What are the management options for a woman with low Anti-Mullerian Hormone (AMH) and decreased libido?

Management of Low AMH and Decreased Libido in Women

For women with low Anti-Müllerian Hormone (AMH) levels and decreased libido, hormone replacement therapy should be considered, particularly DHEA supplementation which has been shown to improve libido in women with diminished ovarian reserve. 1

Understanding the Relationship Between AMH and Libido

AMH is an important marker of ovarian reserve that reflects the number of small antral follicles in the ovaries. Low AMH levels can indicate:

• Diminished ovarian reserve
• Potential for premature ovarian insufficiency (POI)
• Reduced fertility potential

AMH as a Marker of Ovarian Function

• AMH is produced by granulosa cells of pre-antral and small antral follicles 1
• AMH levels correlate with antral follicle counts (AFC) 2
• AMH levels decrease with age and become undetectable after menopause 3
• Low AMH is associated with reduced ovarian function which can impact hormone production

Diagnostic Approach

1. Confirm low AMH status:

   • AMH testing is most reliable in women ≥25 years old 1
   • AMH values should be interpreted with caution in women <25 years 1
   • AMH shows minor fluctuations during the menstrual cycle but generally maintains consistent levels for each individual 4

2. Additional hormonal evaluation:

   • FSH and estradiol levels (preferably early follicular phase)
   • LH levels
   • Consider testosterone levels

3. Assess for symptoms of premature ovarian insufficiency:

   • Irregular menstrual cycles or amenorrhea
   • Vasomotor symptoms (hot flashes, night sweats)
   • Sleep disturbances
   • Vaginal dryness
   • Decreased libido

Management Options

Hormone Replacement Therapy

1. DHEA supplementation:

   • DHEA replacement can be considered in women with low libido and/or energy who are otherwise well-managed on hormone replacement 1
   • DHEA deficiency can be tested and supplementation may improve sexual function

2. Estrogen replacement:

   • For women with confirmed POI or hypogonadism
   • Options include oral, micronized, or transdermal preparations 1
   • Progesterone therapy is also needed for women with an intact uterus to prevent endometrial hyperplasia

3. Testosterone therapy:

   • May be considered for women without contraindications (e.g., history of breast cancer) 1
   • Can improve libido in selected patients

Referrals and Monitoring

• Endocrinology consultation is strongly recommended for women with low AMH and decreased libido 1
• Reproductive endocrinology referral for women concerned about fertility 1
• Gynecology consultation for comprehensive management of sexual health issues

Fertility Considerations

For women concerned about fertility:

• Early referral to reproductive endocrinology is recommended
• Consider fertility preservation options if appropriate
• Antral follicle count (AFC) by transvaginal ultrasound may provide additional information about ovarian reserve 1

Important Caveats

1. AMH interpretation limitations:

   • AMH only reflects the growing follicular pool that is responsive to gonadotropins, not necessarily the underlying primordial pool 2
   • AMH levels can fluctuate in certain conditions and with hormonal treatments 2

2. Age considerations:

   • The relationship between AMH and libido may be age-dependent
   • Women with low AMH should be counseled about potential for early menopause if appropriate 1

3. Other causes of decreased libido:

   • Rule out other medical conditions (thyroid disorders, hyperprolactinemia)
   • Consider psychological factors (depression, anxiety, relationship issues)
   • Medication side effects

Follow-up Recommendations

• Regular monitoring of hormone levels (estradiol, FSH) if on hormone replacement therapy
• Assessment of symptom improvement, particularly libido
• Bone mineral density testing for women with confirmed POI or hypogonadism 1
• Annual follow-up with endocrinology for women with POI or at high risk

By addressing both the hormonal imbalance and the specific symptom of decreased libido, this approach aims to improve quality of life while monitoring for long-term health implications of diminished ovarian reserve.