Anti-Müllerian hormone for the diagnosis and prediction of menopause: a systematic review

Impact of pembrolizumab on ovarian function in young triple-negative breast cancer patients treated with chemo-immunotherapy

PURPOSE

Pembrolizumab plus neoadjuvant chemotherapy (P-CT) is the new standard in early-stage triple-negative breast cancers (TNBC). Pembrolizumab impact on ovarian reserve remained unknown. We evaluated the impact of pembrolizumab on ovarian reserve, through plasmatic Anti-Müllerian (AMH) analysis, in young TNBC patients.

METHODS

TNBC patients < 43 years treated by P-CT (carboplatin/paclitaxel/epirubicin/cyclophosphamide plus pembrolizumab) of which plasma samples were available before and after treatment were included retrospectively (P-CT group). AMH, FSH, and estradiol were analyzed before and after treatment, then compared to a retrospective cohort of TNBC patients treated with chemotherapy alone (cyclophosphamide/anthracycline/taxanes) (No-P group).

RESULTS

P-CT patients (N = 17) and No-P patients (N = 62) had comparable median age, BMI, smoking exposure, BRCA status, oral hormonal contraceptive use at diagnosis, and baseline AMH. Drugs used were comparable in both groups, except for carboplatin and pembrolizumab, only used in P-CT group. One year after the start of treatment, AMH fell from 1.08 to 0.01 ng/mL (p = 0.0001) and from 1.39 to 0.018 ng/mL (p < 0.0001), in the P-CT and No-P groups, respectively, without difference according to pembrolizumab exposure (p = 0.25). 9/17 P-CT patients (53%), and 21/62 No-P patients (34%), had undetectable AMH after treatment (p = 0.25). FSH and estradiol were comparable between the two groups, before and after treatment.

CONCLUSION

No additional impact of pembrolizumab versus chemotherapy alone on AMH evolution was observed in TNBC patients < 43 years. Nevertheless, undetectable AMH 1 year after the start of treatment was common in the P-CT group. Larger studies are essential to confirm these preliminary results and assess long-term impact of pembrolizumab on ovarian reserve.

The role of anti-Müllerian hormone: insights into ovarian reserve, primary ovarian insufficiency, and menopause prediction

This review highlights the role of Anti-Müllerian Hormone (AMH) in ovarian insufficiency and as a predictor of menopause. AMH, produced by granulosa cells in growing follicles, is a key marker of ovarian reserve, reflecting the remaining pool of viable follicles. In cases of primary ovarian insufficiency (POI), AMH levels are significantly reduced, aiding in diagnosis and distinguishing POI from other causes of amenorrhea. AMH levels below 8 pmol/L have shown high sensitivity (85%) and specificity (100%) for diagnosing POI in women with secondary oligomenorrhea. Regarding ovarian aging, AMH declines steadily with age, serving as a reliable predictor of menopausal timing. AMH levels are linked to menopausal symptoms, particularly vasomotor symptoms like hot flashes and their severity. However, its reliability for diagnosing menopause is inconsistent, especially in younger populations or when determining the exact onset. AMH levels can predict an earlier onset of menopause with limited sensitivity and specificity, particularly when using age-specific concentrations, as lower age-specific AMH levels are associated with an earlier menopause onset. Tracking AMH over time can improve the prediction of menopause. The accuracy of AMH measurements can be enhanced when considered alongside other hormonal markers or clinical symptoms. In polycystic ovary syndrome (PCOS), elevated AMH levels suggest a delayed onset of menopause, indicating an approximately two-year longer reproductive lifespan compared to women without PCOS (mean menopause age: 51.4 years in PCOS cases vs. 49.7 years in healthy controls). In endometriosis, AMH levels generally decline after surgery; however, they remain stable after chemotherapy, even years later, indicating that the decline in ovarian reserve may not be significantly affected.

Premature ovarian insufficiency: addressing the most controversial issues

It was a true honor to be invited as President to deliver the Pieter Van Keep oration at the 2024 International Menopause Society (IMS) Congress in Melbourne, Australia. There was never any doubt that the topic of my lecture would be premature ovarian insufficiency (POI). POI is a condition which has been neglected for far too long given its greater global prevalence than originally estimated and its implications to the sufferers, both in terms of quality of life and long-term well-being. The hope is that we are now entering a new era of awareness given the recent update of the European Society of Human Reproduction (ESHRE) POI guideline, achieved through a partnership of the ESHRE, American Society for Reproductive Medicine (ASRM), Centre for Research Excellence in Women's Health in Reproductive Life (CRE WHiRL) at Monash University and IMS with support from numerous global stakeholder organizations. Whilst as a minimum the update of the guideline is expected to improve clinical management of this condition, the process has also identified key areas of much-needed research, where currently only practical guidance can be given due to the lack of data. The aim of my Pieter Van Keep lecture, and therefore this article, was not to replicate the extensive work already conducted to systematically review the literature for the guideline. The aim was to provide a state-of-the-art commentary highlighting the key controversial topics regarding this distressing condition, and how these are being addressed, or should be addressed in the future, for the sake of sufferers and their families.

Low anti-Müllerian hormone mediates the association between childhood trauma and PTSD in women but not in men

Women experience differential risk for childhood trauma and posttraumatic stress disorder (PTSD) when compared to men. Recent research has indicated lasting effects of childhood trauma across the lifespan and a bidirectional relationship between gonadal hormones like anti-Müllerian hormone (AMH) and PTSD that may help explain sex differences in PTSD. However, there is little data to support this hypothesized relationship, the potential direction of this relationship, or its effect in women and men across a large age range. The current study utilized a lifespan approach to examine the association between childhood trauma exposure and adulthood levels of AMH and PTSD symptoms. The current sample included 68 trauma-exposed veteran and non-veteran women (n = 27) and men (n = 41) aged 18-50 with clinical interview, self-report, and blood serum data, including 31 (47.0 %) participants with subthreshold-to-full PTSD. Adult trauma-exposed women had lower AMH levels (M=3.27 sqrt ng/mL) compared to trauma-exposed men (M=8.64 sqrt ng/mL; Hedge's g=1.26). Overall, sex was a critical moderator of the association between AMH and PTSD, demonstrating significant AMH-related effects for women but not for men. To evaluate the potential developmental impact of childhood trauma and bidirectional relationship between AMH and lifetime PTSD symptoms, two moderated mediation analyses were conducted, examining sex as the moderator and 1) AMH and 2) PTSD symptoms as alternative mediators. AMH levels (Indirect Effect β=.391) mediated the relationship between childhood trauma and lifetime PTSD symptom severity for women but not for men. Alternatively, lifetime PTSD symptoms did not significantly mediate the relationship between childhood trauma and AMH levels. Findings from this small trauma-exposed cohort offer preliminary evidence that links developmental exposures to premature gonadal dysfunction and stress pathophysiology across the lifespan, revealing a potentially unidirectional relationship in which greater childhood trauma exposure is associated with reduced AMH levels in adult women and may confer greater lifetime PTSD symptom severity.

Modeling the extension of ovarian function after therapeutic targeting of the primordial follicle reserve

BACKGROUND

Women are increasingly choosing to delay childbirth, and those with low ovarian reserves indicative of primary ovarian insufficiency are at risk for sub- and infertility and also the early onset of menopause. Experimental strategies that promise to extend the duration of ovarian function in women are currently being developed. One strategy is to slow the rate of loss of existing primordial follicles (PFs), and a second is to increase, or 'boost', the number of autologous PFs in the human ovary. In both cases, the duration of ovarian function would be expected to be lengthened, and menopause would be delayed. This might be accompanied by an extended production of mature oocytes of sufficient quality to extend the fertile lifespan.

OBJECTIVE AND RATIONALE

In this work, we consider how slowing physiological ovarian aging might improve the health and well-being of patients, and summarize the current state-of-the-art of approaches being developed. We then use mathematical modeling to determine how interventions are likely to influence the duration of ovarian function quantitatively. Finally, we consider efficacy benchmarks that should be achieved so that individuals will benefit, and propose criteria that could be used to monitor ongoing efficacy in different patients as these strategies are being validated.

SEARCH METHODS

Current methods to estimate the size of the ovarian reserve and its relationship to the timing of the menopausal transition and menopause were compiled, and publications establishing methods designed to slow loss of the ovarian reserve or to deliver additional ovarian PFs to patients were identified.

OUTCOMES

We review our current understanding of the consequences of reproductive aging in women, and compare different approaches that may extend ovarian function in women at risk for POI. We also provide modeling of primordial reserve decay in the presence of therapies that slow PF loss or boost PF numbers. An interactive online tool is provided that estimates how different interventions would impact the duration of ovarian function across the natural population. Modeling output shows that treatments that slow PF loss would need to be applied as early as possible and for many years to achieve significant delay of menopause. In contrast, treatments that add additional PFs should occur as late as possible relative to the onset of menopause. Combined approaches slowing ovarian reserve loss while also boosting numbers of (new) PFs would likely offer some additional benefits in delaying menopause.

WIDER IMPLICATIONS

Extending ovarian function, and perhaps the fertile lifespan, is on the horizon for at least some patients. Modeling ovarian aging with and without such interventions complements and helps guide the clinical approaches that will achieve this goal.

REGISTRATION NUMBER

Not applicable.

Adolescence to Midlife Exercise Trajectories and Age at Natural Menopause: A Population Study of 246 147 Women in Norway

OBJECTIVE

Lifestyle factors influence age at natural menopause, but the role of exercise remains uncertain. We aimed to identify adolescence to midlife exercise trajectories and study the associations of exercise trajectories with age at natural menopause.

DESIGN

Retrospective population-based cohort study.

SETTING

Self-administered questionnaires in the Norwegian breast cancer screening program (BreastScreen Norway) during the years 2005-2016.

POPULATION

A total of 246 147 women, aged 50-69 years.

METHODS

We used latent class mixed model analyses to identify distinct exercise trajectories from adolescence to midlife. The associations were estimated as hazard ratios using Cox proportional hazard models. Adjustments were made for year and country of birth, educational level, number of childbirths, smoking habits and body mass index. We identified four adolescence to midlife exercise trajectories: high (reference), increasing, decreasing and low exercise levels.

MAIN OUTCOME MEASURE

Age at natural menopause.

RESULTS

The adjusted hazard ratio of reaching menopause was highest for women with constantly low exercise levels as compared to women with constantly high exercise levels (adjusted hazard ratio 1.06, 95% CI: 1.05-1.07). Also, decreasing and increasing exercise levels were associated with higher hazards of reaching menopause (adjusted hazard ratios 1.02; 95% CI: 1.01-1.04 and 1.02; 95% CI: 1.00-1.03, respectively).

CONCLUSIONS

Women with low exercise levels from adolescence to midlife had the earliest menopause, and women with high exercise levels had the latest. However, the associations were weak, suggesting little influence of exercise on the large variation in age at menopause.

The Anti-Mullerian Hormone as a Biomarker of Effectiveness of Metformin Hydrochloride Therapy in Polycystic Ovarian Syndrome and Insulin Resistance

Background/Objectives: Among the therapeutic options available for managing PCOS, metformin improves insulin sensitivity, reduces androgen levels, and helps restore menstrual regularity and ovulation. While primarily used for its metabolic effects, metformin therapy may also influence reproductive parameters, including AMH levels, which are pivotal in improving ovarian function and predicting therapeutic outcomes in PCOS. The aim of this study was to search the scientific literature and analyze the correlation between AMH levels and metformin hydrochloride therapy in women with PCOS and IR. Methods: A systematic review of the scientific literature was conducted using the following keywords: polycystic ovarian syndrome, anti-Mullerian hormone, insulin resistance, metformin, treatment, biomarker, and metabolic syndrome. This review was aimed at investigating the potential of AMH as a biomarker of the effectiveness of metformin therapy in patients with PCOS and IR. Results: Metformin treatment in PCOS patients has shown significant reductions in serum AMH levels with prolonged therapy. As an insulin sensitizer, metformin improves insulin sensitivity, reduces hyperinsulinemia, and suppresses hyperandrogenism. This process inhibits the growth of antral follicles, which is reflected in decreased AMH levels. Conclusions: Reductions in AMH levels and improvements in insulin sensitivity can serve as indicators of treatment efficacy and enhancements in reproductive function for these patients. AMH could be considered a prognostic marker for evaluating the effectiveness of metformin therapy. A decrease in AMH levels following treatment may indicate improved ovarian function and a reduction in polycystic morphology. However, further research is necessary to confirm these findings and to determine the optimal dosages and duration of treatment.

Menopause: an opportunity to optimize health and well being for people with HIV

PURPOSE OF REVIEW

Menopause, defined as 12 months without menstruation, is a complex biopsychosocial transition. This review synthesizes current knowledge on menopause in individuals living with HIV, highlighting its clinical significance, research gaps, and approaches for optimizing care.

RECENT FINDINGS

Women and people with ovaries with HIV may experience menopause earlier, and with more severe vasomotor, mood, and musculoskeletal symptoms compared to people without HIV. Increasing severity of symptoms is associated with reduced quality of life and poorer engagement in HIV care. Additionally, estrogen depletion combined with HIV increases the risk of cardiometabolic disease and osteoporosis. Biomarkers like AMH have shown promise for assessing ovarian reserve in this population, but current evidence remains inconclusive. Menopause remains under-recognized in HIV care, with low rates of menopausal hormone therapy use and limited provider confidence in menopause management.

SUMMARY

Addressing menopause in people with HIV is vital for improving quality of life, supporting engagement in HIV care, and reducing comorbidity risk. Integrated and holistic care models, peer support, and focused research are essential to meet the needs of this growing population and close existing gaps in care.

Novel perspectives on growth hormone regulation of ovarian function: mechanisms, formulations, and therapeutic applications

Delayed childbearing has led to a continuous rise in the incidence of infertility because of social development and the evolving roles of women. Assisted reproductive technology (ART) has provided new opportunities for infertility treatment, such as the application of growth hormone (GH). GH regulates ovarian function through multiple pathways, improving follicular development and hormone secretion. However, traditional GH therapy is limited by issues such as low bioavailability and insufficient delivery efficiency. In recent years, drug delivery systems based on novel biomaterials have provided breakthrough solutions for the innovative application of GH in ART. This review summarizes the mechanisms by which GH affects ovarian endocrine function and focuses on the cutting-edge advancements in GH delivery systems with examination of the innovative applications of composite biomaterials in enhancing the therapeutic efficacy of GH. By analyzing the pharmacokinetic properties of novel formulations, the safety and long-term efficacy of their clinical applications can be evaluated. GH delivery systems based on novel biomaterials considerably improve the bioavailability and targeting of GH and could lead to innovative therapeutic strategies for preventing and treating ovarian dysfunction and related diseases. By integrating multidisciplinary research findings, we provide new insights into the field of reproductive medicine that could lead to theoretical and practical importance for promoting the innovative development of ART.

Bariatric Surgery Impact on Women with Polycystic Ovary Syndrome: A Prospective Cohort Study

Bariatric surgery has emerged as a promising intervention for obese women with polycystic ovary syndrome (PCOS), a condition strongly associated with obesity and anovulatory infertility. While weight management is a key therapeutic strategy, the optimal approach remains uncertain. A recent randomized controlled trial evaluated the impact of bariatric surgery on ovulation rates in obese women with PCOS. However, methodological limitations, including baseline body mass index discrepancies and minimal weight loss in the medical management group, necessitate cautious interpretation of the findings. To further investigate this issue, we conducted a prospective cohort study involving 192 women with PCOS who had undergone bariatric surgery. We assessed 30 reproductive and metabolic parameters at baseline and at 3, 6, and 12 months postoperatively. Most metabolic parameters improved significantly by 3 months postsurgery but plateaued thereafter, with only triglycerides and high-density lipoprotein cholesterol showing continued improvement. Reproductive outcomes demonstrated sustained improvements in ovulatory dysfunction, coinciding with a reduction in luteinizing hormone levels. However, testosterone levels and polycystic ovarian morphology showed limited improvement, while anti-Müllerian hormone levels remained unchanged. Despite the total weight loss exceeding 30%, further weight reduction did not proportionally enhance outcomes. These findings suggest that while bariatric surgery effectively improves metabolic health and ovulation in PCOS, its long-term hormonal and ovarian effects remain unclear and require further investigation. Head-to-head comparisons with emerging therapies are also urgently needed to refine weight management strategies for this high-risk population.

Ovarian Endometriosis Accelerates Premature Ovarian Failure and Contributes to Osteoporosis and Cognitive Decline in Aging Mice

Ovarian endometriosis (OEM) is a chronic inflammatory condition that impairs ovarian function. While its effects on ovarian reserve are well established, the long-term consequences of OEM on ovarian dysfunction, premature ovarian failure (POF), and systemic health, particularly in the context of accelerated aging, remain insufficiently studied. In this study, we employed an OEM mouse model and bulk RNA sequencing to investigate the underlying mechanisms. Our results show that OEM accelerates primordial follicle depletion and upregulates mTOR signaling pathway gene expression, along with mechanical stress and paracrine signaling via the Hippo and Myc pathways. OEM also induces irregular estrus and ovarian fibrosis in aging mice, decreases serum AMH levels, and increases FSH levels. Systemically, elevated serum IgG levels contribute to osteoporosis and cognitive decline, both linked to ovarian dysfunction and POF in OEM. These findings elucidate the mechanisms driving premature ovarian reserve depletion in OEM and highlight its broader systemic effects. This study emphasizes the importance of monitoring ovarian health and ectopic tissue to safeguard ovarian reserves and mitigate long-term risks such as osteoporosis and cognitive decline.

Health-related quality of life across menopausal stages among middle-aged Korean women

OBJECTIVES

We examined the health-related quality of life (HRQoL) during menopause transition (MT) among middle-aged Korean women.

METHODS

This cross-sectional study comprised 2,290 middle-aged women who completed web-based questionnaires between 2020 and 2022. Based on self-reported menstrual cycle patterns, menopause status was classified as premenopausal, early or late transition, or postmenopausal. HRQoL was assessed using the Patient-Reported Outcomes Measurement Information system, with all 29 items scored using a T-score metric. Multiple linear regression analyses were performed to investigate whether HRQoL varied based on MT stages. Antimüllerian hormone levels were used as an objective measure instead of self-reported menstrual status in the sensitivity analysis. Logistic regression models were used to estimate the prevalence ratios for moderate or severe HRQoL symptoms across menopausal stages.

RESULTS

The mean T-scores for anxiety, depression, and pain interference and intensity were significantly higher with advancing menopausal stage. Anxiety, depression, sleep disturbances, pain interference, and intensity were significantly and linearly positively correlated with MT stages after adjusting for potential confounders. Physical function significantly worsened in the late transition stage compared with premenopausal status ( β = -1.51 [95% CI, -2.72 to -0.31] in late MT and β = -1.92 [95% CI, -3.46 to -0.37] in postmenopause, P for trend = 0.007). However, no significant trends were observed in the sensitivity analysis using antimüllerian hormone levels. Women with moderate or severe symptoms in all domains except physical function had significantly higher prevalence ratios according to MT.

CONCLUSIONS

Overall HRQoL was lower with advancing menopausal stages. All symptoms should be monitored to control early transition symptoms. Thus, women undergoing MT should consistently assess and manage not only menopausal symptoms but also the overall quality of their health to prevent both menopause-specific and nonspecific conditions and their consequences.

The Genetics of Female and Male Infertility

BACKGROUND

An estimated 17% of all couples worldwide are involuntarily childless (infertile). The clinically identifiable causes of infertility can be found in the male or female partner or in both. The molecular pathophysiology of infertility still remains unclear in many cases but is increasingly being revealed by genetic analyses.

METHODS

This review article is based on pertinent publications retrieved by a selective literature search.

RESULTS

The clinical diagnostic evaluation of an infertile couple may yield an indication for genetic analysis. Women with premature ovarian insufficiency should undergo chromosomal analysis and study of the FMR1 gene. If congenital adrenal hyperplasia is suspected, the CYP21A2 gene should be investigated. In men, genetic diagnosis is based primarily on the findings of semen analysis. Klinefelter syndrome and deletions of the Y-chromosomal azoospermia factors may severely limit sperm production. In both male and female partners, the analysis of a gene panel selected on the basis of the individual indication may identify the cause of infertility, e.g., hypogonadotropic hypogonadism, premature ovarian insufficiency, or severe disturbances of spermatogenesis. In some cases, genetic analysis can help determine the likelihood of success of sperm retrieval via testicular biopsy in men, and the potential indication for oocyte cryopreservation in women.

CONCLUSION

Genetic causes, disease patterns, and the related investigations are becoming increasingly important in the diagnostic evaluation of infertile couples and have implications for further treatment, for the children of the affected couple, and for other family members.

Non-invasive markers of hepatic steatosis and fibrosis following INSTI initiation in women with HIV

BACKGROUND

The impact of integrase strand-transfer inhibitors (INSTIs) on steatotic liver disease in women with HIV (WWH) is unknown.

METHODS

Using data collected in the Women's Interagency HIV Study from 2007-2020, change in Fibrosis-4 index (FIB4), aspartate aminotransferase to platelet ratio index (APRI), and non-alcoholic fatty liver disease fibrosis score (NFS) over 5 years was compared between virologically-suppressed WWH who switched to or added an INSTI to their antiretroviral therapy (ART) and WWH remaining on non-INSTI ART. In participants with transient elastography (TE) measures, estimates of hepatic steatosis (controlled attenuation parameter, CAP), fibrosis (liver stiffness, LS), and steatohepatitis (FibroScan-aspartate aminotransferase scores, FAST) were compared by group.

RESULTS

A total of 872 WWH (323 INSTI, 549 non-INSTI) were included, and 280 (146 INSTI, 134 non-INSTI) had TE. Of these, 61% were Non-Hispanic Black; mean age was 47 years and body mass index was 31.4 kg/m2. Among non-obese women, those in the INSTI compared to the non-INSTI group had a greater increase in NFS (but not FIB4 or APRI) over time (study group*time, p=0.015). Those in the INSTI compared to non-INSTI group also had greater CAP (+25, 95%CI:0.28-49, p=0.048), LS (+1.23, 1.01-1.49, p=0.038), and FAST scores (+1.97, 1.17-3.31, p=0.011) and a 3.7 (1.2-11.4, p=0.021) greater odds of having hepatic steatosis (CAP≥248 dB/m) within 1 year of starting an INSTI.

CONCLUSIONS

Hepatic steatosis risk was increased only within the first year following INSTI initiation among WWH. Longitudinal hepatic assessments are warranted to evaluate whether these changes are associated with clinically significant liver disease.

Evolutionary Perspectives, Comparative Approaches, and the Lived Experience of Menopause

The purpose of this synthesis is to review age at menopause, symptom experience at midlife, and the evolution of menopause in a way that is helpful for biological anthropologists who are interested in the study of this challenging time of life. The synthesis begins with the biology of menopause, then shifts to the evolution of menopause with an emphasis on phylogenetic and adaptationist perspectives. Discussion of the biology and evolution of menopause incorporates a cross-species perspective, with particular attention to whales and primates. The synthesis continues with a cross-population review of variation in age at menopause. The final section is about symptom experience across populations with attention to the medical context of midlife, a focus on hot flashes, and consideration of the strengths and limitations of ethnographic and questionnaire-based research. The review ends with suggestions for where biological anthropology can make important contributions to the research of midlife and menopause.

The Clinical Utility of Measures of Ovarian Reserve

Importance

Measures of ovarian reserve, particularly anti-Müllerian hormone, have been increasingly and inaccurately utilized as "fertility tests." It is important to understand the available measures of ovarian reserve and how to appropriately interpret and integrate their use into clinical practice.

Objectives

The objectives of this article are to review the process of reproductive aging, define ovarian reserve, describe the available measures of ovarian reserve, and discuss the clinical utility of these measures.

Evidence Acquisition

A literature search was performed using the electronic database PubMed. Relevant guidelines, systematic reviews, and original research articles investigating ovarian reserve parameters and their clinical utility were reviewed.

Results

The fecundity of women gradually declines with increasing reproductive age as oocyte quantity and quality decline. Ovarian reserve is defined as the quantity of oocytes remaining in the ovary. Ovarian reserve can be measured indirectly with the use of serum blood tests or ultrasound imaging. Measures of ovarian reserve are clinically useful in several circumstances, particularly for use during fertility treatment and cycles of assisted reproductive technology. However, measures of ovarian reserve are poor predictors of reproductive potential and should not be used as "fertility tests."

Conclusions and Relevance

Measures of ovarian reserve are poor predictors of reproductive potential and should not be used as "fertility tests." Age remains a stronger predictor of reproductive success than measures of ovarian reserve.

Anti-Müllerian hormone regulates ovarian granulosa cell growth in PCOS rats through SMAD4

OBJECTIVE

Polycystic ovary syndrome (PCOS) is a diverse condition with an unknown cause. The precise mechanism underlying ovulatory abnormalities in PCOS remains unclear. It is widely believed that malfunction of granulosa cells is the primary factor contributing to aberrant follicular formation in PCOS.

METHODS

A DHEA-induced PCOS rat model was established, and ovarian granulosa cells were extracted and identified. Anti-Müllerian hormone (AMH) and SMAD family member 4 (SMAD4) expression was detected in the serum, ovarian tissue and ovarian granulosa cells of each group, and proliferating cell nuclear antigen (PCNA), BCL2-associated 2 (BAX), cleaved caspase-3 and BCL-2 protein expression was detected by Western blot in ovarian granulosa cells. Recombinant anti-Müllerian hormone (rAMH) was administered at different concentrations to act on normal rat ovarian granulosa cells, cell proliferation was detected by cell counting kit-8 (CCK-8), apoptosis was detected by flow cytometry, and SMAD4, caspase-3, BCL-2 and cyclin A proteins were detected by Western blot. SMAD4-siRNA was transfected into rat ovarian granulosa cells of the PCOS group, and PCNA and BAX were detected by Western blot.

RESULTS

Compared with those in the control group, the expression of AMH and SMAD4 was increased in the ovarian tissues and granulosa cells of rats in the PCOS group, the expression of PCNA and BCL-2 proteins was decreased in the ovarian granulosa cells of the PCOS group, the expression of BAX proteins was increased, and the expression of cleaved caspase-3 was increased. Western blot results indicated that rAMH upregulated SMAD4 and caspase-3 protein expression in granulosa cells and downregulated cyclin A and BCL-2 protein expression. CCK-8 and flow cytometry results indicated that AMH decreased granulosa cells proliferation and increased apoptosis. SiRNA knockdown of SMAD4 gene increased PCNA and BCL-2 protein expression in the granulosa cells of PCOS rats and decreased BAX and cleaved caspase-3 protein expression.

CONCLUSION

AMH may be involved in regulating impaired ovarian granulosa cells development in PCOS rats via SMAD4.

Evolutionary Perspectives, Comparative Approaches, and the Lived Experience of Menopause

The purpose of this synthesis is to review age at menopause, symptom experience at midlife, and the evolution of menopause in a way that is helpful for biological anthropologists who are interested in the study of this challenging time of life. The synthesis begins with the biology of menopause, then shifts to the evolution of menopause with an emphasis on phylogenetic and adaptationist perspectives. Discussion of the biology and evolution of menopause incorporates a cross-species perspective, with particular attention to whales and primates. The synthesis continues with a cross-population review of variation in age at menopause. The final section is about symptom experience across populations with attention to the medical context of midlife, a focus on hot flashes, and consideration of the strengths and limitations of ethnographic and questionnaire-based research. The review ends with suggestions for where biological anthropology can make important contributions to the research of midlife and menopause.

Antimüllerian hormone levels are associated with time to pregnancy in a cohort study of 3,150 women

OBJECTIVE

To study the association between antimüllerian hormone (AMH) levels and time of pregnancy. Although it has been hypothesized that serum AMH levels may indicate the chance of conception, findings have been mixed. Given that any association is expected to be modest, and it is possible that previous studies have been underpowered, we investigated this relationship in the largest prospective cohort to date.

DESIGN

Prospective time-to-pregnancy cohort study.

SETTING

Community.

PATIENT(S)

A total of 3,150 US women who had been trying to conceive for <3 months and had purchased a Modern Fertility hormone test.

INTERVENTION(S)

We developed a discrete time-to-event model using a binomial complementary log-log error structure within a generalized additive modeling framework, adjusting for confounding factors such as age, body mass index, parity, smoking status, polycystic ovary syndrome, and others. Sensitivity analyses were performed in women with regular menstrual cycles (21-35 days), who did not report using fertility treatments, using alternate AMH level categories (<0.7, 0.7-8.5, >8.5 ng/mL), and AMH levels as a continuous measure.

MAIN OUTCOME MEASURE(S)

Primary outcomes included cumulative conception probability within 12 cycles and relative fecundability per menstrual cycle. Conception was defined by a self-reported positive pregnancy test.

RESULT(S)

Participants contributed 7.21 ± 5.32 cycles, with 1,325 (42.1%) achieving a pregnancy. Women with low AMH levels (<1 ng/mL, n = 427) had a lower chance of natural conception (adjusted hazard ratio [adjHR], 0.77; 95% confidence interval [CI], 0.64-0.94) compared with women with normal AMH levels (1-5.5 ng/mL). There was no difference between high (5.5+ ng/mL) and normal AMH level categories (adjHR, 1.11; 95% CI, 0.94-1.31). The inclusion of AMH improved the model (net reclassification index 0.10 [0.06-0.14]). The instantaneous probability of conception was highest in cycle four across all AMH categories: the probability of natural conception was 11.2% (95% CI, 9.0-14.0) for low AMH levels, 14.3% (95% CI, 12.3-16.5) for normal AMH levels, and 15.7% (95% CI, 12.9-19.0) for high AMH levels. In the regular cycles sensitivity analysis (n = 1,791), the low AMH group had a lower chance of conception (adjHR, 0.77; 95% CI, 0.61-0.97) in the low AMH group compared with normal AMH, and similarly in the continuous model (adjHR, 0.90; 95% CI, 0.85-0.95).

CONCLUSION(S)

Low AMH levels (<1 ng/mL) are independently associated with a modest but significant reduction in the chance of conception.

Dissecting the shared genetic architecture between anti-Müllerian hormone and age at menopause based on genome-wide association study

BACKGROUND

While the phenotypic association between anti-Müllerian hormoneand age at menopause has been widely studied, the role of anti-Müllerian hormone in predicting the age at menopause is currently controversial, and the genetic architecture or causal relationships underlying these 2 traits is not well understood.

AIM

We aimed to explore the shared genetic architecture between anti-Müllerian hormone and age at menopause, to identify shared pleiotropic loci and genes, and to investigate causal association and potential causal mediators.

STUDY DESIGN

Using summary statistics from publicly available genome-wide association studies on anti-Müllerian hormone (N=7049) and age at menopause (N=201,323) in Europeans, we investigated the global genetic architecture between anti-Müllerian hormone and age at menopause through linkage disequilibrium score regression. We employed pleiotropic analysis under composite null hypothesis, Functional Mapping and Annotation of Genetic Associations, multimarker analysis of GenoMic annotation, and colocalization analysis to identify loci and genes with pleiotropic effects. Tissue enrichment analysis based on Genotype-Tissue Expression data was conducted using the Linkage Disequilibrium Score for the specific expression of genes analysis. Functional genes that were shared were additionally identified through summary data-based Mendelian randomization. The relationship between anti-Müllerian hormone and age at menopause was examined through 2-sample Mendelian randomization, and potential mediators were further explored using colocalization and metabolite-mediated analysis.

RESULTS

A positive genetic association (correlation coefficient=0.88, P=1.33×10-5) was observed between anti-Müllerian hormone and age at menopause. By using pleiotropic analysis under composite null hypothesis and Functional Mapping and Annotation of Genetic Associations, 42 significant pleiotropic loci were identified that were associated with anti-Müllerian hormone and age at menopause, and 10 of these (rs10734411, rs61913600, rs2277339, rs75770066, rs28416520, rs9796, rs11668344, rs403727, rs6011452, and rs62237617) had colocalized loci. Additionally, 245 significant pleiotropic genes were identified by multimarker analysis of GenoMic annotation. Genetic associations between anti-Müllerian hormone and age at menopause were markedly concentrated in various tissues including whole blood, brain, heart, liver, muscle, pancreas, and kidneys. Further, summary data-based Mendelian randomization analysis revealed 9 genes that may have a causative effect on both anti-Müllerian hormone and age at menopause. A potential causal effect of age at menopause on anti-Müllerian hormone was suggested by 2-sample Mendelian randomization analysis, with very-low-density lipoprotein identified as a potential mediator.

CONCLUSION

Our study revealed a shared genetic architecture between anti-Müllerian hormone and age at menopause, providing a basis for experimental investigations and individual therapies to enhance reproductive outcomes. Furthermore, our findings emphasized that relying solely on anti-Müllerian hormone is not sufficient for accurately predicting the age at menopause, and a combination of other factors needs to be considered. Exploring new therapeutics aimed at delaying at the onset of menopause holds promise, particularly when targeting shared genes based on their shared genetic architecture.

Huyang Yangkun formula regulates the mitochondria pathway of ovarian granulosa cell apoptosis through FTO/m6A-P53 pathway

Background

Premature ovarian insufficiency (POI) presents a significant challenge to female reproductive health. The Huyang Yangkun Formula (HYF), a traditional Chinese medicinal formulation, has been utilized in clinical settings for the treatment of POI for over a decade. Nevertheless, the therapeutic application of HYF is considerably constrained by the lack of clarity regarding its underlying mechanism of action.

Methods

The experimental procedures entailed administering VCD to female Sprague-Dawley rats at a dosage of 160 mg/kg/day over a period of 15 days, succeeded by a 100-day treatment with HYF. Blood serum samples were collected and analyzed using ELISA to quantify the concentrations of Anti-Müllerian Hormone (AMH), Follicle-Stimulating Hormone (FSH), and Estradiol (E2). The levels of N6-methyladenosine (m6A) were assessed through Dot blot analysis and liquid chromatography-tandem mass spectrometry (LC-MS/MS). Western blotting was employed to validate the differential expression of m6A-related catalytic enzymes and apoptosis-related regulators, including BCL-2, BCL-XL, and MCL-1, which may be implicated in the effects of HYF. Certain shRNA-COV434 cell line was constructed for the exploration of molecular mechanism, and then the potential targets were finally verified by MeRIP-qPCR.

Results

HYF has been identified as having a significant influence on the development of residual ovarian follicles in rats with POI, especially during the initial stages. It was observed that HYF facilitates the progression of escaping antral follicles to full maturation. Additionally, HYF exhibited the capacity to enhance the proliferation of COV434, a human ovarian granulosa cell line, while concurrently inhibiting apoptosis within these cells. Notably, HYF treatment resulted in the downregulation of apoptotic proteins, including BCL-XL, cleaved-caspase 9, cleaved-caspase 3, and Bcl-2. Concurrently, m6A modification is implicated in the regulation of HYF. Both in vitro and in vivo studies indicate that FTO may play a role in the anti-apoptotic mechanisms mediated by m6A in ovarian granulosa cells influenced by HYF. Moreover, employing qPCR and MeRIP-qPCR techniques, P53 has been identified as the target gene for m6A modification mediated by FTO.

Conclusion

These findings suggest that HYF holds promise as a potential treatment for POI and provide a more comprehensive understanding of the mechanism by which HYF operates, specifically its ability to prevent the BCL-2 mitochondrial apoptosis pathway mediated by P53 in ovarian granulosa cells of POI rats by regulating FTO/m6A-Tp53.

Successful Pregnancy in a Poor Responder: Natural In Vitro Fertilization, Menopause Treatment With Oral Contraceptives, and Anti-Müllerian Hormone as a Predictor

The study focuses on spontaneous conception after menopause in a woman with primary ovarian insufficiency (POI), with an emphasis on the role of anti-Müllerian hormone (AMH) in fertility management. This case involves a 33-year-old woman with POI who has experienced both aided and spontaneous pregnancies. She had low AMH and high follicle-stimulating hormone (FSH) levels, which typically indicate a limited ovarian reserve. Despite several unsuccessful in vitro fertilization (IVF) attempts, she ultimately conceived using a modified natural cycle (MNC). Later, while on oral contraception and nearing menopause, she conceived spontaneously, resulting in a viable pregnancy. This case highlights the unpredictability of POI, the relevance of AMH as a biomarker of ovarian reserve, and the potential for spontaneous conception even after menopause, emphasizing the need for individualized reproductive treatments in managing POI patients.

Society for endocrinology guideline for understanding, diagnosing and treating female hypogonadism

Female hypogonadism (FH) is a relatively common endocrine disorder in women of premenopausal age, but there are significant uncertainties and wide variation in its management. Most current guidelines are monospecialty and only address premature ovarian insufficiency (POI); some allude to management in very brief and general terms, and most rely upon the extrapolation of evidence from the studies relating to physiological estrogen deficiency in postmenopausal women. The Society for Endocrinology commissioned new guidance to provide all care providers with a multidisciplinary perspective on managing patients with all forms of FH. It has been compiled using expertise from Endocrinology, Primary Care, Gynaecology and Reproductive Health practices, with contributions from expert patients and a patient support group, to help clinicians best manage FH resulting from both POI and hypothalamo-pituitary disorders, whether organic or functional.

Ovarian reserve does not influence natural conception: insights from infertile women

PURPOSE

There is several albeit not univocal evidence suggesting that ovarian reserve is not related to the chance of natural pregnancy, provided that the remnant follicular pool is sufficient to ensure regular menstrual cycles. Nevertheless, available studies have some methodological limitations, and the issue cannot be considered definitively ascertained.

METHODS

To further address this issue, we retrospectively selected infertile women whose infertility diagnostic work-up was unremarkable (unexplained infertility-cases) and matched them by age and study period to a group of infertile women who were diagnosed with severe male infertility (controls). If ovarian reserve impacts on natural fertility, one had to expect lower ovarian reserve among women with unexplained infertility. Tested biomarkers included AMH, AFC and day 2-3 serum FSH. The primary aim was the frequency of women with serum AMH < 0.7 ng/ml.

RESULTS

Two-hundred fifty-two women with unexplained infertility and 252 women with male infertility were included. All biomarkers of ovarian reserve did not differ between the study groups. AMH levels < 0.7 ng/mL were observed in 26 (10%) women with unexplained infertility and 35 (14%) women with male infertility (p = 0.28). The adjusted OR was 0.76 (95% CI: 0.44-1.33). Significant differences did not also emerge when repeating this dichotomous analysis using other biomarkers and other thresholds for the definition of low-ovarian reserve.

CONCLUSION

This study confirms that ovarian reserve is unremarkable to natural conception. Physicians and patients should be aware of this concept to avoid inappropriate counseling and undue clinical decisions.

History of infertility and anti-Müllerian hormone levels among participants in the Nurses' Health Study II

OBJECTIVES

To better understand whether history of infertility is associated with anti-Müllerian hormone (AMH) levels later in life, outside of reproduction.

METHODS

Among 1,758 premenopausal women in the Nurses' Health Study II with measured AMH, we used multivariable generalized linear models to compare log-transformed plasma AMH for women with a history of infertility compared with fertile women. We investigated AMH levels by cause of infertility and effect modification by menstrual cycle regularity. Lastly, we investigated AMH levels by history of primary and secondary infertility and age at reported infertility.

RESULTS

Mean age at blood collection was 40 years. We observed no association between overall history of infertility and AMH levels (% difference AMH: -8.1% [CI, -19.4 to 4.8]). The association between overall infertility and AMH was strongest among women who first reported infertility at >30 years (-17.7% [CI, -32.1 to -0.3]).

CONCLUSIONS

Overall, we observed no association between the history of infertility and AMH levels later in life. However, specific subgroups of women with a history of infertility may have lower AMH levels throughout life compared with fertile women. This association was observed among subgroups, such as those who first experienced infertility at >30 years. These findings have implications for mechanisms through which infertility may be associated with premature menopause and chronic disease risk.

Factors affecting age at menopause and their relationship with ovarian reserve: a comprehensive review

OBJECTIVE

The aim of this article was to discuss all the factors affecting the age at menopause and their correlation with ovarian reserve.

MATERIALS AND METHODS

A narrative review of original articles was performed using PubMed until December 2023. The following keywords were used to generate the list of citations: 'menopause', 'ovarian reserve' 'oocytes quality and quantity', 'ovarian ageing'.

RESULTS

Menopause is the final step in the process of ovarian ageing and is influenced by the oocyte pool at birth. Conditions that accelerate follicle depletion during the reproductive lifespan lead to premature ovarian insufficiency (POI) and premature ovarian failure (POF), while a higher ovarian reserve is associated with a delayed time to menopause. Reproductive history, sociodemographic, lifestyle and iatrogenic factors may impact ovarian reserve and the age at menopause.

CONCLUSIONS

Some factors affecting the age at menopause are modifiable and the risks of early menopause may be preventable. We hypothesise that by addressing these modifiable factors we may also preserve ovarian reserve. However, further interventional studies are needed to evaluate the effects of the described strategies on ovarian reserve.

Preserving Fertility in People With Rheumatic Diseases

ABSTRACT

Rheumatology patients historically were told they "can't" or "shouldn't" become pregnant. Improved rheumatic diagnostics and treatments have led to decreased morbidity and mortality and increased quality of life resulting in an opportunity to focus on fertility and its preservation. In the same vein as rheumatic disease care, assisted reproductive technology (ART), which includes freezing of egg and sperm as well as in vitro fertilization, has made considerable strides in the recent past. ART is safe for those with rheumatic diseases and has comparable outcomes to the general public, but may take additional effort due to optimal timing, rheumatic medications, and other nuances. In a specialty that treats chronic inflammatory diagnoses using teratogens and gonadotoxins, it is important to address family building desires with patients so their goals can be met.Rheumatologists have little knowledge of ART and how it impacts or applies to their patients; however, patients want their rheumatologist to be the source of knowledge for this information (Arthritis Rheumatol. 2022;74:suppl 9). Many barriers to ART exist and will be explored, with the financial burden being paramount (Glob J Health Sci. 6;1:181-191). Future efforts to examine the future fertility of rheumatology patients in an era of biologics and "treat-to-target" are needed to better understand who would most benefit from this costly and not without risk medical treatment. Given the changing landscape of financial support for ART due to insurance mandates, rheumatologists should not modify counseling based on the anticipated ability of patients to afford care. Preservation should also be broached with patients without partners and those from the LGBTQAI+ community. In addition to expanding the education of rheumatologists regarding this topic and its incorporation into clinical care, advocacy for ART access and insurance coverage is a much-needed future direction.

Primary ovarian insufficiency: update on clinical and genetic findings

Primary ovarian insufficiency (POI) is a disorder of insufficient ovarian follicle function before the age of 40 years with an estimated prevalence of 3.7% worldwide. Its relevance is emerging due to the increasing number of women desiring conception late or beyond the third decade of their lives. POI clinical presentation is extremely heterogeneous with a possible exordium as primary amenorrhea due to ovarian dysgenesis or with a secondary amenorrhea due to different congenital or acquired abnormalities. POI significantly impacts non only on the fertility prospect of the affected women but also on their general, psychological, sexual quality of life, and, furthermore, on their long-term bone, cardiovascular, and cognitive health. In several cases the underlying cause of POI remains unknown and, thus, these forms are still classified as idiopathic. However, we now know the age of menopause is an inheritable trait and POI has a strong genetic background. This is confirmed by the existence of several candidate genes, experimental and natural models. The most common genetic contributors to POI are the X chromosome-linked defects. Moreover, the variable expressivity of POI defect suggests it can be considered as a multifactorial or oligogenic defect. Here, we present an updated review on clinical findings and on the principal X-linked and autosomal genes involved in syndromic and non-syndromic forms of POI. We also provide current information on the management of the premature hypoestrogenic state as well as on fertility preservation in subjects at risk of POI.

Bone Loss and Fractures in Post-Menopausal Women Living with HIV: A Narrative Review

INTRODUCTION

Post-menopausal women living with Human Immunodeficiency Virus (WLHIV) face an increased risk of bone fractures due to the relationship between HIV-related factors and menopause. This narrative review aims to summarise the current knowledge about fracture risk among post-menopausal WLHIV in particular looking at hormonal changes, combined antiretroviral therapy (cART), lifestyle factors, and psychosocial implications. We also profiled a summary of the significant, recent studies of post-menopausal WLHIV residing in low-income countries (LIC).

METHODS

A thorough search of the literature was performed across PubMed, Medline, Scopus, and Google Scholar, focussing on studies published between 2000 and 2024. Inclusion criteria entailed original research, reviews, and meta-analyses addressing bone mineral density (BMD), fracture incidence, and related risk factors in post-menopausal WLHIV.

RESULTS

The review identified 223 relevant studies. Post-menopausal WLHIV exhibit significantly lower BMD and higher fracture rates compared to both HIV-negative post-menopausal women and pre-menopausal WLHIV. cART, particularly tenofovir disoproxil fumarate (TDF), contributes to reduced BMD. Menopausal status exacerbates this risk through decreased oestrogen levels, leading to increased bone resorption. Moreover, lifestyle choices such as smoking, alcohol consumption, and low physical activity are more prevalent in PWHIV, which further elevates fracture risk. Different psychosocial factors may make WLWHIV more vulnerable at this stage of their life, such as depression, isolation, stigma, and housing and nutritional issues. Women living in LICs face a variety of challenges in accessing HIV care. There are gaps in research related to the prevalence of osteoporosis and bone loss in post-menopausal WLHIV in LICs.

CONCLUSION

Post-menopausal women living with HIV face a significantly higher risk of bone loss and fractures due to the combined effects of HIV and menopause. Antiretroviral therapy (particularly TDF), lifestyle factors, and psychosocial challenges exacerbate this risk. There is a need for careful selection of cART, hormone replacement therapy (HRT), and emerging treatments such as Abaloparatide. A holistic approach including lifestyle changes and psychosocial support is crucial to reduce fracture risk in WLHIV, especially in low-income countries.

Is There an Association Between Endometriosis, Early Menopause, and Cardiovascular Disease?

Large-scale studies show endometriosis linked to earlier menopause onset. Recent research targeting women with laparoscopically diagnosed endometriosis found an increase in cases of early natural menopause. Furthermore, recent large-scale cohort studies have found a correlation between endometriosis and an increased risk of cardiovascular disease (CVD). Understanding the causality of early menopause, particularly natural menopause, and cardiovascular risks in women with endometriosis could help medical professionals develop effective strategies for early prevention and new therapies. Endometriosis, early menopause, and cardiovascular risks may be linked by primary or secondary mechanisms. Primary mechanisms involve shared pathways that can lead to all morbidities, while secondary occur due to delayed consequences of management strategies. In these large-scale cohort studies, relevant risk and confounding factors, such as oophorectomy, were considered to refine estimates of associations. However, none of the studies considered endometriotic cystectomy, a globally accepted treatment for endometriosis-associated pelvic pain and infertility, as a mediating factor. There is substantial evidence to indicate that endometriotic cystectomy harms ovarian reserve and may lead to early menopause in cases of multiple surgeries or bilateral cases. Early menopause is a well-established risk factor for CVD. To thoroughly examine the link between endometriosis and early menopause, particularly natural menopause, and their connection with cardiovascular risks, it is imperative to consider all the possible factors that may affect the results, such as endometriotic cystectomy. This will enable us to obtain the most accurate and adjusted hazard ratio.

Women's interest, knowledge, and attitudes relating to anti-Mullerian hormone testing: a randomized controlled trial

STUDY QUESTION

What is the impact of co-designed, evidence-based information regarding the anti-Mullerian hormone (AMH) test on women's interest in having the test?

SUMMARY ANSWER

Women who viewed the evidence-based information about the AMH test had lower interest in having an AMH test than women who viewed information produced by an online company selling the test direct-to-consumers.

WHAT IS KNOWN ALREADY

Online information about AMH testing often has unfounded claims about its ability to predict fertility and conception, and evidence suggests that women seek out and are recommended the AMH test as a measure of their fertility potential.

STUDY DESIGN, SIZE, DURATION

An online randomized trial was conducted from November to December 2022. Women were randomized (double-blind, equal allocation) to view one of two types of information: co-designed, evidence-based information about the AMH test (intervention), or existing information about the AMH test from a website which markets the test direct-to-consumers (control). A total of 967 women were included in the final analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were women recruited through an online panel, who were aged 25-40 years, living in Australia or The Netherlands, had never given birth, were not currently pregnant but would like to have a child now or in the future, and had never had an AMH test. The primary outcome was interest in having an AMH test (seven-point scale; 1 = definitely NOT interested to 7 = definitely interested). Secondary outcomes included attitudes, knowledge, and psychosocial and behavioural outcomes relating to AMH testing.

MAIN RESULTS AND THE ROLE OF CHANCE

Women who viewed the evidence-based information about the AMH test had lower interest in having an AMH test (MD = 1.05, 95% CI = 0.83-1.30), less positive attitudes towards (MD = 1.29, 95% CI = 4.57-5.70), and higher knowledge about the test than women who viewed the control information (MD = 0.75, 95% CI = 0.71-0.82).

LIMITATIONS, REASONS FOR CAUTION

The sample was more highly educated than the broader Australian and Dutch populations and some measures (e.g. influence on family planning) were hypothetical in nature.

WIDER IMPLICATIONS OF THE FINDINGS

Women have higher knowledge of and lower interest in having the AMH test when given evidence-based information about the test and its limitations. Despite previous studies suggesting women are enthusiastic about AMH testing to learn about their fertility potential, we demonstrate that this enthusiasm does not hold when they are informed about the test's limitations.

STUDY FUNDING/COMPETING INTEREST(S)

This project was supported by an NHMRC Emerging Leader Research Fellowship (2009419) and the Australian Health Research Alliance's Women's Health Research, Translation and Impact Network EMCR award. B.W.M. reports consultancy for ObsEva and Merck and travel support from Merck. D.L. is the Medical Director of, and holds stock in, City Fertility NSW and reports consultancy for Organon and honoraria from Ferring, Besins, and Merck. K.H. reports consultancy and travel support from Merck and Organon. K.M. is a director of Health Literacy Solutions that owns a licence of the Sydney Health Literacy Lab Health Literacy Editor. No other relevant disclosures exist.

TRIAL REGISTRATION NUMBER

ACTRN12622001136796.

TRIAL REGISTRATION DATE

17 August 2022.

DATE OF FIRST PATIENT’S ENROLMENT

21 November 2022.

The impact of sickle cell disease and its treatment on ovarian reserve in reproductive-aged Black women

We compared serum anti-Mullerian hormone (AMH) levels in women with sickle cell disease (SCD) (n = 152) to those of Black comparison women (n = 128) between the ages of 20 and 45 years and evaluated the impact of hydroxyurea (HU) and iron overload on ovarian reserve in those with SCD. SCD treatment was abstracted from medical records. Linear regression models were fit to examine the relationship between log(AMH) and SCD, adjusting for age. The analysis was repeated to account for HU use (current, previous, never) and iron overload (ferritin ≥1000 ng/mL vs. <1000 ng/mL). AMH estimates among women with SCD were lower than those among comparison women (2.23, 95% confidence interval [CI] 1.80-2.76 vs. 4.12, 95% CI 3.11-5.45, respectively). Women with SCD who were currently using HU had 63% lower (95% CI 43-76) AMH values than comparison women; those with SCD with prior or no HU use also had lower AMH estimates than comparison women, but the difference was less pronounced. There were no differences in predicted AMH values among women with SCD for those with and without iron overload. Women with SCD and low AMH may have a shorter reproductive window and may benefit from referral to a reproductive specialist.

Genetic Prediction of Osteoporosis by Anti-Müllerian Hormone Levels and Reproductive Factors in Women: A Mendelian Randomization Study

Previous observational studies have suggested that anti-Müllerian hormone (AMH) and reproductive factors are linked to reduced bone mineral density (BMD) and an increased risk of osteoporosis (OP) in women. However, related studies are limited, and these traditional observational studies may be subject to residual confounders and reverse causation, while also lacking a more comprehensive observation of various reproductive factors. Univariate and multivariate two-sample Mendelian randomization analyses were conducted to determine the causal associations of AMH levels and six reproductive factors with BMD and OP, using the random-effects inverse-variance weighted method. Heterogeneity was assessed using Cochran's Q-statistic, and sensitivity analyses were performed to identify causal correlations. Age at menarche (AAM) was negatively associated with total body BMD (TB-BMD) in females aged 45-60 and over 60 years, as well as with heel bone mineral density (eBMD). Conversely, age at natural menopause (ANM) was positively associated with TB-BMD in the same age ranges and with eBMD. ANM was only causally associated with self-reported OP and showed no significant correlation with definitively diagnosed OP. Neither AMH level nor other reproductive factors were significantly associated with a genetic predisposition to BMD at any age and OP. Later AAM and earlier ANM are significantly genetically causally associated with decreased BMD but not with OP. AMH levels, length of menstrual cycle, age at first birth, age at last birth, and number of live births, in terms of genetic backgrounds, are not causally related to BMD or OP.

Postmortem tissue biomarkers of menopausal transition

The menopausal transition (MT) is associated with an increased risk for many disorders including neurological and mental disorders. Brain imaging studies in living humans show changes in brain metabolism and structure that may contribute to the MT-associated brain disease risk. Although deficits in ovarian hormones have been implicated, cellular and molecular studies of the brain undergoing MT are currently lacking, mostly due to a difficulty in studying MT in postmortem human brain. To enable this research, we explored 39 candidate biomarkers for menopausal status in 42 pre-, peri-, and post-menopausal subjects across three postmortem tissues: blood, the hypothalamus, and pituitary gland. We identified thirteen significant and seven strongest menopausal biomarkers across the three tissues. Using these biomarkers, we generated multi-tissue and tissue-specific composite measures that allow the postmortem identification of the menopausal status across different age ranges, including the "perimenopausal", 45-55-year-old group. Our findings enable the study of cellular and molecular mechanisms underlying increased neuropsychiatric risk during the MT, opening the path for hormone status-informed, precision medicine approach in women's mental health.

Social Media Promotion of Health Tests With Potential for Overdiagnosis or Overuse: Protocol for a Content Analysis

BACKGROUND

In recent years, social media have emerged as important spaces for commercial marketing of health tests, which can be used for the screening and diagnosis of otherwise generally healthy people. However, little is known about how health tests are promoted on social media, whether the information provided is accurate and balanced, and if there is transparency around conflicts of interest.

OBJECTIVE

This study aims to understand and quantify how social media is being used to discuss or promote health tests with the potential for overdiagnosis or overuse to generally healthy people.

METHODS

Content analysis of social media posts on the anti-Mullerian hormone test, whole-body magnetic resonance imaging scan, multicancer early detection, testosterone test, and gut microbe test from influential international social media accounts on Instagram and TikTok. The 5 tests have been identified as having the following criteria: (1) there are evidence-based concerns about overdiagnosis or overuse, (2) there is evidence or concerns that the results of tests do not lead to improved health outcomes for generally healthy people and may cause harm or waste, and (3) the tests are being promoted on social media to generally healthy people. English language text-only posts, images, infographics, articles, recorded videos including reels, and audio-only posts are included. Posts from accounts with <1000 followers as well as stories, live videos, and non-English posts are excluded. Using keywords related to the test, the top posts were searched and screened until there were 100 eligible posts from each platform for each test (total of 1000 posts). Data from the caption, video, and on-screen text are being summarized and extracted into a Microsoft Excel (Microsoft Corporation) spreadsheet and included in the analysis. The analysis will take a combined inductive approach when generating key themes and a deductive approach using a prespecified framework. Quantitative data will be analyzed in Stata SE (version 18.0; Stata Corp).

RESULTS

Data on Instagram and TikTok have been searched and screened. Analysis has now commenced. The findings will be disseminated via publications in peer-reviewed international medical journals and will also be presented at national and international conferences in late 2024 and 2025.

CONCLUSIONS

This study will contribute to the limited evidence base on the nature of the relationship between social media and the problems of overdiagnosis and overuse of health care services. This understanding is essential to develop strategies to mitigate potential harm and plan solutions, with the aim of helping to protect members of the public from being marketed low-value tests, becoming patients unnecessarily, and taking resources away from genuine needs within the health system.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56899.

Associations of anti-Müllerian hormone levels among women in their mid-30s with menopausal symptoms ~14 years later

OBJECTIVE

The aim of this study was to examine associations of anti-Müllerian hormone (AMH) levels in gravid women in their mid-30s with menopausal symptoms ~14 years later and age at natural menopause.

METHODS

In this prospective analysis, 474 participants in Project Viva, a longitudinal cohort, were enrolled during pregnancy between 1999 and 2002. AMH levels were determined using plasma samples collected 3 years postpartum. Participants completed the Menopause Rating Scale (MRS) and self-reported age at and reason for menopause at the 17 years postpartum visit (Mid-Life Visit). Primary outcomes were individual MRS item responses and total MRS score. To examine associations between AMH levels and menopausal outcomes, we performed linear and logistic regressions, and survival analyses, adjusting for confounding variables.

RESULTS

Mean (SD) AMH level was 2.80 (2.74) ng/mL, measured at 38.2 (3.9) years. At the Mid-Life Visit, mean (SD) age was 52.3 (3.9) years and total MRS score was 8.0 (5.7). During follow-up, 50% had experienced natural menopause, and self-reported mean (SD) age at natural menopause was 50.4 (3.6) years. AMH in the lowest tertile (mean [SD]: 0.47 [0.32] ng/mL) was associated with higher odds of moderate to severe vaginal dryness (adjusted odds ratio: 2.58; 95% CI: 1.16 to 5.73), a lower MRS psychological subscale (adjusted β: -0.71; 95% CI: -1.35 to -0.07), and earlier attainment of natural menopause (adjusted hazards ratio: 7.1; 95% CI: 4.6 to 11.0) compared with AMH in the highest tertile (mean [SD]: 6.01 [2.37] ng/mL).

CONCLUSIONS

Lower AMH in the mid-30s was associated with earlier menopause and increased odds of vaginal dryness but fewer psychological symptoms ~14 years later.

Can we predict menopause and premature ovarian insufficiency?

The prediction of menopause and premature ovarian insufficiency (POI) involves understanding the factors that contribute to the timing of these events. Menopause is a natural biological process marked by the cessation of menstrual periods, typically occurring around the age of 51. On the other hand, POI refers to the loss of ovarian function before the age of 40. Several factors have been used to predict menopause and POI such as age, antimüllerian hormone, inhibins and follicle-stimulating hormone serum levels, antral follicle counts, menstrual cycle length, and, recently, some genetic markers. It seems that age has the best predictive power and all the other ones are only adding in a very limited way to the prediction of menopause. Low levels of antimüllerian hormone in young women might indicate a greater risk for POI and could facilitate early diagnosis. It is, however, important to note that predicting the exact timing of menopause and POI is challenging, and individual variations are significant. Although these factors can provide some insights, they are not foolproof predictors. Advances in medical research and technology may lead to more accurate methods for predicting menopause and POI in the future.

Reproductive risk factors across the female lifecourse and later metabolic health

Metabolic health is characterized by optimal blood glucose, lipids, cholesterol, blood pressure, and adiposity. Alterations in these characteristics may lead to the development of type 2 diabetes mellitus or dyslipidemia. Recent evidence suggests that female reproductive characteristics may be overlooked as risk factors that contribute to later metabolic dysfunction. These reproductive traits include the age at menarche, menstrual irregularity, the development of polycystic ovary syndrome, gestational weight change, gestational dysglycemia and dyslipidemia, and the severity and timing of menopausal symptoms. These risk factors may themselves be markers of future dysfunction or may be explained by shared underlying etiologies that promote long-term disease development. Disentangling underlying relationships and identifying potentially modifiable characteristics have an important bearing on therapeutic lifestyle modifications that could ease long-term metabolic burden. Further research that better characterizes associations between reproductive characteristics and metabolic health, clarifies underlying etiologies, and identifies indicators for clinical application is warranted in the prevention and management of metabolic dysfunction.

BRCA Mutations and Fertility Preservation

Hereditary cancers mostly affect the adolescent and young adult population (AYA) at reproductive age. Mutations in BReast CAncer (BRCA) genes are responsible for the majority of cases of hereditary breast and ovarian cancer. BRCA1 and BRCA2 act as tumor suppressor genes as they are key regulators of DNA repair through homologous recombination. Evidence of the accumulation of DNA double-strand break has been reported in aging oocytes, while BRCA expression decreases, leading to the hypothesis that BRCA mutation may impact fertility. Moreover, patients exposed to anticancer treatments are at higher risk of fertility-related issues, and BRCA mutations could exacerbate the treatment-induced depletion of the ovarian reserve. In this review, we summarized the functions of both genes and reported the current knowledge on the impact of BRCA mutations on ovarian ageing, premature ovarian insufficiency, female fertility preservation strategies and insights about male infertility. Altogether, this review provides relevant up-to-date information on the impact of BRCA1/2 mutations on fertility. Notably, BRCA-mutated patients should be adequately counselled for fertility preservation strategies, considering their higher sensitivity to chemotherapy gonadotoxic effects.

Seasonal AMH variability implies a positive effect of UV exposure on the deterioration of ovarian follicles

Anti-Müllerian hormone (AMH) is produced exclusively by granulosa cells of ovarian follicles and is an indicator of ovarian reserve which declines with age. Seasonality in AMH levels have been reported to be correlated with variations in Vitamin D levels, which is dependent on sunlight exposure. However, the effects of age and its association with solar radiation intensity with respect to AMH was never studied before. In this study, we investigated the relationship between AMH levels with season and with solar radiation intensity in a cohort of 2235 women aged 19-40 years undergoing hormonal work-up over a four-year period. Our findings revealed that among women aged 20-29 years, there was no significant association between AMH levels and either season or solar radiation intensity. However, for women aged 30-40 years, a seasonal pattern was observed, with higher AMH levels during spring and autumn months characterized by moderate solar radiation intensity. Women in their declining ovarian reserve age were found to be more sensitive to the effects of moderate solar radiation. Moderate solar radiation exposure positively impacted AMH levels, whereas low and high intensity exposure had a negative effect. Our findings indicate that age and solar radiation intensity must be considered when assessing AMH levels and provide valuable insights into the intricate relationship between AMH, seasonality, and UVB exposure in the context of reproductive health.

The 2023 Practitioner's Toolkit for Managing Menopause

OBJECTIVE

The Practitioner's Toolkit for Managing the Menopause, developed in 2014, provided an accessible desk-top tool for health-care practitioners caring for women at midlife. To ensure the Toolkit algorithms and supporting information reflect current best practice, the Toolkit has been revised in accordance with the published literature.

METHODS

A systematic search for guidelines, position and consensus statements pertaining to the menopause and published after 2014 was undertaken, and key recommendations extracted from the Clinical Practice Guidelines determined to be the most robust by formal evaluation. The peer-reviewed literature was further searched for identified information gaps.

RESULTS

The revised Toolkit provides algorithms that guide the clinical assessment and care of women relevant to menopause. Included are the reasons why women present, information that should be ascertained, issues that may influence shared decision-making and algorithms that assist with determination of menopausal status, menopause hormone therapy (MHT) and non-hormonal treatment options for symptom relief. As clear guidelines regarding when MHT might be indicated to prevent bone loss and subsequent osteoporosis in asymptomatic women were found to be lacking, the Toolkit has been expanded to support shared decision-making regarding bone health.

CONCLUSIONS

The 2023 Toolkit and supporting document provide accessible desk-top information to support health-care providers caring for women at midlife.The Toolkit has been endorsed by the International Menopause Society, Australasian Menopause Society, British Menopause Society, Endocrine Society of Australia and Jean hailes for Women's Health.

Making a good egg: human oocyte health, aging, and in vitro development

Mammalian eggs (oocytes) are formed during fetal life and establish associations with somatic cells to form primordial follicles that create a store of germ cells (the primordial pool). The size of this pool is influenced by key events during the formation of germ cells and by factors that influence the subsequent activation of follicle growth. These regulatory pathways must ensure that the reserve of oocytes within primordial follicles in humans lasts for up to 50 years, yet only approximately 0.1% will ever be ovulated with the rest undergoing degeneration. This review outlines the mechanisms and regulatory pathways that govern the processes of oocyte and follicle formation and later growth, within the ovarian stroma, through to ovulation with particular reference to human oocytes/follicles. In addition, the effects of aging on female reproductive capacity through changes in oocyte number and quality are emphasized, with both the cellular mechanisms and clinical implications discussed. Finally, the details of current developments in culture systems that support all stages of follicle growth to generate mature oocytes in vitro and emerging prospects for making new oocytes from stem cells are outlined.

Menopause-Biology, consequences, supportive care, and therapeutic options

Menopause is the cessation of ovarian function, with loss of reproductive hormone production and irreversible loss of fertility. It is a natural part of reproductive aging. The physiology of the menopause is complex and incompletely understood. Globally, menopause occurs around the age of 49 years, with geographic and ethnic variation. The hormonal changes of the menopause transition may result in both symptoms and long-term systemic effects, predominantly adverse effects on cardiometabolic and musculoskeletal health. The most effective treatment for bothersome menopausal symptoms is evidence-based, menopausal hormone therapy (MHT), which reduces bone loss and may have cardiometabolic benefits. Evidence-based non-hormonal interventions are also available for symptom relief. Treatment should be individualized with shared decision-making. Most MHT regimens are not regulator approved for perimenopausal women. Studies that include perimenopausal women are needed to determine the efficacy and safety of treatment options. Further research is crucial to improve menopause care, along with research to guide policy and clinical practice.

Circulating bile acid profile characteristics in PCOS patients and the role of bile acids in predicting the pathogenesis of PCOS

Background

The metabolic profile of bile acids and their potential role as biomarkers in the pathogenesis of polycystic ovary syndrome (PCOS) have not been thoroughly characterized. Assessing their predictive value for PCOS is of significant importance.

Methods

In this study, we enrolled 408 women with PCOS and 204 non-PCOS controls. The serum bile acid profile was measured using high-performance liquid chromatography-tandem mass spectrometry (LC/MS). We analyzed the differences in serum bile acid profiles between PCOS patients using the OPLS-DA model. Additionally, we examined the relationship between bile acid profiles and parameters related to glucose metabolism and hyperandrogenism. ROC analysis was employed to identify potential biomarkers for PCOS pathogenesis. XGboost was utilized for cross-validation.

Results

The bile acid profile was found to be altered in PCOS patients. Specifically, the primary and secondary unconjugated bile acid fractions were significantly higher in the PCOS population. We identified five bile acid metabolite candidates that exhibited the most significant differences between PCOS and non-PCOS controls. DCA was associated with deposition index, fasting and postprandial insulin but was influenced by testosterone. CDCA and LCA combined with testosterone showed potential as biomarkers for the pathogenesis of PCOS.

Conclusion

The circulating bile acid profile undergoes changes in PCOS. DCA is associated with deposition index, fasting and postprandial insulin and its level is influenced by testosterone. CDCA and LCA combined with testosterone have the potential to serve as biomarkers for the pathogenesis of PCOS.

Websites Selling Direct-to-Consumer Anti-Mullerian Hormone Tests

Importance

The recent provision of direct-to-consumer (DTC) Anti-Mullerian Hormone (AMH) testing in several countries has been contentious, particularly due to concerns about judicious testing and informed consent.

Objective

To describe and analyze information on websites that sell DTC AMH tests.

Design, Setting, and Participants

Qualitative study including content analysis of text information from websites in multiple countries that sell AMH tests DTC. The top 50 search results from 4 different internet search strings were captured and reviewed for eligibility. Data were extracted in March 2022 and analyzed from April 2022 to July 2023.

Main outcomes and measures

Themes and categories were derived from the website content using a conventional inductive approach, with a particular focus on information content, quality and accuracy, as well as the tone and language used.

Results

Twenty-seven websites across 7 different countries formed the sample for analysis. Information varied considerably across websites and was organized into 6 overarching categories: (1) whether a test description was included (25 websites [93%]); (2) statements about what the test can do, which included indicating ovarian reserve (26 websites [96%]) and indicating likelihood of conceiving (20 websites [74%]); (3) statements about the usefulness of the test result, which included enabling women to adjust their reproductive timeline (11 websites [41%]) and determining whether egg freezing was a viable option (8 websites [30%]); (4) blood collection method (ie, through a laboratory or an at-home sample); (5) promotion tactics, such as stating the convenience of testing (24 websites [89%]) and using language promoting empowerment and control (7 websites [26%]); and (6) statements about limitations of the test, which included polycystic ovary syndrome falsely inflating AMH levels (13 websites [48%]) and that it cannot accurately predict chances of conceiving (9 websites [33%]).

Conclusion and relevance

In this qualitative study including content analysis, most websites selling DTC AMH tests included false and misleading claims which might lead consumers to purchase an AMH test in the belief that it can reliably predict fertility potential and age of menopause. Depending on the test result, this may in turn lead to misplaced anxiety or reassurance about one's fertility and modifications to subsequent conception or contraceptive plans and behavior.

AMH and other markers of ovarian function in patients with Turner syndrome - a single center experience of transition from pediatric to gynecological follow up

Turner syndrome (TS) is a chromosomal disorder that affects about 1 in 2500 female births and is characterized by the partial or complete absence of the second X chromosome. Depending on karyotype, TS is associated with primary ovarian insufficiency (POI). Approximately 50% of girls with a mosaic 45, X/46, XX karyotype may enter puberty spontaneously, but only 5-10% of women with TS achieve pregnancy without egg donation. In this review, we will evaluate the clinical use of markers of ovarian function in TS patients. Based on longitudinal studies of serum concentrations of reproductive hormones as well as ovarian morphology in healthy females and patients with TS, we will evaluate how they can be applied in a clinical setting. This is important when counseling patients and their families about future ovarian function essential for pubertal development and fertility. Furthermore, we will report on 20 years of experience of transition from pediatric to gynecological and adult endocrinological care in our center at Rigshospitalet, Copenhagen, Denmark.

Antimüllerian Hormone as a Tool to Predict the Age at Menopause

This study aimed to assess an eligible cut-off value of anti-Müllerian hormone (AMH) to detect ovarian senescence in a group of premenopausal Greek women to evaluate the possible link between AMH-values and the severity of climacteric symptoms during a follow-up of 24 months. This study included 180 women (group A, 96 women of late reproductive stage/early perimenopause; group B, 84 women in late perimenopause). We measured AMH blood levels and assessed climacteric symptoms using the Greene scale. Log-AMH is inversely associated with postmenopausal status. The AMH cut-off of 0.012 ng/mL predicts the postmenopausal status with a sensitivity of 24.2% and specificity of 30.5%. The postmenopausal stage associated with age (OR = 1.320, 95%CI: 1.084-1.320) and AMH (values ≥ vs. <0.012 ng/mL, OR = 0.225, 95%CI: 0.098-0.529, p-value < 0.001). Moreover, the severity of vasomotor symptoms (VMS) was only associated inversely with AMH (b-coefficient = -0.272, p-value = 0.027). In conclusion, AMH levels measured in the late premenopausal period are inversely associated with the time to ovarian senescence. In contrast, AMH levels measured in the perimenopausal period are inversely associated only with the severity of VMS. Therefore, a cut-off of 0.012 ng/mL predicts menopause with low sensitivity and specificity, making it challenging to use in a clinical setting.