Prenatal Virilization Associated with Paternal Testosterone Gel Therapy

Transdermal testosterone gels are used in the treatment of hypoandrogenism of males [1]. Virilization due to exposure to testosterone gels has been reported in children ranging from 9 months to 5 years of age [2–6]. In May 2009, the US Food and Drug Administration (FDA) issued a warning for testosterone gel products (AndroGel 1% and Testim 1%), alerting prescribers about secondary exposure to these products [7]. Based on interrogation of medical literature databases, at present we are unaware of prenatal virilization associated with unintentional testosterone gel exposure. We now report prenatal virilization of a female infant due to secondary maternal exposure to the father's testosterone gel. We also describe postnatal virilization of the child's twin sister.Dizygotic twin girls were born after a 30-week gestation. Pregnancy was complicated by premature labor at 26 weeks of gestation requiring 12？mg betamethasone treatment for two days. Medications taken during pregnancy were Wellbutrin, Pepcid, Procardia, and Indocin. The birth weight for Twin A was 1700？gm and Twin B was 1660？gm.Twin A required intubation and mechanical ventilation for 4 days followed by continuous positive airway pressure (CPAP) until day of life 8. Twin B required CPAP for 8 days. Both infants had apnea of prematurity and mild hyperbilirubinemia. The infants were discharged to home at 37 weeks post conception age.At birth, Twin A was found to have clitoromegaly () [8] and was Prader Stage 2. Twin B did not have clitoromegaly (). The urethral openings of the twins were at the base of the phallus.At 96？hours of age, the total testosterone of the virilized twin was 9.8？ng/dL (0.4？nM), androstenedione was 71？ng/dL (2？nM), and the 17-hydroxyprogesterone was 82？ng/dL (2.4？nM) (Table 1; hormonal determinations performed at Esoterix Laboratory Services, Casablanca Hills, CA).Transabdominal ultrasound showed normal Mullerian structures with no evidence of persistent Wolffian structures. The uterus meas