ORIGINAL ARTICLE

Endocrine Research

Circulating irisin and GIP are associated with the development of

polycystic ovary syndrome

Chia Lin Chang,MD† Shang Yu Huang,MD† Yung Kuei Soong,MD, Po Jen

Cheng,MD, Chin-Jung Wang,MD, I Ting Liang,MD
Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital Linkou Medical Center,
Chang Gung University, 5 Fu-Shin St, Kweishan, Taoyuan, Taiwan

Context: Polycystic ovary syndrome (PCOS) is characterized by oligo- or anovulation, polycystic ovary, and/or
hyperandrogenism. In addition, many PCOS patients present with dyslipidemia, insulin resistance, and obesity.
Due to the complexity of this disorder, the causes of PCOS remain to be identified.

Objectives: Because many PCOS patients have a propensity to develop dyslipidemia, we hypothesized that the
brown adipose-differentiation factor, irisin, and the glucose-dependent insulinotropic peptide (GIP) play a role
in the development of PCOS.

Design and Setting: Serum hormone levels in 202 PCOS patients and 47 healthy women were investigated.

PatientsorOtherParticipants:Patientswerestratifiedbasedonthepresence/absenceofmetabolic
syndromeriskfactors,asdefinedbytheNationalCholesterolEducationProgram’sAdultTreatment Panel III report
(ATPIII [] and ATPIII [-]), or BMI (healthy-weight and overweight).

MainOutcomeMeasures:Wemeasuredserumirisin,GIP,luteinizinghormone(LH),anti-Mullerian hormone (AMH),

and androgens as well as metabolic indices including HOMA-IR, ISI Matsuda, and QUICKI.

Results: PCOS patients exhibited hyperandrogenism, dyslipidemia, and hyperinsulinism as well as elevated LH
and AMH levels. In addition, fasting irisin level (p .001) and glucose-induced GIP response (p .013) in PCOS
patients were significantly elevated as compared to those of control women. Remarkably, levels of fasting
irisin and glucose-induced GIP response remained significantly elevated in ATP III [-] PCOS and healthy-weight
PCOS patients when compared to matched controls. Analysis of the effect size indicated that both fasting irisin
and glucose-induced GIP response are significant risk factors for PCOS with odds ratios of 6.63 and 4.21,
respectively.

Conclusion: Although there is as yet no evidence for a causal link between irisin and/or GIP and
PCOS,itisconceivablethatirisinandGIPmightcontributetothethedevelpmentofPCOSandmay also represent novel
PCOS biomarkers.

P
olycysticovarysyndrome(PCOS)isthe
mostcommon endocrine abnormality
of reproductive-age women, and affects
that hyperinsulinemia in PCOS patients
could be
Abbreviations:
about 5%–12% of women worldwide (1–
3). Most PCOS patients suffer oligo- or
anovulation, hyperandrogenism, and/or
hirsutism (4–7). In addition, it was
estimated that 42% of women with PCOS
J Clin Endocrinol Metab
ISSN Print 0021-972X ISSN Online 1945-7197 in the jcem.endojournals.org 1
Printed in U.S.A.
UnitedStatesareoverweightorobese,andha
Copyright © 2014 by the Endocrine Society
Received January 21, 2014. Accepted July 7, 2014. veahighrisk of developing type 2 diabetes
(T2D), atherosclerosis, and cardiovascular associatedwithhyperandrogenism(13–
events (7–10). Although the root causes of 15).Inaddition,it
doi: 10.1210/jc.2014-1180 PCOS remain to be identified, a popular isbelievedthatdyslipidemiaplaysanimportantr
hypothesis considers androgen excess as oleinthe pathogenesis of PCOS-associated
the primary defect in PCOS (11, 12), and metabolic dysfunction. Furthermore, elevated

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2 Serum irisin level is elevated in PCOS patients
production of anti-Mullerian hormone
(AMH) by antral follicles has been shown to
be a PCOS biomarker (16–19).
Given that most PCOS patients have a
tendency to become overweight/obese and
insulin resistant, we speculated that impaired
regulation of select adipogenesis-regulating
hormones may play a role in the
development of PCOS. Recent studies have
shown that the expression of irisin, a newly
discovered muscle-derived brown
adiposedifferentiation factor, is positively
associated with body mass index (BMI) and
muscle mass (20–23). Irisin, encoded by
FNDC5, has been reported to mediate the
beneficial effects of exercise on metabolism
through
activationofUCP1andinsulinaction(15,16).M
oreover,recent studies indicated that irisin
metabolism is abnormal
patientswithT2Dorgestationaldiabetesmellitu
s(GDM) (21, 24–29). Accordingly, we
hypothesized that aberrant regulation of irisin
metabolism may play a role in the
development of PCOS.
Inaddition,studiesofhuman-gut-
derivedincretins,including glucose-dependent
insulinotropic peptide (GIP) and glucagon-
like peptide-1 (GLP-1), have shown that,
between these two incretins, GIP plays a
particularly important role in the regulation
of the deposition
triglyceridesinthemuscleandliver,andinsulin-
mediateduptake
ofglucoseintowhiteadiposetissues(30–
33).BecauseGIP has been shown to increase
body weight and because the insulinotropic
effect of GIP is impaired in many patients
with metabolic syndromes (34, 35), we
further
hypothesizedthataberrantregulationofGIPmet
abolismmayalso contribute to the
development of PCOS.
To investigate whether irisin metabolism
and GIP metabolism are altered in women
with PCOS, and whether these hormones are
associated with the development of PCOS,
we analyzed serum levels of these hormones
in women with PCOS and controls following
stratification
basedonthepresence/absenceofmetabolicsynd
romerisk factors, as defined by the National
Cholesterol Education Program’s Adult
Treatment Panel III report (ATPIII), or BMI.
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J Clin Endocrinol Metab
Subjects and Methods
Subjects and anthropometric
measurements
All studies were conducted with approval from
the Human
ResearchEthicsCommitteeofChangGungMemorial
Hospital. Informed consent forms were obtained
from each participant before beginning the
research. Control cases were healthy women with
regular menstruation. Women with PCOS were
diagnosedbasedontherevisedRotterdamcriteria,whi
chrequire two of the following three
manifestations: (1) oligo- and/or anovulation, (2)
clinical and/or biochemical hyperandrogenism,
and (3) polycystic ovaries (36). Current smokers
and those who consumed alcohol or took
medicines affecting glucose/lipid/androgen
metabolism during the 6 months before
enrollment were excluded. These exclusion
criteria were chosen to avoid the interference of
oral contraceptives and insulin-sensitizing drugs,
in which could be a potential source of bias (7).
Additional exclusion criteria included
hypothyroidism, hyperthyroidism, congenital
adrenal hyperplasia, Cushing’s syndrome,
hyperprolactinemia, and androgen-secreting
tumors.
Atotalof340potentialPCOSpatientsand51hea
lthywomen aged 18 to 34 were enrolled during
the initial screening. Among these patients, 138
potential PCOS and 4 healthy patients were
excluded due to diagnosis of
hyperprolactinemia, hyperthyroidism,
hypothyroidism, T2D, or the presence of only
one of the three diagnosing criteria (ie, oligo-
of and/or anovulation, clinical and/or biochemical
hyperandrogenism, and polycystic ovaries).
Anthropometric measurements including
age, body weight (BW), BMI, body adiposity
index (BAI), lean body weight (LBW), systolic
blood pressure (BP) (SBP), diastolic BP
(DBP), waist circumference (WC), and hip
circumference (HC) were measured following
standard procedures (37, 38). Hirsutism was
measured with a modified version of the
Ferriman–Gallwey evaluation system.
Oral glucose tolerance test and assays of
metabolic indicators
A3hoursoralglucosetolerancetest(OGTT)wa
scarriedout using 75g of glucose (Glucola TM)
after an 8–12 hours overnight fast. All subjects
were advised to follow their normal diet for at
least 3 days prior to being tested.
Blood samples were drawn from the
antecubital vein at 0, 1, 2, and 3 hours after
glucose intake, and stored at -20C. Irisin,
adiponectin,AMH,GIP,GLP-
1,andhepaticsexhormone-binding globulin
(SHBG) were measured by specific
doi: 10.1210/jc.2014-1180 jcem.endojournals.org 3

immunoassays that target the mature peptide or One-way ANOVA and Student’s t test were
protein (Phoenix Pharmaceuticals, Millipore conducted using statistical software PASW18
Corporation, Beckman Coulter, and Siemens package (SPSS version PASW18, SPSS Inc.,
Healthcare Diagnostics Inc.). Serum free- USA). Two-tailed p-values 0.05 were
testosterone, testosterone, D4-androstenedione considered
(4A), dehydroepiandrosterone-sulfate (DHEA- statisticallysignificant.Therelationshipsbetwee
S), estradiol, triglycerides, total cholesterol, nirisin(orGIP) and metabolic indicators were
HDLcholesterol, VLDL-cholesterol, LDL- analyzed based on linear regression analysis.
cholesterol, glucose, insulin, prolactin, FSH, To determine the effect size and the value of
LH, and TSH were determined by standard using irisin and GIP levels to predict PCOS,
laboratory procedures. To determine the we conducted ReceiverOperating
enteroinsular response, glucose and insulin Characteristic curve analyses using Medcalc
levels were measured at 0, 1, 2, and 3 hours (version 12 5.0).
following glucose intake; moreover, GIP and
C-peptide levels were determined at 0 and 1
hour postchallenge.
The homeostasis model assessment Results
(HOMA) and quantitativeinsulin-
sensitivitycheckindex(QUICKI)wereusedtoasse Levels of fasting irisin and glucose-
ss insulin resistance and insulin sensitivity, induced GIP response in PCOS patients
respectively (39). are significantly higher than those in
Peripheralinsulinresistancewasassessedbycalcu control women
latingMatsuda’s sensitivity index (ISI Matsuda). Levels of irisin, GIP, and a variety of
Areas under the curve for plasma glucose
metabolic indicators were analyzed in a
response (AUC glucose) and areas under the
curve for plasma insulin response (AUC
total of 202 PCOS patients and 47 healthy
insulin) were calculated with the trapezoid women who were recruited over a 2-year
rule. period (2010–2012). The age of patients
ranged from 18–34 years old, and the
Subgrouping of subjects average age of PCOS patients was 2 years
To compare levels of hormones and younger than that of the healthy women
metabolic indicators among patients with (PCOS, 25.25 0.35 yrs vs. controls, 27.30
similar metabolic statuses, we subcategorized 0.71 yrs; P .011)(Table 1). Measurements
PCOS patients and healthy women according
of anthropometric and metabolic
to the presence/absence of metabolic
syndromes risk factors(s) as defined by the characteristics showed that BW, BMI,
National Cholesterol Education Program’s BAI, LBW, SBP, DBP, WC, HC, WC to
Adult Treatment Panel III (ATPIII) report (40), HC ratio (WHR), and theFerriman–
or BMI. Although the classification of GallweyscoreaswellaslevelsofAMH,LH,
metabolic syndromes requires the presence of androgens (free-testosterone, testosterone,
three defining criteria, each of the ATPIII
and [4A]), triglycerides, and VLDL-
criteria is known to contribute to the future
development of metabolic syndromes. We cholesterol of PCOS patients were
subdivided patients into ATPIII negative significantly higher than were those of
(ATPIII [-]) and ATPIII positive (ATPIII [], control women. Likewise, PCOS patients
with at least one of the ATPIII risk factors) exhibited significantly higher levels of
subcohorts.Withthisstratification,wewereableto stimulated glucose, fasting and stimulated
comparethe hormonal profiles of PCOS
insulin, and fasting and stimulated C-
patients who were free of signs of metabolic
syndromes (ATPIII [-]) to matched healthy
peptide compared with those of control
controls, women. As expected, measurements of
andbetweentheATPIII[-]PCOSpatientsandATPI HOMA-IR, QUICKI, ISI Matsuda, AUC
II[]PCOS patients. As for BMI, patients were glucose, AUC insulin, and incremental
divided into overweight (BMI 25) and healthy- AUC indicated that glucose and insulin
weight (BMI 25) subcohorts. metabolism in PCOS patients are
Due to the low number of control women
significantly less efficient than are those
who were overweight or had ATPIII risk
factors, the analysis of stratified datasets was of control women (41).
limited to those from the ATPIII [-] or healthy- In addition, PCOS patients had
weight subcohorts. significantly elevated levels of fasting irisin
as compared with control women (Figure 1a,
Statistical analysis PCOS, 975.71 29.42 ng/ml vs. control,

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4 Serum irisin level is elevated in PCOS patients J Clin Endocrinol Metab

669.83 35.61 ng/ml, P .001; Table 1). While Information). Compared to ATPIII [-] PCOS
fasting GIP levels were similar between the patients, patients with the ATPIIIriskfactor(s)
PCOS and control groups (Figure 1b, PCOS, (ATPIII[]PCOSpatients,N104) exhibited
9.34 1.04 pg/ml vs. control, 6.50 2.10 insulin resistance (QUICKI 0.357, Table S1)
pg/ml, P .219), the GIP level at 1 hour (41) and had significantly higher BW, BMI,
postchallenge (denoted as glucose-induced BAI, LBW, SBP, DBP, WC, HC, and WHR.
GIP response hereafter) in PCOS patients In addition, ATPIII [] PCOS patients had a
was significantly higher than that of control significantly higher level of irisin as
women (Figure 1c, PCOS, 82.57 6.49 pg/ml compared to ATPIII [-] PCOS patients
vs. control, 49.68 5.98 pg/ml, P .013). whereas levels of AMH, androgens, and
Likewise, AMH levels in PCOS patients are glucose-induced GIP response were not
more than twice that of controls (Figure 1d, significantly different between ATPIII [-] and
PCOS, 9.97 0.39 ng/ml vs. control, 3.88 ATPIII [] PCOS patients (Table S1).
0.31 ng/ml, P .000). By contrast, levels of Importantly, comparisons of ATPIII [-]
adiponectin, GLP-1, and SHBG were not PCOS patients and ATPIII [-] controls, who
significantly different between PCOS and shared similar anthropometric and metabolic
control groups (Figure 1, e, f, and g; Table 1) characteristics, showed that the only
(42, 43). parameters that differed significantly
between these two subcohorts were levels of
Irisin and GIP metabolism is abnormal in fasting irisin (PCOS, 893.38
ATPIII [-] and healthy-weight PCOS patients 32.14ng/mlvs.control,648.5336.92ng/ml,P.00
To determine whether serum irisin and 1), glucose-
GIP levels are associated with PCOS inducedGIPresponse(PCOS,76.865.63pg/ml
independent of previously recognized PCOS vs. control, 49.88 7.34 pg/ml, P .006), AMH,
risk factors (eg, insulin resistance, obesity, LH, androgens,HDL-
anddyslipidemia),westratifiedpatientsbasedo cholesterol,andfastinginsulinaswellas the
nthepresence/absence of ATPIII metabolic Ferriman–Gallwey score (Table 2).
syndromes risk factors(s), or BMI (40). Of Similarly, analysis of data stratified by
the 202 PCOS patients, 48.5% (N 98) were BMI showed that healthy-weight PCOS
without any ATPIII risk factors (ATPIII [-] patients (BMI 25, N 123,
subcohort)(Table S1 in the Supplementary
Table 1. Anthropometric characteristics and metabolic status of PCOS and control patients.

PCOS (n Control
Total (n 249) 202) (n 47)
Mean Mean Mean
SEM SEM SEM

Age 25.63 25.25 27.30

0.32 0.35 0.71
Height (cm) 160.05 159.93 160.56
0.34 0.37 0.85
Body weight 61.79 63.21 55.68
(kg) 0.92 1.05 1.56
Body mass 24.13 24.73 21.54
Index 0.35 0.40 0.52
(BMI)
Body adiposity index 29.85 30.28 28.04
(BAI) 0.32 0.37 0.48
Lean body 47.66 48.22 45.28
weight (LBW) 0.40 0.45 0.82

SBP (mm Hg) 114.25 115.49 108.98

0.93 1.06 1.70
DBP (mm Hg) 68.65 69.48 65.06
0.65 0.73 1.29

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doi: 10.1210/jc.2014-1180 jcem.endojournals.org 5

Waist circumference 75.92 77.40 69.60

(cm) 0.82 0.93 1.34

Hip circumference 96.75 97.48 93.64

(cm) 0.61 0.69 1.10

Waist to hip ratio 0.78 0.01 0.79 0.01 0.74 0.01

FerrimanGallwe 7.27 0.30 7.94 0.34 4.38 0.48

y score

FSH (mIU/mL) 5.74 0.13 5.68 0.15 6.02 0.21

LH (mIU/liter) 6.68 0.32 7.29 0.38 4.052
0.26
TSH (uIU/mL) 1.70 0.06 1.71 0.07 1.65 0.17
Prolactin (ng/ 12.49 12.22 13.64
mL) 0.37 0.40 0.90
AMH (ng/ml) 8.81 0.35 9.97 0.39 3.88 0.31
Freetestosterone 1.72 0.05 1.80 0.06 1.34 0.05
(pg/ml)

Testosterone 0.52 0.01 0.55 0.01 0.40 0.02

(ng/mL)
DHEA-S (ng/ ml) 2239.38 2253.72 2180.81
60.73 67.20 142.66
4A (ng/ml) 1.78 0.05 1.90 0.06 1.27 0.07
Estradiol (pg/ 42.01 41.98 42.13
mL) 1.82 2.13 3.07
Triglycerides 90.21 95.27 68.45
(mg/dL) 4.00 4.71 5.14
HDL- 55.55 55.00 57.90
cholesterol 0.82 0.95 1.46
(mg/dL)
VLDLcholesterol 17.64 18.54 13.73
(mg/dL) 0.69 0.79 1.17

Table S2), who had metabolic profiles similar to those of matched control women (
significantly ele-
Table 1. Continued

PCOS (n Control
Total (n 249) 202) (n 47)
LDLcholesterol 97.83 98.55 94.79
(mg/dL) 1.67 1.91 3.29

Totalcholesterol 171.54 172.74 166.40

(mg/dL) 1.82 2.04 3.96

Total-C/HDL-C ratio 3.24 0.06 3.32 0.07 2.92 0.08

LDL-C/HDL-C ratio 1.88 0.05 1.93 0.05 1.68 0.07

Glucose-0 h (mg/dL) 82.47 82.44 82.64

0.39 0.45 0.77
Glucose-1 h (mg/dL) 124.69 128.22 109.53
2.23 2.48 4.57
Glucose-2 h (mg/dL) 104.33 106 1.63 97.17
1.43 2.75

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6 Serum irisin level is elevated in PCOS patients J Clin Endocrinol Metab

Glucose-3 h (mg/dL) 82.32 82.91 79.76

1.29 1.50 2.21
Insulin-0 h 9.59 0.45 10.43 5.99 0.44
(mU/liter) 0.52
Insulin-1 h 85.19 92.64 53.13
(mU/liter) 5.15 6.07 6.10
Insulin-2 h 72.95 79.74 43.95
(mU/liter) 4.78 5.70 4.56
Insulin-3 h 30.31 33.06 18.32
(mU/liter) 2.70 3.23 2.79
C-peptide-0 h (ng/mL) 1.77 0.06 1.87 0.07 1.34 0.12

C-peptide-1 h (ng/mL) 9.52 0.27 9.97 0.30 7.61 0.43

HOMA-IR 1.98 0.10 2.16 0.11 1.23 0.09

QUICKI 0.36 0.00 0.36 0.00 0.38 0.00
ISI Matsuda 6.29 0.27 5.82 0.30 8.28 0.53
AUC glucose 311.58 317.14 287.82
3.80 4.28 7.21
AUC insulin 178.41 194.56 109.37
10.36 12.27 10.68
Incremental 0.55 0.03 0.59 0.03 0.37 0.03
AUC
Adiponectin-0 h 8375.71 8185.75 9278.00
(ng/ml) 358.45 422.90 436.95

GLP-1–0 h (pM) 168.132 166.85 173.57

7.46 8.47 21.51
SHBG-0 h 55.58 52.80 67.63
(nmol/liter) 2.32 2.52 5.65
Irisin-0 h (ng/ 919.99 975.71 669.83
ml) 26.01 29.42 35.61
GIP-0 h (pg/ mL) 8.76 0.93 9.34 1.04 6.50 2.10

GIP-1 h (pg/ mL) 75.81 82.57 49.68

5.37 6.49 5.98
p values that are 0.05 are in bold letters, and are indicated by an asterisk.
Abbreviations: SBP, systolic blood pressure; DBP, diastolic blood pressure; HDL-C, high-density lipoprotein
cholesterol; LDL-C, low-density lipoprotein cholesterol.

vatedlevelsoffastingirisin(PCOS,928.7330.84ng/mlvs. control, 656.58 36.68 ng/ml, P

.001), glucose-

Figure 1. Fasting irisin and glucose-induced GIP response are significantly

elevated in PCOS patients. Compared to those of control women, levels of
fasting irisin (a), glucose-induced GIP response (at 1 hour postchallenge)(c),
and fasting AMH (d) in PCOS patients were significantly elevated. By
contrast, levels of fasting GIP (b), fasting adiponectin (e), fasting GLP-1 (f),
and fasting SHBG (g) were similar between the PCOS and control groups. *

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doi: 10.1210/jc.2014-1180 jcem.endojournals.org 7

Circulating irisin and GIP levels are risk factors for PCOS 14.97])), ATPIII [-] (OR
To determine whether the fasting irisin and glucose- 7.30 (95% CI [2.62 -
induced GIP response provide quantitative power for 20.35])), and healthy-weight
detecting PCOS, we performed diagnostic testing (45). The (OR 8.27 (95% CI [3.23 -
Receiver-Operating Characteristic curve analysis indicated 21.17])) populations (Table
that the optimal cut-off points for fasting irisin and glucose- 3). Likewise, an elevated
induced GIP response were 814.2 ng/ml and 62.1 pg/ml, glucose-induced GIP
respectively. Based on these cut-offs, we response
foundthattheriskofPCOSincreases with a high fasting irisin
level in the overall (odds ratio (OR) 6.63 (95% CI [2.94 -
significantly different from controls (P .05). Gallweyscoreaswellaslevelsof
testosterone,triglycerides,AMH,GLP-
1,andglucoseat2 hours postchallenge, but was
inducedGIPresponse(PCOS,68.084.22pg/mlv negatively associated with
s.control, 48.87 6.50 pg/ml, P .025), AMH,
HDL-cholesterol, QUICKI, ISI Matsuda, and
LH, androgens, fasting insulin, and
SHBG in the overall patient population
stimulated C-peptide as compared to matched
(Table S3, P .05). On the other hand,
controls (Table S2).
glucose-induced GIP response was positively
Twodimensionalplotsofthemeansoffastingi
associated with levels of AMH, triglycerides,
risinand glucose-
VLDL-cholesterol, glucose at 1hr, and
inducedGIPresponseshowedthatPCOSpatient
insulin at 1 hour postchallenge, but
s can be readily separated from healthy
negatively associated with ISI Matsuda and
women based on measurements of these two
adiponectin (Table S3, P .05).
hormones with or without controlling for
had an OR of 4.21
metabolic syndrome risk factors or BMI
(95% CI [1.97 9.01]), 3.45 (95% CI [1.48 -
(Figure 2). Thus, PCOS patients are
8.04]), and 3.62 (95% CI [1.52 - 8.63]) for
characterized by significantly elevated levels
the development of PCOS in the overall,
of fasting irisin and glucose-induced GIP, and
ATPIII [-], and healthy-weight populations,
these alterations are obvious in PCOS
respectively (45).
patients who are at a healthy weight or are
Likewise, analyses of the Likelihood
devoid of metabolic syndrome risk factor(s)
Ratios (LR and LR-) and Predictive Values
(44).
(PPV and NPV) indicated that both fasting
Inaddition,linearregressionanalysisshowed
irisin level and glucose-induced GIP
thatfasting irisin was positively associated
response are significant risk factors for
with BW, LBW, blood
PCOS (Table 3).
pressures,andFerriman–

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8 Serum irisin level is elevated in PCOS patients J Clin Endocrinol Metab

Discussion aberrant regulation of muscle-derived irisin

and the gut hormone GIP could represent
Our study revealed that PCOS patients have novel PCOS biomarkers. In addition,
an overtly elevated fasting irisin level and ourdatasuggestedthatthesealterationsmaycont
glucose-induced GIP response when ributeto the development of comorbidities
compared to matched controls even after such as insulin resistance, dyslipidemia, and
controlling for confounding factors such as obesity in PCOS patients.
ATPIII metabolic syndrome risk factors or The muscle-derived irisin was reported as
BMI. These alterations are concurrent with a myokine capable of promoting brown and
the central presentation of PCOS (ie, beige adipose tissue differentiation, and
hyperandrogenism), and are associated with thermogenesis via the p38 MAP kinase and
high levels of ERK MAP kinase signaling (20–22, 46).
LHandAMHaswellasdyslipidemia.Therefore, Because iri-
Table 2. Anthropometric characteristics and metabolic status of ATPIII [-] PCOS and A
[-] control patients.
Control
Total (n 135) PCOS (n 98) (n 37)
Mean Mean Mean
SEM SEM SEM

Age 25.16 24.59 26.65

0.45 0.53 0.80
Height (cm) 160.90 161.02 160.57
0.46 0.52 1.00
Body weight 54.13 54.31 53.64
(kg) 0.62 0.70 1.34
Body mass 20.89 20.94 20.76
Index 0.21 0.24 0.42
(BMI)
Body adiposity index 27.28 27.19 27.51
(BAI) 0.26 0.31 0.47
Lean body 44.74 44.86 44.41
weight (LBW) 0.36 0.40 0.79

SBP (mm Hg) 107.21 107.53 106.38

0.93 1.09 1.82
DBP (mm Hg) 63.99 64.19 63.46
0.62 0.71 1.23
Waist circumference 68.69 69.17 67.41
(cm) 0.53 0.64 0.96

Hip circumference 92.31 92.22 92.54

(cm) 0.50 0.56 1.05

Waist to hip ratio 0.75 0.01 0.75 0.01 0.73 0.01

FerrimanGallwe 6.39 0.34 7.27 0.40 4.08 0.48

y score

FSH (mIU/mL) 5.92 0.20 5.88 0.26 6.01 0.20

LH (mIU/liter) 7.04 0.46 8.16 0.59 4.14 0.30
TSH (uIU/mL) 1.54 0.08 1.52 0.08 1.60 0.21
Prolactin (ng/ 12.42 11.96 13.62
mL) 0.51 0.57 1.06
AMH (ng/ml) 8.65 0.5 10.39 4.05 0.36
0.58
Freetestosterone 1.61 0.07 1.71 0.10 1.34 0.06
(pg/ml)

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doi: 10.1210/jc.2014-1180 jcem.endojournals.org 9

Testosterone 0.51 0.02 0.54 0.02 0.42 0.02

(ng/mL)
DHEA-S (ng/ ml) 2308.29 2311.75 2299.70
87.03 101.43 170.95
4A (ng/ml) 1.73 0.07 1.89 0.08 1.33 0.08
Estradiol (pg/ 41.55 41.47 41.77
mL) 2.58 3.44 2.44
Triglycerides 62.45 61.42 65.19
(mg/dL) 1.95 2.29 3.72
HDL- 63.35 64.43 60.49
cholesterol 0.89 1.06 1.55
(mg/dL)
VLDLcholesterol 12.66 12.56 12.94
(mg/dL) 0.43 0.50 0.85

sin is capable of stimulating browning and UCP-1 expres-

sioninadiposetissues,ithasbeensuggestedthatirisinmay
Table 2. Continued

Control
Total (n 135) PCOS (n 98) (n 37)
LDLcholesterol 92.09 91.22 94.38
(mg/dL) 2.16 2.60 3.89

Totalcholesterol 168.53 168.77 167.92

(mg/dL) 2.31 2.68 4.57

Total-C/HDL-C ratio 2.69 0.05 2.64 0.06 2.80 0.07

LDL-C/HDL-C ratio 1.50 0.04 1.47 0.05 1.58 0.07

Glucose-0 h (mg/dL) 81.39 81.14 82.05

0.49 0.59 0.91
Glucose-1 h (mg/dL) 112.01 113.69 107.57
2.66 3.03 5.46
Glucose-2 h (mg/dL) 95.53 95.69 95.11
1.58 1.82 3.17
Glucose-3 h (mg/dL) 78.72 78.81 78.47
1.64 2.09 2.31
Insulin-0 h 6.48 0.32 6.91 0.42 5.35 0.38
(mU/liter)
Insulin-1 h 59.15 63.71 47.08
(mU/liter) 4.63 5.91 6.06
Insulin-2 h 45.01 47.58 38.27
(mU/liter) 3.23 4.26 3.37
Insulin-3 h 19.21 20.55 15.60
(mU/liter) 1.93 2.47 2.50
C-peptide-0 h (ng/mL) 1.30 0.06 1.32 0.06 1.26 0.14

C-peptide-1 h (ng/mL) 7.95 0.30 8.28 0.37 7.09 0.41

HOMA-IR 1.31 0.07 1.39 0.09 1.09 0.08

QUICKI 0.38 0.00 0.37 0.00 0.39 0.00
ISI Matsuda 8.26 0.38 8.01 0.47 8.92 0.58
AUC glucose 287.83 289.73 282.85
4.30 5.00 8.46
AUC insulin 117.43 125.60 96.03

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10 Serum irisin level is elevated in PCOS patients J Clin Endocrinol Metab

7.97 10.39 8.88

Incremental 0.40 0.02 0.43 0.03 0.34 0.03
AUC
Adiponectin-0 h 10448.31 10793.07 9460.00
(ng/ml) 510.40 664.51 488.73

GLP-1–0 h (pM) 162.62 156.03 179.88

10.46 10.26 26.81
SHBG-0 h 66.73 64.32 73.79
(nmol/liter) 3.15 3.55 6.77
Irisin-0 h (ng/ 827.60 893.38 648.53
ml) 27.12 32.14 36.92
GIP-0 h (pg/ mL) 9.70 1.43 11.21 6.35 2.60
1.69
GIP-1 h (pg/ mL) 68.47 76.86 49.88
4.63 5.63 7.34
p values that are 0.05 are in bold letters, and are indicated by an asterisk.
Abbreviations: SBP, systolic blood pressure; DBP, diastolic blood pressure; HDL-C, high-density lipoprotein
cholesterol; LDL-C, low-density lipoprotein cholesterol.

mediate the beneficial effects of exercise by increasing en- ergy expenditure in brown
adipose tissues (20, 21). In Table 3. Use of glucose-induced GIP response and fasting irisin
level as screening markers for the prediction of PCOS in the overall, ATPIII [-], and healthy-
weight populations.
Sensitivity Specificity LR
Predictor LR(95%
(%) (95% (%) (95% (95% PPV (%) (95%
(cut-off value) CI)
Populations CI) CI) CI) CI)
Overall Irisin-0 h 58.91 82.22 3.31 0.5 93.7 30.
(814.2 ng/ml) (51.8–65.8) (67.9–92.0) (1.7–6.3) (0.4–0.6) (87.97–97.24) (2

GIP-1 h 53.93 78.26 2.48 0.59 90.57 30.

(62.1 pg/ml) (46.3–61.4) (63.6–89.1) (1.4–4.4) (0.5–0.7) (83.33–95.38) (2

ATPIII Irisin-0 h 54.08 86.11 (70.5–95.3) 3.89 (1.7–9.0) 0.53 91.38 40.
[-] (814.2 ng/ml) (43.7–64.2) (0.4–0.7) (81.02–97.14) (2

GIP-1 h 56.1 75.68 2.31 0.58 82.14 42.

(62.1 pg/ml) (44.7–67) (58.8–88.2) (1.3–4.2) (0.4–0.8) (69.6–91.09) (3

Healthy-weight Irisin-0 h 59.35 85 3.96 0.48 92.41 40.

(814.2 ng/ml) (50.1–68.1) (70.2–94.3) (1.9–8.4) (0.4–0.6) (84.2–97.16) (2

GIP-1 h 47.52 (37.5–57.7) 80.49 (65.1–91.2) 2.44 0.65 85.71 37.

(62.1 pg/ml) (1.3–4.7) (0.5–0.8) (73.78–93.62) (2

Abbreviations: CI, confidence interval; LR, Likelihood ratio; PPV, positive predictive value; NPV, negative predictive
value.
addition, studies of circulating irisin in patients. Yet, surprisingly, our study showed
humans indicated that irisin levels decrease that an elevated fasting irisin level
in serums of patients with T2D or GDM (21, distinguishes PCOS patients from the
24, 25, 28, 29, 47). Based on these controls in the overall study population, and
observations, it is reasonable to speculate that in the ATPIII [-] or healthy-weight
serum irisin level is likely reduced in PCOS

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doi: 10.1210/jc.2014-1180 jcem.endojournals.org 11

gulation of irisin metabolism likely

represents an early event in the development
of PCOS, and occurs before the
manifestation of dyslipidemia in PCOS
patients.
The finding that fasting irisin level is
increased in ATPIII [] PCOS patients
(compared to ATPIII [-] PCOS patients
(Table S1)) is consistent with recent
observations that irisin levels increased in
patients with metabolic syndrome (compared
to those of patients without the syndrome)
(26). Because irisin normally increases
energy
Figure 2. Elevated glucose-induced GIP response and
expenditureinbrownandbeigeadiposetissues,it
fasting irisin level can differentiate PCOS patients from
healthy women. Receiver-Operating Characteristic ispossible
curve analysis performed with data from the overall thatirisinincreasesinPCOSpatientsasaprotecti
population (N 249) showed that the diagnostic cut-off vemechanism to counteract excess energy
points for glucose-induced GIP response and fasting
irisin level are 62.1 pg/ml and 814.2 ng/ml,
inflow (20). Alternatively, the elevated irisin
respectively. The diagnostic cut-off points were level may represent an “irisin resistance”
calculated based on the overall population to provide state (52, 53), resembling that of insulin
optimal separation of PCOS patients and control resistance,fibroblastgrowthfactor21resistance
subjects according to two criteria: (1) to provide a
balance between high sensitivity and high specificity, (54),andleptin resistance (55), in which high
and (2) to provide the maximum value of area under circulating hormone levels fail to induce the
the curve (AUC). A 2-dimensional plot, in which levels desired physiologic effect.
of fasting irisin and glucose-induced GIP response are
Earlier studies have indicated that
denoted by the x and y axis, respectively, showed that
PCOS patients can be readily separated from healthy aberrant regulation of incretins could be
women based on measurements of these two associated with PCOS; however, no
hormones in the overall, ATPIII [-], and healthy-weight conclusive results have been reached because
populations. ATPIII risk factors include: (1) waist
earlier studies were performed with a limited
circumference 88cm, (2) fasting plasma glucose 100
mg/dl, (3) blood HDL cholesterol level 50 mg/dl, (4) number of patients that
triglycerides 150 mg/dl, and (5) BP 130/85 mmHg (40).
The SEM of fasting irisin level is indicated by horizontal
arrow bars whereas the SEM of GIP level is indicated by
vertical arrow bars. The base points of x and y axes are
at the cut-off points of glucose-induced GIP response
and fasting insulin level, respectively. PCOS patient and
healthy groups are indicated by triangle and diamond
shaped symbols, respectively.
subcohorts. Although the mechanism via
which circulating irisin is elevated in PCOS
patients remains to be investigated, these
unexpected data indicated that the metabolic
profiles of PCOS patients are distinct from
those of T2D patients even though PCOS
patients have a tendency to develop T2D
later in life (48). Although irisin has been
associatedwithBMIandmusclemassinhumans
(24,49– 51), the significant increase of
fasting irisin in PCOS
patientscannotbeattributedtodifferencesinmus
clemassor BMI because ATPIII [-]/healthy-
weight PCOS patients in the present study
shared similar BW, BMI, BAI, and LBW
withthematchedcontrols.Therefore,aberrantre

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 12 J Clin Endocrinol Metab
Serum irisin level is elevated in PCOS patients findingsalsohintedathowendocrinefactorsfrommuscle, gut,
and ovarian tissues interact to maintain normal ovarian
physiology. Importantly, the finding of these putative PCOS
varied in their clinical phenotypes (56–58). Based on the biomarkers may provide novel means to improve the
study of a large pool of young PCOS patients, our study detection of PCOS, and to facilitate clinical care of PCOS
hasfurthersubstantiatedtheideathataberrantregulation of patients.
glucose-induced GIP response precedes the
developmentofmetabolicdysfunctionsinPCOSpatients.Becaus
e GIPenhancesobesity,insulinresistance,andpostprandial
hyperglycemia under specific conditions (33, 59–61), the
Acknowledgments
elevation of GIP response in PCOS patients may contribute to We thank Yang Ming Jian (Chang Gung Memorial Hospital), and
subsequent development of metabolic syndromelike Li-Ling Tang and Mo Chung Sung (Chiu Clinic and Lezen
phenotypes in PCOS patients as the disease progresses. In Reference Laboratory) for technical assistance. This study was
supported by Chang Gung Memorial Hospital
addition, an elevated GIP response may indirectly contribute
(CMRPG391151–3, CLC).
to hyperandrogenism and ovarian dysfunction in PCOS
patients by stimulating LH release (62). Future studies of the Addressallcorrespondenceandrequestsforreprintsto:Chia Lin
temporal relationships among metabolism of irisin, GIP, LH, Chang, Department of Obstetrics and Gynecology, Chang Gung
AMH, and androgens in adolescent PCOS patients are needed Memorial Hospital Linkou Medical Center, Chang Gung
to reveal how these hormones contribute to the earliest stages University, 5 Fu-Shin Street, Kweishan, Taoyuan, Taiwan; TEL:
886–975365869; Fax: 886–33288252; email:
of PCOS.
amego@cgmh.org.tw.
Consistent with earlier investigations, our study indicated This work was supported by .
that AMH level is significantly elevated in PCOS patients † Equal contributors
(16–19, 63), in parallel with that of irisin and glucose- Disclosure Summary: The authors have nothing to disclose.
inducedGIPresponse.TheelevatedAMHlevelin PCOS patients
is presumed to be a biomarker of the number of antral
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