Anti-Müllerian hormone above or below normal: causes in athletes and what to do

An AMH result outside the reference range often causes anxiety: a “low” one is taken as a fertility verdict, a “high” one as guaranteed PCOS. In reality both conclusions are too hasty. A deviation of anti-Müllerian hormone has several possible explanations, and for female athletes some of them are linked to the specifics of a training lifestyle. The editorial team examines the main causes and the sequence of actions after receiving such a test.

Why the AMH “norm” is relative

Before talking about a deviation, it is worth remembering that AMH reference ranges depend on age, the measurement method, and the laboratory. A value that is low for a 25-year-old woman may be entirely expected at 40. That is why the first step is always to check against the age-specific norm.

In addition, the individual variability of AMH is very high. In healthy women of the same age the value differs several-fold, and most of them have normal fertility. A single result without a clinical picture does not allow a diagnosis to be made.

Separately, it is worth checking whether the woman was taking hormonal contraception at the time of the test. Combined oral contraceptives and other hormonal methods lower AMH, and after they are discontinued the level often returns to higher values.

Finally, different reagent kits may give different numbers for the same sample. Comparing tests from different laboratories “figure for figure” is incorrect — it is better to rely on the reference range and conclusion of the particular laboratory.

Causes of elevated AMH

The most common clinically significant cause of elevated AMH is polycystic ovary syndrome. In PCOS, many small follicles accumulate in the ovaries, each of which produces the hormone. The 2023 international guidelines allow AMH to be used in adults as one of the criteria for polycystic morphology, but the diagnosis is made only on the totality of signs.

For a PCOS diagnosis, according to the Rotterdam criteria in their updated version, at least two of three signs are required: an ovulation disorder, clinical or laboratory signs of androgen excess, and polycystic ovarian morphology. High AMH without other signs of PCOS is not a diagnosis.

High AMH is also physiologically characteristic of young women, especially those under 25. At this age many girls have multifollicular ovaries without any pathology, so the guidelines caution against diagnosing PCOS by morphology in the first years after menarche.

In some female athletes with functional hypothalamic amenorrhea, AMH may also be relatively high, since the follicles stop at early stages of growth. Because of this, mistaken diagnoses of PCOS occur where the real cause is energy deficiency. A rare cause of very high AMH is granulosa cell tumors of the ovary.

Causes of reduced AMH

The main cause is the natural age-related decrease in the number of follicles. The decline accelerates after 35 and ends with a practically undetectable level at menopause. For a woman of older reproductive age, low AMH is often expected.

A premature decline in reserve in young women may be linked to genetic factors, autoimmune processes, ovarian surgery (for example, removal of endometriotic cysts), or chemo- or radiotherapy. Smoking is also associated with lower AMH values.

• age (physiological decline);
• hormonal contraception (reversibly);
• ovarian surgery, chemo- and radiotherapy;
• smoking;
• premature ovarian insufficiency (requires confirmation by FSH and the clinical picture).

A diagnosis of premature ovarian insufficiency is not made by AMH alone. It requires cycle disturbances or amenorrhea for at least several months in a woman under 40 and an elevated FSH in two measurements a few weeks apart.

As for vitamin D, stress, diets, and training, the data are contradictory. Individual studies have described associations, but there is no convincing evidence that changing these factors substantially changes the actual ovarian reserve. Therefore the editorial team considers promises to “raise AMH” with supplements to be unfounded.

What to do with the result: a step-by-step plan

After receiving a deviant AMH, it is worth acting consistently rather than looking for answers on forums. First of all — evaluate the result taking into account age, contraception, and cycle regularity. Next, the need for additional investigations is determined.

If a woman is planning a pregnancy, low AMH is a reason not to delay consulting a reproductive specialist, but not a reason for panic. The chance of natural conception is determined primarily by age and egg quality, not by the number of follicles.

For female athletes with amenorrhea, the key intervention is restoring energy availability: increasing caloric intake, adjusting training loads, and, if needed, working with a nutritionist and a psychologist. This approach is recommended by the IOC consensus on RED-S.

With confirmed PCOS, treatment is aimed at symptoms and metabolic risks: normalizing the cycle, correcting insulin resistance, controlling weight, and managing androgenic manifestations. Specific drugs are prescribed by a doctor.

Mistakes to avoid

The most common mistake is treating AMH as a fertility test. Scientific data, in particular the study by Steiner and colleagues, show that in women trying to conceive naturally, AMH poorly predicts success in the coming months.

The second mistake is diagnosing PCOS on your own based on high AMH. This is especially risky for female athletes, in whom a similar picture may be produced by energy deficiency, and treatment of these conditions is fundamentally different.

The third mistake is taking hormonal drugs, supplements, or “ovarian stimulants” to correct a figure in the test. One should treat the condition, not a laboratory value, and only as prescribed by a specialist.

The fourth mistake is repeating the test often without need. AMH changes slowly, and frequent measurements only add anxiety because of laboratory fluctuations, without providing new information.

Editorial conclusions

Elevated AMH is most often linked to PCOS or young age, but in female athletes it may also be produced by functional hypothalamic amenorrhea. Reduced AMH usually reflects an age-related decrease in reserve, the effect of contraception, or prior treatment.

In any case, the figure on the form is only the beginning of the diagnostic path. The right decision is made together with a doctor after assessing the cycle, hormones, ultrasound, and lifestyle.

We also advise reading our materials on what the AMH test shows, on RED-S syndrome in female athletes, and on laboratory signs of menstrual cycle disturbances.

References

1. Dewailly D, Andersen CY, Balen A, et al. The physiology and clinical utility of anti-Mullerian hormone in women. Hum Reprod Update. 2014;20(3):370–385.
2. Kelsey TW, Wright P, Nelson SM, Anderson RA, Wallace WHB. A validated model of serum anti-Müllerian hormone from conception to menopause. PLoS One. 2011;6(7):e22024.
3. Steiner AZ, Pritchard D, Stanczyk FZ, et al. Association between biomarkers of ovarian reserve and infertility among older women of reproductive age. JAMA. 2017;318(14):1367–1376.
4. Teede HJ, Tay CT, Laven JJE, et al. Recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome. J Clin Endocrinol Metab. 2023;108(10):2447–2469.
5. Practice Committee of the American Society for Reproductive Medicine. Testing and interpreting measures of ovarian reserve: a committee opinion. Fertil Steril. 2020;114(6):1151–1157.
6. Mountjoy M, Ackerman KE, Bailey DM, et al. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med. 2023;57(17):1073–1097.