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Erschienen in: Endocrine 3/2012

01.12.2012 | Original Article

Nesfatin-1 and other hormone alterations in polycystic ovary syndrome

verfasst von: Rulin Deniz, Bilgin Gurates, Suleyman Aydin, Husnu Celik, İbrahim Sahin, Yakup Baykus, Zekiye Catak, Aziz Aksoy, Cihan Citil, Sami Gungor

Erschienen in: Endocrine | Ausgabe 3/2012

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Abstract

Polycystic ovary syndrome (PCOS) is commonly characterised by obesity, insulin resistance (IR), hyperandrogenemia and hirsutism. Nesfatin-1 a recently discovered hormone, acts upon energy balance, glucose metabolism, obesity and probably gonadal functions. This study was to evaluate the circulating levels of nesfatin-1 in patients with PCOS (n = 30) and in age and body mass index (BMI)-matched controls (n = 30). PCOS patients had significantly lower levels of nesfatin-1 (0.88 ± 0.36 ng/mL) than healthy controls (2.22 ± 1.14 ng/mL). PCOS patients also had higher gonadotropin and androgen plasma concentrations, Ferriman–Gallwey scores, blood glucose levels and a homeostasis model of assessment-IR index (HOMA-IR) index than in healthy women. Correlation tests in PCOS subjects detected a negative correlation between nesfatin-1 levels and BMI, fasting blood glucose, insulin levels and a HOMA-IR index. Lower nesfatin-1 concentration may plays a very important role in the development of PCOS.
Literatur
1.
Zurück zum Zitat L. Speroff, Anovulation and polycystic ovary. In Clinical Gynecologic Endocrinology and Infertility, eds. by L. Speroff, M.A. Fritz MA, 6th edn. (Lippincott Williams and Wilkins, Philadelphia, 2005), pp. 465–491 L. Speroff, Anovulation and polycystic ovary. In Clinical Gynecologic Endocrinology and Infertility, eds. by L. Speroff, M.A. Fritz MA, 6th edn. (Lippincott Williams and Wilkins, Philadelphia, 2005), pp. 465–491
2.
Zurück zum Zitat Z.E. Hopkinson, N. Sattar, R. Fleming, I.A. Greer, Polycystic ovarian syndrome: the metabolic syndrome comes to gynecology. BMJ 317, 329–332 (1998)PubMedCrossRef Z.E. Hopkinson, N. Sattar, R. Fleming, I.A. Greer, Polycystic ovarian syndrome: the metabolic syndrome comes to gynecology. BMJ 317, 329–332 (1998)PubMedCrossRef
3.
Zurück zum Zitat R. Azziz, K.S. Woods, R. Reyna, T.J. Key, E.S. Knochenhauer, B.O. Yildiz, The prevalence and feature of the polycystic ovary syndrome in an unselected population. J. Clin. Endocrinol. Metab. 89, 2745–2749 (2004)PubMedCrossRef R. Azziz, K.S. Woods, R. Reyna, T.J. Key, E.S. Knochenhauer, B.O. Yildiz, The prevalence and feature of the polycystic ovary syndrome in an unselected population. J. Clin. Endocrinol. Metab. 89, 2745–2749 (2004)PubMedCrossRef
4.
Zurück zum Zitat The Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group, revised consensus on diagnostic criteria and longterm health risks related to polycystic ovary syndrome (PCOS). Hum. Reprod. 19, 41–47 (2004) The Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group, revised consensus on diagnostic criteria and longterm health risks related to polycystic ovary syndrome (PCOS). Hum. Reprod. 19, 41–47 (2004)
6.
Zurück zum Zitat H.J. Teede, S.K. Hutchison, S. Zoungas, The management of insulin resistance in polycystic ovary syndrome. Trends Endocrinol. Metab. 18, 273–279 (2007)PubMedCrossRef H.J. Teede, S.K. Hutchison, S. Zoungas, The management of insulin resistance in polycystic ovary syndrome. Trends Endocrinol. Metab. 18, 273–279 (2007)PubMedCrossRef
7.
Zurück zum Zitat R. Hamburg, Management of polycystic ovary syndrome in adolescence. Rev. Gynecol. Pract. 4, 148–155 (2004)CrossRef R. Hamburg, Management of polycystic ovary syndrome in adolescence. Rev. Gynecol. Pract. 4, 148–155 (2004)CrossRef
8.
Zurück zum Zitat H. Jia, L. Yu, X. Guo, W. Gao, Z. Jiang, Associations of adiponectin gene polymorphisms with polycystic ovary syndrome: a meta-analysis. Endocrine. (2012, in press) H. Jia, L. Yu, X. Guo, W. Gao, Z. Jiang, Associations of adiponectin gene polymorphisms with polycystic ovary syndrome: a meta-analysis. Endocrine. (2012, in press)
9.
Zurück zum Zitat B. Dilbaz, E. Ozkaya, M. Cinar, E. Cakir, S. Dilbaz, Cardiovascular disease risk characteristics of the main polycystic ovary syndrome phenotypes. Endocrine 39, 272–277 (2011)PubMedCrossRef B. Dilbaz, E. Ozkaya, M. Cinar, E. Cakir, S. Dilbaz, Cardiovascular disease risk characteristics of the main polycystic ovary syndrome phenotypes. Endocrine 39, 272–277 (2011)PubMedCrossRef
10.
Zurück zum Zitat W. Hu, J. Qiao, Expression and regulation of adipocyte fatty acid binding protein in granulosa cells and its relation with clinical characteristics of polycystic ovary syndrome. Endocrine 40, 196–202 (2011)PubMedCrossRef W. Hu, J. Qiao, Expression and regulation of adipocyte fatty acid binding protein in granulosa cells and its relation with clinical characteristics of polycystic ovary syndrome. Endocrine 40, 196–202 (2011)PubMedCrossRef
11.
Zurück zum Zitat S. Palomba, A. Falbo, T. Russo, A. Tolino, F. Orio, F. Zullo, Pregnancy in women with polycystic ovary syndrome: the effect of different phenotypes and features on obstetric and neonatal outcomes. Fertil. Steril. 94, 1805–1811 (2010)PubMedCrossRef S. Palomba, A. Falbo, T. Russo, A. Tolino, F. Orio, F. Zullo, Pregnancy in women with polycystic ovary syndrome: the effect of different phenotypes and features on obstetric and neonatal outcomes. Fertil. Steril. 94, 1805–1811 (2010)PubMedCrossRef
12.
Zurück zum Zitat I. Oh, H. Shimizu, T. Satoh, S. Okada, S. Adachi, K. Inoue, H. Eguchi, M. Yamamoto, T. Imaki, K. Hashimoto, T. Tsuchiya, T. Monden, K. Horiguchi, M. Yamada, M. Mori, Identification of nesfatin-1 as a satiety molecule in the hypothalamus. Nature 443, 709–712 (2006)CrossRef I. Oh, H. Shimizu, T. Satoh, S. Okada, S. Adachi, K. Inoue, H. Eguchi, M. Yamamoto, T. Imaki, K. Hashimoto, T. Tsuchiya, T. Monden, K. Horiguchi, M. Yamada, M. Mori, Identification of nesfatin-1 as a satiety molecule in the hypothalamus. Nature 443, 709–712 (2006)CrossRef
13.
Zurück zum Zitat D. García-Galiano, V.M. Navarro, J. Roa, F. Ruiz-Pino, M.A. Sánchez-Garrido, R. Pineda, J.M. Castellano, M. Romero, E. Aguilar, F. Gaytán, C. Diéguez, L. Pinilla, M. Tena-Sempere, The anorexigenic europeptide, nesfatin-1, is indispensable for normal puberty onset in the female rat. J. Neurosci. 30, 7783–7792 (2010)PubMedCrossRef D. García-Galiano, V.M. Navarro, J. Roa, F. Ruiz-Pino, M.A. Sánchez-Garrido, R. Pineda, J.M. Castellano, M. Romero, E. Aguilar, F. Gaytán, C. Diéguez, L. Pinilla, M. Tena-Sempere, The anorexigenic europeptide, nesfatin-1, is indispensable for normal puberty onset in the female rat. J. Neurosci. 30, 7783–7792 (2010)PubMedCrossRef
14.
Zurück zum Zitat Y. Su, J. Zhang, Y. Tang, F. Bi, J.N. Liu, The novel function of nesfatin-1: anti-hyperglycemia. Biochem. Biophys. Res. Commun. 391, 1039–1042 (2010)PubMedCrossRef Y. Su, J. Zhang, Y. Tang, F. Bi, J.N. Liu, The novel function of nesfatin-1: anti-hyperglycemia. Biochem. Biophys. Res. Commun. 391, 1039–1042 (2010)PubMedCrossRef
15.
Zurück zum Zitat Q.C. Li, H.Y. Wang, X. Chen, H.Z. Guan, Z.Y. Jiang, Fasting plasma levels of nesfatin-1 in patients with type 1 and type 2 diabetes mellitus and the nutrient-related fluctuation of nesfatin-1 level in normal humans. Regul. Pept. 159, 72–77 (2010)PubMedCrossRef Q.C. Li, H.Y. Wang, X. Chen, H.Z. Guan, Z.Y. Jiang, Fasting plasma levels of nesfatin-1 in patients with type 1 and type 2 diabetes mellitus and the nutrient-related fluctuation of nesfatin-1 level in normal humans. Regul. Pept. 159, 72–77 (2010)PubMedCrossRef
16.
Zurück zum Zitat S. Aydin, The presence of the peptides apelin, ghrelin and nesfatin-1 in the human breast milk, and the lowering of their levels in patients with gestational diabetes mellitus. Peptides 31, 2236–2240 (2010)PubMedCrossRef S. Aydin, The presence of the peptides apelin, ghrelin and nesfatin-1 in the human breast milk, and the lowering of their levels in patients with gestational diabetes mellitus. Peptides 31, 2236–2240 (2010)PubMedCrossRef
17.
Zurück zum Zitat M. Aslan, O. Celik, N. Celik, I. Turkcuoglu, E. Yilmaz, A. Karaer, Y. Simsek, E. Celik, S. Aydin, Cord blood nesfatin-1 and apelin-36 levels in gestational diabetes mellitus. Endocrine. (2011, in press) M. Aslan, O. Celik, N. Celik, I. Turkcuoglu, E. Yilmaz, A. Karaer, Y. Simsek, E. Celik, S. Aydin, Cord blood nesfatin-1 and apelin-36 levels in gestational diabetes mellitus. Endocrine. (2011, in press)
18.
Zurück zum Zitat E. Carmina, A.M. Campagna, R.A. Lobo, A 20-year follow-up of young women with polycystic ovary syndrome. Obstet. Gynecol. 119, 263–269 (2012)PubMedCrossRef E. Carmina, A.M. Campagna, R.A. Lobo, A 20-year follow-up of young women with polycystic ovary syndrome. Obstet. Gynecol. 119, 263–269 (2012)PubMedCrossRef
19.
Zurück zum Zitat D. Dewailly, P. Pigny, B. Soudan, S. Catteau-Jonard, C. Decanter, E. Poncelet, A. Duhamel, Reconciling the definitions of polycystic ovary syndrome: the ovarian follicle number and serum anti-Müllerian hormone concentrations aggregate with the markers of hyperandrogenism. J. Clin. Endocrinol. Metab. 95, 4399–4405 (2010)PubMedCrossRef D. Dewailly, P. Pigny, B. Soudan, S. Catteau-Jonard, C. Decanter, E. Poncelet, A. Duhamel, Reconciling the definitions of polycystic ovary syndrome: the ovarian follicle number and serum anti-Müllerian hormone concentrations aggregate with the markers of hyperandrogenism. J. Clin. Endocrinol. Metab. 95, 4399–4405 (2010)PubMedCrossRef
20.
Zurück zum Zitat D. Dewailly, H. Gronier, E. Poncelet, G. Robin, M. Leroy, P. Pigny, A. Duhamel, S. Catteau-Jonard, Diagnosis of polycystic ovary syndrome (PCOS): revisiting the threshold values of follicle count on ultrasound and of the serum AMH level for the definition of polycystic ovaries. Hum. Reprod. 26, 3123–3129 (2011)PubMedCrossRef D. Dewailly, H. Gronier, E. Poncelet, G. Robin, M. Leroy, P. Pigny, A. Duhamel, S. Catteau-Jonard, Diagnosis of polycystic ovary syndrome (PCOS): revisiting the threshold values of follicle count on ultrasound and of the serum AMH level for the definition of polycystic ovaries. Hum. Reprod. 26, 3123–3129 (2011)PubMedCrossRef
21.
Zurück zum Zitat S. Aydin, Discovery of ghrelin hormone: research and clinical applications. Turk. J. Biochem. 32, 76–89 (2007) S. Aydin, Discovery of ghrelin hormone: research and clinical applications. Turk. J. Biochem. 32, 76–89 (2007)
22.
Zurück zum Zitat L. Ibanez, N. Potau, A. Carrascosa, Insulin resistance, premature adrenarche and a risk of the PCOS. Trends Endocrinol. Metab. 9, 72–77 (1998)PubMedCrossRef L. Ibanez, N. Potau, A. Carrascosa, Insulin resistance, premature adrenarche and a risk of the PCOS. Trends Endocrinol. Metab. 9, 72–77 (1998)PubMedCrossRef
23.
Zurück zum Zitat F. Ovalle, R. Azziz, Insulin resistance, polycystic ovary syndrome and type 2 diabetes mellitus. Fertil. Steril. 77, 1095–1105 (2002)PubMedCrossRef F. Ovalle, R. Azziz, Insulin resistance, polycystic ovary syndrome and type 2 diabetes mellitus. Fertil. Steril. 77, 1095–1105 (2002)PubMedCrossRef
24.
Zurück zum Zitat J. Kusari, Y. Takata, E. Hatada, G. Freidenberg, O. Kolterman, J.M. Olefsky, Insulin resistance and diabetes due to different mutations in the tyrosine kinase domain of both insulin receptor gene alleles. J. Biol. Chem. 266, 5260–5267 (1991)PubMed J. Kusari, Y. Takata, E. Hatada, G. Freidenberg, O. Kolterman, J.M. Olefsky, Insulin resistance and diabetes due to different mutations in the tyrosine kinase domain of both insulin receptor gene alleles. J. Biol. Chem. 266, 5260–5267 (1991)PubMed
25.
Zurück zum Zitat A. Dunaif, Insulin resistance and the polycystic ovary syndrome: mechanism and implications for pathogenesis. Endocr. Rev. 18, 774–800 (1997)PubMedCrossRef A. Dunaif, Insulin resistance and the polycystic ovary syndrome: mechanism and implications for pathogenesis. Endocr. Rev. 18, 774–800 (1997)PubMedCrossRef
26.
Zurück zum Zitat B.O. Yildiz, O. Gedik, Assessment of glucose intolerance and insulin sensitivity in polycystic ovary syndrome. Reprod. Biomed. Online 8, 649–656 (2004)PubMedCrossRef B.O. Yildiz, O. Gedik, Assessment of glucose intolerance and insulin sensitivity in polycystic ovary syndrome. Reprod. Biomed. Online 8, 649–656 (2004)PubMedCrossRef
27.
Zurück zum Zitat A.M. Venkatesan, A. Dunaif, A. Corbould, Insulin resistance in polycystic ovary syndrome: progress and paradoxes. Recent Prog. Horm. Res. 56, 295–308 (2001)PubMedCrossRef A.M. Venkatesan, A. Dunaif, A. Corbould, Insulin resistance in polycystic ovary syndrome: progress and paradoxes. Recent Prog. Horm. Res. 56, 295–308 (2001)PubMedCrossRef
28.
Zurück zum Zitat R. Gonzalez, A. Tiwari, S. Unniappan, Pancreatic beta cells colocalize insulin and pronesfatin immunoreactivity in rodents. Biochem. Biophys. Res. Commun. 381, 643–648 (2009)PubMedCrossRef R. Gonzalez, A. Tiwari, S. Unniappan, Pancreatic beta cells colocalize insulin and pronesfatin immunoreactivity in rodents. Biochem. Biophys. Res. Commun. 381, 643–648 (2009)PubMedCrossRef
29.
Zurück zum Zitat M. Nakata, K. Manaka, S. Yamamoto, M. Mori, T. Yada, Nesfatin-1 enhances glucose-induced insulin secretion by promoting Ca(2+) influx through L-type channels in mouse islet β-cells. Endocr. J. 58, 305–313 (2011)PubMedCrossRef M. Nakata, K. Manaka, S. Yamamoto, M. Mori, T. Yada, Nesfatin-1 enhances glucose-induced insulin secretion by promoting Ca(2+) influx through L-type channels in mouse islet β-cells. Endocr. J. 58, 305–313 (2011)PubMedCrossRef
30.
Zurück zum Zitat V.L. Nelson, K.N. Qin, R.L. Rosenfield, J.R. Wood, T.M. Penning, R.S. Legro, J.F. Strauss III, J.M. McAllister, The biochemical basis for increased testosterone production in theca cells propagated from patients with polycystic ovary syndrome. J. Clin. Endocrinol. Metab. 86, 5925–5933 (2001)PubMedCrossRef V.L. Nelson, K.N. Qin, R.L. Rosenfield, J.R. Wood, T.M. Penning, R.S. Legro, J.F. Strauss III, J.M. McAllister, The biochemical basis for increased testosterone production in theca cells propagated from patients with polycystic ovary syndrome. J. Clin. Endocrinol. Metab. 86, 5925–5933 (2001)PubMedCrossRef
31.
Zurück zum Zitat R. Nahum, K.J. Thong, S.G. Hillier, Metabolic regulation of androgen production by human thecal cells in vitro. Hum. Reprod. 10, 75–81 (1995)PubMedCrossRef R. Nahum, K.J. Thong, S.G. Hillier, Metabolic regulation of androgen production by human thecal cells in vitro. Hum. Reprod. 10, 75–81 (1995)PubMedCrossRef
32.
Zurück zum Zitat H. Shimizu, S. Oh, S. Okada, M. Mori, Nesfatin-1: an overview and future clinical application. Endocr. J. 56, 537–543 (2009)PubMedCrossRef H. Shimizu, S. Oh, S. Okada, M. Mori, Nesfatin-1: an overview and future clinical application. Endocr. J. 56, 537–543 (2009)PubMedCrossRef
33.
Zurück zum Zitat D.S. Guzick, R. Wing, D. Smith, S.L. Berga, S.J. Winters, Endocrine consequences of weight loss in obese, hyperandrogenic, anovulatory women. Fertil. Steril. 61, 598–604 (1994)PubMed D.S. Guzick, R. Wing, D. Smith, S.L. Berga, S.J. Winters, Endocrine consequences of weight loss in obese, hyperandrogenic, anovulatory women. Fertil. Steril. 61, 598–604 (1994)PubMed
34.
Zurück zum Zitat R.J. Norman, M.J. Davies, J. Lord, L.J. Moran, The role of lifestyle modification in polycystic ovary syndrome. Trends Endocrinol. Metab. 13, 251–257 (2002)PubMedCrossRef R.J. Norman, M.J. Davies, J. Lord, L.J. Moran, The role of lifestyle modification in polycystic ovary syndrome. Trends Endocrinol. Metab. 13, 251–257 (2002)PubMedCrossRef
35.
Zurück zum Zitat B.K. Tan, M. Hallschmid, W. Kern, H. Lehnert, H.S. Randeva, Decreased cerebrospinal fluid/plasma ratio of the novel satiety molecule, nesfatin-1/NUCB-2, in obese humans: evidence of nesfatin-1/NUCB-2 resistance and implications for obesity treatment. J. Clin. Endocrinol. Metab. 96, E669–E673 (2011)PubMedCrossRef B.K. Tan, M. Hallschmid, W. Kern, H. Lehnert, H.S. Randeva, Decreased cerebrospinal fluid/plasma ratio of the novel satiety molecule, nesfatin-1/NUCB-2, in obese humans: evidence of nesfatin-1/NUCB-2 resistance and implications for obesity treatment. J. Clin. Endocrinol. Metab. 96, E669–E673 (2011)PubMedCrossRef
36.
Zurück zum Zitat M. Ari, O.H. Ozturk, Y. Bez, S. Oktar, D. Erduran, High plasma nesfatin-1 level in patients with major depressive disorder. Prog. Neuropsychopharmacol. Biol. Psychiatry 35, 497–500 (2011)PubMedCrossRef M. Ari, O.H. Ozturk, Y. Bez, S. Oktar, D. Erduran, High plasma nesfatin-1 level in patients with major depressive disorder. Prog. Neuropsychopharmacol. Biol. Psychiatry 35, 497–500 (2011)PubMedCrossRef
37.
Zurück zum Zitat M. Ramanjaneya, J. Chen, J.E. Brown, G. Tripathi, M. Hallschmid, S. Patel, W. Kern, E.W. Hillhouse, H. Lehnert, B.K. Tan, H.S. Randeva, Identification of nesfatin-1 in human and murine adipose tissue: a novel depot-specific adipokine with increased levels in obesity. Endocrinology 151, 3169–3180 (2010)PubMedCrossRef M. Ramanjaneya, J. Chen, J.E. Brown, G. Tripathi, M. Hallschmid, S. Patel, W. Kern, E.W. Hillhouse, H. Lehnert, B.K. Tan, H.S. Randeva, Identification of nesfatin-1 in human and murine adipose tissue: a novel depot-specific adipokine with increased levels in obesity. Endocrinology 151, 3169–3180 (2010)PubMedCrossRef
38.
Zurück zum Zitat Z. Zhang, L. Li, M. Yang, H. Liu, G. Boden, G. Yang, Increased plasma levels of nesfatin-1 in patients with newly diagnosed type 2 diabetes mellitus. Exp. Clin. Endocrinol. Diabetes 120, 91–95 (2012)PubMedCrossRef Z. Zhang, L. Li, M. Yang, H. Liu, G. Boden, G. Yang, Increased plasma levels of nesfatin-1 in patients with newly diagnosed type 2 diabetes mellitus. Exp. Clin. Endocrinol. Diabetes 120, 91–95 (2012)PubMedCrossRef
Metadaten
Titel
Nesfatin-1 and other hormone alterations in polycystic ovary syndrome
verfasst von
Rulin Deniz
Bilgin Gurates
Suleyman Aydin
Husnu Celik
İbrahim Sahin
Yakup Baykus
Zekiye Catak
Aziz Aksoy
Cihan Citil
Sami Gungor
Publikationsdatum
01.12.2012
Verlag
Springer US
Erschienen in
Endocrine / Ausgabe 3/2012
Print ISSN: 1355-008X
Elektronische ISSN: 1559-0100
DOI
https://doi.org/10.1007/s12020-012-9638-7

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