Anti-Müllerian hormone: what the test shows and why it matters for athletes
Anti-Müllerian hormone (AMH) has become one of the most popular “women's” tests: it is taken before planning a pregnancy, with an irregular cycle, and even out of curiosity. At the same time there are many myths around it — from a “biological clock in a test tube” to a test that supposedly determines the chance of conceiving. The editorial team explains what AMH really measures, how it changes with age, and how it can be useful to female and male athletes.
What anti-Müllerian hormone is
AMH is a protein hormone from the transforming growth factor beta family. It got its name from its first known function: in a male embryo, AMH produced by the Sertoli cells of the testes causes the regression of the Müllerian ducts — the rudiments of the uterus and fallopian tubes.
In women, AMH is synthesized by the granulosa cells of small ovarian follicles — preantral and early antral ones. It is precisely these follicles that form the “pool” from which candidates for ovulation are selected each month. The more such follicles there are, the higher the hormone level in the blood.
Within the ovary, AMH acts as a brake: it restrains the too-rapid recruitment of primordial follicles into growth and reduces the follicles' sensitivity to FSH. In this way the hormone helps to “economically” spend the egg reserve throughout reproductive life.
In men, AMH is high in childhood and drops sharply during puberty under the influence of testosterone. In adult men it remains a marker of Sertoli cell function, but in routine practice it is used much less often than in women.
What the test shows and what it does not
The main significance of AMH is as an indirect marker of ovarian reserve, that is, the number of follicles remaining in the ovaries. It correlates well with the antral follicle count on ultrasound and is used in reproductive medicine to predict the ovarian response to stimulation in IVF programs.
However, the number of follicles is neither the quality of the eggs nor the ability to conceive naturally. A large prospective study by Steiner and colleagues in JAMA (2017) showed that in women aged 30–44 who were trying to conceive, low AMH was not associated with a reduced likelihood of natural conception.
| AMH shows | AMH does not show |
|---|---|
| The approximate number of small follicles | Egg quality |
| The likely response to stimulation in IVF | The chance of natural pregnancy in the coming months |
| The trend toward a decline in reserve with age | The exact age of menopause onset |
| Support for a PCOS diagnosis (per the 2023 guidelines) | The cause of absent menstruation on its own |
The second application is polycystic ovary syndrome (PCOS). In women with PCOS, AMH is usually elevated because of the large number of small follicles. The 2023 international guidelines allow the use of AMH in adults as an alternative to ultrasound for assessing polycystic ovarian morphology, but not as a standalone diagnostic test.
The third is assessment of reserve before treatment that may harm it, for example chemotherapy or ovarian surgery, and also monitoring after such treatment.
Age-related dynamics and norms
AMH changes over the course of life along a characteristic curve. After puberty the level gradually rises, reaches a peak in young adulthood, and then slowly declines, becoming practically undetectable at the onset of menopause. This curve was described in detail by the model of Kelsey and colleagues based on pooled data.
There is no single “norm” for AMH. Laboratories provide age-specific reference ranges, and different reagent kits give somewhat different values, so results from different laboratories are hard to compare. The units of measurement also differ: ng/mL or pmol/L.
It is important that individual variation is very large: in women of the same age AMH can differ several-fold, and this does not always mean pathology. That is precisely why the hormone is interpreted together with age, cycle, ultrasound, and the clinical picture.
It was traditionally believed that AMH is almost independent of the day of the cycle, so the test can be taken at any time. Newer data indicate moderate fluctuations, so for comparison over time it is better to adhere to similar conditions.
Why AMH is of interest to female and male athletes
Female athletes often have menstrual cycle disturbances — from irregular periods to complete amenorrhea. The most common cause is functional hypothalamic amenorrhea against the background of low energy availability, which is part of RED-S syndrome according to the IOC consensus.
AMH in such a situation helps to differentiate the causes. In hypothalamic amenorrhea the follicle reserve is usually preserved, so AMH is not reduced, and in some women it may even be relatively high. Very low AMH in a young woman with absent menstruation prompts thinking about other diagnoses.
Another situation is PCOS, which also occurs among female athletes, especially in strength disciplines. High AMH together with signs of androgen excess and an irregular cycle is a reason to consult an endocrinologist or a gynecologist-endocrinologist.
- distinguishing the causes of amenorrhea (hypothalamic, PCOS, decline in reserve);
- assessing reserve before planning a pregnancy after the end of a career;
- monitoring after treatment that may affect the ovaries;
- in men — isolated cases of assessing Sertoli cell function as prescribed by an andrologist.
In male athletes, AMH is usually not part of the standard list of tests. For assessing reproductive function, a semen analysis, LH, FSH, testosterone, and inhibin B are far more informative.
How to prepare for the test
AMH is taken from a vein, preferably in the morning. There is no strict fasting requirement, but most laboratories advise not eating for a few hours before the draw. The day before, it is worth avoiding exhausting training and stress, although the effect of these factors on AMH is small.
It is important to tell the doctor about the use of hormonal contraceptives. They suppress follicle growth and can noticeably lower AMH, so against the background of such contraception the result underestimates the real reserve.
If comparison over time is planned, repeat tests are better done in the same laboratory, by the same method, and under similar conditions. Otherwise the difference between reagent kits may be greater than the real change in the hormone.
The test on its own should not become a source of anxiety. Decisions about pregnancy planning, egg freezing, or treatment are made together with a doctor, taking into account age, history, and the results of other examinations.
Editorial conclusions
Anti-Müllerian hormone is a useful marker of the number of follicles in the ovaries and an auxiliary tool in diagnosing PCOS. But it does not measure egg quality and does not predict the chance of natural pregnancy in the near future.
For female athletes, AMH is valuable primarily as part of a workup for cycle disturbances: it helps distinguish energy deficiency from other causes. It should be interpreted only in combination with the clinical picture.
The editorial team also recommends our materials on the causes of elevated or reduced AMH, on RED-S syndrome in female athletes, and on the hormonal profile in menstrual cycle disturbances.
References
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
Andriy Melnyk
A strength-sports coach and author of programs for beginner and intermediate levels. Writes about training planning.
