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Sexual Precocity in a 16-Month-Old* d8 z5 X+ P, L* H
Boy Induced by Indirect Topical
9 Q: d1 l, b9 q2 ?- }* E) f2 zExposure to Testosterone
) L4 f+ W; S7 U* J. c5 DSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 I+ h" l$ a3 H4 U6 y
and Kenneth R. Rettig, MD1
2 }* @9 o& A! R% IClinical Pediatrics
1 A- S( r; s1 J, I- k1 T; T( DVolume 46 Number 63 F) z; o) I- D! w! b. O$ i$ Z: i/ y8 k
July 2007 540-543
- R0 b6 O$ z% _" W© 2007 Sage Publications y8 A) ]" S, c$ W4 _; k
10.1177/0009922806296651$ K& t! i: y3 B
http://clp.sagepub.com3 e2 Z$ ^6 |( g2 ]2 Z8 r4 ^
hosted at0 i7 X# o" \. C+ @: @' K
http://online.sagepub.com
u4 g2 @% C- f: E: yPrecocious puberty in boys, central or peripheral,
3 s" S7 e1 B/ n& G& k& ?- zis a significant concern for physicians. Central; [6 g. J @+ Y* S# H6 L
precocious puberty (CPP), which is mediated
h! x6 j4 P2 B" k* {& T: Wthrough the hypothalamic pituitary gonadal axis, has
1 A2 x! j' t6 p+ Ea higher incidence of organic central nervous system
u+ H0 p4 J; n9 K) Glesions in boys.1,2 Virilization in boys, as manifested5 u9 T' u0 l+ f2 R
by enlargement of the penis, development of pubic
7 W0 T9 }3 @# B. T6 O" Hhair, and facial acne without enlargement of testi-
g5 \; {, n: @, K9 i/ q4 @cles, suggests peripheral or pseudopuberty.1-3 We
7 r m& e( A+ A d; ^( {& C! _report a 16-month-old boy who presented with the5 w3 v* ]2 `. g/ z. ~( [! d
enlargement of the phallus and pubic hair develop-
4 U5 R( D0 u: ~) i6 zment without testicular enlargement, which was due' o V* ^) @/ l( V7 D( e0 e; o
to the unintentional exposure to androgen gel used by
+ k& p# y6 A5 ~the father. The family initially concealed this infor-
+ p' G# d' h) k* q" {mation, resulting in an extensive work-up for this" S: g2 a# o8 Z
child. Given the widespread and easy availability of2 R5 i) ~/ I D
testosterone gel and cream, we believe this is proba-, K0 V4 k \! B" `# j) T; u5 Q
bly more common than the rare case report in the
2 R; p' C: @- r0 Nliterature.4" @0 E% Z7 [( b# {+ a" E8 P
Patient Report
; p- v0 `2 g1 xA 16-month-old white child was referred to the8 _; Z9 E) w$ j! \
endocrine clinic by his pediatrician with the concern7 W" D2 e6 i1 s$ _/ @
of early sexual development. His mother noticed
6 \( Z6 Q+ B# R% A5 C! @4 P% H( h8 Dlight colored pubic hair development when he was! j) J/ f. o' _& j/ J& y
From the 1Division of Pediatric Endocrinology, 2University of
: e) R! V$ T- K- F4 P: z7 oSouth Alabama Medical Center, Mobile, Alabama.
2 r8 c) R5 w3 |1 o; x( L/ C/ fAddress correspondence to: Samar K. Bhowmick, MD, FACE,2 M+ C* U6 }1 ^: J& G7 ?- X7 w: W( A
Professor of Pediatrics, University of South Alabama, College of
2 o3 e2 q2 ]2 ~$ \# g( C7 yMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;8 G; v# ^2 t% _& w& H% Q
e-mail: [email protected].
0 T3 `9 ~3 u, p; {% T. rabout 6 to 7 months old, which progressively became
4 @! n; A& L, G, Ldarker. She was also concerned about the enlarge-) K- ]5 @, E1 w; b* c3 ?2 m1 g
ment of his penis and frequent erections. The child
: I- s& i) i: g7 g; awas the product of a full-term normal delivery, with
$ y3 q5 h; m. S9 p/ {( S$ ga birth weight of 7 lb 14 oz, and birth length of
3 m5 _6 B" K! D9 }20 inches. He was breast-fed throughout the first year% X L& R9 U7 s/ d2 g
of life and was still receiving breast milk along with5 ]$ l$ ?- D! N; z
solid food. He had no hospitalizations or surgery,8 D; h" A( z- m* f6 l0 R( U2 C
and his psychosocial and psychomotor development
4 z Y3 g b' C" V2 v4 twas age appropriate.
+ N7 W3 y" l3 y+ m; pThe family history was remarkable for the father,# j% t5 D9 |, u5 n; a0 B
who was diagnosed with hypothyroidism at age 16,
/ ?# T, g7 L! f2 B- awhich was treated with thyroxine. The father’s
5 _' S) r& A$ u- l, L( iheight was 6 feet, and he went through a somewhat
) @+ A7 h3 T. ?: W6 {$ L' k) Cearly puberty and had stopped growing by age 14.1 }9 b! I: t! e1 i/ S: t
The father denied taking any other medication. The8 B# B7 O, q y* \6 W2 Q0 p
child’s mother was in good health. Her menarche
7 J$ d$ N) X! I& r# @2 @was at 11 years of age, and her height was at 5 feet
1 {$ I' `' }4 V& e( Z) ?' O+ _5 inches. There was no other family history of pre-9 Z3 `/ s4 H% W: ~+ o' J+ @
cocious sexual development in the first-degree rela-
. j$ q$ V# J. V7 ?: U+ ztives. There were no siblings.) T& a* d3 f- c
Physical Examination
7 p4 \% R& w8 EThe physical examination revealed a very active,3 j9 _# H# z' I, K# c( T* y9 K+ l) i
playful, and healthy boy. The vital signs documented7 l# _2 A2 F9 o" n- W' b
a blood pressure of 85/50 mm Hg, his length was& B0 J7 a! t2 @; u
90 cm (>97th percentile), and his weight was 14.4 kg
; e# U- `3 m0 [2 |- b(also >97th percentile). The observed yearly growth" W0 ~+ G# K, _0 h& r+ w5 ~
velocity was 30 cm (12 inches). The examination of
) n- X( ]- v$ k Tthe neck revealed no thyroid enlargement.* O& @( v! o: D' x& U4 R0 J7 r, R
The genitourinary examination was remarkable for- h& w8 w% B3 J' j, {/ q' i. n
enlargement of the penis, with a stretched length of: C# Q7 b% e( i- q$ f5 @8 v
8 cm and a width of 2 cm. The glans penis was very well
O N1 j; A. @: ydeveloped. The pubic hair was Tanner II, mostly around
+ Q4 L+ n- i2 L- M540" v- R" P2 u0 H7 X( M
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, v5 D0 T6 M- ] w& W$ ithe base of the phallus and was dark and curled. The
; C2 h$ g8 S8 m: e7 @6 U( h d7 ktesticular volume was prepubertal at 2 mL each." t- ~* _4 E1 h
The skin was moist and smooth and somewhat' R) @7 u7 ?+ R( W" l7 {
oily. No axillary hair was noted. There were no
& r N' B' u. G; I. A+ mabnormal skin pigmentations or café-au-lait spots.( x ?9 p9 M9 k/ B' N
Neurologic evaluation showed deep tendon reflex 2+
1 @3 \' u+ Z- U& q) n) vbilateral and symmetrical. There was no suggestion" q; j8 |" L& U* Q
of papilledema.! G: m) `- G' Y, c3 B- p
Laboratory Evaluation
5 X, u* g, ]- qThe bone age was consistent with 28 months by8 l6 Y( p: G9 |; H" h6 R
using the standard of Greulich and Pyle at a chrono-
' f6 C$ ]3 v2 G, F# i- qlogic age of 16 months (advanced).5 Chromosomal- }# i- N1 U8 a6 Q% F* p; r8 q! N
karyotype was 46XY. The thyroid function test4 H6 N1 C3 a. u6 D/ T
showed a free T4 of 1.69 ng/dL, and thyroid stimu-; u4 A) m5 \9 H! a4 Y/ {4 g9 U
lating hormone level was 1.3 µIU/mL (both normal).
. J! l& v& h2 s: o" V2 h: _% W+ aThe concentrations of serum electrolytes, blood
+ u- l3 y. w8 eurea nitrogen, creatinine, and calcium all were' w, K q0 E; O r8 c
within normal range for his age. The concentration
( `- o+ Q1 g+ C7 m) K1 Yof serum 17-hydroxyprogesterone was 16 ng/dL
' D6 V5 |0 W8 G, @" e+ j0 }2 X(normal, 3 to 90 ng/dL), androstenedione was 201 z9 J7 u8 @7 ]3 z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" G L8 G! E2 Kterone was 38 ng/dL (normal, 50 to 760 ng/dL),! ?' G& d/ N- M. N0 `1 ] X+ Y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ N5 ~& ^; t* f' B- b1 h49ng/dL), 11-desoxycortisol (specific compound S)
* n$ @2 V+ u3 E, J/ c; S5 l2 Pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( e3 ?8 _* J1 F, d; O! h
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total8 ?9 ` U# j3 i) b% h
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 [( J. d# x9 F4 z8 zand β-human chorionic gonadotropin was less than% H1 P7 T9 E+ h. v
5 mIU/mL (normal <5 mIU/mL). Serum follicular, `$ i0 K z0 x3 J
stimulating hormone and leuteinizing hormone8 m4 j M2 b2 M+ n9 V" A7 t7 H
concentrations were less than 0.05 mIU/mL
k) Z Y7 I1 W! P! V! N; O(prepubertal).# U0 }, N3 q! Q
The parents were notified about the laboratory( X1 ?0 a; k$ Y' ]* ~. G; ^) h5 P
results and were informed that all of the tests were
6 X2 L) F& o0 j6 c& l: P3 ]normal except the testosterone level was high. The
[9 N! l4 P: @* R8 Cfollow-up visit was arranged within a few weeks to1 }3 N6 s5 @: _
obtain testicular and abdominal sonograms; how-* }9 O5 B2 m& p
ever, the family did not return for 4 months.+ ?5 \# o$ ~/ e2 n( P9 V1 ]5 M$ _3 z
Physical examination at this time revealed that the0 x4 ^" o* d7 q$ \
child had grown 2.5 cm in 4 months and had gained
& O2 I# h- j! S: ^ }4 I# x2 _2 kg of weight. Physical examination remained2 p _. n, F0 I+ S, t8 q
unchanged. Surprisingly, the pubic hair almost com-, `$ Q+ {$ @7 I" c
pletely disappeared except for a few vellous hairs at. O- G4 u% E4 C* d% M/ ^
the base of the phallus. Testicular volume was still 2) b" C, A3 i( v8 c
mL, and the size of the penis remained unchanged.
) ~2 u# Q3 S2 x% n, ]The mother also said that the boy was no longer hav-+ O5 f' Q; X4 V' l; ~
ing frequent erections.0 A% j/ t8 c# U7 v2 q8 v
Both parents were again questioned about use of' Q, a: u- b7 ~
any ointment/creams that they may have applied to; w% U& P: z" s( s9 K$ g! Q* ?
the child’s skin. This time the father admitted the, h) f/ j, v+ d) }
Topical Testosterone Exposure / Bhowmick et al 541
9 b8 _7 ~1 d' E2 Z1 L2 guse of testosterone gel twice daily that he was apply-
0 W! C2 L; J. `6 r$ L5 d6 t9 I7 Jing over his own shoulders, chest, and back area for; d' E. f9 `8 [4 y3 F$ }
a year. The father also revealed he was embarrassed
, n% w5 y4 \8 H7 cto disclose that he was using a testosterone gel pre-' @0 W* q- N$ C/ _( T0 H
scribed by his family physician for decreased libido }; U: Z; y! \3 @$ e- l/ k: }; C
secondary to depression.
6 ]' q4 k" r J$ \The child slept in the same bed with parents.+ c k9 a( [+ |2 D* x
The father would hug the baby and hold him on his
; q- ]! [! y$ e) j- {chest for a considerable period of time, causing sig-9 |. f/ @& M, p" B2 C8 e1 y
nificant bare skin contact between baby and father.
8 w! v+ y9 v; X! `2 ?' oThe father also admitted that after the phone call," {, c4 [5 c2 x, R" h4 Y
when he learned the testosterone level in the baby; B: Y4 J$ T: `9 x
was high, he then read the product information
8 j, E7 K( N# ~: x; M5 C7 Gpacket and concluded that it was most likely the rea-, Z9 I; C; H( b5 k. g
son for the child’s virilization. At that time, they
/ ~& b- p2 m Q, T' k2 Xdecided to put the baby in a separate bed, and the
1 C" @. H" ?' G$ C; E# Pfather was not hugging him with bare skin and had- L: l1 ~7 H/ I5 h' p# V! |- o
been using protective clothing. A repeat testosterone* N# X& Y1 m; N( f/ b
test was ordered, but the family did not go to the! ^" @' O3 m/ c4 Y9 e# x# w
laboratory to obtain the test.+ O U( N0 B" Y# |" c
Discussion
' m$ V0 R" j ]& g S+ YPrecocious puberty in boys is defined as secondary; M4 d0 ^2 F7 s. N# A8 K% Z/ ` P
sexual development before 9 years of age.1,4
- H, E6 c8 c6 e' x2 O3 x# ~Precocious puberty is termed as central (true) when1 U. p- W' A0 n: a
it is caused by the premature activation of hypo-- \' W8 k8 Q$ C( X# e( s4 W
thalamic pituitary gonadal axis. CPP is more com-1 v/ @; v0 g- d2 D9 S4 m7 W
mon in girls than in boys.1,3 Most boys with CPP# `1 u2 g9 ?3 a) ^7 P9 ]
may have a central nervous system lesion that is
5 r9 b# o$ I; Q7 W& Oresponsible for the early activation of the hypothal-% _0 Y- i, m" V; G6 R
amic pituitary gonadal axis.1-3 Thus, greater empha- l# ?1 y# m# I! b( v' W
sis has been given to neuroradiologic imaging in
2 k. \0 ]8 r' O9 j8 \boys with precocious puberty. In addition to viril-9 q* p, F# J3 @8 m
ization, the clinical hallmark of CPP is the symmet-
/ O, P, z8 h# E3 C: Crical testicular growth secondary to stimulation by
; Z) Y" r6 a1 j/ }0 lgonadotropins.1,3
' c$ K1 \! ]3 l& M0 NGonadotropin-independent peripheral preco-
7 i+ A0 Q7 Z. Zcious puberty in boys also results from inappropriate
' }# l& x1 X6 K2 F5 }" |androgenic stimulation from either endogenous or
; B0 _ A3 H% J; |exogenous sources, nonpituitary gonadotropin stim-8 _8 `* Q4 S: ~% b/ S
ulation, and rare activating mutations.3 Virilizing
+ d U- B+ B6 |) W8 ~- p Icongenital adrenal hyperplasia producing excessive
" \' {, B% j- o- l6 r5 `' Oadrenal androgens is a common cause of precocious
4 Q# N3 s3 B2 y# bpuberty in boys.3,4
9 o2 C2 f$ Z! W5 QThe most common form of congenital adrenal
+ X4 o! b& B _& ?0 Hhyperplasia is the 21-hydroxylase enzyme deficiency.
% ~* H7 ^' Y, sThe 11-β hydroxylase deficiency may also result in
' A: \5 R; Q, [' l; @8 J$ j: iexcessive adrenal androgen production, and rarely,
+ E& m# Y+ p# p/ S& w7 n3 F" jan adrenal tumor may also cause adrenal androgen
1 r y2 f3 X/ G, a3 L! ^5 `( X1 @excess.1,3$ o, m& h8 Q) Y! A$ W( a: q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 g8 w; v2 N$ B+ }( R$ U6 B542 Clinical Pediatrics / Vol. 46, No. 6, July 2007) z1 i2 Y. R9 i+ o2 X- V2 u& u
A unique entity of male-limited gonadotropin-
+ F* L: |% r bindependent precocious puberty, which is also known
9 h! [/ b1 f: [7 Ias testotoxicosis, may cause precocious puberty at a
" i; T' G- @$ dvery young age. The physical findings in these boys
1 ]& R, u" j! C9 y$ rwith this disorder are full pubertal development,$ H/ c/ C! o) {5 q8 z$ j! }3 ?7 s
including bilateral testicular growth, similar to boys
' A, y7 [, ?/ c- q8 q) H2 Iwith CPP. The gonadotropin levels in this disorder: c$ E5 P1 N4 o( f5 v! m
are suppressed to prepubertal levels and do not show
& Y B9 F- _/ p0 upubertal response of gonadotropin after gonadotropin-/ }9 e" s7 c- { _! a6 P
releasing hormone stimulation. This is a sex-linked& F% E0 \6 K3 o/ I
autosomal dominant disorder that affects only3 G: {6 H! {0 P D1 g$ u8 r
males; therefore, other male members of the family
8 p1 y( S; j D: k1 F9 W, c- M% Pmay have similar precocious puberty.3* H# a5 O# R- A6 ~
In our patient, physical examination was incon-
% _3 c8 L4 G/ {; O: s- A+ Fsistent with true precocious puberty since his testi-2 B: T: _- u; `- a
cles were prepubertal in size. However, testotoxicosis: @- b& e5 `7 P' f
was in the differential diagnosis because his father
8 B4 B5 D: o4 ], e1 Dstarted puberty somewhat early, and occasionally,: T+ |% E) Q- G5 y9 d7 A
testicular enlargement is not that evident in the
, {3 \! Z; i% X& p& tbeginning of this process.1 In the absence of a neg-: E& V9 o8 Z" h# {
ative initial history of androgen exposure, our
5 r! i( ?# ] Z9 P6 X+ U4 Rbiggest concern was virilizing adrenal hyperplasia,
/ V9 ?$ c8 U- j$ _- \either 21-hydroxylase deficiency or 11-β hydroxylase
4 n+ u% y. ]) v0 z6 k! Pdeficiency. Those diagnoses were excluded by find-
% S& ~2 U6 X5 d3 A8 L+ oing the normal level of adrenal steroids.
5 y+ z% b: U$ ]: _The diagnosis of exogenous androgens was strongly! B( L* {, w+ J1 b, ^
suspected in a follow-up visit after 4 months because9 M/ d/ R; H/ c N3 `" o7 l
the physical examination revealed the complete disap-) L: h. U- V6 W, m% F9 z
pearance of pubic hair, normal growth velocity, and! k! {- E# _6 Y
decreased erections. The father admitted using a testos-
' w t5 Q4 e; k7 J- M, z' d; |6 Oterone gel, which he concealed at first visit. He was, P! l5 U' _7 D. I3 A
using it rather frequently, twice a day. The Physicians’
5 d+ Z( J! W8 t/ T# ?Desk Reference, or package insert of this product, gel or
9 W! `+ j. G" }cream, cautions about dermal testosterone transfer to: H0 e2 U6 N, {$ ]6 S% n
unprotected females through direct skin exposure.$ u* R: v' h1 U- e/ H. N
Serum testosterone level was found to be 2 times the
' S, z1 B b- `baseline value in those females who were exposed to, O- G; J5 r1 v6 }( w8 I
even 15 minutes of direct skin contact with their male
/ z9 C( @1 Z" I8 t$ Vpartners.6 However, when a shirt covered the applica-
4 G' q# o( O4 L$ {/ W" L6 Ktion site, this testosterone transfer was prevented.1 A$ }# O/ ]. I) n6 ^ A
Our patient’s testosterone level was 60 ng/mL,9 l% z( W, ^2 ]% g- m3 p
which was clearly high. Some studies suggest that# ]- J& T' J7 ^
dermal conversion of testosterone to dihydrotestos-/ I+ `6 Z5 ?4 ?/ y8 }: U: v3 u8 Y
terone, which is a more potent metabolite, is more4 d+ z) _% e% }" m {7 }# I
active in young children exposed to testosterone( s; N2 q2 K/ D7 D
exogenously7; however, we did not measure a dihy-7 p% s) z: W) ^, @( B, e+ ]; ~+ j- I
drotestosterone level in our patient. In addition to2 R$ @1 B, V4 @) E
virilization, exposure to exogenous testosterone in7 ]' [" d; ]& m/ b# q3 i
children results in an increase in growth velocity and+ H! X6 z3 d0 k& m, O4 M3 q
advanced bone age, as seen in our patient.' d4 Q$ A$ j$ A' d& H- J! Q
The long-term effect of androgen exposure during
8 v3 @, ~1 X3 L5 B: G( {: _' V4 zearly childhood on pubertal development and final
: V; v: ]' d" m# v2 Vadult height are not fully known and always remain
6 b* i* O' K' k* [7 g$ @a concern. Children treated with short-term testos-: Z0 M. u9 U4 b3 t0 @
terone injection or topical androgen may exhibit some7 P% B4 f8 W/ b8 q
acceleration of the skeletal maturation; however, after
; W, ?+ A3 E7 ecessation of treatment, the rate of bone maturation, D3 v* n7 \7 l; t5 l* a3 {
decelerates and gradually returns to normal.8,9
8 k- `+ E" d% ^+ s! O, SThere are conflicting reports and controversy8 S t3 i' ]$ d9 N: j9 l2 d
over the effect of early androgen exposure on adult
- v& j, G( v2 n: C( H/ w) Q0 Bpenile length.10,11 Some reports suggest subnormal/ U3 n2 W3 y: Z9 S+ `1 J) `" X3 d p5 s
adult penile length, apparently because of downreg-; f2 ^" v) U$ M; G: C M8 p
ulation of androgen receptor number.10,12 However,; O( y, s. p1 t0 E3 H# O" z$ `
Sutherland et al13 did not find a correlation between
: ~) h1 j- M/ Q4 ]5 lchildhood testosterone exposure and reduced adult
( l& Q+ R) V+ Spenile length in clinical studies.
7 v( T/ S- D8 b7 n CNonetheless, we do not believe our patient is
" y, l q) m- x6 [( {going to experience any of the untoward effects from
. x V0 |: C1 o/ Ctestosterone exposure as mentioned earlier because3 f- L* G" m5 y% u' K* {
the exposure was not for a prolonged period of time.# U. \8 I' \( x3 n( @
Although the bone age was advanced at the time of f, `1 F/ @* H, w
diagnosis, the child had a normal growth velocity at$ O9 ]0 W9 ~9 H& K9 m
the follow-up visit. It is hoped that his final adult
3 M) V6 u1 Z0 r+ a% ^, n, x# Y) rheight will not be affected.
P0 k" ~" u' M/ |' i+ X) p: \Although rarely reported, the widespread avail-
! V! B6 S/ I: hability of androgen products in our society may
, P8 g8 {! F9 ?. J7 ^9 Windeed cause more virilization in male or female
! y/ R8 U+ d! n3 `8 _' fchildren than one would realize. Exposure to andro-8 t% g4 R$ S$ C" K8 v
gen products must be considered and specific ques-1 Z2 _1 e3 |. o- d2 @% |
tioning about the use of a testosterone product or
5 f) b4 |' i3 U+ m9 jgel should be asked of the family members during
4 ]3 T$ n/ c& W' \2 N" l4 X* zthe evaluation of any children who present with vir-# ?" `0 {7 [) l9 ^3 G* k5 A9 d0 T
ilization or peripheral precocious puberty. The diag-
+ g7 i9 H/ Q2 R$ ?0 j6 lnosis can be established by just a few tests and by
7 H2 ~1 V* D. \! z" w% Rappropriate history. The inability to obtain such a
5 m4 Q# S0 Z3 h. z) Z- Xhistory, or failure to ask the specific questions, may2 T9 b4 b: B; |7 B0 X" k
result in extensive, unnecessary, and expensive
8 U5 E6 ?! r1 L, L r) j' q, Yinvestigation. The primary care physician should be
/ V. l- W. X. Qaware of this fact, because most of these children
! M# R* N1 h+ ~* i, S- ^may initially present in their practice. The Physicians’
$ F& \# [* J. k1 a1 x6 _6 MDesk Reference and package insert should also put a+ E; x. v3 g; B6 Z7 h
warning about the virilizing effect on a male or9 r8 L) O+ q8 U: c7 ^, o
female child who might come in contact with some-
% A& \/ w7 p: a' Rone using any of these products.4 A# S" i# I$ s/ h: F! t: {- q
References; W9 W; P. G5 o9 t
1. Styne DM. The testes: disorder of sexual differentiation0 h4 i4 M( H3 V" _, T/ {
and puberty in the male. In: Sperling MA, ed. Pediatric
+ I, @. y* l. z" N* ?7 sEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
+ T: L6 L! O# A6 V( ]) D2002: 565-628.
- Q; ~' ^' Y$ Q8 ~2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious% J8 l$ r6 C6 N% h' W- {) k
puberty in children with tumours of the suprasellar pineal |
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