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Iwase A, Asada Y, Sugishita Y, Osuka S, Kitajima M, Kawamura K. Anti-Müllerian hormone for screening, diagnosis, evaluation, and prediction: A systematic review and expert opinions. J Obstet Gynaecol Res 2024; 50:15-39. [PMID: 37964401 DOI: 10.1111/jog.15818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/12/2023] [Indexed: 11/16/2023]
Abstract
AIM To present evidence-based recommendations for anti-Müllerian hormone (AMH) measurement as an ovarian reserve test. METHODS A systematic literature search for the clinical utility of AMH was conducted in PubMed from its inception to August 2022 to identify studies, including meta-analyses, reviews, randomized controlled trials, and clinical trials, followed by an additional systematic search using keywords. Based on this evidence, an expert panel developed clinical questions (CQs). RESULTS A total of 1895 studies were identified and 95 articles were included to establish expert opinions subdivided into general population, infertility treatment, primary ovarian insufficiency, polycystic ovary syndrome, surgery, and oncofertility. We developed 13 CQs and 1 future research question with levels of evidence and recommendations. CONCLUSION The findings of the current systematic review covered the clinical utility of AMH including its screening, diagnosis, evaluation, and prediction. Although some clinical implications of AMH remain debatable, these expert opinions may help promote a better understanding of AMH and establish its clinical significance.
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Affiliation(s)
- Akira Iwase
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | - Yodo Sugishita
- Department of Frontier Medicine, Institute of Medical Science, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Satoko Osuka
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Michio Kitajima
- Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuhiro Kawamura
- Department of Obstetrics and Gynaecology, Juntendo University Faculty of Medicine, Tokyo, Japan
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Li H, Hart JE, Mahalingaiah S, Nethery RC, James P, Bertone-Johnson E, Eliassen AH, Laden F. Environmental Exposures and Anti-Müllerian Hormone: A Mixture Analysis in the Nurses' Health Study II. Epidemiology 2023; 34:150-161. [PMID: 36455251 PMCID: PMC9720700 DOI: 10.1097/ede.0000000000001547] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Previous studies have linked environmental exposures with anti-Müllerian hormone (AMH), a marker of ovarian reserve. However, associations with multiple environment factors has to our knowledge not been addressed. METHODS We included a total of 2,447 premenopausal women in the Nurses' Health Study II (NHSII) who provided blood samples during 1996-1999. We selected environmental exposures linked previously with reproductive outcomes that had measurement data available in NHSII, including greenness, particulate matter, noise, outdoor light at night, ultraviolet radiation, and six hazardous air pollutants (1,3-butadiene, benzene, diesel particulate matter, formaldehyde, methylene chloride, and tetrachloroethylene). For these, we calculated cumulative averages from enrollment (1989) to blood draw and estimated associations with AMH in adjusted single-exposure models, principal component analysis (PCA), and hierarchical Bayesian kernel machine regression (BKMR). RESULTS Single-exposure models showed negative associations of AMH with benzene (percentage reduction in AMH per interquartile range [IQR] increase = 5.5%, 95% confidence interval [CI] = 1.0, 9.8) and formaldehyde (6.1%, 95% CI = 1.6, 10). PCA identified four major exposure patterns but only one with high exposure to air pollutants and light at night was associated with lower AMH. Hierarchical BKMR pointed to benzene, formaldehyde, and greenness and suggested an inverse joint association with AMH (percentage reduction comparing all exposures at the 75th percentile to median = 8.2%, 95% CI = 0.7, 15.1). Observed associations were mainly among women above age 40. CONCLUSIONS We found exposure to benzene and formaldehyde to be consistently associated with lower AMH levels. The associations among older women are consistent with the hypothesis that environmental exposures accelerate reproductive aging.
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Affiliation(s)
- Huichu Li
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Jaime E. Hart
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Shruthi Mahalingaiah
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Rachel C. Nethery
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Peter James
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, USA
- Division of Chronic Disease Research Across the Lifecourse (CoRAL), Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Elizabeth Bertone-Johnson
- Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
| | - A. Heather Eliassen
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Francine Laden
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
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Aydogan Mathyk B, Cetin E, Yildiz BO. Use of anti-Müllerian hormone for understanding ovulatory dysfunction in polycystic ovarian syndrome. Curr Opin Endocrinol Diabetes Obes 2022; 29:528-534. [PMID: 36218229 DOI: 10.1097/med.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to understand how anti-Müllerian hormone (AMH) contributes to ovulatory dysfunction in polycystic ovarian syndrome (PCOS). RECENT FINDINGS In the last few years, new findings have emerged on AMH and its role on the central nervous system causing ovulatory dysfunction. SUMMARY Anovulation is a prominent feature of PCOS. Women with anovulatory PCOS have higher AMH levels than in ovulatory PCOS. Higher levels of AMH may contribute to the pathophysiology of PCOS through central and peripheral actions. Once universal standardization is achieved to measure serum AMH, the benefits would be significant in diagnosing women with PCOS.
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Affiliation(s)
- Begum Aydogan Mathyk
- Department of Obstetrics and Gynecology, HCA/University of South Florida Morsani College of Medicine GME, Brandon Regional Hospital, Brandon, Florida
| | - Esra Cetin
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois, USA
| | - Bulent O Yildiz
- Division of Endocrinology and Metabolism, Hacettepe University School of Medicine, Hacettepe, Ankara, Turkey
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Raeisi-Dehkordi H, Kummer S, Francis Raguindin P, Dejanovic G, Eylul Taneri P, Cardona I, Kastrati L, Minder B, Voortman T, Marques-Vidal P, Dhana K, Glisic M, Muka T. Risk Prediction Models of Natural Menopause Onset: A Systematic Review. J Clin Endocrinol Metab 2022; 107:2934-2944. [PMID: 35908226 DOI: 10.1210/clinem/dgac461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Predicting the onset of menopause is important for family planning and to ensure prompt intervention in women at risk of developing menopause-related diseases. OBJECTIVE We aimed to summarize risk prediction models of natural menopause onset and their performance. METHODS Five bibliographic databases were searched up to March 2022. We included prospective studies on perimenopausal women or women in menopausal transition that reported either a univariable or multivariable model for risk prediction of natural menopause onset. Two authors independently extracted data according to the CHARMS (critical appraisal and data extraction for systematic reviews of prediction modelling studies) checklist. Risk of bias was assessed using a prediction model risk of bias assessment tool (PROBAST). RESULTS Of 8132 references identified, we included 14 articles based on 8 unique studies comprising 9588 women (mainly Caucasian) and 3289 natural menopause events. All included studies used onset of natural menopause (ONM) as outcome, while 4 studies also predicted early ONM. Overall, there were 180 risk prediction models investigated, with age, anti-Müllerian hormone, and follicle-stimulating hormone being the most investigated predictors. Estimated C-statistic for the prediction models ranged from 0.62 to 0.95. Although all studies were rated at high risk of bias mainly due to the methodological concerns related to the statistical analysis, their applicability was satisfactory. CONCLUSION Predictive performance and generalizability of current prediction models on ONM is limited given that these models were generated from studies at high risk of bias and from specific populations/ethnicities. Although in certain settings such models may be useful, efforts to improve their performance are needed as use becomes more widespread.
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Affiliation(s)
- Hamidreza Raeisi-Dehkordi
- Institute of Social and Preventive Medicine (ISPM), University of Bern, 3012 Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, 3012 Bern, Switzerland
| | - Stefanie Kummer
- Institute of Social and Preventive Medicine (ISPM), University of Bern, 3012 Bern, Switzerland
| | - Peter Francis Raguindin
- Institute of Social and Preventive Medicine (ISPM), University of Bern, 3012 Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, 3012 Bern, Switzerland
- Swiss Paraplegic Research, 6207, Nottwil, Switzerland
| | - Gordana Dejanovic
- Institute of Social and Preventive Medicine (ISPM), University of Bern, 3012 Bern, Switzerland
| | - Petek Eylul Taneri
- School of Nursing and Midwifery, National University of Ireland, Galway H91 CF50, Ireland
- HRB-Trials Methodology Research Network, National University Of Ireland, Galway H91 CF50, Ireland
| | - Isabel Cardona
- Institute of Social and Preventive Medicine (ISPM), University of Bern, 3012 Bern, Switzerland
- Department of Obstetrics and Gynaecology, McGill University Health Center, McGill University, Montreal H4A 3J1, Canada
| | - Lum Kastrati
- Institute of Social and Preventive Medicine (ISPM), University of Bern, 3012 Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, 3012 Bern, Switzerland
| | - Beatrice Minder
- Public Health & Primary Care Library, University Library of Bern, University of Bern, 3012 Bern, Switzerland
| | - Trudy Voortman
- Department of Epidemiology, Erasmus MC, University Medical Center, 3000 CA Rotterdam, the Netherlands
- Division of Human Nutrition and Health, Wageningen University & Research, 6708 PB Wageningen, the Netherlands
| | - Pedro Marques-Vidal
- Department of Medicine, Internal Medicine, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne CH-1015, Switzerland
| | - Klodian Dhana
- Section on Nutrition and Nutritional Epidemiology, Department of Internal Medicine, Rush University, Chicago, IL 60612, USA
| | - Marija Glisic
- Institute of Social and Preventive Medicine (ISPM), University of Bern, 3012 Bern, Switzerland
- Swiss Paraplegic Research, 6207, Nottwil, Switzerland
| | - Taulant Muka
- Institute of Social and Preventive Medicine (ISPM), University of Bern, 3012 Bern, Switzerland
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Karlamangla AS, Shieh A, Greendale GA, Yu EW, Burnett-Bowie SAM, Sluss PM, Martin D, Morrison A, Finkelstein JS. Anti-Mullerian Hormone as Predictor of Future and Ongoing Bone Loss During the Menopause Transition. J Bone Miner Res 2022; 37:1224-1232. [PMID: 35373854 PMCID: PMC9283201 DOI: 10.1002/jbmr.4525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 01/19/2022] [Accepted: 02/02/2022] [Indexed: 01/28/2023]
Abstract
The menopause transition in women is a period of significant bone loss, with rapid declines in bone mineral density (BMD) commencing a year before the final menstrual period (FMP). Changes in menstrual bleeding patterns cannot reliably tell us if this rapid bone loss has begun or is imminent. We hypothesized that low circulating levels of anti-Mullerian hormone (AMH), which decline as women approach the FMP, would be associated with future and ongoing rapid bone loss. We used data from The Study of Women's Health Across the Nation, a multisite, multi-ethnic, prospective cohort study of the menopause transition to test this hypothesis. Adjusted for age, body mass index, race/ethnicity, and study site, every 50% decrement in AMH level in premenopause and early perimenopause was associated with 0.14% per year faster decline over the following 3 to 4 years in lumbar spine BMD and 0.11% per year faster decline in femoral neck BMD (p < 0.001 for both). AMH in late perimenopause was not associated with the rate of future BMD decline. AMH was also associated with the magnitude of ongoing bone loss, measured as percent of peak BMD lost by the end of the next 2 to 3 years. Every 50% decrement in AMH level was associated with 0.22% additional loss in spine BMD in premenopause, 0.43% additional loss in early perimenopause, and 0.50% additional loss in late perimenopause (p < 0.001 for all three). If a woman will lose more of her peak BMD than the site-specific least significant change (LSC) at either the lumbar spine or femoral neck by the next 2 to 3 years, then AMH below 100 pg/mL will detect it with sensitivity of 50% in premenopause, 80% in early perimenopause, and 98% in late perimenopause. These findings suggest that AMH measurement can help flag women at the brink of significant bone loss for early intervention. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Arun S Karlamangla
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Albert Shieh
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Gail A Greendale
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Elaine W Yu
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Patrick M Sluss
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Joel S Finkelstein
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Marlatt KL, Pitynski-Miller DR, Gavin KM, Moreau KL, Melanson EL, Santoro N, Kohrt WM. Body composition and cardiometabolic health across the menopause transition. Obesity (Silver Spring) 2022; 30:14-27. [PMID: 34932890 PMCID: PMC8972960 DOI: 10.1002/oby.23289] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/15/2021] [Accepted: 08/09/2021] [Indexed: 12/23/2022]
Abstract
Every year, 2 million women reach menopause in the United States, and they may spend 40% or more of their life in a postmenopausal state. In the years immediately preceding menopause-known as the menopause transition (or perimenopause)-changes in hormones and body composition increase a woman's overall cardiometabolic risk. In this narrative review, we summarize the changes in weight, body composition, and body fat distribution, as well as the changes in energy intake, energy expenditure, and other cardiometabolic risk factors (lipid profile, glucose metabolism, sleep health, and vascular function), that occur during the menopause transition. We also discuss the benefits of lifestyle interventions in women in the earlier stages of menopause before these detrimental changes occur. Finally, we discuss how to include perimenopausal women in research studies so that women across the life-span are adequately represented.
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Affiliation(s)
- Kara L. Marlatt
- Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Dori R. Pitynski-Miller
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Eastern Colorado VA Health Care System, Geriatric Research Education and Clinical Center (GRECC), Denver, Colorado, USA
| | - Kathleen M. Gavin
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Eastern Colorado VA Health Care System, Geriatric Research Education and Clinical Center (GRECC), Denver, Colorado, USA
| | - Kerrie L. Moreau
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Eastern Colorado VA Health Care System, Geriatric Research Education and Clinical Center (GRECC), Denver, Colorado, USA
| | - Edward L. Melanson
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Eastern Colorado VA Health Care System, Geriatric Research Education and Clinical Center (GRECC), Denver, Colorado, USA
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Wendy M. Kohrt
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Eastern Colorado VA Health Care System, Geriatric Research Education and Clinical Center (GRECC), Denver, Colorado, USA
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7
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Denis-Laroque L, Drouet Y, Plotton I, Chopin N, Bonadona V, Lornage J, Salle B, Lasset C, Rousset-Jablonski C. Anti-müllerian hormone levels and antral follicle count in women with a BRCA1 or BRCA2 germline pathogenic variant: A retrospective cohort study. Breast 2021; 59:239-247. [PMID: 34304065 PMCID: PMC8326804 DOI: 10.1016/j.breast.2021.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/05/2021] [Accepted: 07/08/2021] [Indexed: 12/22/2022] Open
Abstract
Background Some studies suggested a decreased ovarian reserve among BRCA1/2 pathogenic variant carriers, with conflicting results. Methods We conducted a retrospective single-center observational study of ovarian reserve and spontaneous fertility comparing BRCA1/2 pathogenic variant carriers to controls (women who attended consultations to discuss fertility preservation before gonadotoxic treatment). Measures of associations between plasma AMH concentration, AFC and BRCA1/2 status were modelled by nonlinear generalized additive regression models and logistic regressions adjusted for age at plasma storage, oral contraceptive use, body mass index, cigarette smoking, and the AMH assay technique. Results The whole population comprised 119 BRCA1/2 pathogenic variant carriers and 92 controls. A total of 110 women (42 carriers, among whom 30 were cancer-free, and 68 controls) underwent an ovarian reserve evaluation. Spontaneous fertility analysis included all women who previously attempted to become pregnant (134 women). We observed a tendency towards a premature decrease in ovarian reserve in BRCA1/2 pathogenic variant carriers, but no difference in mean AMH or AFC levels was found between BRCA1/2 pathogenic variant carriers and controls. An analysis of the extreme levels of AMH (≤5 pmol/l) and AFC (≤7 follicles) by logistic regression suggested a higher risk of low ovarian reserve among BRCA1/2 pathogenic variant carriers (adjusted odds ratio (OR) = 3.57, 95% CI = 1.00–12.8, p = 0.05; and adjusted OR = 4.99, 95% CI = 1.10–22.62, p = 0.04, respectively). Discussion Attention should be paid to BRCA1/2 pathogenic variant carriers’ ovarian reserve, considering this potential risk of premature alteration. A tendency towards a premature decrease in the ovarian reserve in BRCA1/2 pathogenic variant carriers was found. BRCA1/2 pathogenic variant carriers presented a higher risk of a low ovarian reserve. Information and education regarding reproduction is mandatory among BRCA1/2 pathogenic variant carriers.
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Affiliation(s)
- Laurie Denis-Laroque
- Centre Léon Bérard, Department of Surgical Oncology, 28 rue Laënnec, 69008, Lyon, France
| | - Youenn Drouet
- Centre Léon Bérard, Département Prévention et Santé Publique, 28, Rue Laënnec, Lyon, 69008, France; CNRS UMR 5558, Laboratoire de Biométrie et Biologie évolutive, 16, rue Raphael Dubois, Villeurbanne Cedex, 69622, France
| | - Ingrid Plotton
- Hormonology and Molecular Endocrinology, Biology and Est Pathology Center, Hospices Civils de Lyon, 69500, U1208, Université Claude Bernard Lyon1, Bron, France
| | - Nicolas Chopin
- Centre Léon Bérard, Department of Surgical Oncology, 28 rue Laënnec, 69008, Lyon, France
| | - Valérie Bonadona
- Centre Léon Bérard, Département Prévention et Santé Publique, 28, Rue Laënnec, Lyon, 69008, France; CNRS UMR 5558, Laboratoire de Biométrie et Biologie évolutive, 16, rue Raphael Dubois, Villeurbanne Cedex, 69622, France
| | - Jacqueline Lornage
- Hospices Civils de Lyon, Groupement Hospitalier Est, Service de Médecine de La Reproduction, Bron, France
| | - Bruno Salle
- Hospices Civils de Lyon, Groupement Hospitalier Est, Service de Médecine de La Reproduction, Bron, France
| | - Christine Lasset
- Centre Léon Bérard, Département Prévention et Santé Publique, 28, Rue Laënnec, Lyon, 69008, France; CNRS UMR 5558, Laboratoire de Biométrie et Biologie évolutive, 16, rue Raphael Dubois, Villeurbanne Cedex, 69622, France
| | - Christine Rousset-Jablonski
- Centre Léon Bérard, Department of Surgical Oncology, 28 rue Laënnec, 69008, Lyon, France; Hospices Civils de Lyon, Lyon Sud University Hospital, Department of Obstetrics and Gynecology, 165 Chemin Du Grand Revoyet, 69310, Pierre-Bénite, France; Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon 1, France.
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8
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Evaluation of a new automated immunoassay for the quantification of anti-Müllerian hormone. Pract Lab Med 2021; 25:e00220. [PMID: 34095410 PMCID: PMC8145750 DOI: 10.1016/j.plabm.2021.e00220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/08/2021] [Indexed: 12/04/2022] Open
Abstract
Objectives A newly developed fully automated Lumipulse G AMH method (Fujirebio Diagnostics) was recently introduced in clinical laboratories for quantitative determination of anti-Müllerian hormone (AMH) level in human serum or plasma. AMH has emerged as value-added biomarker in the assessment of ovarian reserve, in diagnosis of granulosa cells cancer and in the investigation of gonadal disorders. We compared Lumipulse G AMH assay performances with other methods largely applied for AMH measurements. Design and Methods The Lumipulse G AMH method based on two-step sandwich chemiluminescence enzyme immunoassay was assessed on Lumipulse G600II analyzer. The evaluation study included imprecisions, sensitivity and linearity whereas a comparison study was performed on a heterogeneous population of 114 patients by using the Elecsys AMH Plus assay on COBAS 8000 e602 module (Roche Diagnostics). Results Lumipulse G AMH system showed good repeatability (within-run imprecision) with CV values below 1% (0.5% and 0.9% for high and low serum pools). Similarly within-laboratory imprecision was assessed with CV values of 2.5% and 1.6% for high and low level controls respectively. A linearity regression formula of 1.0119x-0.067 with a coefficient of determination (r2) equal to 0.999 was obtained in a range from 0.044 to 22.42 ng/ml. Passing-Bablok regression analysis was performed for assay comparability of AMH measurements. Results were closely correlated (correlation coefficient = 0.997) with a regression equation (y = 1.230x-0.025) showing a positive slope. Also, Bland-Altman analysis confirmed a good agreement between Lumipulse G AMH and Roche Elecsys AMH Plus assays with a bias of 17.76% in a large measurement range. Conclusions The performance of Lumipulse G AMH system was highly comparable with that of Roche Elecsys AMH Plus assay although approximately 10% higher values of AMH levels were observed for Lumipulse AMH system at all range of concentrations. Nevertheless the Lumipulse G system seems to be largely suitable for quantitative determination of AMH level in small-scale laboratory because of the reduced size and the use of single cartridge per test assuring flexibility and easy handling.
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Soares AG, Kilpi F, Fraser A, Nelson SM, Sattar N, Welsh PI, Tilling K, Lawlor DA. Longitudinal changes in reproductive hormones through the menopause transition in the Avon Longitudinal Study of Parents and Children (ALSPAC). Sci Rep 2020; 10:21258. [PMID: 33277550 PMCID: PMC7718240 DOI: 10.1038/s41598-020-77871-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 10/23/2020] [Indexed: 11/26/2022] Open
Abstract
We characterised changes in reproductive hormones-LH, FSH, SHBG and AMH-by chronological age and time around the menopause (reproductive age) in mid-life women and explored their associations with lifestyle and reproductive factors. We used data from 1608 women from a UK cohort who had repeat hormone measures and experienced a natural menopause. Multilevel models were used to assess: (i) changes in hormones (outcomes) by reproductive age and chronological age (these age variables being the key exposures) and (ii) associations of body mass index (BMI), smoking, alcohol intake, parity and age at menarche with changes in hormones by reproductive age. Both LH and FSH increased until ~ 5 and 7 years postmenopause, respectively, after which they declined, but not to premenopausal levels. SHBG decreased slightly until ~ 4 years postmenopause and increased thereafter. AMH decreased markedly before menopause and remained low subsequently. For all hormones, the best fitting models included both reproductive and chronological age. BMI, smoking and parity were associated with hormone changes; e.g., higher BMI was associated with slower increase in LH and FSH and decrease in AMH. Reproductive and chronological age contribute to changes in LH, FSH, SHBG and AMH across mid-life in women, and BMI, smoking and parity are associated with these hormone changes.
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Affiliation(s)
- Ana Goncalves Soares
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK.
- Population Health Science, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK.
| | - Fanny Kilpi
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Science, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
| | - Abigail Fraser
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Science, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
| | - Scott M Nelson
- Bristol NIHR Biomedical Research Centre, Bristol, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Paul I Welsh
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Kate Tilling
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Science, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
| | - Deborah A Lawlor
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
- Population Health Science, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
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Oktay KH, Bedoschi G, Goldfarb SB, Taylan E, Titus S, Palomaki GE, Cigler T, Robson M, Dickler MN. Increased chemotherapy-induced ovarian reserve loss in women with germline BRCA mutations due to oocyte deoxyribonucleic acid double strand break repair deficiency. Fertil Steril 2020; 113:1251-1260.e1. [PMID: 32331767 DOI: 10.1016/j.fertnstert.2020.01.033] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess whether woman who have BRCA mutations (WBM) experience more declines in ovarian reserve after chemotherapy treatment, as it induces oocyte death by deoxyribonucleic acid (DNA) damage, and BRCA mutations result in DNA damage repair deficiency. DESIGN Longitudinal cohort study. SETTING Academic centers. PATIENT(S) The 108 evaluable women with breast cancer were stratified into those never tested (negative family history; n = 35) and those negative (n = 59) or positive (n = 14) for a pathogenic BRCA mutation. INTERVENTION(S) Sera were longitudinally obtained before and 12-24 months after chemotherapy treatment, assayed for antimüllerian hormone (AMH), and adjusted for age at sample collection. MAIN OUTCOME MEASURE(S) Ovarian recovery, defined as the geometric mean of the after chemotherapy age-adjusted AMH levels compared with baseline levels. RESULT(S) Compared with the controls, the before chemotherapy treatment AMH levels were 24% and 34% lower in those negative or positive for BRCA mutations, consistent with accelerated ovarian aging in WBM. The WBM had a threefold difference in AMH recovery after chemotherapy treatment (1.6%), when compared with BRCA negative (3.7%) and untested/low risk controls (5.2%). Limiting the analysis to the most common regimen, doxorubicin and cyclophosphamide followed by paclitaxel, showed similar results. These findings were mechanistically confirmed in an in vitro mouse oocyte BRCA knockdown bioassay, which showed that BRCA deficiency results in increased oocyte susceptibility to doxorubicin. CONCLUSION(S) Women who have pathogenic BRCA mutations are more likely to lose ovarian reserve after chemotherapy treatment, suggesting an emphasis on fertility preservation. Furthermore, our findings generate the hypothesis that DNA repair deficiency is a shared mechanism between aging, infertility, and cancer. CLINICAL TRIAL REGISTRATION NUMBER NCT00823654.
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Affiliation(s)
- Kutluk H Oktay
- Department of Obstetrics and Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut.
| | - Giuliano Bedoschi
- Department of Obstetrics and Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | | | - Enes Taylan
- Department of Obstetrics and Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Shiny Titus
- Department of Obstetrics and Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Glenn E Palomaki
- Department of Pathology and Laboratory Medicine, Women & Infants Hospital and Alpert Medical School at Brown University, Providence, Rhode Island
| | - Tessa Cigler
- Weill Medical College of Cornell University, New York, New York
| | - Mark Robson
- Memorial Sloan Kettering Cancer Center, New York, New York
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ACOG Committee Opinion No. 773: The Use of Antimüllerian Hormone in Women Not Seeking Fertility Care. Obstet Gynecol 2020; 133:e274-e278. [PMID: 30913198 DOI: 10.1097/aog.0000000000003162] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Antimüllerian hormone is produced by the granulosa cells surrounding each oocyte in the developing ovarian follicle. The production and serum levels of antimüllerian hormone at any given time are reflective of a woman's ovarian reserve, and multiple studies have demonstrated that antimüllerian hormone levels decline across the reproductive lifespan. Data exist to support the use of antimüllerian hormone levels for the assessment of ovarian reserve in infertile women and to select ovarian stimulation protocols in this population; however, using serum antimüllerian hormone levels for fertility counseling in women without a diagnosis of infertility is not currently supported by data from high-quality sources. The obstetrician-gynecologist should exercise caution when considering the predictability of serum antimüllerian hormone levels in any population of women with a low prevalence of infertility, including reproductive-aged women who either have never tried to become pregnant or have become pregnant previously without assistance. Based on the current information, a single serum antimüllerian hormone level assessment obtained at any point in time in a population of women with presumed fertility does not appear to be useful in predicting time to pregnancy and should not be used for counseling patients in this regard. At this time, routine antimüllerian hormone testing for prediction of pregnancy loss is not recommended. More data are needed to determine the utility of antimüllerian hormone as a predictor of time to menopause, a biomarker for polycystic ovary syndrome, or a predictor of future menses in women who have received gonadotoxic therapy.
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Aydogan Mathyk B, Aslan Cetin B, Bilici S, Fasse J, Avci P. Evaluation of ovarian reserve in women with psoriasis. Gynecol Endocrinol 2019; 35:608-611. [PMID: 30698041 DOI: 10.1080/09513590.2018.1563884] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The aim of this study is to evaluate ovarian reserve in women with psoriasis. Thirty-six women with psoriasis and 36 healthy women were enrolled in this prospective study. On day 3 of the menstrual cycle, blood samples for AMH and other hormones were collected. On the same day, antral follicle count (AFC), and ovarian volumes were measured. A multiple regression analysis was carried out to examine the contribution of factors to the serum AMH levels in patients with psoriasis. The serum AMH levels and ovarian volumes were lower in the psoriasis group than in the control group (1.85 ± 1.13 ng/ml vs 2.46 ± 1.21 ng/ml, p = .029 and 10.43 ± 3.08 cm3 vs 11.93 ± 3.01 cm3, p = .038). However, the mean AFC between the two groups was not significantly different. The psoriasis area severity index (PASI) score did not correlate with AMH. On the other hand, the duration of the disease negatively correlated with AMH, total AFC and ovarian volume. In the multiple regression analysis, duration of disease and total AFC were the most significant contributors to the serum AMH levels in patients with psoriasis. Autoimmune diseases may affect ovarian reserve regardless of immunosuppresive treatment. Longitudinal follow-ups regarding reproductive function might be required in women with psoriasis.
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Affiliation(s)
- Begum Aydogan Mathyk
- a Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility , University of North Carolina , Chapel Hill , NC , USA
| | - Berna Aslan Cetin
- b Department of Obstetrics and Gynecology , Kanuni Sultan Suleyman Research and Training Hospital , Istanbul , Turkey
| | - Sule Bilici
- c Department of Dermatology , Kanuni Sultan Suleyman Research and Training Hospital , Istanbul , Turkey
| | - Julia Fasse
- d Department of Obstetrics and Gynecology, Tufts University , Medford , MA , USA
| | - Pinar Avci
- e Department of Dermatology, Dermatooncology and Venerology , Semmelweis University School of Medicine , Budapest , Hungary
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Individualized predictions of time to menopause using multiple measurements of antimüllerian hormone. Menopause 2018; 23:839-45. [PMID: 27326817 DOI: 10.1097/gme.0000000000000642] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The ability of antimüllerian hormone (AMH) to predict age at menopause has been reported in several studies, and a decrease in AMH level has been found to increase the probability of menopause. The rate of decline varies among women, and there is also a variability of decline between women's cycles. As a result, individualized evaluation is required to accurately predict time of menopause. To this end, we have used the AMH trajectories of individual women to predict each one's age at menopause. METHODS From a cohort study, 266 women (ages 20-50 y) who had regular and predictable menstrual cycles at the initiation of the study were randomly selected from among 1,265 women for multiple AMH measurements. Participants were visited at approximately 3-year intervals and followed for an average of 6.5 years. Individual likelihood of menopause was predicted by fitting the shared random-effects joint model to the baseline covariates and the specific AMH trajectory of each woman. RESULTS In total, 23.7% of the women reached menopause during the follow-up period. The estimated mean (SD) AMH concentration at the time of menopause was 0.05 ng/mL (0.06 ng/mL), compared with 1.36 ng/mL (1.85 ng/mL) for those with a regular menstrual cycle at their last assessment. The decline rate in the AMH level varied among age groups, and age was a significant prognostic factor for AMH level (P < 0.001). Adjusting for age and body mass index, each woman had her own specific AMH trajectory. Lower AMH and older age had significant effects on the onset of menopause. Individualized prediction of time to menopause was obtained from the fitted model. CONCLUSIONS Longitudinal measurements of AMH will enable physicians to individualize the prediction of menopause, thereby facilitating counseling on the timing of childbearing or medical management of health issues associated with menopause.
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Ganer Herman H, Gluck O, Keidar R, Kerner R, Kovo M, Levran D, Bar J, Sagiv R. Ovarian reserve following cesarean section with salpingectomy vs tubal ligation: a randomized trial. Am J Obstet Gynecol 2017; 217:472.e1-472.e6. [PMID: 28455082 DOI: 10.1016/j.ajog.2017.04.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 04/17/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Epithelial ovarian cancer is assumed to derive from the fallopian tube. Salpingectomy has been previously demonstrated to reduce the risk of ovarian cancer, and may be used as a means of sterilization. OBJECTIVE We aimed to compare short-term ovarian reserve and operative complications in cases of salpingectomy and tubal ligation during cesarean section. STUDY DESIGN Study patients who underwent elective cesarean section at our institution and requested sterilization were randomized to bilateral salpingectomy or tubal ligation. Prior to surgery, blood samples were obtained for antimüllerian hormone. Surgical course was noted, including overall time, complications, and postoperative hemoglobin. Repeat antimüllerian hormone samples were obtained from patients 6-8 weeks following surgery. RESULTS In all, 46 patients were recruited for participation, of whom 33 completed a follow-up visit, and for whom repeat antimüllerian hormone levels were available. Patients in the salpingectomy group were slightly older (37.0 ± 3.9 vs 34.3 ± 4.1 years, P = .02). No differences were noted in patient parity, body mass index, or gestational age between the groups. Pregnancy and postdelivery antimüllerian hormone levels were not significantly different between the groups, with an average increase of 0.58 ± 0.98 vs 0.39 ± 0.41 ng/mL in the salpingectomy and tubal ligation groups, respectively (P = .45). Surgeries including salpingectomy were longer by an average 13 minutes (66.0 ± 20.5 vs 52.3 ± 15.8 minutes, P = .01). No difference was demonstrated between the groups regarding surgical complications and postoperative hemoglobin decrease. CONCLUSION Sterilization by salpingectomy appears to be as safe as tubal ligation regarding operative complications and subsequent ovarian reserve. As salpingectomy offers the advantage of cancer risk reduction, it may be offered in the settings of elective preplanned surgeries.
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15
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Bas-Lando M, Rabinowitz R, Farkash R, Algur N, Rubinstein E, Schonberger O, Eldar-Geva T. Prediction value of anti-Mullerian hormone (AMH) serum levels and antral follicle count (AFC) in hormonal contraceptive (HC) users and non-HC users undergoing IVF-PGD treatment. Gynecol Endocrinol 2017; 33:797-800. [PMID: 28454495 DOI: 10.1080/09513590.2017.1320376] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Use of hormone contraceptives (HC) is very popular in the reproductive age and, therefore, evaluation of ovarian reserve would be a useful tool to accurately evaluate the reproductive potential in HC users. We conducted a retrospective cohort study of 41 HC users compared to 57 non-HC users undergoing IVF-preimplantation genetic diagnosis (PGD) aiming to evaluate the effect of HC on the levels of anti-Mullerian hormone (AMH), small (2-5 mm), large (6-10 mm) and total antral follicle count (AFC) and the ability of these markers to predict IVF outcome. Significant differences in large AFC (p = 0.04) and ovarian volume (p < 0.0001) were seen, however, there were no significant differences in small and total AFC or in serum AMH and FSH levels. Oocyte number significantly correlated with AMH and total AFC in HC users (p < 0.001) while in non-HC users these correlations were weaker. In HC users, the significant predictors of achieving <6 and >18 oocytes were AFC (ROC-AUC; 0.958, p = 0.001 and 0.883, p = 0.001) and AMH (ROC-AUC-0.858, p = 0.01 and 0.878, p = 0.001), respectively. The predictive values were less significant in non-HC users. These findings are important in women treated for PGD, in ovum donors and for assessing the fertility prognosis in women using HC and wishing to postpone pregnancy.
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Affiliation(s)
- Maayan Bas-Lando
- a Department of Obstetrics & Gynecology , Shaare Zedek Medical Center, Affiliated with the Hebrew University Hadassah School of Medicine , Jerusalem , Israel
| | - Ron Rabinowitz
- a Department of Obstetrics & Gynecology , Shaare Zedek Medical Center, Affiliated with the Hebrew University Hadassah School of Medicine , Jerusalem , Israel
| | - Rivka Farkash
- a Department of Obstetrics & Gynecology , Shaare Zedek Medical Center, Affiliated with the Hebrew University Hadassah School of Medicine , Jerusalem , Israel
| | - Nurit Algur
- a Department of Obstetrics & Gynecology , Shaare Zedek Medical Center, Affiliated with the Hebrew University Hadassah School of Medicine , Jerusalem , Israel
| | - Esther Rubinstein
- a Department of Obstetrics & Gynecology , Shaare Zedek Medical Center, Affiliated with the Hebrew University Hadassah School of Medicine , Jerusalem , Israel
| | - Oshrat Schonberger
- a Department of Obstetrics & Gynecology , Shaare Zedek Medical Center, Affiliated with the Hebrew University Hadassah School of Medicine , Jerusalem , Israel
| | - Talia Eldar-Geva
- a Department of Obstetrics & Gynecology , Shaare Zedek Medical Center, Affiliated with the Hebrew University Hadassah School of Medicine , Jerusalem , Israel
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Ruth KS, Bennett CE, Schoemaker MJ, Weedon MN, Swerdlow AJ, Murray A. Length of FMR1 repeat alleles within the normal range does not substantially affect the risk of early menopause. Hum Reprod 2016; 31:2396-403. [PMID: 27614355 PMCID: PMC5027929 DOI: 10.1093/humrep/dew204] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/22/2016] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Is the length of FMR1 repeat alleles within the normal range associated with the risk of early menopause? SUMMARY ANSWER The length of repeat alleles within the normal range does not substantially affect risk of early menopause. WHAT IS KNOWN ALREADY There is a strong, well-established relationship between length of premutation FMR1 alleles and age at menopause, suggesting that this relationship could continue into the normal range. Within the normal range, there is conflicting evidence; differences in ovarian reserve have been identified with FMR1 repeat allele length, but a recent population-based study did not find any association with age at menopause as a quantitative trait. STUDY DESIGN, SIZE, DURATION We analysed cross-sectional baseline survey data collected at recruitment from 2004 to 2010 from a population-based, prospective epidemiological cohort study of >110 000 women to investigate whether repeat allele length was associated with early menopause. PARTICIPANTS/MATERIALS, SETTING, METHOD We included 4333 women from the Breakthrough Generations Study (BGS), of whom 2118 were early menopause cases (menopause under 46 years) and 2215 were controls. We analysed the relationship between length of FMR1 alleles and early menopause using logistic regression with allele length as continuous and categorical variables. We also conducted analyses with the outcome age at menopause as a quantitative trait as well as appropriate sensitivity and exploratory analyses. MAIN RESULTS AND THE ROLE OF CHANCE There was no association of the shorter or longer FMR1 allele or their combined genotype with the clinically relevant end point of early menopause in our main analysis. Likewise, there were no associations with age at menopause as a quantitative trait in our secondary analysis. LIMITATIONS, REASONS FOR CAUTION Women with homozygous alleles in the normal range may have undetected FMR1 premutation alleles, although there was no evidence to suggest this. We estimate minor dilution of risk of early menopause from the likely inclusion of some women with menopause at over 45 years in the early menopause cases due to age-rounding bias in self-reports. WIDER IMPLICATIONS OF THE FINDINGS There is no robust evidence in this large study that variation within the normal range of FMR1 repeat alleles influences timing of menopause in the general population, which contradicts findings from some earlier, mainly smaller studies. The FMR1 CGG repeat polymorphism in the normal range is unlikely to contribute to genetic susceptibility to early menopause. STUDY FUNDING/COMPETING INTERESTS We thank Breast Cancer Now and The Institute of Cancer Research for funding the BGS. The Institute of Cancer Research acknowledges NHS funding to the NIHR Biomedical Research Centre. The study was funded by the Wellcome Trust (grant number 085943). There are no competing interests. TRIAL REGISTRATION NUMBER Not applicable.
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Affiliation(s)
- Katherine S Ruth
- Genetics of Complex Traits, University of Exeter Medical School, RILD Level 3, Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK
| | - Claire E Bennett
- Genetics of Complex Traits, University of Exeter Medical School, RILD Level 3, Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK
| | - Minouk J Schoemaker
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Michael N Weedon
- Genetics of Complex Traits, University of Exeter Medical School, RILD Level 3, Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK
| | - Anthony J Swerdlow
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK Division of Breast Cancer Research, The Institute of Cancer Research, London, UK
| | - Anna Murray
- Genetics of Complex Traits, University of Exeter Medical School, RILD Level 3, Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK
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