1. Ovarian age is associated with gray matter volume and disability in women with MS independent of chronological age and disease duration Jennifer Graves, MD, PhD, MAS UCSF Adult and Pediatric MS Centers

2. Disclosures This work was supported by a pilot grant from the National MS Society. Additional support received by Dr. Graves includes grants from the NIH BIRCWH program, Race to Erase MS, Foundation for the CMSC, Biogen and Genentech.

3. Background Age has been associated with MS severity independent of disease duration Males may have worse or earlier progression Females have more relapses, inflammation But after age 50 less dimorphism – Gender ratio at onset closer to 1:1 – Women “catch up” in disability Kalincik, T. et al., Brain 2013

4. Mean age of onset of PPMS and SPMS both approximately 45 years of age Mean age of menopause 51 Ovarian aging = up to 10 year period of decline in ovarian function Not yet known if ovarian aging contributes to development of progressive disease Ovarian aging and MS

5. Secreted by granulosa cells of follicles in females (TGF-beta family, 140kDa dimeric glycoprotein) Lowers over course of adult woman’s lifetime Explains at least 82% of the variability of age of menopause New surrogate for ovarian reserve in fertility clinics Ovarian Aging Biomarker: Anti-Mullerian Hormone Matzuk and Lamb Nature Medicine 14 2008; Freeman et al Fertility Sterility 2012 http://www.rmanj.com/2013/09/anti-mullerian-hormone-amh-testing-of-ovarian-reserve/; LeBourrier et al J Cell Sci 2008

6. Ovarian Aging and MS Phenotype (NMSS pilot) Ovarian function of hormone production Early marker of the aging process more specific than chronological age – Follicular cells have 10 x the mitochondria and more sensitive to stress than other cells – Sensitive to telomere length Cedars. M.,I., et al., Fertility and Sterility, 2014; http://www.slideshare.net/drangelosmith/ovarian-reserve-and-infertility

7. Objective To determine if ovarian decline as measured by levels of anti-Mullerian hormone (AMH) is associated with clinical disability or brain atrophy in women with MS.

8. Methods Women with MS (n=412) and healthy controls (n=180) were included from a longitudinal research cohort with up to 10 years of clinical and MRI follow-up AMH levels were measured in batch using ultra- sensitive ELISA on plasma samples from baseline, year 3, year 5 and years 8-10 time-points.

9. Statistical Methods Logistic, linear and mixed model regression techniques were employed Multivariable models adjusted for – age, disease duration, smoking, race, ethnicity, vitamin D level, disease modifying therapy (DMT), birth control, and hormone replacement therapy as appropriate. Final models determined by backwards selection

10. Women with MS have similar AMH levels as healthy controls AMH levels were similar (estimate fold difference 1.01; 95%CI=0.72,1.41; p=0.97) in women with MS (n=412, mean age 42.6) and healthy controls (n=180, mean age 44) after adjustment for age.

11. Cross-sectional Baseline Analyses Ovarian reserve (per 2 fold decrease in AMH pg/ml) was associated with β95% CIP value EDSS0.13*0.045, 0.210.0028 MSFC z score-0.076-0.12, -0.0290.0015 PASAT**-0.067-0.12, -0.0160.011 Adjusted for chronological age (linear splines), disease duration, BMI * Magnitude compared to 0.048 per year disease duration **For PASAT race/ ethnicity were retained but not BMI by backward selection

12. Cross-sectional Baseline Analyses Ovarian reserve (per 2 fold decrease in AMH pg/ml) was associated with β (mm 3 )95% CIP value Cortical GM-2.24*-4.39, -0.090.041 Total GM-2.47-5.13, 0.180.068 Total brain-3.77-7.68, 0.150.059 Total WM-1.30-3.08, 0.480.15 T2 lesion vol237.6-364, 839.10.44 Adjusted for chronological age (linear splines), disease duration, BMI * Magnitude compared to -0.60 per year disease duration

13. Longitudinal Analysis: EDSS Multivariable random-intercept-random-slope model using all observations over time (within and between subject comparisons) Per 2-fold decrease AMH: β= 0.079, 95%CI 0.034, 0.13, p=0.0007 http://img.medscape.com/article/770/601/770601-fig3.jpg

14. Longitudinal Association of AMH with Gray Matter Volume Multivariable random-intercept-random-slope model using all observations over time Adjusted for age, disease duration, BMI Per 2-fold decrease in AMH – Total GM Volume β=-1.95mm 3, 95%CI=-3.9, -0.007,p=0.049 – Cortical GM Volume β=-0.96mm 3, 95%CI=-2.06, 0.15,p=0.09

15. Conclusions AMH levels are similar in MS patients and healthy controls, implying normal follicular reserve and rate of ovarian decline Lower AMH levels are associated with greater disability after adjustment for chronological, disease duration and BMI Lower AMH levels are associated with lower cortical and total gray matter volumes but not associated with T2 lesion volume These results support the hypothesis that ovarian decline may be associated with an increase in MS severity

16. Acknowledgements UCSF Jorge Oksenberg Roland Henry Steve Hauser Bruce Cree Ruth Greenblatt Marcelle Cedars Peter Bacchetti Brown University Geralyn Messerlian Financial Support National MS Society FCMSC-CMSC BIRCWH Race to Erase MS Foundation