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Sexual Precocity in a 16-Month-Old6 _  ^, T) m; }) ]* _
Boy Induced by Indirect Topical
$ u7 S  p7 t) b( x. S5 H5 J5 _0 C$ |Exposure to Testosterone
0 M; o2 r% P* `) SSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
4 H) c7 L& l" A& P& ^8 Pand Kenneth R. Rettig, MD1
& }: V2 N) T+ [4 b2 ^7 ?. t. iClinical Pediatrics; c& @- T. Z; Y& c" S
Volume 46 Number 6
% p; e" y3 H" |# s, `, T  i( zJuly 2007 540-5439 e$ i9 i$ E6 x, [  n1 G9 L
© 2007 Sage Publications
, X; ]' j5 U0 _7 X10.1177/0009922806296651- O2 j8 g: f! X8 F1 C$ h! T
http://clp.sagepub.com$ X4 C: m2 v( r( c) m8 Z
hosted at
0 a! N5 T8 R2 t' v9 d' ]2 [http://online.sagepub.com
5 [. U; K( I7 L2 {. ^Precocious puberty in boys, central or peripheral,! C5 k% A6 y3 w9 [/ s0 i6 w1 j
is a significant concern for physicians. Central+ q0 A! e/ P# [! |+ W
precocious puberty (CPP), which is mediated& n2 x) F8 O& T6 e" J- g  t( Z; V
through the hypothalamic pituitary gonadal axis, has
' x! J' x9 s" w2 k0 f* ]' za higher incidence of organic central nervous system
' z+ p  Y2 F% Z7 jlesions in boys.1,2 Virilization in boys, as manifested, m% U* V- T$ F/ I+ a1 G4 |, M
by enlargement of the penis, development of pubic1 A- h2 R1 O- p; P
hair, and facial acne without enlargement of testi-
7 ]% H# h' G" x6 V" e9 l0 s( I1 A! zcles, suggests peripheral or pseudopuberty.1-3 We" d, n' E5 @3 [# q
report a 16-month-old boy who presented with the
' b2 I/ Q5 `7 d0 `& V! Eenlargement of the phallus and pubic hair develop-
) H* E' i0 _( vment without testicular enlargement, which was due" T6 X5 J: [+ V5 l7 e
to the unintentional exposure to androgen gel used by
4 H( |% R# W! {8 q' e+ J/ V' pthe father. The family initially concealed this infor-
' X4 S% R! a7 M2 k+ {0 Bmation, resulting in an extensive work-up for this
$ p. e) i: P8 ?  c# F* [; |. Mchild. Given the widespread and easy availability of
8 n6 C! P! G0 b3 A* y7 k: W: utestosterone gel and cream, we believe this is proba-9 N* z- S& q* n$ V5 l
bly more common than the rare case report in the5 v) \0 j$ r* N7 V) y  K
literature.4& Q* N* Y3 `8 U" y! s5 |
Patient Report
* v( U3 Y/ F. h7 tA 16-month-old white child was referred to the
5 o* H+ M6 @* h' y) h2 j/ f4 J* }: i# fendocrine clinic by his pediatrician with the concern4 o  M, v4 {! h
of early sexual development. His mother noticed  O) A" S1 f! G- h
light colored pubic hair development when he was
" A& K( k. a3 S# m8 G! \1 v6 C) HFrom the 1Division of Pediatric Endocrinology, 2University of( F" h& b7 S! o2 d
South Alabama Medical Center, Mobile, Alabama.! v( J' ]& I5 l
Address correspondence to: Samar K. Bhowmick, MD, FACE," [$ f+ u# c7 {4 _: D
Professor of Pediatrics, University of South Alabama, College of. a5 J( x/ Y& s
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
2 T1 M: }/ A! }8 q+ R# v6 |/ xe-mail: [email protected].
# b7 [4 p0 L/ [  Oabout 6 to 7 months old, which progressively became. k, a4 q6 X6 A- L  m9 w
darker. She was also concerned about the enlarge-
8 C+ B3 v- J1 P$ n/ vment of his penis and frequent erections. The child+ T/ W  S; I7 O4 X$ H
was the product of a full-term normal delivery, with! t1 i# o4 I& B/ w" a0 k9 ^% W$ J  k
a birth weight of 7 lb 14 oz, and birth length of
+ v8 |( |; L4 V20 inches. He was breast-fed throughout the first year
" m  W. O; k, ]/ x  \3 C6 m' fof life and was still receiving breast milk along with
; d9 n' C7 y5 y+ wsolid food. He had no hospitalizations or surgery,
, O6 c; x( I. m: f2 Z! s: wand his psychosocial and psychomotor development
3 i9 P- w) O* h* Y2 r. E0 S6 nwas age appropriate.
. t/ p1 }3 J! f4 C1 CThe family history was remarkable for the father,
% D  J8 Y9 M( |who was diagnosed with hypothyroidism at age 16,. K4 L+ j2 k& l9 s* y/ b
which was treated with thyroxine. The father’s
; T5 v! b; l3 cheight was 6 feet, and he went through a somewhat
' F- H% B( ]& _5 ~early puberty and had stopped growing by age 14.9 F6 U3 b7 w! o. J, `; q% U
The father denied taking any other medication. The
: K+ N6 \/ t3 f2 m! Cchild’s mother was in good health. Her menarche7 c1 Y5 J3 C( n$ T- z
was at 11 years of age, and her height was at 5 feet7 L, K8 m+ B/ |3 D: }
5 inches. There was no other family history of pre-. t. I- U+ H; P/ A
cocious sexual development in the first-degree rela-! ?. g) r; `( _7 D
tives. There were no siblings.
3 q! L% ^; m3 P. \5 J; l0 k) sPhysical Examination7 v4 G2 E# g* l$ K% N: F9 E
The physical examination revealed a very active,
9 v9 U" j, J% x$ G1 jplayful, and healthy boy. The vital signs documented) M  s% B0 j* X  g
a blood pressure of 85/50 mm Hg, his length was
" h" F* T) `2 y: k90 cm (>97th percentile), and his weight was 14.4 kg% W4 r  F5 O, ^$ M7 X9 J; i
(also >97th percentile). The observed yearly growth
0 Z9 [, B8 c1 C( G. S2 D' C6 U, Jvelocity was 30 cm (12 inches). The examination of
9 a* s  ]" ~5 U& Y2 H" B- gthe neck revealed no thyroid enlargement.. C: B8 |' Y  v) G7 e8 k2 Q; P& Q
The genitourinary examination was remarkable for% l5 E/ _  A; }4 \5 q) ?' L8 ~9 U
enlargement of the penis, with a stretched length of
' h8 z+ Y- {0 }. A  z) P6 L8 cm and a width of 2 cm. The glans penis was very well* I6 U# o% {, f' Q& [2 o3 E0 z
developed. The pubic hair was Tanner II, mostly around
8 |1 w+ b1 r4 }$ E/ r540
' g; \+ F2 A6 V. K7 d0 j: U& T( j' Xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 M( `# h! f, hthe base of the phallus and was dark and curled. The5 ^* U( B4 |8 y" ?% ~
testicular volume was prepubertal at 2 mL each." Z2 h3 _$ P  E" [
The skin was moist and smooth and somewhat+ a7 z" b4 P% d1 Q3 N" Y
oily. No axillary hair was noted. There were no
( Y: O4 v3 ?- S% z" S) ?abnormal skin pigmentations or café-au-lait spots.
4 c- U3 Z8 _$ V; ~6 X( wNeurologic evaluation showed deep tendon reflex 2+
  P, E2 d$ U/ ?& m: Ibilateral and symmetrical. There was no suggestion
0 |7 j$ q# w- r* T! q0 [of papilledema.4 ?1 H6 x3 t& `  ?4 w  i
Laboratory Evaluation+ U/ F5 Z! d4 l! U) ?- U! Q
The bone age was consistent with 28 months by
% G! N. C) V1 s% |1 m! u# f1 zusing the standard of Greulich and Pyle at a chrono-
5 \  A. K' Q/ [  ilogic age of 16 months (advanced).5 Chromosomal
: E9 U8 \0 t9 k9 g& X9 w' ~karyotype was 46XY. The thyroid function test
) D8 w( l' n3 W7 ]. {showed a free T4 of 1.69 ng/dL, and thyroid stimu-( f  M. Q( U% s& B) J, a1 D
lating hormone level was 1.3 µIU/mL (both normal).4 b! B+ D& {. O, S' g! R, }# d
The concentrations of serum electrolytes, blood/ r2 C7 m  f' C) w( R7 o' _
urea nitrogen, creatinine, and calcium all were' t! _  x3 R6 [6 S7 }1 m$ u5 m
within normal range for his age. The concentration
0 e4 l0 @  [6 Q' Eof serum 17-hydroxyprogesterone was 16 ng/dL2 d; g- D, c" B: X4 H' `
(normal, 3 to 90 ng/dL), androstenedione was 20
$ e% \9 J- ~  ~: T$ _ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
7 g% j0 }6 \# Z& ^7 X6 Lterone was 38 ng/dL (normal, 50 to 760 ng/dL),  d9 C' \( ~2 Z9 i8 n: T; s
desoxycorticosterone was 4.3 ng/dL (normal, 7 to1 {7 ?- q" `7 V' ]$ ~: d
49ng/dL), 11-desoxycortisol (specific compound S)
) ^4 u* H0 d( ?was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 S* W7 m# O& O) ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( b2 ?* w2 N( u6 Q6 Stestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
* |7 H/ G- C+ O  U) aand β-human chorionic gonadotropin was less than
: G9 y' Z' h: ^5 mIU/mL (normal <5 mIU/mL). Serum follicular1 W  ?1 C9 N, ]: [
stimulating hormone and leuteinizing hormone
! V0 \$ F/ [8 _* X4 X3 L9 e/ Vconcentrations were less than 0.05 mIU/mL
& N2 f/ m- L' x" |8 }( p6 o  F( j(prepubertal).0 b2 S) @" p/ Q) |
The parents were notified about the laboratory, U. E6 t: j& M
results and were informed that all of the tests were
6 s2 Z+ s" n1 s/ s- ~9 \! Pnormal except the testosterone level was high. The' Z! q' w$ J: r+ V* P1 \4 t
follow-up visit was arranged within a few weeks to5 F* f) |* p0 u1 @: d% }) G
obtain testicular and abdominal sonograms; how-, L/ a8 p2 G( v! D' X8 U, n) L
ever, the family did not return for 4 months.
. c' _% E4 H8 L; \/ hPhysical examination at this time revealed that the8 o! V4 C) q( `' _1 D
child had grown 2.5 cm in 4 months and had gained2 f; l" i: M9 Y# {& C8 N; V
2 kg of weight. Physical examination remained9 \1 n& `/ n6 b) M+ I! `
unchanged. Surprisingly, the pubic hair almost com-
' [( o/ N1 B- c3 m* X: G7 Upletely disappeared except for a few vellous hairs at
& g# |! H+ W$ B8 L/ {7 s. Bthe base of the phallus. Testicular volume was still 2
' `2 S" p1 M% `& MmL, and the size of the penis remained unchanged.! j. h+ w& H* i2 q7 d
The mother also said that the boy was no longer hav-
; v# }, N8 e! J8 w6 _! ~ing frequent erections.
5 j! N0 U! o8 GBoth parents were again questioned about use of" H3 \) `& G6 j
any ointment/creams that they may have applied to
; f, s' t# [$ ^4 f" q7 Wthe child’s skin. This time the father admitted the
% ]* Z8 }; S: vTopical Testosterone Exposure / Bhowmick et al 541
; Z9 v8 d+ }1 L9 C3 t# cuse of testosterone gel twice daily that he was apply-
: O5 p- R- a, Y) L' Ving over his own shoulders, chest, and back area for: x& @/ p1 z& C. H! ~% D& S
a year. The father also revealed he was embarrassed
8 b- {1 M0 l' R: Hto disclose that he was using a testosterone gel pre-
9 V$ b! e/ G' V8 fscribed by his family physician for decreased libido6 p/ M$ x4 u  ]5 V$ R$ y
secondary to depression.
5 ?# }' s9 u) z" }1 N  E" z* \. gThe child slept in the same bed with parents.: E- V! y* F. l6 H9 z' W
The father would hug the baby and hold him on his
9 O# E5 G, ^0 \4 K$ g4 ^0 `chest for a considerable period of time, causing sig-7 K# f; K4 f/ O1 x: |5 f- u" w) I
nificant bare skin contact between baby and father.
  C& S2 A1 [5 u1 T! l" VThe father also admitted that after the phone call,9 I% {# U) K3 v& S2 {
when he learned the testosterone level in the baby$ r  _' H7 R! C& j6 R6 }
was high, he then read the product information8 D3 T% C3 ^% [* z% [( r, h
packet and concluded that it was most likely the rea-1 W2 R7 x) e; C# ~- [$ a
son for the child’s virilization. At that time, they
2 M/ f# x2 F! Z$ x3 w" A2 Xdecided to put the baby in a separate bed, and the1 j8 a6 Q) {* j9 c5 z
father was not hugging him with bare skin and had9 P0 |4 y# ?  a
been using protective clothing. A repeat testosterone1 Z) n' E. B; V2 I9 Q8 ~  k
test was ordered, but the family did not go to the2 H) m- X+ M2 T
laboratory to obtain the test.
# ?$ s# g! D: g' a' `; WDiscussion
5 _. h4 z4 r* w' N8 c& mPrecocious puberty in boys is defined as secondary" X3 a! g' U; h, |" ^
sexual development before 9 years of age.1,4
$ X  |, m, |0 H  S: C6 q9 b4 ~1 S0 ]4 _Precocious puberty is termed as central (true) when+ M7 G4 [3 h0 c5 E; e/ y+ q
it is caused by the premature activation of hypo-
" `$ J1 E( v- @( [, Athalamic pituitary gonadal axis. CPP is more com-
: i/ s& u7 G. w8 p" Fmon in girls than in boys.1,3 Most boys with CPP
- G; O# a+ T& B1 q  i5 @5 G2 Xmay have a central nervous system lesion that is3 k" r  G, `. Q9 u, z+ f4 {* u
responsible for the early activation of the hypothal-
: I7 r1 N3 r- jamic pituitary gonadal axis.1-3 Thus, greater empha-
. J) f' d) i9 L0 h; fsis has been given to neuroradiologic imaging in
9 E% S5 v6 D+ T0 u! w" O, ~boys with precocious puberty. In addition to viril-
! E" y( Y; t' x. r2 i3 p3 \ization, the clinical hallmark of CPP is the symmet-; M6 N& e: b7 q7 W, R  J
rical testicular growth secondary to stimulation by8 @7 w6 f8 \" ]4 \" x
gonadotropins.1,34 X1 B# ~5 i8 C9 F
Gonadotropin-independent peripheral preco-
" Q% _$ y& S9 G! U; U$ @cious puberty in boys also results from inappropriate! g2 R* A- {" Q+ Y
androgenic stimulation from either endogenous or
6 ^1 t4 ^9 o6 texogenous sources, nonpituitary gonadotropin stim-
! L2 P- l$ R: t. |! sulation, and rare activating mutations.3 Virilizing
# ?! q7 H" p4 M6 B: `+ lcongenital adrenal hyperplasia producing excessive
- ]4 x7 z! s3 K/ B0 Y9 Cadrenal androgens is a common cause of precocious- K1 r8 j  L$ R( T
puberty in boys.3,4/ J' T: F3 a2 Y
The most common form of congenital adrenal
. C  }" h, u5 L& B$ C$ Y1 I; e. X- Lhyperplasia is the 21-hydroxylase enzyme deficiency.# J3 z" _  l% U9 X* D0 |* Q/ o
The 11-β hydroxylase deficiency may also result in* X7 Z/ R( p0 ^+ r% H. j5 r
excessive adrenal androgen production, and rarely,
' Q/ R' c' V+ v- Fan adrenal tumor may also cause adrenal androgen6 X' `4 U  N, e8 n
excess.1,3
+ l" R4 O' S* y' bat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 V- U  N' N2 C
542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 R- L. N$ y1 o8 L6 z- J9 A* T
A unique entity of male-limited gonadotropin-4 n' L+ D3 S3 S. t: \" I
independent precocious puberty, which is also known0 H! V& O3 D" J; _& L
as testotoxicosis, may cause precocious puberty at a
5 u" T- x  q4 W. overy young age. The physical findings in these boys
. a8 G3 b% t" V, D5 J. y) ewith this disorder are full pubertal development,# d3 N* G/ O0 G8 r' H! q; P6 V; X
including bilateral testicular growth, similar to boys
1 T( g6 G3 s+ iwith CPP. The gonadotropin levels in this disorder
& t/ q8 A0 |2 a5 s; f4 d0 T% Care suppressed to prepubertal levels and do not show. {; f! Z. W$ g8 y! L. t# o. e
pubertal response of gonadotropin after gonadotropin-- c& f: C* N/ |3 c1 C/ s9 a
releasing hormone stimulation. This is a sex-linked
0 j# @  r) [$ qautosomal dominant disorder that affects only
8 z* |, R& i% M4 r" L. Nmales; therefore, other male members of the family, [( Q1 Z" q3 A2 _
may have similar precocious puberty.3$ N6 [# p& P1 C: Z/ `0 K( Z0 O+ ~
In our patient, physical examination was incon-
3 I8 k- y8 c/ y/ R: o: w' k0 I6 osistent with true precocious puberty since his testi-' L# Z/ Y0 u& s* K3 `2 j
cles were prepubertal in size. However, testotoxicosis
  j3 \+ a/ |1 d" C1 M% hwas in the differential diagnosis because his father7 t9 d- a3 ]) ]5 P3 k1 N! r; U, S
started puberty somewhat early, and occasionally,1 F7 \2 k7 {' J: g% y( G  k; l
testicular enlargement is not that evident in the. u& Z, _  ?2 D; G+ ~# x. X" C
beginning of this process.1 In the absence of a neg-7 e" Y9 L7 w" k5 E5 d
ative initial history of androgen exposure, our$ h: g: y' N. k; c9 D! I1 s" e
biggest concern was virilizing adrenal hyperplasia,% ]: L1 c( K, |' {* b* s2 J/ ^
either 21-hydroxylase deficiency or 11-β hydroxylase
" J0 a; C( Q% R1 m( S6 ~" kdeficiency. Those diagnoses were excluded by find-
' G' H4 V5 M4 g! X1 y: Fing the normal level of adrenal steroids.! p$ i, c, N  X: x) {& I3 ^4 S) h
The diagnosis of exogenous androgens was strongly
$ x+ X6 ~2 ?' B" ?, k; Ssuspected in a follow-up visit after 4 months because
+ N$ U* _; |& A4 uthe physical examination revealed the complete disap-/ h7 J/ e' `8 K( U* J0 y" z) s
pearance of pubic hair, normal growth velocity, and! J' n* u0 j5 ?
decreased erections. The father admitted using a testos-$ c: p+ F! H3 [1 A% ~5 Y
terone gel, which he concealed at first visit. He was
7 v6 L/ w5 M3 a9 b: E7 Q! \using it rather frequently, twice a day. The Physicians’; @9 |, H4 c4 X3 {( p0 R  t3 s& d  A
Desk Reference, or package insert of this product, gel or
- g4 j# O) U& I% T6 f" x1 fcream, cautions about dermal testosterone transfer to1 D& U( Z; G" H* q/ A$ Q4 D0 Q
unprotected females through direct skin exposure., s& ]5 `" Y" N0 d# i0 C
Serum testosterone level was found to be 2 times the3 r# |8 l- c( n2 D& U+ n6 L- M6 U
baseline value in those females who were exposed to
8 P& P1 N8 u5 n$ z0 Neven 15 minutes of direct skin contact with their male8 z- w# ?5 F7 d1 n+ X6 J2 m
partners.6 However, when a shirt covered the applica-
& u5 `! @/ }  \8 V# ation site, this testosterone transfer was prevented.
* x! d+ f# K- q8 @! R4 m! gOur patient’s testosterone level was 60 ng/mL,7 U4 @  v& }, g6 X
which was clearly high. Some studies suggest that3 z; c3 e1 E, V& m! [
dermal conversion of testosterone to dihydrotestos-; G; B. p, u6 o$ T0 D: c1 @' t
terone, which is a more potent metabolite, is more% |- r& y& m$ _( Y# h% S3 {
active in young children exposed to testosterone7 R+ O+ I) v) |) _
exogenously7; however, we did not measure a dihy-. q4 p8 i$ S8 [" u
drotestosterone level in our patient. In addition to" z* j& m' P$ f  H, V
virilization, exposure to exogenous testosterone in
  Z* `3 b. ]+ e6 Qchildren results in an increase in growth velocity and4 X/ N0 n7 \  z
advanced bone age, as seen in our patient.
: C' L% J# N- ^8 ~1 y; LThe long-term effect of androgen exposure during& a8 c! h; m, \6 W& M. G" q) K
early childhood on pubertal development and final3 j) a' D& x3 e4 s$ u  z/ L& H& o8 [
adult height are not fully known and always remain
" J7 |5 _3 w' f6 Ha concern. Children treated with short-term testos-) ?$ ^! ~: g# I. r: Q
terone injection or topical androgen may exhibit some* m& k  ^, u4 K
acceleration of the skeletal maturation; however, after9 T* Q" n9 u9 \2 G, }
cessation of treatment, the rate of bone maturation- I$ D+ V, `, n7 j2 w
decelerates and gradually returns to normal.8,91 [7 i+ J- R- f6 c: e
There are conflicting reports and controversy
& {/ r( Y3 r: B$ _& \8 h9 B. `& Zover the effect of early androgen exposure on adult  O' V4 Y  D; ~! k
penile length.10,11 Some reports suggest subnormal
. R0 p; ^+ A4 H  b5 `) radult penile length, apparently because of downreg-  O4 m0 U" l7 c& O" h8 N+ {
ulation of androgen receptor number.10,12 However,. n2 |& u4 |  C- e
Sutherland et al13 did not find a correlation between3 s3 j7 D( K7 i7 q3 _6 K
childhood testosterone exposure and reduced adult9 G8 {3 O/ ?) k5 ]* B7 m
penile length in clinical studies.
( @, g5 J' s; {6 o( TNonetheless, we do not believe our patient is0 `/ K( g7 ]: P0 y0 v" {' J0 J' r
going to experience any of the untoward effects from
; v3 v5 O/ K9 R+ A4 S( O/ O" U/ Htestosterone exposure as mentioned earlier because: Y* G9 @6 o* V; \$ O
the exposure was not for a prolonged period of time.
+ f) B: u6 _  tAlthough the bone age was advanced at the time of
  s/ d+ e$ v2 B2 H8 \# \diagnosis, the child had a normal growth velocity at
8 o" M/ u' ?: `0 q- Othe follow-up visit. It is hoped that his final adult
: k  N; d4 j, B  z) L  l( }0 Cheight will not be affected.# @3 u) e/ k; @8 B" H8 W0 A
Although rarely reported, the widespread avail-
) x4 p! H+ a) M4 E: Yability of androgen products in our society may7 A6 V" \! }8 J  |6 \2 g+ Q6 K
indeed cause more virilization in male or female% T: R- V* j, e7 L$ l( n6 }7 \
children than one would realize. Exposure to andro-
' u8 j, y$ c. Q4 N1 ngen products must be considered and specific ques-
8 _. U( g) R8 }/ Itioning about the use of a testosterone product or
8 H- ?0 Y  m" Tgel should be asked of the family members during1 `+ o5 g" p7 X- P! b
the evaluation of any children who present with vir-% O' x6 P( g9 d2 X8 N$ e; k
ilization or peripheral precocious puberty. The diag-- k' K- e9 _; f; f* b. q5 ]; G
nosis can be established by just a few tests and by# T" D/ U$ h' Y. Q" H: z6 G# J( E( H
appropriate history. The inability to obtain such a& k: o& K5 t' ^8 d/ y/ v
history, or failure to ask the specific questions, may
+ e8 q: k4 m, U5 aresult in extensive, unnecessary, and expensive
+ K- }7 W+ s* e3 A- \! e( Zinvestigation. The primary care physician should be
9 _) f0 O& z" g, iaware of this fact, because most of these children
- [6 \$ m8 `) r6 v4 e  Lmay initially present in their practice. The Physicians’
% V# g4 Q0 c) UDesk Reference and package insert should also put a
3 c' c$ E% y/ S& q7 p% F/ @; W7 Twarning about the virilizing effect on a male or
# O! O% J' g- d4 ^2 U$ d7 b: Vfemale child who might come in contact with some-+ }- `+ ^8 ?0 ]* C* j0 Z
one using any of these products.
2 f2 K! g& w/ b, z$ l9 L0 b8 ^$ T6 PReferences8 h0 y5 {+ _! B. u
1. Styne DM. The testes: disorder of sexual differentiation
7 ?* f# F! P' h+ y" O* r* _and puberty in the male. In: Sperling MA, ed. Pediatric
6 a2 M; U( M/ E$ iEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ q- J- i' x) I. ~( }" c: i: Q2002: 565-628.0 K: e& S( c  i6 M, P, L8 C8 l
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 S) |5 d$ I3 W7 W
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
( w0 O5 G) h, o# ]+ p' |Boy Induced by Indirect Topical
0 D/ Y* o, a0 o& O: K# ?Exposure to Testosterone+ r4 `# Z4 x* r) q2 v1 D
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 I8 r! Z" g7 a2 X/ tand Kenneth R. Rettig, MD1
6 g$ ~6 X0 j. y6 T3 ~Clinical Pediatrics
: R  D+ [: C# J" bVolume 46 Number 6
% Q* X& n  h5 R. RJuly 2007 540-5434 W/ c+ `; f! D! X: ?
© 2007 Sage Publications+ U. X7 \5 C9 z5 b) o) v/ \" y
10.1177/00099228062966515 t0 C2 G& {6 N  P$ X1 a' T. C
http://clp.sagepub.com
( g) W4 }% u- w+ l3 Nhosted at
. ~' g5 F6 g; i1 H  ^! _$ uhttp://online.sagepub.com
  F9 z% B( ]* s8 K/ e+ ~* b5 cPrecocious puberty in boys, central or peripheral,6 E+ y9 V; Y% s" E3 _
is a significant concern for physicians. Central5 D7 }6 k& {" I2 i9 X  F  c- g
precocious puberty (CPP), which is mediated+ u. i5 ]4 t3 d9 q  A5 e, I
through the hypothalamic pituitary gonadal axis, has, H6 c+ V) s# m5 e% G
a higher incidence of organic central nervous system
% ^$ g2 W* O  |1 \lesions in boys.1,2 Virilization in boys, as manifested0 q' R4 e7 b. X9 s6 p3 }
by enlargement of the penis, development of pubic5 g% k8 n: g- d
hair, and facial acne without enlargement of testi-' e" e. v( D, _* R
cles, suggests peripheral or pseudopuberty.1-3 We9 g7 ^3 V% `' z' l4 q2 [9 {
report a 16-month-old boy who presented with the
0 L) G" }5 {  Henlargement of the phallus and pubic hair develop-* O4 u5 K7 x4 j. n; H
ment without testicular enlargement, which was due6 |; F* U9 k, O
to the unintentional exposure to androgen gel used by
0 K! X. ^3 M; S: ?; sthe father. The family initially concealed this infor-
; G. L- t8 Q0 F0 x) J/ b& mmation, resulting in an extensive work-up for this- {1 R& p, y: O5 k/ t0 L& i
child. Given the widespread and easy availability of
3 j- x' n3 b$ T: ztestosterone gel and cream, we believe this is proba-
! k* i( h) p! l5 b$ {6 Hbly more common than the rare case report in the
+ P# h6 f" I& c* aliterature.4& Q! Q1 z9 a) h/ Y! M+ N5 d$ v2 f" t
Patient Report
* M. U+ e$ [: a0 y: uA 16-month-old white child was referred to the
/ T. s/ M; Q* ^5 z6 b4 e0 U6 Uendocrine clinic by his pediatrician with the concern& D. g7 _9 i- `8 x
of early sexual development. His mother noticed  v2 p- P5 j. o5 s
light colored pubic hair development when he was- ]; I6 h, X5 P' U1 G# I
From the 1Division of Pediatric Endocrinology, 2University of
- M- M% I7 h8 A0 ISouth Alabama Medical Center, Mobile, Alabama.
5 R* v; V* X% A4 r( k9 r) JAddress correspondence to: Samar K. Bhowmick, MD, FACE,
; K" `& R) x2 wProfessor of Pediatrics, University of South Alabama, College of$ Z% S$ [# K: T
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 u. _% R. F: Z1 b8 S4 ~, @e-mail: [email protected].& q$ V% ^) P3 V3 l$ I. x) B
about 6 to 7 months old, which progressively became" _; \1 m, y% W9 G
darker. She was also concerned about the enlarge-" Q" s$ U. v- }: F" O0 m- N- c) X3 U- M
ment of his penis and frequent erections. The child
! j) S* S7 y6 W; Twas the product of a full-term normal delivery, with0 S- {3 d7 f% O" C8 k  ]' F' S
a birth weight of 7 lb 14 oz, and birth length of
9 }- x+ W( [: |, D4 [( g20 inches. He was breast-fed throughout the first year5 K" m! h2 ?7 Z- O* b
of life and was still receiving breast milk along with2 X# L/ N0 }# K& @, x
solid food. He had no hospitalizations or surgery,
2 Z* M7 ?& |3 f' `and his psychosocial and psychomotor development  U: f/ g. V7 _3 R- A1 T
was age appropriate.
' W# Z8 I) f+ R. VThe family history was remarkable for the father,
5 P% [# v% Z1 a+ i7 R& {, [who was diagnosed with hypothyroidism at age 16,
; p4 t/ o% N* O5 c9 K; \which was treated with thyroxine. The father’s8 A& a% i3 Z+ R- Y8 J# N4 ^0 H) I7 D
height was 6 feet, and he went through a somewhat
# Y; V  O5 L  W$ Searly puberty and had stopped growing by age 14." ?& D$ ^, P7 y: \. }" Y
The father denied taking any other medication. The
# B% k, z) k. c& ~3 z2 Echild’s mother was in good health. Her menarche( |  t: e  `" Q6 z% U& W
was at 11 years of age, and her height was at 5 feet- K3 B8 g8 h& a! y! p
5 inches. There was no other family history of pre-0 p# K% i; ~1 l
cocious sexual development in the first-degree rela-' j, r! H4 @" C% Q: V) `
tives. There were no siblings.
4 e5 b$ s2 w2 e0 s! p3 X, IPhysical Examination% v. N4 \3 n. S, h2 ~
The physical examination revealed a very active,) \' j$ I- P' f' c7 M4 ^
playful, and healthy boy. The vital signs documented
9 e3 h- K- i& M) {) f% [" Ya blood pressure of 85/50 mm Hg, his length was3 G- S  W7 k5 l1 Q5 V1 o
90 cm (>97th percentile), and his weight was 14.4 kg% N2 i* x/ @9 Q
(also >97th percentile). The observed yearly growth7 d/ o& n* Y6 w, d  Z- _% H
velocity was 30 cm (12 inches). The examination of
0 U# z+ Q9 F; j; kthe neck revealed no thyroid enlargement.
' `2 U" }; h' }" G) c' v" m0 R% RThe genitourinary examination was remarkable for: H  ?; t  p5 t2 _/ X+ P
enlargement of the penis, with a stretched length of
2 @. P% X# Z! B/ `0 }$ j9 H4 t8 cm and a width of 2 cm. The glans penis was very well- I/ t  b- ^+ L; v
developed. The pubic hair was Tanner II, mostly around
, o/ G  r+ \# X# e: s540
" G) j0 e8 I0 Z* Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. m( T3 m6 ^- Y
the base of the phallus and was dark and curled. The
3 s! z+ s9 b) W% l! @- Ytesticular volume was prepubertal at 2 mL each.& z; Z; d+ K- M6 T" a' s7 V6 g  o
The skin was moist and smooth and somewhat( h, Q9 y. u: I0 @$ X
oily. No axillary hair was noted. There were no$ R% B- E$ b) X% q! L5 i4 w, C  g
abnormal skin pigmentations or café-au-lait spots./ _8 J' k+ e4 ~6 @: a, B
Neurologic evaluation showed deep tendon reflex 2+! b! m3 r$ V0 x) f
bilateral and symmetrical. There was no suggestion! {) p1 t9 B4 C; V
of papilledema.
& h$ D6 B7 M$ ]* x% ~+ v& ^6 @Laboratory Evaluation: S# ^# |: C  x' d7 `2 m
The bone age was consistent with 28 months by5 ^  N* e6 i5 X3 N8 h
using the standard of Greulich and Pyle at a chrono-
: F1 e/ l# M: H1 U6 M' J9 h$ |logic age of 16 months (advanced).5 Chromosomal
' F- D6 j1 x# u! vkaryotype was 46XY. The thyroid function test
& T) w7 B/ y1 K; L+ O: Y! @0 \3 M1 ~4 Yshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 i* y- j( U+ S8 ]& y8 O$ ]lating hormone level was 1.3 µIU/mL (both normal).
/ G& C. L! K) E) v2 e/ ?The concentrations of serum electrolytes, blood% O. p- M1 f6 ?1 j# x& b  i9 h
urea nitrogen, creatinine, and calcium all were
) Q1 G: t4 \9 n& G6 P; ^, s. a, o% L6 t8 xwithin normal range for his age. The concentration
4 {8 n: t% I7 R  Eof serum 17-hydroxyprogesterone was 16 ng/dL
4 ]: r0 v: E# Q; Y9 F* U(normal, 3 to 90 ng/dL), androstenedione was 20
7 h4 d; A, t* X5 e* M) c/ m; Rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 m' B2 Z+ V! W6 C/ q) [8 x
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
; S' n; q/ N0 r$ [, y/ M" x, J! H( ndesoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ K: Z/ O5 `8 o* X$ S$ I$ ]- C49ng/dL), 11-desoxycortisol (specific compound S)7 H( F2 ^3 I' {7 N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& r: ?) O* _' }9 B" k& Xtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. l4 q5 u; M* G4 n2 I/ M& W1 e
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 [) M: O5 R1 K' s, r9 S( f
and β-human chorionic gonadotropin was less than+ [# D9 C! ?) {; D; v, F
5 mIU/mL (normal <5 mIU/mL). Serum follicular
* H6 g/ N- }" I+ |( p* ?stimulating hormone and leuteinizing hormone
( C: Y  U2 y. J8 ^2 q8 Y$ A. Gconcentrations were less than 0.05 mIU/mL' ~3 x1 C/ O" j" P6 z& |7 E
(prepubertal).
; {0 E9 a2 R( E8 t. LThe parents were notified about the laboratory$ p7 C7 o$ t/ [: C( Z4 v
results and were informed that all of the tests were
6 l' l4 T6 n1 }normal except the testosterone level was high. The* ?  K# a9 E4 _+ U1 @
follow-up visit was arranged within a few weeks to
( ]0 L! t: J9 o7 P6 @3 T/ B- Mobtain testicular and abdominal sonograms; how-) o4 Y: q1 y$ f. I# e- n, z( J
ever, the family did not return for 4 months.
& m) v* F2 c4 _  x4 W. TPhysical examination at this time revealed that the
, k" l: K6 d+ Z& B* ~2 Q9 c" A' J5 R3 Bchild had grown 2.5 cm in 4 months and had gained5 G' m/ h" U& j# G; M! i
2 kg of weight. Physical examination remained8 i9 S/ v# P  `7 i; r0 u
unchanged. Surprisingly, the pubic hair almost com-* \6 N$ d9 D; Y
pletely disappeared except for a few vellous hairs at
* ^1 q) ~7 Y. \4 k* Z& Q! {9 }& Pthe base of the phallus. Testicular volume was still 2
5 R$ C7 {( q0 @7 PmL, and the size of the penis remained unchanged.
8 L3 R7 L% B6 i# BThe mother also said that the boy was no longer hav-0 n8 Y0 `$ }- Z& |
ing frequent erections.0 n- {" K1 ^5 I! A
Both parents were again questioned about use of
' s  ]7 E( x; z9 i: ?5 W- Y. z; fany ointment/creams that they may have applied to
+ k! ?/ K7 S7 H: dthe child’s skin. This time the father admitted the
, G! D2 p. K& LTopical Testosterone Exposure / Bhowmick et al 541
0 h1 k% t% q7 T4 s+ I3 guse of testosterone gel twice daily that he was apply-$ ~, Z: r- v% @4 ?
ing over his own shoulders, chest, and back area for
7 y6 q1 g# P- h4 da year. The father also revealed he was embarrassed, ]! J+ I% \5 V6 b& a
to disclose that he was using a testosterone gel pre-
5 G+ P3 a+ X9 M3 q) w+ sscribed by his family physician for decreased libido0 Q2 c; G( O. K2 r* \8 }
secondary to depression.  S7 ?: V2 m; ~7 }# G4 g" J
The child slept in the same bed with parents.
/ N( h& d/ B+ p& c  B6 `+ K; LThe father would hug the baby and hold him on his
% I* G! C3 G6 ]4 vchest for a considerable period of time, causing sig-
2 R& C5 u8 e  Z7 ~nificant bare skin contact between baby and father.
, w+ m8 A1 ^! o$ Y7 h! C1 v! lThe father also admitted that after the phone call,! S) a3 A/ y1 {# ~0 L4 w' @! E
when he learned the testosterone level in the baby6 u& {/ S" q$ Q
was high, he then read the product information
$ O' g, B# ]$ f* Cpacket and concluded that it was most likely the rea-6 @4 c! V! Q  O, F/ e
son for the child’s virilization. At that time, they6 b# _  e, [+ h2 w2 j/ A+ l6 a
decided to put the baby in a separate bed, and the
" ^4 r- ^( D0 u" lfather was not hugging him with bare skin and had
' k1 F" j9 p2 \7 N( _been using protective clothing. A repeat testosterone
2 N5 `" Z, \: K' L/ Rtest was ordered, but the family did not go to the9 `* C6 l$ I% S+ b8 I6 k
laboratory to obtain the test.
- f$ n! q( V; ]. m* q" t* r/ RDiscussion8 X2 t1 o3 @. o/ H7 B
Precocious puberty in boys is defined as secondary
1 E# v0 X7 R( G' u! B3 osexual development before 9 years of age.1,4
$ J# g' p2 s5 b4 n1 N4 Q* O7 m1 GPrecocious puberty is termed as central (true) when
9 T  F+ N: O' Y1 r7 V% n+ {it is caused by the premature activation of hypo-
% Y; ~0 C5 H7 r- v9 m1 D: Kthalamic pituitary gonadal axis. CPP is more com-
- t+ I# s$ w) h6 a9 `6 A! m: rmon in girls than in boys.1,3 Most boys with CPP4 ~2 [  J/ @7 k$ J: v. H
may have a central nervous system lesion that is
) r% z  _6 e& ?- l. n. x( Vresponsible for the early activation of the hypothal-' b- Z: S/ C0 r8 P
amic pituitary gonadal axis.1-3 Thus, greater empha-
" F4 i2 k' @3 fsis has been given to neuroradiologic imaging in2 o: e' h8 z' u$ c) A9 N
boys with precocious puberty. In addition to viril-
4 q/ G; z& t$ d) {: D4 \% Sization, the clinical hallmark of CPP is the symmet-
8 v% n+ t6 ^+ Y7 Urical testicular growth secondary to stimulation by* q2 d% T' q( i% p/ v" I
gonadotropins.1,31 t; y& x  |9 d7 ?
Gonadotropin-independent peripheral preco-
9 e' O7 i$ k" h) w. b" p3 icious puberty in boys also results from inappropriate' b1 {" Q3 t! R3 n% |& r& W
androgenic stimulation from either endogenous or
7 e6 A0 Z, [9 E# ~; aexogenous sources, nonpituitary gonadotropin stim-
5 e2 P5 O" {( `2 mulation, and rare activating mutations.3 Virilizing
1 |5 S$ J+ P" l- I- }- J  @congenital adrenal hyperplasia producing excessive# f& X' i# P9 A8 x/ y# }3 f6 e1 a5 V
adrenal androgens is a common cause of precocious
! i& @4 U+ c  P4 O2 O  H% H, lpuberty in boys.3,4
3 A" m" f( r+ B7 pThe most common form of congenital adrenal; |' N" l) P) \7 v
hyperplasia is the 21-hydroxylase enzyme deficiency.1 k2 U! V- v. M- ?5 B* s
The 11-β hydroxylase deficiency may also result in
3 t2 `. W& [# W) }- j: Kexcessive adrenal androgen production, and rarely,
7 Z3 o  o+ c# s6 S) Zan adrenal tumor may also cause adrenal androgen! S* v- l, I/ O' v" L4 ^- [
excess.1,3$ |& k' _4 k2 f7 L
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' b- W# V4 H$ o" k2 A6 r# [) e
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, N6 v5 e* j: a! {4 `4 d
A unique entity of male-limited gonadotropin-
& a, D* _; W2 u  _8 g1 Yindependent precocious puberty, which is also known+ }' g, N8 x9 X1 G
as testotoxicosis, may cause precocious puberty at a
- O9 c7 o7 b, s  cvery young age. The physical findings in these boys
3 ]  p3 u3 s5 I5 G) l3 N. @" e5 Hwith this disorder are full pubertal development,
$ r; t  n  m! D5 s, dincluding bilateral testicular growth, similar to boys  f/ T, F2 ^# k. T4 l
with CPP. The gonadotropin levels in this disorder
6 p& x, b. t0 [# Care suppressed to prepubertal levels and do not show# k0 \" d# {, Q" A
pubertal response of gonadotropin after gonadotropin-
9 K6 H" B4 |1 J0 m2 u6 Freleasing hormone stimulation. This is a sex-linked, q$ M3 i' e4 g! h2 a8 m5 x( W) _9 J
autosomal dominant disorder that affects only% m3 M5 q; b6 E+ S$ @1 O3 x& R1 J! Y# S
males; therefore, other male members of the family
" e( J: V. Y9 A" imay have similar precocious puberty.3
3 ~- M$ E  o: l4 h& j- F; qIn our patient, physical examination was incon-. i, K- K$ u( C: c! v% Y- b
sistent with true precocious puberty since his testi-4 G! Y. Q% B# }4 H8 F
cles were prepubertal in size. However, testotoxicosis
' a6 n$ P7 t8 u5 O# h: vwas in the differential diagnosis because his father
2 q+ o% p5 O/ Z* |. Z, J+ k  x; q1 Q4 O9 Fstarted puberty somewhat early, and occasionally,
( E/ b7 u7 z1 `testicular enlargement is not that evident in the0 |, ?! Z1 ^* `% i# e* Y; z
beginning of this process.1 In the absence of a neg-
; W. }4 W* N) O# }5 ?1 h! P: Oative initial history of androgen exposure, our+ R% w) ~0 F* X; z' w5 d( |
biggest concern was virilizing adrenal hyperplasia,
' e% W1 p# d( k! ~! b3 O4 B. Geither 21-hydroxylase deficiency or 11-β hydroxylase. n  @( w" ^6 n2 }7 i
deficiency. Those diagnoses were excluded by find-4 h8 P  k; w1 t7 d$ k4 X
ing the normal level of adrenal steroids.
& A9 d1 s5 w! P' S6 v7 j8 eThe diagnosis of exogenous androgens was strongly
0 Y: Q9 d* M3 G7 `$ V' O: Asuspected in a follow-up visit after 4 months because4 K( Z- h# P: ?( H. b/ s. H
the physical examination revealed the complete disap-
7 f# O  v9 n/ {7 R' w* b& Zpearance of pubic hair, normal growth velocity, and
! R# r( I9 _0 l+ ^+ h3 w7 A+ T$ e+ l% udecreased erections. The father admitted using a testos-
( u& C# n0 W, `3 \9 M* Jterone gel, which he concealed at first visit. He was) b$ O( s: {" o$ m& S! J
using it rather frequently, twice a day. The Physicians’
. o& Q. |9 J: cDesk Reference, or package insert of this product, gel or3 k/ E% _  `- E9 ]$ q) K
cream, cautions about dermal testosterone transfer to  Y: d- o: x0 N/ M
unprotected females through direct skin exposure.
9 b7 f- A% c( m$ C! `Serum testosterone level was found to be 2 times the
$ ~, Q* W+ G8 F, d8 O* r) rbaseline value in those females who were exposed to
& _8 Y, W& C/ r! heven 15 minutes of direct skin contact with their male- S8 O  o$ [! u+ m: k
partners.6 However, when a shirt covered the applica-# c% N8 j" m% k- R) d5 |# R
tion site, this testosterone transfer was prevented.* F) |# K9 s+ Y
Our patient’s testosterone level was 60 ng/mL,4 g7 u. |* L- N; \7 W7 a" U8 B! ^( d
which was clearly high. Some studies suggest that4 [" P) [! R: @& z* S6 x* c
dermal conversion of testosterone to dihydrotestos-
: G! C' f1 w" Rterone, which is a more potent metabolite, is more
8 y( i9 L+ H$ I& cactive in young children exposed to testosterone1 \& f" i: X( p
exogenously7; however, we did not measure a dihy-
: }  u# h8 `7 j  |drotestosterone level in our patient. In addition to
7 n+ W6 P, H6 M' z8 V2 M8 @virilization, exposure to exogenous testosterone in
( k- j+ j' Y3 Y/ ^1 H# jchildren results in an increase in growth velocity and3 t9 `- A! e4 `( p0 W
advanced bone age, as seen in our patient.1 E1 B3 D* d; }8 }$ d  a
The long-term effect of androgen exposure during
* p7 g- K* z/ S" d+ a  eearly childhood on pubertal development and final# l* h  ~* ~3 x  h9 B8 L; x6 A
adult height are not fully known and always remain
0 a- [$ Q* `, S% l- Xa concern. Children treated with short-term testos-* W( M. u# D& W3 m
terone injection or topical androgen may exhibit some/ R7 a2 I% K8 F# Q! z$ d; I
acceleration of the skeletal maturation; however, after6 _3 S7 B4 C. T4 X" p
cessation of treatment, the rate of bone maturation: e  C7 u$ L$ |( y
decelerates and gradually returns to normal.8,9% x+ @% W0 B7 D# c, L2 M+ P; p
There are conflicting reports and controversy
  T/ y$ X, \2 @8 P: b. Jover the effect of early androgen exposure on adult% F! W' K) a# p
penile length.10,11 Some reports suggest subnormal
. d. J6 \2 i! \7 a+ Radult penile length, apparently because of downreg-
9 u8 p' M0 Y, ^. c0 X. r  s! _: `$ ~ulation of androgen receptor number.10,12 However,  e/ U" n& O* G8 v' a7 @2 b
Sutherland et al13 did not find a correlation between. G# a6 l9 E2 J# g8 T- a( N
childhood testosterone exposure and reduced adult) L+ ~. R6 `( z7 ~2 i8 p; I
penile length in clinical studies.3 m6 Z0 |  B- D. L. f
Nonetheless, we do not believe our patient is
0 P! m( d) D# N- |going to experience any of the untoward effects from& A' D: p/ b3 B1 K" s0 ^
testosterone exposure as mentioned earlier because5 j& S9 ~) @. A5 x5 D$ ?
the exposure was not for a prolonged period of time.
  a9 |0 t; L: q5 OAlthough the bone age was advanced at the time of
; \8 h8 V" {$ {- a8 O, z3 a/ tdiagnosis, the child had a normal growth velocity at. t% L* h+ c  |6 O
the follow-up visit. It is hoped that his final adult, F" r9 {0 e0 D5 i( E
height will not be affected.
" ~! k2 B% G: oAlthough rarely reported, the widespread avail-
" e8 N% \+ r9 {8 r! p; Y* Kability of androgen products in our society may) b; N, v; i! w! O
indeed cause more virilization in male or female
: y( u9 f- }5 v. f. @* Achildren than one would realize. Exposure to andro-! \2 C* ~% \) U% ^0 z
gen products must be considered and specific ques-
, E# Q1 O( i& d* s, ?8 l5 e0 B4 Ptioning about the use of a testosterone product or
+ H- K% W* U% ]* Kgel should be asked of the family members during
, ]/ t5 R( g# zthe evaluation of any children who present with vir-
1 G5 L* F' H) g( e8 S" s" J' Nilization or peripheral precocious puberty. The diag-
& g1 R+ J! i3 Q2 Hnosis can be established by just a few tests and by
, q/ b  D7 ?9 @6 x5 Lappropriate history. The inability to obtain such a
$ m( E! r; H  l* Y% qhistory, or failure to ask the specific questions, may
, z0 ^+ q! J# E. j* fresult in extensive, unnecessary, and expensive$ ~6 X3 b) X8 \( e' ]: \" |% q
investigation. The primary care physician should be
$ n! b$ F; ]9 Eaware of this fact, because most of these children4 P, B7 d3 t% m; r
may initially present in their practice. The Physicians’+ z( z2 }) r) x0 V! R
Desk Reference and package insert should also put a
  c% v3 i7 ~' }! u/ q5 |) s* h7 S3 v( Fwarning about the virilizing effect on a male or( U2 F$ V9 ^8 j8 e
female child who might come in contact with some-
- [( R0 y7 \3 g7 ~2 D) y7 h- Rone using any of these products., l) \0 ?( N% I3 [1 `, u* @
References
  k( }  d1 p$ R4 i9 A3 P2 |: x1. Styne DM. The testes: disorder of sexual differentiation
+ v1 _, G& w1 Zand puberty in the male. In: Sperling MA, ed. Pediatric: }( ?) {4 Y/ n5 f' Q
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& Y* @$ {6 h7 m/ i8 d2002: 565-628.
5 k1 a3 k9 Q' |5 q# u- l" S/ Y; a2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 k1 w1 n7 g/ J! N' \/ K0 o! L3 mpuberty 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

' B/ N/ g2 A. y% I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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