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Sexual Precocity in a 16-Month-Old
- ?. T. p1 ]- y/ [Boy Induced by Indirect Topical
; |, H% e& M& y- fExposure to Testosterone6 `/ ]. d8 `+ n
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
6 L4 G4 T( G% D. V5 m" ]and Kenneth R. Rettig, MD1- ]9 J. i3 u/ H2 P* _  ]+ Q' k" k
Clinical Pediatrics: l5 C- S3 l+ u1 C1 I
Volume 46 Number 6
) }& n, m" U) x' {July 2007 540-543* p" p$ G; K( i  G8 u2 B0 q6 x( l
© 2007 Sage Publications
; K; `+ k! C$ l& c10.1177/0009922806296651
4 v1 R8 }3 @  m. F; x' \. f0 Lhttp://clp.sagepub.com3 a& [, f/ `7 n# Y
hosted at
5 m9 ?. L1 }9 Z5 a% \0 j9 Jhttp://online.sagepub.com
9 E5 {5 ?& g  L9 i7 ]( `- a3 rPrecocious puberty in boys, central or peripheral,
( M. F/ o' O# ]1 z9 h! ]is a significant concern for physicians. Central
7 F, K7 G7 {' D' L) L0 @precocious puberty (CPP), which is mediated
, }4 _7 ]* F% ]7 J9 tthrough the hypothalamic pituitary gonadal axis, has8 i/ l' [7 u) C. q1 G
a higher incidence of organic central nervous system3 d$ G* h- m. l3 e7 `3 `
lesions in boys.1,2 Virilization in boys, as manifested
* F8 C/ X4 q: lby enlargement of the penis, development of pubic
. h9 P- w9 N* T- S7 chair, and facial acne without enlargement of testi-) N; b0 E, e- F! |! f/ q/ u8 }( a
cles, suggests peripheral or pseudopuberty.1-3 We) |3 q" ?9 f+ W, j
report a 16-month-old boy who presented with the2 j" v+ X4 G  s6 x, L
enlargement of the phallus and pubic hair develop-
% i' m: N: [! A# ?, }- |ment without testicular enlargement, which was due+ x6 h" J4 x+ b1 E$ ^7 M
to the unintentional exposure to androgen gel used by. ~" C' a5 \' G5 u$ M$ B
the father. The family initially concealed this infor-6 u. R5 @% B0 x
mation, resulting in an extensive work-up for this
3 t! q5 M) y- K4 X4 m9 W- `child. Given the widespread and easy availability of
3 d; d8 q7 N& a2 u' m& mtestosterone gel and cream, we believe this is proba-% A  m$ f1 {: F$ ]7 R
bly more common than the rare case report in the; z' Y# ?$ b9 s+ v
literature.44 A% |3 p3 ~4 {1 U1 M0 z: X
Patient Report
* u9 E) W0 }+ @# j$ a( GA 16-month-old white child was referred to the
4 \+ N  m: _* C9 u/ mendocrine clinic by his pediatrician with the concern
/ k8 a& b( Y) [6 B( q) Jof early sexual development. His mother noticed
- D: p$ S4 u, ]! q, K: Ulight colored pubic hair development when he was
# ~, n/ F( P8 tFrom the 1Division of Pediatric Endocrinology, 2University of
9 I5 |3 ^0 S" E# A6 X5 t5 ySouth Alabama Medical Center, Mobile, Alabama.
; w. g0 c* q1 OAddress correspondence to: Samar K. Bhowmick, MD, FACE,
+ V, I# Y: a0 w+ @/ }9 RProfessor of Pediatrics, University of South Alabama, College of$ m5 |7 S) z; U3 U2 r2 V) j+ ^, v" Z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
; q: _# R' c, b3 E, w3 ze-mail: [email protected].1 I# S' U/ y) g; ]
about 6 to 7 months old, which progressively became
: y5 O+ j6 U! I2 X" v" Xdarker. She was also concerned about the enlarge-
3 f# b* d$ a8 u1 sment of his penis and frequent erections. The child
$ ^' k& |$ M( x# G1 \& Jwas the product of a full-term normal delivery, with
( G" B8 E" N& y( za birth weight of 7 lb 14 oz, and birth length of, G0 U! d/ x; I
20 inches. He was breast-fed throughout the first year1 k2 ]& F; J$ O4 @
of life and was still receiving breast milk along with
7 m5 X) g7 x6 Z2 V) \# n$ Jsolid food. He had no hospitalizations or surgery,$ ?' c, Z4 [7 Y2 R  J+ {
and his psychosocial and psychomotor development" Y) f. p7 [# A4 t. C( O& O8 m1 h
was age appropriate.
0 }! Z. R% b& ]5 m  r6 lThe family history was remarkable for the father,2 d' A+ m9 O  B% D2 L. U. z$ G$ p
who was diagnosed with hypothyroidism at age 16,
) W* \1 s! X. Y+ c" k5 Q( \which was treated with thyroxine. The father’s
- c2 t3 w6 x$ f6 g/ P8 J! xheight was 6 feet, and he went through a somewhat
& x, B( k- L2 }early puberty and had stopped growing by age 14.. \9 [4 N) d# z
The father denied taking any other medication. The& p: t% A2 h' J+ x" P# R# p
child’s mother was in good health. Her menarche; z. e) [8 Y& p  z" e( i3 I( T
was at 11 years of age, and her height was at 5 feet
7 `) j1 k: u9 w4 l$ q  @5 inches. There was no other family history of pre-. v) B% I- A4 ]$ o, O) }# v
cocious sexual development in the first-degree rela-
& v# `( |. e" A& D; |" r: Gtives. There were no siblings.3 }6 Z" E$ V. H8 y
Physical Examination
$ t6 Y7 Q9 j/ w0 s' \The physical examination revealed a very active,
# Q; l: ]) U4 T( e# ]playful, and healthy boy. The vital signs documented5 {: Q$ R9 l% S5 r% i) d
a blood pressure of 85/50 mm Hg, his length was! o6 R. E* A/ U, h. e
90 cm (>97th percentile), and his weight was 14.4 kg
) k; l4 h5 H3 k$ `) D(also >97th percentile). The observed yearly growth/ W: G% e+ S+ x2 ]6 G# R: Z
velocity was 30 cm (12 inches). The examination of3 w& m$ B6 F! C5 e( l- A, W
the neck revealed no thyroid enlargement., R3 {  @. v: r+ n
The genitourinary examination was remarkable for* t6 ?, v3 F6 |4 K7 K
enlargement of the penis, with a stretched length of2 m9 q. `7 ~. W0 L( `
8 cm and a width of 2 cm. The glans penis was very well6 m1 q% Y& a( M  Y+ y
developed. The pubic hair was Tanner II, mostly around
* r8 H; l* k0 F  H* C5 V540$ V/ g; M- I9 }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 j0 ?% p" B% \% v4 N% m$ n
the base of the phallus and was dark and curled. The, }0 |% e" v+ L; x6 }
testicular volume was prepubertal at 2 mL each.
4 x1 _( T( l/ `, s  {- q( z) LThe skin was moist and smooth and somewhat
) z4 M* S/ S9 q4 ~) d  i# n4 w' Noily. No axillary hair was noted. There were no4 {( L2 Q- W( L! J( C% q2 Y  \5 B2 ~
abnormal skin pigmentations or café-au-lait spots.  s" N( Z: c0 P$ Z
Neurologic evaluation showed deep tendon reflex 2++ E% _, |5 b6 Z  r
bilateral and symmetrical. There was no suggestion# g2 m9 o8 m* b6 c: P6 D) f
of papilledema.
2 L  b4 C* ^$ ~8 \6 qLaboratory Evaluation) L+ H4 v3 q: S; _/ a4 j
The bone age was consistent with 28 months by
/ d5 K, s) H' n. Nusing the standard of Greulich and Pyle at a chrono-
- I" b  m& `" F' [2 dlogic age of 16 months (advanced).5 Chromosomal
: o5 J' ~8 A) Z0 m  I- G( C9 [karyotype was 46XY. The thyroid function test
2 F2 [6 e. |, j% vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
( T$ f! p) v4 j, g0 h* [) Flating hormone level was 1.3 µIU/mL (both normal).& [* L  R7 y6 P, P
The concentrations of serum electrolytes, blood% i+ O0 p, \7 X4 G
urea nitrogen, creatinine, and calcium all were
) ^, Q. w2 U3 {  E# [% twithin normal range for his age. The concentration) s" ~2 }1 S8 Y: R1 J1 K8 I
of serum 17-hydroxyprogesterone was 16 ng/dL
3 B$ e0 D) T  B9 d; |(normal, 3 to 90 ng/dL), androstenedione was 20) X- a" q2 j. u- V! \. \
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
; V) S& R0 t5 H" V6 O& ~5 {! @- hterone was 38 ng/dL (normal, 50 to 760 ng/dL),
, e) v/ @3 V6 |5 t# M! Xdesoxycorticosterone was 4.3 ng/dL (normal, 7 to3 V6 j8 v4 S. @. b$ L! M
49ng/dL), 11-desoxycortisol (specific compound S)
' Q, b4 A2 N  o) Bwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 r- b% e1 A# M+ _3 v, ?; K5 A. ^tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ a7 D. }5 ?* `% D1 c
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),% h7 I/ a" m! ^0 {) [, [% z
and β-human chorionic gonadotropin was less than
9 {, z  t+ `! y" k. ]" J1 k3 p5 mIU/mL (normal <5 mIU/mL). Serum follicular
' d( p7 T. J( U' }# j' |0 bstimulating hormone and leuteinizing hormone" \- G+ @; Z- r/ f% |" J
concentrations were less than 0.05 mIU/mL
( z* s; C" O2 ^2 {+ D% b(prepubertal).
8 h" A' b/ s6 ~- |The parents were notified about the laboratory4 G2 p5 L5 T2 ~, y
results and were informed that all of the tests were
6 `# i# p9 P# Inormal except the testosterone level was high. The* Q9 B& G. y( j* Q; W
follow-up visit was arranged within a few weeks to# i+ C) U' G8 H  k' ?0 R6 |
obtain testicular and abdominal sonograms; how-/ A( u( p/ Y9 G. [( I0 ]( {
ever, the family did not return for 4 months.% B2 ?6 Y; B7 J, u( @/ A
Physical examination at this time revealed that the8 u3 J  i! S1 A/ P6 N
child had grown 2.5 cm in 4 months and had gained4 c1 t! e' D( ~) Z: k( D8 ~' M" T
2 kg of weight. Physical examination remained/ `5 a+ [  W$ I  \& [
unchanged. Surprisingly, the pubic hair almost com-7 I' h! h. i* N; ^& o) o) h, p
pletely disappeared except for a few vellous hairs at
2 N2 S. w$ _9 t' h. hthe base of the phallus. Testicular volume was still 2/ ^# O" Q. ?  P9 f' [0 L0 F% K
mL, and the size of the penis remained unchanged.
' q& N1 v6 m7 q2 |The mother also said that the boy was no longer hav-6 G" f7 D8 P* [# W8 v+ o
ing frequent erections.
' x5 F  k; Z' cBoth parents were again questioned about use of- }( O3 f0 c8 U+ w
any ointment/creams that they may have applied to
# Q, n6 u% x1 B8 A% Z6 Qthe child’s skin. This time the father admitted the/ S4 N0 N  z5 j( i' J
Topical Testosterone Exposure / Bhowmick et al 541
! G% a; I3 \  q2 ^( duse of testosterone gel twice daily that he was apply-
  z" t- m7 W) x+ N$ Y+ M( v2 [( eing over his own shoulders, chest, and back area for% Q$ X# \3 D* |- d7 ^  P/ o
a year. The father also revealed he was embarrassed3 o3 u( o$ o. K5 s
to disclose that he was using a testosterone gel pre-! c5 S$ e" o  `% T4 @1 z; ?
scribed by his family physician for decreased libido
: @  \$ o2 o$ a- [6 o4 zsecondary to depression.
6 D8 R3 ^( ^$ `. M7 VThe child slept in the same bed with parents.
- a9 c: _- C3 E/ K( X" d7 gThe father would hug the baby and hold him on his
' k" f$ ]6 i2 h2 _/ [! k( V# D  Ochest for a considerable period of time, causing sig-
4 D* p# ]* w8 x- e2 w7 Q# Rnificant bare skin contact between baby and father./ `7 W% W& C% n$ v
The father also admitted that after the phone call,
0 X8 {) C5 W# ^# bwhen he learned the testosterone level in the baby
) {' H! O3 F+ F* L, M1 }3 f1 Swas high, he then read the product information! Z& `; E. ~0 x3 b
packet and concluded that it was most likely the rea-9 J" P8 Q# k! R2 ]4 q
son for the child’s virilization. At that time, they
. i' A- a& G$ J4 E/ O; }decided to put the baby in a separate bed, and the
2 ?+ @( Q  b1 y8 q) Cfather was not hugging him with bare skin and had
" {+ m8 y4 N% N5 _2 Z3 s" Ybeen using protective clothing. A repeat testosterone% d4 }. P3 p4 R6 |8 n( ^
test was ordered, but the family did not go to the
$ w; j. `9 n# ~9 W1 Q; @! Alaboratory to obtain the test." B* n1 j1 K! j+ Q# ~
Discussion! g9 s/ z* }' X3 s8 j1 g
Precocious puberty in boys is defined as secondary6 c# p" c- B1 x4 T" u
sexual development before 9 years of age.1,4
1 N+ B1 B4 ?8 oPrecocious puberty is termed as central (true) when
/ i+ D6 D: ~' t- M  oit is caused by the premature activation of hypo-8 W  o2 d; b  y$ V9 ~
thalamic pituitary gonadal axis. CPP is more com-: K; _. ]: ]) n
mon in girls than in boys.1,3 Most boys with CPP
( \* z. R3 {' N! `% k$ z0 |; Ymay have a central nervous system lesion that is
% p# n8 w' l/ o( i& k4 F5 hresponsible for the early activation of the hypothal-& `8 G+ M/ W+ l0 f  H3 c% o( i& r) }
amic pituitary gonadal axis.1-3 Thus, greater empha-9 `7 i+ o) D1 k1 o: D0 V1 d
sis has been given to neuroradiologic imaging in7 ?) F3 W" F1 K% Y4 j
boys with precocious puberty. In addition to viril-
1 c. H7 c) u, q) }$ |% Z+ W& nization, the clinical hallmark of CPP is the symmet-4 D# \+ N7 P" V% h
rical testicular growth secondary to stimulation by
7 |3 W) Z7 c9 F5 `" b. @2 @! a) Hgonadotropins.1,3
$ F' @/ g- F' E# ~Gonadotropin-independent peripheral preco-
: E% a! v3 z) B2 p2 ?( Tcious puberty in boys also results from inappropriate
8 ?0 Z3 z. o! `. v- E- kandrogenic stimulation from either endogenous or
9 t9 V' c8 {8 z8 j& k4 N8 @exogenous sources, nonpituitary gonadotropin stim-# d& l" l& T7 A: W
ulation, and rare activating mutations.3 Virilizing
- \1 X, O3 J2 X4 z6 m4 O' X0 Icongenital adrenal hyperplasia producing excessive
/ E% ^5 w1 v; |/ F# ^' t; U' ]' @adrenal androgens is a common cause of precocious
: |. G( g! D. apuberty in boys.3,47 M) [. U+ b" N
The most common form of congenital adrenal
; i# W# F, q1 _* G) E2 h9 [hyperplasia is the 21-hydroxylase enzyme deficiency.
6 ]- F+ h# j" PThe 11-β hydroxylase deficiency may also result in
5 r0 W3 @# G& ]3 lexcessive adrenal androgen production, and rarely,- E" ?8 D* }: T+ x% v& g
an adrenal tumor may also cause adrenal androgen
5 C' [* R6 x- x9 l  H) M5 Xexcess.1,34 H4 r  I  Y% I( U$ ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 r, }) S) [# w/ \. a9 y( q. F542 Clinical Pediatrics / Vol. 46, No. 6, July 2007+ e6 L4 e" k" \
A unique entity of male-limited gonadotropin-
' D% P' P- Y4 p5 F7 vindependent precocious puberty, which is also known. z  s% ]) r1 x6 v& }
as testotoxicosis, may cause precocious puberty at a% F* _' A! Q. L8 Y4 x1 w% }
very young age. The physical findings in these boys
' g1 V2 u# J% A- H' Twith this disorder are full pubertal development,
4 @1 D; B) h* M/ m3 ]# q) N. F4 f, qincluding bilateral testicular growth, similar to boys, l" v) X$ S, |( _9 G# n0 h
with CPP. The gonadotropin levels in this disorder5 N$ _) n4 N5 A$ p- k
are suppressed to prepubertal levels and do not show$ m4 C! }" @4 A( e: L& K3 u) V
pubertal response of gonadotropin after gonadotropin-
7 j& @2 n. A  N7 A8 i5 Rreleasing hormone stimulation. This is a sex-linked! t% x) s" \- @  \" X1 ]+ Q
autosomal dominant disorder that affects only9 ]. b" ?- h0 B. h8 ]+ ?2 U! y- l
males; therefore, other male members of the family
1 d: t9 z8 u* x  imay have similar precocious puberty.3
+ T0 q+ Y/ \0 w/ K- W$ HIn our patient, physical examination was incon-
  E2 m0 B, H6 |sistent with true precocious puberty since his testi-* A5 E  `; w% L- m" \* R6 Q: }1 l
cles were prepubertal in size. However, testotoxicosis
# Z+ g3 y& v. [8 y2 lwas in the differential diagnosis because his father
& \' m# U  k/ O7 c8 Y0 p+ y, ?# X+ sstarted puberty somewhat early, and occasionally,
  m/ }; U. j" c" k# N6 ntesticular enlargement is not that evident in the
8 V5 |/ x# m  y& M* q7 k# Bbeginning of this process.1 In the absence of a neg-
, @- j* j# J3 Vative initial history of androgen exposure, our
/ A5 z8 v# N0 d" F$ G+ D: \' }biggest concern was virilizing adrenal hyperplasia,; x8 m0 v9 H( N0 D
either 21-hydroxylase deficiency or 11-β hydroxylase
  y' D8 q/ A. a+ S, E5 jdeficiency. Those diagnoses were excluded by find-9 F- n4 m) h5 @5 ?) l; G% G
ing the normal level of adrenal steroids.- `% H" E& j( }: J. S2 d% _- K
The diagnosis of exogenous androgens was strongly
$ v9 Y! {9 o5 N: r( |suspected in a follow-up visit after 4 months because
7 b% s* `! X5 ~" Nthe physical examination revealed the complete disap-/ S4 a8 @3 O) [  g" A# }% m
pearance of pubic hair, normal growth velocity, and" M" L$ \+ G+ W7 y
decreased erections. The father admitted using a testos-
, C. g5 x" d- E; hterone gel, which he concealed at first visit. He was4 H2 H$ Z( u3 }" |& i% S( U( j
using it rather frequently, twice a day. The Physicians’
( B- z  P2 d3 P" KDesk Reference, or package insert of this product, gel or
! P0 n  b8 Y1 D6 r/ D6 H8 M( e( xcream, cautions about dermal testosterone transfer to
, c$ x+ F  ]' Punprotected females through direct skin exposure.
) C. A  g+ d# n: W( A3 w2 aSerum testosterone level was found to be 2 times the5 A, R1 Y8 T1 A# k, C/ t" r& b
baseline value in those females who were exposed to" H  T. _2 P* d3 G4 R- g, |
even 15 minutes of direct skin contact with their male
, O6 U+ C: a& l' U; Spartners.6 However, when a shirt covered the applica-, m( {# F3 L- ?  m0 [' R5 l( F
tion site, this testosterone transfer was prevented.
& U6 L2 b3 G* E9 HOur patient’s testosterone level was 60 ng/mL,3 ~5 e6 A) Y, |3 ]* k' Y  p
which was clearly high. Some studies suggest that
$ U5 g5 _, s8 D/ [, @' zdermal conversion of testosterone to dihydrotestos-7 L1 W5 ]5 m. k0 h  Q. g9 m0 `
terone, which is a more potent metabolite, is more+ ]8 K4 Y9 L8 H9 F* e
active in young children exposed to testosterone
; v0 p; B! F# ~exogenously7; however, we did not measure a dihy-0 w( g* `# Z2 Y$ @, `
drotestosterone level in our patient. In addition to( F. H; u2 t' T1 D$ S" M+ ^
virilization, exposure to exogenous testosterone in
- @9 K: K. k  {# _1 ?children results in an increase in growth velocity and* _; l( L) N* O. w$ [
advanced bone age, as seen in our patient.' z/ B) T8 M0 |6 W; x
The long-term effect of androgen exposure during# P; ^: @7 B& O" D9 {$ u. e. V  d
early childhood on pubertal development and final
6 o! y! X5 l9 _" H; ]/ K+ Zadult height are not fully known and always remain* g% A. A3 W: V/ ?) G$ ]
a concern. Children treated with short-term testos-
& J. `4 K( S8 a) ~terone injection or topical androgen may exhibit some
$ H  F' Z8 W2 \( P/ dacceleration of the skeletal maturation; however, after
, X4 N) S3 U- E2 Vcessation of treatment, the rate of bone maturation, U: w9 G; F, {- Y8 n
decelerates and gradually returns to normal.8,9
- c% f2 {2 E% m- l) E" J% LThere are conflicting reports and controversy
% U; e+ `, H& c" a" k1 B+ lover the effect of early androgen exposure on adult6 F: T3 s& F+ ?0 {  {9 V* T
penile length.10,11 Some reports suggest subnormal
  k: d! R1 R$ Z: Y3 ~! b) e" I8 ?adult penile length, apparently because of downreg-
1 J% g" ^7 S( j( g# Yulation of androgen receptor number.10,12 However,7 s3 R. S6 w) n3 Q! v8 h9 r, `1 l! M) O
Sutherland et al13 did not find a correlation between/ b, P+ `) b: U, s) ^8 `2 s
childhood testosterone exposure and reduced adult2 O1 p8 r, P! X, b: n
penile length in clinical studies.# F/ |! Y5 o( @4 a4 C! Y
Nonetheless, we do not believe our patient is2 b. ?9 e$ |6 h
going to experience any of the untoward effects from0 I- w: E7 P5 |8 z% j1 r
testosterone exposure as mentioned earlier because& v0 o: S6 n7 ]( W4 A- D* e) i7 A/ i
the exposure was not for a prolonged period of time.8 `( n& p$ ~4 B) ^# A% _1 z4 X
Although the bone age was advanced at the time of* L. i( |& Z! h, {
diagnosis, the child had a normal growth velocity at7 i) S' L: `; @4 N7 Y
the follow-up visit. It is hoped that his final adult5 B9 h" d, c5 z7 q9 E
height will not be affected.
' J$ \6 B8 K5 tAlthough rarely reported, the widespread avail-) q: M* c5 r# b- G3 `! L- r
ability of androgen products in our society may
0 }1 m; j; w9 `% Vindeed cause more virilization in male or female# R' h1 R; P! E, J" r$ I
children than one would realize. Exposure to andro-
1 ]8 k; Z" q7 Y8 W( E% H. L. ogen products must be considered and specific ques-7 \0 \, W1 |( X1 s: _. v. q
tioning about the use of a testosterone product or) i# T( Y% \* C$ h8 b
gel should be asked of the family members during
' t- W. I# s2 h9 e2 o1 f1 c( r$ Tthe evaluation of any children who present with vir-
$ u' [; P- L  Y  kilization or peripheral precocious puberty. The diag-7 g, b$ C* J: e5 T% u0 F1 ]  P
nosis can be established by just a few tests and by
$ y) \' n- h1 wappropriate history. The inability to obtain such a
6 R; V  w8 W  Q1 k% Chistory, or failure to ask the specific questions, may
' i2 \& E/ W$ b: ^0 s1 _1 I+ aresult in extensive, unnecessary, and expensive
% t" a6 J' r" l) [7 {) P. tinvestigation. The primary care physician should be7 Q! o  _3 r" ~' n( T' K
aware of this fact, because most of these children
5 Q0 |% j7 `9 R& Q7 f9 [+ [4 Hmay initially present in their practice. The Physicians’
, V- h6 K! g+ H$ c$ ~8 z  zDesk Reference and package insert should also put a
& A- a/ ?5 H4 Cwarning about the virilizing effect on a male or
% i$ [* m8 w+ s; m& V& `6 Z! Nfemale child who might come in contact with some-# T& b( S, V0 n2 U: k; Q# Q
one using any of these products.. E' q4 n1 C& U' w" B' R
References) Z+ E6 C) c1 s& R9 d: s: X
1. Styne DM. The testes: disorder of sexual differentiation
5 [1 L6 |7 Y- f/ W& K* V  [and puberty in the male. In: Sperling MA, ed. Pediatric
! F8 n8 F- d, qEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;0 W. Q9 t# m* c# q4 z
2002: 565-628.
( M+ v# H/ M  I" H2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious6 _, Z  W' e6 y7 ]3 `( V8 s
puberty in children with tumours of the suprasellar pineal
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Sexual Precocity in a 16-Month-Old
2 q* m2 m3 ~6 r  I3 _: rBoy Induced by Indirect Topical# k# M- y% n: {- a0 ]
Exposure to Testosterone
, ^3 k1 _  G  \, n7 ~0 T3 fSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
+ G$ \4 x9 n! c' iand Kenneth R. Rettig, MD1( [; x9 p0 G9 o, F" q
Clinical Pediatrics
& D' k9 X# n  r7 {Volume 46 Number 6
5 l5 l5 r" j7 ^& k& EJuly 2007 540-543% z2 Z, z% U3 O
© 2007 Sage Publications$ [$ {! q# {( `. d) t& [
10.1177/0009922806296651
. O% U, j; h; _http://clp.sagepub.com& |& Y( d- B& Z8 n
hosted at
5 c. m, K0 K1 z/ b. Xhttp://online.sagepub.com
6 L" u$ X5 w: y$ l2 tPrecocious puberty in boys, central or peripheral,
2 m8 @# q& r8 X) l% V! b& sis a significant concern for physicians. Central5 Y3 ]7 ^: ?& S6 ]- L: B
precocious puberty (CPP), which is mediated" F& ]2 y4 S0 n
through the hypothalamic pituitary gonadal axis, has
/ Y- [, W* b- T+ ?a higher incidence of organic central nervous system
( B& s& w, {2 klesions in boys.1,2 Virilization in boys, as manifested
# [& @- F1 D" j- ~6 {by enlargement of the penis, development of pubic
/ n) X) [7 M4 @+ _6 \6 H+ a/ ehair, and facial acne without enlargement of testi-8 J% r. {  k: U/ q0 ~% r
cles, suggests peripheral or pseudopuberty.1-3 We
+ P2 T9 u: ~# S7 m  Z' [( greport a 16-month-old boy who presented with the
( X  ~0 l9 G( b# e  Benlargement of the phallus and pubic hair develop-
/ }2 {& M# [7 o9 j9 f7 m: zment without testicular enlargement, which was due
7 p: _1 P, j) }# K$ `' k4 Jto the unintentional exposure to androgen gel used by  m: A9 n# d7 O/ J0 E- p1 n' T& M; @( f1 u2 z
the father. The family initially concealed this infor-3 h' E9 t/ s5 [; N* g1 B6 y" Z
mation, resulting in an extensive work-up for this. E6 i2 _6 d! j( Q* V
child. Given the widespread and easy availability of" w! u+ }) J9 k: C: s% B& i
testosterone gel and cream, we believe this is proba-
$ w2 l4 a( V% u  w2 i6 Ebly more common than the rare case report in the
6 v5 ]# U# l: _  m* X! x6 Pliterature.4
$ _# k9 a  E& zPatient Report. x, t2 i6 Y% `5 O0 c! U
A 16-month-old white child was referred to the/ E+ e' i& U# ~8 k7 ]
endocrine clinic by his pediatrician with the concern
; b0 M) l. W- g8 E  x% tof early sexual development. His mother noticed! G! B/ I, Q& ^5 D
light colored pubic hair development when he was
3 A6 ~, b& ?9 e1 j5 {4 ^' M* {8 SFrom the 1Division of Pediatric Endocrinology, 2University of0 W( I+ `% C2 M
South Alabama Medical Center, Mobile, Alabama.0 @, y) W- P/ F3 b3 [( c+ ^
Address correspondence to: Samar K. Bhowmick, MD, FACE,, m" `/ \/ X' H: [" g. ]
Professor of Pediatrics, University of South Alabama, College of
9 H9 D, O' S7 V3 |Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;9 ^& f: Z% i+ ?, [6 z+ g; Z& n9 A
e-mail: [email protected].7 f. m3 Z7 Q6 h, V' D; W1 G5 D
about 6 to 7 months old, which progressively became( a% Y# t0 u" Z7 i  F5 p+ o# K
darker. She was also concerned about the enlarge-
: c! |, f$ R% P& ?  Z2 g; o3 Mment of his penis and frequent erections. The child1 C4 V* f; g5 r) E) D
was the product of a full-term normal delivery, with' E! P7 v4 p5 \# o! q$ v6 l! f' W8 h
a birth weight of 7 lb 14 oz, and birth length of
0 |  h9 ^. x5 y- N' Z20 inches. He was breast-fed throughout the first year
3 m# u0 C2 S. C4 {' s" Oof life and was still receiving breast milk along with9 l+ M5 e& y' h$ d2 p" [- m3 X
solid food. He had no hospitalizations or surgery,
/ w1 G* G& O2 @! i: \) Y+ gand his psychosocial and psychomotor development  S& V3 p* S  @4 g% _" i7 d: u2 v
was age appropriate.
; H' i; L5 q. [- X% i, E( a; RThe family history was remarkable for the father,) G1 i' ]% V3 C/ c. g
who was diagnosed with hypothyroidism at age 16,9 G+ }! l% H( V4 C" P* A
which was treated with thyroxine. The father’s% c3 r  X' b# h4 a% z
height was 6 feet, and he went through a somewhat
4 T9 E7 L; ]2 k8 C9 M! Oearly puberty and had stopped growing by age 14.
  P5 V1 W' }) r4 \The father denied taking any other medication. The& X. U* I( {$ i6 n
child’s mother was in good health. Her menarche
, C$ D& i5 v& T$ o. H- Awas at 11 years of age, and her height was at 5 feet
$ e1 R* @- A4 y. ~' e( [5 p5 inches. There was no other family history of pre-; h$ T! m( H& n4 d
cocious sexual development in the first-degree rela-5 i$ [1 p0 W& G& Z' d# P
tives. There were no siblings.
* B" m! v3 G, O8 X$ `9 PPhysical Examination. b% Q4 t; t+ O( s  V
The physical examination revealed a very active,. U" R, c$ ]- U4 ^0 u8 n
playful, and healthy boy. The vital signs documented
4 y2 O( V( `5 @& k6 E" B2 T* d' ^a blood pressure of 85/50 mm Hg, his length was6 l& v0 O+ I  u% }
90 cm (>97th percentile), and his weight was 14.4 kg
7 J' F2 A. r9 [(also >97th percentile). The observed yearly growth
! n/ G; ?' A. T0 mvelocity was 30 cm (12 inches). The examination of
( i4 j# J" x* x% Y' othe neck revealed no thyroid enlargement.
$ W# O4 k; `! H# q. X( U7 qThe genitourinary examination was remarkable for" `  P. ]7 s  Z; u0 Z
enlargement of the penis, with a stretched length of0 ^& T) S+ Q* }( y; M2 I
8 cm and a width of 2 cm. The glans penis was very well
9 G- @' N; p, X5 j& @: b) s- P$ Rdeveloped. The pubic hair was Tanner II, mostly around
8 d2 p8 ^  i! @4 p5406 ?, N. x( P( b3 |) r  h; ~' r2 y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, |/ M. T& \* j
the base of the phallus and was dark and curled. The
' ^1 t; ^* T  {, I$ y4 ]. H5 _# B8 z" ptesticular volume was prepubertal at 2 mL each.) E6 u5 p+ O( X' m
The skin was moist and smooth and somewhat
! ?; }! i& y$ b2 x( k# roily. No axillary hair was noted. There were no
6 h6 {" W6 k; a9 cabnormal skin pigmentations or café-au-lait spots.7 H* y# a2 ~, t+ ^6 n4 ^
Neurologic evaluation showed deep tendon reflex 2+
9 P: Q7 g+ F: ?3 e" Wbilateral and symmetrical. There was no suggestion
: Y. Y8 b1 ~! I* Z6 Iof papilledema.6 k5 n% t& n  L6 a
Laboratory Evaluation* Q( |( U$ T% X4 l
The bone age was consistent with 28 months by
$ s; l6 L5 C) j' h0 _- jusing the standard of Greulich and Pyle at a chrono-% d9 ]" m0 i5 k' A# X6 u/ Q
logic age of 16 months (advanced).5 Chromosomal
3 s* O( m9 Y+ {5 H& m8 j9 Jkaryotype was 46XY. The thyroid function test0 H  S$ K( @/ F; O0 w7 E
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 }+ E* S. [( S' `. jlating hormone level was 1.3 µIU/mL (both normal).% |5 q5 W1 O% B! I6 k" |3 G
The concentrations of serum electrolytes, blood, l$ j( N% _$ H8 x: {
urea nitrogen, creatinine, and calcium all were
% |' e* G( ~& x" ?  ]: f: Dwithin normal range for his age. The concentration: |0 H, J# c, o' K/ M( F* V* B0 a
of serum 17-hydroxyprogesterone was 16 ng/dL
- Q8 \+ t2 T" _& L$ Q(normal, 3 to 90 ng/dL), androstenedione was 20: L' p1 L' r- X# a$ b$ M$ x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-5 J8 @2 b, U2 `& I( t2 m
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 o# E1 D! `( L7 _' h; ^4 [/ Z2 Cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to2 Q/ Q( _* M# ]% D  n
49ng/dL), 11-desoxycortisol (specific compound S)
" {8 N1 Z5 I* g2 o/ Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 q& n* M2 r: t, C9 f$ V) m3 w9 Z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 ~: o( R7 F- d+ O" W6 dtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ `% j& [" @4 f- X$ ~5 u) z* sand β-human chorionic gonadotropin was less than0 o$ D) b5 K: \# f
5 mIU/mL (normal <5 mIU/mL). Serum follicular
% D3 f5 |# s  s8 }" ^6 wstimulating hormone and leuteinizing hormone( e" X1 C  l, R
concentrations were less than 0.05 mIU/mL  [6 b$ `" ]. z7 Z5 r
(prepubertal).
; t, `1 f! D8 F5 ^9 g  }8 G! ^The parents were notified about the laboratory7 s. h& ~. z% ~7 m9 f# u
results and were informed that all of the tests were# T. H$ U5 I3 c4 s) b. r) r
normal except the testosterone level was high. The
1 e) T* M3 k* V/ ]# V' [$ T9 Ofollow-up visit was arranged within a few weeks to
& R' b! F1 _1 J% f$ e+ uobtain testicular and abdominal sonograms; how-. x! h9 Y) }0 ~# ?' W/ C# c
ever, the family did not return for 4 months.
4 P. }# u( \7 V* LPhysical examination at this time revealed that the4 _$ i* \8 u( t
child had grown 2.5 cm in 4 months and had gained
) Q* Z6 A, h3 F1 U2 kg of weight. Physical examination remained
  ]4 p" \) V! Dunchanged. Surprisingly, the pubic hair almost com-9 C& Q* p0 z) g2 z
pletely disappeared except for a few vellous hairs at
/ i8 J, k7 A  F& j% Nthe base of the phallus. Testicular volume was still 27 X6 d3 m. b7 D1 B
mL, and the size of the penis remained unchanged.
+ R" C  `- h% u- n+ v+ X' G# YThe mother also said that the boy was no longer hav-$ E" n4 f! a3 Q+ R" B) J3 N$ E
ing frequent erections.
$ s3 @% x8 d2 @/ u. _Both parents were again questioned about use of3 \" B/ z, P1 X  Z- a
any ointment/creams that they may have applied to" E# O: g4 h3 r: U  L
the child’s skin. This time the father admitted the
* f; ^: O6 V9 l& ~% L$ DTopical Testosterone Exposure / Bhowmick et al 541
! S4 L) X0 L# o" Q+ I, z* Ouse of testosterone gel twice daily that he was apply-, w6 |& I) t+ \0 y/ m4 O
ing over his own shoulders, chest, and back area for/ k1 g3 l6 [, X
a year. The father also revealed he was embarrassed
2 Z% t- @" n& h0 O4 u. _- h: qto disclose that he was using a testosterone gel pre-
- K/ `5 h8 X; {+ U% p) vscribed by his family physician for decreased libido- h+ X* W/ w1 J% b
secondary to depression.
$ b2 G* A, y5 l$ o' Z. N0 EThe child slept in the same bed with parents.; s& o( c: b# q7 |/ H8 Y" K
The father would hug the baby and hold him on his
; t1 E/ y: _; ~% \" S9 schest for a considerable period of time, causing sig-, Y- A5 M+ [/ y2 e
nificant bare skin contact between baby and father.$ w; C9 R  l/ `' A! q" K+ ?5 a: Y" x
The father also admitted that after the phone call,
4 i& s" `+ f# p: ?when he learned the testosterone level in the baby
# \2 O4 U+ ]. K3 ^" bwas high, he then read the product information
5 ]& M9 m, [: S- o8 ppacket and concluded that it was most likely the rea-% c/ m( T6 J; M" D
son for the child’s virilization. At that time, they
3 k& u5 i6 `: o2 ~$ c2 kdecided to put the baby in a separate bed, and the$ p! g- G% {1 p8 ?
father was not hugging him with bare skin and had
$ D( g$ S$ |9 \( O& W' X6 r6 P, c; Ubeen using protective clothing. A repeat testosterone0 x/ V  |+ [1 |2 y! V' O/ \
test was ordered, but the family did not go to the
, f5 I+ s; C) s. _$ h& llaboratory to obtain the test.: `; s! ?- v2 t, P
Discussion! g, e0 C, s/ E( N9 E2 x
Precocious puberty in boys is defined as secondary
( ^- Q5 {/ j3 v2 \5 A% dsexual development before 9 years of age.1,4
" z+ N9 g/ g- O: J9 @Precocious puberty is termed as central (true) when
! ?, ?1 t8 C8 B/ H: H2 ait is caused by the premature activation of hypo-! r% w. e! e6 X1 z% F' B$ L% i
thalamic pituitary gonadal axis. CPP is more com-: f+ I9 R" r. i
mon in girls than in boys.1,3 Most boys with CPP
  p! o& c' e. c: e& v) F# A5 Jmay have a central nervous system lesion that is) E! X7 D5 ?( R' i/ K# R
responsible for the early activation of the hypothal-
; [8 D+ Y' s2 Gamic pituitary gonadal axis.1-3 Thus, greater empha-" Y* t/ f2 r  ]+ P3 ?- G
sis has been given to neuroradiologic imaging in+ I; h$ ~* |2 ~$ r: b1 B: O/ O
boys with precocious puberty. In addition to viril-& K+ r( j( F6 r8 z3 ^. F
ization, the clinical hallmark of CPP is the symmet-" A' \' S) F; [7 l1 F5 y
rical testicular growth secondary to stimulation by1 H1 m. }( J0 M: ^
gonadotropins.1,3
: D% W- g& E$ w1 ^. V6 ]Gonadotropin-independent peripheral preco-7 J: J7 V& I# v/ L# T: `: z
cious puberty in boys also results from inappropriate
8 a) G5 V" k4 r2 @( Candrogenic stimulation from either endogenous or
) c" d1 v/ n4 a4 R) D. |3 Fexogenous sources, nonpituitary gonadotropin stim-
8 B+ l/ u  b, y: eulation, and rare activating mutations.3 Virilizing
' ?6 Z, U  j" a. Z2 @, Ocongenital adrenal hyperplasia producing excessive$ N8 ~# {. W' H; J( M/ I7 P. o( w  K
adrenal androgens is a common cause of precocious
) d4 Q- |; N9 ~1 G5 L& _& Y$ b  }* kpuberty in boys.3,4
+ _. }( j- Q& k( T9 X3 ~) }1 SThe most common form of congenital adrenal" J" C& g3 _) h& L! ^
hyperplasia is the 21-hydroxylase enzyme deficiency./ F, o- s) b1 H9 C
The 11-β hydroxylase deficiency may also result in
) i0 K5 m( ]; I2 w! d4 u. X/ Yexcessive adrenal androgen production, and rarely,
& h3 f; ^2 W1 Fan adrenal tumor may also cause adrenal androgen
' P. A' }5 z, Q$ nexcess.1,3# h2 `6 A7 L5 x; K1 u8 h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 P3 C; o3 u1 O542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
" x. E4 x. r! RA unique entity of male-limited gonadotropin-% e- Y2 G; E/ o" j
independent precocious puberty, which is also known
; U  C6 x( v4 a% s8 [* \as testotoxicosis, may cause precocious puberty at a
  W) E6 M+ c% g( h) S* v1 Gvery young age. The physical findings in these boys
* h6 X, a8 \1 Y/ E2 Rwith this disorder are full pubertal development,, B2 n, C  B. W% t7 k( s' S
including bilateral testicular growth, similar to boys
+ x/ ?+ b% V" U) kwith CPP. The gonadotropin levels in this disorder
+ |" s$ ^+ J0 ^" l3 K" Uare suppressed to prepubertal levels and do not show
( f& `! a- t% M$ Spubertal response of gonadotropin after gonadotropin-
6 A0 Z% Z0 i2 N7 `% `% X1 |7 ureleasing hormone stimulation. This is a sex-linked9 a0 A# ~% F. c5 i2 \! U2 ~/ |8 t
autosomal dominant disorder that affects only
" c# W3 l$ Q- y& k4 p6 Jmales; therefore, other male members of the family
( N1 I4 l$ S. p5 g" ~may have similar precocious puberty.3* u* l0 k4 N3 s9 |  g& V3 f) t
In our patient, physical examination was incon-
0 E; O) `+ o$ o1 J# [* Vsistent with true precocious puberty since his testi-
8 |& R' M3 f, u+ r+ Acles were prepubertal in size. However, testotoxicosis# c! C/ g  M/ @; F
was in the differential diagnosis because his father  H. _$ e1 Y" [3 b/ Q7 ]
started puberty somewhat early, and occasionally,
/ s* t0 ?$ C- q. d6 b8 K; e3 Ttesticular enlargement is not that evident in the
% W; x. I  l$ ~8 w% [( i) {beginning of this process.1 In the absence of a neg-
( h7 V" g& U+ t% o, @' @ative initial history of androgen exposure, our# C5 F  }% r/ p3 }) H
biggest concern was virilizing adrenal hyperplasia,8 x! J9 e# B3 y0 e; ^
either 21-hydroxylase deficiency or 11-β hydroxylase: ~4 d$ X, u# Z- [
deficiency. Those diagnoses were excluded by find-( J" r  {" S. A8 o$ M
ing the normal level of adrenal steroids." z; W) t9 K3 i5 _' L/ B
The diagnosis of exogenous androgens was strongly
3 e! x! S4 F: dsuspected in a follow-up visit after 4 months because
: ]7 L) a( l2 O2 ^! H5 Fthe physical examination revealed the complete disap-
  |$ J- b( U% e2 a& h9 ~pearance of pubic hair, normal growth velocity, and
3 i$ M" c; X' H2 r" T" Idecreased erections. The father admitted using a testos-
0 A2 u1 P3 s) a$ P5 C3 b  dterone gel, which he concealed at first visit. He was
+ ~, S' O! M- ]7 ^3 x# Jusing it rather frequently, twice a day. The Physicians’- n7 H" W& k  n" Q
Desk Reference, or package insert of this product, gel or4 J# K. O! T' G% f7 M! {4 Y
cream, cautions about dermal testosterone transfer to, S5 H- q: v4 \2 {# x/ ?
unprotected females through direct skin exposure.
2 V/ }7 F' |* T: O: g+ ]% ESerum testosterone level was found to be 2 times the
% V) G' d9 N& x! a6 bbaseline value in those females who were exposed to$ r9 ~4 a. W* U5 a4 ^# z* G
even 15 minutes of direct skin contact with their male+ z; q2 r& T8 z# X% A4 F
partners.6 However, when a shirt covered the applica-
! L# o/ M/ a- f8 _5 P* Q1 wtion site, this testosterone transfer was prevented.' {# M2 l; P1 V: `; U
Our patient’s testosterone level was 60 ng/mL,
. ~9 `6 c! F8 \, A' I1 Uwhich was clearly high. Some studies suggest that
  {- {+ [7 U' t! ?  D, Q' C+ Ddermal conversion of testosterone to dihydrotestos-* O: {5 x' t# A% F4 E% c
terone, which is a more potent metabolite, is more4 {; W) i' q! e5 ]) s4 z$ l% z
active in young children exposed to testosterone" I2 S3 D) u& y* x! Y$ S, V6 ~
exogenously7; however, we did not measure a dihy-
3 f7 M" O5 Z  E* [6 Ddrotestosterone level in our patient. In addition to
* k$ `6 s; h6 D* ^$ ]/ evirilization, exposure to exogenous testosterone in
! g  ?, ^  _& t, x3 q+ l/ i# zchildren results in an increase in growth velocity and# @3 n8 y: K4 n' \$ u
advanced bone age, as seen in our patient.
8 s( e" D/ h5 H6 N1 \1 CThe long-term effect of androgen exposure during
2 z2 x' ]5 a! I2 A3 b; Eearly childhood on pubertal development and final
$ r! k% p  i6 @9 Q. O- `- Fadult height are not fully known and always remain
' }& H& j! T4 T7 l3 N4 ia concern. Children treated with short-term testos-
: k. H6 r2 t2 A, j/ [+ g; |' D' Uterone injection or topical androgen may exhibit some
  c6 q, K0 q$ Zacceleration of the skeletal maturation; however, after. X6 n& f  [! e
cessation of treatment, the rate of bone maturation
' n2 g, v6 b5 c% H1 t5 T7 hdecelerates and gradually returns to normal.8,9
% |$ h) {2 G+ P0 N0 @# r* ]' OThere are conflicting reports and controversy. E1 L8 ~$ `; o; D# O! X4 a* L) ^8 _
over the effect of early androgen exposure on adult
7 z# z- {5 ?: a9 ^penile length.10,11 Some reports suggest subnormal
0 v* Z) b6 C0 I) uadult penile length, apparently because of downreg-! k+ Q* Y8 l0 @$ r/ Y
ulation of androgen receptor number.10,12 However,
* y) i2 L) M* p" z) g8 m3 BSutherland et al13 did not find a correlation between
9 u4 Z0 l3 Q1 fchildhood testosterone exposure and reduced adult
1 H, b- K2 y" q, a% cpenile length in clinical studies.
' {0 @, M6 l' W/ t7 k1 BNonetheless, we do not believe our patient is
% f7 x( w1 }- Igoing to experience any of the untoward effects from
0 b# E. H: P) r* h3 H  Ktestosterone exposure as mentioned earlier because
! M3 B! B7 c, M3 Nthe exposure was not for a prolonged period of time.
; k) z" w8 {  B8 LAlthough the bone age was advanced at the time of
# U) B, u! P9 B, Ldiagnosis, the child had a normal growth velocity at  T! S. I% ~8 r0 `# Y+ M$ K0 }
the follow-up visit. It is hoped that his final adult9 P1 |1 P( F1 m, \
height will not be affected.# p9 {5 X3 A' F! u
Although rarely reported, the widespread avail-* R4 R1 E$ k: P5 d7 O
ability of androgen products in our society may- Y! E! l4 [9 c7 w: J$ J
indeed cause more virilization in male or female, a6 g: _( L4 E2 n& T6 p  |
children than one would realize. Exposure to andro-1 ^1 e2 j0 M. k: t
gen products must be considered and specific ques-
1 t; z8 b8 j& ~8 J" i& z( {+ Ktioning about the use of a testosterone product or" |2 R* }+ G) D3 X8 G$ R( N, F
gel should be asked of the family members during( P6 \; F- F$ L% t; U- x0 s" w
the evaluation of any children who present with vir-6 C" s( S( O8 w' W% L4 z& x' }
ilization or peripheral precocious puberty. The diag-
$ D$ q" |4 a0 d* X, ~! j- L/ Z" r& enosis can be established by just a few tests and by
: z- G9 v$ ^8 |7 K) B; qappropriate history. The inability to obtain such a' U$ Q" F, A/ [$ W7 u3 T
history, or failure to ask the specific questions, may
, ]+ M( r+ J1 d! V  M$ I1 \. aresult in extensive, unnecessary, and expensive
$ V8 ~4 f! W) W3 N3 ginvestigation. The primary care physician should be
2 @3 c2 @* M( Laware of this fact, because most of these children/ e" T' J4 ]( F2 d1 ^6 d. {
may initially present in their practice. The Physicians’
% C5 b( \$ N/ L" f1 d) D# fDesk Reference and package insert should also put a; W; g7 Z" O! c' N
warning about the virilizing effect on a male or
1 d7 a; {0 i& `' _6 V: F$ ifemale child who might come in contact with some-" ?# D$ Z1 `( o0 f
one using any of these products.+ k% \. h- g! T- w, U& J
References
1 l, Y% ~2 K& @* h* C8 X1. Styne DM. The testes: disorder of sexual differentiation
" [* ~/ @5 g% e! W* B4 _0 \, a- L) eand puberty in the male. In: Sperling MA, ed. Pediatric- k# M2 j& K& U- e- @3 G. @* |
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 m0 z4 g  i; {; m1 ^- M
2002: 565-628.% n" O/ ?& d) D* s& L
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& y& [6 r) {4 u' \
puberty in children with tumours of the suprasellar pineal
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這個我收藏了!謝謝分享!WK的資源越來越豐富,這少不了大大的辛勞!
發表於 2025-1-10 10:43:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
感謝大大的辛勞分享!我會繼續在WK關注大大的文章!
發表於 2025-1-11 22:18:01 | 顯示全部樓層
女厕偷拍辅导班主任尿尿老师的逼很嫩还有一点
發表於 2025-1-17 16:31:39 | 顯示全部樓層
VIP精品區,資源無限好賺金任務區,輕松賺金幣
加入VIP,享受高級特權宣傳賺金又升級,超級棒
4个什么样的?
發表於 2025-1-19 02:41:05 | 顯示全部樓層
$ a; O8 ~) K- H8 Q$ k
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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