Vaginal cytology in endocrinopathies

In order to evaluate the diagnostic significance of vaginal smears in endocrinopathies associated with menstrual disorders, the cytologic pattern of vaginal smears was examined in 703 patients who had a well-established diagnosis of the disorder's origin. The patients were classified into four groups according to their menstrual disorders: primary amenorrhea (159 patients), secondary amenorrhea (116 patients), primary oligomenorrhea (214 patients) and secondary oligomenorrhea (214 patients). Using the maturation index and the maturation value, three cytologic patterns of vaginal smears were distinguished: parabasal cell pattern, intermediate cell pattern and superficial cell pattern. The frequency with which the cytologic patterns occurred in the groups of patients and their subdivisions are presented. As a whole, the 703 patients showed 25.2% with a parabasal cell pattern, 58.3% with an intermediate cell pattern and 16.5% with a superficial cell pattern. Although the cytohormonal pattern of vaginal smears in endocrinopathies with associated menstrual disorders is not diagnostic of a specific endocrinopathy, the cellular patterns may prove helpful in suggesting a range of diagnoses or in excluding some possibilities.

X-Chromosome monosomy (37,XO) in a Burmese cat with gonadal dysgenesis

A 37,XO-chromosome complement was detected in a 21/2-year-old sable Burmese cat examined because of primary anestrus. The cat was smaller than its littermates; other somatic abnormalities associated with the XO karyotype in other species were not present. The ovaries, which did not respond to gonadotropin stimulation, contained inactive germinal epithelium (lacking follicles and primordial germ cells), which was similar to that of adult human patients with XO-gonadal dysgenesis.

[Bilateral sexual cord tumors in male pseudohermaphroditism]

Authors report a case of male pseudohermaphroditism reared as a female since birth. At abdominal exploration gonads showed the histologic pattern of immature testes, but were almost completely replaced by sex-cord mesenchymal tumors. It is remarked the opportunity of removing dysgenetic gonads earlier than usually suggested.

[Crossed testicular ectopia: description of a case with retention of the orthotopic gonad]

A case of transverse ectopia of the testis with ortotopic undescended testis in a baby of 2 - 1/2 years is reported. The authors stress the unusual association of ectopic and maldescended testis and describes the surgical treatment.

Dysgenesis of testicular and streak gonads in the syndrome of mixed gonadal dysgenesis: perspective derived from a clinicopathologic analysis of twenty-one cases

The clinical and pathologic aspects of 21 cases of mixed gonadal dysgenesis (MGD) were studied. The gonads in 15 patients consisted of a macroscopic testis and a streak gonad; six patients had variants, including two with bilateral testes and four with bilateral streak gonads or tumors. Functionally, the gonads were incompetent. Testes 1) failed to completely inhibit müllerian development, 2) failed to support full differentiation of mesonephric duct structures, 3) failed to adequately masculinize development of the external genitalia, or 4) often failed to mediate their own descent, resulting in asymmetry of the internal and external genitalia. None of the streak gonads mediated normal female adolescent development or fertility. Microscopic examination revealed that every gonad, regardless of its gross appearance, was morphologically abnormal. Although gonads with seminiferous tubules usually developed to a moderately advanced state, macroscopically resembling testes, the hilar zone remained architecturally disorganized; the cortex invariably lacked more than a rudimentary tunica albuginea or exhibited partial ovarian differentiation, sometimes even with a rare primordial follicle. Over time, the seminiferous tubules atrophied and hyalinized. Gonads that grossly resembled streak gonads were observed microscopically to be composed of a stroma resembling that of normal ovarian cortex. In patients more than several years of age, the entire complement of germ cells in streak gonads disappeared. It is suggested that patients with MGD be raised as females. Early removal of gonads will prevent the development of gonadoblastoma and dysgerminoma. If the uterus is retained and the patient is subsequently given exogenous estrogen, care should be taken to detect early any signs of the development of endometrial carcinoma or its precursor, to which these patients may be prone.

Identical twins discordant for the "rudimentary testes" syndrome

A 20-year-old man was found to have rudimentary testes, microphallus and minimal evidence of sexual maturation, along with low serum testosterone and high serum gonadotropin levels, consistent with the syndrome of rudimentary testes and microphallus. His identical twin brother was unaffected, confirming that this unusual congenital disorder does not have a genetic basis in all cases.

Ovarian development in 46,XY gonadal dysgenesis

In humans the XY ovary is degenerative, there being scant evidence of persistence of that organ beyond the perinatal period. Here we describe indications of functional ovarian tissue in a 17-year-old female with male karyotype, H-Y+ cellular phenotype, and some signs of the Turner syndrome. Her gonads were removed after the onset of secondary amenorrhea. Histological examination revealed a degenerative right ovary devoid of germ cells and follicles, and a left streak gonad. There was no trace of testicular development in either side.

Permeability to lanthanum of blood testis barrier in human germinal aplasia

The permeability of Sertoli tight junctions to lanthanum administrated during fixation is demonstrated in biopsies of patients with partial germinal aplasia. In freeze-fracture replicas the number of fibrils is not significantly different from the data obtained in normal testis. Thus, in these pathological conditions junctional permeability is not related solely to the complexity of the network revealed by freeze-fracture.

Pure gonadal dysgenesis in a triple-x female

A tall 15 1/2-year-old-girl with an xxx sex chromosome complement, absence of secondary sexual characteristics and histologically verified pure gonadal dysgenesis is described. In contrast to patients with an xxy sex chromosome configuration who--after puberty--are recognisable by typical somatic abnormalities, triple-x females generally show no physical anomalies. Speech and language problems can be features of the triple-x condition; ovarian dysfunction in triple-x females has been described only sporadically. Probably one patient is the second case described having this chromosomal aberration combined with pure gonadal dysgenesis. The presence of three x chromosomes (and thereby possibly extra growth determinants) could be the reason for the extra growth potential in these patients. This contrasts with the reduced growth in patients with the xo sex chromosome configuration who tend to remain small.

Hormonal and cytogenetic studies in phenotypically female patients with gonadal dysgenesis

In 4 cases of gonadal dysgenesis the clinical, hormonal, cytogenetic, and histological findings were correlated. There were 2 patients with 46,XY karyotype, one patient with 45,X Turner's syndrome and one patient with a 46,XX chromosome complement. All patients had streak gonads with ovarian stroma. In one phenotypically female 46,XY individual an involuted gonadoblastoma was found. Her testosterone was four-fold higher in gonadal vein blood compared to peripheral blood. Cytogenetic analysis of multiple tissues in both cases with the 46,XY karyotype greatly reduced the probability of mosaicism. In the patient with 45,X Turner's syndrome and in the one with 46,XX gonadal dysgenesis only peripheral blood cells were karyotyped and mosaicism was not further excluded by analysis of other tissues. The concentrations of steroid hormones in gonadal vein blood were low. The levels ranged as follows: estrone 41-98 pg/ml, estradiol 18-90 pg/ml, testosterone 37-294 ng/100 ml, dihydrotestosterone 13-22 ng/100 ml, and progesterone 0.3-1.5 ng/ml. It was concluded that gonadal streaks were similarly deficient in biosynthesis of steroid hormones despite different chromosomal complements.

Mixed germ cell-sex cord stromal tumor. A gonadal tumor distinct from gonadoblastoma

A mixed germ cell-sex cord stromal tumor and a gonadoblastoma were examined by light and electron microscopy. The mixed germ cell-sex cord stromal tumor occurred in a normal adult male, father of two children, whereas the gonadoblastoma arose in a dysgenetic gonad of a phenotypic female. The light-microscopic appearance of the gonadoblastoma was distinctive for its organoid arrangement of sex cord cells and germ cells and its pattern of secondary alterations resultings in mulberry areas of hyalinization and calcification. The ultrastructural features of the sex cord stromal cells were similar in both lesions; however, the germ cells of the mixed germ cell-sex cord stromal tumor were distinctive for the presence of true intercellular bridges. This finding suggested primary spermatogenic differentiation. It was concluded that the mixed germ cell-sex cord stromal tumor was clinically and pathologically distinct from the more widely recognized gonadoblastoma.

Cytogenetic and clinical studies in gonadal dysgenesis with 46,X,Xt(qter leads to p221::p223 leads to qter) karyotype: review and phenotype/karyotype correlations

Chromosome analysis by Q, R, and C banding was performed in a case diagnosed clinically as gonadal dysgenesis and the karyotype was shown to be 46,X,Xt(qter leads to p221::p223 leads to qter). Localisation of the breakpoints in the fused X chromosomes and replication studies have led to a hypothesis on the origin of the translocation. A comparison of clinical and cytogenetical findings in this and other published cases has also been made in an attempt to detect some phenotype/karyotype correlations.

XY (h-y+) gonadal dysgenesis. Morphological examination of 4 cases by light and electron microscopy

The gonads of 4 phenotypically female individuals with XY chromosomal constitution and signs of virilisation were examined by light microscopy. Electron microscopic examination was also performed in two cases. Serological analysis of H-Y antigen titer yielded positive results. The matrix of the gonads is shown to be ovarian stroma, in which tubular and follicular structures are embedded. The epithelia of the follicles resemble granulosa cells of the ovary, the tubular epithelia are resemble Sertoli cells. Tubules and follicles both show extensive regressive changes. A varying number of Leyding cells/stroma lutein cells were found in each gonad. The different degree of development of testicular and ovarian structures in the dysgenetic gonads might be explained by a defect of the gonadal specific receptor for the H-Y antigen, this defect varying in time of occurrence, duration and severity.

XY gonadal dysgenesis in a heifer

The anatomical and histological features of the genital tract of a six-year-old Haryana heifer, which had failed to show oestrus, are described. The heifer had a 60 XY karyotype in the leucocyte culture. The external genital organs were absent and a small opening at the ventral perineal border acted as the external urogenital opening. The ovaries were completely hypoplastic and a uterus didelphys opened into a single cervix. No male sex organs or their rudiment were observed.

Steroid production in a woman with gonadal dysgenesis, breast development, and clitoral hypertrophy

Androgen and estrogen production was measured in a 46,XX woman with gonadal dysgenesis, breast development, and clitoral hypertrophy. The production rates of androstenedione (438 micrograms/24 hr), estrone (26 micrograms/24 hr), and estradiol-17 beta (13 micrograms/24 hr) were low compared to values obtained in normal young women. The production rate of testosterone (239 micrograms/24 hr) was similar to that of normal women. Bilateral nodular streaks were found in the usual anatomic site occupied by ovaries. By microscopic examination of the streaks, fibrous tissue containing nests of hilar cells was found. The karyotype of skin, peripheral leukocytes, and gonadal streak fibroblasts in culture was 46,XX. The possible causes and implications of breast development and clitoral enlargement in subjects with gonadal dysgenesis are discussed.

Aberrant testicular differentiation in 46,XY gonadal dysgenesis: morphology, endocrinology, serology

In an infant with gonadal dysgenesis and somatic anomalies, the internal and external genitalia were female but the gonads contained tubular structures suggesting male differentiation. The karyotype was 46,XY with no evidence of structural aberration or mosaicism. Hormonal metabolism and H-Y antigen expression were assayed in cultured gonadal cells. Although unable to synthesize testosterone, the cultured cells were able to convert it to dihydrotestosterone. H-Y antigen was present, perhaps at a level lower than that in cells from normal XY males. Our observations indicate that a modicum of testicular organogenesis may precede the involution that results in a streak gonad in some cases of gonadal dysgenesis.

Diffuse intratubular undifferentiated germ cell tumor in both testes of a male subject with a uterus and ipsilateral testicular dysgenesis

A case of müllerian pseudohermaphroditism in a male subject with a uterus is described. The patient showed normal secondary sex characteristics as well as normal external genitalia, except for right cryptorchidism and a painful tumoral mass in the left testis. Examination of surgical specimens revealed a uterus attached to the left ductus deferens. Areas of seminoma and embryonal carcinoma were present in the left testis. In addition, there was a thin insufficiently collagenized albuginea that contained a cellular connective tissue resembling the ovarian stroma, as well as hypoplastic and atrophic seminiferous tubules. In the testicular parenchyma most of the seminiferous tubules located far away from the tumor possessed the atypical malignant germ cells characteristic of intratubular undifferentiated germ cell tumors. No spermatogenesis was seen. The right abdominal testis was atrophic and showed a normal albuginea. However, there was an undifferentiated germ cell tumor similar to that observed in the left testis. We describe the first case of a tumor in a scrotal testis of a male subject with a uterus. The occurrence of this tumor is discussed with regard to tubular dysgenesis present in both testes and supported by the intrinsically abnormal germ cells as well as by the immature Sertoli cells found in both testes.

Body measurements of patients with streak gonads and their bearing upon the karyotype

Anthropometric and cytogenetic investigations were carried out in 32 patients with streak gonads. The physique of the patients was delineated according to their chromosomal complements. For the possible localization of the determinants of the X chromosome for the physique the following conclusions were drawn. 1. For normal height both the short and the long arm of the X chromosome are essential. 2. The short arm of the X chromosome contains determinants that, if deleted, result in a high weight-to-height ration, i.e., proportionally heavier weight. The weight-to-height ratio is also shifted to the left in deleted Xq cases, but to a lesser extent. 3. Determinants are present in both the short and the long arms of the X chromosomes, which are involved in the proportional development of the ratio of the limbs to trunk. In all deleted-X cases the limbs were shorter. 4. Duplication of the long arm of the X chromosome does not compensate for loss of the short arm.

Microscopic gonadoblastoma in dysgenetic gonad of an infant: an ultrastructural study

A microscopic gonadoblastoma found in the dysgenetic gonad of a six-month-old phenotypic female with a 46,XY genotype was studied with the electron microscope and compared with the cells from the testicular portion of the contralateral gonad. The germ cells within the tumor resembled the testicular germ cells and were not different from previously described germ cells in other gonadoblastomas of postpubertal patients. The sex cord cells of the present tumor were inactive and immature, but differed from the Sertoli cells of the patient's testis. The presence of hyalin globules and Call-Exner bodies in the epithelial tumor nests, coupled with the ultrastructural appearance of the sex cord cells is more consistent with them being immature granulosa rather than Sertoli cells. The immaturity of the sex cord cells in gonadoblastoma of this infant suggest that they are responsive to normal regulatory hormonal influences.

Malignant stromal tumour of the ovary with virilizing effects in an XXX female with streak ovaries. Clinical and pathological studies

In gonadal dysgenesis, the presence of the Y sex chromosome appears to have a strong influence on the development of germ cell tumours. The risk of malignancy associated with other sex chromosomal abnormalities is much lower. In the present report, the clinical manifestations--including primary amenorrhoea, tall stature, infertility and poor development of the genitalia and breasts--associated with a predominantly 47, XXX karyotype are described. Malignant change of the streak ovary to an unusual gonadal stromal tumour with lipid-containing cells occurred at a late stage in her life, and this was associated with progressive virilization and production of androgenic and oestrogenic steroids. In view of the risk of malignancy as well as the abnormal endocrine effects, especially in the presence of a Y chromosome, there is a place for the prophylactic removal of these dysgenetic gonads.

[Functional activity of gonadal glandular cells in patients with testicular dysgenesis]

Results of histochemical study of testicular tissue in 31 patients, aged 2.5 to 31 years, suffering from dysgenesia syndrome of the testis are presented. Enzymes and lipids furnishing synthesis of steroid hormones (3-beta-oxysteroid dehydrogenase, alcohol dehydrogenase, glucose-6-phosphate dehydrogenase. NAD- and NADP-diaphorase, cholesterol and its esters) were revealed in Leydig's cells of pubertal-juvenile and adult patients, in Leydig's cells precursors in children, and also in Sertoli's cells of all these patients. All these cellular elements possessed high activity of the enzymes under study. It is suggested that Sertoli cells and Leydig's cells precursors, along with mature Leydig's cells, provide a sufficiently high functional activity of the gonads in patients with dysgenesia of the testis.

Gonadal dysgenesis with mosaicism and a nonfluorescent Y chromosome: report of two cases with correlation of clinical, pathologic, and cytogenetic findings

Two phenotypic girls with nonfluorescent Y chromosome mosaicism and histologic streak gonads were presented. H-Y antigen (a Y chromosome--determined antigen) was negative in both patients. Electron microscopic findings of "streak gonads" were presented for the first time. The authors recommend bilateral gonadectomy in patients with nonfluorescent Y chromosomes and correlation between the histologic findings and H-Y antigen status.

Sex chromosome and chromatin examination in gynecology

Sex chromosome and chromatin examinations with hormone determinations were done on 41 cases seen at the gynecologic clinic suspected of having sexual developmental abnormalities. 22 (53.7%) had genetic, gonadal or hormonal abnormalities, including ovarian dysgenesis 9 cases, superfemale 1 case, XY pure gonadal dysgenesis 4 cases, 3 of whom had already developed gonadal malignancy, pseudovaginal perineoscrotal hypospadias 1 case, androgen insensitivity syndrome 2 cases and congenital adrenal hyperplasia 3 cases. The values and limitations of sex chromosome and chromatin examinations as well as the prevention of gonadal malignancy are discussed.

Mixed gonadal dysgenesis, pathogensis, and management

Fourteen patients with Mixed Gonadal Dysgenesis who presented as infants or children are discussed. Gonadal asymmetry, and/or sex chromosomal mosaicism, as well as retained Mullerian Ducts characterize the anomaly. The dysgenetic testis may occur as the result of a cascade of development mishaps stemming from abnormalities of H-Y antigen expression or function that lead to abnormal differentiation of the indifferent urogenital ridge and, in turn, to aberrant production of Mullerian inhibiting Substance and testosterone. The latter two cause retention of Mullerian ducts and incomplete masculinization of the external genitalia. Absence of a second X chromosome may lead to the formation of a streak ovary, in which the dysgenetic testis may invoke formation of hilar and medullary cords. Neoplastic transformation, so characteristic of this group of patients, may result from unprotected germ cells and abnormally high and prolonged gonadotropin stimulation. Gonadoblastoma and seminoma-dysgerminomas are the tumors found in the gonads with the risk exceeding 50% as the third decade is approached. Laterality of the gonads in this anomaly remains an enigma. The gonads should be removed at birth if possible and the external genitalia repaired soon thereafter. These patients should be raised as females. The risk of neoplastic transformations must be considered at all stages of management.

Anorchia and persistent Müllerian duct: a variant of the embryonic testicular regression syndrome

A 20-yr-old phenotypical male with a 46, XY chromosome complement, a hernia uteri inguinale, and bilateral anorchia was studied. Eunochoidal body proportions, infantile type of male external genitalia with empty scrotum, underdeveloped sexual characteristics, and delayed bone age suggested the existence of inadequate testicular function. Extremely low levels of circulating testosterone and a lack of response to hCG stimulation was found. Persistently elevated blood levels of LH and FSH with an adequate pituitary response to an iv bolus of synthetic LRH was demonstrated, thus indicating inadequate endocrine gonadal function as well as functional integrity of the hypothalamic-pituitary unit. At the time of an inguinal hernioplasty, a small but well developed uterus was removed. No gonads were found within the true pelvis, inguinal canals, or along the anatomical pathways of testicular descent. A cord-like structure found in the left inguinal canal contained only fibrous tissue without gonadal elements. It is proposed that the occurrence of two altered events during embryogenesis, failure of Müllerian duct regression and late testicular regression, may explain the underlying defect in this unusual abnormality of sexual differentiation.

Clinical, histological and cytogenic observations in pure gonadal dysgenesis

Clinical observations, gonadal histology and cytogenic studies are described in eight cases of pure gonadal dysgenesis.

The general appearance of the patients was feminine. They had never menstruated spontaneously. Most cases showed eunuchoidal body proportions and absence of breast development. The external genitalia were infantile.

All patients had the streak gonads which consisted of undifferentiated embryonic stroma without any germinal elements. The gonadotrophin level was normal or high. In four cases, apparently normal male karyotype and in three cases apparently normal female karyotype was found. In one case chromosomal mosaic XO/XX was encountered. No clinical or histological differences between patients with male and female karyotype were found, except for phallic enlargement which was present in three out of four cases with male chromosome complement.