Humangenetik 29, 99--109 (1975) © by Springer-Verlag 1975
Familial True Hermaphrodism in Three Siblings Clinical, C y t o g e n e t i c , H i s t o l o g i c a l a n d H o r m o n a l S t u d i e s * S. A r m e n d a r e s , l~. S a l a m a n c a , J. 1V[. Canttl, V. del Castillo, S. N a v a , E. D o m i n g u e z - d e - l a - P i e d r a , V. Cortgs-Gallegos, A. Gallegos, C. Cervantes, a n d A. P a r r a Secei6n de Gen6tiea y Divisi6n de BiologXa de la geprodueci6n, Departamento de Investigaeidn CientYfica, I.M.S.S., Mexico City Received April 23, 1975
Summary. Three affected siblings with true hermaphrodism are described. The propositi showed the following characteristics: male phenotype and gender role, hypospadias, bilateral scrotal ovotestes with palpable nodules, and absence of mfillerian structures. The X ehromatin was positive and the Y ehromatin negative in the 3 affected subjects. Their karyotype in peripheral blood lymphocytes and in gonadal fibroblasts was 46,XX and no Y chromosome fluorescence was observed. Plasma FSI-I was elevated in the 2 older patients and plasma LH was elevated only in the oldest. Plasma testosterone was low and plasma estradiol high in the 3 siblings; plasma, progesterone was elevated in 2, but normal in 1 sibling. Since some of the clinical characteristics of these 3 affected siblings are not the most common features in the majority of sporadic eases of true hermaphrodism, it is suggested that~ the presence of all of them may be the first clue for the clinical suspicion of the familial type of true hermaphrodism. True h e r m a p h r o d i t e s h a v e b o t h t e s t i c u l a r a n d o v a r i a n tissue in different combinations. The g r e a t m a j o r i t y of cases in h u m a n s h a v e been sporadic b u t in at least t h r e e instances, familial h e r m a p h r o d i s m has been described (Milner et al., 1958; R o s e n b e r g et al., 1963; Mori a n d Mizutani, 1968). I t is g e n e r a l l y a c c e p t e d t h a t in h u m a n s t h e ¥ chromosome is necessary for t h e d e v e l o p m e n t of fetal testes. However, a p p r o x i m a t e l y h a l f of all cases of t r u e h e r m a p h r o d i t e s are X X (Polani, 1970) a n d in t h e m a j o r i t y of " X X - m a l e " eases there has been no evidence of t h e presence of Y chromosomM m a t e r i a l (De la Chapelle, 1972). Several h y p o t h e s e s h a v e been p r o p o s e d (Ferguson-Smith, 1966; Milunsky, 1973) to e x p l a i n this controversial issue, none of which has been fully d e m o n s t r a t e d or sufficient to comprise e v e r y case. Thus, t h e s t u d y of cases of familial h e r m a p h r o d i s m m a y p r o v i d e v a l u a b l e i n f o r m a t i o n for f u r t h e r unders t a n d i n g this subjeet. This r e p o r t describes a f a m i l y w i t h 3 affected siblings w i t h t r u e h e r m a p h r o d i s m , m a l e p h e n o t y p e a n d 4 6 , X X chromosome c o m p l e m e n t . A c o m p r e h e n s i v e clinical, cytogenetic a n d endocrine e v a l u a t i o n was u n d e r t a k e n in a n a t t e m p t to e x p l a i n t h e m e c h a n i s m of t e s t i e u l a r tissue d e v e l o p m e n t in t h e absence of Y ehromosome. * This work was partially supported by a grant from The Ford Foundation.
100
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Case Reports The 3 affected sibs (Cases 1, 2 and 3) were first seen simultaneously. They were products of the 5th, 6th and 7th uneventful full-term pregnancies in a sibship of 11 (Fig. 1). There was no history of drug ingestion or X-ray exposure during the pregnancies and the parents were not consanguineous. In the 3 cases the phenotype and gender role were masculine (Fig. 2). I n Case 1, at 15 years of age his height was 159 cm, weight 50 kg, and head circumference 53 em. In Case 2, at 13 years of age his height was 153 cm, weight 42 kg and head circumference 52.5 cm. In Case 3, at 11 years of age his height was 137.5 era, weight 28 kg, and head circumference 50.5 cm. On physical examination moderate bilateral gynecomastia and pubic and axillary hair were observed in Cases 1 and 2. Case 1 showed a small penis and normal scrotum (Fig. 3a); Case 2 had a normal penis and a hypoplastie scrotum (Fig. 3 b); in Case 3 the penis was small ehordee and the scrotum was bifid and hypoplastic (Fig. 3 c). In the 3 cases, a grade I I I hypospadias was observed. I n all cases both gonads were within the scrotum, their consistency was soft but in their superior poles a hard nodule was palpated. The rest of the examination was normal. In Case 1 cystoseopy revealed a normal bladder and a normal posterior bulbar and membranous urethra; the verumontanum was edematous and the prostate was considered normal. There was no evidence of a vagina. In Cas~s 2 and 3 cystoseopy revealed a single external meatal orifice. At 1 cm from this orifice a bifurcation was observed: a posterior duct ending in a "eul de sac" interpreted as a rudimentary vagina and an anterior urethral duet, 3 cm in length. There was no evidence of a prostatic urethra and the bladder was normal; neither verumontanum nor prostate were observed. At laparatomy no uterus or fallopian tubes were found in the 3 eases. I n each patient both gonads were examined. I n case 1 the right gonad was 2.0 by 1.0 cm, with 2 well defined zones: one of them was whitish-nacreous and the other pale-brown; a vas deferens and epididymis were identified. The left gonad measured 3.0 by 1.0 cm, and 2 different zones were also observed (two thirds of the gonad corresponding to the pale-brown coloured area) ; the epididymis was identified but not the vas deferens. I n Case 2 the right gonad measured 2.0 by 1.0 cm and 2 well-defined areas were observed, one whitish and the other pale-brown, each
© 4
]
[]
( ~ - - NORMAL. PHENOTYPE--KARYOTYPE CONCORDANCE
Q~--NORMAL.
m -/4
INDIRECT ASCERTAIMENT
P ROPOSITI Fig. 1. Pedigree
Familial True I-Iermaphrodism
101
Fig. 2. Partial view of the patients
Fig. 3a--c. External genitalia of the patients. Cases 1 (a), 2 (b) and 3 (c)
corresponding approximately to half of the gonad. The left gonad measured 3.0 by 2.0 cm and macroscopically was similar to the right gonad. Vas deferens and epididymis were identified in both sides. In Case 3 scrotal examination revealed a right gonad measuring 1.5 by 1.0 cm with a greyish-white color and some pale-brown striae. The left gonad measured 2.0 by 1.0 cm with characteristics similar to those of the right gonad; epididymis and vas deferens were identified on both sides. Bilateral mastectomy was performed in Cases 1 and 2, and in Case 3, extirpation of breast tissue of both sides. In the 3 patients the following studies were normal or negative: complete blood cell count, urinalysis, blood chemistry, PBI, X-rays of the skull, skeleton, chest and an i.v. pyelogram. Other Family Members. The parents and the sibs of the probands were examined physically and no abnormality was found (Fig. 1). Their oldest sister (111-9) had the menarche at age 13.
S. Armendares et al.
i02
) I a t e r i a l and M e t h o d s
Cytogenetic Studies. Chromosome studies in the 3 patients were performed in cultures of peripheral blood lymphocytes and gonadal fibroblasts following ordinary non-banding technics. Y fluorescence was studied in interphase nuclei and in metaphase chromosomes from both cultures (Pearson et al., ]970). X chromatin was studied in buccal smears and in gonadal fibroblasts. The karyotype of the propositi's parents and sibs were studied in peripheral blood lymphocytes. Histological Studies. Semiserial studies were performed on longitudinal fusiform biopsies from each gonad of the 3 patients. Breast tissue was also studied. Endocrine Studies. On each patient, daily heparinized venous blood samples were obtained between 8:00 and 9:00 a.m., throughout a period of 16 consecutive days. The samples were centrifuged immediately and the plasma separated and kept frozen at - - 2 0 ° C for future analysis. On each plasma sample, duplicate determinations of the following hormones were performed: Follicle stimulating hormone (FSH) (Midgley, 1967), luteinizing hormone (LH) (M:idgley, 1966), 17 fl-estradiol (E-2) (Cortds-Gallegos and Gallegos, 1971), progesterone (P) (Cort~s-Gallegos, 1973) and testosterone (T) (Barberia et al., 1973). The standard used for F S t t and L H determinations was LER-9071. The plasma concentrations of the different homones obtained during 16 consecutive days were pooled for each hormone and the values expressed as mean ~ 1 S.D. Statistical analysis was performed by means of the 2 tail Student t test.
Results Cytogenetic Studies. The cytogenetie analyses of the patients are listed in Table 1. The X chromatin was positive in buccal smears in the affected subjects with percentages similar to those observed in normal females. In peripheral blood lymphocytes from the 3 patients the chromosomal complement was 46,XX. Fluorescence of the ¥ chromosome was not found in any of the metaphases. There was no evidence of ¥-chromatin in interphase nuclei. In gonadal fibroblasts cultures from the 3 patients the chromosomal complement was 46,XX and no evidence of Y chromosome fluorescence was found. The X chromatin was positive in interphase nuclei. Y chromatin was negative in the analyzed cells.
Table 1. Cytogenetic data Case
Tissue
X chromatin (%)
III-13
Buccal smears Peripheral blood Gonadal
-~ (18)
III-14
III-15
Buccal smears Peripheral blood Gonadal Buccal smears Peripheral blood Gonadal
-~ (42)
Y chromatin (No. of cells analyzed)
Chromosome constitution (No. of mitosis analyzed)
- - (507) - - (200)
46,XX (100) 4 6 , X X (10)
- - (510) - - (213)
46,XX (100) 46,XX ( 1 2 )
- - (520) - - (215)
46,XX (100) 46,XX ( 1 5 )
-~- (23) ~- (38) ~- (17) + (30)
1 1 mg of LER-907 equals 20 I.U. of 2nd II~P-HMG in terms of FSH and 60 I.U. of 2nd II~P~HMG in terms of L H (biological potency), NIAMDD, National Pituitary Agency, U.S.A. (Accepted January 1972, revised January 1973).
Familial True Hermaphrodism
i03
Fig. 4. (a) Ovotestis showing immature tubules and ovarian stroma with a primordial follicle. × 25. (b) High magnification of two nuclei of Leydig cells showing X chromatin. × 1000
In the parents and sibs of the affected individuals, karyotypes were in accordance with the phenotype. The ¥ chromosome was apparently normal in the male subjects of the family. Histological Studies. The biopsy of the gonads showed bilateral ovotestes with very similar histological findings in the 3 patients (Fig. 4a). The left gonad, in one part, showed numerous
104
S. Armendares et al. Table 2. Hormonal plasma concentrations (mean =L 1 S.D.)
Case ~0.
FSH (ng/ml)
L H (ng/ml)
Estradiol (ng/ml)
Progesterone (ng/ml)
Testosterone (ng/ml)
1
223.6 ~ 105.5 (n = 16)
151.8 ~ 65.5 (n = 16)
0.21 :J: 0.03 (n = 16)
2.23 ~ 0.11 (n = 16)
2.98 ~: 0.42 (n = 16)
2
375.4 ~ 67.9 (n = 16)
57.5 ~ 14.1 ( n = 16)
0.06 :J: 0.01 (n = 16)
0.40 ~ 0.09 (n = 16)
4.43 ~= 0.37 (n = 16)
3
8.4 ~ 21.7 (n = 16)
5.7 ± 7.7 (n = 16)
0.12 ± 0.02 (n = 16)
2.35 ± 0.14 (n = 16)
0.50 ± 0.07 (n = 16)
111.4 ~ 32.1 (n = 87)
65.7 ~= 29.1 (n = 87)
0.004 ~= 0.002 (n = 87)
0.44 ~ 0.11 (n = 87)
6.80 ~: 2.10 ( n = 87)
Preovulatory phase
211.6 ~ 50.1 (n ~ 133)
189.7 ~= 120.5 (n = 139)
0.08 ~ 0.02 (n = 212)
0.51 =t- 0.37 (n = 212)
0.25 ~= 0.09 (n = 157)
Postovulatory phase
152.5 =t= 75.1 (n ~ 150)
153.3 ~= 113.0 (n = 167)
0.19 ~= 0.04 (n = 227)
7.5 ~= 4.6 (n = 227)
0.58 ~= 0.28 (n = 168)
Normal adulta Male values Normal adultb :Female values
a Ages 20--38 years. b n = 15 menstrual cycles, ages 21--34 years.
Table 3. Summarized hormonal plasma findings Case
Normal control
FSH
LH
E-2
P
T
1 compared to :
Adult males Pre0 PostO
~= +
¢ = =
¢ + =
# + +
+ + ¢
2 compared to :
Adult males PreO PostO
~ ¢ ~
= + +
+ + +
= = +
4 ~t
3 compared to:
Adult males PreO PostO
4~ + +
+ + +
~: ~" +
f ¢ +
+ f =
= : similar to. PreO: preovulatory. PostO : postovulatory. + : increased. + : decreased. Level of statistical significance in all cases P __< 0.05.
seminiferous tubules of infantile type, with germinal and Sertoli cells, occasionally with calcifications within the lumen, surrounded by thickened basement membrane, and intermingled with hyalinized tubules. The stroma contained large groups of Leydig cells with round shaped nuclei in which X chromatin was frequently identified (Fig. 4b). The other part of the gonad contained ovarian tissue and compact stroma, with small spindle cells with ovoid cytoplasm, numerous primordial and secondary follicles (Cases 1, 2 and 3) and a tertialT follicle with theca cells and several layers of granulosa cells (Cases 1 and 2). The right gonad showed the same pattern of testicular tissue and a small piece of ovarian stroma with primordial follicles. Breast tissue from Cases 1 and 2 showed numerous dilated ducts surrounded by dense fibrous stroma. Primitive breast tissue, as seen in prepuberal females, was observed in Case 3.
Familial True Hermaphrodism
105
IZO0-
I000
PATIENT
I
PATIENT
2 ----~
•
•
PATIENT
3 *--*
"2-E
BOO
? 600
J i
2"
4oo-
',
; ',
200
g -~4
-Jo
-5
o
DAYS
OF
'+~
~-,b
+14
+5
-~ 10
+ 14
CYCLE
12GO
IO00-
BOOt
J
600-
d
m
400
02 -I4
-I0
0
-S DAYS
OF
CYCLE
Fig'. 5. Daily plasma FSH and LH levels of each patient as compared to mean ~: SEM in 15 women with ovulatory cycles (shadded area). "Day 0" was considered the day of LI-I and/or FSH peak both in normal women and in patients 1 and 2 Endocrine Studies. The results are shown in Table 2. Table 3 summarizes the comparative hormonal plasma findings of each ease. The daily pattern of plasma FSH and LH levels in each case is illustrated in Fig. 5. Discussion
F a m i l i a l true h e r m a p h r o d i s m is very rare a n d so far this is the fourth family described. I n all the tissues from the 3 affected subjects there was a consistent 4~6,XX k a r y o t y p e . The presence of X e h r o m a t i n in different tissues including Leydig cells
106
S. Armendares et al.
and the lack of evidence of Y ehromatin, strongly support the karyotype and practically exclude the possibility of a stemline with a Y chromosome. A normal female karyotype was also found in previous eases (i~osenberg et al., i963; Mori and Mizutani, 1968). However, this karyotype is not distinctive of familial true hermaphrodism, since nearly one-half of all the eases of sporadic true hermaphrodism show 46,XX karyotype (Polani, 1970; Jones and Scott, 1971). I n order to explain the development of testes in X X cases of true hermaphrodism as well as the presence of testes and male phenotype in X X males, three main hypothetieM approaches have been postulated and recently reviewed by De la Chapelle (1972): 1) male sexdetermining genes located on either an X chromosome or an autosome; 2) an interchange b y crossing over between X and Y chromosomes or a transloeation of Y material to another chromosome; and 3) the occurrence of mosaieism with an undiscovered cell line containing the ¥ chromosome. Hypotheses 2 and 3 are quite improbable to explain Rosenberg's eases and ours, because in both instances true hermaphrodism was familial and the affected individuals in both families had normal parents and normal sibs of both sexes. Thus, the more feasible explanation for familial true hermaphrodism is the presence of an autosomal male determining gene. In this regard it is well established that the existence of such autosomal genes in goats and mice lead to a male phenotype in X X animals (Hamerton et al., 1969; Cattanach et al., 1971). The absence of parental consanguinity in all the sibships with familial true hermaphrodism and the occurrence of normal sibs of both sexes suggest an autosomal dominant mutation, limited to the female, as the cause of this type of intersexual disorder. For genetic counselling purposes it is important to be aware of the existence of familial true hermaphrodism when studying sporadic cases. The clinical characteristics of the affected subjects in our family and those familial cases previously reported (Milner et al., 1958 ; Rosenberg et al., 1963 ; Mori and Mizutani, 1968), are summarized in Table 4~. Excluding the eases of Mori and Mizutani (1968) there is a striking homogeneity in the phenotypieal manifestations. The presence of descended bilateral ovotestes with palpable nodules and the absence of uterus is of particular interest since these characteristics are not the most common in the majority of sporadic cases of 46,XX true hermaphrodism (Jones and Scott, 1971). I f these features are demonstrated in subsequent eases of familial true hermaphrodism, they m a y prove to be relevant in leading the clinician to suspect this anomaly during the differential diagnosis of the possible etiological types of true hermaphrodism. The 2 sibs reported by Mori and Mizutani (1968) were phenotypieally different since both showed ovotestes on the right side and ovary and a fallopian tube on the left. The clinical differences between these eases and the others m a y be explained either by variable expressivity of the same m u t a n t gene or by two different mutations. Further support for the first possibility could be the family reported by Kasdan et al. (1973) in which the propositus was a true hermaphrodite, phenotypically very similar to our eases, and whose brother and a paternal uncle were X X males. Hormonal studies in eases of familial true hermaphrodism have been performed mostly in urine (Milner et al., 1958; l~osenberg et al., 1963; Clayton et al., 1958). I n 1 case, plasma F S H and L t I were found to be normal (Kasdan et al., 1973). In
Familial True Hermaphrodism
107
Table 4. Clinical features
Age (in years) Phenotype Gynecomastia at puberty Hypospadias Scrotal gonads Gonadal nodules Right gonad Left gonad Prostate Epididymis Vas deferens Uterus Fallopian tubes Vagina
Present family
Milner et al., 1958
Rosenberg et al., 1963 Mori and Mizutani, 1968
Casel Case2 Case3
Case1 Case2
Casel Case2 Case3
Casel
Case2
15 M -~
13 M +
11 M
13 M +
11/12 IV[
16 M +
7 3/[ +
14 M +
3a/12 F
21/12
~ q+ OT OT q+ q_ . . --
-+ -k OT OT --@
+ ~-OT OT -+ _.L
~ q+ OT OT NS NS NS
+ ,+ + OT OT @ + NS
+ + -k OT OT NS + NS
__ @ Left OT OT NS NS NS
Ru --
I~u --
__b Right a -OT O NS NS NS + + +
__b Right a -OT O NS NS NS -i+ +
.
. . Ru
+ Left a -k OT OT -~qq. .
. . t~u
.
. --
NS
.
. Ve --
F
M ~ Male. F = Female. + ~ Present. - - = Absent. NS ~ Not stated. 0 = Ovary. T ~- Testis. OT = Ovotestis. = In the inguinal duct. Ru ~ Rudimentary. Ve = Vestigial. b Clitoromegaly.
the present report, the oldest p a t i e n t (Case 1, with complete p u b e r t a l developm e n t ) h a d plasma F S H levels higher t h a n n o r m a l males, as one would expect from the appearance of the seminiferous t u b u l e s ; also, plasma L H was elevated p r o b a b l y in a n a t t e m p t to increase the low testosterone levels as a consequence of the poor f u n c t i o n i n g of a n X c h r o m a t i n positive Leydig cells. However, the o v a r i a n s t r u c t u r e s of the ovotestes, seem to be responsive to the high plasma F S H a n d LH, since plasma E-2 was even higher t h a n in n o r m a l women. The latter finding would explain the existing g y n e c o m a s t i a (Cort6s-Gallegos et al., 1975). I n Case 2, which can be considered at midstage of p u b e r t y ( T a n n e r ' s stage I I - - - I I I , T a n n e r , 1962) elevated F S H was observed, again in accordance with the testicular histology. The fact t h a t plasma L H was n o r m a l correlates well with the presence of n e a r l y n o r m a l a d u l t male testosterone levels. The findings i n L H a n d testosterone in Cases 1 a n d 2 would suggest the existence of a feedback m e c h a n i s m even i n these X c h r o m a t i n positive Leydig cells. I n Case 2 one again m a y postulate t h a t the high E-2 levels are the consequence of the o v a r i a n structures response to elevated plasma F S H concentrations a n d also would explain the g y n e c o m a s t i a (Cort~s-Gallegos et al., 1975). F i n a l l y , Case 3, at the initial stage of p u b e r t a l development, h a d plasma F S H , L H a n d testosterone levels comparable to prepuberal children (Winter a n d Faim a n , 1973; A u g u s t et al., 1972). However, plasma E-2 a n d progesterone levels were higher t h a n i n n o r m a l a d u l t males. No plausible e x p l a n a t i o n can be offered to this observation.
108
S. Armendares et al.
A n interesting o b s e r v a t i o n is t h a t in p a t i e n t 1 (with complete p u b e r t a l developm e n t ) p l a s m a F S H a n d L H levels showed a " c y c l i c " v a r i a t i o n . F u r t h e r m o r e , t h e p l a s m a F S H values after " d a y 0" were consistently lower t h a n before it. I n p a t i e n t 2 (with m o d e r a t e p u b e r t a l development) t h e " c y c l i c " v a r i a t i o n was o b s e r v e d only for F S H b u t n o t for L H . Thus, t h e h o r m o n a l p l a s m a c o n c e n t r a t i o n s of F S H a n d L H r e s e m b l e d m o r e closely t h e female p a t t e r n (Fig. 5) in t h e oldest p a t i e n t s a n d were in accordance with t h e h i s t o l o g y of t h e gonads. A l t h o u g h no p a r t i c u l a r h o r m o n a l profile is p o s t u l a t e d as c h a r a c t e r i s t i c of this syndrome, it is quite clear t h a t t h e a b n o r m a l i t i e s in t h e p l a s m a c o n c e n t r a t i o n s of t h e different h o r m o n e s will be fully expressed only after t h e i n d i v i d u a l reaches puberty.
Acknowledgements. We are grateful to the NIAMDD, NIH for the kind supply of the following materials: Gonadotropin standard LER-907, hFSH-LER 1366 and hLH-LER 960 for iodination, as well as the antiserum to hFSH and hLH. We are indebted to Dr. H6ctor M~rquez Monter for assistance with histological studies and to Dr. Joe Leigh Simpson, Obstetric Service, Brooke Army Medical Center, San Antonio, Texas for helping in the bibliographical review. We acknowledge the secretarial assistance of Miss Luz Elena Hernhndez de Alba. References August, G. P., Grumbach, M. M., Kaplan, S. L. : Hormonal changes in puberty: III. Correlation of plasma testosterone, LH, FSH, testicular size, and bone age with male pubertal development. J. clin. Endocr. 84, 319--326 (1972) Barberia, J. M., Giner, J., Cort6s-Gallegos, V. : Diurnal variations of plasma testosterone in men. Steroids 22, 615--625 (1973) Cattanach, B. M., Pollard, C. E., I-Iawskes, S. G.: Sex reversed mice: XX and XO males. Cytogenetics 10, 318--337 (1971) Clayton, G. W., Smith, J. D., Rosenberg, H. S.: Familial true hermaphrodism in pre and postpuberal genetic females. Hormonal and morphologic studies. J. clin. Endocr. 18, 1349--1358 (1958) Cort6s-Gallegos, V.: II. - - A new index to predict ovulation in the human. Int. J. Fertil. 18, 93--96 (1973) Cort6s-Gallegos, V., Gallegos, A. J. : E1 ciclo menstrual f6rtil en el humano, pp. 139--148. XI Reuni6n Anual Soc. Mex. Nutr. Endocr. Acapulco, M6xico, Noviembre (1971) Cort6s-Gallegos, V., Gallegos, A. J., S£nchez-Basurto, C., Rivadeneyra, J.: Estrogen peripheral levels vs estrogen tissue concentration in the human female reproductive tract. J. Steroid. Bioehem. (in press, 1975) De la Chapelle, A.: Nature and origin of males with XX sex chromosomes. Amer. J. hum. Genet. 24, 71--105 (1972) Ferguson-Smith, M. A. : X-Y chromosomal interchange in the aetiology of true hermaphroditism and of XX Klinefelter's syndrome. Lancet 1966 II, 475--476 ttamerton, J. L., Dickson, J. M., Pollard, C. E., Grieves, S. A., Short, R. V.: Genetic intersexuality in goats. J. Reprod. Fertil., Suppl. 7, 25--51 (1969) Jones, H. W., Scott, W. W. : Hermaphroditism, genital anomalies and related endocrine disorders, pp. 290--317, 2nd ed. Baltimore: Williams and Wilkins 1971 Kasdan, 1~., Naukin, H. R., Troen, P., Wald, N., Pan, S., Yanaihara, T. : Paternal transmission of maleness in XX human beings. New Engl. J. Med. 288, 539--545 (1973) Midgley, A. R. : Radioimmunoassay: A method for human chorionic gonadotropin and human luteinizing hormone. Endocrinology 79, 10--18 (1966) Midgley, A. R. : Radioimmunoassay for human follicle stimulating hormone. J. clin. Endocr. 27, 295--299 (1967) Milner, W. A., Garlick, W. B., Fink, A. J., Stein, A. A.: True hermaphrodite siblings. J. Urol. 79, 1003--1009 (1958)
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Milunsky, A. : Sex-determining genes and the Y-chromosome. New Engl. J. Med. 288, 577--578 (1973) Mori, Y., Mizutani, S. : Familial true hermaphroditism in genetic females. Jap. J. Urol. 59, 857--864 (1968) Pearson, P. L., Bobrow, M., Vosa, C. G. : Technique for identifying Y chromosomes in human interphase nuclei. Nature (Lond.) 2~.6, 78--80 (1970) Polani, P. E. : Hormonal and clinical aspects of hermaphroditism and the testicular feminizing syndrome in man. Phil. Trans. B 259, 187--204 (1970) Rosenberg, H. S., Clayton, G. W., Hsu, T. C. : Familial true hermaphrodism. J. olin. Endocr. ~ , 203~206 (1963) Tanner, J. M. : Growth at adolescence, pp. 28--39, 2nd ed. Oxford: Blaekwell 1962 Winter, J. S. D., Faiman, Ch. : Pituitary-gonadal relations in female children and adolescents. Pediat. Res. 7, 948--953 (1973) Dr. Salvador Armendares Secci6n de Gen6tica Departamento de Investigaci6n Cientifica I.M.S.S. Apdo. Postal 73-032 M~xico 73, D.F. M6xico
Familial True Hermaphrodism in Three Siblings Clinical, C y t o g e n e t i c , H i s t o l o g i c a l a n d H o r m o n a l S t u d i e s * S. A r m e n d a r e s , l~. S a l a m a n c a , J. 1V[. Canttl, V. del Castillo, S. N a v a , E. D o m i n g u e z - d e - l a - P i e d r a , V. Cortgs-Gallegos, A. Gallegos, C. Cervantes, a n d A. P a r r a Secei6n de Gen6tiea y Divisi6n de BiologXa de la geprodueci6n, Departamento de Investigaeidn CientYfica, I.M.S.S., Mexico City Received April 23, 1975
Summary. Three affected siblings with true hermaphrodism are described. The propositi showed the following characteristics: male phenotype and gender role, hypospadias, bilateral scrotal ovotestes with palpable nodules, and absence of mfillerian structures. The X ehromatin was positive and the Y ehromatin negative in the 3 affected subjects. Their karyotype in peripheral blood lymphocytes and in gonadal fibroblasts was 46,XX and no Y chromosome fluorescence was observed. Plasma FSI-I was elevated in the 2 older patients and plasma LH was elevated only in the oldest. Plasma testosterone was low and plasma estradiol high in the 3 siblings; plasma, progesterone was elevated in 2, but normal in 1 sibling. Since some of the clinical characteristics of these 3 affected siblings are not the most common features in the majority of sporadic eases of true hermaphrodism, it is suggested that~ the presence of all of them may be the first clue for the clinical suspicion of the familial type of true hermaphrodism. True h e r m a p h r o d i t e s h a v e b o t h t e s t i c u l a r a n d o v a r i a n tissue in different combinations. The g r e a t m a j o r i t y of cases in h u m a n s h a v e been sporadic b u t in at least t h r e e instances, familial h e r m a p h r o d i s m has been described (Milner et al., 1958; R o s e n b e r g et al., 1963; Mori a n d Mizutani, 1968). I t is g e n e r a l l y a c c e p t e d t h a t in h u m a n s t h e ¥ chromosome is necessary for t h e d e v e l o p m e n t of fetal testes. However, a p p r o x i m a t e l y h a l f of all cases of t r u e h e r m a p h r o d i t e s are X X (Polani, 1970) a n d in t h e m a j o r i t y of " X X - m a l e " eases there has been no evidence of t h e presence of Y chromosomM m a t e r i a l (De la Chapelle, 1972). Several h y p o t h e s e s h a v e been p r o p o s e d (Ferguson-Smith, 1966; Milunsky, 1973) to e x p l a i n this controversial issue, none of which has been fully d e m o n s t r a t e d or sufficient to comprise e v e r y case. Thus, t h e s t u d y of cases of familial h e r m a p h r o d i s m m a y p r o v i d e v a l u a b l e i n f o r m a t i o n for f u r t h e r unders t a n d i n g this subjeet. This r e p o r t describes a f a m i l y w i t h 3 affected siblings w i t h t r u e h e r m a p h r o d i s m , m a l e p h e n o t y p e a n d 4 6 , X X chromosome c o m p l e m e n t . A c o m p r e h e n s i v e clinical, cytogenetic a n d endocrine e v a l u a t i o n was u n d e r t a k e n in a n a t t e m p t to e x p l a i n t h e m e c h a n i s m of t e s t i e u l a r tissue d e v e l o p m e n t in t h e absence of Y ehromosome. * This work was partially supported by a grant from The Ford Foundation.
100
S. Armendares et al.
Case Reports The 3 affected sibs (Cases 1, 2 and 3) were first seen simultaneously. They were products of the 5th, 6th and 7th uneventful full-term pregnancies in a sibship of 11 (Fig. 1). There was no history of drug ingestion or X-ray exposure during the pregnancies and the parents were not consanguineous. In the 3 cases the phenotype and gender role were masculine (Fig. 2). I n Case 1, at 15 years of age his height was 159 cm, weight 50 kg, and head circumference 53 em. In Case 2, at 13 years of age his height was 153 cm, weight 42 kg and head circumference 52.5 cm. In Case 3, at 11 years of age his height was 137.5 era, weight 28 kg, and head circumference 50.5 cm. On physical examination moderate bilateral gynecomastia and pubic and axillary hair were observed in Cases 1 and 2. Case 1 showed a small penis and normal scrotum (Fig. 3a); Case 2 had a normal penis and a hypoplastie scrotum (Fig. 3 b); in Case 3 the penis was small ehordee and the scrotum was bifid and hypoplastic (Fig. 3 c). In the 3 cases, a grade I I I hypospadias was observed. I n all cases both gonads were within the scrotum, their consistency was soft but in their superior poles a hard nodule was palpated. The rest of the examination was normal. In Case 1 cystoseopy revealed a normal bladder and a normal posterior bulbar and membranous urethra; the verumontanum was edematous and the prostate was considered normal. There was no evidence of a vagina. In Cas~s 2 and 3 cystoseopy revealed a single external meatal orifice. At 1 cm from this orifice a bifurcation was observed: a posterior duct ending in a "eul de sac" interpreted as a rudimentary vagina and an anterior urethral duet, 3 cm in length. There was no evidence of a prostatic urethra and the bladder was normal; neither verumontanum nor prostate were observed. At laparatomy no uterus or fallopian tubes were found in the 3 eases. I n each patient both gonads were examined. I n case 1 the right gonad was 2.0 by 1.0 cm, with 2 well defined zones: one of them was whitish-nacreous and the other pale-brown; a vas deferens and epididymis were identified. The left gonad measured 3.0 by 1.0 cm, and 2 different zones were also observed (two thirds of the gonad corresponding to the pale-brown coloured area) ; the epididymis was identified but not the vas deferens. I n Case 2 the right gonad measured 2.0 by 1.0 cm and 2 well-defined areas were observed, one whitish and the other pale-brown, each
© 4
]
[]
( ~ - - NORMAL. PHENOTYPE--KARYOTYPE CONCORDANCE
Q~--NORMAL.
m -/4
INDIRECT ASCERTAIMENT
P ROPOSITI Fig. 1. Pedigree
Familial True I-Iermaphrodism
101
Fig. 2. Partial view of the patients
Fig. 3a--c. External genitalia of the patients. Cases 1 (a), 2 (b) and 3 (c)
corresponding approximately to half of the gonad. The left gonad measured 3.0 by 2.0 cm and macroscopically was similar to the right gonad. Vas deferens and epididymis were identified in both sides. In Case 3 scrotal examination revealed a right gonad measuring 1.5 by 1.0 cm with a greyish-white color and some pale-brown striae. The left gonad measured 2.0 by 1.0 cm with characteristics similar to those of the right gonad; epididymis and vas deferens were identified on both sides. Bilateral mastectomy was performed in Cases 1 and 2, and in Case 3, extirpation of breast tissue of both sides. In the 3 patients the following studies were normal or negative: complete blood cell count, urinalysis, blood chemistry, PBI, X-rays of the skull, skeleton, chest and an i.v. pyelogram. Other Family Members. The parents and the sibs of the probands were examined physically and no abnormality was found (Fig. 1). Their oldest sister (111-9) had the menarche at age 13.
S. Armendares et al.
i02
) I a t e r i a l and M e t h o d s
Cytogenetic Studies. Chromosome studies in the 3 patients were performed in cultures of peripheral blood lymphocytes and gonadal fibroblasts following ordinary non-banding technics. Y fluorescence was studied in interphase nuclei and in metaphase chromosomes from both cultures (Pearson et al., ]970). X chromatin was studied in buccal smears and in gonadal fibroblasts. The karyotype of the propositi's parents and sibs were studied in peripheral blood lymphocytes. Histological Studies. Semiserial studies were performed on longitudinal fusiform biopsies from each gonad of the 3 patients. Breast tissue was also studied. Endocrine Studies. On each patient, daily heparinized venous blood samples were obtained between 8:00 and 9:00 a.m., throughout a period of 16 consecutive days. The samples were centrifuged immediately and the plasma separated and kept frozen at - - 2 0 ° C for future analysis. On each plasma sample, duplicate determinations of the following hormones were performed: Follicle stimulating hormone (FSH) (Midgley, 1967), luteinizing hormone (LH) (M:idgley, 1966), 17 fl-estradiol (E-2) (Cortds-Gallegos and Gallegos, 1971), progesterone (P) (Cort~s-Gallegos, 1973) and testosterone (T) (Barberia et al., 1973). The standard used for F S t t and L H determinations was LER-9071. The plasma concentrations of the different homones obtained during 16 consecutive days were pooled for each hormone and the values expressed as mean ~ 1 S.D. Statistical analysis was performed by means of the 2 tail Student t test.
Results Cytogenetic Studies. The cytogenetie analyses of the patients are listed in Table 1. The X chromatin was positive in buccal smears in the affected subjects with percentages similar to those observed in normal females. In peripheral blood lymphocytes from the 3 patients the chromosomal complement was 46,XX. Fluorescence of the ¥ chromosome was not found in any of the metaphases. There was no evidence of ¥-chromatin in interphase nuclei. In gonadal fibroblasts cultures from the 3 patients the chromosomal complement was 46,XX and no evidence of Y chromosome fluorescence was found. The X chromatin was positive in interphase nuclei. Y chromatin was negative in the analyzed cells.
Table 1. Cytogenetic data Case
Tissue
X chromatin (%)
III-13
Buccal smears Peripheral blood Gonadal
-~ (18)
III-14
III-15
Buccal smears Peripheral blood Gonadal Buccal smears Peripheral blood Gonadal
-~ (42)
Y chromatin (No. of cells analyzed)
Chromosome constitution (No. of mitosis analyzed)
- - (507) - - (200)
46,XX (100) 4 6 , X X (10)
- - (510) - - (213)
46,XX (100) 46,XX ( 1 2 )
- - (520) - - (215)
46,XX (100) 46,XX ( 1 5 )
-~- (23) ~- (38) ~- (17) + (30)
1 1 mg of LER-907 equals 20 I.U. of 2nd II~P-HMG in terms of FSH and 60 I.U. of 2nd II~P~HMG in terms of L H (biological potency), NIAMDD, National Pituitary Agency, U.S.A. (Accepted January 1972, revised January 1973).
Familial True Hermaphrodism
i03
Fig. 4. (a) Ovotestis showing immature tubules and ovarian stroma with a primordial follicle. × 25. (b) High magnification of two nuclei of Leydig cells showing X chromatin. × 1000
In the parents and sibs of the affected individuals, karyotypes were in accordance with the phenotype. The ¥ chromosome was apparently normal in the male subjects of the family. Histological Studies. The biopsy of the gonads showed bilateral ovotestes with very similar histological findings in the 3 patients (Fig. 4a). The left gonad, in one part, showed numerous
104
S. Armendares et al. Table 2. Hormonal plasma concentrations (mean =L 1 S.D.)
Case ~0.
FSH (ng/ml)
L H (ng/ml)
Estradiol (ng/ml)
Progesterone (ng/ml)
Testosterone (ng/ml)
1
223.6 ~ 105.5 (n = 16)
151.8 ~ 65.5 (n = 16)
0.21 :J: 0.03 (n = 16)
2.23 ~ 0.11 (n = 16)
2.98 ~: 0.42 (n = 16)
2
375.4 ~ 67.9 (n = 16)
57.5 ~ 14.1 ( n = 16)
0.06 :J: 0.01 (n = 16)
0.40 ~ 0.09 (n = 16)
4.43 ~= 0.37 (n = 16)
3
8.4 ~ 21.7 (n = 16)
5.7 ± 7.7 (n = 16)
0.12 ± 0.02 (n = 16)
2.35 ± 0.14 (n = 16)
0.50 ± 0.07 (n = 16)
111.4 ~ 32.1 (n = 87)
65.7 ~= 29.1 (n = 87)
0.004 ~= 0.002 (n = 87)
0.44 ~ 0.11 (n = 87)
6.80 ~: 2.10 ( n = 87)
Preovulatory phase
211.6 ~ 50.1 (n ~ 133)
189.7 ~= 120.5 (n = 139)
0.08 ~ 0.02 (n = 212)
0.51 =t- 0.37 (n = 212)
0.25 ~= 0.09 (n = 157)
Postovulatory phase
152.5 =t= 75.1 (n ~ 150)
153.3 ~= 113.0 (n = 167)
0.19 ~= 0.04 (n = 227)
7.5 ~= 4.6 (n = 227)
0.58 ~= 0.28 (n = 168)
Normal adulta Male values Normal adultb :Female values
a Ages 20--38 years. b n = 15 menstrual cycles, ages 21--34 years.
Table 3. Summarized hormonal plasma findings Case
Normal control
FSH
LH
E-2
P
T
1 compared to :
Adult males Pre0 PostO
~= +
¢ = =
¢ + =
# + +
+ + ¢
2 compared to :
Adult males PreO PostO
~ ¢ ~
= + +
+ + +
= = +
4 ~t
3 compared to:
Adult males PreO PostO
4~ + +
+ + +
~: ~" +
f ¢ +
+ f =
= : similar to. PreO: preovulatory. PostO : postovulatory. + : increased. + : decreased. Level of statistical significance in all cases P __< 0.05.
seminiferous tubules of infantile type, with germinal and Sertoli cells, occasionally with calcifications within the lumen, surrounded by thickened basement membrane, and intermingled with hyalinized tubules. The stroma contained large groups of Leydig cells with round shaped nuclei in which X chromatin was frequently identified (Fig. 4b). The other part of the gonad contained ovarian tissue and compact stroma, with small spindle cells with ovoid cytoplasm, numerous primordial and secondary follicles (Cases 1, 2 and 3) and a tertialT follicle with theca cells and several layers of granulosa cells (Cases 1 and 2). The right gonad showed the same pattern of testicular tissue and a small piece of ovarian stroma with primordial follicles. Breast tissue from Cases 1 and 2 showed numerous dilated ducts surrounded by dense fibrous stroma. Primitive breast tissue, as seen in prepuberal females, was observed in Case 3.
Familial True Hermaphrodism
105
IZO0-
I000
PATIENT
I
PATIENT
2 ----~
•
•
PATIENT
3 *--*
"2-E
BOO
? 600
J i
2"
4oo-
',
; ',
200
g -~4
-Jo
-5
o
DAYS
OF
'+~
~-,b
+14
+5
-~ 10
+ 14
CYCLE
12GO
IO00-
BOOt
J
600-
d
m
400
02 -I4
-I0
0
-S DAYS
OF
CYCLE
Fig'. 5. Daily plasma FSH and LH levels of each patient as compared to mean ~: SEM in 15 women with ovulatory cycles (shadded area). "Day 0" was considered the day of LI-I and/or FSH peak both in normal women and in patients 1 and 2 Endocrine Studies. The results are shown in Table 2. Table 3 summarizes the comparative hormonal plasma findings of each ease. The daily pattern of plasma FSH and LH levels in each case is illustrated in Fig. 5. Discussion
F a m i l i a l true h e r m a p h r o d i s m is very rare a n d so far this is the fourth family described. I n all the tissues from the 3 affected subjects there was a consistent 4~6,XX k a r y o t y p e . The presence of X e h r o m a t i n in different tissues including Leydig cells
106
S. Armendares et al.
and the lack of evidence of Y ehromatin, strongly support the karyotype and practically exclude the possibility of a stemline with a Y chromosome. A normal female karyotype was also found in previous eases (i~osenberg et al., i963; Mori and Mizutani, 1968). However, this karyotype is not distinctive of familial true hermaphrodism, since nearly one-half of all the eases of sporadic true hermaphrodism show 46,XX karyotype (Polani, 1970; Jones and Scott, 1971). I n order to explain the development of testes in X X cases of true hermaphrodism as well as the presence of testes and male phenotype in X X males, three main hypothetieM approaches have been postulated and recently reviewed by De la Chapelle (1972): 1) male sexdetermining genes located on either an X chromosome or an autosome; 2) an interchange b y crossing over between X and Y chromosomes or a transloeation of Y material to another chromosome; and 3) the occurrence of mosaieism with an undiscovered cell line containing the ¥ chromosome. Hypotheses 2 and 3 are quite improbable to explain Rosenberg's eases and ours, because in both instances true hermaphrodism was familial and the affected individuals in both families had normal parents and normal sibs of both sexes. Thus, the more feasible explanation for familial true hermaphrodism is the presence of an autosomal male determining gene. In this regard it is well established that the existence of such autosomal genes in goats and mice lead to a male phenotype in X X animals (Hamerton et al., 1969; Cattanach et al., 1971). The absence of parental consanguinity in all the sibships with familial true hermaphrodism and the occurrence of normal sibs of both sexes suggest an autosomal dominant mutation, limited to the female, as the cause of this type of intersexual disorder. For genetic counselling purposes it is important to be aware of the existence of familial true hermaphrodism when studying sporadic cases. The clinical characteristics of the affected subjects in our family and those familial cases previously reported (Milner et al., 1958 ; Rosenberg et al., 1963 ; Mori and Mizutani, 1968), are summarized in Table 4~. Excluding the eases of Mori and Mizutani (1968) there is a striking homogeneity in the phenotypieal manifestations. The presence of descended bilateral ovotestes with palpable nodules and the absence of uterus is of particular interest since these characteristics are not the most common in the majority of sporadic cases of 46,XX true hermaphrodism (Jones and Scott, 1971). I f these features are demonstrated in subsequent eases of familial true hermaphrodism, they m a y prove to be relevant in leading the clinician to suspect this anomaly during the differential diagnosis of the possible etiological types of true hermaphrodism. The 2 sibs reported by Mori and Mizutani (1968) were phenotypieally different since both showed ovotestes on the right side and ovary and a fallopian tube on the left. The clinical differences between these eases and the others m a y be explained either by variable expressivity of the same m u t a n t gene or by two different mutations. Further support for the first possibility could be the family reported by Kasdan et al. (1973) in which the propositus was a true hermaphrodite, phenotypically very similar to our eases, and whose brother and a paternal uncle were X X males. Hormonal studies in eases of familial true hermaphrodism have been performed mostly in urine (Milner et al., 1958; l~osenberg et al., 1963; Clayton et al., 1958). I n 1 case, plasma F S H and L t I were found to be normal (Kasdan et al., 1973). In
Familial True Hermaphrodism
107
Table 4. Clinical features
Age (in years) Phenotype Gynecomastia at puberty Hypospadias Scrotal gonads Gonadal nodules Right gonad Left gonad Prostate Epididymis Vas deferens Uterus Fallopian tubes Vagina
Present family
Milner et al., 1958
Rosenberg et al., 1963 Mori and Mizutani, 1968
Casel Case2 Case3
Case1 Case2
Casel Case2 Case3
Casel
Case2
15 M -~
13 M +
11 M
13 M +
11/12 IV[
16 M +
7 3/[ +
14 M +
3a/12 F
21/12
~ q+ OT OT q+ q_ . . --
-+ -k OT OT --@
+ ~-OT OT -+ _.L
~ q+ OT OT NS NS NS
+ ,+ + OT OT @ + NS
+ + -k OT OT NS + NS
__ @ Left OT OT NS NS NS
Ru --
I~u --
__b Right a -OT O NS NS NS + + +
__b Right a -OT O NS NS NS -i+ +
.
. . Ru
+ Left a -k OT OT -~qq. .
. . t~u
.
. --
NS
.
. Ve --
F
M ~ Male. F = Female. + ~ Present. - - = Absent. NS ~ Not stated. 0 = Ovary. T ~- Testis. OT = Ovotestis. = In the inguinal duct. Ru ~ Rudimentary. Ve = Vestigial. b Clitoromegaly.
the present report, the oldest p a t i e n t (Case 1, with complete p u b e r t a l developm e n t ) h a d plasma F S H levels higher t h a n n o r m a l males, as one would expect from the appearance of the seminiferous t u b u l e s ; also, plasma L H was elevated p r o b a b l y in a n a t t e m p t to increase the low testosterone levels as a consequence of the poor f u n c t i o n i n g of a n X c h r o m a t i n positive Leydig cells. However, the o v a r i a n s t r u c t u r e s of the ovotestes, seem to be responsive to the high plasma F S H a n d LH, since plasma E-2 was even higher t h a n in n o r m a l women. The latter finding would explain the existing g y n e c o m a s t i a (Cort6s-Gallegos et al., 1975). I n Case 2, which can be considered at midstage of p u b e r t y ( T a n n e r ' s stage I I - - - I I I , T a n n e r , 1962) elevated F S H was observed, again in accordance with the testicular histology. The fact t h a t plasma L H was n o r m a l correlates well with the presence of n e a r l y n o r m a l a d u l t male testosterone levels. The findings i n L H a n d testosterone in Cases 1 a n d 2 would suggest the existence of a feedback m e c h a n i s m even i n these X c h r o m a t i n positive Leydig cells. I n Case 2 one again m a y postulate t h a t the high E-2 levels are the consequence of the o v a r i a n structures response to elevated plasma F S H concentrations a n d also would explain the g y n e c o m a s t i a (Cort~s-Gallegos et al., 1975). F i n a l l y , Case 3, at the initial stage of p u b e r t a l development, h a d plasma F S H , L H a n d testosterone levels comparable to prepuberal children (Winter a n d Faim a n , 1973; A u g u s t et al., 1972). However, plasma E-2 a n d progesterone levels were higher t h a n i n n o r m a l a d u l t males. No plausible e x p l a n a t i o n can be offered to this observation.
108
S. Armendares et al.
A n interesting o b s e r v a t i o n is t h a t in p a t i e n t 1 (with complete p u b e r t a l developm e n t ) p l a s m a F S H a n d L H levels showed a " c y c l i c " v a r i a t i o n . F u r t h e r m o r e , t h e p l a s m a F S H values after " d a y 0" were consistently lower t h a n before it. I n p a t i e n t 2 (with m o d e r a t e p u b e r t a l development) t h e " c y c l i c " v a r i a t i o n was o b s e r v e d only for F S H b u t n o t for L H . Thus, t h e h o r m o n a l p l a s m a c o n c e n t r a t i o n s of F S H a n d L H r e s e m b l e d m o r e closely t h e female p a t t e r n (Fig. 5) in t h e oldest p a t i e n t s a n d were in accordance with t h e h i s t o l o g y of t h e gonads. A l t h o u g h no p a r t i c u l a r h o r m o n a l profile is p o s t u l a t e d as c h a r a c t e r i s t i c of this syndrome, it is quite clear t h a t t h e a b n o r m a l i t i e s in t h e p l a s m a c o n c e n t r a t i o n s of t h e different h o r m o n e s will be fully expressed only after t h e i n d i v i d u a l reaches puberty.
Acknowledgements. We are grateful to the NIAMDD, NIH for the kind supply of the following materials: Gonadotropin standard LER-907, hFSH-LER 1366 and hLH-LER 960 for iodination, as well as the antiserum to hFSH and hLH. We are indebted to Dr. H6ctor M~rquez Monter for assistance with histological studies and to Dr. Joe Leigh Simpson, Obstetric Service, Brooke Army Medical Center, San Antonio, Texas for helping in the bibliographical review. We acknowledge the secretarial assistance of Miss Luz Elena Hernhndez de Alba. References August, G. P., Grumbach, M. M., Kaplan, S. L. : Hormonal changes in puberty: III. Correlation of plasma testosterone, LH, FSH, testicular size, and bone age with male pubertal development. J. clin. Endocr. 84, 319--326 (1972) Barberia, J. M., Giner, J., Cort6s-Gallegos, V. : Diurnal variations of plasma testosterone in men. Steroids 22, 615--625 (1973) Cattanach, B. M., Pollard, C. E., I-Iawskes, S. G.: Sex reversed mice: XX and XO males. Cytogenetics 10, 318--337 (1971) Clayton, G. W., Smith, J. D., Rosenberg, H. S.: Familial true hermaphrodism in pre and postpuberal genetic females. Hormonal and morphologic studies. J. clin. Endocr. 18, 1349--1358 (1958) Cort6s-Gallegos, V.: II. - - A new index to predict ovulation in the human. Int. J. Fertil. 18, 93--96 (1973) Cort6s-Gallegos, V., Gallegos, A. J. : E1 ciclo menstrual f6rtil en el humano, pp. 139--148. XI Reuni6n Anual Soc. Mex. Nutr. Endocr. Acapulco, M6xico, Noviembre (1971) Cort6s-Gallegos, V., Gallegos, A. J., S£nchez-Basurto, C., Rivadeneyra, J.: Estrogen peripheral levels vs estrogen tissue concentration in the human female reproductive tract. J. Steroid. Bioehem. (in press, 1975) De la Chapelle, A.: Nature and origin of males with XX sex chromosomes. Amer. J. hum. Genet. 24, 71--105 (1972) Ferguson-Smith, M. A. : X-Y chromosomal interchange in the aetiology of true hermaphroditism and of XX Klinefelter's syndrome. Lancet 1966 II, 475--476 ttamerton, J. L., Dickson, J. M., Pollard, C. E., Grieves, S. A., Short, R. V.: Genetic intersexuality in goats. J. Reprod. Fertil., Suppl. 7, 25--51 (1969) Jones, H. W., Scott, W. W. : Hermaphroditism, genital anomalies and related endocrine disorders, pp. 290--317, 2nd ed. Baltimore: Williams and Wilkins 1971 Kasdan, 1~., Naukin, H. R., Troen, P., Wald, N., Pan, S., Yanaihara, T. : Paternal transmission of maleness in XX human beings. New Engl. J. Med. 288, 539--545 (1973) Midgley, A. R. : Radioimmunoassay: A method for human chorionic gonadotropin and human luteinizing hormone. Endocrinology 79, 10--18 (1966) Midgley, A. R. : Radioimmunoassay for human follicle stimulating hormone. J. clin. Endocr. 27, 295--299 (1967) Milner, W. A., Garlick, W. B., Fink, A. J., Stein, A. A.: True hermaphrodite siblings. J. Urol. 79, 1003--1009 (1958)
Familial True Hermaphrodism
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