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Sexual Precocity in a 16-Month-Old
7 A, e" o8 b$ b. b& QBoy Induced by Indirect Topical; v$ x8 n5 e9 y+ s
Exposure to Testosterone; G4 c& T: b6 d
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
- I/ G3 w' k0 g2 l. V- k9 vand Kenneth R. Rettig, MD1( Z$ w7 B. F7 [+ C* W1 e, F" N
Clinical Pediatrics2 U$ ?; b2 [& D1 B; {: X
Volume 46 Number 6! v( n2 b% w5 [
July 2007 540-543
: ^. B) K4 J/ }( x© 2007 Sage Publications1 g" k6 f  c) Z5 k, k% Q
10.1177/0009922806296651
  F6 A0 e2 T5 t5 {( H2 [4 [% khttp://clp.sagepub.com
5 G# O' I! Q0 {# w9 w4 o4 Ihosted at
; R) g/ M; S6 E; l( Y" J! ihttp://online.sagepub.com. V* Q4 f4 Y1 P, V( e$ L
Precocious puberty in boys, central or peripheral,
5 I8 k% V: ?" }4 G- c% q$ I" Jis a significant concern for physicians. Central
. P: ~/ \' ^( f8 Z/ vprecocious puberty (CPP), which is mediated6 Y( j8 _) f  T% {1 f! Y2 p4 ~
through the hypothalamic pituitary gonadal axis, has1 k) i  Q* R8 I( j9 Z  [1 d
a higher incidence of organic central nervous system
6 p' L1 g) b! U+ d0 }lesions in boys.1,2 Virilization in boys, as manifested( G! F6 G( ~4 A2 `# t' Z/ r2 e% y9 i/ v
by enlargement of the penis, development of pubic
. x2 K9 W8 d" _) \hair, and facial acne without enlargement of testi-! M$ c# j5 Y6 k
cles, suggests peripheral or pseudopuberty.1-3 We
- A9 ^. N* ~3 P' @4 Y0 h6 n6 oreport a 16-month-old boy who presented with the
* ^: n9 J; Y6 Wenlargement of the phallus and pubic hair develop-
6 i6 N# p6 y5 @( b% Ement without testicular enlargement, which was due
" p% a- H1 f9 q# @- @to the unintentional exposure to androgen gel used by
/ b% P$ s6 T7 y8 Z* |9 Fthe father. The family initially concealed this infor-) T9 M- L( g: B$ s+ m
mation, resulting in an extensive work-up for this
' h+ [  b9 h  y9 |# Qchild. Given the widespread and easy availability of
1 L8 `, {. K* \9 r! ~0 dtestosterone gel and cream, we believe this is proba-8 Z" V  ~: h7 Y* ]! i% P/ r6 y
bly more common than the rare case report in the& C6 y4 q5 S, d* L1 s- n. V
literature.4
6 E0 T$ Y5 y: g4 `, W1 SPatient Report
7 W# R- ]6 O0 J) |- Q4 J/ G  {A 16-month-old white child was referred to the
# s7 v/ C3 r5 @4 G# ~2 W! r9 aendocrine clinic by his pediatrician with the concern: Y$ h3 r4 W1 t) D9 _& Q  T
of early sexual development. His mother noticed! X5 ?6 ^5 \$ _  M4 G9 a
light colored pubic hair development when he was" N' J3 Y/ g( _& a
From the 1Division of Pediatric Endocrinology, 2University of
3 o( p8 i6 f( ^9 t/ A" N' n$ O1 _. KSouth Alabama Medical Center, Mobile, Alabama.
  L' o3 g$ @; S7 ?0 y6 TAddress correspondence to: Samar K. Bhowmick, MD, FACE,1 Y# j4 l; _) q7 |$ E2 N' T
Professor of Pediatrics, University of South Alabama, College of' w4 Q8 }; R6 I3 \! r5 g- S
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# n5 _; w, i( O0 |* B2 B1 K0 h
e-mail: [email protected].1 |) \+ ?4 c8 d7 F& B% U( W4 y
about 6 to 7 months old, which progressively became
2 o7 {/ O: s# H& ^8 f9 J# R2 Idarker. She was also concerned about the enlarge-
" P/ h* E# t1 |6 |2 U( w! s) fment of his penis and frequent erections. The child
& A  F2 W* A; |: ~1 Hwas the product of a full-term normal delivery, with. C9 o( D6 J5 ~# I4 w* X2 |; C
a birth weight of 7 lb 14 oz, and birth length of# U; B7 }( Y0 H7 _
20 inches. He was breast-fed throughout the first year( B# j; f, G( ^, S5 a8 u+ a
of life and was still receiving breast milk along with
) {: A; y# k8 s8 i" r4 e) g* ~$ Isolid food. He had no hospitalizations or surgery,
# S$ }( F/ H& sand his psychosocial and psychomotor development. M, q9 Z& U( E5 x
was age appropriate.
# m+ R; h  |9 E! g& M7 jThe family history was remarkable for the father,/ i: c4 V8 K4 M
who was diagnosed with hypothyroidism at age 16,
/ i5 G3 s) x: C8 K) z3 ywhich was treated with thyroxine. The father’s
1 a9 ]- b* M1 U9 \* |height was 6 feet, and he went through a somewhat
: {  Q2 i6 F! p* y5 iearly puberty and had stopped growing by age 14.
* N( t5 B3 R) o1 AThe father denied taking any other medication. The6 ?8 j: e4 {# f1 w
child’s mother was in good health. Her menarche( z) E3 ?9 E" ?( g# u
was at 11 years of age, and her height was at 5 feet
& ?$ l4 n9 M% H/ [+ l+ X3 U6 a5 inches. There was no other family history of pre-- T0 u* I- p7 L1 n# U% y
cocious sexual development in the first-degree rela-
) E; }7 A0 @# r0 C# btives. There were no siblings.
; z1 g! a# B  e; U8 HPhysical Examination
! n2 {, X( }6 j( _4 z+ ?The physical examination revealed a very active,+ u+ C% U# z8 y0 K9 W% C
playful, and healthy boy. The vital signs documented
4 p" [  `4 Z7 B3 La blood pressure of 85/50 mm Hg, his length was
/ E8 C6 d- M9 b9 B; S; _# l2 Y90 cm (>97th percentile), and his weight was 14.4 kg
$ S3 l6 H% }  e7 p7 j0 `% t8 a3 C(also >97th percentile). The observed yearly growth- u! Z3 N5 G# b9 j9 s# Y+ N% v
velocity was 30 cm (12 inches). The examination of6 f& y+ d' M: j9 y' W
the neck revealed no thyroid enlargement.
# P. z2 @  _' n  Q6 GThe genitourinary examination was remarkable for
3 A8 i1 j+ m# K$ i3 Qenlargement of the penis, with a stretched length of- n) |- p- {% |7 x4 h* q* A
8 cm and a width of 2 cm. The glans penis was very well
7 F7 @, [8 w& O$ W" Adeveloped. The pubic hair was Tanner II, mostly around
+ i  e6 q1 [7 j( K5408 U. u6 [( G4 w* n. Q1 l* f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ M8 o9 u# {3 J6 Tthe base of the phallus and was dark and curled. The
4 \7 j, r# D5 {: m' L! i( ?testicular volume was prepubertal at 2 mL each.# X( G4 a! a  ^9 \: f
The skin was moist and smooth and somewhat; }% y$ F& ?6 R6 u: j+ C- i9 P
oily. No axillary hair was noted. There were no1 q7 w2 [. s6 Q7 w; w, P
abnormal skin pigmentations or café-au-lait spots.
! ?9 a2 \; v1 O* e5 }+ U+ KNeurologic evaluation showed deep tendon reflex 2+7 q' d1 v0 D( u
bilateral and symmetrical. There was no suggestion3 T) Y: G: B( n/ |7 H
of papilledema.2 X) h! J7 \% _, R
Laboratory Evaluation
& U* |0 s  Y0 _# Q% Z) u, Z: P6 wThe bone age was consistent with 28 months by
9 R/ {: D! H# l- V2 ~$ X  wusing the standard of Greulich and Pyle at a chrono-
% j& N; s/ p+ a( Plogic age of 16 months (advanced).5 Chromosomal
  C+ M, J5 T. W. r: X, vkaryotype was 46XY. The thyroid function test
/ P& V0 I/ v, cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
" H+ ~: Y4 d" D% U: S: y3 Alating hormone level was 1.3 µIU/mL (both normal).' _. y! R3 L$ M+ w+ T4 \
The concentrations of serum electrolytes, blood
+ |& g# b) O& Eurea nitrogen, creatinine, and calcium all were0 L5 m* t- R( X: ^5 I# H
within normal range for his age. The concentration
7 p! A1 I( S8 ]3 |of serum 17-hydroxyprogesterone was 16 ng/dL
: S( x( {+ s4 @6 J7 O  s6 Y(normal, 3 to 90 ng/dL), androstenedione was 20
0 H6 v$ e- t7 S( z! L6 @; gng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& `6 p& X* {9 F6 s$ |- F* @" ~
terone was 38 ng/dL (normal, 50 to 760 ng/dL)," t; y, G) T+ }2 Q" U% \; Y" n( g
desoxycorticosterone was 4.3 ng/dL (normal, 7 to) b8 E% w2 s6 |: R6 v) o
49ng/dL), 11-desoxycortisol (specific compound S)
7 L, v7 ]. Y$ Z' e( Owas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
  S, G2 F; s" C! t8 C5 Qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 K- q* x* W: p( M4 Z* P3 L0 O, y
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
& v  K: v0 `% @and β-human chorionic gonadotropin was less than+ d5 o6 b; i! w- b5 n' A. X
5 mIU/mL (normal <5 mIU/mL). Serum follicular
/ V# ~  \, }- [stimulating hormone and leuteinizing hormone! h( w/ f+ H1 s- D. ]+ {
concentrations were less than 0.05 mIU/mL
( N0 W! v# S' f+ `' ?# N& K* F(prepubertal).
( _) ?/ O6 d# X% M' |+ `The parents were notified about the laboratory2 S* A  y6 C# N" I# d9 C
results and were informed that all of the tests were
2 t2 n( P0 e" O1 C( B7 w) Rnormal except the testosterone level was high. The
* w2 `( P5 ?( Ofollow-up visit was arranged within a few weeks to% c9 r0 C) h  H/ C
obtain testicular and abdominal sonograms; how-
9 f6 s/ z8 R) h  N4 N4 ]ever, the family did not return for 4 months.
" z1 W9 M- E& FPhysical examination at this time revealed that the
, Y  S8 q$ X1 f$ t4 u% y+ ^child had grown 2.5 cm in 4 months and had gained
4 H5 c7 s& R+ S# l3 O, v2 kg of weight. Physical examination remained
2 B! c" D" G# H, a9 L) x; Sunchanged. Surprisingly, the pubic hair almost com-7 X5 W8 f* Q8 ]6 |$ p! a; k, G
pletely disappeared except for a few vellous hairs at+ t. ?+ T/ \0 m" y, L; C
the base of the phallus. Testicular volume was still 28 \. D) b  m- F+ ^) r* M5 C
mL, and the size of the penis remained unchanged.: O( [8 D, z" L- F. w
The mother also said that the boy was no longer hav-+ A0 ?7 k; k) h) ?  K: I0 r
ing frequent erections.
3 N) V  \" e' N( a1 j  d8 ^: t) L, uBoth parents were again questioned about use of3 g6 I' c: q: I' _2 D
any ointment/creams that they may have applied to( ^9 v7 |) I3 I5 U- g7 ^3 `
the child’s skin. This time the father admitted the5 c8 @% N$ C, M  g; [2 x2 v
Topical Testosterone Exposure / Bhowmick et al 541
, q0 e0 L9 O0 S9 E' l! I; Puse of testosterone gel twice daily that he was apply-
( g9 E5 d- ^/ N# Q6 k/ ning over his own shoulders, chest, and back area for( l5 ?4 P: z% R
a year. The father also revealed he was embarrassed
9 ]- b' s* x3 }2 k/ o2 Q8 eto disclose that he was using a testosterone gel pre-
5 W9 I* j3 K$ }7 M2 I* pscribed by his family physician for decreased libido
, s- h# i, F( y% ~6 S1 Usecondary to depression.1 J% ^  q8 _5 A8 d  ^7 \( S8 Q6 g8 T
The child slept in the same bed with parents.( i  s$ O0 j% g, h
The father would hug the baby and hold him on his
. z/ |0 w$ V$ C  W' p$ S6 Dchest for a considerable period of time, causing sig-4 L: ^! h8 g$ u0 J
nificant bare skin contact between baby and father.* a6 w9 ^* V+ d0 n) f# C( O3 Y
The father also admitted that after the phone call,
' ]+ d8 y) E3 U% x; H' Ywhen he learned the testosterone level in the baby
0 i! ]% `7 Y( p) a* vwas high, he then read the product information
) a2 K4 H; i* p* Q: Y" b) Gpacket and concluded that it was most likely the rea-: d8 Y1 d( m9 R; q0 P7 F
son for the child’s virilization. At that time, they
# c' K' N+ ?# v. A3 y! [( S' ]decided to put the baby in a separate bed, and the
! p  u# G) _- Y6 gfather was not hugging him with bare skin and had. w" x& a) V9 ^) @: h2 R
been using protective clothing. A repeat testosterone
0 T: ]& d3 N* E% Z, \test was ordered, but the family did not go to the
$ S; A2 J# l  O  Z3 ?laboratory to obtain the test.( X! f/ F9 m# B$ T6 W* _: m
Discussion9 `! i) y, }  J4 b# w6 x) g- ~
Precocious puberty in boys is defined as secondary
& a" B6 o/ i1 h3 \. g/ o, y9 I: V2 Vsexual development before 9 years of age.1,4
, L! V. z& M3 j" k# _9 {Precocious puberty is termed as central (true) when
3 O8 V8 S0 H0 [! N7 A/ |( O. _it is caused by the premature activation of hypo-
  x/ l+ c# s% v& ^& U6 t9 j. Mthalamic pituitary gonadal axis. CPP is more com-
5 t% v# J$ l  e9 j+ amon in girls than in boys.1,3 Most boys with CPP
3 e! D) E, [. z9 A% J4 z; ]. nmay have a central nervous system lesion that is
- F6 u- E  d$ ]. [responsible for the early activation of the hypothal-
* f  C% y- F* Q) D3 _amic pituitary gonadal axis.1-3 Thus, greater empha-
( o1 `! R) @5 Osis has been given to neuroradiologic imaging in( D1 h" U- G& l, ~4 ?% b1 b' p. _
boys with precocious puberty. In addition to viril-
" T3 Q+ {. M1 Zization, the clinical hallmark of CPP is the symmet-- [7 q( q6 S8 g
rical testicular growth secondary to stimulation by
( J( q( v/ P# w, U7 O  Y2 {gonadotropins.1,3
: b; I- U# I4 b9 t/ ~Gonadotropin-independent peripheral preco-
$ ]9 f- E4 Y- ]9 O* {cious puberty in boys also results from inappropriate
. U' f- @8 g; ^$ J. [androgenic stimulation from either endogenous or: E% s% w  t1 M/ l4 Z1 }; d
exogenous sources, nonpituitary gonadotropin stim-: w+ ^! F6 F4 a) a& @& j
ulation, and rare activating mutations.3 Virilizing" J4 f  [1 \: j& A8 x
congenital adrenal hyperplasia producing excessive
3 k6 Q3 `6 f6 v1 aadrenal androgens is a common cause of precocious
( A1 v5 o# B' {  m  hpuberty in boys.3,4* W+ J& i8 ~7 t9 q  `; w3 o4 P# n
The most common form of congenital adrenal
8 _- f5 G% M9 H, ?* o8 v) uhyperplasia is the 21-hydroxylase enzyme deficiency./ D/ K! h; X2 M3 m, n# e* M$ x
The 11-β hydroxylase deficiency may also result in4 A7 v# o9 U4 P3 Y" |, d9 ^
excessive adrenal androgen production, and rarely,0 Y$ \" D1 P& E6 G0 H7 D& p
an adrenal tumor may also cause adrenal androgen
4 z  m5 K, z' x% h2 H# @excess.1,3
/ E0 y1 W5 _' K" Xat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* F. E/ t# {. X( i" f542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 I5 |  C9 T# W7 Y" Y
A unique entity of male-limited gonadotropin-7 T( U& H1 }8 z. R( }
independent precocious puberty, which is also known
! a2 ~# s* r9 [6 Nas testotoxicosis, may cause precocious puberty at a
* G/ T# [- [+ @0 k. x2 j& Overy young age. The physical findings in these boys3 M9 T' x6 x5 u: e1 P, E
with this disorder are full pubertal development,
! ~' C% m. r: r$ Sincluding bilateral testicular growth, similar to boys) B. N# t7 X6 N3 _+ [( |. C2 @* r
with CPP. The gonadotropin levels in this disorder
  E' i, h1 q$ \, \. n5 H* G/ dare suppressed to prepubertal levels and do not show
9 Q! w. @1 M5 x7 p( W! Zpubertal response of gonadotropin after gonadotropin-" b. @& r6 N! x. ?1 L: m0 Y$ D( y, _
releasing hormone stimulation. This is a sex-linked/ g" D5 L( B- F; ^
autosomal dominant disorder that affects only# v4 g- F+ w( Q6 L
males; therefore, other male members of the family; e: }0 D" ^& e0 {/ ?
may have similar precocious puberty.3- I4 x  O: H: I3 A& ]
In our patient, physical examination was incon-1 q+ ], N8 k# r8 C/ X* v8 ~2 O! ~6 c
sistent with true precocious puberty since his testi-
" l& t" W: ^$ }. u9 ^6 tcles were prepubertal in size. However, testotoxicosis1 w9 f  V8 h, [* w& f. o1 D
was in the differential diagnosis because his father
2 C' v0 g: y2 I% p% Astarted puberty somewhat early, and occasionally,6 ^, Q1 L! y3 P$ @3 \/ k7 G* g; I
testicular enlargement is not that evident in the
3 j( I# H9 n) R- m0 H7 Q" y; ibeginning of this process.1 In the absence of a neg-
: A0 c; {5 o* ~( V& p3 }% C8 _9 e/ Eative initial history of androgen exposure, our
! N4 m: N, X* pbiggest concern was virilizing adrenal hyperplasia,
) p5 q( y& l" v, V# A; \either 21-hydroxylase deficiency or 11-β hydroxylase
  R; D, H* w2 Y( ]0 Vdeficiency. Those diagnoses were excluded by find-
3 m& ~# ~( X- x! i- B7 zing the normal level of adrenal steroids.9 G% G$ [( ~' t
The diagnosis of exogenous androgens was strongly
, ^3 ?6 D# ?* Csuspected in a follow-up visit after 4 months because: Z8 @1 T$ Z3 ^5 j9 Y1 F! K
the physical examination revealed the complete disap-) k( e. F& k, Q0 c  [7 I
pearance of pubic hair, normal growth velocity, and
$ Y$ m& n* D! Y2 P7 Cdecreased erections. The father admitted using a testos-8 U& G0 K& D* |% Z3 S
terone gel, which he concealed at first visit. He was
  ]0 k: m' {6 I- q  Q3 busing it rather frequently, twice a day. The Physicians’
/ y$ w8 @; ~/ q9 i) G: EDesk Reference, or package insert of this product, gel or
9 Q  G% K/ [& v3 [cream, cautions about dermal testosterone transfer to+ G7 }! m- J+ k6 D' g
unprotected females through direct skin exposure.3 g1 y( m8 x8 ?1 i6 R- s
Serum testosterone level was found to be 2 times the
# R4 D8 I, ~) ^( m5 Pbaseline value in those females who were exposed to% {& w& s) v# G0 h/ J
even 15 minutes of direct skin contact with their male8 s. C( b0 P- u7 c2 u' t6 S* n  K
partners.6 However, when a shirt covered the applica-/ g% v- J9 |$ ~: P6 z% G
tion site, this testosterone transfer was prevented.' R0 I. y* ~$ U( {0 S
Our patient’s testosterone level was 60 ng/mL,$ d6 N  l" H( R2 {5 C& J
which was clearly high. Some studies suggest that
. z* Z1 A. A% ^& ydermal conversion of testosterone to dihydrotestos-
: ?9 m) [1 U5 X. F5 z. Y0 Hterone, which is a more potent metabolite, is more
" F1 g) y3 L# t1 Y& Y" cactive in young children exposed to testosterone
/ `( E. w. a- h! ^! Jexogenously7; however, we did not measure a dihy-; l  u, n, _* L( A7 R: h% h
drotestosterone level in our patient. In addition to
) o( g' B& v) M) s' M& Kvirilization, exposure to exogenous testosterone in  q* K8 ~8 ~0 [* j
children results in an increase in growth velocity and7 V; t! m( F8 E& J1 n
advanced bone age, as seen in our patient.
" ?- j; q7 Y8 ~( c/ p8 ]The long-term effect of androgen exposure during, {" X* M- a$ [+ U+ g
early childhood on pubertal development and final7 t1 u/ `- \) M9 |5 w
adult height are not fully known and always remain" t( W/ y8 U" Q0 }  `2 X
a concern. Children treated with short-term testos-
/ m4 ?8 \+ k! h$ e# sterone injection or topical androgen may exhibit some
& O& x9 K3 W3 X: o3 C* K. e; ~7 [acceleration of the skeletal maturation; however, after, M: T. l5 x* E& u5 `
cessation of treatment, the rate of bone maturation& n% o* L, V3 F5 V0 a, i
decelerates and gradually returns to normal.8,9; P. j  W/ @; B9 l
There are conflicting reports and controversy5 q7 J9 ?+ Q& K- k
over the effect of early androgen exposure on adult, r2 @+ i* S0 g+ P: R& L3 Q2 o; l1 n
penile length.10,11 Some reports suggest subnormal
2 F9 o( H+ ~9 }2 b; z# ^) tadult penile length, apparently because of downreg-
; @/ d( D! W# d6 b; w5 Sulation of androgen receptor number.10,12 However,) G- I+ _% i) E! H; c! l$ V0 b
Sutherland et al13 did not find a correlation between
* L2 i- H! d6 c2 ?7 echildhood testosterone exposure and reduced adult) d9 ~1 p$ B9 T; W0 x6 S
penile length in clinical studies.* u  h4 f2 r1 k; e. d0 g1 T
Nonetheless, we do not believe our patient is
( y2 C+ X; _6 Q& ?& xgoing to experience any of the untoward effects from
5 ^7 o7 |! r1 A9 U- U! `testosterone exposure as mentioned earlier because& J# U0 K- d( w- A3 Z, a
the exposure was not for a prolonged period of time.2 }; o7 _0 C1 [7 \: Q
Although the bone age was advanced at the time of
8 ^# o) H+ F2 v& t+ _diagnosis, the child had a normal growth velocity at
6 N# ]* v% ]; B7 b- B( @the follow-up visit. It is hoped that his final adult
8 z6 Y  g  O# Eheight will not be affected.
. z8 R/ J( C, y& AAlthough rarely reported, the widespread avail-* m! D0 i  x% @1 ~$ ]6 a
ability of androgen products in our society may- H+ g5 |6 U3 F1 B# `7 M- B
indeed cause more virilization in male or female/ s6 z  U7 W; }" G, Z. Z
children than one would realize. Exposure to andro-
- z* L' s8 V/ [, U" Dgen products must be considered and specific ques-
2 N9 \. Q$ o$ \! Itioning about the use of a testosterone product or5 }8 ^! J4 k" i( C
gel should be asked of the family members during# ~3 _5 N( p1 v
the evaluation of any children who present with vir-
$ m  f1 ^$ P+ eilization or peripheral precocious puberty. The diag-2 W1 J/ a6 X' k9 A
nosis can be established by just a few tests and by
- [/ Z! S( A$ C! s; Q2 sappropriate history. The inability to obtain such a
" E3 |! P1 T4 e5 U: F4 ]history, or failure to ask the specific questions, may
; |& G3 @1 D; u' @result in extensive, unnecessary, and expensive1 u3 e# J+ |9 I
investigation. The primary care physician should be
6 M; k/ R6 b) G; y% `9 f: ^" f& p( A1 caware of this fact, because most of these children3 q  t7 d/ E8 r9 N7 h  S- e
may initially present in their practice. The Physicians’  X2 k3 w" q! M1 C
Desk Reference and package insert should also put a
9 Z% D% B+ e6 w  m& J% n+ Q. f7 Dwarning about the virilizing effect on a male or
! h) U  D7 k7 O9 H7 s8 P1 Efemale child who might come in contact with some-8 q8 _0 W; ]+ h2 E" v9 c, L7 g
one using any of these products.* _1 r6 ?1 |' C3 _. y6 s
References7 E- |( h" G" W* d+ T0 o* f& y# ]4 v
1. Styne DM. The testes: disorder of sexual differentiation& c- Q" q' O9 Z+ }2 A
and puberty in the male. In: Sperling MA, ed. Pediatric
8 Y* c& L. X; _, I9 w. PEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( E( [3 V! Z! V$ p
2002: 565-628." j- P5 H9 e6 ^
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 X# v. \1 ~7 S/ K
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old6 J8 q9 b$ F, K. d3 }3 L$ I
Boy Induced by Indirect Topical6 Y+ ]8 [! S  p
Exposure to Testosterone
& B/ s6 @! }1 U" \1 T) R/ wSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2; w: V" \! S( [- }) x/ f
and Kenneth R. Rettig, MD1
1 R( ^) h; W6 a* ?Clinical Pediatrics) R. W( [$ D8 A/ b3 S/ r/ q6 x0 N$ N
Volume 46 Number 6
& ~; X1 }) N, J' A; e! R9 Z# MJuly 2007 540-5433 e# Z# x* V' R# U8 z
© 2007 Sage Publications5 U& J6 p: `$ F$ s1 S" l% J+ S( q
10.1177/0009922806296651) l+ o) ~% R  ^, z
http://clp.sagepub.com5 N; l- T% Z. s
hosted at
9 Z6 a* R/ r1 e( Ahttp://online.sagepub.com
2 h$ g. f9 ~, A3 LPrecocious puberty in boys, central or peripheral,
2 I# s: G% ?! M* Z8 ~is a significant concern for physicians. Central& \& i) i9 b+ s2 y* o! D+ b! g8 [
precocious puberty (CPP), which is mediated
9 P8 L2 Y0 k) }7 Tthrough the hypothalamic pituitary gonadal axis, has8 h: {8 E6 {- ^
a higher incidence of organic central nervous system2 U- u5 E* [' K; h6 B; l
lesions in boys.1,2 Virilization in boys, as manifested8 y; D$ H0 @2 |; [$ f; r7 u( I
by enlargement of the penis, development of pubic
' D/ d: v, O1 Q( m7 phair, and facial acne without enlargement of testi-8 Z7 @3 _7 s+ q& q/ m. o
cles, suggests peripheral or pseudopuberty.1-3 We
% h# P5 f+ _' S- l! X) \. X; H8 xreport a 16-month-old boy who presented with the
* ^& w. Z3 @8 D: A+ o9 Venlargement of the phallus and pubic hair develop-
& P4 w/ a$ d+ ~& F: }7 Z% Vment without testicular enlargement, which was due
+ y, z0 w( h% B& V: k5 m" {3 ito the unintentional exposure to androgen gel used by6 R* P% v$ B5 |  }
the father. The family initially concealed this infor-
/ ~( V, @$ A/ D3 Q% smation, resulting in an extensive work-up for this# L9 Z7 C# i3 n4 f4 Y0 M* M% d4 n
child. Given the widespread and easy availability of
* t* h" Q- e% h) V! h( D) Ttestosterone gel and cream, we believe this is proba-! z- I- Y4 Q* v6 b
bly more common than the rare case report in the! A) O$ ]. B3 t! s
literature.4
( @; h0 v5 s( \1 ~Patient Report
8 m# ~8 C9 B/ D, M- X  jA 16-month-old white child was referred to the
$ F* P$ z2 o. E4 O( @/ hendocrine clinic by his pediatrician with the concern
$ L* ]3 K* W& |) O* ^. t# Zof early sexual development. His mother noticed
/ O3 q8 g/ l( I( `& P: clight colored pubic hair development when he was
" j/ l- D9 Q0 `. ~7 M$ BFrom the 1Division of Pediatric Endocrinology, 2University of& r+ N  N8 p6 q5 G; O
South Alabama Medical Center, Mobile, Alabama.
% l. o6 g: n3 D, k% _Address correspondence to: Samar K. Bhowmick, MD, FACE,# O! T9 |6 N! }) s9 W
Professor of Pediatrics, University of South Alabama, College of- t$ l& |7 l" r8 F# J# v. ?
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- K4 @- [- Z0 F5 be-mail: [email protected].. P; _3 o4 U8 V, h/ w8 [, f& y! U
about 6 to 7 months old, which progressively became
+ ^9 \" _& G6 @+ r4 j  \1 Wdarker. She was also concerned about the enlarge-
& J4 I3 m" U6 n' ^+ M6 l6 N% S" i- yment of his penis and frequent erections. The child  H- `9 m) O" o/ X$ \
was the product of a full-term normal delivery, with4 z$ p$ X* x* V5 a- Z; m
a birth weight of 7 lb 14 oz, and birth length of$ b. n" n! |/ G# U% ]3 L& T3 P
20 inches. He was breast-fed throughout the first year
( T; U/ t0 a% B  n5 Uof life and was still receiving breast milk along with
. `2 O7 j8 L! ]9 E6 W0 v8 ]solid food. He had no hospitalizations or surgery,
6 g# h4 i2 ~1 _, B6 gand his psychosocial and psychomotor development: i' H& _* q) V4 p8 ^5 ]" r
was age appropriate.# Y3 g  ?- s& {) l8 X2 o
The family history was remarkable for the father,: ~4 m! v8 h7 L( w; d7 N
who was diagnosed with hypothyroidism at age 16,
1 k) ^' @. g# gwhich was treated with thyroxine. The father’s  L) z8 t1 W1 `# t
height was 6 feet, and he went through a somewhat8 o: U- t0 y  e- N
early puberty and had stopped growing by age 14.
6 Q* k# S8 F% y0 |4 \* D6 j* pThe father denied taking any other medication. The6 v/ ?# F6 x1 x6 K0 V0 p
child’s mother was in good health. Her menarche" r+ x! q- Y6 j
was at 11 years of age, and her height was at 5 feet+ n2 R( q% p( a! y
5 inches. There was no other family history of pre-
. d' f: q. }8 V* t3 H2 \9 c! Scocious sexual development in the first-degree rela-
1 T$ {0 I+ _7 F( y' {3 J+ Ltives. There were no siblings.9 T, }! V& f1 T5 ~) i
Physical Examination- M' l* c8 v' t* d1 B$ F
The physical examination revealed a very active,
& W; G4 M+ T/ y8 eplayful, and healthy boy. The vital signs documented
: j0 G' {$ K9 F" v1 T8 Q6 I, ^+ Ea blood pressure of 85/50 mm Hg, his length was4 U# T) q  H" U* ]
90 cm (>97th percentile), and his weight was 14.4 kg+ s# [1 U, l, _) e: Z' f( x' B
(also >97th percentile). The observed yearly growth
3 w. H  A" @& b1 N+ xvelocity was 30 cm (12 inches). The examination of
$ S# {6 D' a0 {2 x2 A- D! E& tthe neck revealed no thyroid enlargement.
/ A& y8 K* @& T. G$ MThe genitourinary examination was remarkable for
' [# u! r* B/ q; X- s' Jenlargement of the penis, with a stretched length of
6 v$ c( H6 e" b* T* ~/ k( f# M+ M8 cm and a width of 2 cm. The glans penis was very well
  h8 e+ ?- r4 ddeveloped. The pubic hair was Tanner II, mostly around
! a2 W7 K8 N" y- t4 {4 H( V6 ^- z540
: P3 D* ~6 [, Q  iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' [' [9 K  u! I& zthe base of the phallus and was dark and curled. The. l0 @- X0 s1 k$ w
testicular volume was prepubertal at 2 mL each.1 o6 A9 R, Z$ W( S
The skin was moist and smooth and somewhat
; M. Q9 B, \% J7 A# Foily. No axillary hair was noted. There were no& [3 m6 v5 T( ?
abnormal skin pigmentations or café-au-lait spots.
+ B' X9 Z- p! K* B2 {Neurologic evaluation showed deep tendon reflex 2+
/ b& u5 A1 R6 v% T" r: Y) kbilateral and symmetrical. There was no suggestion
; I2 k% g" x5 q! Wof papilledema.$ W" v4 s0 r1 N4 ?
Laboratory Evaluation9 f+ \* W+ G( v9 C. {6 c
The bone age was consistent with 28 months by
' n4 m0 X* N3 q  h5 w, {" ]using the standard of Greulich and Pyle at a chrono-1 l2 q# g4 j# l( g, G4 u) L
logic age of 16 months (advanced).5 Chromosomal/ W( S5 J0 x3 X  \: ~4 A8 }% d4 f
karyotype was 46XY. The thyroid function test1 z* e5 U1 D0 D& G
showed a free T4 of 1.69 ng/dL, and thyroid stimu-9 }# `/ \, w7 ^
lating hormone level was 1.3 µIU/mL (both normal).
8 U7 |3 y4 q* D' nThe concentrations of serum electrolytes, blood
" d, Z3 d  \9 Y) ~6 z* }! Rurea nitrogen, creatinine, and calcium all were! @5 N  d5 ]8 q, K$ K9 l
within normal range for his age. The concentration
6 }8 w+ h0 V, E+ Mof serum 17-hydroxyprogesterone was 16 ng/dL
" r9 Y8 E" S' g9 {2 t) v( k' S(normal, 3 to 90 ng/dL), androstenedione was 20+ |1 e0 H0 h2 V* d5 |- C( P% ]1 W5 c' h
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 r( n, i6 x  `: r- ]+ c, i1 ?" pterone was 38 ng/dL (normal, 50 to 760 ng/dL),
0 G3 u- s6 B3 o8 fdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
* J" }6 E3 A! l7 C3 x49ng/dL), 11-desoxycortisol (specific compound S)! X, E- p3 p! I0 r3 I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 G/ c$ C; ]& V8 A! w$ k1 B' E/ v# wtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 J- x( ~5 `* ]: z7 R$ _6 z( x
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! @. [0 g$ w" k6 G% T: uand β-human chorionic gonadotropin was less than9 q) e& x3 S, K' ~, K. I
5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 c( }& u7 j5 ]6 ]- D( [+ r5 I1 o' ~- ^" |stimulating hormone and leuteinizing hormone* i. p% Z% l" P- }8 ?- B4 J$ V
concentrations were less than 0.05 mIU/mL6 F+ e# b  z  X5 o4 b1 t4 u
(prepubertal).: x7 @9 n9 M5 Z) w
The parents were notified about the laboratory
& V) M& `2 O1 o, r+ Bresults and were informed that all of the tests were
% n8 x/ w6 g2 [# X8 y( f$ n" ynormal except the testosterone level was high. The6 b" Y* o: {4 ?& L4 |- R' _" [0 K5 k
follow-up visit was arranged within a few weeks to
" y5 F. I& s9 Z: [+ K8 V1 gobtain testicular and abdominal sonograms; how-6 @% H6 `8 O; G9 {; V# r
ever, the family did not return for 4 months.4 L+ Q) h% T+ M, P5 f' b% g) w
Physical examination at this time revealed that the' \  G( h9 s8 e/ X7 I+ B5 P
child had grown 2.5 cm in 4 months and had gained
9 C  |. V0 ]; ^! E% R4 @% o; }5 s$ i2 kg of weight. Physical examination remained# w, ~; s1 E! i, K! O( D
unchanged. Surprisingly, the pubic hair almost com-2 t. M4 M4 L/ k/ N) @  ~" K
pletely disappeared except for a few vellous hairs at9 _, Q5 G+ \( ]9 v
the base of the phallus. Testicular volume was still 2
( B' N# f8 o, l0 @; cmL, and the size of the penis remained unchanged.
9 K/ n5 H9 Z- gThe mother also said that the boy was no longer hav-: x1 l% R* r% y% ?; F- E& R, \
ing frequent erections.
' z) V5 a2 o+ g4 [Both parents were again questioned about use of
  H4 v) A! y7 dany ointment/creams that they may have applied to
+ `/ U. u* E5 z; \& {7 vthe child’s skin. This time the father admitted the+ f, }: J: A; w% G" ^; r( q
Topical Testosterone Exposure / Bhowmick et al 541
7 k5 o, m" V1 @( ~use of testosterone gel twice daily that he was apply-
# _) G) ?1 A- z# h2 p  E4 K: b, wing over his own shoulders, chest, and back area for2 {% u$ B: d7 [* l
a year. The father also revealed he was embarrassed7 I7 t, ]" c: `) d9 C: w: E4 I
to disclose that he was using a testosterone gel pre-) D* |' I- f( w# ?
scribed by his family physician for decreased libido
+ c' Q( J7 V& m: ?: M4 w" Usecondary to depression.: }' a/ l) F4 n3 ~# M
The child slept in the same bed with parents.1 |% v4 Z, ?% U9 b( Z
The father would hug the baby and hold him on his( |( }* z: }( ?, g  {, ^
chest for a considerable period of time, causing sig-
' b6 S$ |0 d4 p  snificant bare skin contact between baby and father.. t! L" U, u' r+ f$ ]
The father also admitted that after the phone call,
3 S) F* Z+ B$ J- N+ _$ Twhen he learned the testosterone level in the baby
' W6 X- ?: i- ~# x$ y: [, y$ x: q  qwas high, he then read the product information
- Q1 w, o5 X" Y- P3 `' E- Dpacket and concluded that it was most likely the rea-
' I2 b( g: z9 sson for the child’s virilization. At that time, they
) J6 V! E6 q( X: j% L- o5 o' _7 Pdecided to put the baby in a separate bed, and the" A$ |. q" @# [) U
father was not hugging him with bare skin and had
1 b% E2 z* }$ P* s+ U& fbeen using protective clothing. A repeat testosterone
. g2 i7 x6 z9 ^, xtest was ordered, but the family did not go to the
) _* ^4 l6 H- L$ G8 z/ Ulaboratory to obtain the test.+ L/ ~# v( S2 h8 w8 G: M
Discussion
2 K- p1 w( m; n7 e( b6 t. QPrecocious puberty in boys is defined as secondary
1 M% m* V- k, i8 H# d$ u4 u' gsexual development before 9 years of age.1,4- u& e: T5 Y4 b" L' D2 P. r
Precocious puberty is termed as central (true) when, t/ ~+ {0 Z. h: q! c) e2 U$ Z/ f
it is caused by the premature activation of hypo-/ t. ~  w$ D- v
thalamic pituitary gonadal axis. CPP is more com-2 ?& ^; X, L$ `) w3 `, F
mon in girls than in boys.1,3 Most boys with CPP
' l- A* U6 X7 W8 dmay have a central nervous system lesion that is) Z! E$ X/ }* L/ U# @
responsible for the early activation of the hypothal-
! z1 U: P+ R! i  @, x+ h1 V) Samic pituitary gonadal axis.1-3 Thus, greater empha-
, T8 `) G# L0 p  d8 jsis has been given to neuroradiologic imaging in
, |; v5 s, ^  G: p5 D4 z0 Nboys with precocious puberty. In addition to viril-- s) Z& H6 j7 q* O, t5 j! q
ization, the clinical hallmark of CPP is the symmet-
: E$ S4 O3 a& Krical testicular growth secondary to stimulation by
( v. D: ~& y! Y: d8 \7 K3 i% egonadotropins.1,3
0 V4 H* |  i& j  D% X# E) PGonadotropin-independent peripheral preco-4 R" j/ S( k! _0 x8 x  Q6 {
cious puberty in boys also results from inappropriate
1 R& S% K  g$ p9 d: fandrogenic stimulation from either endogenous or
$ A+ V$ I0 @5 G4 M: n4 a$ eexogenous sources, nonpituitary gonadotropin stim-
5 c+ B6 r! y0 Q" Zulation, and rare activating mutations.3 Virilizing" R+ L( C+ s2 O) K8 u
congenital adrenal hyperplasia producing excessive
$ u0 T% x! K: {1 M0 l+ Z4 xadrenal androgens is a common cause of precocious
  F. f1 X* c7 X% \# N$ H, _1 Upuberty in boys.3,4
8 R7 l3 t7 v+ @# v: U9 MThe most common form of congenital adrenal
  g/ n. J9 m9 G, x4 b4 V3 Phyperplasia is the 21-hydroxylase enzyme deficiency.
4 a8 O0 F9 J' x! qThe 11-β hydroxylase deficiency may also result in
3 }% _6 b: V% bexcessive adrenal androgen production, and rarely,$ s: T8 e% C5 h' q8 A2 D+ z
an adrenal tumor may also cause adrenal androgen
6 U* f9 {2 }5 Lexcess.1,3
! D* D' S9 c+ m- i2 K6 ]) n+ m% `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. ~+ O( ]" ]  R5 ^, C1 J( D
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- d# Z3 V! Y2 a4 z$ \9 B
A unique entity of male-limited gonadotropin-
. V! x5 m/ I; K6 s: b" c1 aindependent precocious puberty, which is also known% b* w* E. b1 I- G9 y
as testotoxicosis, may cause precocious puberty at a
' S' f- b+ k1 ^# Bvery young age. The physical findings in these boys
% \* W; S0 r5 C- rwith this disorder are full pubertal development,  W0 X6 {  @3 r* |
including bilateral testicular growth, similar to boys5 E* @! H! `4 @8 @1 E9 D' T
with CPP. The gonadotropin levels in this disorder
# w- K5 W. s) a/ M- yare suppressed to prepubertal levels and do not show
* g" a! l& _5 T* c  \' K/ u& W) ppubertal response of gonadotropin after gonadotropin-; P5 w+ a$ r2 b# c/ T2 k9 k4 G7 ~) O
releasing hormone stimulation. This is a sex-linked
  |" u  Y# `( S, D% P7 c$ K( sautosomal dominant disorder that affects only
# g8 ~- I' `# O4 O( {+ Vmales; therefore, other male members of the family, \1 ]5 M9 G3 a: V2 x3 k  ]. C
may have similar precocious puberty.3: t5 B3 V( \8 I: S( O
In our patient, physical examination was incon-! [0 N: h) f) A4 f
sistent with true precocious puberty since his testi-* w9 T4 s8 X& }  w% A
cles were prepubertal in size. However, testotoxicosis
4 Z( y/ n" _0 j# Q; Y3 `was in the differential diagnosis because his father
  z& t# j% p1 Nstarted puberty somewhat early, and occasionally,
' b8 B% M5 w7 m- Qtesticular enlargement is not that evident in the! [4 O! @3 r- f$ \+ N
beginning of this process.1 In the absence of a neg-
( m* L: G  S( Q) X7 Y# _ative initial history of androgen exposure, our; ~, L! p2 i' [$ x
biggest concern was virilizing adrenal hyperplasia,3 R3 @' ~! Q, P  X# F1 w
either 21-hydroxylase deficiency or 11-β hydroxylase; m; e# \# K) B; {5 X( n
deficiency. Those diagnoses were excluded by find-
+ b8 T7 C$ k! B1 Uing the normal level of adrenal steroids./ i' O7 n# Q9 s" T
The diagnosis of exogenous androgens was strongly, B, q0 ^5 r. Z2 Y2 P9 \
suspected in a follow-up visit after 4 months because, y9 ^9 t+ F, R1 ~
the physical examination revealed the complete disap-" }% g+ n6 `6 }( T  _' r! q' _: \
pearance of pubic hair, normal growth velocity, and% H) j& v+ n$ _) D& Y0 F+ A  ]
decreased erections. The father admitted using a testos-
' Z. K- Q! V) H1 @) F/ m! A, Cterone gel, which he concealed at first visit. He was# p; F* v$ Q7 j) ?0 w
using it rather frequently, twice a day. The Physicians’
* J/ D4 g8 K2 _( W7 E" ]( FDesk Reference, or package insert of this product, gel or# U& y1 O3 j2 t7 m( K3 Q
cream, cautions about dermal testosterone transfer to
1 I; T& d9 Y7 W2 L  x! [unprotected females through direct skin exposure." U1 Q6 Z1 R# ?4 f  h
Serum testosterone level was found to be 2 times the9 L* V' a) y! S" I; x% |6 R, W. t" d: R0 v
baseline value in those females who were exposed to& Z: g! {% q( \1 y
even 15 minutes of direct skin contact with their male$ X  X1 N! S; q8 @% x
partners.6 However, when a shirt covered the applica-
0 V+ }# ]7 ^9 x0 ltion site, this testosterone transfer was prevented.
  [7 w2 s% s3 U' uOur patient’s testosterone level was 60 ng/mL,
- f; j- r- A( e& X8 g4 uwhich was clearly high. Some studies suggest that
4 t$ b2 K- N" A4 F) {4 n5 s" pdermal conversion of testosterone to dihydrotestos-
! D& M& @/ A, }: f/ |* f6 n' ^: Uterone, which is a more potent metabolite, is more# h9 [. Q0 s  b2 @4 {1 i7 s) I( ?
active in young children exposed to testosterone& @2 e6 \! u8 j, g3 t( ?$ j
exogenously7; however, we did not measure a dihy-
* x+ S7 }% {( C1 F- E" q% Z& Udrotestosterone level in our patient. In addition to' L3 W4 k* \4 \) `: v
virilization, exposure to exogenous testosterone in
! T8 @( @, |0 e" tchildren results in an increase in growth velocity and; A  z0 z9 s% V
advanced bone age, as seen in our patient.
' G+ u) G* I! V) z0 U! ~The long-term effect of androgen exposure during
/ ]. Z/ p' X. g! N" Yearly childhood on pubertal development and final9 K3 Y6 I/ r+ {1 r( w
adult height are not fully known and always remain; b3 k* j6 y- v; L, c
a concern. Children treated with short-term testos-
) M" M" l" o5 [% B& aterone injection or topical androgen may exhibit some/ K# C4 v: D' M, |6 K! G
acceleration of the skeletal maturation; however, after
  S: a- f& H3 |3 F9 Bcessation of treatment, the rate of bone maturation
. ~7 B* K- N+ vdecelerates and gradually returns to normal.8,9- i& N* s8 Q: p2 O4 J0 g2 c
There are conflicting reports and controversy
; ~2 ^0 @- s8 o0 n; Xover the effect of early androgen exposure on adult. J  x& t6 @) A$ ?9 Q+ q( e+ T
penile length.10,11 Some reports suggest subnormal- L  I) y1 b* B: [: R* R
adult penile length, apparently because of downreg-; j0 s+ G2 l$ T( {& x
ulation of androgen receptor number.10,12 However,3 q3 v4 N! F+ I$ ?
Sutherland et al13 did not find a correlation between  _6 g' L# E, q
childhood testosterone exposure and reduced adult
/ r+ i# k: G2 B" q4 `1 t7 V1 U9 Ppenile length in clinical studies.
, H1 I% n* F' g) l5 u' uNonetheless, we do not believe our patient is
, b3 q8 B* ^; t+ g8 S) p( d2 `4 pgoing to experience any of the untoward effects from
- G( o2 W  j8 C. D/ o3 atestosterone exposure as mentioned earlier because
0 `) p+ _2 S% t9 @! A( ithe exposure was not for a prolonged period of time.
% }8 p+ ~  E7 x8 W" nAlthough the bone age was advanced at the time of, I/ O$ n/ t  @$ J
diagnosis, the child had a normal growth velocity at3 K- b" h( T: a+ i3 [
the follow-up visit. It is hoped that his final adult: M% U/ w1 z# r/ b; f
height will not be affected.
) \" n) ~6 K5 I% w+ gAlthough rarely reported, the widespread avail-: h8 r8 k7 z( w% m; I
ability of androgen products in our society may9 e" u% ~  m4 n& V' b" m
indeed cause more virilization in male or female$ z& ~, w& _1 J9 q9 ]% {
children than one would realize. Exposure to andro-% D# U8 n( J' \, C
gen products must be considered and specific ques-
7 S, n2 W& ]! Ltioning about the use of a testosterone product or* F# Y8 _1 {6 N4 W
gel should be asked of the family members during0 y+ ?3 b1 a6 D
the evaluation of any children who present with vir-
3 _% C- \$ I' {" M6 Z1 x- R% Hilization or peripheral precocious puberty. The diag-
8 h8 q# q. j: [' p* Z& jnosis can be established by just a few tests and by& O* k+ U' ]' i# ?. s0 K1 U9 l
appropriate history. The inability to obtain such a: v# ~9 v/ D$ ^
history, or failure to ask the specific questions, may+ w; @5 l/ w. n' q1 t2 E
result in extensive, unnecessary, and expensive
; T# ?4 m$ f2 P3 x  y" r8 winvestigation. The primary care physician should be
* l( F# C6 _; uaware of this fact, because most of these children$ y  p8 P0 |& @1 a1 e
may initially present in their practice. The Physicians’
" R. _. E6 N4 L  C: |3 ~. V% wDesk Reference and package insert should also put a
+ j: e+ O( T* u" q2 Hwarning about the virilizing effect on a male or, H9 j$ ]7 ]6 i4 K3 a, e6 @
female child who might come in contact with some-
# `. ~) i5 S0 K3 J# o* ?; @one using any of these products.3 ~3 Q7 d1 F# {* w+ D4 q8 ^
References
* H( p1 ~& M) h6 U1. Styne DM. The testes: disorder of sexual differentiation6 u" L5 X+ Z0 E9 z( t: C9 `
and puberty in the male. In: Sperling MA, ed. Pediatric$ {* p5 X: Q0 g, @0 p  F; b8 J) q
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 a1 Q1 |7 G  e7 a. U+ g- ^/ f2002: 565-628.
/ P$ c, f+ n1 X% u, A6 g$ K2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious  v4 r3 _* H2 A% g! {
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
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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

& S" U( s( \! g0 z  S. e) X7 u7 _  e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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