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Sexual Precocity in a 16-Month-Old
8 I' k Z2 M `Boy Induced by Indirect Topical- ]2 U" e+ F+ p2 I, A# c a8 O
Exposure to Testosterone2 v- s& r% a& z9 m6 j$ G! n
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2/ ?- E! @! z( c9 e7 Y
and Kenneth R. Rettig, MD1
3 U& e( h! |, h( a6 n+ }6 VClinical Pediatrics5 k* R1 i6 g3 y5 o, u
Volume 46 Number 6
( g9 I5 l: ~, p. cJuly 2007 540-543
6 ]; c) t- B, U© 2007 Sage Publications
% ^4 M$ e$ B/ Q8 w2 i. O% S! C10.1177/0009922806296651
- d% S4 Y7 a; Yhttp://clp.sagepub.com
& x2 n: v) k% I! s: |# G1 Lhosted at: i! u8 s3 W+ e5 c+ R9 r
http://online.sagepub.com
+ N1 f1 U3 `# Z( u4 P1 C+ Q7 ^- k2 TPrecocious puberty in boys, central or peripheral,
, G6 m9 B6 j: vis a significant concern for physicians. Central
% {; @4 M) b) e" D, z5 Dprecocious puberty (CPP), which is mediated. @- J% ?) w, F1 Z5 }* p0 d; Q
through the hypothalamic pituitary gonadal axis, has
# k1 \1 F5 Z) J+ \ F3 r/ Aa higher incidence of organic central nervous system
9 R: o7 V/ a- Zlesions in boys.1,2 Virilization in boys, as manifested
) F& J! a. J& `" j- ^by enlargement of the penis, development of pubic
: Z3 ~: L' H( Y& J% o/ lhair, and facial acne without enlargement of testi-
1 i* V2 J# g5 g: X& @cles, suggests peripheral or pseudopuberty.1-3 We
+ |6 g6 Y& B3 t0 d) }report a 16-month-old boy who presented with the4 y& B5 j5 K% i2 F1 M1 U( u
enlargement of the phallus and pubic hair develop-
6 U1 R- m+ m/ n; Qment without testicular enlargement, which was due: Y0 Q' k; g& E. W
to the unintentional exposure to androgen gel used by
: C0 H5 g5 |# X% t; i; cthe father. The family initially concealed this infor-
2 g4 i* ] h3 C. k, L9 A( ?mation, resulting in an extensive work-up for this
8 X# K1 T |, F: Xchild. Given the widespread and easy availability of# N, O- ?# k1 u
testosterone gel and cream, we believe this is proba-) E. Q4 C2 Q/ \( G
bly more common than the rare case report in the
0 Z/ E) x# i. q# O7 vliterature.4! V8 A7 W8 D& {
Patient Report+ F, s v1 U: g% S5 T2 F" y
A 16-month-old white child was referred to the
. I) B. S! Z( b2 h+ j( {0 c$ P) @9 wendocrine clinic by his pediatrician with the concern7 r V( z+ e c X1 x/ Z7 V
of early sexual development. His mother noticed' x3 n6 t: x: J/ S" G3 n
light colored pubic hair development when he was2 ~! o+ T0 X6 A6 {$ [
From the 1Division of Pediatric Endocrinology, 2University of8 {$ [; Y. P5 b5 q: ]
South Alabama Medical Center, Mobile, Alabama.. z6 S6 u# o& Q# g$ Z) L
Address correspondence to: Samar K. Bhowmick, MD, FACE,
. w- d0 L8 v( y8 P# q: q) xProfessor of Pediatrics, University of South Alabama, College of0 l5 d+ M, j N% W c2 @2 K
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ i3 l$ ~( S. c; q" T6 K4 V3 O- S
e-mail: [email protected].
3 x. f: \; @8 n8 ?$ e3 Nabout 6 to 7 months old, which progressively became2 u* }- {, S6 i: F
darker. She was also concerned about the enlarge-
3 n7 |6 e2 g/ i1 fment of his penis and frequent erections. The child
8 {1 j( U Z$ u& V: lwas the product of a full-term normal delivery, with
9 u% l% ]' z7 `/ Y. |/ |9 Ra birth weight of 7 lb 14 oz, and birth length of
) D* _1 K0 z0 z' t20 inches. He was breast-fed throughout the first year: l2 J" E8 z0 S
of life and was still receiving breast milk along with; ^ K/ E/ h- g3 W7 \3 O, A4 e
solid food. He had no hospitalizations or surgery,' }, x& `& }: j' W
and his psychosocial and psychomotor development Z0 X# h& R6 J0 F- J1 C+ k
was age appropriate.
$ X' i. L- { E7 t. L& i4 qThe family history was remarkable for the father,
2 e4 H3 X$ j' @" b. {7 @) Vwho was diagnosed with hypothyroidism at age 16,
: s$ n+ h- @. |" {which was treated with thyroxine. The father’s
# T+ @2 v1 `; Qheight was 6 feet, and he went through a somewhat
8 X s. J4 i' l. ^: N5 Fearly puberty and had stopped growing by age 14.
: I0 H. m% n9 [ t. ^4 e2 P* ^3 UThe father denied taking any other medication. The% i. R s; m& M
child’s mother was in good health. Her menarche
, L# ]$ [5 \/ V5 E( E( U) mwas at 11 years of age, and her height was at 5 feet+ Z2 E4 l4 }/ R: }, X
5 inches. There was no other family history of pre-6 Z6 \( H* ?# L3 R
cocious sexual development in the first-degree rela-; x% i v6 j6 k; ~/ n; |- V
tives. There were no siblings.
$ `" D7 }' I; q1 v( t2 N+ [* ]( wPhysical Examination: n8 e& H& R) L3 |
The physical examination revealed a very active,( P( I& u/ R* D2 R
playful, and healthy boy. The vital signs documented3 X' x0 F4 _ i) ?0 V9 J/ a; S: w
a blood pressure of 85/50 mm Hg, his length was
4 u2 p2 H5 q& x, y& u" R" H {90 cm (>97th percentile), and his weight was 14.4 kg! @) E# d( k9 p; H+ ]/ E
(also >97th percentile). The observed yearly growth5 \: R4 A# }# C& I- L+ i9 L+ _
velocity was 30 cm (12 inches). The examination of5 {: Y2 C* K& d+ Z( v9 M7 M P% K, j
the neck revealed no thyroid enlargement.
" c+ |$ p% j' o/ A, wThe genitourinary examination was remarkable for5 F% i% A( S- O( t0 F; Y8 v# N
enlargement of the penis, with a stretched length of) E% U. y9 U, w- M) R* B
8 cm and a width of 2 cm. The glans penis was very well4 S a9 h2 z1 b1 M; E1 W
developed. The pubic hair was Tanner II, mostly around# p t( W$ \0 }) t% n
540
) n* T( T- o% _* T& y4 {at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 b: m u4 b, P
the base of the phallus and was dark and curled. The
0 p$ I U, I. G" J0 Ptesticular volume was prepubertal at 2 mL each.; R+ A- B% y0 n5 V* B4 Y( V6 {! |
The skin was moist and smooth and somewhat
/ a! |% M/ l7 X8 K( ~1 M, voily. No axillary hair was noted. There were no
$ k$ }9 R- i' @; x/ A# n; tabnormal skin pigmentations or café-au-lait spots.0 _! f, W, U K9 a: s# ]
Neurologic evaluation showed deep tendon reflex 2+
' ?; V) K* {7 p/ }% E+ zbilateral and symmetrical. There was no suggestion' j* x: ]) f! [5 T, g. c% O* c
of papilledema.1 B& c6 Y2 `3 j7 @$ x. ]% u
Laboratory Evaluation3 R H, p! C. B: a, O
The bone age was consistent with 28 months by
% h- I/ y. X3 R# u1 r7 U- c/ T9 Ousing the standard of Greulich and Pyle at a chrono-& c8 e: x" ]$ O$ u
logic age of 16 months (advanced).5 Chromosomal ~) }1 ^: J/ |% H; J1 ~
karyotype was 46XY. The thyroid function test, ?4 V5 I& q4 u' m1 t2 ]
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
8 i& @ o/ F+ slating hormone level was 1.3 µIU/mL (both normal)., B) \ f# H( x
The concentrations of serum electrolytes, blood" D9 D, H1 j! b; X5 \
urea nitrogen, creatinine, and calcium all were) i3 `9 g; F1 z) `( _+ J3 M; ]; _2 U b
within normal range for his age. The concentration
1 s0 ?( _; e9 F- rof serum 17-hydroxyprogesterone was 16 ng/dL
4 Z, A8 M& H! m% W3 V1 q, H4 k; L(normal, 3 to 90 ng/dL), androstenedione was 20
# J$ P% h/ B1 c& u. cng/dL (normal, 18 to 80 ng/dL), dehydroepiandros- P! H" j# }" ]; Q4 q8 b) T+ v' z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 e/ [: x8 H$ }4 I n1 tdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
. l" h" O. o7 j49ng/dL), 11-desoxycortisol (specific compound S)) O1 i; @" A6 Q$ b0 \, d1 K
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
6 N& F9 Y. l* B6 J& i% L6 Jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total/ _3 _3 Y2 k- d) D$ r' }- `
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
1 s2 F$ }6 D2 Y9 o) q; r' {and β-human chorionic gonadotropin was less than( ^/ Z q& i' n% T; Q
5 mIU/mL (normal <5 mIU/mL). Serum follicular
) t# Q/ ^% q4 ]* y- zstimulating hormone and leuteinizing hormone" [) V+ e9 n4 } r6 L. E
concentrations were less than 0.05 mIU/mL* @4 d5 ]( ~: |1 @) s8 H$ z2 N
(prepubertal).
* T2 S5 N# s# X/ ?& [: pThe parents were notified about the laboratory/ y- v: X0 N. n1 u1 D9 U5 R
results and were informed that all of the tests were0 L* Q2 _9 F0 C% a: b4 Q, `
normal except the testosterone level was high. The0 a. l7 F! C' x; K/ Z
follow-up visit was arranged within a few weeks to
0 e1 }4 K; X* T% R' y3 |obtain testicular and abdominal sonograms; how-1 R! ?. G+ E# H3 s; c8 `
ever, the family did not return for 4 months.4 [' r4 x' n! r
Physical examination at this time revealed that the2 @: d6 m) {+ b6 V& E
child had grown 2.5 cm in 4 months and had gained
/ ]: e1 l9 g& [& C2 kg of weight. Physical examination remained
7 x$ s2 J6 {' K2 iunchanged. Surprisingly, the pubic hair almost com-6 s% Y3 _% U: ^! q; Z
pletely disappeared except for a few vellous hairs at
% [' e3 O( o( w1 `" N: h7 cthe base of the phallus. Testicular volume was still 2
* J2 q) b8 H: H) U9 BmL, and the size of the penis remained unchanged." c& b4 F+ R% |2 u7 x+ ?
The mother also said that the boy was no longer hav-
- t" y% g; s7 z9 cing frequent erections., K/ }6 E$ O) m- B& h0 A, ~
Both parents were again questioned about use of& }+ K1 f: z I" y ?1 v. H: ]
any ointment/creams that they may have applied to
% p, d2 w2 L0 Y8 N! \7 Lthe child’s skin. This time the father admitted the1 Q9 T9 V, x3 g5 i: L/ |" _
Topical Testosterone Exposure / Bhowmick et al 541
; f. ?* A$ j3 Y- A! F* `3 y% Iuse of testosterone gel twice daily that he was apply-7 b* H7 G8 i8 M# [
ing over his own shoulders, chest, and back area for
+ n0 g1 M6 w7 t2 r& h, xa year. The father also revealed he was embarrassed
7 n' p2 f3 S' L# ~7 r% u! \( y6 Mto disclose that he was using a testosterone gel pre-( h9 d0 H+ ] \1 p2 w w. U
scribed by his family physician for decreased libido ]5 n9 U1 v* L W( _
secondary to depression.
6 @ p& ^" ~' a6 x) lThe child slept in the same bed with parents.
: ^$ F0 q0 Z6 M. C+ bThe father would hug the baby and hold him on his. }1 Y. X1 x7 g( U$ z% H8 A
chest for a considerable period of time, causing sig-
( b8 y5 u! {2 l$ l4 |nificant bare skin contact between baby and father.
# a0 f8 ]: [$ r/ p$ jThe father also admitted that after the phone call,
& J4 Q8 P' K) A2 Mwhen he learned the testosterone level in the baby
# z! G9 a, y: ]% ]7 y3 M7 A6 N& t. _was high, he then read the product information- [8 @, c/ p& Z
packet and concluded that it was most likely the rea-6 v% x! G/ S& o8 J+ a" \( `; J
son for the child’s virilization. At that time, they" X7 }. V' v0 B
decided to put the baby in a separate bed, and the% i* m+ x3 f5 m& z; k! T w* @0 t
father was not hugging him with bare skin and had5 G9 u6 K. w( C9 k) e: i
been using protective clothing. A repeat testosterone. h+ X7 C# R3 J# T" x* ?0 \3 A
test was ordered, but the family did not go to the
+ S J( N, }& T4 f5 N5 glaboratory to obtain the test.4 y- k, M e/ V. t. d5 q6 S
Discussion5 h) Z; W: S2 {$ R0 G/ J" [# q, A
Precocious puberty in boys is defined as secondary2 l4 S+ Q% ?' |& C N2 Q& p; n/ w7 @
sexual development before 9 years of age.1,4
0 g# V% P( N' y4 W ~( t2 @2 ]Precocious puberty is termed as central (true) when
, s* f7 W1 J+ I U: A/ p' E: l3 g4 cit is caused by the premature activation of hypo-
0 Y f4 m: Z. @/ Y# R- Kthalamic pituitary gonadal axis. CPP is more com-
- r$ I! ]2 ]% y2 C; ]mon in girls than in boys.1,3 Most boys with CPP
7 ~, m+ V5 k8 D7 Y) [may have a central nervous system lesion that is9 V8 w: U% w$ g
responsible for the early activation of the hypothal-
1 y$ e* v! y' W/ Zamic pituitary gonadal axis.1-3 Thus, greater empha-3 \+ \8 o+ k4 L) e I& C
sis has been given to neuroradiologic imaging in8 X7 ^5 u1 o; n
boys with precocious puberty. In addition to viril-* c' x( }1 e' ?
ization, the clinical hallmark of CPP is the symmet-: F! U' \1 x. F2 _9 E9 [
rical testicular growth secondary to stimulation by
8 C$ Q' e0 g$ P* |9 Xgonadotropins.1,31 F5 @1 |/ `* i- W- @
Gonadotropin-independent peripheral preco-9 ^' U" B" U8 n, C$ l! b7 L
cious puberty in boys also results from inappropriate
; g+ J/ M9 `; n9 z. I% c7 O! fandrogenic stimulation from either endogenous or2 W, u& g+ O- a/ [
exogenous sources, nonpituitary gonadotropin stim-
9 S# P4 h4 Q6 c5 R Culation, and rare activating mutations.3 Virilizing
+ q! @4 |- l4 V5 ^congenital adrenal hyperplasia producing excessive
5 u" i* Q0 h: F: g& S1 {( B3 nadrenal androgens is a common cause of precocious, D! G/ X& M, [! @/ h5 p
puberty in boys.3,4
$ `8 r1 j3 Z5 H DThe most common form of congenital adrenal
* Q" ?" k, |# m. Lhyperplasia is the 21-hydroxylase enzyme deficiency.
7 G7 q; n+ H) t$ \ |7 g1 Z; q4 Z9 bThe 11-β hydroxylase deficiency may also result in
- y* u. ~/ v$ C3 Xexcessive adrenal androgen production, and rarely,
0 ~: i% Y0 X8 U1 K3 can adrenal tumor may also cause adrenal androgen
1 }( G) p l2 i% j/ E9 I1 _3 yexcess.1,32 L, h) W" h3 ~# R2 i: k+ \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 V7 O& y. F# p! F. o( k/ ^( m; V
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& j# x8 n/ N% X1 I$ c2 P! h# nA unique entity of male-limited gonadotropin-
( W/ |. ?& x8 v5 W+ R' i' z3 mindependent precocious puberty, which is also known' B6 i5 J: Y3 F' f( c
as testotoxicosis, may cause precocious puberty at a5 S v* R3 w; Y) o7 x8 i' Z
very young age. The physical findings in these boys: r: O: b* @9 c8 C. n \
with this disorder are full pubertal development,5 a p0 Z7 t& O( a% n+ f$ R. H
including bilateral testicular growth, similar to boys0 N6 G E6 |# T7 p& d% Z
with CPP. The gonadotropin levels in this disorder
( X0 I6 P' p, h6 u; Fare suppressed to prepubertal levels and do not show
2 Z- u, W D) \& U1 S' m; Gpubertal response of gonadotropin after gonadotropin-( s0 ?- G R& V- o9 T
releasing hormone stimulation. This is a sex-linked
/ a% Q- f; C0 x6 ~1 f, b6 v' Oautosomal dominant disorder that affects only
/ U$ |" U5 x% d, Amales; therefore, other male members of the family
; H. R/ i& ]5 ~1 t2 V. Q8 Lmay have similar precocious puberty.3
$ z0 D: c' {- T& N/ e4 ~8 jIn our patient, physical examination was incon-
+ o, q* r. P& ^0 b5 B3 o5 hsistent with true precocious puberty since his testi-- t8 U; F5 l! H1 `3 d: A( d
cles were prepubertal in size. However, testotoxicosis
' r! n3 }3 j8 a/ d! A. uwas in the differential diagnosis because his father
4 o/ b8 v; K0 k2 F. lstarted puberty somewhat early, and occasionally,
7 }! T1 a$ F, g' [$ t" ~testicular enlargement is not that evident in the
" \7 ?& H+ ^$ X) `# t% y' Zbeginning of this process.1 In the absence of a neg-
/ {5 D$ r |% j, }+ ~- I9 ]ative initial history of androgen exposure, our
6 u9 m8 d. i! f) W; [biggest concern was virilizing adrenal hyperplasia,
/ p/ B3 ^5 V+ @8 n; g7 F1 s0 Ieither 21-hydroxylase deficiency or 11-β hydroxylase+ K6 W& [/ A7 j# q5 o' U$ S! S
deficiency. Those diagnoses were excluded by find-
& G( G- B- H- ning the normal level of adrenal steroids.% d# \4 I, v9 b
The diagnosis of exogenous androgens was strongly
+ `; v0 y* ?4 ]% q; _suspected in a follow-up visit after 4 months because
' N8 I" q8 y2 p V7 U A3 Nthe physical examination revealed the complete disap-
4 K2 S: W3 V& a* @pearance of pubic hair, normal growth velocity, and6 `" C8 m; q6 F& K6 `) y0 i
decreased erections. The father admitted using a testos-
* [9 z9 Q3 G C7 L7 d! sterone gel, which he concealed at first visit. He was
; A/ I& C- Y, |. kusing it rather frequently, twice a day. The Physicians’
& K9 t) }) e2 p) a. H8 aDesk Reference, or package insert of this product, gel or/ [# w) H, K, S R- v- g( G, e5 p
cream, cautions about dermal testosterone transfer to$ K% C, ]+ o5 {2 \ w9 U& O# [
unprotected females through direct skin exposure.
& ~& j1 V# i# n9 jSerum testosterone level was found to be 2 times the
2 z* }- D9 r9 ~% a1 dbaseline value in those females who were exposed to) @4 Y8 s q4 u, J o
even 15 minutes of direct skin contact with their male
3 d% S9 C9 P7 |) j( T) R! t3 lpartners.6 However, when a shirt covered the applica-
" r) \8 {* Y! x( r' H% Ytion site, this testosterone transfer was prevented.' N; H/ o& P0 Q3 F
Our patient’s testosterone level was 60 ng/mL,/ J2 o3 S. ]2 u" z0 k% R T
which was clearly high. Some studies suggest that
9 n3 g, a5 G- v* `dermal conversion of testosterone to dihydrotestos-# p/ W2 ` k% T: r6 Y& F
terone, which is a more potent metabolite, is more% y9 G) ^! j, @0 T- U
active in young children exposed to testosterone
9 P5 w# ]. M. ^* Mexogenously7; however, we did not measure a dihy-
6 Z" s$ b+ j* u7 h3 ~2 pdrotestosterone level in our patient. In addition to5 A8 \; Z; R* r7 E. c* s. }/ X- D
virilization, exposure to exogenous testosterone in8 n0 b. ~6 o! u6 R" b4 [
children results in an increase in growth velocity and% s! r0 ~# B) p0 c0 J& U; K
advanced bone age, as seen in our patient.. n) o; ^ f) Q2 x! J/ k5 }
The long-term effect of androgen exposure during) z+ q+ U# \* P3 |+ V% p: s
early childhood on pubertal development and final0 K( N, h) R; X! s, P) U4 Y
adult height are not fully known and always remain
; H! b. S1 L/ `a concern. Children treated with short-term testos-7 C1 U2 s; I. j$ E
terone injection or topical androgen may exhibit some+ U- ?2 ]4 J+ b* f
acceleration of the skeletal maturation; however, after
; P* S& N! Z2 f! wcessation of treatment, the rate of bone maturation
$ ?; Z* r5 |) f4 mdecelerates and gradually returns to normal.8,9+ O, J: R( x3 X( c! | R
There are conflicting reports and controversy% B7 H% ~9 [" r8 P8 c
over the effect of early androgen exposure on adult
4 W; m! Z# r2 m0 r/ k& _8 Spenile length.10,11 Some reports suggest subnormal
2 V4 v, ^! a$ g! [8 T$ d. sadult penile length, apparently because of downreg-! X a- ^) Z7 L- Y
ulation of androgen receptor number.10,12 However,
# t* j* B0 a' o3 _: ?Sutherland et al13 did not find a correlation between7 r* D" S3 o3 R: G. ~
childhood testosterone exposure and reduced adult
( }' Q7 R; v q4 Z$ E% vpenile length in clinical studies.
8 m/ a' ^& w* |Nonetheless, we do not believe our patient is
& {8 N, I7 V9 w+ f3 v' U) v: U+ igoing to experience any of the untoward effects from8 W! x. j3 B3 J0 } Y/ d; j' \
testosterone exposure as mentioned earlier because
3 f$ a, f3 P; k! p8 pthe exposure was not for a prolonged period of time.3 B' W9 U) B* R
Although the bone age was advanced at the time of, q" H2 j, N$ w' y6 }
diagnosis, the child had a normal growth velocity at, ]0 f* Q; Z4 L8 S- |
the follow-up visit. It is hoped that his final adult, u0 V' h+ r' _1 h- K$ a
height will not be affected.
: x) _) t F/ V5 F, CAlthough rarely reported, the widespread avail-
3 B+ t- Q& Y$ d" {& |# _ability of androgen products in our society may
) ~- y% r/ M0 ?. h6 P( @% y$ y( sindeed cause more virilization in male or female
. R2 z: z% N; s6 ichildren than one would realize. Exposure to andro-$ g) V; `, z% S: L
gen products must be considered and specific ques-/ E/ {" L) }; {+ k4 o
tioning about the use of a testosterone product or
8 x0 C1 M0 k6 \, Ogel should be asked of the family members during/ Q( Q2 ^) `; z7 X
the evaluation of any children who present with vir-: x. u1 L, H' y, R: d
ilization or peripheral precocious puberty. The diag-# `( q* o, W/ u6 @9 `
nosis can be established by just a few tests and by
1 Q$ K; |% V8 z0 C4 qappropriate history. The inability to obtain such a. A8 b9 t2 n( ]% r: V. L) z. k
history, or failure to ask the specific questions, may
- P. N) s- @8 V8 A; Hresult in extensive, unnecessary, and expensive+ p2 [ T+ I+ x% N8 `; m
investigation. The primary care physician should be
1 b8 z) P/ J! faware of this fact, because most of these children
- F! F+ ]9 |" A- P& }* Mmay initially present in their practice. The Physicians’5 Q- z- b. Z1 d+ Q7 C$ m* a
Desk Reference and package insert should also put a" w5 b8 b$ V q3 H4 Y
warning about the virilizing effect on a male or @8 R5 X8 a* J/ m5 c; G: j- M Z
female child who might come in contact with some-3 i' E* o; Z! C% d
one using any of these products.8 _* V( R/ x* d0 @
References
I: X" d4 [2 O# [1 ]1. Styne DM. The testes: disorder of sexual differentiation
$ y" ]. ~/ W$ ^$ hand puberty in the male. In: Sperling MA, ed. Pediatric1 t! u' E3 t* p
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 J) v$ J& p3 I
2002: 565-628.9 T$ n- S0 E2 E( ~" C( x
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' \, z" s# G! k2 Wpuberty in children with tumours of the suprasellar pineal |
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