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Sexual Precocity in a 16-Month-Old' B8 p% N! z. M7 r6 u
Boy Induced by Indirect Topical
4 H/ @2 ~+ |7 ?! Z# SExposure to Testosterone
+ ] I4 X# I8 m' M8 j- v4 sSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 F5 q' W1 r1 ~
and Kenneth R. Rettig, MD1. @5 g/ q9 b5 H- l# l5 B( H
Clinical Pediatrics; i8 Y# c! A& X' z
Volume 46 Number 6
# E( ^. @5 R9 O$ G4 Z. k4 FJuly 2007 540-5439 ~( Z& Z _, Q7 Z& _
© 2007 Sage Publications4 Y5 ~' k0 G4 g- g& \6 S
10.1177/0009922806296651+ _! E, @0 W5 J# ^* o U
http://clp.sagepub.com. b! ~: g8 N% r
hosted at
) W6 J; Z& N3 s5 _; z$ j5 Chttp://online.sagepub.com( z; g7 _' T7 J9 ?/ g( E5 e5 ^
Precocious puberty in boys, central or peripheral,% {/ O4 X3 v; c7 q$ K
is a significant concern for physicians. Central8 @; E! Y2 r9 R3 w4 e F# ]9 R9 K
precocious puberty (CPP), which is mediated
, m( _ W! w8 W8 r7 H; j, {1 Rthrough the hypothalamic pituitary gonadal axis, has5 X# P3 f* |7 V& `# E
a higher incidence of organic central nervous system
( G* G+ D; R" j' B4 H9 Y& wlesions in boys.1,2 Virilization in boys, as manifested
, m8 N0 f3 H+ ]1 J' w+ Bby enlargement of the penis, development of pubic
( X: I% U) A+ x; Ghair, and facial acne without enlargement of testi-9 s$ }$ z$ `# G+ d$ r M7 |1 n
cles, suggests peripheral or pseudopuberty.1-3 We7 {/ m- K8 j/ I1 G
report a 16-month-old boy who presented with the
. J& h7 s2 }6 s& ]' N# l5 cenlargement of the phallus and pubic hair develop-
4 w' z/ w9 g+ w- Q7 }& Ument without testicular enlargement, which was due8 L! T! J3 e3 F+ }; ~
to the unintentional exposure to androgen gel used by0 v9 L( U! W! g- P. r8 u- ~" W
the father. The family initially concealed this infor-
# h/ Y, W. r: R" w& r0 _mation, resulting in an extensive work-up for this" O; `, p% X. l) f
child. Given the widespread and easy availability of: t: F; E4 h8 p* g! @) e
testosterone gel and cream, we believe this is proba-: D7 v/ C8 I! w2 f
bly more common than the rare case report in the
0 f6 a# H, `1 N. q J' Fliterature.4; }) G2 U9 K+ x3 f! j
Patient Report* F& f! D: T" L8 `( b$ @/ w# D
A 16-month-old white child was referred to the* i1 e( w- ^# G+ `
endocrine clinic by his pediatrician with the concern
& J$ s" ]4 v" h7 E' ]- ]of early sexual development. His mother noticed
) _$ W% F- f' alight colored pubic hair development when he was
3 w, {1 C% ]1 B5 N6 aFrom the 1Division of Pediatric Endocrinology, 2University of: H" s8 s/ E" j# `" V
South Alabama Medical Center, Mobile, Alabama.0 W- m2 ~, K% ^2 ?
Address correspondence to: Samar K. Bhowmick, MD, FACE,
9 k6 x+ s5 \8 n# o: hProfessor of Pediatrics, University of South Alabama, College of
E: s) K6 ?2 ]4 FMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" z1 M/ i4 t" e* Be-mail: [email protected].. q& W- \. i% ~9 n; Y- X# w6 U
about 6 to 7 months old, which progressively became9 s4 e7 I6 `: W1 @( ]
darker. She was also concerned about the enlarge-+ P; J" C+ @6 C( s, f2 M( w
ment of his penis and frequent erections. The child, N0 ?6 N3 h( T1 ^7 E; n( N
was the product of a full-term normal delivery, with
7 b! |3 k+ \1 c$ H- fa birth weight of 7 lb 14 oz, and birth length of
) z" l r. O- Q+ W9 K20 inches. He was breast-fed throughout the first year
& ?( M; z/ r3 c9 v9 [# H; d/ Bof life and was still receiving breast milk along with. o* x$ W1 X4 F( Y0 ~3 X1 y3 ?
solid food. He had no hospitalizations or surgery,
+ |2 w; x' c% z9 }and his psychosocial and psychomotor development4 I+ L% x \5 i; Y. C. L
was age appropriate.0 \) ?1 ?% G# a9 o# Z C. ?
The family history was remarkable for the father,' y; D8 b% M* O4 x" x. a
who was diagnosed with hypothyroidism at age 16,
) J# {2 ]0 ~( Y# e+ @! Mwhich was treated with thyroxine. The father’s
: v/ C7 b* t5 t4 k% y: U uheight was 6 feet, and he went through a somewhat3 z2 Z) H9 j! z; J0 b
early puberty and had stopped growing by age 14.2 g' L7 n8 d% n0 f" ]: E/ ~
The father denied taking any other medication. The- m- @( D+ _ N/ W) e" \6 \$ s
child’s mother was in good health. Her menarche) X* @+ ~* N u0 Z+ A8 X0 @& P
was at 11 years of age, and her height was at 5 feet0 ^; K. O& u( z- x# Y# l4 C: d
5 inches. There was no other family history of pre-4 i4 w$ p. V! m) n
cocious sexual development in the first-degree rela-
/ n2 @1 B. n+ k1 W4 W, otives. There were no siblings." U" X) N; s$ e$ Q, P
Physical Examination } j0 f% X2 e# G
The physical examination revealed a very active,- r% |' @' I* m
playful, and healthy boy. The vital signs documented2 B" t+ z# f0 A" Y' Q
a blood pressure of 85/50 mm Hg, his length was7 @' n; z h" ~6 p: f# x+ S6 [
90 cm (>97th percentile), and his weight was 14.4 kg$ h+ l# }6 m! x" U0 Z6 l2 w
(also >97th percentile). The observed yearly growth
5 ~' A/ o5 O5 Pvelocity was 30 cm (12 inches). The examination of. ]/ f" _* o9 A) N& m+ x3 s }
the neck revealed no thyroid enlargement.
6 s: ]/ s, K, H1 SThe genitourinary examination was remarkable for, M8 w5 p6 t r* u4 V
enlargement of the penis, with a stretched length of
1 {, ]; R, F( t# o# O8 cm and a width of 2 cm. The glans penis was very well3 n2 Y" ~% f' r" i
developed. The pubic hair was Tanner II, mostly around2 K" K7 w, |) {# v b) L
540
5 i- l' g5 f! h# Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ T- d+ N4 g! u; ~1 f% u: f1 dthe base of the phallus and was dark and curled. The& r6 N& G8 f m- P1 E+ t- w" o) k
testicular volume was prepubertal at 2 mL each.& t+ X' \# n0 V% g, I
The skin was moist and smooth and somewhat
( h+ R6 L, X9 k) ?oily. No axillary hair was noted. There were no5 T" B" a2 A$ C7 ^4 P. W
abnormal skin pigmentations or café-au-lait spots.& R8 q7 `: l$ I) @6 v
Neurologic evaluation showed deep tendon reflex 2+
r; n; v5 l8 p( Q7 o# s1 R( G5 q$ {bilateral and symmetrical. There was no suggestion
" x6 Q- _% O9 |! gof papilledema.
' T- X, p6 K2 \5 j) V( h2 G0 x- v( @Laboratory Evaluation1 W* O {! ^7 j9 c8 q6 @
The bone age was consistent with 28 months by
1 Q" B' f# C2 \! l* n# O- a7 {using the standard of Greulich and Pyle at a chrono-; Z Z+ f0 o' Y" @ y9 H+ A
logic age of 16 months (advanced).5 Chromosomal
+ Q7 p& X" H. vkaryotype was 46XY. The thyroid function test
i- p8 L5 ]' G1 }/ x, k6 M) }showed a free T4 of 1.69 ng/dL, and thyroid stimu-( M$ k! l/ N! K5 }4 ^
lating hormone level was 1.3 µIU/mL (both normal).* `4 Z5 J/ X* T* k! T( F
The concentrations of serum electrolytes, blood" x; V9 B0 ?7 c. w
urea nitrogen, creatinine, and calcium all were
4 z) r* S. w& M0 R; [, `( Cwithin normal range for his age. The concentration7 [0 ?8 u9 r% w/ C& k
of serum 17-hydroxyprogesterone was 16 ng/dL
& S& a% W; `. c2 t5 p5 w. S(normal, 3 to 90 ng/dL), androstenedione was 20
* _* m. Y3 @+ ]& C4 `2 @ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 N( H7 u$ o) J: K1 O0 J$ _# K, J; g) [terone was 38 ng/dL (normal, 50 to 760 ng/dL),
3 V1 t' A1 G+ y4 T V" Odesoxycorticosterone was 4.3 ng/dL (normal, 7 to
; ]6 Y# g( X9 D* v$ f) j \0 `49ng/dL), 11-desoxycortisol (specific compound S)! D" G- }4 v J) q8 L( N0 v" k
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. i B3 O1 r" x" h# M/ F; o! h! Stisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 O' z2 C# m8 O6 H, I, J% J7 z) [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 p* f4 T; H5 hand β-human chorionic gonadotropin was less than
0 G3 r0 O; Z: p- X9 B5 mIU/mL (normal <5 mIU/mL). Serum follicular2 P" I- {) Z) |! @
stimulating hormone and leuteinizing hormone1 Y- f8 l" R1 O$ r
concentrations were less than 0.05 mIU/mL# ?: j, q2 X1 M6 m! B+ k* }: v& k6 ]
(prepubertal).. K; o$ k* _" C5 }; \# L9 u
The parents were notified about the laboratory) x) t2 ?1 O; z+ @. u! \* V2 h3 f
results and were informed that all of the tests were
3 p# y; N: ?2 c7 @8 I( d% }+ Wnormal except the testosterone level was high. The2 |5 V) e1 E, [$ M2 k' I! Q
follow-up visit was arranged within a few weeks to
; ~# K; L" C0 Iobtain testicular and abdominal sonograms; how-0 K7 f! A( }9 {1 |' d! O }
ever, the family did not return for 4 months.* ]# R' D9 t7 v3 @
Physical examination at this time revealed that the8 `, J1 h# n1 a. T$ K: r8 I0 _
child had grown 2.5 cm in 4 months and had gained; e( S3 E( b1 a
2 kg of weight. Physical examination remained
6 J% [3 d. U5 ^6 [& uunchanged. Surprisingly, the pubic hair almost com-
2 m% Y+ |7 C1 ]& b1 ~0 J5 m Z. V _pletely disappeared except for a few vellous hairs at
5 N) f# H6 Z2 t8 J9 Dthe base of the phallus. Testicular volume was still 29 H' ]8 e! |; i& q5 b
mL, and the size of the penis remained unchanged.
6 f" q2 N; b2 A/ @. {+ _7 W. f. JThe mother also said that the boy was no longer hav-4 B1 G& K2 G, b- d
ing frequent erections.
$ I3 t% K: v5 l; }) ?! oBoth parents were again questioned about use of
9 W9 u% s" L$ s+ o# H9 s% qany ointment/creams that they may have applied to- I; p G7 {* Z
the child’s skin. This time the father admitted the7 o4 `# J! S5 B% S- r" @* m0 }7 P
Topical Testosterone Exposure / Bhowmick et al 541
, a+ _! I# E0 ?% w4 ?: ause of testosterone gel twice daily that he was apply-
6 E' E" c- ]# s5 _. g! \$ Y$ qing over his own shoulders, chest, and back area for
/ o- L- g7 N- A/ _9 u% oa year. The father also revealed he was embarrassed# c* E& K7 k/ h
to disclose that he was using a testosterone gel pre-
& K2 S% C/ O3 k2 j% zscribed by his family physician for decreased libido
$ f$ B+ z x. Psecondary to depression.
+ q1 Q& V0 x& L" f- AThe child slept in the same bed with parents.
$ _/ r! ~& U8 y) J. z/ G; fThe father would hug the baby and hold him on his9 G7 ^: T, T, D3 T0 V
chest for a considerable period of time, causing sig-# H: a- y) S5 {0 z! g2 N
nificant bare skin contact between baby and father.
0 u9 `2 ]; C$ {( y# r% GThe father also admitted that after the phone call,
7 v8 j5 N% e% I2 t& Pwhen he learned the testosterone level in the baby
9 i# R7 ] y/ b3 gwas high, he then read the product information/ r; p4 i. `. J# J
packet and concluded that it was most likely the rea-
$ W; d& I2 d$ k* Qson for the child’s virilization. At that time, they
$ M: r4 G: D* ^/ M3 n/ Rdecided to put the baby in a separate bed, and the0 a9 A& P; l2 G- [' U; G5 V$ }
father was not hugging him with bare skin and had
9 g0 [3 N" k y+ a+ Z$ Q: Cbeen using protective clothing. A repeat testosterone. U, q+ A4 K( o) @0 {9 }/ [
test was ordered, but the family did not go to the
; O4 t, _7 [1 s0 q8 ]laboratory to obtain the test.8 ^5 x( p& a: F) c; _
Discussion
& k- T' C3 ~- R9 O8 MPrecocious puberty in boys is defined as secondary
) ~/ J: b3 ~$ k4 Y9 ~sexual development before 9 years of age.1,4* ~( \2 i6 G" m6 p1 O/ x
Precocious puberty is termed as central (true) when2 p; B; H, p1 C& f( y! E& X
it is caused by the premature activation of hypo-
3 `) M0 x% I7 k5 i2 _4 ?8 Rthalamic pituitary gonadal axis. CPP is more com-
: Q: [* t3 D* e4 lmon in girls than in boys.1,3 Most boys with CPP
) @; a4 K2 V) ], S: v4 R* _may have a central nervous system lesion that is
$ ^# G# p% b6 ? K$ nresponsible for the early activation of the hypothal-
2 V$ R( m+ B4 n; B! ]7 k; W* |amic pituitary gonadal axis.1-3 Thus, greater empha-
9 E$ E. ]7 L2 ^3 s$ U- o) Qsis has been given to neuroradiologic imaging in
! a |" D8 m4 \7 O8 u( }# wboys with precocious puberty. In addition to viril-
% p; D0 b9 q& F7 ], P" a6 Lization, the clinical hallmark of CPP is the symmet-* u, t I7 n, \$ K" b% q9 E
rical testicular growth secondary to stimulation by
4 r/ {1 y8 t2 m' @# x( W" L7 Wgonadotropins.1,37 T7 d! X9 b+ m2 V
Gonadotropin-independent peripheral preco-4 N* D0 R- G9 B
cious puberty in boys also results from inappropriate
! C: h3 G8 l8 K; H5 x+ D" o4 I4 Randrogenic stimulation from either endogenous or
. X- ~) k) B: w, jexogenous sources, nonpituitary gonadotropin stim-& i; u# ?/ f* k9 i0 M- f+ Y5 `6 U
ulation, and rare activating mutations.3 Virilizing
) E) a9 W* m* F6 Q; n mcongenital adrenal hyperplasia producing excessive% Y' }/ B6 }$ Y
adrenal androgens is a common cause of precocious
: o8 } {8 D" `8 h( e6 k1 {! v- Opuberty in boys.3,4
, f7 }" z5 s6 b9 C9 L: {9 o" QThe most common form of congenital adrenal
. ]( a) w6 U% V' K) ohyperplasia is the 21-hydroxylase enzyme deficiency.
9 X T5 Z- _+ G; s( _0 vThe 11-β hydroxylase deficiency may also result in) m B# c3 Z" l
excessive adrenal androgen production, and rarely,
6 k6 l) h! E; D2 Y, i% Man adrenal tumor may also cause adrenal androgen
$ c/ M0 {0 a1 u4 c8 A! v* i' Zexcess.1,3
* C8 D0 o: z, iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from l7 z- B7 |5 _6 b5 M$ e
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, i V! K/ V+ A9 ` y" jA unique entity of male-limited gonadotropin-' m6 {& R4 h1 u- |7 L+ f9 \
independent precocious puberty, which is also known9 u; b. Y$ p0 A( h, M1 s
as testotoxicosis, may cause precocious puberty at a: P0 h3 f3 M2 Y* c2 S# p: J4 z
very young age. The physical findings in these boys$ I3 x% H7 h' O# K7 L- \
with this disorder are full pubertal development,
3 O* E: R% U5 h; {including bilateral testicular growth, similar to boys4 d& d3 ]: B: G/ [( {. ~4 W
with CPP. The gonadotropin levels in this disorder
* i# @7 {6 s$ g0 ?* }/ bare suppressed to prepubertal levels and do not show6 [/ X) W, ^& Z9 M
pubertal response of gonadotropin after gonadotropin-/ y _- b2 _+ P; ]
releasing hormone stimulation. This is a sex-linked' \9 J. }1 N, p! ]4 \9 i/ ?2 k
autosomal dominant disorder that affects only
* M* v+ a" b2 V# M; j7 Zmales; therefore, other male members of the family6 L5 W5 R* Y* t6 D7 A2 ]! U
may have similar precocious puberty.38 O/ H4 Y) q9 ^
In our patient, physical examination was incon-8 F" c5 B+ C$ |
sistent with true precocious puberty since his testi-* `2 n: E% |8 H
cles were prepubertal in size. However, testotoxicosis
' d/ f5 `( ]; b |) r- Ywas in the differential diagnosis because his father
' |) ^5 Y, I" q1 `: bstarted puberty somewhat early, and occasionally,8 R$ \6 v3 V5 ] q2 ~* u
testicular enlargement is not that evident in the" ?, a( }) l3 i4 `3 N- _* |
beginning of this process.1 In the absence of a neg-
7 i) o5 t9 |9 d2 r: C7 ?ative initial history of androgen exposure, our
2 b6 s2 F: x4 o# W1 V0 [: ^biggest concern was virilizing adrenal hyperplasia," t# z, u) r( ?5 e/ x
either 21-hydroxylase deficiency or 11-β hydroxylase
) w+ B$ K9 O- q+ h$ j% fdeficiency. Those diagnoses were excluded by find-
/ {& \0 h" x( R' j0 h# iing the normal level of adrenal steroids.
1 S# M2 ]% G; A# ^The diagnosis of exogenous androgens was strongly& U- p7 O6 o" N
suspected in a follow-up visit after 4 months because7 K' j6 a/ k/ t% m+ _
the physical examination revealed the complete disap-/ ^3 o8 l4 x$ ?& `. w' N& e
pearance of pubic hair, normal growth velocity, and7 v9 t+ E! x9 P8 P
decreased erections. The father admitted using a testos-; B, a% R, @; G8 J" U
terone gel, which he concealed at first visit. He was
7 U! @& u, `3 p3 l# _: zusing it rather frequently, twice a day. The Physicians’
4 l) |6 y: M/ F) D2 \Desk Reference, or package insert of this product, gel or3 p# ^" u. X; y! H* U
cream, cautions about dermal testosterone transfer to/ A" ^/ C: ?; b* Y
unprotected females through direct skin exposure.) O0 t; Q/ k* [9 U2 w% E
Serum testosterone level was found to be 2 times the( ~) y3 J. y; _7 w& D
baseline value in those females who were exposed to
7 F8 P7 \8 Y) heven 15 minutes of direct skin contact with their male; i2 w9 L2 H/ ]$ |. H
partners.6 However, when a shirt covered the applica-1 L# K7 ~+ w. X* A" y. c8 e: w
tion site, this testosterone transfer was prevented.
# h) w- f8 v$ h; o/ mOur patient’s testosterone level was 60 ng/mL,. ~" A7 P* C! {2 O( k9 Z# g
which was clearly high. Some studies suggest that- z& R1 e: G2 j
dermal conversion of testosterone to dihydrotestos-3 X) ~, e: l) H1 m! ^$ K! O A
terone, which is a more potent metabolite, is more0 M. c, L+ n7 Y6 k$ F+ s
active in young children exposed to testosterone8 i. X5 e& P8 V5 F
exogenously7; however, we did not measure a dihy-6 v8 c" v+ b/ n8 R, K' p
drotestosterone level in our patient. In addition to9 u9 F0 [, D& C) l! A1 }# G
virilization, exposure to exogenous testosterone in
- o6 B5 n% f; Y9 [% t/ _) b. tchildren results in an increase in growth velocity and+ s, W0 A; ]. a9 T' ]- j; c
advanced bone age, as seen in our patient.
5 V& p# v; s' e4 t' x' X; O, M' ~) e$ wThe long-term effect of androgen exposure during
5 v) j7 \7 J# X/ ]2 @3 |early childhood on pubertal development and final3 C: b2 H. F0 X! a
adult height are not fully known and always remain
- O; m {0 {' O, q' S/ r/ Ia concern. Children treated with short-term testos-0 `* b6 b/ z/ k/ K
terone injection or topical androgen may exhibit some W* X, U" Y6 w0 B
acceleration of the skeletal maturation; however, after
& T! v+ [, F( S- u" ^cessation of treatment, the rate of bone maturation
0 W; f6 _# r8 p; w7 W) s* U2 z- Tdecelerates and gradually returns to normal.8,9/ Y- k( ~0 S) B5 \
There are conflicting reports and controversy. E: R6 q4 W+ @: S) |! P, _
over the effect of early androgen exposure on adult
@0 `* l4 e7 r, Xpenile length.10,11 Some reports suggest subnormal
! G" o; z0 P* G/ R* e1 P' L& ?! J! u# cadult penile length, apparently because of downreg-2 Z* F/ t! t4 f" @/ A
ulation of androgen receptor number.10,12 However,
0 i; [. z' }) C: ySutherland et al13 did not find a correlation between
0 ?8 [$ z) Y; W4 D2 [, ichildhood testosterone exposure and reduced adult
1 \; z/ B/ k7 f7 |penile length in clinical studies.8 w2 J: T" D7 R, o# B. b+ Z. S
Nonetheless, we do not believe our patient is$ e+ L" \9 B% z# M: \9 P( M
going to experience any of the untoward effects from$ ~4 r9 J& u' r5 I& J" g
testosterone exposure as mentioned earlier because
7 N) p/ m& i1 {+ |( Pthe exposure was not for a prolonged period of time.
* Y: C9 `# z: F1 T, R" WAlthough the bone age was advanced at the time of
9 o0 y( R5 a) V% adiagnosis, the child had a normal growth velocity at+ j9 T) L$ j; c) [1 w
the follow-up visit. It is hoped that his final adult
0 G( T5 l& l" S% D7 R* \height will not be affected.7 ]. r" D' G6 u3 j+ D6 b
Although rarely reported, the widespread avail-
$ K, X: I* ]* C) ]; R9 uability of androgen products in our society may
+ {8 t6 k2 L! d; L" d5 bindeed cause more virilization in male or female
0 }! q- z& [ E: Z. B( nchildren than one would realize. Exposure to andro-
, I8 w% q6 W$ W5 P! Ugen products must be considered and specific ques-, D s Q i; \4 F/ h$ [! `
tioning about the use of a testosterone product or
[" S2 N: |- T$ o4 X8 M5 Zgel should be asked of the family members during K% ?6 B% O) t" S
the evaluation of any children who present with vir-
. d7 i9 l5 e9 l. Iilization or peripheral precocious puberty. The diag-
1 G( k+ @5 ~; ]nosis can be established by just a few tests and by
1 l1 f7 R; Z4 ~) ]- D# @appropriate history. The inability to obtain such a( H, K1 X% w# B Q# ^: D/ f
history, or failure to ask the specific questions, may7 S* a9 E, D2 A/ M' ]5 K
result in extensive, unnecessary, and expensive5 s' a* }; V) }' y* p' ^6 K, L) ~# s
investigation. The primary care physician should be$ f0 }) n. H$ T7 e( G
aware of this fact, because most of these children
6 I; K( }: U \6 N2 R: Z7 q! Q# ~may initially present in their practice. The Physicians’
* f+ }: d. S2 V3 F. Z8 ]Desk Reference and package insert should also put a& J. S$ o( Q4 _ h: A8 P& v0 d
warning about the virilizing effect on a male or0 i" J9 B2 n+ A9 _. O4 [
female child who might come in contact with some-
! c% w2 ~) Y8 Z+ G; D* Y, Z X) e' F% aone using any of these products.
8 U' R G0 s: t rReferences) A+ ? |6 L$ K6 X' @) N
1. Styne DM. The testes: disorder of sexual differentiation
' n: A7 n9 [6 Y l k7 I Kand puberty in the male. In: Sperling MA, ed. Pediatric
1 a2 B) ^1 L# \9 eEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% K0 ^0 @, t3 I! x9 S) [
2002: 565-628.; |/ v5 r, W7 U' A
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' M2 ^1 I) i5 ^/ \- }3 b5 l; apuberty in children with tumours of the suprasellar pineal |
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