Testosterone Transfer

            Topically applied testosterone gel has been proven as an effective measure in androgen replacement (de Ronde, 425). However, while there are positive results for men, the use of topically applied testosterone can have negative and often dangerous implications when women and children become exposed. The testosterone gel can be transferred to others via skin contact and can cause hyperandrogenism in women and virilization in young children (de Ronde, 425). Intramuscular, oral or transdermal applications all have the possibility of a positive reaction in men but they also have several drawbacks that make the testosterone gel more attractive. For example, intramuscular and oral testosterone treatments can cause severe fluctuations in testosterone levels while transdermal applications require shaving the scrotal area and can also cause a reaction at the application site (Rolf, Knie, Lemmnitz & Nieschlag, 637). A testosterone gel was recently approved for use in the United States and contains 1% testosterone which can last for up to twenty-four hours. The use of the gel was accompanied by improved sexual function and mood, increased muscle mass and decreased fat mass. Topical application also resulted in fewer reactions at the application site (Rolf, et al, 637). However, as mentioned previously, women and children who come into skin contact with the gel face unnecessary and preventable side effects. These are discussed using current literature and research to examine case studies.

            One specific case of a two year old boy who came into skin contact with testosterone gel presents some of the negative implications associated with exposure. The boy was taken to his pediatrician because of pubic hair growth. It was discovered that this pubic hair growth was not accompanied by testicular enlargement, acne or body odor (Stephen, Jahaimi, Brosnan & Yafi, 1027). Further investigation revealed that the pubic hair growth had been present for four months and neither parent had a history of precocious sexual development. However, it was also discovered that the child’s father had been using testosterone cream for the past twelve months to treat his own testosterone deficiency syndrome. The child’s father applied the cream to his forearms nightly but did not usually have contact with his son until the following morning (Stephen, et al, 1027). Further tests all revealed normal results and when the father ceased use of the testosterone cream the boy demonstrated no progression of puberty (Stephen, et al, 1027).

            Similar results were found among other children. An eighteen month old female was taken to a doctor following pubic hair growth and clitoromegaly. Her stepfather applied testosterone cream to his thighs and then allowed the child to sit on his lap. When examined it was revealed that her bone age was three years old while her chronological age was eighteen months. Her serum testosterone level was measured at 390 when the desired measurement for children is less than 10. The child’s mother began applying the cream to the stepfather’s back using rubber gloves and subsequent measurements revealed that the child’s testosterone level had returned to less than 10 (Kunz, Klein, Clemens, Gottschalk & Jones, 282). Similarly, a 5 year old female also presented marked pubic hair growth and acne that had been present for nine months. He father used a spray containing testosterone for body building and often allowed the child to sleep in his bed. When the father stopped using the product the puberty progression displayed in the child ceased (Kunz, et al, 282).

            Long term effects of childhood exposure to topically applied testosterone cream result in the onset of puberty related symptoms (Bhowmick, Ricke & Rettig, 540). The most common symptoms include pubic hair growth, acne and an increase in skeletal size so that the age a child is developmentally begins to differ significantly from the age a child is chronologically (Bhowmick, et al, 540). Exposure to a parent who uses a topical form of testosterone is uncommon but has been shown to cause virilization in the majority of children who suffer from long term exposure. However, the research has also shown stabilization or decrease of symptoms following a cessation in exposure (Bhowlick, et al, 540). Overall, the literature suggests that the prognosis is very good for children who are not longer exposed to topically applied forms of testosterone.

            Topical testosterone cream use can also have negative implications for partners and spouses. Women are more likely to suffer from these implications, particularly postmenopausal women. For example, a sixty-three year old female professional singer began to notice a deepening and coarsening of her voice which was later followed by balding towards the front of her cranium as well as clitoromegalgy. She also noticed increased muscle mass and hair growth on her chin and stomach area as well as the need to shave more often (Merhi & Santoro, 976). Further examinations revealed that her husband had been using a topical testosterone cream for the past two years. However, he reported that he applied the cream to his shoulders and then immediately washed his hands. It was later discovered that the women was exposed through the shared use of a washcloth that the husband used to wipe his hands on after applying the cream (Merhi & Santoro, 976). The woman saw marked improvement when her husband switched to a testosterone patch. He later switched back to the cream but the couple refrained from sharing a washcloth and the woman’s symptoms remained stable (Merhi & Santoro, 976).

            A similar case study involves a thirty-one year old female who showed signs of progressive hirsutism (deRonde, 425). She started menstruating at age thirteen and had normal cycles until age twenty-six when she began using a levonorgesterel IUD which resulted in oligomenorrhea (deRonde, 425). She had no evidence of clitoromegalgy, baldness or deepening of the voice. Her testosterone levels ranged from 1.6 and 6.7 with less than 2.5 being considered within the normal range. She was indirectly exposed to testosterone because her partner used a topical cream following treatment for testicular cancer. When the couple took steps to reduce exposure the patient continued to have elevated levels of testosterone but once her partner switched to an injectable form of testosterone her levels returned to normal (deRonde, 426).

            The transfer of testosterone via skin to skin contact does not necessarily result in the symptoms presented. However, the testosterone levels in women and children are significantly smaller than the levels found in men. Therefore, even small amounts of exposure can have immediate and negative implications for these populations (deRonde, 428). While not common, in order to protect women and children, men who use topically applied testosterone must take precautions to prevent indirect exposure. To date, there have been ten documented cases of children who were indirectly exposed to topically applied testosterone gels or creams and eleven documented cases of female spouses who were indirectly exposed (deRonde, 428). While these numbers are very small they are not insignificant and there may be many more undocumented cases as well.

            Further, several of the cases resulted in a continuation of elevated testosterone levels even after a cessation in exposure. This suggests that there are other avenues of exposure apart from skin to skin exposure or exposure via clothing or, as described above, a washcloth. One possible theory is that testosterone is dissolved in sweat and females and children may come into contact with it this way (deRonde, 428). Ultimately, these case studies emphasize that exposure to topically applied testosterone is possible and “clinically relevant” (deRonde, 428). Further, this literature highlights the evidence for testosterone transfer and also highlights the need to take the necessary precautions to protect women and children (deRonde, 428). The increasing widespread use of topically applied testosterone cream makes it necessary to conduct further research in order to determine ways to prevent and treat testosterone transfer.

Bhowlick, Samar K.; Ricke, Tracy & Rettig, Kenneth R. “Sexual precocity in a 16-month old

            boy induced by indirect topical exposure to testosterone.” Clinical Pediatrics 46 (2007):

            540 – 543.

de Ronde, William. “Hyperandrogenism after transfer of topical testosterone gel: case report and

            review of published and unpublished studies. Human Reproduction 24.2 (2009):

            425 – 428.

Kunz, Gregory J.; Klein, Karen O.; Clemons, Robert D.; Gottschalk, Michael E. & Jones,

            Kenneth Lee. “Virilization of young children after topical androgen use by their

            parents.” Pediatrics 114.1 (2004): 282 – 287.

Merhi, Zaher O. & Santoro, Nanette. “Postmenopausal virilization after spousal use of topical

            androgens. Fertility and Sterility 87.4 (2007): 976 – 978.

Rolf, C.; Knie, U.; Lemmnitz, G. & Nieschlag, E. “Interpersonal testosterone transfer after

            topical application of a newly developed testosterone gel preparation. Clinical

            Endocrinology 56 (2002): 637 – 641.

Stephen, Matthew D.; Jehaimi, Cayce T.; Brosnan, Patrick G. & Yafi, Michael. “Sexual

            precocity in a 2-year old boy caused by indirect exposure to testosterone cream.

            Endocrine Practice 14.8 (2008): 1027 – 1030.

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