# AMH in PCOS and Beyond—Rare Case Series

## TL;DR

This paper presents rare cases of women with high AMH levels, highlighting challenges in diagnosing PCOS and other ovarian disorders.

## Contribution

The study contributes a rare case series emphasizing AMH's diagnostic role in hypogonadism and granulosa cell tumors.

## Key findings

- High AMH levels can be associated with hypogonadotropic hypogonadism and granulosa cell tumors.
- AMH elevation in unusually enlarged ovaries may represent a subgroup distinct from typical PCOS.
- Granulosa cell tumors should be considered in differential diagnosis of chronic anovulation with high AMH.

## Abstract

Background and Clinical Significance: Anti-Müllerian hormone (AMH) is a dimeric glycoprotein secreted from the granulosa cells of the preantral and small antral follicles, which has entered routine clinical practice as a valuable tool for the diagnosis of different ovarian disorders. Increased AMH levels have been recommended as a criterion for polycystic ovary syndrome (PCOS). However, its widespread use remains limited due to analytical diversity and contradictory age-specific thresholds, among other factors that modulate AMH levels. Case Presentation: Herein, we present a rare case series of women with increased AMH levels. The difficulties in the differential diagnosis of patients with elevated AMH levels, because of PCOS combined with pituitary dysfunction, increased ovarian volume, or granulosa cell tumors (GCTs), are discussed. Conclusions: The presented rare cases of increased AMH emphasize the important role of AMH as a diagnostic marker in women with hypogonadotropic hypogonadism and granulosa cell tumors. On the other hand, it is still unknown if increased AMH produced by unusually enlarged or supernumerary ovaries should be considered as actual PCOS cases or as a specific subgroup. Additionally, the unusual case of GCTs with pronounced AMH and LH increase but normal steroids supports the pathophysiological role of AMH for the development of neuroendocrine dysfunction. Moreover, it suggests that GCTs should be considered in the differential diagnosis of chronic anovulation even in women with normal ovarian steroid production in case of unusually high AMH levels for the age. Further studies are needed to explain PCOS heterogeneity and to ensure proper differential diagnosis for every affected woman.