ORIGINAL

E n d o c r i n e

ARTICLE
R e s e a r c h

Evidence for Association between Polycystic Ovary

Syndrome (PCOS) and TCF7L2 and Glucose Intolerance
in Women with PCOS and TCF7L2
Assel Biyasheva, Richard S. Legro, Andrea Dunaif, and Margrit Urbanek
Division of Endocrinology, Metabolism, and Molecular Medicine (A.B., A.D., M.U.), Northwestern University Medical
School, Chicago, Illinois 60611; and Department of Obstetrics and Gynecology (R.S.L.), Pennsylvania State University,
Hershey, Pennsylvania 17033

Context and Objective: Of the recently identified type 2 diabetes mellitus (T2D) susceptibility loci,
transcription factor 7-like 2 (TCF7L2) confers the greatest relative risk for T2D and significantly
predicts conversion to T2D in persons with impaired glucose tolerance. TCF7L2 is, therefore, also
a strong candidate gene for polycystic ovary syndrome (PCOS), a common endocrine disorder
characterized by androgen excess and menstrual irregularities and associated with insulin resistance and a 7-fold increased risk for T2D.
Research Design and Methods: We tested for association between 58 single nucleotide polymorphisms mapping to TCF7L2 and PCOS in 624 index (PCOS) cases and 553 control women of European
ancestry. Furthermore, in the women with PCOS, we tested for association with seven reproductive
and metabolic quantitative traits.
Results: Although we did not detect evidence for association between the previously described
TCF7L2 T2D locus, the proinsulin:insulin molar ratio, a marker of pancreatic -cell dysfunction, was
strongly associated with this locus (P 2.1 104). We also observed evidence for association
between PCOS and two single nucleotide polymorphisms, rs11196236 (P 9.0 104) and
rs11196229 (P 0.0027) mapping more than 100 kb centromeric to the previously published T2D
susceptibility loci.
Conclusions: We have observed evidence of association with two independent TCF7L2 loci in a
PCOS cohort: 1) association between the proinsulin:insulin molar ratio and the T2D locus; and 2)
association with reproductive PCOS phenotype and a novel locus. This study suggests that variation
in different regions of a susceptibility gene contributes to distinct phenotypes. (J Clin Endocrinol
Metab 94: 26172625, 2009)

olycystic ovary syndrome (PCOS) is a common endocrine

disorder affecting 510% of reproductive-age women in
Western societies (1) and is characterized by hyperandrogenemia
and irregular menses. Furthermore, PCOS is also associated with
insulin resistance, pancreatic -cell dysfunction, and obesity, abnormalities that confer a substantially increased risk for metabolic syndrome and type 2 diabetes mellitus (T2D) (reviewed in
Ref. 2). These reproductive and metabolic abnormalities are heritable, and male as well as female first-degree relatives are at risk
for metabolic syndrome and T2D (37).

Despite its phenotypic overlap with T2D and obesity, PCOS

has a number of unique features (e.g. hyperandrogenism, disordered gonadotropin secretion, postbinding defect in insulin signaling). This observation raises the fundamental question: is
PCOS a genetically distinct disorder or do the same obesity/T2D
susceptibility genes interact with additional genetic or environmental factors to result in the PCOS phenotype? Although PCOS
is likely the most common T2D subphenotype (8), this question
is also relevant to other T2D subgroups such as gestational diabetes mellitus (reviewed in Ref. 9). Multiple obesity/T2D can-

ISSN Print 0021-972X ISSN Online 1945-7197

Printed in U.S.A.
Copyright 2009 by The Endocrine Society
doi: 10.1210/jc.2008-1664 Received July 30, 2008. Accepted March 27, 2009.
First Published Online April 7, 2009

Abbreviations: %B, -Cell function; BMI, body mass index; DHEAS, dehydroepiandrosterone sulfate; HDL, high-density lipoprotein; HOMA-IR, homeostatic index of insulin resistance; LD, linkage disequilibrium; OGTT, oral glucose tolerance test; PCOS, polycystic
ovary syndrome; SNP, single nucleotide polymorphism; T, total testosterone; TCF7L2, transcription factor 7-like 2; T2D, type 2 diabetes mellitus; uT, non-SHBG-bound testosterone.

J Clin Endocrinol Metab, July 2009, 94(7):26172625

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2617

2618

Biyasheva et al.

TCF7L2 Genetic Variation in PCOS

didate genes have been investigated in PCOS (reviewed in Ref.

10). However, studies with sufficiently large sample sizes have
failed to detect significant association between the potential T2D
susceptibility loci calpain 10 and PCOS (11).
To date the locus with strongest and most reproducible evidence for association with T2D is the transcription factor 7-like
2 (TCF7L2) gene, and more specifically the single nucleotide
polymorphisms (SNPs), rs7903146 and rs12255372, which
map to introns 3 and 4 of TCF7L2, respectively (12). TCF7L2,
also known as TCF4, is a transcription factor in the wnt-signaling pathway, and it functions as a nuclear receptor for -catenin.
The wnt- signaling pathway is critical for cell proliferation, motility, and embryogenesis including the development of the pancreas and islets. The risk allele T of rs7903146 has been shown
to be a strong predictor of future T2D and is associated with
increased pancreatic-cell TCF7L2 expression, decreased insulin
secretion, and increased proinsulin:insulin ratio (1316). Also
depletion of TCF7L2 in cultured human pancreatic islets results
in increased pancreatic -cell apoptosis, decreased -cell proliferation, and decreased glucose-stimulated insulin secretion (17).
Only one study has examined the role of genetic variation in
TCF7L2 in PCOS (18). This study found no evidence for association between rs7903146 or rs12255372, the SNPs that are
associated with T2D, and PCOS in two large Caucasian cohorts.
Limiting the study to these SNPs is based on the a priori assumption that the same variants that are associated with T2D will also
be associated with PCOS. We know that this assumption is not
true in genes causing Mendelian disorders. For instance, mutations in the gene for lamin a/c can result in such diverse phenotypes as Hutchison-Gilford progeria, Dunnigan-type familial
partial lipodystrophy, or Emery-Dreyfuss muscular dystrophy,

J Clin Endocrinol Metab, July 2009, 94(7):26172625

depending on the location within the gene of the disease-associated mutation or variant (reviewed in Ref. 19). Different mutations in the cystic fibrosis gene, CFTR, are associated with
pancreatic insufficiency, with impaired lung function, or with
congenital bilateral absence of the vas deferens (reviewed in Ref.
20). Among complex traits, examples of phenotypic heterogeneity include the apolipoprotein E locus, which is associated with
Alzheimers, Parkinsons, and cardiovascular disease among
others (reviewed in Ref. 21) and the CDKN2A/B locus on
chr9p21.3, which is associated with T2D and myocardial infarction (22, 23).
We performed this study to test the hypothesis that variation in the TCF7L2 gene is associated with PCOS or related
metabolic traits. In light of the genetic heterogeneity observed
at TCF7L2 (12, 24), we examined the role of genetic variation
in the entire approximately 260-kb genomic region encompassing TCF7L2.

Subjects and Methods

Subjects
This study was approved by the Institutional Review Boards of the
Brigham and Womens Hospital, Northwestern University Feinberg
School of Medicine, Pennsylvania State University College of Medicine,
and University of Pennsylvania Medical Center. Written informed consent was obtained from all participants. We studied 624 index cases
(probands) with PCOS, and 553 control women (81 intensively phenotyped and 472 minimally phenotyped from a DNA repository) of European Caucasian ancestry. Phenotypic characteristics of cases and controls are given in Table 1.

TABLE 1. Phenotypic characteristics of study participants

PCOS
(n 624)
n
Age (yr)
BMI (kg/m2)
Waist circumference (cm)
T (ng/dl) (mmol/liter)
uT (ng/dl) (mmol/liter)
DHEAS (ng/ml) (mol/liter)
SHBG (nmol)
Fasting insulin (U/ml)
(pmol/liter)
Proinsulin (pmol)
Fasting glucose (mg/dl)
(mmol/liter)
2-h glucose (mg/dl)
(mmol/liter)
HDL (mg/dl) (mmol/liter)
TTG (mg/dl) (mmol/liter)

Median (range)

Minimally phenotyped
controls (n 472)

Intensively phenotyped
controls (n 81)

Median (range)

Median (range)

472
463
ND
ND
ND
ND
ND
ND

35 (18 45)
23.2 (16.7 68.1)
ND
ND
ND
ND
ND
ND

81
81
70
81
81
79
39
74

30 (18 55)
27.3 (18.0 53.5)
85 (63134)
85 (63134) 1.0 (0.21.7)
6.0 (116.0) 0.2 (0.03 0.6)
1,341 (1023,484) 3.6 (0.39.5)
124 (46 331)
11 (4 29) 66 (24 174)

14.9 (2.0 114.4)c

88 (58 189) 4.9 (3.210.5)

ND
ND

ND
ND

66
80

9.1 (3.8 20.4)

90 (72130) 5.0 (4.0 7.2)

259

128 (68 324)c 7.1 (3.8 18.0)c

ND

ND

80

108 (54 204) 6.0 (3.0 11.3)

577
578

40 (15107)c 1.03 (0.39 2.77)c

137 (352,427)c 3.54 (0.91 62.76)c

ND
ND

ND
ND

66
66

624
624
408
624
621
616
514
601

28 (14 48)a
35.0 (16.5 64.5)b
101 (58 170)
73 (29 337)c 2.5 (1.0 11.7)c
24 (1.7109)c 0.8 (0.06 3.8)c
2089 (50 13,336)c 5.7 (0.136.2)c
56 (12 426)c
22 (3152) 132 (18 912)

560
607

50 (27 88) 1.29 (0.70 2.28)

76 (37306) 1.97 (0.96 7.91)

Conversion factors: uT and T (ng/dl to mmol/liter), multiply by 0.03467; DHEAS (ng/ml to mol/liter), multiply by 0.002714; insulin (U/ml to pmol/liter), multiply by
6.0; glucose (mg/dl to mmol/liter), multiply by 0.05551; HDL (mg/dl to mmol/liter), multiply by 0.02586; and TTG (mg/dl to mmol/liter), multiply by 0.01129. ND, Not
determined; TTG, total triglycerides.
a

P 0.01 vs. intensively phenotyped controls.

P 0.0001 vs. intensively phenotyped controls.

P 0.0001 vs. intensively phenotyped controls after adjusting for BMI and age.

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J Clin Endocrinol Metab, July 2009, 94(7):26172625

PCOS cases

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2619

PCOS was defined according to the classic National Institute of Child

Health and Human Development (NICHD) criteria and as previously
implemented by us (57, 25). In brief, all women with PCOS had hyperandrogenemia and chronic anovulation with the exclusion of specific
disorders of the ovaries, adrenal, or pituitary (57, 25) and therefore,
fulfill the NICHD, Rotterdam, Androgen Excess Society criteria for the
diagnosis of PCOS (26 28).

fected if they fulfilled any three of the following five criteria: systolic
blood pressure of at least 130 mm Hg and/or diastolic blood pressure of
at least 85 mm Hg; waist circumference at least 88 cm; fasting glucose
above 100 mg/dl (5.6 mmol/liter); HDL above 50 mg/dl (1.42 mmol/
liter); and triglycerides of at least 150 mg/dl (1.69 mmol/liter). A total
of 457 PCOS cases had complete data to assign metabolic syndrome
affected status: 227 women with PCOS had metabolic syndrome, and
230 women with PCOS were unaffected.

Controls

Glucose intolerance phenotype in women with PCOS

Intensively phenotyped reproductively normal control women (n

81) were phenotyped as previously reported (5, 6) with normal androgen
levels and regular menses of similar age, weight, and ethnicity to the
PCOS cases. To increase the number of control subjects, we used minimally phenotyped women (n 472) selected from NUgene, a large scale
GenBank (http://www.nugene.org) that combines a centralized genomic
DNA sample collection and storage system with the ability to update
participants health status with periodic data uploads from electronic
medical records. Such population-based controls have been used successfully in multiple studies, including genome-wide association studies,
because they are relatively easy and inexpensive to collect and can be used
as controls for multiple phenotypes (29). To decrease the likelihood of
including women with PCOS, we excluded women with known diabetes
based on a questionnaire and preferentially included women with documented pregnancies. Of the 472 subjects, 272 had at least one pregnancy (average, 2.2 pregnancies; range, 1 to 11). Women who had undergone in vitro fertilization were excluded. We, therefore, expect that
our control cohort will include fewer women with PCOS than the population prevalence of PCOS (510%) (1). Nevertheless, we assumed that
the control population would have the population prevalence of PCOS
in our power calculations, which had minimal impact on power (see
Power analysis).

Glucose intolerance was defined as postchallenge glucose of at least

140 mg/dl (7.8 mmol/liter) (n 99), or a fasting glucose above 100
mg/dl (5.6 mmol/liter) (n 53) in women who did not have an OGTT.
A total of 149 women with PCOS had glucose intolerance, and 422 had
normal glucose tolerance. The cases with normal glucose tolerance are
henceforth referred to as normoglycemic, and the women with glucose
intolerance are referred to as dysglycemic. We estimated steady-state
-cell function (%B) and the homeostatic index of insulin resistance
(HOMA-IR) with the HOMA Calculator v2.2.2 (http://www.dtu.ox.
ac.uk/index.php?maindoc/homa) in 563 women with PCOS. Clinical
characteristics of women with PCOS and intensively phenotyped controls were compared using the Students t test.

Study protocols
None of the subjects were receiving medications known to alter reproductive hormone levels or glucose homeostasis for at least 1 month
before study. Contraceptive steroids were stopped at least 3 months
before study. Anthropometric measurements (blood pressure, waist circumference, weight, and height) were taken as reported (30). A 75-g oral
glucose tolerance test (OGTT) was carried out as previously described (7)
after a 300-g carbohydrate diet and overnight fast in 259 women with
PCOS (7). After a baseline blood sample for fasting reproductive and
metabolic hormones, blood samples were obtained for insulin and glucose levels at 0 and 2 h after glucose challenge.

Biochemical assays
Circulating levels of glucose, insulin, proinsulin, total testosterone
(T), non-SHBG-bound testosterone (uT), dehydroepiandrosterone sulfate (DHEAS), SHBG, high-density lipoprotein (HDL) cholesterol, and
triglyceride were determined as previously reported (5, 25).

Genotyping
We genotyped SNPs mapping to 258 kb that encompass TCF7L2 and
20 kb of genomic sequence upstream and downstream of TCF7L2 (Fig.
1). The SNPs were selected using the HAPMAP Tagger function (http://
www.hapmap.org/cgi-perl/gbrowse/hapmap_B35/) to tag the entire
genomic segment in Caucasians (i.e. the CEPH trios genotyped by HAPMAP) at an r2 of 0.8. SNPs were genotyped using the Illumina Goldengate array system (Illumina, San Diego, CA) according to the manufacturers recommendations.

Data analyses: secondary phenotypes

Metabolic syndrome
The metabolic syndrome phenotype was assigned according to the
American Heart Association criteria (31). Women were considered af-

Power analysis
We used the Genetic Power Calculator package to calculate the
power to detect an association between rs12255372 and PCOS in our
cohort (32). The parameters used for this analysis were: 553 controls,
624 cases, genotypic relative risk for GT of 1.64, genotypic risk for TT
of 3.29, and rs12255372 allele T frequencies of 0.386 for cases and 0.260
for controls (see Ref. 12 for U.S. genotypic risk and allele frequencies in
Grant et al.) and using unselected controls with a 5% population prevalence of PCOS. Assuming these parameters, we had more than 97%
power to detect an effect at P 1 105. We also calculated our power
for average Caucasian (U.S., Danish, and Icelandic) allele frequencies
(cases 0.362, controls 0.268) and had more than 75% power to
detect an effect at P 1 104. We, therefore, had sufficient power to
detect a relevant effect in our cohort.
We calculated power for our metabolic syndrome cohort (227 affected, 230 unaffected) using the same parameters as for the PCOS cohort. We had more than 76% power for the U.S. allele frequencies and
P 1 103. We had more than 60% power given the Caucasian allele
frequencies and P 1 102. Therefore, we also had reasonable if
reduced power for the much smaller metabolic syndrome cohort.
Similarly, power analyses for quantitative traits were carried out for
624 PCOS probands using the program CaTSQT2 (Skol, A., personal
communications and Ref. 33) assuming an additive model. We had 61%
power to detect a variant that explains 2% of the variance of the
quantitative trait analysis and 83% power to detect a variant that
explains 3% of the variance of the quantitative trait analysis.

Genetic analysis
We tested for association between 58 SNPs and 60 haplotypes belonging to 15 haplotype blocks with two dichotomous traits: PCOS and
metabolic syndrome as defined above. These analyses were implemented
using Haploview 4.0 (haploview@broad.mit.edu/haploview/haploviewdownloads) (34). We corrected for multiple testing by generating corrected significance levels by carrying out 10,000 permutations by swapping case control labels. Pairwise linkage disequilibrium (LD) plots of D
were generated using Haploview 4.0.
We also assessed the impact of genetic variation at the SNPs on the
distribution of seven quantitative traits in the subjects with PCOS. The
traits tested were body mass index (BMI) (n 624), T (n 624), DHEAS
(n 616), SHBG (n 514), proinsulin:insulin ratio (n 556),
HOMA-IR (n 562), and HOMA%B (n 562). These analyses were
implemented using PLINK 0.99 (http://pngu.mgh.harvard.edu/purcell/
plink/) (35). We corrected for multiple testing by generating corrected
significance levels by carrying out at least 100,000 permutations by

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2620

Biyasheva et al.

TCF7L2 Genetic Variation in PCOS

J Clin Endocrinol Metab, July 2009, 94(7):26172625

rs11196192, rs11196199, rs17685538, rs7895340, and

rs12255372 in our study. We designated this region the
Caucasian T2D locus. Similarly, we designated the region at the 3end of the gene identified in a Taiwanese
cohort (24) as the Taiwanese T2D locus.

Results
Clinical features
Clinical features of the PCOS cases and both control cohort are shown in Table 1. Women with
PCOS were significantly younger than the intensively phenotyped controls. As expected, women
with PCOS also had significantly higher BMI, larger
waist circumference, elevated T, elevated uT, elevated DHEAS, and lower SHBG than the intensively
phenotyped controls. Furthermore, women with
PCOS had significantly elevated 2-h glucose levels,
proinsulin levels, and TTG levels and lower HDL
levels. Fasting insulin and fasting glucose levels did
not differ significantly between women with PCOS
and the intensively phenotyped controls.
Genotyping
All of the genotyped SNPs passed all quality control measures including Hardy Weinberg equilibrium values of at least 0.001, minimum genotyping
frequency of at least 75%, and minimum minor allele frequency of at least 0.001 (Table 2 and Fig. 1).
Average call rates were above 99% for each SNP and
each DNA sample.
FIG. 1. Schematic of TCF7L2 association study in PCOS. A, TCF7L2 genomic region. The
horizontal line indicates the genomic region encompassed in our genetic analysis. The vertical
lines indicate the relative positions of the exons of the TCF7L2 gene. B, Association results. The
Log10(pobserved) values are plotted along the y-axis. The relative location of each SNP is
indicated along the x-axis. The diamonds correspond to association results of individual SNPs.
The short horizontal line corresponds to the haplotype with statistically significant evidence for
association with PCOS. Blue diamonds correspond to SNPs that are in LD (D 0.4) with SNPs
that are associated with T2D susceptibility SNPs in Caucasians in the Grant et al. study (12),
whereas the orange diamonds correspond to variants in LD with SNPs associated with T2D in the
Taiwanese cohort (24). C, Pairwise LD (D) plot. Pairwise D results were plotted with Haploview.
Dark red indicates strong LD, whereas white indicates no LD. The location and number of each
haplotype block are shown above the pairwise LD plot.

swapping subject IDs. All quantitative trait analyses were carried out
only in the PCOS subjects.
We used genomic control (36, 37) to control for possible population
stratification. The genomic inflation factor was calculated from 91
SNPs. These SNPs were selected from 384 SNPs genotyped in the cohort
studied in this report and were selected to be maximally informative for
differentiating between continental groups based on the Hapmap Phase
1 populations (Caucasians CEU, Han Chinese from Beijing CHB,
Japanese from Tokyo JPT, and Africans from the Yoruban tribe of
Ibadan, Nigeria YRI). Allele frequencies are not in LD with each other
(r2 0.2) and do not map to or were in LD with suspected PCOS susceptibility loci. was calculated as median 2 value of the 91 genomic
control SNPs divided by 0.456. Genomic control corrected study statistic
Y2 equals 2/.

Definition of TCF7L2 T2D loci

The original TCF7L2 T2D locus (12) mapped to introns 3 and 4
of the gene and is delimited by the SNPs rs4506565, rs7896811,

Genomic control
From a panel of 384 SNPs, 91 SNPs were not
in significant LD (r2 0.2) and were not in LD
with a PCOS susceptibility locus and maximally
differed in allele frequency in the HAPMAP Phase
1 continental populations. Average for the 91
SNPs was 0.182 CEU vs. CHB, 0.170 CEU vs. JPT,
0.222 CEU vs. YRI, 0.049 CHB vs. JPT, 0.201
CHB vs. YRI, and 0.201 JPT vs. YRI. The genomic
control inflation factor for the subjects studied in
this analysis median 2/0.456 1.07. These findings
show that there is some population stratification between the
cases and controls in our study, so all test statistics in the case
control analyses are corrected for population stratification
(Y2 2/). Although our method of selection of ancestry
informative markers primarily differentiates populations
based on continental origin, these markers do also differentiate to a lesser degree between European populations. Average for the 91 ancestry informative markers between a population of northwestern European origins (HAPMAP CEU)
and a population of southern European origin (HAPMAP
TSITuscans in Italy) was 0.04. Genomic control correction
was not needed for the quantitative trait analyses because
those analyses were limited to PCOS cases.

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J Clin Endocrinol Metab, July 2009, 94(7):26172625

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2621

TABLE 2. Results of dichotomous trait analysis

Metabolic
syndrome

PCOS
Name

Location

HW

Call
rate

rs11196152
rs10885392
rs17746916
rs3814570
rs2094405
rs6585194
rs6585195
rs10885399
rs7917983
rs11196175
rs7081062
rs4074718
rs11196181
rs17747324
rs4506565
rs7896811
rs11196192
rs11196199
rs17685538
rs7895340
rs12255372
rs12245680
rs4918789
rs10885410
rs7919409
rs7100388
rs7908486
rs12184389
rs11196218
rs3750805
rs3814572
rs11196224
rs6585206
rs7085532
rs10885414
rs11196228
rs10749128
rs11196229
rs4918796
rs12772424
rs290494
rs11196236
rs1362943
rs3814573
rs10787476
rs290489
rs290488
rs17686448
rs176632
rs1555485
rs1028629
rs11595128
rs1225404
rs290483
rs290481
rs12243558
rs7915609
rs11196260

114676795
114683123
114694771
114698500
114705679
114707461
114712944
114716167
114722872
114726604
114730735
114738607
114739008
114742493
114746031
114756707
114772277
114786107
114787461
114791515
114798892
114810181
114811797
114814463
114814966
114815803
114824488
114829760
114830484
114837133
114837713
114845387
114849241
114849453
114851294
114854287
114855479
114856162
114870332
114870541
114875861
114877712
114878598
114888083
114888904
114897045
114898972
114900402
114901069
114902524
114902646
114903468
114904655
114905204
114913815
114930492
114932355
114934868

0.466
0.687
0.363
0.540
0.997
0.903
0.166
0.04
0.790
0.527
0.658
0.771
0.307
0.458
0.991
0.798
0.898
0.792
0.192
0.645
1
0.543
0.172
1
0.503
0.698
0.444
0.404
0.261
0.186
0.256
0.673
1
0.053
0.055
0.478
0.376
0.327
0.231
0.146
0.363
0.175
0.480
0.032
0.251
0.987
0.003
1
0.817
0.312
0.679
0.715
0.102
0.336
0.672
0.145
0.077
0.570

99.3
99.4
99.4
99.2
99.4
99.4
99
99.4
99.6
99.4
99.4
99.4
99.4
99.4
99.1
99.2
99.6
98.7
99.7
99.8
99.6
99.2
99.3
99.3
99.2
99.4
99.1
99.4
99.5
99.5
99.4
99.6
99
99.8
99
99.2
93.5
99.5
99.4
99.3
99
99.4
99.7
99.7
99.4
99.1
82.9
99.5
99.8
99
99.4
99.4
98.9
99.5
99.8
99.2
99.6
99.8

Casesb
MAF

Controlsb
MAF

Y2 c

P
valued

Y2 c

P
valued

0.509
0.265
0.075
0.263
0.287
0.287
0.135
0.216
0.488
0.282
0.369
0.475
0.071
0.226
0.309
0.153
0.070
0.171
0.111
0.468
0.273
0.095
0.464
0.262
0.111
0.107
0.354
0.172
0.278
0.117
0.133
0.318
0.185
0.321
0.277
0.096
0.257
0.207
0.25
0.401
0.159
0.246
0.310
0.340
0.061
0.235
0.061
0.048
0.139
0.190
0.160
0.142
0.337
0.382
0.159
0.217
0.225
0.036

0.499
0.270
0.061
0.288
0.267
0.271
0.137
0.217
0.486
0.282
0.366
0.464
0.068
0.233
0.319
0.15
0.076
0.159
0.120
0.464
0.295
0.104
0.464
0.268
0.120
0.094
0.365
0.139
0.261
0.120
0.176
0.273
0.171
0.288
0.335
0.077
0.22
0.269
0.206
0.387
0.171
0.189
0.345
0.367
0.058
0.243
0.066
0.040
0.149
0.211
0.186
0.165
0.364
0.401
0.156
0.203
0.222
0.029

0.001
0.083
1.486
0.532
0.387
0.165
0.023
0.009
0.003
0.079
0.062
0.390
0.044
0.751
0.511
0.318
0.000
1.011
0.808
0.088
1.438
0.132
0.003
0.130
0.153
0.554
0.066
3.188
0.402
0.118
6.515
4.036
0.729
2.611
6.975
3.067
2.814
9.005
6.155
0.377
0.339
10.973
2.611
2.119
0.011
0.689
0.164
0.006
0.131
1.732
2.336
2.967
1.485
0.801
0.037
0.373
0.012
0.810

0.976
0.773
0.223
0.466
0.534
0.685
0.879
0.924
0.958
0.779
0.803
0.532
0.834
0.386
0.475
0.573
1.000
0.315
0.369
0.767
0.230
0.716
0.958
0.718
0.696
0.457
0.797
0.074
0.526
0.731
0.0106
0.045
0.393
0.106
0.0083
0.080
0.093
0.0027
0.013
0.539
0.560
0.0009
0.106
0.145
0.916
0.407
0.686
0.938
0.717
0.188
0.126
0.085
0.223
0.371
0.847
0.541
0.913
0.368

0.191
1.374
0.000
0.610
0.312
0.077
0.022
0.021
0.509
4.012
0.180
0.109
0.124
1.701
0.940
0.807
0.369
0.783
1.819
0.003
0.977
0.497
1.118
1.693
0.646
0.037
0.786
0.087
0.436
0.007
0.092
0.012
0.208
0.533
0.330
0.202
0.332
0.001
0.013
0.300
0.128
0.000
0.006
0.126
0.828
3.279
0.113
0.627
0.222
0.470
0.931
1.740
0.209
0.321
2.148
1.758
0.435
1.005

0.662
0.241
1.000
0.435
0.576
0.781
0.882
0.885
0.476
0.045
0.671
0.741
0.725
0.192
0.332
0.369
0.544
0.376
0.177
0.958
0.323
0.481
0.290
0.193
0.422
0.847
0.375
0.768
0.509
0.933
0.762
0.913
0.648
0.465
0.566
0.653
0.564
0.976
0.909
0.584
0.721
1.000
0.938
0.723
0.363
0.070
0.727
0.428
0.638
0.493
0.335
0.187
0.648
0.571
0.143
0.185
0.510
0.316

MAF, Minor allele frequency; HW, Hardy Weinberg Equilibrium.

a

Location on chromosome based on dbSNP build 125.

Minor allele defined based on control frequency.

Corrected for population stratification using genomic control 1.07.

Observed P value.

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2622

Biyasheva et al.

TCF7L2 Genetic Variation in PCOS

Association testing
Of the markers we genotyped, six variants mapped to the T2D
region identified by Grant et al. (12) and the whole genome
association studies for T2D (rs4506565, rs7896811,
rs11196192, rs11196199, rs17685538, rs7895340, and
rs12255372; Fig. 1 and Table 2). None of these markers showed
evidence for association with PCOS (624 cases, 553 controls) or
in the women with PCOS with metabolic syndrome (227 cases,
230 controls; Table 2) after correction for multiple testing.
The preliminary evidence for association between TCF7L2
and PCOS was found approximately 100 kb downstream of the
Caucasian T2D locus. We will refer to this locus as the TCF7L2
PCOS locus to differentiate it from the T2D locus. This region
includes six SNPs and six haplotypes with nominally significant
evidence for association with PCOS (Table 1 and Fig. 1). After
correction for multiple testing and population stratification, one
SNP (rs11196236, allele G, pobserved 9.0 104; pcorrected
0.047) remains statistically significant, and one locus approaches statistical significance (rs11196229, allele G, pobserved
0.0027; pcorrected 0.14). Similarly, two haplotype (block 11,
haplotype GAA, pobserved 2.9 104, pcorrected 0.016; block
12, haplotype AA, pobserved 0.0009, pcorrected 0.049)
reached statistical significance.
The strongest evidence for association with the metabolic
syndrome was with rs11196175, although this finding did not
remain statistically significant after correction for multiple testing (pobserved 0.045; pcorrected 0.08). However, sample sizes
for the metabolic syndrome phenotype (227 affected, 230 unaffected) are significantly smaller that those for the PCOS phenotype and, consequently, have substantially lower power. Larger
sample sizes are needed to establish the role of rs11196175 in the
metabolic syndrome in women with PCOS.
Our second major finding is that the proinsulin:insulin molar
ratio (a marker of pancreatic -cell dysfunction) showed statistically significant evidence for association in the PCOS subjects
(rs4506565; pobserved 2.1 104; pcorrected 0.010) even
after correction for multiple testing. Interestingly, this association maps to the Caucasian TCF7L2 T2D locus (see Fig. 3A).
Other metabolic measures, including BMI (rs4506565; pobserved
0.0036; pcorrected 0.14), SHBG (rs7081062; pobserved
0.014; pcorrected 0.45; rs7917983; pobserved 0.046; pcorrected
0.83), HOMA-IR (rs17747324; pobserved 0.021; pcorrected
0.58; rs11196175; pobserved 0.036; pcorrected 0.77),
HOMA%B (rs4074718; pobserved 0.0038; pcorrected 0.15),
fasting insulin levels (rs4506565; pobserved 0.023; pcorrected
0.60; rs11196175; pobserved 0.035; pcorrected 0.75;
rs7081062; pobserved 0.047; pcorrected 0.84), and waist circumference (rs17747324; pobserved 0.023; pcorrected 0.61),
also showed nominal evidence for association with SNPs in this
region, although these findings did not remain significant after
correction for multiple testing. Neither T nor DHEAS levels
showed even nominal evidence for association in this region
(data not shown). However, these androgen levels did show
nominal evidence for association with the PCOS specific locus
(T, rs37500805; pobserved 0.021; pcorrected 0.57; DHEAS,
rs6585206, pobserved 0.011; pcorrected 0.38). These findings
did not remain significant after correction for multiple testing.

J Clin Endocrinol Metab, July 2009, 94(7):26172625

All the quantitative trait analyses were carried only in the PCOS
subjects.
Association testing of PCOS cohort stratified based on
glucose tolerance
To determine whether the proinsulin:insulin molar ratio-associated locus is restricted to a subset of women with PCOS, we
tested for association in normoglycemic and dysglycemic PCOS.
Virtually all the evidence for association with PCOS phenotype
was found in the normoglycemic PCOS (Fig. 2B), and with only
nominal evidence for association with PCOS in women with
PCOS and glucose intolerance (Fig. 2C), implying that the
TCF7L2 locus has a different role in women with PCOS and
normal glucose tolerance than in women with PCOS who have
evidence for impaired glucose tolerance. Henceforth, we will
refer to this locus as the PCOS locus. Conversely, after stratification by glucose tolerance, there was no evidence for association between the proinsulin:insulin ratio and any of the SNPs
tested in normoglycemic PCOS (Fig. 3B). In contrast, there is a

FIG. 2. Association results of PCOS trait in the complete PCOS cohort (A),
normoglycemic women with PCOS (B), and glucose-intolerant women with PCOS
(C). Black symbols correspond to SNPs that are in LD (D 0.4) with SNPs that
are associated with T2D susceptibility SNPs in Caucasians in the Grant et al. study
(12), whereas stippled symbols correspond to variants in LD with SNPs associated
with T2D in the Taiwanese cohort (24). The Log10(pobserved) value for each
association test is shown along the y-axis, and the location of each SNP is
indicated along the x-axis.

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J Clin Endocrinol Metab, July 2009, 94(7):26172625

FIG. 3. Quantitative trait analysis of proinsulin:insulin ratio in the complete PCOS

cohort (A), normoglycemic women with PCOS (B), and glucose-intolerant women
with PCOS (C). Solid black shading corresponds to SNPs that are in LD (D 0.4)
with SNPs that are associated with T2D susceptibility SNPs in Caucasians in the
Grant et al. study (12), whereas the stippled shading corresponds to variants in
LD with SNPs associated with T2D in the Taiwanese cohort (24). The
Log10(pobserved) value for each association test is shown along the y-axis, and
the location of each SNP is indicated along the x-axis.

very robust association with rs4506565 (pobserved 9.8 105;

pcorrected 1.7 104) in PCOS with glucose intolerance, even
in a relatively small cohort (n 139; Fig. 3C).

Discussion
In a detailed screen for association between PCOS and PCOSassociated quantitative traits and 58 SNPs mapping to the
TCF7L2 gene, we identified two independent TCF7L2 loci with
potential evidence for association. The first locus mapped approximately 100 kb downstream of the previously identified
Caucasian T2D locus and was associated with PCOS. The second locus was associated with proinsulin:insulin ratio in women
with PCOS and mapped to the previously identified Caucasian
T2D susceptibility locus.
TCF7L2 confers the greatest risk for T2D (odds ratio 1.37)
of any susceptibility locus identified to date (38). Because of the
overlap in the T2D and PCOS phenotypes, TCF7L2 is a very
plausible candidate gene for PCOS. Barber et al. (18) found no
evidence for association between the Caucasian T2D locus, map-

jcem.endojournals.org

2623

ping to rs7903146 and rs12255372, and PCOS in two cohorts:

1) 369 PCOS cases and 2577 controls of U.K. British/Irish origin;
and 2) 540 women with symptoms of PCOS and 1083 controls
from the Northern Finland Birth Cohort of 1966. In contrast to
our study, Barber et al. (18) did not investigate the association
between measures of glucose homeostasis and this TCF7L2 Caucasian in their PCOS cohort.
We studied the entire genomic region of TCF7L2 because we
were investigating a distinct phenotype, PCOS, rather than typical T2D. Furthermore, studies have already demonstrated genetic heterogeneity within TCF7L2 in T2D cohorts of different
ethnicities with the identification of a novel T2D locus in a Taiwanese cohort that maps to the 3 end of the TCF7L2 gene (12,
24). We also found no evidence for association between the
rs7903146/rs12255372 region and PCOS in our cohort. However, we did observe preliminary evidence for association with
PCOS in a region approximately 100 kb downstream of the
Caucasian T2D locus. This PCOS susceptibility region was not
in significant LD with the rs7903146/rs12255372 region and,
therefore, was not due to an indirect effect of the Caucasian T2D
locus. Although these findings remain significant after correction
for population stratification and multiple testing, they will need
to be replicated in an independent cohort to be firmly established
as a new PCOS locus.
The putative PCOS locus was predominantly associated
with the complete PCOS phenotype rather than PCOS subphenotypes because the evidence for association with PCOS (hyperandrogenemia and menstrual irregularities) was stronger
than with androgen levels per se (total T or DHEAS). Our assignation of the PCOS phenotype required that a PCOS subject
have both hyperandrogenemia and menstrual irregularities. Furthermore, a PCOS subject is considered hyperandrogenic by having either elevated T or elevated uT. Association with any given
androgen therefore is not identical to association with PCOS.
Furthermore, the quantitative trait analyses used to assess
the association with androgen levels was carried out only in the
PCOS patients, therefore by definition limiting the analysis to the
subjects with elevated androgen levels. The evidence for association might be significantly stronger if the entire spectrum of
androgen levels were included in the analysis. Although these
findings reach statistical significance after correction for multiple testing even in a relatively small cohort, the association between PCOS and the TCF7L2 PCOS locus will need to be replicated in an independent cohort.
All evidence for association at the T2D locus with the proinsulin:insulin ratio was completely accounted for by the subset
of PCOS women with glucose intolerance. Stratification of the
PCOS cohort by glucose tolerance and examination of quantitative metabolic phenotypes suggested that, whereas PCOS per
se was not associated with the Caucasian T2D locus, among a
subset of women with PCOS (i.e. those with glucose intolerance),
the Caucasian T2D locus was strongly associated with the proinsulin:insulin molar ratio, a marker of pancreatic -cell dysfunction (39, 40). Under normal circumstances, the majority of
proinsulin is processed into the mature insulin peptide, and only
a small percentage is secreted into the circulation (39). However,
in subjects with T2D and individuals at high risk of T2D, there

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2624

Biyasheva et al.

TCF7L2 Genetic Variation in PCOS

appears to be decreased processing resulting in increased circulating proinsulin:insulin molar ratios (41). Our findings of an
association between the proinsulin:insulin ratio in PCOS women
with abnormal glucose tolerance and the TCF7L2 Caucasian
T2D locus are consistent with evidence from other studies that
demonstrate that variation in the TCF7L2 gene is associated with
defects in insulin secretion (13, 14, 42), perhaps by altering conversion of proinsulin to insulin by the pancreatic -cell (42).
Lyssenko et al. (13) found that the T2D-associated alleles at
rs7903146 and rs12255372 are associated with defect in arginine-stimulated insulin secretion in women with abnormal glucose tolerance but not in women with normal glucose tolerance
(13). Furthermore, Kirchhoff et al. (42) found that in a cohort of
Germans from Tubingen at high risk of developing diabetes
based on a family history of T2D, the TCF7L2 rs7903146 risk
allele was positively associated with the proinsulin:insulin ratio.
Similarly, Gonzalez-Sanchez et al. (43) found evidence for association between rs7903146 and proinsulin:insulin ratio after 2-h
OGTT in a nondiabetic Spanish cohort, although they did not
find any evidence for association with the fasting proinsulin:
insulin ratio. Although it is probable that our cohort of PCOS
women with normal glycemia also included a small number of
women with undiagnosed glucose intolerance because post-challenge testing was not performed in all PCOS, this misclassification would modestly reduce our power to detect an association,
but it would not generate a false-positive finding.
Interestingly, the T2D-associated locus and the PCOS-specific locus are inherited independently (i.e. the two loci are not in
LD) and are associated with different biochemical features of
PCOS. Further detailed genetic studies of the TCF7L2 genomic
region in multiple related disorders (T2D, gestational diabetes,
and PCOS) and multiple ethnicities are required to fully dissect
the functional regions of the gene and their impact on specific
phenotypes.

Acknowledgments
We thank all the women and their families for participating in this study
and Dr. Deborah Driscoll for sharing with us DNA from her PCOS
cohort.
Address all correspondence and requests for reprints to: Margrit
Urbanek, Division of Endocrinology, Metabolism, and Molecular Medicine, Northwestern University School of Medicine, 303 East Chicago
Avenue, Tarry 15-717, Chicago, Illinois 60611. E-mail m-urbanek@
northwestern.edu.
This work was supported by National Institutes of Health Grants P50
HD44405 (to M.U. and A.D.), U54 HD34449 (to A.D.), M01 RR00048
[to Northwestern University General Clinical Research Center (GCRC)],
M01 RR10732 and C06 RR016499 (to Pennsylvania State University
GCRC), and M01 RR02635 (to Brigham and Womens Hospital
GCRC).
Disclosure Summary: The authors have nothing to disclose.

References
1. Kahsar-Miller MD, Nixon C, Boots LR, Go RC, Azziz R 2001 Prevalence of
polycystic ovary syndrome (PCOS) in first degree relatives of patients with
PCOS. Fertil Steril 75:5358

J Clin Endocrinol Metab, July 2009, 94(7):26172625

2. Cooper HE, Spellacy WN, Prem KA, Cohen WD 1968 Hereditary factors in
Stein-Leventhal syndrome. Am J Obstet Gynecol 100:371387
3. Yildiz BO, Yarali H, Oguz H, Bayraktar M 2003 Glucose intolerance, insulin
resistance, and hyperandrogenemia in first degree relatives of women with
polycystic ovary syndrome. J Clin Endocrinol Metab 88:20312036
4. Yilmaz M, Bukan N, Ersoy R, Karakoca, Yetkin I, Ayvaz G, Cakir N, Arslan
M 2005 Glucose intolerance, insulin resistance and cardiovascular risk factors
in first degree relatives of women with polycystic ovary syndrome. Hum Reprod 20:2414 2420
5. Sam S, Legro RS, Bentley-Lewis R, Dunaif A 2005 Dyslipidemia and metabolic
syndrome in the sisters of women with polycystic ovary syndrome. J Clin
Endocrinol Metab 90:4797 4802
6. Sam S, Legro RS, Essah PA, Apridonidze T, Dunaif A 2006 Evidence for
metabolic and reproductive phenotypes in mothers of women with polycystic
ovary syndrome. Proc Nat Acad Sci USA 103:7030 7035
7. Sam S, Sung YA, Legro RS, Dunaif A 2008 Evidence for pancreatic -cell
dysfunction in brothers of women with polycystic ovary syndrome. Metabolism 57:84 89
8. Legro RS, Kunselman AR, Dodson WC, Dunaif A 1999 Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in
polycystic ovary syndrome: a prospective, controlled study in 254 affected
women. J Clin Endocrinol Metab 84:165169
9. Robitaille J, Grant AM 2008 The genetics of gestational diabetes mellitus:
evidence for relationship with type 2 diabetes mellitus. Genet Med 10:240 250
10. Urbanek M 2007 The genetics of the polycystic ovary syndrome. Nat Clin
Pract Endocrinol Metab 3:103111
11. Haddad L, Evans JC, Gharani N, Robertson C, Rush K, Wiltshire S, Frayling
TM, Wilkin TJ, Demaine A, Millward A, Hattersley AT, Conway G, Cox NJ,
Bell GI, Franks S, McCarthy MI 2002 Variation within the type 2 diabetes
susceptibility gene calpain-10 and polycystic ovary syndrome. J Clin Endocrinol Metab 87:2606 2610
12. Grant SF, Thorleifsson G, Reynisdottir I, Benediktsson R, Manolescu A, Sainz
J, Helgason A, Stefansson H, Emilsson V, Helgadottir A, Styrkarsdottir U,
Magnusson KP, Walters GB, Palsdottir E, Jonsdottir T, Gudmundsdottir T,
Gylfason A, Saemundsdottir J, Wilensky RL, Reilly MP, Rader DJ, Bagger Y,
Christiansen C, Gudnason V, Sigurdsson G, Thorsteinsdottir U, Gulcher JR,
Kong A, Stefansson K 2006 Variant of transcription factor 7-like 2 (TCF7L2)
gene confers risk of type 2 diabetes. Nat Genet 38:320 323
13. Lyssenko V, Lupi R, Marchetti P, Del Guerra S, Orho-Melander M, Almgren
P, Sjogren M, Ling C, Eriksson KF, Lethagen AL, Mancarella R, Berglund G,
Tuomi T, Nilsson P, Del Prato S, Groop L 2007 Mechanisms by which common variants in the TCF7L2 gene increase risk of type 2 diabetes. J Clin Invest
117:21552163
14. Florez JC, Jablonski KA, Bayley N, Pollin TI, de Bakker PI, Shuldiner AR,
Knowler WC, Nathan DM, Altshuler D 2006 TCF7L2 polymorphisms and
progression to diabetes in the Diabetes Prevention Program. N Engl J Med
355:241250
15. Saxena R, Gianniny L, Burtt NP, Lyssenko V, Giuducci C, Sjogren M, Florez
JC, Almgren P, Isomaa B, Orho-Melander M, Lindblad U, Daly MJ, Tuomi T,
Hirschhorn JN, Ardlie KG, Groop LC, Altshuler D 2006 Common single
nucleotide polymorphisms in TCF7L2 are reproducibly associated with type
2 diabetes and reduce the insulin response to glucose in nondiabetic individuals. Diabetes 55:2890 2895
16. Loos RJ, Franks PW, Francis RW, Barroso I, Gribble FM, Savage DB, Ong KK,
ORahilly S, Wareham NJ 2007 TCF7L2 polymorphisms modulate proinsulin
levels and -cell function in a British Europid population. Diabetes 56:1943
1947
17. Shu L, Sauter NS, Schulthess FT, Matveyenko AV, Oberholzer J, Maedler K
2008 Transcription factor 7-like 2 regulates -cell survival and function in
human pancreatic islets. Diabetes 57:645 653
18. Barber TM, Bennett AJ, Groves CJ, Sovio U, Ruokonen A, Martikainen H,
Pouta A, Hartikainen AL, Elliott P, Wass JA, Jarvelin MR, Zeggini E, Franks
S, McCarthy MI 2007 Disparate genetic influences on polycystic ovary syndrome (PCOS) and type 2 diabetes revealed by a lack of association between
common variants within the TCF7L2 gene and PCOS. Diabetologia 50:2318
2322
19. Worman HJ, Bonne G 2007 Laminopathies: a wide spectrum of human
diseases. Exp Cell Res 313:21212133
20. Rowntree RK, Harris A 2003 The phenotypic consequences of CFTR mutations. Ann Hum Genet 67:471 485
21. Jofre-Monseny L, Minihane AM, Rimbach G 2008 Impact of apoE genotype
on oxidative stress, inflammation and disease risk. Mol Nutri Food Res 52:
131145
22. Helgadottir A, Thorleifsson G, Manolescu A, Gretarsdottir S, Blondal T,
Jonasdottir A, Jonasdottir A, Sigurdsson A, Baker A, Palsson A, Masson G,

The Endocrine Society. Downloaded from press.endocrine.org by [${individualUser.displayName}] on 16 November 2015. at 00:31 For personal use only. No other uses without permission. . All rights reserved.

J Clin Endocrinol Metab, July 2009, 94(7):26172625

23.

24.

25.

26.

27.

28.

29.

30.

31.

Gudbjartsson DF, Magnusson KP, Andersen K, Levey AI, Backman VM,

Matthiasdottir S, Jonsdottir T, Palsson S, Einarsdottir H, Gunnarsdottir S,
Gylfason A, Vaccarino V, Hooper WC, Reilly MP, Granger CB, Austin H,
Rader DJ, Shah SH, Quyyumi AA, Gulcher JR, Thorgeirsson G,
Thorsteinsdottir U, Kong A, Stefansson K 2007 A common variant on
chromosome 9p21 affects the risk of myocardial infarction. Science 316:
14911493
Zeggini E, Weedon MN, Lindgren CM, Frayling TM, Elliott KS, et al 2007
Replication of genome-wide association signals in UK samples reveals risk loci
for type 2 diabetes. Science 316:1336 1341
Chang YC, Chang TJ, Jiang YD, Kuo SS, Lee KC, Chiu KC, Chuang LM 2007
Association study of the genetic polymorphisms of the transcription factor
7-like 2 (TCF7L2) gene and type 2 diabetes in the Chinese population. Diabetes
56:26312637
Legro RS, Driscoll D, Strauss 3rd JF, Fox J, Dunaif A 1998 Evidence for a
genetic basis for hyperandrogenemia in polycystic ovary syndrome. Proc Natl
Acad Sci USA 95:14956 14960
Zawadski JK, Dunaif A 1992 Diagnostic criteria for polycystic ovary syndrome. In: Givens J, Haseltine F, Merriman G, eds. The polycystic ovary syndrome. Cambridge, MA: Blackwell Scientific; 377384
The Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop
Group 2004 Revised 2003 consensus on diagnostic criteria and long-term
health risks related to polycystic ovary syndrome (PCOS). Hum Reprod 19:
41 47
Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale
HF, Futterweit W, Janssen OE, Legro RS, Norman RJ, Taylor AE, Witchel SF
2006 Positions statement: criteria for defining polycystic ovary syndrome as a
predominantly hyperandrogenic syndrome: an Androgen Excess Society
guideline. J Clin Endocrinol Metab 91:4237 4245
McCarthy MI, Abecasis GR, Cardon LR, Goldstein DB, Little J, Ioannidis JP,
Hirschhorn JN 2008 Genome-wide association studies for complex traits:
consensus, uncertainty and challenges. Nat Rev Genet 9:356 369
Legro RS, Bentley-Lewis R, Driscoll D, Wang SC, Dunaif A 2002 Insulin
resistance in the sisters of women with polycystic ovary syndrome: association
with hyperandrogenemia rather than menstrual irregularity. J Clin Endocrinol
Metab 87:2128 2133
Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA,
Gordon DJ, Krauss RM, Savage PJ, Smith Jr SC, Spertus JA, Costa F 2005
Diagnosis and management of the metabolic syndrome: an American Heart

jcem.endojournals.org

32.

33.
34.
35.

36.
37.
38.

39.

40.

41.

42.

43.

2625

Association/National Heart, Lung, and Blood Institute Scientific Statement.

Circulation 112:27352752
Purcell S, Cherny SS, Sham PC 2003 Genetic Power Calculator: design of
linkage and association genetic mapping studies of complex traits. Bioinformatics 19:149 150
Skol AD, Scott LJ, Abecasis GR, Boehnke M 2007 Optimal designs for twostage genome-wide association studies. Genet Epidemiol 31:776 788
Barrett JC, Fry B, Maller J, Daly MJ 2005 Haploview: analysis and visualization of LD and haplotype maps. Bioinformatics 21:263265
Purcell S, Neale B, Todd-Brown K, Thomas L, Ferreira MA, Bender D, Maller
J, Sklar P, de Bakker PI, Daly MJ, Sham PC 2007 PLINK: a tool set for
whole-genome association and population-based linkage analyses. Am J Hum
Genet 81:559 575
Devlin B, Roeder K 1999 Genomic control for association studies. Biometrics
55:9971004
Bacanu SA, Devlin B, Roeder K 2000 The power of genomic control. Am J
Hum Genet 66:19331944
Zeggini E, Scott LJ, Saxena R, Voight BF, Marchini JL, et al 2008 Metaanalysis of genome-wide association data and large-scale replication identifies
additional susceptibility loci for type 2 diabetes. Nat Genet 40:638 645
Wang PW, Abbasi F, Carantoni M, Chen YD, Azhar S, Reaven GM 1997
Insulin resistance does not change the ratio of proinsulin to insulin in normal
volunteers. J Clin Endocrinol Metab 82:32213224
Tura A, Pacini G, Kautzky-Willer A, Ludvik B, Prager R, Thomaseth K 2003
Basal and dynamic proinsulin-insulin relationship to assess -cell function
during OGTT in metabolic disorders. Am J Physiol Endocrinol Metab 285:
E155E162
Rder ME, Porte Jr D, Schwartz RS, Kahn SE 1998 Disproportionately elevated proinsulin levels reflect the degree of impaired B cell secretory capacity
in patients with noninsulin-dependent diabetes mellitus. J Clin Endocrinol
Metab 83:604 608
Kirchhoff K, Machicao F, Haupt A, Schafer SA, Tschritter O, Staiger H, Stefan
N, Haring HU, Fritsche A 2008 Polymorphisms in the TCF7L2, CDKAL1 and
SLC30A8 genes are associated with impaired proinsulin conversion. Diabetologia 51:597 601
Gonzalez-Sanchez J, Martnez-Larrad M, Zabena C, Perez-Barba M, SerranoRos M 2008 Association of variants of the TCF7L2 gene with increases in the
risk of type 2 diabetes and the proinsulin:insulin ratio in the Spanish population. Diabetologia 51:19931997

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