Repurposing reproductive hormones as a cost-effective triage tool for osteoporosis in resource-limited settings: A prospective study

This study aimed to determine whether specific diagnostic cutoff thresholds of serum reproductive hormones - anti-Müllerian hormone (AMH), estradiol (E2), and follicle-stimulating hormone (FSH) - can function as cost-effective triage tools for identifying postmenopausal women at high risk of osteoporosis in settings with limited access to dual-energy X-ray absorptiometry (DXA). This prospective cross-sectional study was conducted at the Department of Obstetrics and Gynecology, Harran University Faculty of Medicine, between April and October 2025. A total of 312 postmenopausal women were enrolled. Bone mineral density (BMD) was assessed using DXA and categorized as normal, osteopenia, or osteoporosis according to World Health Organization criteria. Serum AMH, E2, and FSH concentrations were measured using an electrochemiluminescence immunoassay. Logistic regression and receiver operating characteristic analyses were performed to identify independent predictors and determine optimal hormonal thresholds for the diagnosis of osteoporosis. Of 312 participants, 84 (26.9%) had normal BMD, 139 (44.6%) had osteopenia, and 89 (28.5%) had osteoporosis. As BMD declined, AMH and E2 levels decreased, while FSH increased significantly (P < .001). Logistic regression identified low AMH (odds ratio [OR] = 0.01, P = .001), low E2 (OR = 0.89, P < .001), and high FSH (OR = 1.02, P = .042) as independent predictors of osteoporosis based on femoral neck BMD. Receiver operating characteristic analysis demonstrated excellent discriminative performance for AMH (area under the curve [AUC] = 0.83 for femoral neck; 0.81 for lumbar spine) and E2 (AUC = 0.82 for femoral neck; 0.80 for lumbar spine), both outperforming FSH (AUC = 0.72 and 0.71, respectively). Optimal Youden thresholds were ≤0.01 ng/mL for AMH and ≤21 pg/mL for E2, each achieving strong positive predictive values of approximately 90%. AMH ≤ 0.02 ng/mL yielded 90.8% sensitivity, suggesting potential utility as a screening marker. E2 and AMH demonstrated superior diagnostic performance across both femoral and lumbar sites, with optimal cutoffs (AMH ≤ 0.01 ng/mL; E2 ≤ 21 pg/mL) achieving positive predictive values near 90%. This strongly supports their utility as accessible, biologically grounded triage tools for prioritizing high-risk women for DXA scanning in resource-constrained settings.