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Journal of Clinical Endocrinology & Metabolism , doi:10.1210/jc.2007-1188
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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.


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  		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
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  		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
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  		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
 

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