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An XY human female with ovaries
An XY human female with ovaries TETSUJI KOSO
KADOTANI, OHAMA,
TOSHIO
Hiroshima,
D.Sc.
M.D.
SOFUNI,
TAKAYOSHI
M.D.,
IKEDA,
D.Sc. M.D.
Japan
A female patient hospitalized with primary amenorrhea was studied cytogenetically. The case was diagnosed clinically and fiathologically as afollicular ovarian dysgenesis, with the presen.ce of a vagina, a uterus, bilateral Fallopian tubes, and the absence of testes as well as of the somatic signs of Turner’s syndrome. Chromosome studies were carried out on cultured leukocytes and fibroblasts derived from several different organs. It wasfound that the patient had an apparently normal male chromosome constitution of 46, XY and that the deoxyribonucleic acid-replicating pattern and the &orescent-staining property observed in cultured leukocytes of this patient were consistent with that of normal male cells. The possible mechanisms for the occurrence of the XY sex constitution in a phenotypical female are discussed.
Case
PATIENTS with a sex chromosome constitution indistinguishable from that of a normal male have occasionally been seen. In general, XY females have been diagnosed by exploratory laparotomy and have been found to have gonadal agenesis,with and without other abnormalities, or male pseudohermaphroditism.lVsThe present report describes a phenotypic female with afollicular ovarian dysgenesisand an XY FEMALE
sex chromosome
report
The patient, a 31-year-oldfemale (Fig. 1, A), was hospitalized for evaluation of primary amenorrhea. She was born to a normal healthy 43year-old father and 40-year-old mother. The mother, also healthy, had an uneventful pregnancy with no history of taking drugs. The patient is the eighth of ten live-born children, of whom one male and four female sibs died in early childhood. She had a history of measles and pneumonia in childhood, a head contusion at 7 years of age, gonorrhea at 13, and epilepsy which developed at age 30. She married at the age of 23 but had never been pregnant. She was not in Hiroshima at the time of the atomic bomb explosion in 1945. Though phenotypically a female, she was slightly masculine appearing, with small underdeveloped breasts and scanty axillary and pubic hair. She had normally developed vulva and clitoris (Fig. 1, B). No gonads were palpable in the labia majora or in the inguinal region. The vagina admitted two fingers and was normal in length. She showed no webbing of the neck or cubitus valgus. The remainder of the examina-
constitution.
From the Department of Obstetrics and Gynecology, Hiroshima University School of Medicine, the Cytogenetics Laboratory, Department of Clinical Laboratones, Atomic Bomb Casualty Commission, and the Department of Geneticopathology, The Research Institute for Nuclear Medicine and Biology. The Atomic Bomb Casualty Commission (ABCC), is a cooperative research agency of the United States National Academy of Sciences-National Research Council and the Jafianese Institute of Health of the Ministry of Health and Welfare. subborted bv the United States Atomic &neigy Commission, the Japanese National Institute of Health, and the United States Public Health Service.
tion
was
normal.
On cyclic hormone therapy she had withdrawal bleeding. Laparotomy showed a normalsized uterus, two normal Fallopian tubes, and 98
XY female
with ovaries
99
Fig. 1. A, Photograph of the patient; B, photograph of the external genitalia; C and D, operative findings, showing the internal genital organs (C shows right side, and D shows left side) ; E, low-power photomicrograph of a cross-section of the right ovary; F, section through the hilar zone showing the rete tubules (ovarian rete) and a nest of hilar cells; and G, photomicrograph of gonadal stroma and corpus albicans-like structure. UT: uterus; OV: ovary; FT: Fallopian tube; HC: nest of hilar cells; G’S: gonadal stroma; CA: corpus albicans--lihc structure: RT: rete tubules. two gonads in the normal position (Fig. and D). On inspection the gonads were metrical in size (1.0 by 0.7 by 3.5 cm.) consisted of white-streaked tissue adjacent red
1, C symand to a
edematous area. Serial sections at the center of both gonads (Fig. 1, E) showed that fibrous tissue was the major component of the stroma, suggestive of normal ovarian stroma. No structure resembliug primary germ cells or follicular apparatus was detected in the stroma. In the hilar zone (Fig. a tubular structure which was indistin1, F), guishable from ovarian rete and a few nests of hilar cells were seen. In the deep part of the
corpus albicanslike structures streaked tissue, were present (Fig. 1, G), and calcified nodules, whose original structure was unidentifiable, were scattered in or near the corpus albicans-like tissues. Neither testicular tissues nor areas suggesting neoplasm were detected on either side of the gonad. X-ray examination demonstrated the presence of normal kidneys, uterus, and Fallopian tubes. No bony abnormality was seen by x-ray examination of the hands, femora, Iuml~ar spine, and pituitary fossa. Urinary excretion of estrogen was slightly higher than normal (39.0 ,.,,g per day--normal
100
Kadotani
et al. Amer.
Fig. 2. Karyotype from the proband. The chromosomes were photographed autoradiography. Arrow indicates the Y chromosome, showing heavy labeling. 2 to 30 Pg per day), while the gonadotropin value was within normal limits. These findings are unusual and inexplicable, inasmuch as the patient’s clinical appearance, with little breast development and eunuchoid features, was compatible with hypoestrogenism. Functional tests of the endocrine glands were essentially normal : Is11 uptake was 21.5 per cent in 24 hours, and a thyroid scan was normal; the Thorn test showed a decrease of eosinophils of 51.4 per cent; water-loading test showed normal antidiuretic hormone responsiveness. Responses to adrenocorticotropic hormone and metyrapone ditartrate* were normal. Fasting blood sugar was 7.40 mg. per 100 per ml., and a glucose tolerance test was normal.
l Metopirone, Jersey.
Ciba
Pharm.
Products,
Inc.,
Summit,
New
May J. Obster.
1, 1971 Gynec.
before and after
Intelligence testing showed a Wexler Adult Intelligence Scale score of 65 and a TanakaBinet score of 67.7. Cytogenetic findings. Acetoorcein-stained squash preparations from material derived from the buccal mucosa, both ovaries, Fallopian tubes, endometrium, appendix, and skin were examined for the presence of sex chromatin. Fivehundred nuclei from each tissue were examined, and no sex chromatin masses were seen. Chromosome studies were carried out on leukocytes cultured following a minor modification of the technique of Moorhead and associates.O Monolayer cultures were derived from the ovaries, Fallopian tubes, endometrium, appendix, and skin (for details, see Kadotani and colleagueslO). Slides were made by the routine airdry method.
Volume Number
XY female
110 1
with ovaries
101
Fig. 3. Photographs of cultured leukocytes from the proband, stained with a fluorescent acrid& derivative. A: a metaphase with a brightly fluorescing Y chromosome (arrow) ; B: an interphase nucleus having a single fluorescent body (arrow). Chromosome counts based on 20 or more cells of each specimen described indicated that, of a total of 334 metaphases, 307 had a normal chromosome number of 46. Detailed karyotype analyses were performed on 10 to 30 cells from each tissue, and all cells with 46 chromosomes had a normal male chromosome constitution (XY) (Fig. 2). Cells with 45 chromosomes showed a random absence of any one chromosome, and there was no evidence of XV/X0 or other mosaicism. The chromosome-replicating pattern at the end of the deoxyribonucleic acid-synthesis period was studied in cultured leukocytes by means of autoradiography (for procedure, see Sofuni and Sandbergll). Sixty labeled metaphases were examined, but no late-replicating X chromosome or partial X chromosome was seen. The labeling pattern of the Y chromosome of the patient was virtually identical to that of the Y chromosome in normal males, that is, the Y labeled later than the GZf-22 autosomes but not as Iate as the late-replicating X chromosome in femaIes (Fig. 2). A fluorescent-staining technique for identifying the Y chromosome’aa l3 was applied to chromosome preparations from this patient for confirmation of presence of the Y chromosome. Slides were prepared from leukocyte cultures of the patient and from normal males and females. Staining and observation were carried out according to a modified method of Pearson and co-workers12 In 50 metaphase preparations from the patient a brightly fluorescing Y chromosome was seen to be identical with that observed in
normal male cells (Fig. 3, A). A small ~IUOWScent body was also recognized in interphase nuclei (Fig. 3, B) . These results demonstrate that this female patient has an XY sex-chromosome constitution. Cultured leukocytes from the subject’s father, brother, and sister had normal chromosome complements. Comment Recently, Sasaki and Kamadal* reported a case of a phenotypically normal female golden hamster, with apparently functional ovaries, showing an XY sex chromosome complement. They offered two possible interpretations : the loss of male factors in the Y chromosome caused by an interchange between the X and Y during meiosis, or a partial short-arm deletion of one of the two X chromosomes. They pointed out that the chance of an interchange between the X and the Y chromosomes might be expected to occur less frequently in the human than in the golden hamster, since the X and the Y are seen to be associated end to end without forming chiasma in human male meiosis, whereas in the golden hamster chiasma formation between the X and Y has been observed during male meiosis. The loss of male factors from the Y chromosome seems less likely in the case reported here. The possibility that the Y chromosome in this case was not Y but
102
Kadotani
et al. Amer.
rather a deleted X probably derived from a long-arm deletion may be excluded with reasonable confidence on the basis of the evidence described above. Jostl’ has shown that rabbits, whether genetically male or female, develop female internal and external genitalia, if gonadectomy is performed during early intrauterine development. This finding suggeststhat the testis-determining genes on the Y chromosome act only at a critical period as a trigger to start the differentiation of the medulla into testis. In other words, if the testis of a genetic male fails to differentiate at a critical stage, its gonads begin to differentiate into ovaries in a succeeding stage.151 I6 If the above assumption is applied to the present case, the occurrence of the XY female may be explained as follows: The testis-determining effect of the Y chromosome was adversely affected by some environmental factor (i.e., anoxia, infection,
REFERENCES
Alexander, D. S., and Furguson-Smith, M. A.: Pediatrics 28: 758, 1961. C. J., Paine, C. G., and Blank, 2. Dewhurst, C. E.: J. Obstet. Gynaec. Brit. Comm. 70: 675, 1963. Greenblatt, R. B., and 3. Graham, T. C., Byrd, J. R.: Obstet. Gynec. 24: 701, 1964. 4. Kinch, R. A. H., Phmkett, E. R., Smout, M. S., and Carr, D. H.: AMER. J. OBSTET. GYNEC. 91: 630, 1965. 5. Dewhurst, C. J.: J. Obstet. Gynaec. Brit. Comm. 74: 353, 1967. 6. Sternberg, W. H., Barclay, D. L., and Kloepfer, H. W.: New Eng. J. Med. 278: 695, 1968. 7. Espmer, E. A., Veale, A. M. O., Sands, V. E., and Fitzgerald, P. H.: New Eng. J. Med. 283: 6, 1970.
May J. Obstcr.
1, 1971 Gynec.
maternal hormone imbalance, etc.), resuhing in the development of both internal and external female genitalia. Recently, there have been several reports of familial occurrences of XY females with pure gonadal dysgenesis,6-8suggesting the possibility that an abnormal gene or genes, X-linked or carried on an autosome, may suppress the male-determining capacity of the Y chromosome, thus leading to female development and pure gonadal dysgenesis with an XY sex constitution. While this explanation might apply to the XY female reported here, complete investigation of the kindred was not possible, thus precluding the possibility of confirming this assumption. The help and advice of ProfessorAkira Tabuchi, Hiroshima University; Dr. Howard B. Hamilton, ABCC; and Emeritus ProfessorSajiro Makino, Hokkaido University; are very gratefully acknowledged.
8.
1.
9.
10. 11. 12. 13. 14. 15. 16.
Chemke, J., Carmichael, R., Stewart, J. M., Geer, R. H., and Robinson, A.: J. Med. Genet. 7: 105, 1970. Moorhead, P. S., Nowell, P. C., Mellman, W. J., Battips, D. M., and Hungerford, D. A.: Exp. Cell Res. 20: 613, 1960. Kadotani, T., Ohama, K., Tabuchi, A., and Omura, Y.: Proc. Japan Acad. 44: 707, 1968. Sofuni, T., and Sandberg, A. A.: Cytogenetics 6: 357, 1967. Pearson, P. L., Bobrow, M., and Vosa, C. G.: Nature 226: 78. 1970. George, K. P.: Nature 226: 80, 1970. Sasaki, M., and Kamada, T.: Jap. J. Genet. 44: 11, 1969. Jost, A.: Recent Progr. Hormone Res. 8: 379, 1953. Turner, C. D.: AMER. J. OBSTET. GYNEC. 90: 1208, 1964.
KADOTANI, OHAMA,
TOSHIO
Hiroshima,
D.Sc.
M.D.
SOFUNI,
TAKAYOSHI
M.D.,
IKEDA,
D.Sc. M.D.
Japan
A female patient hospitalized with primary amenorrhea was studied cytogenetically. The case was diagnosed clinically and fiathologically as afollicular ovarian dysgenesis, with the presen.ce of a vagina, a uterus, bilateral Fallopian tubes, and the absence of testes as well as of the somatic signs of Turner’s syndrome. Chromosome studies were carried out on cultured leukocytes and fibroblasts derived from several different organs. It wasfound that the patient had an apparently normal male chromosome constitution of 46, XY and that the deoxyribonucleic acid-replicating pattern and the &orescent-staining property observed in cultured leukocytes of this patient were consistent with that of normal male cells. The possible mechanisms for the occurrence of the XY sex constitution in a phenotypical female are discussed.
Case
PATIENTS with a sex chromosome constitution indistinguishable from that of a normal male have occasionally been seen. In general, XY females have been diagnosed by exploratory laparotomy and have been found to have gonadal agenesis,with and without other abnormalities, or male pseudohermaphroditism.lVsThe present report describes a phenotypic female with afollicular ovarian dysgenesisand an XY FEMALE
sex chromosome
report
The patient, a 31-year-oldfemale (Fig. 1, A), was hospitalized for evaluation of primary amenorrhea. She was born to a normal healthy 43year-old father and 40-year-old mother. The mother, also healthy, had an uneventful pregnancy with no history of taking drugs. The patient is the eighth of ten live-born children, of whom one male and four female sibs died in early childhood. She had a history of measles and pneumonia in childhood, a head contusion at 7 years of age, gonorrhea at 13, and epilepsy which developed at age 30. She married at the age of 23 but had never been pregnant. She was not in Hiroshima at the time of the atomic bomb explosion in 1945. Though phenotypically a female, she was slightly masculine appearing, with small underdeveloped breasts and scanty axillary and pubic hair. She had normally developed vulva and clitoris (Fig. 1, B). No gonads were palpable in the labia majora or in the inguinal region. The vagina admitted two fingers and was normal in length. She showed no webbing of the neck or cubitus valgus. The remainder of the examina-
constitution.
From the Department of Obstetrics and Gynecology, Hiroshima University School of Medicine, the Cytogenetics Laboratory, Department of Clinical Laboratones, Atomic Bomb Casualty Commission, and the Department of Geneticopathology, The Research Institute for Nuclear Medicine and Biology. The Atomic Bomb Casualty Commission (ABCC), is a cooperative research agency of the United States National Academy of Sciences-National Research Council and the Jafianese Institute of Health of the Ministry of Health and Welfare. subborted bv the United States Atomic &neigy Commission, the Japanese National Institute of Health, and the United States Public Health Service.
tion
was
normal.
On cyclic hormone therapy she had withdrawal bleeding. Laparotomy showed a normalsized uterus, two normal Fallopian tubes, and 98
XY female
with ovaries
99
Fig. 1. A, Photograph of the patient; B, photograph of the external genitalia; C and D, operative findings, showing the internal genital organs (C shows right side, and D shows left side) ; E, low-power photomicrograph of a cross-section of the right ovary; F, section through the hilar zone showing the rete tubules (ovarian rete) and a nest of hilar cells; and G, photomicrograph of gonadal stroma and corpus albicans-like structure. UT: uterus; OV: ovary; FT: Fallopian tube; HC: nest of hilar cells; G’S: gonadal stroma; CA: corpus albicans--lihc structure: RT: rete tubules. two gonads in the normal position (Fig. and D). On inspection the gonads were metrical in size (1.0 by 0.7 by 3.5 cm.) consisted of white-streaked tissue adjacent red
1, C symand to a
edematous area. Serial sections at the center of both gonads (Fig. 1, E) showed that fibrous tissue was the major component of the stroma, suggestive of normal ovarian stroma. No structure resembliug primary germ cells or follicular apparatus was detected in the stroma. In the hilar zone (Fig. a tubular structure which was indistin1, F), guishable from ovarian rete and a few nests of hilar cells were seen. In the deep part of the
corpus albicanslike structures streaked tissue, were present (Fig. 1, G), and calcified nodules, whose original structure was unidentifiable, were scattered in or near the corpus albicans-like tissues. Neither testicular tissues nor areas suggesting neoplasm were detected on either side of the gonad. X-ray examination demonstrated the presence of normal kidneys, uterus, and Fallopian tubes. No bony abnormality was seen by x-ray examination of the hands, femora, Iuml~ar spine, and pituitary fossa. Urinary excretion of estrogen was slightly higher than normal (39.0 ,.,,g per day--normal
100
Kadotani
et al. Amer.
Fig. 2. Karyotype from the proband. The chromosomes were photographed autoradiography. Arrow indicates the Y chromosome, showing heavy labeling. 2 to 30 Pg per day), while the gonadotropin value was within normal limits. These findings are unusual and inexplicable, inasmuch as the patient’s clinical appearance, with little breast development and eunuchoid features, was compatible with hypoestrogenism. Functional tests of the endocrine glands were essentially normal : Is11 uptake was 21.5 per cent in 24 hours, and a thyroid scan was normal; the Thorn test showed a decrease of eosinophils of 51.4 per cent; water-loading test showed normal antidiuretic hormone responsiveness. Responses to adrenocorticotropic hormone and metyrapone ditartrate* were normal. Fasting blood sugar was 7.40 mg. per 100 per ml., and a glucose tolerance test was normal.
l Metopirone, Jersey.
Ciba
Pharm.
Products,
Inc.,
Summit,
New
May J. Obster.
1, 1971 Gynec.
before and after
Intelligence testing showed a Wexler Adult Intelligence Scale score of 65 and a TanakaBinet score of 67.7. Cytogenetic findings. Acetoorcein-stained squash preparations from material derived from the buccal mucosa, both ovaries, Fallopian tubes, endometrium, appendix, and skin were examined for the presence of sex chromatin. Fivehundred nuclei from each tissue were examined, and no sex chromatin masses were seen. Chromosome studies were carried out on leukocytes cultured following a minor modification of the technique of Moorhead and associates.O Monolayer cultures were derived from the ovaries, Fallopian tubes, endometrium, appendix, and skin (for details, see Kadotani and colleagueslO). Slides were made by the routine airdry method.
Volume Number
XY female
110 1
with ovaries
101
Fig. 3. Photographs of cultured leukocytes from the proband, stained with a fluorescent acrid& derivative. A: a metaphase with a brightly fluorescing Y chromosome (arrow) ; B: an interphase nucleus having a single fluorescent body (arrow). Chromosome counts based on 20 or more cells of each specimen described indicated that, of a total of 334 metaphases, 307 had a normal chromosome number of 46. Detailed karyotype analyses were performed on 10 to 30 cells from each tissue, and all cells with 46 chromosomes had a normal male chromosome constitution (XY) (Fig. 2). Cells with 45 chromosomes showed a random absence of any one chromosome, and there was no evidence of XV/X0 or other mosaicism. The chromosome-replicating pattern at the end of the deoxyribonucleic acid-synthesis period was studied in cultured leukocytes by means of autoradiography (for procedure, see Sofuni and Sandbergll). Sixty labeled metaphases were examined, but no late-replicating X chromosome or partial X chromosome was seen. The labeling pattern of the Y chromosome of the patient was virtually identical to that of the Y chromosome in normal males, that is, the Y labeled later than the GZf-22 autosomes but not as Iate as the late-replicating X chromosome in femaIes (Fig. 2). A fluorescent-staining technique for identifying the Y chromosome’aa l3 was applied to chromosome preparations from this patient for confirmation of presence of the Y chromosome. Slides were prepared from leukocyte cultures of the patient and from normal males and females. Staining and observation were carried out according to a modified method of Pearson and co-workers12 In 50 metaphase preparations from the patient a brightly fluorescing Y chromosome was seen to be identical with that observed in
normal male cells (Fig. 3, A). A small ~IUOWScent body was also recognized in interphase nuclei (Fig. 3, B) . These results demonstrate that this female patient has an XY sex-chromosome constitution. Cultured leukocytes from the subject’s father, brother, and sister had normal chromosome complements. Comment Recently, Sasaki and Kamadal* reported a case of a phenotypically normal female golden hamster, with apparently functional ovaries, showing an XY sex chromosome complement. They offered two possible interpretations : the loss of male factors in the Y chromosome caused by an interchange between the X and Y during meiosis, or a partial short-arm deletion of one of the two X chromosomes. They pointed out that the chance of an interchange between the X and the Y chromosomes might be expected to occur less frequently in the human than in the golden hamster, since the X and the Y are seen to be associated end to end without forming chiasma in human male meiosis, whereas in the golden hamster chiasma formation between the X and Y has been observed during male meiosis. The loss of male factors from the Y chromosome seems less likely in the case reported here. The possibility that the Y chromosome in this case was not Y but
102
Kadotani
et al. Amer.
rather a deleted X probably derived from a long-arm deletion may be excluded with reasonable confidence on the basis of the evidence described above. Jostl’ has shown that rabbits, whether genetically male or female, develop female internal and external genitalia, if gonadectomy is performed during early intrauterine development. This finding suggeststhat the testis-determining genes on the Y chromosome act only at a critical period as a trigger to start the differentiation of the medulla into testis. In other words, if the testis of a genetic male fails to differentiate at a critical stage, its gonads begin to differentiate into ovaries in a succeeding stage.151 I6 If the above assumption is applied to the present case, the occurrence of the XY female may be explained as follows: The testis-determining effect of the Y chromosome was adversely affected by some environmental factor (i.e., anoxia, infection,
REFERENCES
Alexander, D. S., and Furguson-Smith, M. A.: Pediatrics 28: 758, 1961. C. J., Paine, C. G., and Blank, 2. Dewhurst, C. E.: J. Obstet. Gynaec. Brit. Comm. 70: 675, 1963. Greenblatt, R. B., and 3. Graham, T. C., Byrd, J. R.: Obstet. Gynec. 24: 701, 1964. 4. Kinch, R. A. H., Phmkett, E. R., Smout, M. S., and Carr, D. H.: AMER. J. OBSTET. GYNEC. 91: 630, 1965. 5. Dewhurst, C. J.: J. Obstet. Gynaec. Brit. Comm. 74: 353, 1967. 6. Sternberg, W. H., Barclay, D. L., and Kloepfer, H. W.: New Eng. J. Med. 278: 695, 1968. 7. Espmer, E. A., Veale, A. M. O., Sands, V. E., and Fitzgerald, P. H.: New Eng. J. Med. 283: 6, 1970.
May J. Obstcr.
1, 1971 Gynec.
maternal hormone imbalance, etc.), resuhing in the development of both internal and external female genitalia. Recently, there have been several reports of familial occurrences of XY females with pure gonadal dysgenesis,6-8suggesting the possibility that an abnormal gene or genes, X-linked or carried on an autosome, may suppress the male-determining capacity of the Y chromosome, thus leading to female development and pure gonadal dysgenesis with an XY sex constitution. While this explanation might apply to the XY female reported here, complete investigation of the kindred was not possible, thus precluding the possibility of confirming this assumption. The help and advice of ProfessorAkira Tabuchi, Hiroshima University; Dr. Howard B. Hamilton, ABCC; and Emeritus ProfessorSajiro Makino, Hokkaido University; are very gratefully acknowledged.
8.
1.
9.
10. 11. 12. 13. 14. 15. 16.
Chemke, J., Carmichael, R., Stewart, J. M., Geer, R. H., and Robinson, A.: J. Med. Genet. 7: 105, 1970. Moorhead, P. S., Nowell, P. C., Mellman, W. J., Battips, D. M., and Hungerford, D. A.: Exp. Cell Res. 20: 613, 1960. Kadotani, T., Ohama, K., Tabuchi, A., and Omura, Y.: Proc. Japan Acad. 44: 707, 1968. Sofuni, T., and Sandberg, A. A.: Cytogenetics 6: 357, 1967. Pearson, P. L., Bobrow, M., and Vosa, C. G.: Nature 226: 78. 1970. George, K. P.: Nature 226: 80, 1970. Sasaki, M., and Kamada, T.: Jap. J. Genet. 44: 11, 1969. Jost, A.: Recent Progr. Hormone Res. 8: 379, 1953. Turner, C. D.: AMER. J. OBSTET. GYNEC. 90: 1208, 1964.