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Sexual Precocity in a 16-Month-Old6 u/ }) B) Z0 e* O% w- P
Boy Induced by Indirect Topical. @* i5 P/ t9 h- [
Exposure to Testosterone
( Z. T/ k+ T: Y4 U% ^" CSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 y' Y  ~( a5 f# O# e& T
and Kenneth R. Rettig, MD1
- W8 G: K! `" `Clinical Pediatrics5 w0 }9 s; b! W
Volume 46 Number 6
" i7 h5 L5 T2 J5 IJuly 2007 540-543* n+ Q$ q* y! ?; h# _! T
© 2007 Sage Publications
2 }' R% {7 B+ Z! R, X9 N( k" O10.1177/0009922806296651" a  T$ m4 ?0 n  d) G
http://clp.sagepub.com8 w/ X; P5 ^! @: r$ t; L
hosted at
+ Q* g, @5 k. @+ o9 }  ^3 x+ k# Z$ \& a$ Phttp://online.sagepub.com! X' X4 \6 G% }$ c8 S
Precocious puberty in boys, central or peripheral,
: `* b1 W6 u" s! P0 {is a significant concern for physicians. Central3 E) W- L: T+ N0 ]
precocious puberty (CPP), which is mediated2 f+ z' Z8 ~' M) Y
through the hypothalamic pituitary gonadal axis, has+ ?2 h: h/ r2 Q  K
a higher incidence of organic central nervous system) k- }, W: O( q" p! i2 q0 P
lesions in boys.1,2 Virilization in boys, as manifested
) K5 c! e" P/ ?4 y+ P' h& R/ jby enlargement of the penis, development of pubic( ^* O5 s5 m# k0 y
hair, and facial acne without enlargement of testi-  X: _' x, I' x( a0 V4 g9 _5 Q
cles, suggests peripheral or pseudopuberty.1-3 We
" y) ]; o7 [; Y$ n, q: J+ j( p, }report a 16-month-old boy who presented with the
3 W, e; [5 n* a& w$ A+ fenlargement of the phallus and pubic hair develop-+ |4 _3 @6 r+ ?: N: S. x+ H
ment without testicular enlargement, which was due
. b% u3 b: Z# B" k$ R+ Cto the unintentional exposure to androgen gel used by
4 {0 y5 u% K! [the father. The family initially concealed this infor-
5 X5 G; T2 M8 W2 `9 }8 G* @mation, resulting in an extensive work-up for this5 R& M6 P5 J3 \3 d& c
child. Given the widespread and easy availability of
: V& F& {: D' Mtestosterone gel and cream, we believe this is proba-) G- G, w/ X# @
bly more common than the rare case report in the  C/ ^/ g; T( O7 F$ m- T8 [
literature.4; V( i( H) q& P+ P
Patient Report
# c; P  g6 ^; A; V3 u& ^0 B) G& DA 16-month-old white child was referred to the
; p# @5 X: g. [2 t4 Hendocrine clinic by his pediatrician with the concern
# x0 C5 s+ \3 N/ z  jof early sexual development. His mother noticed
  G* N& g) Y9 s8 Z' |6 |$ E+ olight colored pubic hair development when he was
1 U/ Y7 g9 [% o0 ?/ eFrom the 1Division of Pediatric Endocrinology, 2University of0 ]0 ]  v; L- T2 y6 N) @
South Alabama Medical Center, Mobile, Alabama.$ {" v5 K8 x4 Q5 T7 Q3 X% n
Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 L: e: n3 f" |3 m" w& i! BProfessor of Pediatrics, University of South Alabama, College of; t$ D/ v7 Q* |% c8 d
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
# n& I7 t& Q5 q$ o9 ]# Pe-mail: [email protected].
. k- G1 ?) m* s1 O4 I6 Gabout 6 to 7 months old, which progressively became
; F* s5 |) u2 q. Udarker. She was also concerned about the enlarge-. ?% `: J+ Z9 `9 x5 b
ment of his penis and frequent erections. The child; h# C  w; H" ?) L/ G7 D
was the product of a full-term normal delivery, with
; E+ c4 g) m6 Ya birth weight of 7 lb 14 oz, and birth length of6 O; h# C/ @1 q" t, ^/ z) M
20 inches. He was breast-fed throughout the first year
: R' I, G0 _+ |9 Hof life and was still receiving breast milk along with
: t7 r0 I( U' v7 o; |solid food. He had no hospitalizations or surgery,
: Z1 `* p' \2 O' t! _0 m4 Eand his psychosocial and psychomotor development
6 h8 n. d" D- u1 C5 jwas age appropriate.% k+ E+ [' r  c8 o2 L8 |0 D9 B% h  T+ g
The family history was remarkable for the father," |& {$ t( s% m$ z4 ?
who was diagnosed with hypothyroidism at age 16,
. H9 z* B& C. l( k& Kwhich was treated with thyroxine. The father’s5 O" H. e  U9 U) y
height was 6 feet, and he went through a somewhat
" A; a9 Z8 Q3 xearly puberty and had stopped growing by age 14.
+ ]& |0 D; |9 t* A$ aThe father denied taking any other medication. The
7 s4 m! b9 D% z) b8 v& gchild’s mother was in good health. Her menarche
1 P$ v' a4 F, ]5 b6 M8 M$ {% L. x3 Rwas at 11 years of age, and her height was at 5 feet+ j6 M7 r4 `; i7 k3 F
5 inches. There was no other family history of pre-  P$ Y8 C" r+ A& |+ I/ D# P
cocious sexual development in the first-degree rela-
. D+ t; G. L  _tives. There were no siblings.$ ^: K6 a* p, T
Physical Examination
3 R* C; j' H6 w7 A; Y! ?6 P# C$ V7 qThe physical examination revealed a very active,# k5 ?3 w. p* h' C- g
playful, and healthy boy. The vital signs documented, ?" j( W5 k0 B! k* Y& }
a blood pressure of 85/50 mm Hg, his length was* q) c! I% k; L! N5 ]/ S, g  y
90 cm (>97th percentile), and his weight was 14.4 kg% I/ J" g# S+ V0 x: \' k
(also >97th percentile). The observed yearly growth6 N+ o" j) L) H
velocity was 30 cm (12 inches). The examination of; i) Z9 Z  M# L5 ]
the neck revealed no thyroid enlargement.9 j% U/ G" z* b: ~: e: I
The genitourinary examination was remarkable for
1 e' R) g: D7 V6 ]enlargement of the penis, with a stretched length of$ F7 Y6 j5 G$ b% G0 J) `2 ^
8 cm and a width of 2 cm. The glans penis was very well
8 k# T1 o! k( E: Tdeveloped. The pubic hair was Tanner II, mostly around
& l- ^* N7 N. A: S2 E6 j540, r5 b: U1 \" P; f. q6 W/ t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from+ l' [6 P$ N2 j* y! m9 t0 L9 o
the base of the phallus and was dark and curled. The
. b# p! l$ y. {/ H' S; @! R9 Ntesticular volume was prepubertal at 2 mL each.
$ g# J1 A' `+ h2 j: ?The skin was moist and smooth and somewhat8 |2 v# G' |* [! O, d- x$ D2 ~3 {
oily. No axillary hair was noted. There were no
  X0 i4 t4 `) ?3 w( F, ]abnormal skin pigmentations or café-au-lait spots.: S/ O; v: `" r& q; H2 `9 ]
Neurologic evaluation showed deep tendon reflex 2+
. j7 H+ B- R7 Y% }% m0 Bbilateral and symmetrical. There was no suggestion
, d0 v( J; \0 U& T1 k( R4 f# Tof papilledema.
. [: W1 N/ t) [$ V* G1 P/ hLaboratory Evaluation
7 d8 C7 P9 E, {The bone age was consistent with 28 months by
3 t9 h& A  F& C6 k* N3 R/ Q& u0 rusing the standard of Greulich and Pyle at a chrono-
3 D) |2 l4 T+ v9 M5 Z- }logic age of 16 months (advanced).5 Chromosomal; O) N. [6 Y# P) D0 D( J4 [6 R
karyotype was 46XY. The thyroid function test
; ?6 c; R2 v  Z" vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-* S4 r" C. z1 F+ g/ c, A' V
lating hormone level was 1.3 µIU/mL (both normal).
, {7 Y* u+ {" S# g" \/ ]The concentrations of serum electrolytes, blood. G( k- |" a4 }9 [
urea nitrogen, creatinine, and calcium all were
7 n! r: o* o; n5 |2 ]7 Wwithin normal range for his age. The concentration
9 o5 t* u) p+ F& u1 o9 T& ^' qof serum 17-hydroxyprogesterone was 16 ng/dL" [& C1 |/ ~% B+ r( {; b% I
(normal, 3 to 90 ng/dL), androstenedione was 20
" j; I6 N: U% x% Ong/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* K4 }: B" F4 f
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
# c1 A* U' K" {% C9 X8 ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ o/ I% c* A& z1 ], a8 t49ng/dL), 11-desoxycortisol (specific compound S)0 I# y4 ^' x5 l. `" I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- _% y- c% K3 U4 t  B
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 \* b' ]% c- _8 a; j8 o
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ N* \: ?/ v+ cand β-human chorionic gonadotropin was less than9 c1 \; k) d6 d
5 mIU/mL (normal <5 mIU/mL). Serum follicular: Q$ i6 |0 d' H0 Z- B3 C) ]6 l
stimulating hormone and leuteinizing hormone  l* _- i4 a4 H9 A
concentrations were less than 0.05 mIU/mL
3 R5 b) {# K# l& q! p(prepubertal).
: e7 ^+ \- }# R2 O& MThe parents were notified about the laboratory
3 O, Z  H* `2 F/ D  k. s- ^results and were informed that all of the tests were
; K7 V3 u% L' mnormal except the testosterone level was high. The
: a2 V# ^6 K3 H: k) h) jfollow-up visit was arranged within a few weeks to' F: _9 a# O: \* d8 h9 u" Q
obtain testicular and abdominal sonograms; how-
" k) X5 E7 m4 B" Z8 M" `ever, the family did not return for 4 months.
1 |5 y! A( ]% M1 ]6 X7 A# SPhysical examination at this time revealed that the
2 |  y' i; ?) P% d% U- `$ Zchild had grown 2.5 cm in 4 months and had gained
  v% T: f3 I# E2 N; q9 C: q2 kg of weight. Physical examination remained) ~* f1 d1 B/ o
unchanged. Surprisingly, the pubic hair almost com-( ]4 n" v: A# n7 y: N+ a# q
pletely disappeared except for a few vellous hairs at7 Y. s4 i% @& F2 g) a8 ^( a1 T
the base of the phallus. Testicular volume was still 2
1 ?3 @% x* u; U' {1 lmL, and the size of the penis remained unchanged.
# h# T6 p! I/ f& E* s2 e/ G. _The mother also said that the boy was no longer hav-
' W" ^+ y* _( P' E1 T3 I/ T6 King frequent erections.
5 f' }1 z1 d8 ]8 R- v1 c' gBoth parents were again questioned about use of9 |3 W& N* g1 e5 y$ f
any ointment/creams that they may have applied to& w. N$ F: Y2 l; j6 c/ {. w
the child’s skin. This time the father admitted the6 D8 g$ D& [9 \9 _" F8 {% k' G5 v7 j& e
Topical Testosterone Exposure / Bhowmick et al 541* }+ M, q& k7 O$ W: T. \# ]
use of testosterone gel twice daily that he was apply-
8 U& l# E: N2 k- ^% k% m5 [ing over his own shoulders, chest, and back area for
9 \! s0 N) G% h3 U$ u1 Qa year. The father also revealed he was embarrassed
8 c6 l$ \/ r$ Vto disclose that he was using a testosterone gel pre-, s9 M0 M1 ~& J: \; s1 e
scribed by his family physician for decreased libido
  }7 _( B- @6 Dsecondary to depression.# `0 Z# Q. A" t+ W+ D, U. e, o
The child slept in the same bed with parents.
5 e8 n  a6 w+ R2 z# H/ [; u0 K, VThe father would hug the baby and hold him on his+ v5 d! L; s8 ~$ T
chest for a considerable period of time, causing sig-% Z, ?# B& ]2 K, O! K
nificant bare skin contact between baby and father." x; P4 b- ?4 T* a6 z1 T, b# S7 x
The father also admitted that after the phone call,
  q; t! [( E+ G6 w, dwhen he learned the testosterone level in the baby3 Q8 l$ x: ^  S2 Y6 L/ T
was high, he then read the product information, y% A* s" T% }( a! }; F) z
packet and concluded that it was most likely the rea-3 E: ?* a% E5 L% B
son for the child’s virilization. At that time, they
% I; w- g; ?+ B8 f/ m5 ?# J# qdecided to put the baby in a separate bed, and the7 v7 h# o6 K7 ~' p3 Y. Q
father was not hugging him with bare skin and had7 P! S7 u9 K, b/ ]3 ]2 t
been using protective clothing. A repeat testosterone
  Q' Z  l- c' q/ T& \test was ordered, but the family did not go to the
# U! a% v6 k# k& Y* q4 S1 c4 k7 w2 Hlaboratory to obtain the test.' Q6 n) [: O2 G
Discussion! L1 T9 T  K% o7 J' n. G  f3 |9 U8 L
Precocious puberty in boys is defined as secondary
+ |: o6 u/ v. \8 C2 lsexual development before 9 years of age.1,4" C% v8 Z8 q- D' v" b
Precocious puberty is termed as central (true) when- i  E- ^8 i! ~8 l; z1 e# d* s
it is caused by the premature activation of hypo-
' M, |. {1 a0 A; uthalamic pituitary gonadal axis. CPP is more com-
6 ^3 t3 X& ]1 T+ A2 f- o! lmon in girls than in boys.1,3 Most boys with CPP
  T: g4 T+ r6 o% X5 vmay have a central nervous system lesion that is
6 O' z0 k4 I3 d/ F4 ^! Qresponsible for the early activation of the hypothal-
, E0 s) r' Y4 Xamic pituitary gonadal axis.1-3 Thus, greater empha-5 O2 Y$ d( E# T1 ], u" k
sis has been given to neuroradiologic imaging in
  ?" ?. l7 ?& X) cboys with precocious puberty. In addition to viril-; m4 `. L0 N6 [$ l  c6 s
ization, the clinical hallmark of CPP is the symmet-
) K. f2 x, p$ [+ q! grical testicular growth secondary to stimulation by
$ O8 p7 j7 |( h# jgonadotropins.1,3
, w: f- M6 U! ?9 `& O( L6 s5 p* S. Y6 aGonadotropin-independent peripheral preco-5 w  \/ `2 |) `) y! h1 _8 u
cious puberty in boys also results from inappropriate8 f1 S' v9 j9 f" K
androgenic stimulation from either endogenous or3 l& t* s6 f. j; O3 x
exogenous sources, nonpituitary gonadotropin stim-. p3 G3 v8 Y3 {& a9 h; M9 `
ulation, and rare activating mutations.3 Virilizing
: T/ ?5 O+ h/ ~/ e+ Q2 [1 y  econgenital adrenal hyperplasia producing excessive
  r5 a3 J$ N: h- b, Y8 `/ _adrenal androgens is a common cause of precocious8 c, w9 z) B! K( Z5 n# O- l5 F
puberty in boys.3,43 ^$ m0 H7 U7 ^7 e
The most common form of congenital adrenal
6 [+ V$ ]8 u! o" rhyperplasia is the 21-hydroxylase enzyme deficiency.8 w. G, |( i0 L- ?, l. Z4 O
The 11-β hydroxylase deficiency may also result in
: [' `* u2 Z% a- [3 _; M+ x9 `5 iexcessive adrenal androgen production, and rarely,
# |) s/ s  I/ k) A& _  yan adrenal tumor may also cause adrenal androgen
7 I; y( x4 w- y: ^2 W4 Rexcess.1,3! \8 i+ j0 f  S6 T" ]! D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from  ~9 v% n* v" ^
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. L' x1 Q. V2 v4 Q) R  U+ g+ s
A unique entity of male-limited gonadotropin-0 s) s! Q- l) T. E3 f
independent precocious puberty, which is also known) U5 |* @, A0 K( t) e. N4 f
as testotoxicosis, may cause precocious puberty at a
  N) w: F- y5 d) ]. Kvery young age. The physical findings in these boys& F- c8 s7 A0 a, ^: n/ F7 g: j
with this disorder are full pubertal development,
+ X9 N. @2 }, r! l  aincluding bilateral testicular growth, similar to boys- w  o$ w! s+ I3 {+ y9 l
with CPP. The gonadotropin levels in this disorder
# \4 H! C" n/ i" I4 pare suppressed to prepubertal levels and do not show
  |4 h+ l' F% D! @pubertal response of gonadotropin after gonadotropin-
$ Y! ^. @/ m. i9 o0 k) C5 u$ a1 mreleasing hormone stimulation. This is a sex-linked- |8 ~* z. A; h7 }
autosomal dominant disorder that affects only
/ N* c) l) _# X" smales; therefore, other male members of the family
8 D8 Q# H# |" |; Z2 g" xmay have similar precocious puberty.39 a0 ^& }# m3 m+ h
In our patient, physical examination was incon-
4 S4 g6 Q- ~4 [5 E0 B" L. \8 lsistent with true precocious puberty since his testi-
/ t( s  Q8 f6 hcles were prepubertal in size. However, testotoxicosis3 _$ r5 l  P, W0 ^' p' H
was in the differential diagnosis because his father
/ q: p/ k5 y$ h; z2 gstarted puberty somewhat early, and occasionally,
( `. k% G# Z0 z4 b' ?testicular enlargement is not that evident in the
3 K+ R7 S2 ?. G( C. Cbeginning of this process.1 In the absence of a neg-4 @! E2 V* ?9 m6 x4 {
ative initial history of androgen exposure, our8 M% E6 a4 K' D6 V6 W' X
biggest concern was virilizing adrenal hyperplasia,
2 Y; a' T% ~  [( ^3 heither 21-hydroxylase deficiency or 11-β hydroxylase
* o# N$ f) G' R2 j; e/ S$ Gdeficiency. Those diagnoses were excluded by find-
& m. K; D, M$ I2 Eing the normal level of adrenal steroids.
- L6 f$ \$ y: w- r; [The diagnosis of exogenous androgens was strongly5 t( u; Q: ?6 W% L
suspected in a follow-up visit after 4 months because
" l" V. q/ H( B' F& o9 mthe physical examination revealed the complete disap-
8 R- B2 s$ H% p7 n- |pearance of pubic hair, normal growth velocity, and) a2 i& _3 `( H9 [- t3 U' B0 i/ `
decreased erections. The father admitted using a testos-3 ~0 ^: j3 ]; b' P& N& t. F& F
terone gel, which he concealed at first visit. He was$ Y9 s. x  T! z+ Q/ q! S* R
using it rather frequently, twice a day. The Physicians’
& }& O, `% B+ M9 \9 bDesk Reference, or package insert of this product, gel or
9 k+ L: O% K9 \5 a9 V2 Q( }cream, cautions about dermal testosterone transfer to
+ j( X) p) ?- y) c$ N/ runprotected females through direct skin exposure.  Z* K1 r% M- O, |+ ?3 Q. _
Serum testosterone level was found to be 2 times the4 L: u3 j* p5 e3 \9 Q4 f0 o
baseline value in those females who were exposed to$ a8 Q: v  q. \' C5 i- a
even 15 minutes of direct skin contact with their male  x$ \6 z# Z/ ~5 L: D: a
partners.6 However, when a shirt covered the applica-: U$ Y2 K2 B0 C0 j" p: I
tion site, this testosterone transfer was prevented.
0 K' h- |; y4 eOur patient’s testosterone level was 60 ng/mL,1 f. f7 X4 |" K
which was clearly high. Some studies suggest that
1 w( u8 t9 D5 ~) vdermal conversion of testosterone to dihydrotestos-, e+ T2 n( C, @4 W8 P5 G
terone, which is a more potent metabolite, is more" J: m) A5 q: O) ~; B6 A
active in young children exposed to testosterone
8 C0 V: \# V! l* p% C# H' Iexogenously7; however, we did not measure a dihy-2 Q# H. M. `  J3 F  C/ r7 ^5 S
drotestosterone level in our patient. In addition to
- [, K' Y9 m6 Y6 y6 b8 S! x! hvirilization, exposure to exogenous testosterone in
' X& P. W$ V, ]) C' \6 o# C/ N4 f) Wchildren results in an increase in growth velocity and& _5 e" I  h/ v: E# y
advanced bone age, as seen in our patient.2 N1 {  t3 }3 W# y
The long-term effect of androgen exposure during6 ^' y- X& C7 K/ @9 M! q) C
early childhood on pubertal development and final
* I1 A$ ^+ G+ J- }  @adult height are not fully known and always remain
6 y* f7 J& K0 k2 Ra concern. Children treated with short-term testos-' a) U' y# U* c4 V9 W9 H) T# A. ]5 V
terone injection or topical androgen may exhibit some9 o. t+ `# _: G% _% t& K5 y
acceleration of the skeletal maturation; however, after
, {- ^1 p( V5 w8 s" F) L2 _cessation of treatment, the rate of bone maturation4 A2 C! x- y$ q6 y1 K
decelerates and gradually returns to normal.8,9. e* r/ G5 E; C: g; Y$ S
There are conflicting reports and controversy
5 A! D- l( j6 N/ q" yover the effect of early androgen exposure on adult
  ^* R; R) P+ ?, r! j" ?6 Y0 ^penile length.10,11 Some reports suggest subnormal" w% l; ^" w9 q1 c7 A7 b, u
adult penile length, apparently because of downreg-% v8 Y0 J) F5 y' z$ ]3 G: n
ulation of androgen receptor number.10,12 However,
9 j- Y' h7 H; \, g6 B* ?+ T/ SSutherland et al13 did not find a correlation between0 j/ B  [" K3 s2 Y" {5 {
childhood testosterone exposure and reduced adult
8 X+ U$ e/ W2 G! W/ E, r9 x( Rpenile length in clinical studies.
% l; U2 T! E" a/ ANonetheless, we do not believe our patient is. t" N* R# L* Z' n
going to experience any of the untoward effects from
$ Q6 B* z+ w$ a+ H3 d  v* gtestosterone exposure as mentioned earlier because" F2 X2 z, g" C( R5 o% ?2 h7 j- Y
the exposure was not for a prolonged period of time.
4 ?2 L) G& I3 C& c5 xAlthough the bone age was advanced at the time of
1 t6 W! `! w( @4 s9 I( E& Tdiagnosis, the child had a normal growth velocity at5 A& I! T( `8 ]6 z: F! R" [
the follow-up visit. It is hoped that his final adult& L% j! z9 x3 l
height will not be affected.3 f- X3 c: A! ^" t: u& ]# X$ j
Although rarely reported, the widespread avail-
# n+ e; K! A5 y# f. Wability of androgen products in our society may
: V; W. X7 z# A( lindeed cause more virilization in male or female
5 A( W8 a7 J5 I4 T! j" i% J7 xchildren than one would realize. Exposure to andro-' ?% O6 [  L- p  w" k; [  H+ x
gen products must be considered and specific ques-; c/ X& \" Z# E0 y: o0 Y
tioning about the use of a testosterone product or
; K' r6 l. S1 @2 x  H3 n! o! Cgel should be asked of the family members during' _; F# A; ~8 V% N6 n5 l; c
the evaluation of any children who present with vir-- s5 v6 |6 f0 r, X
ilization or peripheral precocious puberty. The diag-* h4 H9 y; h4 t& {
nosis can be established by just a few tests and by& \) u; K7 J0 k% T; Q
appropriate history. The inability to obtain such a( _! Y$ g* t* F; q
history, or failure to ask the specific questions, may
' _! x, M+ b- {result in extensive, unnecessary, and expensive
1 K. p7 h) w( ?- Y. einvestigation. The primary care physician should be, t  a: y' Q& y4 g' ?  V
aware of this fact, because most of these children
+ H8 V, m; v* R* \4 p* ~may initially present in their practice. The Physicians’3 L6 @6 ?5 D4 X+ _1 B/ H, t
Desk Reference and package insert should also put a1 o2 ?' v( R$ |/ u4 k* M
warning about the virilizing effect on a male or& D% j8 _2 c8 q4 r$ i( o
female child who might come in contact with some-
, k/ i/ y1 ~/ ?" _+ {one using any of these products.6 Q* I8 C3 Z6 A4 T
References+ r2 `" @0 o" v1 e' u. U$ `
1. Styne DM. The testes: disorder of sexual differentiation1 _; H  \, c) [/ ^$ q& F# h
and puberty in the male. In: Sperling MA, ed. Pediatric
4 S( M: @' G" I2 V% R% _# N' B* CEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
2 @' z& `. R  s2002: 565-628.
& r) C9 B  ?/ A& l; S% i+ t% b+ |2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
) R) ?$ y) _3 r& B: J9 K( ypuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old/ x% U& J7 S- E
Boy Induced by Indirect Topical
& q0 p  c4 [% ]. l+ i3 eExposure to Testosterone5 F: X& E, |6 D8 G' z7 ^3 z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,28 {4 l3 T, U2 O
and Kenneth R. Rettig, MD1  c: u$ O1 X: O1 {+ q
Clinical Pediatrics
1 n! O& Y, j4 Z8 X& \7 }* m: Q0 XVolume 46 Number 6
! V+ U( a/ z, ~0 u! D6 n5 iJuly 2007 540-543/ i3 U) X5 L% U6 p
© 2007 Sage Publications9 p4 r* X+ H# K% ]9 ~$ T
10.1177/00099228062966516 ^& ]# w8 x! C8 O
http://clp.sagepub.com9 `# M+ v2 f7 A7 I4 V2 f2 ?
hosted at
; i! u6 G% J$ @http://online.sagepub.com
) e( v3 u2 r% i% |6 u6 U. NPrecocious puberty in boys, central or peripheral,
' X0 a$ O$ T2 ~0 P: fis a significant concern for physicians. Central
! G* w" h9 O2 I+ R+ F! Iprecocious puberty (CPP), which is mediated
/ r" I; c/ J- i3 U" g- ythrough the hypothalamic pituitary gonadal axis, has
, ]+ Y! n7 Z& T$ r' C# I, Za higher incidence of organic central nervous system5 j4 J- Y8 K# G4 y
lesions in boys.1,2 Virilization in boys, as manifested: ?2 m1 m  H3 L/ D% v$ b; n+ [
by enlargement of the penis, development of pubic
5 V7 q2 N5 u0 ehair, and facial acne without enlargement of testi-
0 y5 F! V$ V" R) F( a! p. y% Y* f& u4 i6 [cles, suggests peripheral or pseudopuberty.1-3 We
  V2 n: U; D2 d$ s: ^/ Dreport a 16-month-old boy who presented with the3 \1 }% l; f4 Q
enlargement of the phallus and pubic hair develop-  g3 H1 b% l: t& A: f
ment without testicular enlargement, which was due
) d, Q5 g* E0 a' ^. {4 W* s( b, @to the unintentional exposure to androgen gel used by% n! Y3 N! W% D9 M+ I
the father. The family initially concealed this infor-
9 J- A; ^* q+ ^' C! C% U/ J1 dmation, resulting in an extensive work-up for this
' l" _  j7 |" w% D/ hchild. Given the widespread and easy availability of
- r. o0 e& b" Z$ N$ C% U4 Ytestosterone gel and cream, we believe this is proba-
( Q5 e; P- Z" w1 K2 o* cbly more common than the rare case report in the
# m( T* N# f& Y' V2 k/ t$ J% Y# uliterature.4" N8 l+ M& J) L+ U( T/ z
Patient Report' I/ L8 y& H. i- [2 X( L
A 16-month-old white child was referred to the/ A; [/ J) @6 ^0 z  C
endocrine clinic by his pediatrician with the concern
6 C8 z% }; s$ B9 R+ q% _7 |' `of early sexual development. His mother noticed4 [7 }, v7 P' @6 V
light colored pubic hair development when he was# f/ D$ O' Y( D( v* X, }$ f
From the 1Division of Pediatric Endocrinology, 2University of3 X2 t4 v% M. L& }
South Alabama Medical Center, Mobile, Alabama.* o( J& C( W1 B$ h4 X9 C) ]
Address correspondence to: Samar K. Bhowmick, MD, FACE,' B, [! V7 B: g. X8 a; s5 J1 i
Professor of Pediatrics, University of South Alabama, College of
  K) ]# J, k9 f6 g, f# k) M; ZMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
  G  M5 c/ z  [& L5 y4 B: Ve-mail: [email protected].. }) @: L- |: ]8 R) r
about 6 to 7 months old, which progressively became
. C9 ]4 z; \1 [darker. She was also concerned about the enlarge-. A# f5 _  F, _5 O# Y$ O
ment of his penis and frequent erections. The child
+ V/ W* n, m( zwas the product of a full-term normal delivery, with
( c9 m  `: `8 j0 M" e; j- ba birth weight of 7 lb 14 oz, and birth length of
& p; K9 _: Y; ]! V! @20 inches. He was breast-fed throughout the first year
, Z8 n( {4 H# a% d* l5 lof life and was still receiving breast milk along with6 |( x3 ?0 _& h( i) R
solid food. He had no hospitalizations or surgery,
9 w% z# s: n$ o* ]and his psychosocial and psychomotor development
$ ]4 E0 @8 Q% w3 O9 ~+ O! \was age appropriate.
; |' B; A- O6 `/ Y  DThe family history was remarkable for the father,! B1 a. ?+ |6 o; d  }
who was diagnosed with hypothyroidism at age 16,) N2 o# I/ Q2 p- ]; E8 Z
which was treated with thyroxine. The father’s
8 _( ?1 G/ m# [5 J/ d6 Rheight was 6 feet, and he went through a somewhat
* _; f, y4 H* f+ z( Xearly puberty and had stopped growing by age 14.' S  p3 X( o0 j$ k
The father denied taking any other medication. The; @: \/ m! ]& }$ f! C3 c3 o3 a7 g$ ~
child’s mother was in good health. Her menarche# v5 W& R# f$ x9 p* N4 W. R7 b; `8 O) ?
was at 11 years of age, and her height was at 5 feet! ?# V  @: e/ a" s( G. R
5 inches. There was no other family history of pre-  v0 z0 L5 `6 w7 `* {
cocious sexual development in the first-degree rela-
# e% y, F- p0 Q; b- a, q7 y( N. z/ }tives. There were no siblings.2 K6 u0 D- B: t. B& V' M
Physical Examination7 s: z2 c$ [  H- B
The physical examination revealed a very active,
9 n& E" C1 \( U# Dplayful, and healthy boy. The vital signs documented
3 v0 T) q" L9 B9 ha blood pressure of 85/50 mm Hg, his length was
9 ?  R, M* Z7 F5 Z0 L- x7 P! E90 cm (>97th percentile), and his weight was 14.4 kg: X1 o& W2 ~( p8 D
(also >97th percentile). The observed yearly growth  f' s+ J% B5 u$ b& p9 c% {; ]; }
velocity was 30 cm (12 inches). The examination of. k4 R" O7 }) h( P7 {$ V
the neck revealed no thyroid enlargement.
" K# J: L* g! K4 X/ X" AThe genitourinary examination was remarkable for5 g+ H# X7 Z! n- E5 p
enlargement of the penis, with a stretched length of
9 g' O* ]( t' }6 R$ c8 cm and a width of 2 cm. The glans penis was very well/ U# Z- [; t5 B
developed. The pubic hair was Tanner II, mostly around2 q  F' Q- S: y3 P! O" |/ r
540' ^  Q$ z* {# s8 N$ H
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 i- q& B0 b* F# m0 h3 k' f& S
the base of the phallus and was dark and curled. The
- w1 x9 d! M/ k- S& B) _* z( J3 ttesticular volume was prepubertal at 2 mL each.8 B: X; t  B, m4 {
The skin was moist and smooth and somewhat1 B* o2 p* \& N% Z- Y% t
oily. No axillary hair was noted. There were no9 f3 d  v$ F" q, y& |9 a5 h8 m
abnormal skin pigmentations or café-au-lait spots.
6 ~6 V4 V  Y4 N: RNeurologic evaluation showed deep tendon reflex 2+1 T& m; E% e- p* ~( a3 V! w; [
bilateral and symmetrical. There was no suggestion- Z2 x; }7 A( B) n+ W7 B  T- L
of papilledema.
5 M3 N5 i) `9 G: _3 |5 eLaboratory Evaluation
. `5 K( M- z* D& Z4 E7 D9 t/ ?# yThe bone age was consistent with 28 months by1 N, Z4 R  q* ]; k, I/ T  i7 D$ g+ P
using the standard of Greulich and Pyle at a chrono-! v3 P# i! n4 `* G9 E
logic age of 16 months (advanced).5 Chromosomal8 m) I9 J, g: `' o9 n! G
karyotype was 46XY. The thyroid function test3 u0 R: O& @: |9 O' w, W3 D
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
+ Y. P9 Y: m% ]0 b+ Plating hormone level was 1.3 µIU/mL (both normal).2 `: v  N  F' ?
The concentrations of serum electrolytes, blood7 T6 {1 ]; k2 q. v7 b! ]7 g
urea nitrogen, creatinine, and calcium all were: T2 a2 G3 B" k
within normal range for his age. The concentration8 j% v" X+ g. i6 F% k
of serum 17-hydroxyprogesterone was 16 ng/dL4 r% z' o0 [3 A+ a7 z4 K1 K
(normal, 3 to 90 ng/dL), androstenedione was 208 H4 j3 ~# y9 @/ N' K) P
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-% I9 @/ Q: v2 e5 v1 o, W
terone was 38 ng/dL (normal, 50 to 760 ng/dL),3 n* @8 d% I2 V1 g: ~
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
; g* s5 G3 p0 M2 f# Z49ng/dL), 11-desoxycortisol (specific compound S)4 m+ Z& F  Z# W7 A8 A& \
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- E6 k- z; v- B8 E- A% m
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 {: p. v6 |* _6 r- D& X
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* N2 I, v/ L5 i; mand β-human chorionic gonadotropin was less than
$ D, f9 v8 G; C1 T5 mIU/mL (normal <5 mIU/mL). Serum follicular) W$ K* D' v$ z, x9 y' a
stimulating hormone and leuteinizing hormone$ T- f' y. m/ D9 a2 t. Z, o( e
concentrations were less than 0.05 mIU/mL
4 h( A8 ?, q* m$ d6 t' J(prepubertal).: s& C) Z- f! D# o4 W% H
The parents were notified about the laboratory
: j9 H( t& D2 R- F( x9 ~; q, O4 @results and were informed that all of the tests were
) q7 s4 [4 n9 rnormal except the testosterone level was high. The
8 L5 s5 T, Z. \+ [+ I+ Sfollow-up visit was arranged within a few weeks to' U& u. E1 k- ^; r3 x
obtain testicular and abdominal sonograms; how-9 z) p. S+ F, u; B4 {! v2 n
ever, the family did not return for 4 months.1 z# |  p( v) L; A% X
Physical examination at this time revealed that the
5 v$ L. A4 A) L) y! g* L( @+ k* tchild had grown 2.5 cm in 4 months and had gained2 x9 S: W2 D8 {' `
2 kg of weight. Physical examination remained$ \0 k+ @) P% h  l3 W0 N
unchanged. Surprisingly, the pubic hair almost com-, W& A' c  N, D* i9 q
pletely disappeared except for a few vellous hairs at
3 G: u; m. t! a+ y: cthe base of the phallus. Testicular volume was still 2, N* z4 ^) v' |/ x' o, O: d3 r
mL, and the size of the penis remained unchanged./ H& K% ~* y% Q7 b0 @3 J2 }
The mother also said that the boy was no longer hav-, E9 r$ g$ B2 L! f5 y/ v
ing frequent erections.
; c* k* G  t: ~' V- v" ?! Y, ABoth parents were again questioned about use of
9 T/ E! {  \/ c" Q) Qany ointment/creams that they may have applied to
3 Z* @$ V0 b. [7 c5 D; Ithe child’s skin. This time the father admitted the
9 ^. e! ?, o9 q4 n- S, \' YTopical Testosterone Exposure / Bhowmick et al 541
) c# y+ g1 H$ A; F- `) Huse of testosterone gel twice daily that he was apply-
7 N$ e) c2 u+ N3 Iing over his own shoulders, chest, and back area for
! h+ s( M2 B0 ya year. The father also revealed he was embarrassed
3 V7 |/ P5 p* k2 L- \% Jto disclose that he was using a testosterone gel pre-& Z5 _! c$ Z( b$ n) @
scribed by his family physician for decreased libido% }/ d+ Z% C( l/ v$ v
secondary to depression.: m) ~% J* A2 W# d$ W
The child slept in the same bed with parents./ Y* X6 M7 |2 k) q3 |+ Z: k
The father would hug the baby and hold him on his
. w  c% f  M, n. K/ t% jchest for a considerable period of time, causing sig-  U0 O- g7 C+ ^9 [
nificant bare skin contact between baby and father.
# p. ]7 Q1 E- B1 U" n; NThe father also admitted that after the phone call,
0 \$ m9 }$ ~1 f% gwhen he learned the testosterone level in the baby
( c2 L2 i5 h, L# O. Bwas high, he then read the product information/ N& k. H( k' }0 \9 J( z. z
packet and concluded that it was most likely the rea-
5 r) V2 G/ x0 Q7 h3 Bson for the child’s virilization. At that time, they
5 X0 q9 Z" U+ x) edecided to put the baby in a separate bed, and the7 U& G8 D, `8 \" R2 O  w* E. J0 n0 q
father was not hugging him with bare skin and had) A) h3 X# Z' C
been using protective clothing. A repeat testosterone' X, c! t5 n1 m
test was ordered, but the family did not go to the; h; c" {! ?  ~
laboratory to obtain the test.
3 }; ?5 w; r/ K( j0 ^+ N! y0 }5 ADiscussion
8 z2 }2 m5 X0 [  p  {$ K9 APrecocious puberty in boys is defined as secondary
) e4 H& `* d6 |sexual development before 9 years of age.1,4
0 E, U7 |: s0 l- q1 pPrecocious puberty is termed as central (true) when
$ D" W; r8 s2 B& Y# Q3 i. ait is caused by the premature activation of hypo-
/ ^! Q' A( M- \$ n% v8 c" s  a! Dthalamic pituitary gonadal axis. CPP is more com-& W+ A0 g) E. z9 m$ d, U; v
mon in girls than in boys.1,3 Most boys with CPP
8 ^) b% n. D; ?4 X9 w1 Q2 s% ymay have a central nervous system lesion that is
4 N- }& N* U' f/ Fresponsible for the early activation of the hypothal-2 s6 C& K/ [6 j' R' c8 ^
amic pituitary gonadal axis.1-3 Thus, greater empha-2 e( S' V6 u' T3 c+ ?: w" r
sis has been given to neuroradiologic imaging in1 h2 v0 s. N/ q# \: l5 g: M; W
boys with precocious puberty. In addition to viril-
1 d+ F5 `& Y% R3 Y  H" T9 |, j4 `ization, the clinical hallmark of CPP is the symmet-& V6 c  {- G4 h% y; D- R0 n
rical testicular growth secondary to stimulation by- h. t, s) T3 L! b
gonadotropins.1,3* e8 j; h( {) |/ y
Gonadotropin-independent peripheral preco-
7 P: r: z# }# K  P1 M+ Bcious puberty in boys also results from inappropriate
) q4 o9 |5 {/ \* n5 F- Randrogenic stimulation from either endogenous or
7 U- p8 |9 z; P/ ]# b3 Lexogenous sources, nonpituitary gonadotropin stim-
3 T( J6 O& E- t4 q: Rulation, and rare activating mutations.3 Virilizing
( d3 g5 G2 x* Ocongenital adrenal hyperplasia producing excessive
7 `) K8 K; J# I3 C  Z$ j7 G0 iadrenal androgens is a common cause of precocious
+ \1 n5 z/ C! I: I! Jpuberty in boys.3,41 i+ r, D( l, T! Y0 {+ c
The most common form of congenital adrenal
1 B) v7 m9 y; r6 R' Ehyperplasia is the 21-hydroxylase enzyme deficiency.
; q" K8 p$ O" VThe 11-β hydroxylase deficiency may also result in+ u4 C, N1 m7 P& g' P+ G
excessive adrenal androgen production, and rarely,
( ]9 R& o9 Y6 {. \$ |+ aan adrenal tumor may also cause adrenal androgen
3 i( X; i4 w8 h3 w3 k! W2 Iexcess.1,3' u9 O' z2 t$ L$ ]6 M3 D6 `
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 v+ N, J, Z; ^6 |6 w  ^7 i5 p3 |0 ?
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; u/ e( q5 q/ mA unique entity of male-limited gonadotropin-
/ R; T: P( O/ w  aindependent precocious puberty, which is also known
5 A5 `$ }3 A) sas testotoxicosis, may cause precocious puberty at a
9 G. n( L; U+ d: i3 \: {% Jvery young age. The physical findings in these boys
. l) o$ [+ l  ?* c) Swith this disorder are full pubertal development,2 r: `7 j3 j8 [0 J" ?+ `2 D& o
including bilateral testicular growth, similar to boys; w2 B1 q' I+ j0 Q0 q8 [/ @" m
with CPP. The gonadotropin levels in this disorder5 f- _0 K+ Z, I- z0 T3 L# |% v
are suppressed to prepubertal levels and do not show( x) c$ C! _# p5 L: A  |% y+ J, U- k
pubertal response of gonadotropin after gonadotropin-- @' K9 `+ Z- O( @9 m1 ^
releasing hormone stimulation. This is a sex-linked6 j, `' \. ?5 I4 V2 J
autosomal dominant disorder that affects only, d$ A: M1 e, g5 Q- v+ i
males; therefore, other male members of the family" t5 j7 k- ]# ]7 Y) ?! {/ [
may have similar precocious puberty.3
1 w1 Z6 O, x3 e& n+ vIn our patient, physical examination was incon-- z1 ]* r# `* L* N! }/ ~4 Z6 B  i
sistent with true precocious puberty since his testi-
  [$ F) H1 U% u, U6 B6 v( z) {cles were prepubertal in size. However, testotoxicosis& t' c( I4 x. i$ ~* k2 Q
was in the differential diagnosis because his father
9 Y# d4 b% g; C1 \started puberty somewhat early, and occasionally,# ~" T1 ^* B3 t. ^3 \1 p5 ^0 n
testicular enlargement is not that evident in the
/ N2 ?. z# V9 S; w- \3 [beginning of this process.1 In the absence of a neg-
% X+ _! D, H6 Q9 T6 J1 R% v& ?$ Tative initial history of androgen exposure, our
  U  p8 T" }/ q# i. U. Wbiggest concern was virilizing adrenal hyperplasia,
+ `8 m' G0 ?$ @6 ?- veither 21-hydroxylase deficiency or 11-β hydroxylase
! s  O" i) E4 n) v( `3 _8 Adeficiency. Those diagnoses were excluded by find-2 T* w6 |2 w: S+ T
ing the normal level of adrenal steroids./ y% S- F% h) A( w. S
The diagnosis of exogenous androgens was strongly9 f+ S6 r8 O/ _, t; }
suspected in a follow-up visit after 4 months because
' W; N' h* X( W3 r8 Sthe physical examination revealed the complete disap-+ r1 A5 f# W! d/ R
pearance of pubic hair, normal growth velocity, and
/ `) @) S1 d* z( U5 k  {decreased erections. The father admitted using a testos-, Y0 H8 C) x( ?2 q' k/ Y/ S% D
terone gel, which he concealed at first visit. He was- `- a) i/ r/ L3 }8 C/ g
using it rather frequently, twice a day. The Physicians’$ Z* F8 Y0 D7 Z! F
Desk Reference, or package insert of this product, gel or
$ C( u* m- c' }cream, cautions about dermal testosterone transfer to* G# d/ R3 _/ R% Q2 U7 N
unprotected females through direct skin exposure.$ ~. |* @# {2 Z) ?
Serum testosterone level was found to be 2 times the
% P! Y0 J# r: C& Obaseline value in those females who were exposed to
- m1 L- _9 q0 K. n5 M1 peven 15 minutes of direct skin contact with their male
$ ^* V) i5 h& @, h* v& hpartners.6 However, when a shirt covered the applica-
4 m. e9 G5 R$ U3 Vtion site, this testosterone transfer was prevented.
7 A" O8 o  L# F4 p( W/ h9 O9 V4 v3 |Our patient’s testosterone level was 60 ng/mL,! b$ o' j2 V- }, k/ d
which was clearly high. Some studies suggest that
* l& p. p# h+ Ldermal conversion of testosterone to dihydrotestos-1 F; f7 ]: M* w' z
terone, which is a more potent metabolite, is more
* M+ n; v. m, f9 vactive in young children exposed to testosterone
! T5 h& s& v3 M  X, Q3 m7 I* nexogenously7; however, we did not measure a dihy-; S3 F/ J( B( I8 m( O8 b5 n
drotestosterone level in our patient. In addition to
0 {/ c! j0 J8 y5 `3 L5 b- Nvirilization, exposure to exogenous testosterone in
9 u# r, Z5 [6 r+ e& G! s" V# mchildren results in an increase in growth velocity and, f, N4 }# U1 J' }# a6 \+ o0 \
advanced bone age, as seen in our patient.
; s5 v' }0 r2 t5 r1 A# nThe long-term effect of androgen exposure during
3 o( W3 k5 R. rearly childhood on pubertal development and final$ e* [$ V- z* G+ S
adult height are not fully known and always remain
8 b: R5 I7 z+ ga concern. Children treated with short-term testos-& }# \6 N1 U5 x' y4 k
terone injection or topical androgen may exhibit some& M: N3 {- e* V! o5 K2 A
acceleration of the skeletal maturation; however, after5 p# O$ x5 d. {1 ~4 M1 V
cessation of treatment, the rate of bone maturation
# P* m$ F: t' N) D! k5 p7 j6 I+ udecelerates and gradually returns to normal.8,9
7 _! j! M* _( k; [- ]2 kThere are conflicting reports and controversy
5 V& P2 M  ?+ uover the effect of early androgen exposure on adult+ R& G/ I+ q( k
penile length.10,11 Some reports suggest subnormal
/ }; l5 o! Y' ~/ Dadult penile length, apparently because of downreg-
! E) e; q( H% {6 D: ]ulation of androgen receptor number.10,12 However,4 C- \0 O+ E/ F4 @, M! ]% g# k
Sutherland et al13 did not find a correlation between
! c& E5 t/ d/ m% l" ]childhood testosterone exposure and reduced adult5 l6 W( s8 u; h5 T' [4 L. p
penile length in clinical studies.
- J' J) e! D- s1 e% D+ XNonetheless, we do not believe our patient is- T/ I7 u, @  C1 K. e' S
going to experience any of the untoward effects from
) P4 A* G( x1 d+ D, y6 ?% Ntestosterone exposure as mentioned earlier because3 l& ~4 U2 j' D/ b3 |% E
the exposure was not for a prolonged period of time.1 a3 A' i1 F7 h' ^5 W6 }& I
Although the bone age was advanced at the time of+ z: i  W7 p3 m- c% V
diagnosis, the child had a normal growth velocity at' P" s0 ~% A3 H
the follow-up visit. It is hoped that his final adult
* @7 l+ M; c+ hheight will not be affected.
; [( U1 y/ ~1 o: q% m1 _6 RAlthough rarely reported, the widespread avail-  o4 S( _' N2 t+ {! o
ability of androgen products in our society may' X. h- k0 x* O9 w* f
indeed cause more virilization in male or female& e8 y# L2 h" k% E5 a0 s
children than one would realize. Exposure to andro-
! a" M2 w: D: p0 F5 W: d* @; rgen products must be considered and specific ques-
+ \2 N7 n9 w/ `tioning about the use of a testosterone product or, v: S2 {. j8 f, R8 A& p6 C
gel should be asked of the family members during- w# k9 b3 M# @+ ~! }( `2 z
the evaluation of any children who present with vir-0 K: J& @/ `; H8 }/ O
ilization or peripheral precocious puberty. The diag-
& A; a5 S4 G- e/ S( N/ v4 `, ?2 bnosis can be established by just a few tests and by8 T: D  {! T4 i8 I: y, a8 Q
appropriate history. The inability to obtain such a
# N  l6 x! K/ J/ J- r. A) Thistory, or failure to ask the specific questions, may8 S0 h6 B, f7 o9 f; d
result in extensive, unnecessary, and expensive) ~( @2 R+ @' M3 ?
investigation. The primary care physician should be
1 F7 n* K8 D4 \% `% _0 Caware of this fact, because most of these children
2 P+ n3 p  K( E8 K1 emay initially present in their practice. The Physicians’
/ t7 J1 H$ T/ a; KDesk Reference and package insert should also put a
1 \9 g3 O( a1 K" iwarning about the virilizing effect on a male or8 _5 l7 e( j1 V; c7 z* x+ N7 S
female child who might come in contact with some-4 a9 t% t8 D! j& d& B
one using any of these products.
3 v6 M2 i. g6 i# W) ~9 O! C) x* w' dReferences5 J5 H3 w4 ~- e
1. Styne DM. The testes: disorder of sexual differentiation
" n7 O6 D0 S! Yand puberty in the male. In: Sperling MA, ed. Pediatric
. D2 ^# F" w* r6 kEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. m, K$ @$ {  U5 W% g
2002: 565-628.
( K# f, E! j+ K& l+ B2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- H& G( v# q* V7 }9 K7 spuberty in children with tumours of the suprasellar pineal
發表於 2025-1-7 21:59:43 | 顯示全部樓層
這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
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感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
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4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
  Y2 s1 y6 ~* F
精妙絕倫的精品,感謝啊!期待你更多更好的創作哦!
發表於 2025-3-8 22:04:50 | 顯示全部樓層
絕對的好貼!謝謝啊!逐字逐圖地看完這個帖子以後,我的心久久不能平靜,感恩啊!
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