June 22, 2016
PCOS or Accidental
Testosterone Exposure?

“Low T” is becoming common terminology among aging men, with the number of men receiving prescriptions for testosterone rapidly growing over the last decade and a half. Demand doesn’t seem to be dwindling. In 2013, annual revenue for testosterone replacement therapies reached 2.4 billion dollars and, by the year 2018, it is projected that generated revenue for testosterone drugs will reach 3.8 billion dollars.

Many of these prescriptions are transdermal gels or creams and are often prescribed in supraphysiological doses that require vast areas of application. While convenient and effective for the intended recipient, application of this nature poses the risk for skin to skin transference and/or transference to household objects such as towels, countertops, door knobs, sink handles, etc. and may subject household members to incidental, inadvertent exposure. This risk carries clinical relevance that is minimally explored in the current medical literature. Much of what is discussed focuses on pediatric exposures with cases of precocious puberty resulting from involuntary exposure to testosterone. Published case studies also include progressive hirsutism in a premenopausal woman and postmenopausal virilization in household members unintentionally exposed to their partner’s topical testosterone prescriptions. These publications conclude that the potential of testosterone transfer in transdermal application should be recognized as a potential side effect and that differential diagnosis of virilization in adults should be expanded to include exogenous androgen exposure.

Clinicians may wish to expand these conclusions beyond virilization and give thought to potential exposure in women fitting criteria for a Polycystic Ovarian Syndrome (PCOS) diagnosis as they include demonstrated clinical symptoms of (acne, hirsutism, etc.) or laboratory-established hyperandrogenism (i.e. elevated testosterone).

For example, the following salivary testosterone results are for an 18 year old premenopausal female. At her initial presentation, she weighed 155 pounds at 5 foot 6 inches tall. Acne was a chief concern and she had recently received a diagnosis of PCOS based on symptoms and demonstrated elevation in total serum testosterone levels.

Note that her initial salivary testosterone value is significantly elevated - beyond that which would be expected for endogenous production in most cases of PCOS. Upon further questioning it was discovered that her father, with whom she resided, was using transdermal axillary testosterone. While the patient had no skin to skin contact with her father’s application site she was responsible for cleaning his bathroom (where he kept his testosterone product) as well as doing his laundry (which may have exposed her to residual testosterone). After discussion, her father agreed to discontinue use. Repeat testing 6 weeks later demonstrated a decline in her salivary testosterone value to an expected level and follow up revealed resolution of her acne. Thus, while initially diagnosed with PCOS, this patient’s concerns and lab values were actually a result of incidental household testosterone exposure.

As testosterone use among men continues to rise, incidental exposure is a consideration in the differential diagonsis of hyperandrogen conditions such as virilization, precocious puberty and PCOS. In addition, counseling regarding the potential for transference and proper application techniques may help diminsh the possibility of unwittingly transfering to others. Application considerations include:

  1. Use a separate towel from everyone else in the bathroom.
  2. Apply cream/gel with disposable gloves to backs of shoulders in AM before getting dressed. Dispose of gloves in such a manner as they will not be touched by anyone else.
  3. Place used clothing into separate hamper.
  4. Do own laundry or provide gloves to the person who does testosterone-exposed laundry (including towels).
  5. Take a shower before bedtime to minimize exposure to partner
  6. Never use testosterone cream before physical intimacy

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References:
  • DeRonde. Hyperandrogenism after transfer of topical testosterone gel: case report and review of published and unpublished studies. Human Reproduction Vol 24:2 pp 425-428
  • Merhi MD, Santoro MD.. Postmenopausal virilization after spousal use of topical androgens. Fertility and Sterility April 2007 vol 87:4 pgs976
  • Statista. Annual testosterone drug revenue in the US in 2014 and 2018. http://www.statista.com/statistics/320301/predicted-annual-testosterone-drug-revenues-in-the-us/ Accessibility verified 6/20/2016

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