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Sexual Precocity in a 16-Month-Old5 t0 q2 ?  @+ O- M! Y+ e  `
Boy Induced by Indirect Topical
  c! R. L& r! i9 m+ [Exposure to Testosterone+ c# c# m$ H! Z8 u
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# R7 I) N' Z- U8 y" g9 t* }4 Cand Kenneth R. Rettig, MD1
$ W, a0 R+ R0 X. I* [' K4 x$ j! ?9 c6 c, _Clinical Pediatrics( _# i# m: o. A  b
Volume 46 Number 6
' d3 N% P- N: L& \1 H5 y# M2 fJuly 2007 540-543
( _$ N( l1 V" g5 L1 t& D© 2007 Sage Publications
4 j' Z- K* R( Z, Z' P( s10.1177/0009922806296651
4 ~/ E9 x7 B/ Z$ s/ I  Phttp://clp.sagepub.com  U+ Q9 v; Z2 ~+ u$ h
hosted at
7 e7 M" a- ?3 w+ ~http://online.sagepub.com. \* F4 [; ]8 U5 z4 E. V
Precocious puberty in boys, central or peripheral,) M. q" _) Q4 t3 V% K" [9 C# A8 j
is a significant concern for physicians. Central
. M4 R2 [, z7 y2 J" D) \: uprecocious puberty (CPP), which is mediated* @, H4 k) f& ]
through the hypothalamic pituitary gonadal axis, has6 ^( m7 p/ {! c% e! _
a higher incidence of organic central nervous system
: l; x6 L& ]; z& W  n5 D% }5 klesions in boys.1,2 Virilization in boys, as manifested
. d$ ^* U$ I- P8 _0 Tby enlargement of the penis, development of pubic
( A6 s# ^; l' m, g* qhair, and facial acne without enlargement of testi-
% N4 k7 O( L& m$ Z1 ncles, suggests peripheral or pseudopuberty.1-3 We
7 a0 B0 g( W' |4 u7 j  g9 Qreport a 16-month-old boy who presented with the- o( X3 I2 g$ X& d, w/ ~
enlargement of the phallus and pubic hair develop-
8 P7 y, A; X9 Tment without testicular enlargement, which was due' c1 I0 k& v: v  k$ I5 s* k$ G8 Y6 T
to the unintentional exposure to androgen gel used by' |2 x8 s; e7 s
the father. The family initially concealed this infor-- R* Y: }' j/ p; c
mation, resulting in an extensive work-up for this3 b" W# G. `5 [' W
child. Given the widespread and easy availability of) ?* f% Z0 ?6 p! K
testosterone gel and cream, we believe this is proba-% d2 V- H, r5 i. v- L+ ~( L9 p
bly more common than the rare case report in the: X7 b1 ^& g1 ?
literature.4
" }& Z, L3 m+ r7 gPatient Report+ h6 k* @/ n0 G/ y2 ]
A 16-month-old white child was referred to the) C" M, k  d. e5 v, O8 ~) [
endocrine clinic by his pediatrician with the concern
+ H8 X$ u& Q8 J- Mof early sexual development. His mother noticed
" H# r! D& K# U" x( zlight colored pubic hair development when he was
: ]" U) X; n& S, {# O  tFrom the 1Division of Pediatric Endocrinology, 2University of" f3 u4 V: ]- a* K
South Alabama Medical Center, Mobile, Alabama.: X2 ^4 C0 u3 N
Address correspondence to: Samar K. Bhowmick, MD, FACE,
/ j7 T, a& A9 N3 E5 x& K- sProfessor of Pediatrics, University of South Alabama, College of
+ e/ b7 H3 o' X. l' R( F7 F* `5 W* AMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
) Z, i4 a7 I7 H# n/ D) |( ie-mail: [email protected].) ]0 w3 r. i( H7 w0 o
about 6 to 7 months old, which progressively became# q7 y! W% H! q+ A, D- x
darker. She was also concerned about the enlarge-. C) I3 o' E' t  Z
ment of his penis and frequent erections. The child
- R+ T8 Q/ _: ^' g( Qwas the product of a full-term normal delivery, with
5 ~* N' `* @4 }  }, w: q2 R/ Za birth weight of 7 lb 14 oz, and birth length of
5 `( R' m% _* x5 r( s7 i" Z$ J20 inches. He was breast-fed throughout the first year- x3 [7 _" ?7 P6 q" S
of life and was still receiving breast milk along with/ z( p. o! g# S2 {
solid food. He had no hospitalizations or surgery,$ A! a1 b- ^' f: i# A5 O6 p0 X" Y
and his psychosocial and psychomotor development
9 q) x( M9 C% n8 f: y! Jwas age appropriate.; @, @, i1 T6 F, C) t# b1 p
The family history was remarkable for the father,! W0 E7 L, H- ]0 t. B
who was diagnosed with hypothyroidism at age 16,
7 a7 G3 W2 g: X5 [% Twhich was treated with thyroxine. The father’s
& e; r0 e( _7 ]; r' ^) G* h3 Jheight was 6 feet, and he went through a somewhat2 Q# b, }4 u: S" Q) K. z
early puberty and had stopped growing by age 14.
! i; Y+ N5 T4 h2 F; f) IThe father denied taking any other medication. The
& j* t9 E* H- f4 m$ a- |" R, tchild’s mother was in good health. Her menarche8 @- H7 N8 K3 ]# A: q* k$ q+ ?
was at 11 years of age, and her height was at 5 feet
2 Z. `5 _& \5 \: T$ h5 s. |4 t) |5 inches. There was no other family history of pre-; {4 e" H) C6 k# o4 T  q
cocious sexual development in the first-degree rela-
6 y; m1 h- ^% n; V, _tives. There were no siblings.1 e5 v  G5 w1 n( X* ^  ]; h
Physical Examination
( {  L* P- p( N4 J5 J$ e/ Z' CThe physical examination revealed a very active,# R1 |8 P; a+ {) }) k% R
playful, and healthy boy. The vital signs documented
$ c9 s: u/ j7 o  T; R3 V( _a blood pressure of 85/50 mm Hg, his length was; o: l/ p' V9 N0 F
90 cm (>97th percentile), and his weight was 14.4 kg
# l* I. P5 s! A6 Z(also >97th percentile). The observed yearly growth9 ?+ N, p! G9 F( b( F  O5 \( k
velocity was 30 cm (12 inches). The examination of
6 V3 s! t( n6 Z& `1 \- C6 Vthe neck revealed no thyroid enlargement.8 J- W0 d" X% @# r
The genitourinary examination was remarkable for+ D( S" u! l% N* a; r0 {. R
enlargement of the penis, with a stretched length of5 x6 e  U, D) W/ s, s# q
8 cm and a width of 2 cm. The glans penis was very well6 e) \" t/ g+ b  _, Y% @" ]
developed. The pubic hair was Tanner II, mostly around5 q2 \( g5 ~. f% T; [- o
5408 ?2 A9 @9 Y1 v) \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 L0 Z0 B4 W8 L8 {2 {( @3 T4 s: B2 Bthe base of the phallus and was dark and curled. The# e5 D$ R8 h2 Y8 o& z# `7 W0 o
testicular volume was prepubertal at 2 mL each.
$ \  @( G. i, B4 ?4 n/ ?0 dThe skin was moist and smooth and somewhat5 C& K* \$ r0 J9 q/ Z! f0 [+ ~
oily. No axillary hair was noted. There were no
; g8 d, A* @& c+ Habnormal skin pigmentations or café-au-lait spots.
8 u' j3 u0 C  dNeurologic evaluation showed deep tendon reflex 2+/ @* h8 L) m7 z8 k
bilateral and symmetrical. There was no suggestion
: H4 F3 W& b* f0 Gof papilledema.
, _5 ]  N4 h  B% K0 q7 u  d! ~Laboratory Evaluation
% o0 c2 d; [# v9 n! WThe bone age was consistent with 28 months by
# w7 h; Y! L  p$ W6 e3 {using the standard of Greulich and Pyle at a chrono-( R- P, n4 u9 O6 ^/ v" I+ R
logic age of 16 months (advanced).5 Chromosomal+ k# D" \8 q7 |8 G! A
karyotype was 46XY. The thyroid function test
( O" o3 T& x& zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-3 P% ]' O- g" r  S: q
lating hormone level was 1.3 µIU/mL (both normal).
2 ]: ]; c4 F9 b6 C$ v4 \% ~) j7 C5 SThe concentrations of serum electrolytes, blood% b: m/ S. `7 {3 [1 M
urea nitrogen, creatinine, and calcium all were" T$ _5 K# ~: F$ z4 U' {& X) {) b9 _
within normal range for his age. The concentration
; B- {* r3 J* N; v6 @: tof serum 17-hydroxyprogesterone was 16 ng/dL
2 D9 p& S$ @6 U" U1 o6 i$ r(normal, 3 to 90 ng/dL), androstenedione was 20$ n8 p: y# q" y$ `0 n5 h7 @: W% M
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 q# G$ X4 E3 f8 {: \  {+ b
terone was 38 ng/dL (normal, 50 to 760 ng/dL),/ g- y, B9 z9 V, z. i5 q; _) M
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ V; x$ r$ }. \1 a49ng/dL), 11-desoxycortisol (specific compound S)3 _% d% o' B. y
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-& n7 i9 Q. T( `8 o8 H" R
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 v6 ~/ _* N  ^  l' u& v
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),# j+ f2 S0 M7 Q( l
and β-human chorionic gonadotropin was less than
, Y; J( F5 q; e. y* X( l5 mIU/mL (normal <5 mIU/mL). Serum follicular
. d4 `+ A4 p. F2 _stimulating hormone and leuteinizing hormone
) N2 J( j! K, S, D: ?concentrations were less than 0.05 mIU/mL
2 d$ T: k9 Y* X. O4 }4 h, J5 U(prepubertal).6 B1 P: {% ]3 f- Y4 h+ S  v! m9 }- J
The parents were notified about the laboratory& k; _7 U( t/ D
results and were informed that all of the tests were& E, f: ]3 d1 a" ~1 S, m4 \
normal except the testosterone level was high. The
# z; m9 R+ B1 x& Ufollow-up visit was arranged within a few weeks to
- X4 r' B' p0 Nobtain testicular and abdominal sonograms; how-
# `& v% v0 X4 R0 R5 o! Z0 S0 y8 s% l( ~ever, the family did not return for 4 months.
3 V6 X7 E. e3 G; @' X) S6 X+ uPhysical examination at this time revealed that the& N: u, G  Z( o
child had grown 2.5 cm in 4 months and had gained
! j. N6 E1 n2 t% d$ d4 D2 kg of weight. Physical examination remained8 v' o; m, Q% h# j
unchanged. Surprisingly, the pubic hair almost com-
2 T/ M; w4 x/ x* opletely disappeared except for a few vellous hairs at' o3 U9 y9 }. Q* S1 X  |
the base of the phallus. Testicular volume was still 2! ^$ V  Z' }/ l% G7 X
mL, and the size of the penis remained unchanged./ v, Q+ Q+ ]. V" J0 \
The mother also said that the boy was no longer hav-
; M( F1 ]7 u7 Bing frequent erections." D! ~8 v$ B1 j2 N
Both parents were again questioned about use of; E. \* Q& ?& W# r! T9 q
any ointment/creams that they may have applied to. p  _! L$ o) [/ @0 N6 a
the child’s skin. This time the father admitted the
0 h, q$ q& k0 ?/ vTopical Testosterone Exposure / Bhowmick et al 541! _: S& q: ?4 E  C$ L7 t
use of testosterone gel twice daily that he was apply-
& q: r  T% _4 s  [: n- king over his own shoulders, chest, and back area for& W3 u" ^( q+ B! Y
a year. The father also revealed he was embarrassed
6 d# r: }0 Y4 @$ ]0 ~: W; `to disclose that he was using a testosterone gel pre-+ E" K/ L: [% }; E: q" W9 _
scribed by his family physician for decreased libido
5 H  K6 F* y8 w+ b+ P" _8 U( isecondary to depression.
: H$ W: u' G2 J+ g( }/ pThe child slept in the same bed with parents.
, s- g! |3 \% R3 M5 BThe father would hug the baby and hold him on his
! |8 A3 l. F, U; _chest for a considerable period of time, causing sig-
# ]" i  a3 L# c; v7 Pnificant bare skin contact between baby and father.
! J$ ~5 {3 G4 B6 F: ^6 t6 OThe father also admitted that after the phone call,
) _1 q4 E+ I* E- R% O8 Twhen he learned the testosterone level in the baby. A9 s* q' N$ v0 z9 X  W% {
was high, he then read the product information" Z; I# q! L8 K" p* o; G- E+ @& k
packet and concluded that it was most likely the rea-
+ a; O8 z+ \6 Eson for the child’s virilization. At that time, they5 Y) M2 X' B  t) |# `" T
decided to put the baby in a separate bed, and the6 k' Y5 b% f9 n/ d. M# s1 o
father was not hugging him with bare skin and had
' W6 i" R) c8 v  C; p. \been using protective clothing. A repeat testosterone, @6 m; z0 K1 q& }
test was ordered, but the family did not go to the
) `; A! a& n% f( s1 wlaboratory to obtain the test.
' C2 {+ H% Q1 L  d3 A& EDiscussion6 N2 }, h9 ~% X3 d+ Q- E3 R; R5 |
Precocious puberty in boys is defined as secondary3 N' e6 [+ N0 }5 P6 x+ i
sexual development before 9 years of age.1,45 M1 E4 }% q+ m4 Z6 n
Precocious puberty is termed as central (true) when9 a$ k/ D, s7 ~
it is caused by the premature activation of hypo-
6 X5 ^; `) {2 p) tthalamic pituitary gonadal axis. CPP is more com-
8 K+ M6 K6 K1 U/ o& ?% gmon in girls than in boys.1,3 Most boys with CPP
. U9 p7 M! J' w$ h$ r5 ^may have a central nervous system lesion that is
1 v* k0 B) g& h1 D7 l/ E9 ^# Dresponsible for the early activation of the hypothal-
- c$ s% x! `% d# O  |$ }amic pituitary gonadal axis.1-3 Thus, greater empha-# P8 c( `( J2 ?( A* @2 M2 S
sis has been given to neuroradiologic imaging in2 _3 A& o$ P+ E8 g8 s5 ^7 Y) j4 T
boys with precocious puberty. In addition to viril-
5 S5 I/ U3 |( R( nization, the clinical hallmark of CPP is the symmet-
# p1 w# P$ V! p: @  d# q; Mrical testicular growth secondary to stimulation by* u  y* n! Q& K- O9 v0 M( O( ?( C
gonadotropins.1,3$ t9 I. _; B  G0 e# P7 n/ S
Gonadotropin-independent peripheral preco-
& T, x# D5 s% Y; t+ M& W+ P2 F: @cious puberty in boys also results from inappropriate
( e+ F3 A' T4 v1 k  Eandrogenic stimulation from either endogenous or2 w2 W6 M- Q, y8 {
exogenous sources, nonpituitary gonadotropin stim-/ Q4 p) P, f8 C! ^
ulation, and rare activating mutations.3 Virilizing9 I+ _/ y, o) _# w
congenital adrenal hyperplasia producing excessive8 \! ^) T9 H, i* d
adrenal androgens is a common cause of precocious9 ~9 S' \" ^( p2 K) g
puberty in boys.3,4
+ |/ K* J: a* t$ n' e2 [* I: |4 \0 IThe most common form of congenital adrenal
1 J' Y3 B: J3 rhyperplasia is the 21-hydroxylase enzyme deficiency.
& m; I- a/ w! I( S" m% TThe 11-β hydroxylase deficiency may also result in( E! ]7 T- C% J% U- t1 X8 f! [
excessive adrenal androgen production, and rarely,
( D* Y6 P: T) A, P0 Fan adrenal tumor may also cause adrenal androgen
1 q+ T$ q# E; ^! Z8 }, z) ~7 Xexcess.1,34 r& y: n3 `; y/ }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
  F; ^0 n' N% d4 H542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 ~! ?4 A8 l1 A" \6 S% L9 K2 VA unique entity of male-limited gonadotropin-8 J$ J0 x6 q! a* z4 S
independent precocious puberty, which is also known
* t% [+ i  b: \0 ?, j) Mas testotoxicosis, may cause precocious puberty at a
7 k( r8 A: K! T) k  Z  xvery young age. The physical findings in these boys. t1 h; B3 n# _3 P
with this disorder are full pubertal development,
4 |# N# m% X% F; Oincluding bilateral testicular growth, similar to boys% t; S) w# `" |& @! Q" Q
with CPP. The gonadotropin levels in this disorder
5 x+ E9 ~1 _; M& {+ Ware suppressed to prepubertal levels and do not show& C1 ]) G" {& n0 e+ X
pubertal response of gonadotropin after gonadotropin-/ b( t4 Q+ M4 k7 O7 E
releasing hormone stimulation. This is a sex-linked5 |5 U6 `9 c8 F6 S$ H) [
autosomal dominant disorder that affects only
& G% |! q; v  c2 K5 b& o8 u/ smales; therefore, other male members of the family/ F( u/ t" U" @2 S. V0 m
may have similar precocious puberty.3
$ t$ A) {/ r9 x8 u, f: C) yIn our patient, physical examination was incon-
% E  q& N5 b) Z- q5 @6 p, Wsistent with true precocious puberty since his testi-
* t3 V' ^" V+ h7 xcles were prepubertal in size. However, testotoxicosis$ ]0 X! P7 Y6 r+ h  ^
was in the differential diagnosis because his father/ Q. Q$ @8 I7 Z5 X: @1 \' M
started puberty somewhat early, and occasionally,
4 @* S; C; g* U+ M. g6 Ktesticular enlargement is not that evident in the- R, Y$ ~( x6 q9 ~) I
beginning of this process.1 In the absence of a neg-
2 p# w7 [4 e% O% x3 F! Q9 F9 r8 Wative initial history of androgen exposure, our
* B% `  B/ }1 Y  \6 |: hbiggest concern was virilizing adrenal hyperplasia,3 O" W$ ~% l/ R. M5 g+ r
either 21-hydroxylase deficiency or 11-β hydroxylase
2 P: T1 |5 L% _) H9 Zdeficiency. Those diagnoses were excluded by find-
) _4 S+ |! |& N- Z& }7 aing the normal level of adrenal steroids.! X7 z# N* T, g+ N. \
The diagnosis of exogenous androgens was strongly
4 `5 C! o8 o9 a) N1 Qsuspected in a follow-up visit after 4 months because
8 f% }; g; F' x9 D6 ~/ @" P' Qthe physical examination revealed the complete disap-
( B' O7 p* W0 \pearance of pubic hair, normal growth velocity, and5 b- l% }% ]# H5 _0 m# C8 x' \$ `9 s
decreased erections. The father admitted using a testos-3 h: ]6 q+ F1 P/ s/ o
terone gel, which he concealed at first visit. He was# i( [, r/ b; {% T2 i) W9 t" k
using it rather frequently, twice a day. The Physicians’' Z$ O1 v4 P3 T& x) K8 \; }
Desk Reference, or package insert of this product, gel or' i2 j) x! @& ^% _) V2 {
cream, cautions about dermal testosterone transfer to
4 _) m- D2 j* N. U; Qunprotected females through direct skin exposure.
4 e- f- R0 E: c# }Serum testosterone level was found to be 2 times the
/ O( K& _# i# j- G; Kbaseline value in those females who were exposed to
2 f/ [6 `2 _; ceven 15 minutes of direct skin contact with their male1 v# z& b9 T7 B$ x
partners.6 However, when a shirt covered the applica-0 H) |3 n/ S6 b) L2 g: c$ L6 p
tion site, this testosterone transfer was prevented.7 y3 I( V; m. Q8 I/ f6 k
Our patient’s testosterone level was 60 ng/mL," |9 a3 @, u* N* E: q
which was clearly high. Some studies suggest that* v) m; N1 _2 F* ?5 U, ^; D
dermal conversion of testosterone to dihydrotestos-
6 _7 C/ `7 S* U+ i& L, G7 J: Pterone, which is a more potent metabolite, is more# O$ ^7 h$ F$ ]
active in young children exposed to testosterone4 Y9 J! }# U/ g- W1 G8 D1 s
exogenously7; however, we did not measure a dihy-4 M: V' \  m8 b. ~. g" `/ a7 q
drotestosterone level in our patient. In addition to) |. I0 u9 c4 w
virilization, exposure to exogenous testosterone in0 D9 f# T; J+ T
children results in an increase in growth velocity and( {9 Q) c0 c, J/ H; \
advanced bone age, as seen in our patient.: l: B8 {5 e" Y- ?
The long-term effect of androgen exposure during
8 e! A7 g( b$ {: S+ rearly childhood on pubertal development and final6 j0 K6 F) j+ \% V. W
adult height are not fully known and always remain
. V/ s: l2 X+ F/ U$ X( Ta concern. Children treated with short-term testos-: L3 ^9 h" b) ]4 ]# F
terone injection or topical androgen may exhibit some
5 L7 U* x% O) }, \acceleration of the skeletal maturation; however, after0 l- ?3 r' S* u7 q
cessation of treatment, the rate of bone maturation
/ ]+ R( e  r# p7 mdecelerates and gradually returns to normal.8,95 g; M9 Q. w5 ]5 I
There are conflicting reports and controversy
" p2 i; h1 B: _over the effect of early androgen exposure on adult8 V0 D* [4 l4 h5 n% i
penile length.10,11 Some reports suggest subnormal6 A2 K2 }. x7 N' r! F. [; x' j
adult penile length, apparently because of downreg-
1 W# Y# Y2 |. T5 sulation of androgen receptor number.10,12 However,$ T. m& z; \  p* u
Sutherland et al13 did not find a correlation between/ @% o- N4 m* `7 L/ Q& A
childhood testosterone exposure and reduced adult; n! z0 I3 X* ^3 n/ M% U& I9 ~
penile length in clinical studies.
" ~. c: Q5 y$ @9 ANonetheless, we do not believe our patient is
0 P, s# r- x4 j. k! ~( W1 b/ Q3 ?8 ~going to experience any of the untoward effects from7 S; ?  ~1 T1 P1 Z* r
testosterone exposure as mentioned earlier because
% v* i1 f: ~* e0 gthe exposure was not for a prolonged period of time.
; @) _( m, ]) g4 {5 \4 LAlthough the bone age was advanced at the time of6 z+ J9 s' E! L: _" }; p: J
diagnosis, the child had a normal growth velocity at& U& l$ i9 [% X  `: }
the follow-up visit. It is hoped that his final adult$ w9 ?# [$ u$ L" [5 `; Y
height will not be affected.
; v# N  T1 L, e0 p* a# bAlthough rarely reported, the widespread avail-" e0 Y( Y6 s- j$ ?  I2 _3 N
ability of androgen products in our society may
' M: u+ N. O$ _6 @( ]. V# uindeed cause more virilization in male or female& W8 k  |0 D! S  r
children than one would realize. Exposure to andro-* r0 w0 V; m1 p/ Z1 e
gen products must be considered and specific ques-( U, W+ z8 n( t
tioning about the use of a testosterone product or( N0 x3 q6 q8 Y5 \; R3 m# w2 l
gel should be asked of the family members during
- ^7 `* r, l, Z, t% Y) P  Q9 Gthe evaluation of any children who present with vir-2 v5 j2 I' a& C; O( ~+ [
ilization or peripheral precocious puberty. The diag-
( [0 ]0 z# h6 _* T  h- r0 V& knosis can be established by just a few tests and by
1 f$ B+ B6 J' Pappropriate history. The inability to obtain such a
: E3 a# q; m& H; R, X" w; uhistory, or failure to ask the specific questions, may( O& N5 Q/ r4 v0 _# Z. i
result in extensive, unnecessary, and expensive
  K& O0 X0 ^( ?; Q: D: Jinvestigation. The primary care physician should be- f8 x! t4 m6 @, S; b
aware of this fact, because most of these children8 Y" t! b9 p0 H; _' N+ m' P9 B; ]
may initially present in their practice. The Physicians’
0 z6 ~; }$ m" f, k" M, S# V. }Desk Reference and package insert should also put a1 x' B6 N. K. Q: T" A( r, |( G6 a
warning about the virilizing effect on a male or# d! w+ }3 ?2 I. j- s) A% w
female child who might come in contact with some-  l. \8 j& y) ~/ L- m+ W  S
one using any of these products.
9 t9 |1 B. n( q( k6 ^7 b- c  SReferences
( o! x: i, x5 X- ^. s" q1. Styne DM. The testes: disorder of sexual differentiation
6 N' S6 t- d0 g9 f7 t- |4 Rand puberty in the male. In: Sperling MA, ed. Pediatric
/ [3 J  V, r8 ^8 Y% n' }Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ j4 X% _  u( K% g2002: 565-628.
, D( {! m9 N- r2 S, G2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
% z/ _; w) m8 |8 s* z) cpuberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old4 S! a9 d2 Y$ [* U8 R! d
Boy Induced by Indirect Topical
' a5 y3 n5 O' A$ Q3 I! OExposure to Testosterone
' x% x& Y5 S9 M7 VSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2- n7 w( E2 S; O8 `% i  X3 o
and Kenneth R. Rettig, MD1. Q7 ?+ W1 D; p0 _- [* p3 X5 p& \
Clinical Pediatrics
3 {6 T. L) v; t% A9 F3 BVolume 46 Number 6' g7 A4 @! j' P+ s9 u+ }+ Q
July 2007 540-543) S9 \5 k; A, N' G4 z, O5 O% N
© 2007 Sage Publications0 k4 V0 ?' g8 N7 J' x
10.1177/0009922806296651' T. T; Z+ ~: }: J/ O+ n8 N
http://clp.sagepub.com1 }4 L! U- y+ _) `0 J2 y6 y
hosted at. N: h) n6 h- c
http://online.sagepub.com0 i2 @5 i2 B% `( x
Precocious puberty in boys, central or peripheral,! E, P5 ?4 J' j; E3 J
is a significant concern for physicians. Central$ E0 ?% b8 X6 U( \6 y4 |8 X+ c: i
precocious puberty (CPP), which is mediated' x0 O4 |0 a0 X8 y8 Z
through the hypothalamic pituitary gonadal axis, has
# J7 o) ?2 _( ba higher incidence of organic central nervous system* [: \" K* G9 J4 D0 y
lesions in boys.1,2 Virilization in boys, as manifested0 {! |. E1 M5 j8 R% D
by enlargement of the penis, development of pubic
1 l2 m: v, B& Xhair, and facial acne without enlargement of testi-+ F$ N0 h  f+ a
cles, suggests peripheral or pseudopuberty.1-3 We3 @4 G3 `2 z" R& x0 c
report a 16-month-old boy who presented with the
- r" S: d% Q. a/ `0 Tenlargement of the phallus and pubic hair develop-6 y/ ~9 f' U+ w. k8 B3 A4 m. {
ment without testicular enlargement, which was due  q+ W  {' m# e0 @
to the unintentional exposure to androgen gel used by0 {" U$ v$ W5 ^7 `. ~
the father. The family initially concealed this infor-& Z% U8 n) Y4 x" ~/ z$ i
mation, resulting in an extensive work-up for this
0 F! s. \5 k! f: F1 F# P- T) Rchild. Given the widespread and easy availability of' D: I$ N1 H1 A) w$ A4 D
testosterone gel and cream, we believe this is proba-
  w8 w/ y8 d+ F9 wbly more common than the rare case report in the# _5 c; L! {# j- H# l& o5 X% O
literature.4
5 }" I8 U- P  z, J( N6 P/ [Patient Report+ A7 f' V6 f  ]" x8 d+ w% u/ K
A 16-month-old white child was referred to the
7 }' l1 n$ b8 p0 o7 j4 xendocrine clinic by his pediatrician with the concern( a1 o. O0 v2 q4 N+ b
of early sexual development. His mother noticed
2 ?: O/ X( A. Q" }light colored pubic hair development when he was
0 z8 g* G) }% g. l5 O$ uFrom the 1Division of Pediatric Endocrinology, 2University of1 B' q2 J6 }; J% }9 R. i2 V( h  u1 C
South Alabama Medical Center, Mobile, Alabama.1 ]; L2 x, [* \9 x
Address correspondence to: Samar K. Bhowmick, MD, FACE,
, s. @/ x) q4 l3 T! E, n, ?" UProfessor of Pediatrics, University of South Alabama, College of: B% {! f2 d- G# s; J; Z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
: c! s& h/ K9 fe-mail: [email protected].0 [, u8 s% f, C7 j2 a; F/ B/ M7 a5 L
about 6 to 7 months old, which progressively became, s" d2 }4 y0 P
darker. She was also concerned about the enlarge-
+ U# W, u9 n( l- Jment of his penis and frequent erections. The child
( W' C) N/ w4 P) owas the product of a full-term normal delivery, with; Q+ a+ d" F' T8 t5 n1 Y! ]9 j, f
a birth weight of 7 lb 14 oz, and birth length of
/ r- R: g$ {/ x& P% X' @% _20 inches. He was breast-fed throughout the first year8 N- S6 o+ H* b( e& f' s
of life and was still receiving breast milk along with* ^( I5 R3 N5 H
solid food. He had no hospitalizations or surgery,
; A1 {; M8 `0 V. ~: Wand his psychosocial and psychomotor development
6 y& m, E  K  t, w; t  ]. J4 Qwas age appropriate.
5 n/ _  e* a7 P3 ]2 R9 UThe family history was remarkable for the father,4 Q8 ^, Q$ D, u" i
who was diagnosed with hypothyroidism at age 16,
5 w+ a6 c6 }% q" bwhich was treated with thyroxine. The father’s
+ u8 p0 b, Y: Y, _5 {0 zheight was 6 feet, and he went through a somewhat
5 R) F; S0 O0 ~$ Z/ {6 _2 p4 q3 Fearly puberty and had stopped growing by age 14.
! {& g& c6 B& U1 eThe father denied taking any other medication. The
6 h  k7 _! ]0 i& r. hchild’s mother was in good health. Her menarche& l1 B$ p. ~- F# ]- r
was at 11 years of age, and her height was at 5 feet' `. K2 o/ c4 ?* A* D, F
5 inches. There was no other family history of pre-
) d% B( n. B( d  t4 tcocious sexual development in the first-degree rela-
7 u) \/ e! H3 w% S# f( X7 |tives. There were no siblings.
& W8 l: O" a4 [2 u7 r( t2 BPhysical Examination
4 b- B' q4 {- X: D3 {- Y& ^! q) pThe physical examination revealed a very active,
9 i2 X+ H4 n2 p% ^3 D* O8 d3 c8 Pplayful, and healthy boy. The vital signs documented
! s1 C# U( a! Y# C; P' O8 ^a blood pressure of 85/50 mm Hg, his length was
$ y  K! i% A: ~90 cm (>97th percentile), and his weight was 14.4 kg
- G- c* t+ p/ P& ^# y3 l' _9 \(also >97th percentile). The observed yearly growth
4 M6 W6 D5 \. n' Lvelocity was 30 cm (12 inches). The examination of
$ ]0 S- v3 Y$ X7 `* Rthe neck revealed no thyroid enlargement.
0 p1 g3 ?* I% Y, D5 o+ SThe genitourinary examination was remarkable for
3 Q4 `0 {! s5 O% eenlargement of the penis, with a stretched length of
3 w8 E, A1 N- T" r6 {  u  X8 cm and a width of 2 cm. The glans penis was very well
4 n; M, A# n2 c9 d4 Y3 O' g% adeveloped. The pubic hair was Tanner II, mostly around
/ }. u$ K1 j" E- H540! d$ E: ?$ ]7 @& i& q. n
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 E% j+ {$ W/ ^: {8 K5 Lthe base of the phallus and was dark and curled. The
& t8 ?6 {. d6 [+ j5 }0 Ytesticular volume was prepubertal at 2 mL each.: Q/ {0 f3 d2 r; t
The skin was moist and smooth and somewhat
7 L. ~4 q/ H5 \, ]+ Joily. No axillary hair was noted. There were no! q6 I$ f2 W8 v1 Q/ _
abnormal skin pigmentations or café-au-lait spots.
0 B* {" _5 Y2 i) uNeurologic evaluation showed deep tendon reflex 2+
, i7 M; `0 M6 s' {, d: Vbilateral and symmetrical. There was no suggestion
& T' ]& k! J4 {' T$ Yof papilledema.
5 w5 U9 C6 f( Z& t& p3 xLaboratory Evaluation6 ^$ Z; I8 L7 j: z" s4 j
The bone age was consistent with 28 months by: w. v0 I3 c& e% B+ p, B& q
using the standard of Greulich and Pyle at a chrono-/ D; m7 L3 Q) s9 N
logic age of 16 months (advanced).5 Chromosomal, e% ?% V1 S, a( Q
karyotype was 46XY. The thyroid function test
* y- Z7 Z5 ^% d6 s$ pshowed a free T4 of 1.69 ng/dL, and thyroid stimu-, i) O" F3 [. p* k
lating hormone level was 1.3 µIU/mL (both normal).
- K$ @# N1 u( y/ U- qThe concentrations of serum electrolytes, blood
4 Z+ u$ f% }0 V+ p2 `' wurea nitrogen, creatinine, and calcium all were" X' g2 i: b! @
within normal range for his age. The concentration
5 o9 {  z6 o- Y# ~& F2 t& Eof serum 17-hydroxyprogesterone was 16 ng/dL
( L8 m' u5 z6 T9 ^# p" O# K4 Q5 Y(normal, 3 to 90 ng/dL), androstenedione was 20
  t. Y/ V9 H, K/ q2 H0 T6 Rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 r; S& N- o  R/ _4 h( s9 b& K" `
terone was 38 ng/dL (normal, 50 to 760 ng/dL),# t) y, f0 R8 M+ I! n; p4 ]
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 A1 M2 D  ]& B49ng/dL), 11-desoxycortisol (specific compound S)
/ C" p% a, i4 C* g6 }was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# B# X) O! p- w4 g0 M2 r% ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total3 N" f" Q+ d  M
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),' ~0 s% {8 Z! _' B/ T" k, ?+ j  a
and β-human chorionic gonadotropin was less than
. E  o& S+ |9 G' e& ?* a3 P4 c. T* ^5 mIU/mL (normal <5 mIU/mL). Serum follicular
; c1 K% J- A0 F8 I# dstimulating hormone and leuteinizing hormone  A" H2 d  m5 T1 E0 ~, I6 _- R+ Z
concentrations were less than 0.05 mIU/mL
4 \: _# d1 Y. _) o: p. U& L' n(prepubertal).
% U7 f' l# S: @- kThe parents were notified about the laboratory
, f2 v) i( {- Z. u& K; f. Z- Kresults and were informed that all of the tests were
3 u2 |- O# {( S4 s. a3 [normal except the testosterone level was high. The" n! z5 r7 B- \- F
follow-up visit was arranged within a few weeks to3 h; o- M) u. X3 j+ m8 {
obtain testicular and abdominal sonograms; how-' \8 t( K  u* _! r8 `
ever, the family did not return for 4 months.; l4 g9 L/ s* B0 F9 R
Physical examination at this time revealed that the$ l# G# _8 o9 k8 D
child had grown 2.5 cm in 4 months and had gained% R  R4 r9 t1 |
2 kg of weight. Physical examination remained1 i  s. f8 \6 [" n' ~0 E' v
unchanged. Surprisingly, the pubic hair almost com-5 s# K8 l. Q  ~) z
pletely disappeared except for a few vellous hairs at
; W* W3 n" h; ~5 x. u4 P5 z! ?the base of the phallus. Testicular volume was still 25 q/ q" |/ U; @, P+ F: q( Z
mL, and the size of the penis remained unchanged.7 X) @+ I% q8 h& ?
The mother also said that the boy was no longer hav-+ C& Q0 u& g8 H( Z, V
ing frequent erections.8 L! n9 L9 m  H
Both parents were again questioned about use of& g9 O# v4 O6 @* |7 F! t- m4 K
any ointment/creams that they may have applied to% D2 r% k& x7 c: f2 X
the child’s skin. This time the father admitted the) G* o$ E0 T$ D: m& o
Topical Testosterone Exposure / Bhowmick et al 541
0 d5 W6 Q1 `) A# y# P1 Duse of testosterone gel twice daily that he was apply-
* w6 n; f  \! I$ U6 I! k8 X& `) ?ing over his own shoulders, chest, and back area for( ~& F3 {+ g+ f9 h1 y" F
a year. The father also revealed he was embarrassed
- X3 z4 q; S2 [" j/ s! C' G; \to disclose that he was using a testosterone gel pre-
* [. b' v9 N& Oscribed by his family physician for decreased libido# A8 o4 H5 d" V" J. v
secondary to depression.9 K8 ~4 X2 d& j( `$ h& E: w/ }
The child slept in the same bed with parents.% A8 F0 ]. W. D9 L
The father would hug the baby and hold him on his" ]4 h8 X" h4 X4 h: m
chest for a considerable period of time, causing sig-6 c" D$ b0 s1 P- H; h) C2 b' ^
nificant bare skin contact between baby and father.6 M& I  u9 y& o, p/ @; V
The father also admitted that after the phone call,6 y5 D) {- a" U
when he learned the testosterone level in the baby. y7 b: r9 D# f; X2 P
was high, he then read the product information
8 [" j, n$ y8 b$ i' u+ P! j  O! Cpacket and concluded that it was most likely the rea-
# E6 @/ @* [" a+ f& Json for the child’s virilization. At that time, they
# R0 A# w0 ~- q% i; [decided to put the baby in a separate bed, and the9 [$ ?9 h7 {7 S0 g, \
father was not hugging him with bare skin and had' L0 l# A4 t" g& ~6 o2 m
been using protective clothing. A repeat testosterone4 \& ]" `+ E2 g2 g  X% l
test was ordered, but the family did not go to the
  \+ N9 y9 r5 xlaboratory to obtain the test.2 G/ B3 ]5 Y1 X2 N; D
Discussion8 N/ s- J4 z7 z( A0 P
Precocious puberty in boys is defined as secondary# X+ N  ^5 j: i, y
sexual development before 9 years of age.1,4, e+ P& Y( C1 z, ^7 T# R& E4 ^2 e5 h& L! ^
Precocious puberty is termed as central (true) when2 o$ z2 m$ ]6 r3 v) _+ ?/ ]4 p3 Q4 S
it is caused by the premature activation of hypo-: n4 |# k3 C& B& e
thalamic pituitary gonadal axis. CPP is more com-
& k8 }7 d  A2 omon in girls than in boys.1,3 Most boys with CPP
+ u2 e# A0 C7 Q6 a3 d2 C/ r4 |may have a central nervous system lesion that is
& `* q8 x( @; R0 b" Fresponsible for the early activation of the hypothal-
! ~3 x$ C# }- i; ^9 xamic pituitary gonadal axis.1-3 Thus, greater empha-
8 d' X2 F; ]7 n7 jsis has been given to neuroradiologic imaging in) g8 k2 o$ |1 p& S  O8 y
boys with precocious puberty. In addition to viril-) x# n4 y1 u( ]9 ~, T
ization, the clinical hallmark of CPP is the symmet-
% \4 _. a0 }  O$ prical testicular growth secondary to stimulation by
% s( y+ J# T' g# i8 N& {5 J- N' b' ^gonadotropins.1,3, L) r) D! v6 D. w$ [( i2 V: N
Gonadotropin-independent peripheral preco-
% c+ S! G+ {3 y. M+ ~7 tcious puberty in boys also results from inappropriate- A2 _# ~: p8 y
androgenic stimulation from either endogenous or
" ^" F6 \; I  N+ T" ?( jexogenous sources, nonpituitary gonadotropin stim-
, a' G/ ?  y0 o# aulation, and rare activating mutations.3 Virilizing" s4 A) O! G* ?" c# S9 m
congenital adrenal hyperplasia producing excessive
/ i$ h  S! o% M( D+ W! wadrenal androgens is a common cause of precocious3 ^* N2 m2 @  O( B7 \
puberty in boys.3,4
5 G* S- w- }0 Q* N# h' C, @The most common form of congenital adrenal" [# }4 q: L6 N8 Q" R
hyperplasia is the 21-hydroxylase enzyme deficiency.& H- a7 p+ L% C$ [% u- _4 o$ W
The 11-β hydroxylase deficiency may also result in" _/ ~+ \0 {# o9 u
excessive adrenal androgen production, and rarely,
- \  L; ?3 r) B% N1 O( _5 T& yan adrenal tumor may also cause adrenal androgen9 d" N$ ?" o& |2 ]9 i" A
excess.1,39 }+ N! x9 I9 W0 ?. ]( u! A3 F* H
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 B' O( A' n9 @9 }! }3 I5 V5 w
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
; V% j7 p  ]8 s, c# t4 NA unique entity of male-limited gonadotropin-, {" O! [" z2 o1 n1 z
independent precocious puberty, which is also known4 m3 _0 c( ^; L! A
as testotoxicosis, may cause precocious puberty at a" ?, T9 p7 H  t8 |( x0 n+ [
very young age. The physical findings in these boys
4 b% e/ a- J( ]with this disorder are full pubertal development,. o# J4 B( Y2 c/ c/ p( d
including bilateral testicular growth, similar to boys  M$ i2 u# c4 J6 ^; F* G0 y" ?+ c' [
with CPP. The gonadotropin levels in this disorder
2 U$ h" D2 n: ?* O$ tare suppressed to prepubertal levels and do not show0 t6 u; J( d2 W, P7 a* r
pubertal response of gonadotropin after gonadotropin-3 ~6 [- c4 j5 W; ^2 B( O7 D2 R
releasing hormone stimulation. This is a sex-linked' l) s9 [, {1 K4 c: K9 ~
autosomal dominant disorder that affects only9 L3 ]# f  R/ p8 W$ A& O
males; therefore, other male members of the family
0 a. K0 }! m+ p6 z! Tmay have similar precocious puberty.3
2 i) m& {% @7 P9 b8 |" p1 `  u4 j* W/ wIn our patient, physical examination was incon-! u% ^9 ~* H7 m0 f/ ?
sistent with true precocious puberty since his testi-
  L8 K; ]* o, q& H- `cles were prepubertal in size. However, testotoxicosis
/ T/ c: i, u3 _( H9 wwas in the differential diagnosis because his father( c% B, l4 {+ ?8 x
started puberty somewhat early, and occasionally,
5 f2 Y( H/ y& t5 @% ptesticular enlargement is not that evident in the
8 G4 c0 Z! v* S) Z3 t3 `8 B9 _beginning of this process.1 In the absence of a neg-
  X) M% I: G  F3 y! \' m3 [) Qative initial history of androgen exposure, our
2 P3 U% y0 f, n" P: m" ~biggest concern was virilizing adrenal hyperplasia,
: D- v! m9 S: O! Leither 21-hydroxylase deficiency or 11-β hydroxylase
& h* Q* R8 m4 V' L& edeficiency. Those diagnoses were excluded by find-
$ n: V1 ]# |4 n; n4 K4 y# f3 King the normal level of adrenal steroids.
/ G4 n3 M) S6 Q) [5 U4 j$ W6 RThe diagnosis of exogenous androgens was strongly' e0 t8 `6 O4 |1 d" z
suspected in a follow-up visit after 4 months because
- ^" H9 c6 q7 {7 J; c6 P' X: Y4 Cthe physical examination revealed the complete disap-
  y' V) b1 a; k1 ?3 _( `6 cpearance of pubic hair, normal growth velocity, and; |2 T7 S9 x: s5 t# E
decreased erections. The father admitted using a testos-
& T: d& }6 k! c* S! H6 ]; H8 Uterone gel, which he concealed at first visit. He was
, e9 A6 @: }' X9 v. ~1 yusing it rather frequently, twice a day. The Physicians’3 r5 Z- R% b3 ^  K( ]
Desk Reference, or package insert of this product, gel or
6 Y7 p3 D, {; i0 Y- F5 wcream, cautions about dermal testosterone transfer to
4 x) K9 M( J" }3 w' |2 p- ]unprotected females through direct skin exposure.
! ?5 w, H6 H% [  _7 j. |Serum testosterone level was found to be 2 times the$ K9 P! H0 p1 ~$ ?3 M& N0 G
baseline value in those females who were exposed to
# s; j" v# d4 U6 Ieven 15 minutes of direct skin contact with their male. ]5 n7 z& |  K. l
partners.6 However, when a shirt covered the applica-" @' o5 g  f8 T3 a3 j* [* b2 h
tion site, this testosterone transfer was prevented.! P' v# Q4 o" i
Our patient’s testosterone level was 60 ng/mL,6 b& P; q8 f& B6 O8 s; R
which was clearly high. Some studies suggest that
. n# D  z' z- c: Z; O# ^: {dermal conversion of testosterone to dihydrotestos-
( x3 q' \2 B% m5 kterone, which is a more potent metabolite, is more
5 |! I/ x3 `8 z' Y2 e2 Jactive in young children exposed to testosterone
: x6 X$ y4 l- G& G! Rexogenously7; however, we did not measure a dihy-# g' g2 U/ z5 Y# g/ h  ^/ ?
drotestosterone level in our patient. In addition to
; Q2 a( X# X" d2 e' l/ S7 Mvirilization, exposure to exogenous testosterone in
: e5 n( o; _: d1 s( n/ R0 Achildren results in an increase in growth velocity and
+ d0 f# o  h  r( `' ?6 Padvanced bone age, as seen in our patient.
: P* D: q' o& @: ^7 Q, H2 ]The long-term effect of androgen exposure during- h; i1 b( {' @* y" t
early childhood on pubertal development and final* v1 \" R) H& Y! |/ `' j/ \' b7 U
adult height are not fully known and always remain3 x/ H: q# d3 Y8 Q
a concern. Children treated with short-term testos-4 n' e$ x% A; h: `" \# D% z& V
terone injection or topical androgen may exhibit some
$ m) E" N. B' I4 xacceleration of the skeletal maturation; however, after
" I. |2 F+ c  D$ {cessation of treatment, the rate of bone maturation
+ B0 X# ?6 J1 j! rdecelerates and gradually returns to normal.8,9
8 f% j& A  S. VThere are conflicting reports and controversy4 W% L3 D% J8 y+ l/ e2 }" |
over the effect of early androgen exposure on adult& T4 {; g' J/ g) [) s- J
penile length.10,11 Some reports suggest subnormal+ t; i+ g, c1 l5 q& j$ V4 V" Z4 P
adult penile length, apparently because of downreg-/ f/ n4 l: Q5 g: H& t* h4 }$ ^
ulation of androgen receptor number.10,12 However,
4 K3 }- j7 b7 ~0 S; cSutherland et al13 did not find a correlation between
6 r# @' }4 m, @+ Q/ ochildhood testosterone exposure and reduced adult
% ~# s4 \2 j2 m* v1 y3 o8 m' Tpenile length in clinical studies.7 z( N1 T- B8 w6 a. u  E, G& S
Nonetheless, we do not believe our patient is
+ S" v& c7 ~0 t) l# Ygoing to experience any of the untoward effects from
8 E, F0 \, F9 L5 A9 m7 K  @6 C: t& Atestosterone exposure as mentioned earlier because
! _& a! n! H0 @4 c! {the exposure was not for a prolonged period of time.
/ s" f; ]4 p3 G$ C5 z0 TAlthough the bone age was advanced at the time of$ c  E$ H* z$ r1 v7 `" j
diagnosis, the child had a normal growth velocity at! h2 H: z0 l/ ^. ^" u3 ~
the follow-up visit. It is hoped that his final adult# E! g7 u* u0 E2 x9 [& X4 L, I
height will not be affected.* w/ Z5 i! w% }% P
Although rarely reported, the widespread avail-8 W( f: T5 Y0 k# P
ability of androgen products in our society may0 b9 {7 Y" v3 A0 v4 D/ |/ I
indeed cause more virilization in male or female2 p% ?9 ?5 P' `" C  V
children than one would realize. Exposure to andro-8 S* I7 R( ~9 ~0 o9 w- [. U
gen products must be considered and specific ques-7 T7 r* w$ o# R
tioning about the use of a testosterone product or
, a/ z* T9 X( `  k* I( wgel should be asked of the family members during
: t) v5 \( T' W5 P7 \: V/ wthe evaluation of any children who present with vir-
9 x: t7 O6 e2 V7 b3 c. j+ Nilization or peripheral precocious puberty. The diag-( z& Y( _: n* `1 D. ^+ V
nosis can be established by just a few tests and by2 v% F* S+ P. q4 w* ?
appropriate history. The inability to obtain such a
: k& i: v7 Y# y; Ohistory, or failure to ask the specific questions, may
9 z8 H( }! ]6 Q1 v; Cresult in extensive, unnecessary, and expensive
$ @* w" h& m8 Q+ ~0 Qinvestigation. The primary care physician should be; E( `" n1 e& n
aware of this fact, because most of these children8 G8 C  w2 B* G+ i" u" f
may initially present in their practice. The Physicians’
! }6 g7 ~: h  z6 k' {# I% k& A" R" LDesk Reference and package insert should also put a
# H7 Y8 v' D0 v- L1 z& {warning about the virilizing effect on a male or! d4 K' s; L4 z# o& o. @9 C
female child who might come in contact with some-0 O2 `2 @" Z8 G+ ]' F. a7 I6 V- Y
one using any of these products.8 Y& e+ @3 Y" M% v/ o
References8 s1 J& Q9 F4 M) g2 y
1. Styne DM. The testes: disorder of sexual differentiation: U" l  P" u! I. k) f
and puberty in the male. In: Sperling MA, ed. Pediatric
3 ^- B: ]9 e# IEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& K* B; p* m; g  a& R1 o2002: 565-628.
, {0 n' F+ G9 S. ^# p2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( S  R' j4 j1 g5 {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
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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
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

7 x# P% C2 F, r/ P0 H# T' ?% ?% I: X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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