Endocrine Abstracts

We present a 37-year-old gentleman (Mr. A) who self-referred to the endocrine clinic for review of his testosterone replacement therapy.

He required testosterone replacement therapy aged 11 years old following surgical removal of underdeveloped testes of unknown aetiology. He was prescribed testosterone injections until the age of 22 years old when testosterone patches were trialled, which he did not tolerate. He commenced testosterone replacement gel (TESTOGEL 50 mg/5 g sachets) with good effect for 15 years. His biochemical hormone profile was in keeping with primary hypogonadism; LH 33.2 U/l [normal range (NR) 1.7–8.6 U/l], FSH 93.4 IU/l (NR 1.5–12.4 IU/l), testosterone 10.5 nmol/l (NR 8.6–29.0 nmol/l), SHBG 57 nmol/l (NR 14.5–48.4 nmol/l) with a free androgen index of 18 (NR 30–150). Genital examination identified prosthetic testicles with an unremarkable examination of all other systems. Despite good replacement with TESTOGEL he sought alternatives due to ongoing medical complications with his 18-month-old adopted baby girl (Child X) who had concurrently been referred to the paediatric endocrinology team with increased downy hair in the pubic region and an enlarged clitoris. Examination by a paediatric endocrinologist identified dark hair in the pubic region and mild clitoromegaly of approximately 1 cm. There was no axillary hair nor breast development. Child X was born weighing 7lbs and healthy. As minimal information was available regarding her genetic background, further investigations were sought. Child X’ genetic karyotyping confirmed 46XX (genetically female) without mosaicism. Full biochemical profile included; testosterone 10.5 nmol/l with undetectable androgen precursors, LH, FSH and HCG with an AFP level in the normal range; suggestive of exogenous testosterone exposure. On further questioning, Mr. A confirmed he only applied TESTOGEL to the upper arms and shoulders, washed his hands fully with soap and covered himself with clothes in the morning prior to attending to Child X, in accordance with manufacturing guidance. TESTOGEL was immediately stopped and testosterone injections commenced. Within two weeks, Child X’ testosterone levels improved to 4.5 nmol/l and further fell to 0.9 nmol/l a few weeks later. TESTOGEL 50 mg/5 g is licensed for transdermal testosterone replacement in men with hypogonadism due to androgen deficiency. The manufacturer’ Summary of Product Characteristics (SmPC) states the percutaneous absorption of testosterone ranges from 9% to 14% of the applied dose. Application of one TESTOGEL 50 mg/5 g sachet produces an average plasma testosterone concentration increase of 2.5 ng/ml (8.7 nmol/l).

Conclusion: Despite following manufacturing guidelines there was still evidence of testosterone transmission. Do we need to advise and educate against light clothing despite adequate hand washing?