A prospective study of anti-mullerian hormone and other ovarian and adrenal hormones in adult female acne

New insights into the relationship of antimüllerian hormone with polycystic ovary syndrome and its diagnostic accuracy: an updated and extended meta-analysis using a marginal beta-binomial model

OBJECTIVE

This study aimed to investigate the diagnostic role of antimüllerian hormone in polycystic ovary syndrome using an advanced marginal beta-binomial statistical model, and present the optimal cutoff by different age groups, geographical locations, body mass indexes, and other relevant factors.

DATA SOURCES

A comprehensive and systematic literature search was conducted in Web of Science, PubMed/Medline, Scopus, Cochrane Library, Embase, and ProQuest until August 2024.

STUDY ELIGIBILITY CRITERIA

Epidemiologic studies that used the Androgen Excess and Polycystic Ovary Syndrome Society, National Institutes of Health, or Rotterdam diagnostic criteria for polycystic ovary syndrome were included in this meta-analysis. Studies were eligible for inclusion if they provided information on the sensitivity and specificity of antimüllerian hormone or related data that allowed for the calculation of these parameters, and/or data on odds ratios and means.

METHODS

The diagnostic efficacy of antimüllerian hormone was assessed using the marginal beta-binomial statistical model and the summary receiver operating characteristic method in terms of pooled sensitivity, specificity, and diagnostic odds ratio with 95% confidence interval. Pooled weighted mean difference and pooled odds ratios with 95% confidence interval were estimated using a random effects model.

RESULTS

A total of 202 observational studies were included in the pooled analysis, of which 106 studies (including 19,465 cases and 29,318 controls) were used for meta-analysis of sensitivity/specificity and 186 studies (including 30,656 cases and 34,360 controls) for meta-analysis of mean difference. The pooled sensitivity, specificity, and diagnostic odds ratio for antimüllerian hormone were 0.79 (95% confidence interval, 0.52-0.97), 0.82 (95% confidence interval, 0.64-0.99), and 17.12 (95% confidence interval, 14.37-20.32), respectively. The area under the curve based on the summary receiver operating characteristic model was 0.90 (95% confidence interval, 0.87-0.93). Antimüllerian hormone levels were significantly higher in women with polycystic ovary syndrome than in control women (weighted mean difference, 4.91; 95% confidence interval, 4.57-5.27). In addition, individuals with higher antimüllerian hormone levels were more likely to be affected by polycystic ovary syndrome (odds ratio, 23.17; 95% confidence interval, 18.74-28.66; I2=94%; P<.001). A serum antimüllerian hormone concentration of >5.39 ng/mL was associated with polycystic ovary syndrome (sensitivity, 88.6%; specificity, 92.75%; likelihood ratio for a positive test result, 12.21; likelihood ratio for a negative test result, 0.12).

CONCLUSION

According to the results of this meta-analysis, serum antimüllerian hormone concentration is a valuable biomarker for the diagnosis of polycystic ovary syndrome. The cutoff points suggested by the current meta-analysis need to be evaluated and validated by future studies before their implementation into clinical practice.

Evaluating the diagnostic accuracy of androgen measurement in polycystic ovary syndrome: a systematic review and diagnostic meta-analysis to inform evidence-based guidelines

BACKGROUND

Biochemical hyperandrogenism is a hallmark and diagnostic feature of polycystic ovary syndrome (PCOS). However, the most accurate androgen measurement for assessing biochemical hyperandrogenism in PCOS diagnosis remains uncertain.

OBJECTIVE AND RATIONALE

This systematic review aimed to assess different androgen measures [including total testosterone (TT), calculated free testosterone (cFT), free androgen index (FAI), androstenedione (A4), dehydroepiandrosterone sulfate (DHEAS), and dihydrotestosterone (DHT)] for accuracy in diagnosing biochemical hyperandrogenism in women with PCOS, to inform the 2023 International PCOS Evidence-based Guidelines.

SEARCH METHODS

To update evidence from the 2018 International PCOS Guidelines, a systematic search from 3 July 2017 to 23 June 2023 was conducted across Medline (Ovid), CINAHL, all EBM, EMBASE, and PsycInfo for articles evaluating androgens in the diagnosis of biochemical hyperandrogenism. The revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) was used to assess the risk of bias and applicability. A diagnostic test accuracy meta-analysis was performed using STATA 18 software. Summary sensitivity and specificity were calculated with 95% CIs using the bivariate model, while the hierarchical summary receiver operating characteristics (ROC) model was used to produce a summary ROC curve.

OUTCOMES

Of 23 studies reviewed, 18 were included in the meta-analysis, with data from 2857 participants (1650 with PCOS and 1207 controls). For diagnosing biochemical hyperandrogenism in PCOS, the pooled sensitivity, specificity, and AUC with 95% CI were for TT: 0.74 (0.63-0.82), 0.86 (0.77-0.91), and 0.87 (0.84-0.90); cFT: 0.89 (0.69-0.96), 0.83 (0.79-0.86), and 0.85 (0.81-0.88); FAI: 0.78 (0.70-0.83), 0.85 (0.76-0.90), and 0.87 (0.84-0.90); A4: 0.75 (0.60-0.86), 0.71 (0.51-0.85), and 0.80 (0.76-0.83); and DHEAS: 0.75 (0.61-0.85), 0.67 (0.48-0.81), and 0.77 (0.73-0.81), respectively. In subgroup analyses, liquid chromatography with tandem mass spectrometry (LC-MS/MS) had superior sensitivity for measuring cFT, FAI, A4, and DHEAS, and superior specificity for measuring TT, cFT, and FAI, compared to the direct immunoassay method.

WIDER IMPLICATIONS

Our results directly informed the 2023 International PCOS Guideline recommendations to use TT and FT as the first-line laboratory tests to assess biochemical hyperandrogenism in the diagnosis of PCOS. cFT should be assessed by equilibrium dialysis or ammonium sulfate precipitation, or calculated using FAI. If TT or cFT are not elevated, A4 and DHEAS could also be considered, noting their poorer specificity. Laboratories should utilize LC-MS/MS for androgen measurement given its high accuracy. Future studies should focus on establishing optimal normative cut-off values in large, unselected, and ethnically diverse cohorts of women.

REGISTRATION NUMBER

The review protocol was prepublished in the 2023 PCOS Guideline Technical Report (https://www.monash.edu/__data/assets/pdf_file/0010/3379591/TechnicalReport-2023.pdf).

Anti-müllerian hormone as a diagnostic biomarker for polycystic ovary syndrome and polycystic ovarian morphology: a systematic review and meta-analysis

IMPORTANCE

As part of the 2023 international evidence-based polycystic ovary syndrome (PCOS) guideline, this meta-analysis investigated the inclusion of Anti-Müllerian hormone (AMH) levels in the diagnostic criteria for PCOS.

OBJECTIVE

To answer the following three questions: 1) Are AMH levels effective in diagnosing PCOS in adult women? 2) Are AMH levels effective in diagnosing PCOS in adolescents? Are AMH levels effective in diagnosing polycystic ovarian morphology (PCOM)?

DATA SOURCES

Searches were conducted in six databases until July 31, 2023.

STUDY SELECTION AND SYNTHESIS

Eligible studies were those conducted in humans, published in English, and reporting sensitivity, specificity, and/or area under the curve values. Extracted data included study population, age, body mass index, AMH assay, cut-off value of AMH levels, sensitivity, specificity, and area under the curve values. The risk of bias was assessed using the quality assessment of diagnostic accuracy studies tool. A random effects model was used to test diagnostic accuracy.

MAIN OUTCOMES

Pooled sensitivity and specificity to use AMH levels for PCOS diagnosis in adults as well as adolescents and for detecting PCOM in adults.

RESULTS

Eighty-two studies were included. The adult AMH-PCOS meta-analyses (n = 68) showed a pooled sensitivity and specificity of 0.79 (95% confidence interval [CI], 0.76-0.82; I2 = 86%) and 0.87 (95% CI, 0.84-0.89; I2 = 91%). The adolescent AMH-PCOS meta-analysis (n = 11) showed a pooled sensitivity and specificity of 0.66 (95% CI, 0.58-0.73; I2 = 74%) and 0.78 (95% CI, 0.71-0.83; I2 = 45%). The adult AMH-PCOM meta-analysis (n = 7) showed a pooled sensitivity and specificity of 0.79 (95% CI, 0.72-0.85; I2 = 94%) and 0.87 (95% CI, 0.78-0.93; I2 = 94%). CONCLUSION AND RELEVANCE: This study investigated the most profound change in the 2023 international evidence-based PCOS guideline, which now recommends AMH levels for defining PCOM in adults in accordance with the diagnostic algorithm. Antimüllerian hormone levels alone are insufficient for PCOS diagnosis and are nonspecific for PCOM in adolescents. Multiple factors influence AMH levels and cause heterogeneity as well as limitations in this study. Consequently, no international cut-off value could be recommended, emphasizing the need for research on more individualized cut-off values.

An updated clinico-investigative approach to diagnosis of cutaneous hyperandrogenism in relation to adult female acne, female pattern alopecia & hirsutism a primer for dermatologists

INTRODUCTION

Hyperandrogenism is a clinical state consequent to excess androgen production by the ovary, adrenals, or increased peripheral conversion of androgens. The varied manifestations of hyperandrogenism include seborrhea, acne, infertility, hirsutism, or overt virilization of which adult female acne, hirsutism, and female pattern hair loss are of clinical relevance to dermatologists.

AREAS COVERED

We limited our narrative review to literature published during period from 1 January 1985 to Dec 2022 and searched PubMed/MEDLINE, Web of Science (WOS), Scopus, and Embase databases with main search keywords were 'Hyperandrogenism,' 'Female,' 'Biochemical,' 'Dermatological', and 'Dermatology.' We detail the common etiological causes, nuances in interpretation of biochemical tests and imaging tools, followed by an algorithmic approach which can help avoid extensive tests and diagnose the common causes of hyperandrogenism.

EXPERT OPINION

Based on current data, total testosterone, sex hormone binding globulin, DHEAS, prolactin, free androgen index, and peripheral androgenic metabolites like 3-alpha diol and androsterone glucuronide are ideal tests though not all are required in all patients. Abnormalities in these biochemical investigations may require radiological examination for further clarification. Total testosterone levels can help delineate broadly the varied causes of hyperandrogenism. Serum AMH could be used for defining PCOM in adults.

Utility of Serum Anti-Müllerian Hormone Measurement as Part of Polycystic Ovary Syndrome Diagnosis

The 2023 international evidence-based guideline update for the assessment and management of polycystic ovary syndrome (PCOS) recommends using the Rotterdam criteria for the diagnosis of PCOS. The updated guideline has evidence-based recommendation for the diagnosis, and it now also includes serum anti-Müllerian hormone (AMH) measurement as an alternative tool for gynecological ultrasound to diagnose polycystic ovary morphology (PCOM). The aim of this new recommendation was to facilitate PCOS diagnostic workup in primary care and other disciplines, as currently most diagnosing is done in gynecology and infertility clinics. Here, we review factors affecting AMH levels as well as the utility of AMH in PCOS diagnosis. We identified relevant studies that report different cut-offs for AMH to diagnose PCOM as part of PCOS diagnosis. There are, however, some limitations when using AMH that should be acknowledged. These include physiological aspects like age, ethnicity, and obesity and iatrogenic causes like hormonal medication and ovarian surgery. Also reference ranges are different depending on AMH assay used. As a summary, we conclude that AMH is a usable tool in PCOM diagnostics, but it does not have a single cut-off. Therefore, further studies are needed to establish age and assay-based reference ranges.

Influencing of serum inflammatory factors on IVF/ICSI outcomes among PCOS patients with different BMI

Introduction

Overweight and obese are important factors leading to the occurrence of long-term complications in women with polycystic ovary syndrome (PCOS). There has been controversy over whether dissatisfaction with pregnancy outcomes in PCOS patients is influenced by chronic inflammatory status or obesity. This retrospective study analyzed the levels of inflammatory factors in PCOS patients with different body mass index (BMI) groups and effective predictors of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) pregnancy outcomes.

Methods

There were 273 women with PCOS diagnosed who completed serum inflammatory factors test between January 2017 and June 2022 were selected. The data of 7,649 infertility PCOS patients who received their first IVF/ICSI treatment in the Reproductive Center of Peking University Third Hospital during the period of the study were collected. Finally, 92 PCOS patients were included in the high BMI group, while 97 patients were included in the normal BMI group. Baseline characteristics were collected and the pregnancy outcomes were compared among the two groups. Then, serum inflammatory factors' effect on IVF/ICSI pregnancy outcomes were analyzed with age, anti-Mullerian Hormone (AMH) and BMI adjusted.

Results

PCOS patients in the high BMI group significantly had a lower number of oocytes retrieved and good quality embryos. The high BMI group PCOS patients had higher levels of IL-6 and lower cumulative clinical pregnancy and live birth rates. The level of GM-CSF was higher in the first cycle transfer and cumulative miscarriage group. High TNF-α was negatively correlated with the first transfer cycle and cumulative clinical pregnancy rates after age, AMH and high BMI adjusted. In addition, the cumulative live birth rate was negatively correlated with high IL-6, but the first cycle transfer and cumulative live birth rates were positively correlated with high IL-1β.

Discussion

For PCOS patients, in addition to BMI, attention should also be paid to inflammatory indicators. High levels of TNF-α and IL-6 were negatively correlated with pregnancy outcomes, but high IL-1β was positively correlated with live birth rates among PCOS patients. The level of GM-CSF was higher in miscarriage PCOS patients.

The Role of Serum Anti-Mullerian Hormone Measurement in the Diagnosis of Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common endocrinological disorder in women with significant reproductive, metabolic, and psychological health implications. The lack of a specific diagnostic test poses challenges in making the diagnosis of PCOS, resulting in underdiagnosis and undertreatment. Anti-Mullerian hormone (AMH) synthesized by the pre-antral and small antral ovarian follicles appears to play an important role in the pathophysiology of PCOS, and serum AMH levels are often elevated in women with PCOS. The aim of this review is to inform the possibility of utilizing anti-Mullerian hormone either as a diagnostic test for PCOS or as an alternative diagnostic criterion in place of polycystic ovarian morphology, hyperandrogenism, and oligo-anovulation. Increased levels of serum AMH correlate highly with PCOS, polycystic ovarian morphology, hyperandrogenism, and oligo/amenorrhea. Additionally, serum AMH has high diagnostic accuracy as an isolated marker for PCOS or as a replacement for polycystic ovarian morphology.

Updated meta-analysis on the diagnostic accuracy of serum anti-Mullerian hormone in poly cystic ovary syndrome involving 13 509 subjects

AIM

To determine the diagnostic accuracy of anti-Mullerian hormone (AMH) in the diagnosis of polycystic ovary syndrome (PCOS).

METHODS

Two independent reviewers searched the electronic databases and search engines using PubMed, Cochrane library, and Google Scholar systematically to retrieve relevant articles published from inception to September 2021. The diagnostic efficacy of AMH was computed using the random-effects model in terms of pooled sensitivity, specificity, and diagnostic odds ratio (DOR) with 95% confidence interval (CI). A meta-regression and subgroup analysis were performed to check for any source which could explain possible heterogeneity. Risk of bias assessment was conducted using the QUADAS-2 tool recommended by Cochrane Library.

RESULTS

This meta-analysis included a total of 41 studies involving 13 509 subjects. We observed promising pooled sensitivity 0.78 (95% CI 0.74 to 0.81), specificity 0.87 (95% CI 0.84 to 0.90), and diagnostic odds ratio (DOR) 24 (95% CI 15 to 37), for AMH in detecting PCOS and discriminatory power (summary receiver operating characteristic [SROC] curves, 0.89 [95% CI 0.86-0.92]). The most prominent bias was noted in the patient selection and index test assessment.

CONCLUSIONS

With the findings of this current meta-analysis, we conclude serum AMH to be a promising biomarker for the diagnosis of PCOS, however, substantial heterogeneity among studies needs individual patient data analysis in order to identify an optimal cut-off value and homogenous findings.

REGISTRATION NUMBER AND GUIDELINES

This meta-analysis was performed according to constructed protocol registered in the PROSPERO database with registration number CRD42021246910.