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Open Access Journal of Gynecology Exploration and Comparison of Ovarian

Hormones with Anti-Mullerian Hormone amongst Women with Polycystic
Ovarian Syndrome Exploration and Comparis...

Research Proposal · July 2019

DOI: 10.23880/oajg-16000179

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 Open Access Journal of Gynecology
ISSN: 2474-9230

Exploration and Comparison of Ovarian Hormones with Anti-

Mullerian Hormone amongst Women with Polycystic Ovarian
Syndrome

Dwajani S1 and Rupakala BM2* Research Article

1Assistant Professor / Senior Research Associate, Pharmacology/Central Research Volume 4 Issue 2

Lab, India Received Date: June 28, 2019

Published Date: July 17 , 2019
2Professor, Department of Obstetrics and Gynecology, Rajarajeswari Medical
DOI: 10.23880/oajg-16000179
College and Hospital, India

*Corresponding author: Dr. Rupakala BM, Professor, Department of Obstetrics and Gynecology Rajarajeswari Medical
College and Hospital, India, Email: drbmrkala@gmail.com

Abstract
Introduction: Polycystic ovarian syndrome (PCOS) is a common endocrine disorder in reproductive women and leading
causes of female sub fertility. Symptoms include amenorrhea, infertility, anovulation with irregular menstruation, and
excessive release of androgenic hormones. When compared to normal women, PCOS patients have higher serum Anti-
Mullerian hormone (AMH) levels, along with increased serum androgens and higher number of small-antral follicles.
Objective: This study seeks to explore the effectiveness of previous literature on usefulness of testing serum levels of, LH,
FSH in comparison with AMH for a period of 3 months of treatment.
Methods: Prospective and cross sectional study, conducted from march 2017 to Oct 2018. 100 women reporting to OBG
clinic with inclusion criteria were , Age group: ≥ 18 to ≤ 40 years, Patients complaining of irregular menstruation,
amenorrhea and infertility, while exclusion criteria were women with any other co morbid conditions, receiving any
medications, Pregnant, lactating and post-menopausal women. We divided them into two groups of 50 each. Group 1 was
analyzed for LH, FSH, and scanning (as routine) and group 2 were analyzed for LH, FSH, AMH and scanning (as routine).
The blood was centrifuged, separated and analyzed at Central laboratory. To compare between LH, FSH with AMH, we
use USG scan as standard diagnostic tool to prove the efficacy of AMH.
Conclusion: Our results showed that serum AMH has significant increase in PCOS compared to serum LH and FSH levels.
Our findings conclude that AMH is good clinical parameters that can be used for diagnostic testing of PCOS.

Keywords: PCOS; Follicle Stimulating Hormone; Luteinizing Hormone; Anti-Mullerian Hormone

Exploration and Comparison of Ovarian Hormones with Anti-Mullerian J Gynecol

Hormone amongst Women with Polycystic Ovarian Syndrome
2
Open Access Journal of Gynecology

Introduction effectiveness of previous literature on usefulness of

testing serum levels for a period of 3 months of treatment
Polycystic ovarian syndrome (PCOS), a common of AMH in comparison with LH, FSH. Hence our objective
endocrine disorder in women with leading cause of was to explore the effect of testing serum levels of AMH
female fertility. The symptoms of polycystic ovaries with LH, FSH women with PCOS.
include amenorrhea, infertility, anovulation with irregular
menstruation and excessive release of androgenic Methods
hormones [1-7]. This syndrome of ovarian dysfunction
has shown to affect 4-18% of reproductive women Institutional Ethical Review Board approval was
worldwide [8]. Women diagnosed with PCOS have obtained prior to initiation of the study and ICH-GCP
additionally revealed to exhibit a pattern for pre-obesity guidelines will be followed until completion. Study was
with links indicating a high progression of 30-40% of conducted by department of pharmacology/central
them progressing towards having type 2diabetes (T2D). research lab along with department of obstetrics and
Some may also present with abnormalities in insulin gynaecology, at rajarajeswari medical college, Bangalore.
resistance (IR), inflammation, adipose tissue dysfunction,
impaired fasting glucose (IGF) and impaired glucose This is a prospective, cross sectional study, conducted
tolerance (IGT) [9,10]. from March 2017 to oct 2018. We enrolled 100 women
reporting to OBG clinic with complaints/ symptoms of
In 1990, at consensus workshop which was sponsored PCOS. Inclusion criteria were – 1. Age group: ≥ 18 to ≤ 40
by NIH/NICHD the diagnostic criterion for PCOS was years 2. Patients complaining of irregular menstruation,
defined. It was said that PCOS patient has androgen amenorrhea and infertility. 3. Patients who consented to
excess, oligo ovulation, and other entities [11,12]. In 2003, participate, while exclusion criteria were 1. Women with
workshop sponsored by ESHRE/ASRM in Rotterdam, said any other co morbid conditions. 2. Women receiving any
that PCOS patient suffering from with any two from three medications. 3. Pregnant, lactating and post-menopausal
criteria like anovulation or oligo, polycystic ovaries women
detected by gynecologic ultrasound, excess androgenic
activity and, other entities are to be excluded that would Data was collected using specially designed Case
cause the same [13], while the definition by Rotterdam Record Form [CRF], includes demographic data, personal
includes more patients with or without excess of history, disease characteristics, treatment details, adverse
androgen. The study results of patients with androgen event profile if any, and investigational data. After initial
excess and without androgen excess cannot be screening as per Rotterdam definition by the clinician,
extrapolated [14-16]. patients were subjected for baseline study at third day of
menstrual cycle by collecting the blood samples. Women
Studies have suggested that during PCOS imbalance of were divided into two groups of 50 each. Group 1 were
other hormones also can occur, along with androgenic analyzed for FSH, LH, and scan (as routine) while group 2
excess while when compared to normal subjects, in PCOS were analyzed for LH,FSH,AMH, and scanning (as
patients the levels of serum Anti-Mullerian hormone routine). The blood was centrifuged, separated and
(AMH) will be increased [16-18]. In female, from pre- analyzed at Central laboratory.
antral and small-antral follicles it produces post-natally
by granulosa cells and in male, sertoli cells produce To compare between LH, FSH with AMH, we use USG
during fetal sex differentiation and induces Mullerian duct scan as standard diagnostic tool to prove the efficacy of
inhibition [19-21]. Women with PCOS have increase AMH. We also tried to prove the efficacy of LH FSH by
number of small-antral follicles with high serum combining two groups and as separate entity. In order to
androgens. Controversies still exist with its correlation to estimate the efficacy of LH and AMH measurements into
serum androgens even though, serum AMH levels have “normal” and “high”, their Receiver operating
been correlated positively with numbers of small-antral characteristics [ROC] curve were plotted. The ROC curve
follicles [21,22]. plots specificity v/s sensitivity. Area under curve [AUC] is
expressed in percentage which represents the ability to
We consider that, there are very few explorative study classify normal and high values.
among women with PCOS for detecting serum levels of
luteinizing hormone (LH), follicle stimulating hormone All the data were entered into Microsoft excel sheet
(FSH) and AMH. Therefore this study seeks to explore the before analysis. The data was analyzed using descriptive

Dwajani S and Rupakala BM. Exploration and Comparison of Ovarian Copyright© Dwajani S and Rupakala BM.
Hormones with Anti-Mullerian Hormone amongst Women with
Polycystic Ovarian Syndrome. J Gynecol 2019, 4(2): 000179.
3
Open Access Journal of Gynecology

statistics. Quantitative data was expressed as mean, of statistical parameters, detection effectiveness, ROC
standard deviation, qualitative data as percentage and curve and welsch independent ‘t’ test were performed.
frequency distribution. Statistical package “R” version 4.2
was used for analysis. For comparing the efficacy of LH, Results
FSH and AMH bar graphs were used which represents the
fraction. The standard errors on mean fraction were Total 100 women with PCOS were recruited in the
computed using SE = √ p(1-p) / n, where p is the fraction study. Among two groups majority of women were in age
of patients in group-2 showing “high” for the test. ROC range between 18-25 years and represented in Figure 1.
curve for LH and AMH classification were plotted using 70% of women with PCOS were married. 70% in group 1
pROC library. All the computations including estimation and 58% in group 2 were from rural background.

Figure 1: Age wise distribution of patients with PCOS.

To calculate the socioeconomic status we used revised women with PCOS in group 2 who were in the lower
kuppuswamy scale we had 54% in group 1 and 52% of middle class (Figure 2) [23].

Figure 2: Socioeconomic status of women with PCOS as per revised kuppuswamy scale.

Dwajani S and Rupakala BM. Exploration and Comparison of Ovarian Copyright© Dwajani S and Rupakala BM.
Hormones with Anti-Mullerian Hormone amongst Women with
Polycystic Ovarian Syndrome. J Gynecol 2019, 4(2): 000179.
4
Open Access Journal of Gynecology

Among 100 women with PCOS, only 5% of patients From this plot, we notice that within standard errors,
had family history. Majority of the women had irregular the AMH has considerable higher efficacy of detection
cycles between 60 days to 90 days and had a menstrual [>82%] when compared to LH and FSH [< 30%]. The
flow for 10 to 15 days. All patients were newly diagnosed values of the above plot are summarized in the table
patients who were not on any treatment for PCOS. below
Majority of them complained of dysmennorhea and heavy
flow. No of Fraction SE (Standard
High Normal
patients of high Error)
Comparison of Detection Efficiency of PCOS for
AMH and LH, FSH LH 12 38 50 0.24 0.01

The bar chart below shows the fraction of patients in FSH 1 49 50 0.02 0.032
Group 2 for whom the LH, FSH and AMH were performed AMH 43 7 50 0.86 0.081
and the results showed “high”. For all the 50 patients,
scan report showed confirmation for PCOS. Hence these Table 1: Values of LH,FSH, AMH.
ratios represent efficiency for detecting PCOS. The error
bars represent standard error on observed mean
Comparison between Group-1 and Group-2
fractions
In order to compare the values of LH, FSH and AMH
across Group-1 and Group-2, two sample independent t
test with unequal variances (Welsch test) was performed.
The results are summarized here in the table. The p
values between Group 1 and Group 2 indicate that the
values of LH and FSH are not significantly different, with a
significance level of 0.05 assumed for the test.

Mean and SD Men and SD in P-value of t-

Variable
in Group-1 Group-2 test
LH 9.09 ±5.72 8.35 ± 3.39 0.434
FSH 7.15 ± 4.22 6.85 ± 2.70 0.68
Table 2: Values of LH and FSH across two groups.

Detection Efficiencies by Combining Data Sets

of Group 1 and Group 2
The two data sets of Group-1 and Group-2 were
combined to get the detection efficiencies for LH and FSH.
The efficiency of AMH was available only for Group-2 as
computed before. This combined data is shown in the
Figure 3: Detecting the efficacy of LH, FSH, AMH. table below and plotted in the following graph.

High Normal No. of patients Fraction of high Standard error SE

LH 28 72 100 0.28 0.074
FSH 9 91 100 0.09 0.047
AMH 43 7 50 0.86 0.081

Table 3: Values of LH, FSH and AMHb.

Dwajani S and Rupakala BM. Exploration and Comparison of Ovarian Copyright© Dwajani S and Rupakala BM.
Hormones with Anti-Mullerian Hormone amongst Women with
Polycystic Ovarian Syndrome. J Gynecol 2019, 4(2): 000179.
5
Open Access Journal of Gynecology

Figure 4: Efficiency of LH, FSH and AM.

ROC curve for the LH and AMH Figure 6: ROC curve of AMH – Group 2.
In order to estimate the efficiency of the classification
of LH and AMH measurements into “normal” and “high”
categories, their ROC curves were plotted using “pROC” Discussion
library of R statistical package. The two figures
corresponding to LH and AMH are given below: In our study we observed to have higher levels of AMH
in women with PCOS. Studies have shown that women
with PCOS differed in their LH concentrations and it can
also peak to three times the levels of their FSH values
[24,25]. We also observed that LH/FSH levels were
significantly different on comparing with other groups. In
contrast, according to 2003 Rotterdam ESHRE/ASRM
criteria, it was stated clearly that LH/FSH should not be
recommended as an identifier for women having PCOS
where a study later proved them correct by concluding
that LH/FSH ratio had little effect in diagnosing PCOS
[26].

PCOS has a broad spectrum of biochemical and clinical

characteristics while its distinctive feature of follicular
maturation is a failure. FSH sensitivity is inhibited by
AMH synthesized in small antral follicles and an
important parameter which plays a pivotal role in
diagnosis of PCOS. Our study results show that women
Figure 5: ROC curve of LH – combining group 1 and 2. with PCOS have significantly higher serum AMH levels
while correlations with androgens in PCOS have been
reported [27]. On contrary, no correlations has been
found either in normal women or in PCOS [28-31].
The ROC curve for LH has a very good AUC of 97.5%
indicating that the LH classification of high and low A positive relationship had been revealed by our
classification is efficient. Similarly, the Roc curve for AMH study, between levels of FSH and AMH. Hence, lower
classification into high and low has a good AUC value of levels of FSH are associated with higher levels of AMH.
90.4%. This is in support of the speculation that excess of AMH is
involved in decreasing FSH induced aromatase activity

Dwajani S and Rupakala BM. Exploration and Comparison of Ovarian Copyright© Dwajani S and Rupakala BM.
Hormones with Anti-Mullerian Hormone amongst Women with
Polycystic Ovarian Syndrome. J Gynecol 2019, 4(2): 000179.
6
Open Access Journal of Gynecology

which is a characteristic feature for follicular arrest in technologies and female reproduction. Human
PCOS [32]. Since PCOS is leading cause of female Reproduction Update 17(6): 829-847.
infertility, it is therefore recommended that women who
experience these symptoms seek their gynecologist for 4. Teede H, Deeks A, Moran L (2010) Polycystic ovary
advice. Physicians must continue to highlight the syndrome: a complex condition with psychological,
importance dietary changes to include grains, vegetables reproductive and metabolic manifestations that
and fruits as prevention of PCOS. Dietary and lifestyle impact on health across the lifespan. BMC Medicine 8:
modifications of women must be looked at from all angles 41.
and their development to PCOS. As research calls it, “this
5. Azziz R, Woods KS, Reyna R, Key TJ, Knochenhauer
thief of womanhood” is been affecting women daily while
ES, et al. (2004) The prevalence and features of
more importance should be given on women living with
polycystic ovary syndrome in an unselected
PCOS [33]. Even though we live in a “gender-polarized”
population. J Clin Endocrinol Metab 89(6): 2745-
and advanced technological world, a young woman
2749.
without a menstrual cycle, psychological discomfort and
infertility problems can soon be sadly outnumbered with 6. Boomsma CM, Fauser BC, Macklon NS (2008)
our future children being computers, machines and Pregnancy complications in women with polycystic
robots [34]. ovary syndrome. Semin Reprod Med 26(1): 72-84.

Limitations of Study 7. Goldenberg N, Glueck C (2008) Medical therapy in

women with polycystic ovary syndrome before and
More detailed information on quality of life, life style during pregnancy and lactation. Minerva Ginecol
modifications and dietary changes would have added 60(1): 63-75.
more impact on this manuscript.
8. Moran LJ, Hutchison SK, Norman RJ, Teede HJ (2011)
Conclusion Lifestyle changes in women with polycystic ovary
syndrome. The Cochrane Library 16(2): CD007506.
From our results of present study, we conclude that
9. Trolice MP (2011) Defining prediabetes in polycystic
serum AMH levels are significantly increased in PCOS
ovarian syndrome. Open Journal of Obstetrics and
when compared to serum LH and FSH levels. Our findings
Gynecology 1: 36.
conclude that AMH can be considered as good clinical
parameters which can be used for diagnostic testing of 10. Chaoyang Li ESF, Guixiang Zhao, Mokdad Ali H
PCOS. (2008) Prevalence of Pre-Diabetes and Its Association
with Clustering of Cardio metabolic Risk Factors and
Acknowledgment Hyperinsulinemia Among U.S. Adolescents: National
Health and Nutrition Examination Survey 2005–2006.
Authors wish to sincerely thank our statistician Dr. R. Diabetes Care 32(2): 342-347.
Srivatsan and all the patients who gave their invaluable
contributions to this research 11. Goodarzi MO, Azziz R (2006) Diagnosis, epidemiology
and genetics of the polycystic ovary syndrome. Best
References Practice and Research 20(2): 193-205.

1. Legro RS, Strauss JF (2002) Molecular progress in 12. Hsu MI, Liou TH, Chou SY, Chang CY, Hsu CS (2007)
infertility: polycystic ovary syndrome. Fertil Steril Diagnostic criteria for polycystic ovary syndrome in
78(3): 569-576. Taiwanese Chinese women: comparison between
Rotterdam and NIH 1990. Fertil Steril 88(3): 727-729.
2. Kandarkis ED, Kandarakis H, Legro RS (2006) The
role of genes and environment in the etiology of 13. Rotterdam ESHRE/ASRM Sponsored PCOS Consensus
PCOS. Endocrine 30(1): 19-26. Workshop Group (2004) Revised 2003 consensus on
the diagnostic criteria and long term health risks
3. Fauser BCJM, Diedrich K, Bouchard P, Dominiguez F, related to polycystic ovary syndrome. Hum Reprod
Matzuk M, et al. (2011) Contemporary genetic 81(1): 19-25.

Dwajani S and Rupakala BM. Exploration and Comparison of Ovarian Copyright© Dwajani S and Rupakala BM.
Hormones with Anti-Mullerian Hormone amongst Women with
Polycystic Ovarian Syndrome. J Gynecol 2019, 4(2): 000179.
7
Open Access Journal of Gynecology

14. Carmina E (2004) Diagnosis of polycystic ovary 24. Polson DW, Wadsworth J, Adams J, Franks S (1988)
syndrome: from NIH criteria to ESHRE-ASRM Polycystic Ovaries: a common finding in normal
guidelines. Minerva ginecologica 56(1): 1-6. women. The Lancet 1(8590): 870-872.

15. Hart R, Hickey M, Franks S (2004) Definitions, 25. Cook CL, Siow Y, Brenner AG, Fallat ME (2002)
prevalence and symptoms of polycystic ovaries and Relationship between serum mullerian- inhibiting
polycystic ovary syndrome. Best Practice & Research substance and other reproductive hormones in
Clinical Obstetrics & Gynecology 18(5): 671-683. untreated women with polycystic ovarian syndrome
and normal women. Fertility and Sterility 77(1): 141-
16. Fallat ME, Siow Y, Marra M, Cook C, Carillo A (1997) 146.
Mullerian inhibiting substance in follicular fluid and
serum: a comparison of patients with tubal factor 26. Wei CL, Jayagopal V, Kilpatrick E, Holding S, Atkin SL
infertility, polycystic ovary syndrome and (2006) The LH/FSH ratio has little use in diagnosing
endometriosis. Fertil Steril 67(5): 962-965. polycystic ovarian syndrome. Annals Clinical Biochem
43(3): 217-219.
17. Cook CL, Siow Y, Brenner AG, Fallat ME (2002)
Relationship between serum mullerian- inhibiting 27. Stephanie Mohammed, Shivananda Nayak B (2017)
substance and other reproductive hormones in Exploration of ovarian hormones, diet and lifestyle of
untreated women with polycystic ovary syndrome women with Polycystic ovarian syndrome.
and normal women. Fertil Steril 77(1): 141-146. International Journal of Current Advanced Research
6(1): 1671-1675.
18. Laven JS, Mulders AG, Visser JA, Themmen AP, De
Jong FH, et al. (2004) Anti-Mullerian hormone serum 28. Balen AH, Conway GS, Kaltsas G, Techatrasak K,
concentrations in normoovulatory and anovulatory Manning PJ, et al. (1995) Polycystic ovary syndrome:
women of reproductive age. J Clin Endocrinol Metab the spectrum of the disorder in 1741 patients. Human
89: 318-323. Reproduction 10(8): 2107-2111.

19. Cate RL, Mattaliano RJ, Hession C, Tizard R, Farber 29. Chang WY, Knochenhauer ES, Bartolucci AA, Azziz R
NM, et al. (1986) Isolation of the bovine and human (2005) Phenotypic spectrum of polycystic ovarian
genes for Mullerian inhibiting substance and syndrome:clinical and biochemical characterization
expression of the human gene in animal cells. Cell of the three major clinical subgroups. Fertility
45(5): 685-698. Sterility 83(6): 1717-1723.

20. Durlinger AL, Gruijters MJ, Kramer P, Karels B, 30. Rondanelli M, Perna S, Faliva M, Monteferrario F,
Ingraham HA, et al. (2002) Anti-Mullerian hormone Repaci E, et al. (2014) Focus on metabolic and
inhibits initiation of primordial follicle growth in the nutritional correlates of polycystic ovary syndrome
mouse ovary. Endocrinology 143(3): 1076-1084. and update on nutritional management of these
critical phenomena. Archives of gynaecology and
21. Weenen C, Laven JS, Von Bergh AR, Cranfield M, obstetrics 290(6): 1079-1092.
Groome NP, et al. (2004) Anti-Mullerian hormone
expression pattern in the human ovary: potential 31. Alili A, Idrizi EA (2014) Clinical and Biochemical
implications for initial and cyclic follicle recruitment. characteristics in women with polycystic ovarian
Mol Hum Reprod 10: 77-83. syndrome in the region of Pollog, Republic of
Macedonia. European Scientific Journal.
22. Pigny P, Merlen E, Robert Y, Cortet Rudelli C, Decanter
C, et al. (2003) Elevated serum level of anti-mullerian 32. Douglas CC, Norris LE, Oster RA, Darnell BE, Azziz R,
hormone in patients with polycystic ovary syndrome: et al. (2006) Difference in dietary intake between
relationship to the ovarian follicle excess and to the women with polycystic ovary syndrome and healthy
follicular arrest. J ClinEndocrinol Metab 88(12): controls. Fertility and sterility 86(2): 411-417.
5957-5962.
33. Kitzinger C, Willmott J (2002) The thief of
23. Tulika Singh, Sanju Sharma, Seetharamiah Nagesh womanhood: women's experience of polycystic
(2017) Socio-economic status scales updated for ovarian syndrome. Social science & medicine 54(3):
2017. J Res Med Sci 5(7): 3264-3267. 349-361.

Dwajani S and Rupakala BM. Exploration and Comparison of Ovarian Copyright© Dwajani S and Rupakala BM.
Hormones with Anti-Mullerian Hormone amongst Women with
Polycystic Ovarian Syndrome. J Gynecol 2019, 4(2): 000179.
8
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34. Braun V, Wilkinson S (2005) Vagina equals woman? International Forum 28(6): 509-522.
On genitals and gendered identity. Women's Studies

Dwajani S and Rupakala BM. Exploration and Comparison of Ovarian Copyright© Dwajani S and Rupakala BM.
Hormones with Anti-Mullerian Hormone amongst Women with
Polycystic Ovarian Syndrome. J Gynecol 2019, 4(2): 000179.

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