habbema JD, Fauser BC 2002 A nomogram to predict the probability of live birth after clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility. Fertil Steril 77:91–97[CrossRef][Medline]
  35. Pasquali R, Antenucci D, Casimirri F, Venturoli S, Paradisi R, Fabbri R, Balestra V, Melchionda N, Barbara L 1989 Clinical and hormonal characteristics of obese amenorrheic hyperandrogenic women before and after weight loss. J Clin Endocrinol Metab 68:173–179[Abstract/Free Full Text]
  36. Van Dam EW, Roelfsema F, Veldhuis JD, Hogendoorn S, Westenberg J, Helmerhorst FM, Frolich M, Krans HM, Meinders AE, Pijl H 2004 Retention of estradiol negative feedback relationship to LH predicts ovulation in response to caloric restriction and weight loss in obese patients with polycystic ovary syndrome. Am J Physiol Endocrinol Metab 286:E615–E620
  37. La Marca A, Stabile G, Artenisio AC, Volpe A 2006 Serum anti-Mullerian hormone throughout the human menstrual cycle. Hum Reprod 21:3103–3107[Abstract/Free Full Text]
  38. Pellatt L, Hanna L, Brincat M, Galea R, Brain H, Whitehead S, Mason H 2007 Granulosa cell production of anti-Müllerian hormone is increased in polycystic ovaries. J Clin Endocrinol Metab 92:240–245[Abstract/Free Full Text]
  39. Trbovich AM, Sluss PM, Laurich VM, O’Neill FH, MacLaughlin DT, Donahoe PK, Teixeira J 2001 Mullerian inhibiting substance lowers testosterone in luteinizing hormone-stimulated rodents. Proc Natl Acad Sci USA 98:3393–3397[Abstract/Free Full Text]
  40. Pigny P, Merlen E, Robert Y, Cortet-Rudelli C, Decanter C, Jonard S, Dewailly D 2003 Elevated serum level of anti-müllerian hormone in patients with polycystic ovary syndrome: relationship to the ovarian follicle excess and to the follicular arrest. J Clin Endocrinol Metab 88:5957–5962[Abstract/Free Full Text]
  41. La Marca A, Pati M, Orvieto R, Stabile G, Carducci Artenisio A, Volpe A 2006 Serum anti-mullerian hormone levels in women with secondary amenorrhea. Fertil Steril 85:1547–1549[CrossRef][Medline]
  42. Cook CL, Siow Y, Brenner AG, Fallat ME 2002 Relationship between serum mullerian-inhibiting substance and other reproductive hormones in untreated women with polycystic ovary syndrome and normal women. Fertil Steril 77:141–146[CrossRef][Medline]
  43. La Marca A, Orvieto R, Giulini S, Jasonni VM, Volpe A, De Leo V 2004 Mullerian-inhibiting substance in women with polycystic ovary syndrome: relationship with hormonal and metabolic characteristics. Fertil Steril 82:970–972[CrossRef][Medline]
  44. Wachs DS, Coffler MS, Malcom PJ, Chang RJ 2007 Serum anti-müllerian hormone concentrations are not altered by acute administration of follicle stimulating hormone in polycystic ovary syndrome and normal women. J Clin Endocrinol Metab 92:1871–1874[Abstract/Free Full Text]
  45. La Marca A, Malmusi S, Giulini S, Tamaro LF, Orvieto R, Levratti P, Volpe A 2004 Anti-Mullerian hormone plasma levels in spontaneous menstrual cycle and during treatment with FSH to induce ovulation. Hum Reprod 19:2738–2741[Abstract/Free Full Text]
  46. Budak E, Fernandez Sanchez M, Bellver J, Cervero A, Simon C, Pellicer A 2006 Interactions of the hormones leptin, ghrelin, adiponectin, resistin, and PYY3–36 with the reproductive system. Fertil Steril 85:1563–1581[CrossRef][Medline]
  47. Caminos JE, Tena-Sempere M, Gaytan F, Sanchez-Criado JE, Barreiro ML, Nogueiras R, Casanueva FF, Aguilar E, Dieguez C 2003 Expression of ghrelin in the cyclic and pregnant rat ovary. Endocrinology 144:1594–1602[Abstract/Free Full Text]
  48. Fernandez-Fernandez R, Tena-Sempere M, Navarro VM, Barreiro ML, Castellano JM, Aguilar E, Pinilla L 2005 Effects of ghrelin upon gonadotropin-releasing hormone and gonadotropin secretion in adult female rats: in vivo and in vitro studies. Neuroendocrinology 82:245–255[CrossRef][Medline]
  49. Gaytan F, Barreiro ML, Chopin LK, Herington AC, Morales C, Pinilla L, Casanueva FF, Aguilar E, Dieguez C, Tena-Sempere M 2003 Immunolocalization of ghrelin and its functional receptor, the type 1a growth hormone secretagogue receptor, in the cyclic human ovary. J Clin Endocrinol Metab 88:879–887[Abstract/Free Full Text]
  50. Komarowska H, Wasko R, Iwanik K, Majewski P, Rafinska L, Warenik-Szymankiewicz A, Sowinski J 2006 Ghrelin ovarian cell expression in patients with polycystic ovary syndrome: an immunohistochemical evaluation. Horm Metab Res 38:783–788[CrossRef][Medline]
  51. Skommer J, Katulski K, Poreba E, Meczekalski B, Slopien R, Plewa R, Gozdzicka-Jozefiak A, Warenik-Szymankiewicz A 2005 Gherlin expression in women with polycystic ovary syndrome–a preliminary study. Eur J Gynaecol Oncol 26:553–556[Medline]
  52. Gambineri A, Pagotto U, Tschop M, Vicennati V, Manicardi E, Carcello A, Cacciari M, De Iasio R, Pasquali R 2003 Anti-androgen treatment increases circulating ghrelin levels in obese women with polycystic ovary syndrome. J Endocrinol Invest 26:629–634[Medline]
  53. Saad MF, Bernaba B, Hwu CM, Jinagouda S, Fahmi S, Kogosov E, Boyadjian R 2002 Insulin regulates plasma ghrelin concentration. J Clin Endocrinol Metab 87:3997–4000[Abstract/Free Full Text]
  54. Moran LJ, Luscombe-Marsh ND, Noakes M, Wittert GA, Keogh JB, Clifton PM 2005 The satiating effect of dietary protein is unrelated to postprandial ghrelin secretion. J Clin Endocrinol Metab 90:5205–5211[Abstract/Free Full Text]
  55. Balen AH, Conway GS, Kaltsas G, Techatrasak K, Manning PJ, West C, Jacobs HS 1995 Polycystic ovary syndrome: the spectrum of the disorder in 1741 patients. Hum Reprod 10:2107–2111[Abstract/Free Full Text]
  56. Poretsky L, Cataldo NA, Rosenwaks Z, Giudice LC 1999 The insulin-related ovarian regulatory system in health and disease. Endocr Rev 20:535–582[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Hum ReprodHome page
A. La Marca, F.J. Broekmans, A. Volpe, B.C. Fauser, N.S. Macklon, and on behalf of the ESHRE Special Interest Group for
Anti-Mullerian hormone (AMH): what do we still need to know?
Hum. Reprod., June 11, 2009; (2009) dep210v1.
[Abstract] [Full Text] [PDF]

Home page
 Hum ReprodHome page
R.L. Thomson, J.D. Buckley, L.J. Moran, M. Noakes, P.M. Clifton, R.J. Norman, and G.D. Brinkworth
The effect of weight loss on anti-Mullerian hormone levels in overweight and obese women with polycystic ovary syndrome and reproductive impairment
Hum. Reprod., April 20, 2009; (2009) dep101v1.
[Abstract] [Full Text] [PDF]

Home page
 Hum ReprodHome page
M.-J. Chen, W.-S. Yang, C.-L. Chen, M.-Y. Wu, Y.-S. Yang, and H.-N. Ho
The relationship between anti-Mullerian hormone, androgen and insulin resistance on the number of antral follicles in women with polycystic ovary syndrome
Hum. Reprod., April 1, 2008; 23(4): 952 - 957.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Submit a related Letter to the Editor
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Copyright Permission
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Moran, L. J.
Right arrow Articles by Norman, R. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Moran, L. J.
Right arrow Articles by Norman, R. J.
Related Collections
Right arrow Female Endocrinology
Right arrow Obesity

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Endocrinology Endocrine Reviews J. Clin. End. & Metab.
Molecular Endocrinology Recent Prog. Horm. Res. All Endocrine Journals