AMH, or Anti-Mullerian Hormone, can be a useful marker in evaluating those with polycystic ovary syndrome (PCOS) and fertility. While it does have utility, it also has limitations. But what is AMH and why might your doctor order it?
The quick and simple answer is, AMH can give you information about the number of eggs you have. Low levels can indicate a decreased ovarian reserve (fewer eggs available for fertilization), higher levels may indicate polycystic ovary syndrome (PCOS). It's usually part of a fertility workup, especially for those considering fertility treatment methods or freezing eggs.
Here I'll explain what AMH is, how it's connected to PCOS, and why it's used as a marker of fertility.
What is Anti-Mullerian Hormone (AMH)?
Anti-Mullerian Hormone (AMH) is made by the follicles (where eggs are made) in your ovaries.
It's always amazing to think that you are actually born with all the eggs you will have in your lifetime—1 to 2 million eggs! Several follicles can develop in each menstrual cycle, but only one releases an egg for ovulation. The rest will dissolve, so the total available eggs go down over time (I know this sounds kind of scary if you're trying to get pregnant but just stay with me).
Your follicles go through multiple stages. The highest amount of AMH is produced when they are not yet mature (called the preantral and small antral follicles). The more antral follicles and eggs someone has, the higher their AMH levels.
This measurement is also called ovarian reserve and is used in fertility testing. AMH levels increase during reproductive years, peak around the mid-twenties, and start to fall somewhere in your 30s until menopause.
Aside from menopause, low AMH can be caused by chronic illness (including hypothyroidism), family history, endometriosis, hypothalamic amenorrhea (when your period stops because of a problem with the hypothalamus), or lifestyle factors like smoking.
High AMH can be caused by PCOS, as it's associated with increased antral follicles. More follicles mean higher AMH levels (more details on PCOS and AMH this below).
We'll dive into specifics about testing AMH and what that means in just a bit. For now, keep in mind that AMH on its own can't tell you whether you will become pregnant or even the quality of the eggs available. Fertilization only takes one egg, so it doesn't indicate infertility. That said, studies show it is a good predictor of menopause, so it’s possible it can indicate how much time you have left in your reproductive window.
Now let's take a closer look at testing AMH, when it's used, and what it tells us.
What is an AMH Blood Test?
An AMH blood test measures the amount of AMH found in the blood. It's not directly measuring the number of eggs but indicates the number of follicles present. The test can help to determine fertility potential and ovarian reserve compared to other people in the same age group.
Why is an AMH Test Done?
AMH tests are usually done during a comprehensive fertility workup. It's not necessarily something an OB-GYN orders immediately, but rather for those trying to conceive and running into difficulties. It can also be used to help evaluate the effect of fertility treatments like IVF (in vitro fertilization), as women with high AMH levels tend to respond better to treatments to maximize egg retrieval.
It can also be used to examine reasons for early menopause or as part of a workup for PCOS (although you'll learn below that it's not yet a test every physician uses for PCOS).
Understanding AMH Test Results
As you learned earlier, AMH helps predict the number of eggs available for fertilization. The test result compares reference ranges for others in the same age group to assess for normal, high, or low levels.
Again, a lower AMH doesn't automatically mean someone can't become pregnant and isn't diagnostic for infertility, but it could mean fewer undeveloped follicles are left, meaning there's less time to conceive before menopause.
High AMH, as seen with PCOS, isn't a good indicator of ovarian reserve. PCOS can present differently in different people, but one of the clinical symptoms is a higher-than-expected number of follicles that won't necessarily develop into mature eggs. So even if it looks like a person with PCOS has many antral follicles, they aren't necessarily mature and viable for fertilization.
What is A Good AMH Level for Fertility?
While popular TV shows like New Girl and Harlem make it seem like AMH is the end all, be all of fertility testing, it’s not. And in fact, because it hasn’t been widely used for a substantial period of time, there’s a lot of debate about what is a normal AMH level.
It’s also important to note that while nutrition and lifestyle factors can negatively affect AMH levels, they also can have a positive effect too. And while your AMH may show up in the low range now, I have had patients successfully improve their AMH levels through some of the approaches I’m sharing with you in this article.
|What It Means
|Over 4.0 ng/ml
|High (may indicate PCOS)
|1.5 – 4.0 ng/ml
|0.5 – 1.0 ng/ml
|Less than 0.5 ng/ml
AMH and PCOS
PCOS is one of the most common endocrine (hormone) conditions for reproductive-aged women, affecting roughly 10% of women. Signs and symptoms of PCOS can vary, but it's rooted in hormone imbalances that affect metabolic health, the menstrual cycle, and fertility.
The connection between AMH and PCOS is complex, but studies show that women with PCOS can have an increased AMH level by up to four times the “normal” value for age. Research has also found that ovaries in women with PCOS who don't get their period secrete AMH up to 75 times higher than controls.
While elevated AMH has traditionally been seen elevated in PCOS, it was regarded as merely a byproduct of the condition. As it turns out, it may be a factor contributing to infertility in PCOS patients. Newer research has shown that AMH may cause the eggs to mature too quickly in the cycle and contributing to the many symptoms of PCOS. This is the first time we’ve seen AMH as a possible contributor to the PCOS symptom picture.
There's a lot of discussion about diagnosing PCOS because it can present so differently between each person. The Rotterdam Criteria is used to diagnose PCOS, where someone must have two of the following three:
- Irregular or no period
- High levels of androgens
- Polycystic ovarian morphology (meaning ultrasound shows more small antral follicles).
But PCOS has many phenotypes, which means it can present in different ways. There's so much variability in age, use of oral contraceptives (the pill can mask androgen levels), and other symptoms, so some scientists are interested in adding additional tools to the mix. Some believe that AMH testing could be added to the Rotterdam Criteria for a PCOS diagnosis, but this idea is still under investigation.
Regardless, it may prove to be a very useful marker in not only diagnosis, but in tracking the success of medical interventions.
How AMH Can Be Used in Evaluating PCOS
Not everyone with PCOS has high AMH because not everyone will have higher-than-expected antral follicles. On the other hand, high AMH could help if someone has difficulty becoming pregnant and doesn't meet the Rotherham diagnostic criteria.
In addition, because AMH may very well be part of the root cause that leads to the constellation of symptoms of those with PCOS experience, it may prove to be a very useful screening exam in women’s health, beyond just fertility screening.
Anti-Mullerian Hormone and Infertility
Low AMH does not necessarily equal infertility. In fact, a study on older women with low ovarian reserve found no difference in the ability to become pregnant, as well as how long it took to become pregnant, compared to women with normal AMH levels. That said, another study did link decreased ovarian reserve with an increased risk of miscarriage, so more research is needed.
But high AMH may indicate more issues with fertility, possibly related to problems with ovulation. In one study, women with PCOS that were given medication to induce ovulation needed higher doses to jump-start ovulation if their AMH levels were higher. Again, this may be related to AMH accelerating egg maturation.
Higher AMH levels are also associated with decreased endometrial thickness, which researchers suggest could partially explain why some people with PCOS have a more challenging time becoming or staying pregnant.
If you are concerned about your AMH levels, I have suggestions to help you bring it into an optimal range.
Additionally, measuring a day 3 FSH and estradiol, along with having an antral follicle count via ultrasound can help provide a cleared picture of your fertility.
How to Reduce AMH Levels
Since high AMH is linked to PCOS and issues with fertility, addressing hormone balance is essential. One way to do this is through supplementation. While there isn't a lot of research on the use of supplements to reduce or manage AMH, there is some evidence that certain nutrients can help.
For example, in one study, women with PCOS who were given a supplement containing PCOS-supportive nutrients like omega-3 fatty acids, selenium, vitamin E, and CoQ10 for three months significantly reduced their AMH levels. You’ll find omega-3 fatty acids in our Omega Plus and selenium with vitamin E in our Prenatal Plus. Both of these are found in our Pregnancy Support Kit.
Some of the supplements I rely on for my patients with PCOS may also have AMH-lowering benefits, according to research. Let's look at a few below. And remember, supplements should be part of a healthy diet and lifestyle plan to have the most benefit. You can find a free recipe guide and meal plan here to help optimize your hormones.
Vitamin D is a fat-soluble vitamin that helps to regulate hormones, but people with PCOS often have lower levels of vitamin D that researchers link to cycle disruptions, insulin resistance, and high androgens. There are vitamin D receptors all over the body, including the reproductive organs, suggesting its role in reproductive health.
Supplementing with vitamin D could improve the menstrual cycle, androgen levels, and other PCOS-related symptoms. Interestingly, vitamin D affects AMH differently depending on whether someone has PCOS. A meta-analysis found that vitamin supplements did help lower AMH for people with PCOS but increased AMH for those without. With my patients, I use our Vitamin D3/K2.
Melatonin is a hormone made in the pineal gland that helps with regulating the sleep-wake cycle and other biological processes. It's often taken as a sleep aid but may also have anti-inflammatory properties.
A small study found that when women with PCOS took melatonin for six months, AMH levels dropped along with testosterone levels into a normal range, and menstrual cycles normalized. This is only one study, but it shows promise.
One of the most beneficial supplements in PCOS, per the research, is Inositol. This is why as a Naturopathic Endocrinologist, it is one of my top recommended supplements for those with PCOS. Inositol comes in multiple forms, but a combo of Myo-inositol and D-chiro-inositol can support ovarian function, egg quality, and the menstrual cycle (you can learn all about why I suggest inositol for PCOS in my article here and why it's helpful for fertility here).
Inositol also may help lower AMH levels. A study on women with PCOS who took myo-inositol along with folic acid found it lowered AMH and decreased antral follicles better than birth control, which is typically prescribed to manage PCOS.
With all the inositol benefits in mind, I created one of my most popular supplements, Myoinositol Plus. Myoinositol Plus—a proprietary formula combining Myo-inositol and D-chiro-inositol in the clinically demonstrated 40:1 ratio to support ovarian function, egg quality, and regular menstrual cycles. This inositol supplement also includes other nutrients and herbs backed by scientific research to balance hormones and address symptoms of PCOS.
What about raising AMH?
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Listen, I know it can feel completely overwhelming and a little scary to think about fertility and what it means when you have PCOS. But taking steps to address hormone imbalances is a huge step in the right direction.
And if you've been told your AMH levels are higher than they should be, I urge you to start working on addressing the root causes of PCOS and find a knowledgeable healthcare provider that can help guide you through the process of finding what works best for your body.