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Sexual Precocity in a 16-Month-Old
+ v8 k1 J( T& E+ mBoy Induced by Indirect Topical
' I9 a* k# M3 W* X: Q/ q! QExposure to Testosterone
% I+ f5 a3 [# y" tSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
7 t6 l7 _& F. P& ~$ Gand Kenneth R. Rettig, MD1
7 D/ N' j; n8 s* w  \/ t: wClinical Pediatrics
3 v( f5 e5 m: Y, x( I* `4 H& E/ a5 _Volume 46 Number 6
+ O7 r. o* \% R. a9 r5 [July 2007 540-543
* D) A# }: z5 w& J© 2007 Sage Publications
' E1 W1 t' j( C% z0 \- F10.1177/0009922806296651
2 D! V+ n: M) m7 ^( M9 ^) w9 d5 b! m; Phttp://clp.sagepub.com0 n& U% N% y6 k9 _
hosted at
; X& N6 [9 j. g2 F/ jhttp://online.sagepub.com: Z1 n; j1 U; Z0 _4 I9 c: s; q5 d
Precocious puberty in boys, central or peripheral,
9 P  q% e  S" Y9 L6 a& Cis a significant concern for physicians. Central5 `' s2 x& }" P7 N# Y$ E" }2 }9 O( _; v' {
precocious puberty (CPP), which is mediated
" @$ Z9 z; I5 y" D6 gthrough the hypothalamic pituitary gonadal axis, has) G  B; M0 _. G0 c
a higher incidence of organic central nervous system% j) G% J5 i4 _& b8 W
lesions in boys.1,2 Virilization in boys, as manifested
( s: A6 u' Q3 a% qby enlargement of the penis, development of pubic
! Z- x8 F5 o9 F  X6 j) T2 Rhair, and facial acne without enlargement of testi-
* Q- |; l) f) e1 Q( w( h# m  Pcles, suggests peripheral or pseudopuberty.1-3 We) U( c+ R, s5 P1 K, m2 M: a2 F
report a 16-month-old boy who presented with the
! S* y8 o) _' p8 w5 t0 ~6 T& N* X! tenlargement of the phallus and pubic hair develop-
- T' g4 Y3 b: _3 \3 W8 yment without testicular enlargement, which was due* J8 H% |. ^- L
to the unintentional exposure to androgen gel used by5 ^1 w- z3 |' C9 O
the father. The family initially concealed this infor-
( h6 }6 g% a- ?7 K+ {mation, resulting in an extensive work-up for this1 n1 X& k: b  q" q! ?$ \3 a# g  Q& s/ X
child. Given the widespread and easy availability of
' R" y1 U7 z1 q( R- ?7 q; [testosterone gel and cream, we believe this is proba-/ Y4 T' v8 p# k& x% F$ _  @
bly more common than the rare case report in the4 c: [' M+ G! P! W
literature.4
+ l  F1 a9 e) ]: i+ A- ^$ hPatient Report
0 c1 K' e& _4 ~/ a' o/ ?A 16-month-old white child was referred to the
! b3 W! o: j0 S, a0 e1 pendocrine clinic by his pediatrician with the concern
5 Z& ]5 ~+ O4 Q; R* C% o5 X: e, A4 Pof early sexual development. His mother noticed
3 p! @# b  P9 l8 \9 Tlight colored pubic hair development when he was4 q" ?+ A* t' c
From the 1Division of Pediatric Endocrinology, 2University of
5 W( O1 C" t  e, J; {1 T0 j( }South Alabama Medical Center, Mobile, Alabama.4 {0 I3 F" R8 p
Address correspondence to: Samar K. Bhowmick, MD, FACE,
. G* u7 }" C- P" ?Professor of Pediatrics, University of South Alabama, College of
$ d; \  q# J8 Q7 OMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 o3 a* x2 p9 ?1 W) o2 |" y
e-mail: [email protected].7 y" Q# Y; Q! F" ]- L
about 6 to 7 months old, which progressively became
; M6 @/ q3 E3 @4 ?darker. She was also concerned about the enlarge-
& L; F7 U5 _- G6 k( |, nment of his penis and frequent erections. The child2 u! p, R( k( X
was the product of a full-term normal delivery, with
: O0 i4 ]/ r; Z6 Oa birth weight of 7 lb 14 oz, and birth length of
) T1 R3 X" K$ z# u8 a+ k+ ]2 R20 inches. He was breast-fed throughout the first year$ \, a( s* H7 p: V7 D$ J6 e
of life and was still receiving breast milk along with
: |6 D' k0 B3 m. k& n$ |' \) Ksolid food. He had no hospitalizations or surgery,
; z, a' W& j* ?  iand his psychosocial and psychomotor development
" @8 ^, K8 U" i8 t1 w2 g  S1 q4 pwas age appropriate.
8 y0 N- g4 Z' ?3 x6 t8 uThe family history was remarkable for the father,
4 y/ ?, |* K; j* W" m( K5 ywho was diagnosed with hypothyroidism at age 16,
# t% w2 G  r$ t1 L9 @8 hwhich was treated with thyroxine. The father’s
' M% x6 C+ |, ~& I5 uheight was 6 feet, and he went through a somewhat
& m0 z) i, U8 t) S  _2 y7 B" aearly puberty and had stopped growing by age 14.5 X8 q  e: s. ~3 S
The father denied taking any other medication. The- M# }/ J4 S8 D
child’s mother was in good health. Her menarche
% F* [% T$ Z& W. M( ^0 gwas at 11 years of age, and her height was at 5 feet
1 o! N2 ~/ {$ Y' q8 Y, [/ _- E# u$ u5 inches. There was no other family history of pre-
1 V( i/ j9 ^; e% Zcocious sexual development in the first-degree rela-4 b5 ~! t2 Q9 y9 P, O
tives. There were no siblings.
* M+ y; B$ }( R* i' vPhysical Examination2 _# {9 |. n9 W6 f
The physical examination revealed a very active,
) Q' p- c2 g; {" d. I5 Jplayful, and healthy boy. The vital signs documented7 ]3 @- Z1 Q: ~3 Y6 F1 u
a blood pressure of 85/50 mm Hg, his length was
5 A7 r, s1 u" {+ c90 cm (>97th percentile), and his weight was 14.4 kg7 K8 d, j6 W( f2 ~3 ]" d4 b2 {
(also >97th percentile). The observed yearly growth/ {8 {) o* z2 {! o1 p& X6 {
velocity was 30 cm (12 inches). The examination of, Y7 z! s" G9 |) {% _, ^
the neck revealed no thyroid enlargement.5 K  F) E$ q1 }9 c
The genitourinary examination was remarkable for$ h( Q" q3 i5 i" h. l! `
enlargement of the penis, with a stretched length of
/ a; }# U/ u& K! U# |$ u$ J8 cm and a width of 2 cm. The glans penis was very well6 f9 m: W; u* H4 b4 V% k
developed. The pubic hair was Tanner II, mostly around
( _+ f7 f- T% G6 J' ^. G3 {( z- X9 j540% H* I1 p( X1 I& Y* p, p* p8 x
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 y% m0 j2 n0 H; \9 k8 _2 ethe base of the phallus and was dark and curled. The
& J' b' E2 B& ~" K2 Q" G7 q* ptesticular volume was prepubertal at 2 mL each.; R! |- a2 h% s7 J9 s8 x2 s: u  J
The skin was moist and smooth and somewhat3 l  ^" B& c5 b2 f1 B
oily. No axillary hair was noted. There were no# R: a, G3 A% e% H
abnormal skin pigmentations or café-au-lait spots.
" D  K3 q4 f9 M2 @Neurologic evaluation showed deep tendon reflex 2+
. f" t# q) v- C9 @7 j# V- m" s6 Nbilateral and symmetrical. There was no suggestion
' o0 z2 B" t2 C/ h- P) h) Iof papilledema.
8 Y% p, G* e( t  a7 fLaboratory Evaluation
) t4 `) L( \# V# A8 `The bone age was consistent with 28 months by
% m: N! ]0 A. L+ ~0 B5 lusing the standard of Greulich and Pyle at a chrono-
" N! x, e# n( T/ t7 Ologic age of 16 months (advanced).5 Chromosomal) w  r: D( R, s! M4 A+ J
karyotype was 46XY. The thyroid function test8 j' X3 z- U# ]
showed a free T4 of 1.69 ng/dL, and thyroid stimu-4 O, J) D0 f% }: Z& M" n
lating hormone level was 1.3 µIU/mL (both normal).
( d" D. D( \2 R) \1 m6 ]The concentrations of serum electrolytes, blood
: z5 V% Q# |4 i1 ?6 Y6 p2 b+ I" M, L/ ?urea nitrogen, creatinine, and calcium all were
* Y) ?: w4 f' a. e! z* A8 _within normal range for his age. The concentration" Q: M& g0 Z8 k9 g
of serum 17-hydroxyprogesterone was 16 ng/dL. z( H! L# F+ o$ t; c& v: f
(normal, 3 to 90 ng/dL), androstenedione was 20$ M1 _* b" f- V: `% C
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 G/ ]7 U' S( T2 x) `
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 S* j2 i1 L' Tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
1 {" F' A# L: H1 W6 R49ng/dL), 11-desoxycortisol (specific compound S): j$ `7 @4 C4 B0 s$ w
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-' b9 m( q" Y9 A/ y$ ]1 v
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ Q; E, L4 q! ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),6 }! q. w, h2 W
and β-human chorionic gonadotropin was less than
  v6 x8 Q! I$ N! ]1 t5 mIU/mL (normal <5 mIU/mL). Serum follicular) _* j1 H: I, `# @9 Q- }
stimulating hormone and leuteinizing hormone
8 B0 P; G1 ~2 e: zconcentrations were less than 0.05 mIU/mL' y! U  o" C3 W  G$ t
(prepubertal).
" ~8 i& d+ W4 o8 N! o9 f& J2 pThe parents were notified about the laboratory
6 J: A, _; `2 i- e; \2 Presults and were informed that all of the tests were
8 b7 S* e* }' Q0 nnormal except the testosterone level was high. The
/ |. Z; D& w9 h5 ^" _follow-up visit was arranged within a few weeks to
2 m! t3 x7 m' t% `& ^3 oobtain testicular and abdominal sonograms; how-+ R& u& L% A! W' B' C
ever, the family did not return for 4 months.2 H' R; [! D. x  I# c* d/ j( i9 q
Physical examination at this time revealed that the* k$ w& @) m- p/ r9 V
child had grown 2.5 cm in 4 months and had gained
: L+ A  [9 k3 ^' ]3 g2 kg of weight. Physical examination remained
  p4 \: c7 [/ e1 R. C6 h5 runchanged. Surprisingly, the pubic hair almost com-
1 B( b8 Q( T$ C5 F2 ?8 X, o6 ^  Kpletely disappeared except for a few vellous hairs at9 k3 _5 o) v- s* ~# ^6 e
the base of the phallus. Testicular volume was still 2
' l. _" |! b7 z4 S5 \* [- SmL, and the size of the penis remained unchanged.
6 A2 m) j# Z9 A# BThe mother also said that the boy was no longer hav-
3 O: o' U' t# h0 `' Ying frequent erections.& P/ f& M, T- O3 R( p; b
Both parents were again questioned about use of
5 ~4 X5 @9 A& nany ointment/creams that they may have applied to
. R* W6 ]; l) nthe child’s skin. This time the father admitted the
, f: J2 z+ Q* TTopical Testosterone Exposure / Bhowmick et al 541
6 i% x+ ~5 t6 X* @  _use of testosterone gel twice daily that he was apply-* j. P0 P6 f. }5 U
ing over his own shoulders, chest, and back area for
+ P; k- `* z4 z7 ca year. The father also revealed he was embarrassed1 J' C5 c3 m& X' a. d
to disclose that he was using a testosterone gel pre-7 s$ p. k! b5 g! @: |
scribed by his family physician for decreased libido
; K" d$ |4 x* t3 C6 ^3 k' P+ fsecondary to depression.
; a- j5 P7 w8 m. y% b/ ^The child slept in the same bed with parents.$ @( Q  f. J1 Y5 M$ `9 ^5 N- @& e
The father would hug the baby and hold him on his
! W' g: E/ i! R/ l4 n; hchest for a considerable period of time, causing sig-6 k1 e6 m( i9 s2 ^5 N0 `" ]+ F
nificant bare skin contact between baby and father.5 c0 n6 b% A% U& _
The father also admitted that after the phone call,; W4 V% m+ |5 l! g
when he learned the testosterone level in the baby
1 S8 B# A) j1 u: V0 j( Rwas high, he then read the product information0 F6 w. ~9 }( D( [5 H, Z) p! R
packet and concluded that it was most likely the rea-2 ^9 {3 O8 [8 m8 H$ h  X
son for the child’s virilization. At that time, they
" ^6 z: X4 G7 U- D" d5 zdecided to put the baby in a separate bed, and the5 o! O. Q; m# i
father was not hugging him with bare skin and had2 C) f* }% g5 k2 ]7 O6 K' l( h
been using protective clothing. A repeat testosterone+ z8 N" _1 Z. C( M' A3 ]; X
test was ordered, but the family did not go to the; O# L8 l) w5 X9 U* ]2 [
laboratory to obtain the test.
. A: f: p* @3 L, }" X0 GDiscussion
" A- k# v2 e3 M8 V: R; [Precocious puberty in boys is defined as secondary
- g4 y; i. Z3 ~sexual development before 9 years of age.1,48 H  ^- W/ s1 t8 Z  i* g
Precocious puberty is termed as central (true) when0 D: e9 ?# c6 `7 k  v5 M
it is caused by the premature activation of hypo-& Y& U% t# U9 T" |3 k
thalamic pituitary gonadal axis. CPP is more com-
% T% X, A3 g: r+ G0 b* G  `- Zmon in girls than in boys.1,3 Most boys with CPP
6 K, j' L7 K, Emay have a central nervous system lesion that is
9 e& |! R/ W! D1 Lresponsible for the early activation of the hypothal-
2 K$ ^1 W+ r. `) a9 h7 [, oamic pituitary gonadal axis.1-3 Thus, greater empha-$ B" V0 A# `6 O" C$ C
sis has been given to neuroradiologic imaging in
6 t/ C* F5 }2 Y# wboys with precocious puberty. In addition to viril-! o' S3 T0 \4 L: y3 x3 |) |/ H
ization, the clinical hallmark of CPP is the symmet-. L% Y; H, @6 D
rical testicular growth secondary to stimulation by6 j; V3 u: g, U& V6 {5 @. |/ G
gonadotropins.1,3
8 o3 b# `  {+ Z# d6 @" uGonadotropin-independent peripheral preco-  V( F1 D# j4 }% |
cious puberty in boys also results from inappropriate3 o3 G" H4 ~5 @5 V( h' P
androgenic stimulation from either endogenous or
2 K' H% ?2 A3 Q2 S( \exogenous sources, nonpituitary gonadotropin stim-  S+ `6 k' u) S- P2 n* P- u
ulation, and rare activating mutations.3 Virilizing
: _# A  \$ w! @" w+ I5 l9 x, qcongenital adrenal hyperplasia producing excessive
- z( t5 b8 k7 h8 Cadrenal androgens is a common cause of precocious4 J5 e" @0 _+ [& ]9 S
puberty in boys.3,49 R; a& C  \) i: s
The most common form of congenital adrenal, N+ f3 f# w/ A; R2 j5 N
hyperplasia is the 21-hydroxylase enzyme deficiency.
3 _; O( a2 A9 J& i7 S+ r' ZThe 11-β hydroxylase deficiency may also result in
$ A- F5 I3 w5 B0 o% T6 T. Texcessive adrenal androgen production, and rarely,
" P' ]0 X/ i, Dan adrenal tumor may also cause adrenal androgen/ N  z. T+ ]- Z9 Z  O" m
excess.1,38 h! k/ D" v2 r7 D; r3 E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& g9 z/ X6 \+ ~% |) N5 F6 i
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
) c' L7 b: N3 W/ M0 X# yA unique entity of male-limited gonadotropin-! |. k$ Q1 r& c3 U% g8 _1 Z* ]$ s
independent precocious puberty, which is also known" f$ n7 O- G, H
as testotoxicosis, may cause precocious puberty at a
) O  ?. N+ s* c8 B# h1 X1 cvery young age. The physical findings in these boys1 s5 ~2 H1 k7 [' G- E
with this disorder are full pubertal development,3 d, B8 g+ N2 B. o# j! P0 V# y
including bilateral testicular growth, similar to boys
  g0 R/ ?/ E$ Owith CPP. The gonadotropin levels in this disorder& k, s1 k/ G% ]2 ?) K; R
are suppressed to prepubertal levels and do not show
7 p8 Y/ b4 {: s# ppubertal response of gonadotropin after gonadotropin-
! h5 _( y0 P' c* O) Hreleasing hormone stimulation. This is a sex-linked
  T6 r% p2 Q7 ~# {autosomal dominant disorder that affects only
/ a3 @: C( ^4 E) \males; therefore, other male members of the family" [( d1 B0 d* ]* G
may have similar precocious puberty.3: ?7 c, T6 Q$ A6 W6 j) E( g8 W) Z
In our patient, physical examination was incon-
  R. j+ n! \/ i% R( Ssistent with true precocious puberty since his testi-
. w6 Z$ b% Y9 H, T; U4 f* Gcles were prepubertal in size. However, testotoxicosis
# h* ^% J$ `+ [/ L7 U( qwas in the differential diagnosis because his father
' u( W8 k; s+ ?: c6 y1 Nstarted puberty somewhat early, and occasionally,
7 ?& e6 o) U& S$ }/ _. ?& [testicular enlargement is not that evident in the
9 Y  S* G7 [8 t1 k2 C% {& f, R8 O) xbeginning of this process.1 In the absence of a neg-
! ]$ L8 K7 _+ {$ i4 Q) l- Rative initial history of androgen exposure, our
7 K/ J8 X( M) h9 A2 c5 Z9 Obiggest concern was virilizing adrenal hyperplasia,1 ?  T: ?' p, z
either 21-hydroxylase deficiency or 11-β hydroxylase$ }1 r) O; e7 S9 ]
deficiency. Those diagnoses were excluded by find-* @: U, u) R& e! k4 S
ing the normal level of adrenal steroids.4 d9 e: J& @( S" c& T
The diagnosis of exogenous androgens was strongly# z$ G+ V' R4 S6 i# ^. ]! W! K
suspected in a follow-up visit after 4 months because: d* q1 B9 X) n  b4 o2 c1 ^* J6 r# m
the physical examination revealed the complete disap-1 ~0 M, j% e% j4 Z* ~, w
pearance of pubic hair, normal growth velocity, and
6 }& |. R; e" {$ Ddecreased erections. The father admitted using a testos-) ~% T* Y( l" P# u3 \$ F1 _6 H
terone gel, which he concealed at first visit. He was
0 x# p" O  m7 f& a8 {* ^% b9 cusing it rather frequently, twice a day. The Physicians’
! O, B0 Q0 b6 r/ RDesk Reference, or package insert of this product, gel or
, F  R# U  N9 q2 s4 Kcream, cautions about dermal testosterone transfer to
1 P$ F+ M: j  X) u- Y+ I5 C( Funprotected females through direct skin exposure., s9 E( k; W  y( I7 x) C2 V1 K
Serum testosterone level was found to be 2 times the
* D3 {8 ]$ R! f8 `, Cbaseline value in those females who were exposed to, ]2 D' n/ K6 Z) t4 `3 _( A
even 15 minutes of direct skin contact with their male
2 G1 `. W; S$ C5 Y6 ?& kpartners.6 However, when a shirt covered the applica-' W3 F; r, s3 B
tion site, this testosterone transfer was prevented.. {( c: ^* Z3 r( Q' r2 T! L: ]! p
Our patient’s testosterone level was 60 ng/mL,$ Y! W2 @% B* b# C
which was clearly high. Some studies suggest that7 o( S7 |: A  Z/ w" T' s1 w! I
dermal conversion of testosterone to dihydrotestos-2 P3 o! e: X* ~6 ^- u% n) k
terone, which is a more potent metabolite, is more
7 O1 b- E1 e) h/ ]active in young children exposed to testosterone4 O! A4 e: Y( }+ ~0 ]* a
exogenously7; however, we did not measure a dihy-7 E6 c: Y, n" [/ z# l1 y# r
drotestosterone level in our patient. In addition to6 L# }' Q  [3 T8 S. j
virilization, exposure to exogenous testosterone in
9 c6 B- F  U. k8 F; e; H5 tchildren results in an increase in growth velocity and
4 ^) g9 w, M  ?& O; v, m; F2 ~advanced bone age, as seen in our patient.7 [: M6 ?; z2 u" m3 Q
The long-term effect of androgen exposure during
0 |5 i9 C6 D& Gearly childhood on pubertal development and final# }/ b+ l- Q* E4 n( ~0 a
adult height are not fully known and always remain0 P# ^1 x9 `4 Z$ u" [& W5 {
a concern. Children treated with short-term testos-
# f9 w! q0 c- b% T1 `terone injection or topical androgen may exhibit some
$ m" F, ~1 W/ q: e$ m/ [* _. ]6 eacceleration of the skeletal maturation; however, after
& ~! }: W( z# R) e  X" f0 Mcessation of treatment, the rate of bone maturation
' W0 K+ D4 n! z2 `$ Rdecelerates and gradually returns to normal.8,9
2 M8 D+ E# ~7 O6 [- uThere are conflicting reports and controversy3 |+ Q. h3 W, O* z+ C/ k
over the effect of early androgen exposure on adult) J8 U1 x+ ?) o6 ~# ^# t( ^- j& h% j
penile length.10,11 Some reports suggest subnormal
' A8 D0 |) F( \4 n9 }9 y7 [2 l7 ladult penile length, apparently because of downreg-1 K8 |+ e7 @$ |
ulation of androgen receptor number.10,12 However,
  `8 s7 K0 g: A! mSutherland et al13 did not find a correlation between, F, t' _, E# O& F' o7 ^2 y! ^; y
childhood testosterone exposure and reduced adult
- [, n4 Q! U, X' z3 z, q- I; _penile length in clinical studies.
1 V8 A/ p2 [: ^- l3 _# \# `& PNonetheless, we do not believe our patient is
0 a0 |1 O- n+ @' egoing to experience any of the untoward effects from4 K7 X0 z, F8 ~; w
testosterone exposure as mentioned earlier because
8 }6 N; k% m0 F/ nthe exposure was not for a prolonged period of time.% F- d8 b  F3 i( x0 e
Although the bone age was advanced at the time of
% k. J6 J! z6 m$ K) O$ |/ Ldiagnosis, the child had a normal growth velocity at8 z% ?' m3 q; p
the follow-up visit. It is hoped that his final adult  j( g1 o5 A9 O7 O# i9 X! b/ v# e
height will not be affected.! G+ }1 v# s6 [" Z2 M# P
Although rarely reported, the widespread avail-5 v- K$ W  I4 W- K* Q
ability of androgen products in our society may- H. o( j$ [* d% c! G4 [* y. ]3 m( Z3 `
indeed cause more virilization in male or female
* ^: p- Q9 e  C1 [children than one would realize. Exposure to andro-0 ]$ l5 ]) ~# u( A2 U! Y
gen products must be considered and specific ques-
: ?8 F3 j4 u8 q( m* ~tioning about the use of a testosterone product or5 D; j2 W( A1 Z, L2 Y6 e1 R1 E
gel should be asked of the family members during1 l8 |) N$ h, |7 ~
the evaluation of any children who present with vir-
: a5 S# p8 R/ S0 h+ k- c! E5 ailization or peripheral precocious puberty. The diag-
2 j( V# K' G6 n- q. V; Qnosis can be established by just a few tests and by8 i4 [& H5 z; |: X) g. s/ @" [
appropriate history. The inability to obtain such a+ |% L. s! e6 y4 U! N9 m" v
history, or failure to ask the specific questions, may0 Y# r; F5 C6 @& w0 w: X
result in extensive, unnecessary, and expensive
- x  ^' s* z' {investigation. The primary care physician should be
0 Q( u1 i3 S8 e2 k6 Caware of this fact, because most of these children8 `/ c. g( F6 j& J
may initially present in their practice. The Physicians’
' P5 S% s% ^; }Desk Reference and package insert should also put a+ D7 y8 J7 m5 [. K& S5 j+ Y
warning about the virilizing effect on a male or4 R- ^& m) q' ~2 Z
female child who might come in contact with some-
# w  Y, O8 w; @9 c4 L+ eone using any of these products.; Y: ^1 T+ P4 j5 z9 T
References2 p) {/ i4 g8 l4 o5 \4 Z
1. Styne DM. The testes: disorder of sexual differentiation
  p6 D4 l3 U4 aand puberty in the male. In: Sperling MA, ed. Pediatric
- ~* T) n+ z5 \8 eEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
" X) }' U6 R, s8 G2002: 565-628.) M$ O" h* y' X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 ]: s: V  L* P9 r* [& }9 Fpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old; d  T7 v& T! \+ d: N' u
Boy Induced by Indirect Topical) x# T0 k+ t' Q/ g/ }* P
Exposure to Testosterone+ C* C: M; [4 L' H
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: O6 o. W6 `' X$ I  |and Kenneth R. Rettig, MD1# D: J. |0 G) E* p
Clinical Pediatrics
" X  e# a* Z; C& u# `9 MVolume 46 Number 6
# R8 k1 C5 S* ]$ j2 \, A8 TJuly 2007 540-543
* j6 W% R4 H, G& c6 H© 2007 Sage Publications
+ `$ y* O/ W# F6 C  z5 Z10.1177/00099228062966516 \( V( K; g( W& Y+ H& p7 P
http://clp.sagepub.com, O9 W, Y* e. l- @1 k8 \1 Y4 v* l
hosted at2 A  |5 k) |# V+ X
http://online.sagepub.com
$ S- \1 X- z5 w3 F) u& G* CPrecocious puberty in boys, central or peripheral,: I/ E( O1 c' i8 n( s* ~: S: N: }  x+ m
is a significant concern for physicians. Central; y$ u0 }, H0 ~1 V$ F3 ~9 n
precocious puberty (CPP), which is mediated
6 p: J. ^0 y6 y* Ethrough the hypothalamic pituitary gonadal axis, has
! F5 i% o- R% j$ F9 ja higher incidence of organic central nervous system
: M1 j& M6 c) S9 a5 Slesions in boys.1,2 Virilization in boys, as manifested# J% e( F* o- c# G# }+ J
by enlargement of the penis, development of pubic" d' X* g' y) [2 C
hair, and facial acne without enlargement of testi-
/ m' T) s: [0 |+ tcles, suggests peripheral or pseudopuberty.1-3 We: {; N9 E% f6 c& O( v
report a 16-month-old boy who presented with the
: W2 G5 y- N: ^5 b+ Yenlargement of the phallus and pubic hair develop-
' n5 A' d* M) e  Iment without testicular enlargement, which was due! t/ D4 A6 n2 M) r8 N( a
to the unintentional exposure to androgen gel used by0 K* a( q; [/ X& m' q( J! \% l- z
the father. The family initially concealed this infor-
  P) f! t& c  R( mmation, resulting in an extensive work-up for this) s9 x' a" f7 B3 P. W, a
child. Given the widespread and easy availability of" O' p0 h; q. [% }
testosterone gel and cream, we believe this is proba-6 b1 C5 W5 Z. `" W: u9 H. G1 i7 L4 h
bly more common than the rare case report in the
. f0 P! h- a* I$ \: xliterature.4: A/ d6 k) J# Y9 C  S$ i/ z; I6 a
Patient Report& a; X8 u) a) W$ H
A 16-month-old white child was referred to the
7 }/ P# J/ R0 @1 D, S& Tendocrine clinic by his pediatrician with the concern4 G% J7 L7 [/ c; h) Y6 y3 ]
of early sexual development. His mother noticed& j  G- M: V0 a# Y( Z
light colored pubic hair development when he was* }# M4 Y& p5 f  k. k6 r
From the 1Division of Pediatric Endocrinology, 2University of" ]8 ]4 _) x$ S4 u5 p- _& u& L! Z
South Alabama Medical Center, Mobile, Alabama.' M/ [) l( o, r, S" n% j- _* n* {3 _
Address correspondence to: Samar K. Bhowmick, MD, FACE,, P0 ~5 `- ^5 {5 v2 G" y
Professor of Pediatrics, University of South Alabama, College of# ]8 ^4 B8 X: S/ k5 i
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 f+ b8 l: Q) Q, X
e-mail: [email protected].6 f, i3 q9 D7 D* |2 L- B
about 6 to 7 months old, which progressively became
) W' ^/ P7 [$ idarker. She was also concerned about the enlarge-( T/ H& h! D" x8 J9 E/ R
ment of his penis and frequent erections. The child$ x/ z6 |  M; L8 J
was the product of a full-term normal delivery, with: |' L& |. q( U9 X' G) w! I6 C* C8 s
a birth weight of 7 lb 14 oz, and birth length of
, w: V) a; ^0 W: r/ L4 E20 inches. He was breast-fed throughout the first year
& a6 T# k' F! D8 sof life and was still receiving breast milk along with8 X! P" h4 ~% Z; I0 n7 J) J
solid food. He had no hospitalizations or surgery,4 `; l+ s* j# {/ m
and his psychosocial and psychomotor development* F/ y6 L. A# S/ Z) G! B
was age appropriate.. `) C/ z: g1 ?# [
The family history was remarkable for the father,
8 W% b1 p" o8 K; ]! ]7 ?who was diagnosed with hypothyroidism at age 16,& X. j% H* p: _5 V8 K& [# g7 Y4 i* D" Q
which was treated with thyroxine. The father’s6 t& H2 {5 D0 N5 z3 O/ X' [' T
height was 6 feet, and he went through a somewhat
' S" w4 B0 z: U! l8 }early puberty and had stopped growing by age 14.+ i* O# u6 |* {. t8 {. x( N+ @% P4 ^
The father denied taking any other medication. The
! F" N+ V4 h9 W1 {child’s mother was in good health. Her menarche! f% J  L- {( @- E3 A
was at 11 years of age, and her height was at 5 feet
& u9 l2 \( J% r* c% [5 inches. There was no other family history of pre-" m& v1 u" G$ Y- ?# c/ l
cocious sexual development in the first-degree rela-
( P9 x; I  O/ |* {tives. There were no siblings.4 n! A# h1 Q! l9 [
Physical Examination
3 x+ c" m! Y/ w6 V8 D! j) B- IThe physical examination revealed a very active,0 ?* O9 C  B6 b2 `6 B
playful, and healthy boy. The vital signs documented
$ s' j* Q; o$ U& Ca blood pressure of 85/50 mm Hg, his length was* z  Z4 H1 ^+ E* G$ W8 [
90 cm (>97th percentile), and his weight was 14.4 kg
6 V) L# \, ]8 x, i2 o' a(also >97th percentile). The observed yearly growth
. P! }- D. [2 j+ B0 v% Svelocity was 30 cm (12 inches). The examination of
8 g/ o% d  ?' |1 xthe neck revealed no thyroid enlargement.9 e4 U) X, ~: @# |: l
The genitourinary examination was remarkable for7 E8 ]' m+ V, E( q8 ?
enlargement of the penis, with a stretched length of+ x$ z$ ~8 a7 A/ g- [
8 cm and a width of 2 cm. The glans penis was very well& k; B' i5 M  w! O0 h1 x6 M1 d
developed. The pubic hair was Tanner II, mostly around
4 R8 W6 N  t  R8 [" [9 k540
, g9 Q. l' v3 ~, E' Q* `" I" Qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 \; o) \/ M3 M" _
the base of the phallus and was dark and curled. The- B5 m; B7 R* A1 s5 s. Y
testicular volume was prepubertal at 2 mL each.5 X; d3 M6 p0 u- F+ ^) V
The skin was moist and smooth and somewhat" L$ }( ?5 k, T5 G; A  X
oily. No axillary hair was noted. There were no
7 \$ o# y. u. k9 s; sabnormal skin pigmentations or café-au-lait spots.
7 S  v: D) f/ rNeurologic evaluation showed deep tendon reflex 2+
( S& v; q, ^! ]. x: Abilateral and symmetrical. There was no suggestion6 S. r! O; t- L. a& K! g# }% S9 n
of papilledema.
# i6 Q; Y! ?: A+ u% y9 zLaboratory Evaluation, V- {7 E0 ?. ^  a7 l
The bone age was consistent with 28 months by7 }+ B) |( [$ P+ n! T9 [' D
using the standard of Greulich and Pyle at a chrono-: [) x/ w; B$ k
logic age of 16 months (advanced).5 Chromosomal8 I7 E; r! w- {3 I
karyotype was 46XY. The thyroid function test) b" v( J3 f9 G  ~: W
showed a free T4 of 1.69 ng/dL, and thyroid stimu-. {! ]# z5 [- y/ k  d1 [  _! d9 I+ N- a
lating hormone level was 1.3 µIU/mL (both normal).: a& @- o$ G. g
The concentrations of serum electrolytes, blood
& ^: T' q% [& G. ~1 ^( P" Lurea nitrogen, creatinine, and calcium all were
0 |. C  u4 u, E& A: hwithin normal range for his age. The concentration# |# u; b/ M! R. b, [
of serum 17-hydroxyprogesterone was 16 ng/dL
* t" q' l3 x+ D$ R+ {2 ?  y(normal, 3 to 90 ng/dL), androstenedione was 204 K# p3 Z( D7 m: y- i/ K+ C4 m
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-+ v" D+ x1 z+ W, j2 J) E
terone was 38 ng/dL (normal, 50 to 760 ng/dL),9 _7 f$ Y0 q7 A( n( W
desoxycorticosterone was 4.3 ng/dL (normal, 7 to5 e0 X. K2 J3 v4 M+ X* u' y
49ng/dL), 11-desoxycortisol (specific compound S)
& \: r' @$ Q3 e' Iwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 O) L/ e; m+ q; Qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ J4 |) a# m0 a# F" A- stestosterone was 60 ng/dL (normal <3 to 10 ng/dL),2 {8 W# _  x. B9 O* V" |# S& Q
and β-human chorionic gonadotropin was less than; L" A" V3 ~( ^9 T$ u
5 mIU/mL (normal <5 mIU/mL). Serum follicular0 d3 C, Z' x  o% ?
stimulating hormone and leuteinizing hormone8 R6 o# M& i: v) }: w- S! A" I5 ~4 ]
concentrations were less than 0.05 mIU/mL; y" |7 C+ G0 G; A" J
(prepubertal).% i8 N' P1 k; q7 u, }3 x
The parents were notified about the laboratory, D' ^7 C# s( F0 Z" d
results and were informed that all of the tests were
8 Q- i7 u6 T: w5 @* u# Jnormal except the testosterone level was high. The% L5 B. B6 N0 {& [4 @
follow-up visit was arranged within a few weeks to  Q0 ^" V4 q8 r! F5 t1 @2 o
obtain testicular and abdominal sonograms; how-' n: j; \, S% B* `7 h0 \" i6 k
ever, the family did not return for 4 months.
( Y* n: Q9 ~' C9 b5 N; f8 SPhysical examination at this time revealed that the$ x) `: |! A' b1 S
child had grown 2.5 cm in 4 months and had gained
& V  A/ J1 C) ?0 ?1 }1 N+ V2 kg of weight. Physical examination remained% \) F2 C4 q+ v) V: V6 V& Q# [9 j
unchanged. Surprisingly, the pubic hair almost com-
4 Y; }$ b9 C& @3 O# p0 B$ Npletely disappeared except for a few vellous hairs at
0 v9 u/ {% E) }4 L+ ^8 I- Hthe base of the phallus. Testicular volume was still 2
4 ^6 T7 r( p% l+ T, ]! N9 AmL, and the size of the penis remained unchanged.
; _( I9 W) B2 x/ d1 KThe mother also said that the boy was no longer hav-
- z4 n) a, i7 U7 ?1 A' Ning frequent erections.
% J' w' J9 Y% ]9 Q8 [/ K; j+ }  FBoth parents were again questioned about use of$ j# h, D0 |% Z4 T
any ointment/creams that they may have applied to
1 R3 g5 Y7 g9 x4 \8 wthe child’s skin. This time the father admitted the
3 B7 o) r7 W( G; G( D2 z8 `( M" G. {Topical Testosterone Exposure / Bhowmick et al 541
6 V& J  d+ r1 o. b3 j# ?, E' iuse of testosterone gel twice daily that he was apply-
; k. T6 g3 m! y+ Aing over his own shoulders, chest, and back area for
) j4 b. u! B3 L* Q2 \a year. The father also revealed he was embarrassed
- P% N' I2 S) ^3 @# C" o' a4 s) d: Sto disclose that he was using a testosterone gel pre-
' }6 M4 V6 \3 g/ p# B4 c0 pscribed by his family physician for decreased libido
  t' h& E1 K  ~- ], a' _3 Fsecondary to depression.: z$ V3 j7 F! P
The child slept in the same bed with parents.
  E2 c5 H: D9 x' nThe father would hug the baby and hold him on his+ |' H& ?' B; `: q2 \* t
chest for a considerable period of time, causing sig-% g  l& Q1 X" B* I  o$ g5 H
nificant bare skin contact between baby and father.! j) `* J$ [$ V& @
The father also admitted that after the phone call,
1 s- c- |1 L* f2 Z. pwhen he learned the testosterone level in the baby
/ H1 n6 K1 M" |! s0 d7 uwas high, he then read the product information
% c6 `# o( O! a% S5 u6 ]packet and concluded that it was most likely the rea-' `* y" e; f* J4 g, m# p
son for the child’s virilization. At that time, they1 _) Y# H# F, J% a( L: P9 v; V1 B
decided to put the baby in a separate bed, and the
- D" z/ J1 R' V8 K* a+ yfather was not hugging him with bare skin and had
% v* s7 Q9 @3 K" I; hbeen using protective clothing. A repeat testosterone9 b# L" o& G- H: b: e' ]/ Z- R
test was ordered, but the family did not go to the- U' P0 f$ Z7 ?* s) A  [
laboratory to obtain the test.
- k* C) A1 R: U! ^; l! W2 BDiscussion3 N9 l8 C2 B6 g8 t% z# p8 d( B/ n4 j6 A
Precocious puberty in boys is defined as secondary* j% M5 f0 F0 O8 S8 e
sexual development before 9 years of age.1,4! t* B+ J3 C8 v- e2 M. f
Precocious puberty is termed as central (true) when% E( |5 [& d$ y8 X) z
it is caused by the premature activation of hypo-
, U: }# S5 h; P7 D6 A0 wthalamic pituitary gonadal axis. CPP is more com-0 _/ d6 o! @! J" ]- \6 k; z6 V8 J
mon in girls than in boys.1,3 Most boys with CPP
1 Y8 f9 R5 j' F# j6 O5 |+ p* |/ ?may have a central nervous system lesion that is
9 w1 T- ]0 X& J8 A7 Rresponsible for the early activation of the hypothal-
% y7 _2 N6 c. F) zamic pituitary gonadal axis.1-3 Thus, greater empha-2 Z5 |& {1 |& q9 z9 c% u3 ^  }$ U
sis has been given to neuroradiologic imaging in
! c/ l% p, W1 `7 T7 i! {. V  Hboys with precocious puberty. In addition to viril-
: L! i7 z# O8 N$ k1 Y5 x+ Xization, the clinical hallmark of CPP is the symmet-
. h, g9 q. Z6 D/ s; \# `rical testicular growth secondary to stimulation by
  a) ], V+ G+ jgonadotropins.1,3
) e- p* [7 v& b* w4 ]Gonadotropin-independent peripheral preco-0 W8 s$ {, Z( |' u2 ^+ V; ^
cious puberty in boys also results from inappropriate
% K, ~. V( {+ q) ?4 |androgenic stimulation from either endogenous or
# V% p' L+ x. m" F# m! E4 P/ y& Rexogenous sources, nonpituitary gonadotropin stim-
2 x: |8 S, P# z! u) O/ oulation, and rare activating mutations.3 Virilizing6 l* N- F$ y( ?! v
congenital adrenal hyperplasia producing excessive
8 d2 X8 T! }) r3 A2 K& b4 s- Yadrenal androgens is a common cause of precocious
/ J& C5 _* U6 H: p; Z( Bpuberty in boys.3,4
5 [% Z6 l3 }( j5 t0 A% x" Q9 p* RThe most common form of congenital adrenal
! A9 N7 V. {: C5 ?4 xhyperplasia is the 21-hydroxylase enzyme deficiency.
5 ]# @  [! m8 U8 x  q  dThe 11-β hydroxylase deficiency may also result in, l% V- d" M3 {0 P& ]
excessive adrenal androgen production, and rarely,
, q5 Y& i1 [/ I) c) Wan adrenal tumor may also cause adrenal androgen# H4 U. f$ e2 e7 k, T2 D6 x! ~
excess.1,36 n' E5 u3 i+ u6 K- W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% @# B* N- y- K! H542 Clinical Pediatrics / Vol. 46, No. 6, July 20073 n# C" m. B2 c# i& b
A unique entity of male-limited gonadotropin-* V$ C  V0 u. A: ?5 o8 i9 k; r
independent precocious puberty, which is also known0 M1 G; j( C" F( \$ R
as testotoxicosis, may cause precocious puberty at a
) u& @8 F* Q8 ^5 Cvery young age. The physical findings in these boys7 l% V# T: Q; w
with this disorder are full pubertal development,
9 ^, S- z) g; ]- g6 m8 \including bilateral testicular growth, similar to boys$ V! ]/ S2 h1 D; A% }3 d: F
with CPP. The gonadotropin levels in this disorder3 \' z# x% }8 Q. D6 n
are suppressed to prepubertal levels and do not show: s' j( I- q: _3 `9 n
pubertal response of gonadotropin after gonadotropin-
. I8 U$ ]! X; c" S: Hreleasing hormone stimulation. This is a sex-linked, x- n6 ]5 M& X6 ]
autosomal dominant disorder that affects only7 q  s, r) e+ o
males; therefore, other male members of the family4 w+ a2 b1 M5 s3 z" Q$ I; g2 H: I
may have similar precocious puberty.3
, F0 B3 ~: P/ KIn our patient, physical examination was incon-7 s$ O# G3 o: h8 `1 O1 K# k
sistent with true precocious puberty since his testi-' ]) `2 @$ E3 T/ m
cles were prepubertal in size. However, testotoxicosis
) C( z' N) X+ R; lwas in the differential diagnosis because his father2 a4 t8 E: }/ \; K$ b  ]0 E
started puberty somewhat early, and occasionally,
; q. N0 Q' \( w; ?6 `2 K! {testicular enlargement is not that evident in the( c, f8 v0 {% f+ Q% r1 n
beginning of this process.1 In the absence of a neg-
' u  t0 y' S6 v9 w9 ^, w, oative initial history of androgen exposure, our
/ ^  p. a" W3 H7 R" J) |' i9 i7 Abiggest concern was virilizing adrenal hyperplasia,
  ~. t6 D" ^0 [% i7 t" Leither 21-hydroxylase deficiency or 11-β hydroxylase
3 M! t6 g: \6 Edeficiency. Those diagnoses were excluded by find-
5 Q% x8 D$ y. z& a+ {& L% m! _; B+ Q' ming the normal level of adrenal steroids.
8 [8 R$ F% p5 e1 |$ ?The diagnosis of exogenous androgens was strongly$ p% h) N8 ], Z5 R5 l/ O6 Z% B+ `
suspected in a follow-up visit after 4 months because
4 D" @: ^: L& p% othe physical examination revealed the complete disap-9 n1 K  U5 k0 ^$ |6 ?* o# A( M
pearance of pubic hair, normal growth velocity, and+ M4 a- a* V+ {6 E; ~$ t- {4 x
decreased erections. The father admitted using a testos-
9 M( `, }0 Z9 [; ]  gterone gel, which he concealed at first visit. He was
# c) c6 q0 ?6 Y$ s! O/ _0 rusing it rather frequently, twice a day. The Physicians’! K  l, E* d: C. q, G. Q, c; l
Desk Reference, or package insert of this product, gel or' |4 I7 [- c5 A2 b9 R  r- L
cream, cautions about dermal testosterone transfer to' }9 ^  {1 t: U$ u- x1 [/ s
unprotected females through direct skin exposure.( z$ f7 w0 I. |' `+ P9 V
Serum testosterone level was found to be 2 times the
( ~1 h; J( i6 q$ h' @' j9 dbaseline value in those females who were exposed to
4 f6 w% g* L0 W0 C4 Heven 15 minutes of direct skin contact with their male
* p: i" z6 Z0 ]) B( K+ N7 ipartners.6 However, when a shirt covered the applica-
1 P7 c# L# H+ N5 q  B0 Btion site, this testosterone transfer was prevented.
2 f" e; o7 E, U# f6 r* k4 HOur patient’s testosterone level was 60 ng/mL,- B5 k$ O' i- t  Z6 [. r6 c: a
which was clearly high. Some studies suggest that- v9 Y0 y# r/ i! a/ P1 H2 J
dermal conversion of testosterone to dihydrotestos-
5 i) s; X: [+ x: ]terone, which is a more potent metabolite, is more+ o9 F1 t0 L9 F
active in young children exposed to testosterone, c( B9 M0 c  U+ b, b  q# m3 Y
exogenously7; however, we did not measure a dihy-
7 \7 z7 t2 h( h  Udrotestosterone level in our patient. In addition to
: n  n, J/ c7 @8 u0 H( rvirilization, exposure to exogenous testosterone in
0 |' |* Y+ M  F. ?children results in an increase in growth velocity and
( l; `0 q9 j+ aadvanced bone age, as seen in our patient.' r2 ^, p- R. V
The long-term effect of androgen exposure during
7 k5 N' x- U6 i6 y# x" Y& e# z7 C# `early childhood on pubertal development and final# U4 f$ L( h# |8 a
adult height are not fully known and always remain. Z3 v& y1 k) ?
a concern. Children treated with short-term testos-
) C  B# ~$ g0 n+ b" n6 Bterone injection or topical androgen may exhibit some
. E/ |* r% l3 V  ?2 ]. zacceleration of the skeletal maturation; however, after6 i$ J  ?$ O) b1 W/ g
cessation of treatment, the rate of bone maturation/ O; A1 y" K4 e, q: x' `
decelerates and gradually returns to normal.8,9
: G: k+ U) c4 ?& L1 j1 ~; r$ P, ZThere are conflicting reports and controversy
4 d/ v/ U7 H7 Q0 R+ I+ b# Wover the effect of early androgen exposure on adult
' n! H* ^4 {- ]$ X" D; npenile length.10,11 Some reports suggest subnormal" X0 I% d" R& ~
adult penile length, apparently because of downreg-
4 {5 p8 L! i! D/ S0 rulation of androgen receptor number.10,12 However,
5 h+ P4 l. k$ F. n) H0 r/ OSutherland et al13 did not find a correlation between
& n2 l9 J7 Z0 \! r6 Tchildhood testosterone exposure and reduced adult
3 l* l' f3 [" k; o7 Ipenile length in clinical studies.
* r) C, v; Q, P0 ?Nonetheless, we do not believe our patient is1 d' W4 G! {5 b5 V# ]7 p
going to experience any of the untoward effects from. `  l+ A4 P3 v
testosterone exposure as mentioned earlier because/ X8 ^2 d# X# ^" _
the exposure was not for a prolonged period of time.2 Q# X: f; i. u8 E( `$ m* z4 |
Although the bone age was advanced at the time of
* h2 @: X- O. d/ H; S  \+ k% Ydiagnosis, the child had a normal growth velocity at
% v$ t, }" M  C/ [the follow-up visit. It is hoped that his final adult
) M: n8 T9 G( O4 Theight will not be affected.
( b8 b6 A# u$ R9 `Although rarely reported, the widespread avail-
2 m# Z7 a. Y* ?ability of androgen products in our society may9 C% h* x- B5 N% R
indeed cause more virilization in male or female1 x" p8 p$ ]. t) K
children than one would realize. Exposure to andro-* |" e8 \6 a9 p& m" K! [
gen products must be considered and specific ques-
: |+ k" k! P" x1 l1 otioning about the use of a testosterone product or1 M9 B$ e; ]% d3 k
gel should be asked of the family members during4 ]2 C  o' v+ c9 K- X
the evaluation of any children who present with vir-
$ Y5 g+ I4 E8 O: k  R1 P) V: N; Vilization or peripheral precocious puberty. The diag-) g5 I+ v. h9 [9 p+ i
nosis can be established by just a few tests and by3 J6 s! ^. l* J8 D% u, M/ e+ m
appropriate history. The inability to obtain such a
  X; \( y4 |) k# S9 I; hhistory, or failure to ask the specific questions, may9 E3 M+ \  E* F" O- v
result in extensive, unnecessary, and expensive
9 t' r- X& K! M; _- ~% Cinvestigation. The primary care physician should be( M/ K9 F0 R) E5 v
aware of this fact, because most of these children
* o" b/ ^- S- u) {, Tmay initially present in their practice. The Physicians’: s0 |5 H/ v) g
Desk Reference and package insert should also put a
1 @* C2 K$ L- @! Bwarning about the virilizing effect on a male or
- C6 N+ R6 ]8 }5 o+ n. N, ?) Tfemale child who might come in contact with some-% M. Y* o& C$ H2 t) ~
one using any of these products.# S- g* R( Z7 Y& I0 _
References
; U/ F' a- T1 z/ y+ O$ S1. Styne DM. The testes: disorder of sexual differentiation
9 _3 S( W9 B; \0 {" nand puberty in the male. In: Sperling MA, ed. Pediatric
2 s0 D! O5 ?" [$ I0 UEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. k+ ^# Q  c1 a+ q2 ?
2002: 565-628.
" W5 T# ?3 W! D9 E5 O) x2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious2 U2 S4 t& M* ?. B
puberty 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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
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
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
5 T) p# D- M; M+ \; t
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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