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Sexual Precocity in a 16-Month-Old7 k& `1 ^1 {- }5 |* R
Boy Induced by Indirect Topical \# N' Y% {) R' G% A9 g" y
Exposure to Testosterone
3 `+ W& f! W5 q3 r" QSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! H- Y+ j* o, C: F# }
and Kenneth R. Rettig, MD1! h( `2 @) A) q7 f: y
Clinical Pediatrics* n A# S, Q' i7 b5 x4 i' E% H
Volume 46 Number 6
! O H# W! [0 a$ D N6 CJuly 2007 540-5439 \+ Y( |/ V( A6 `- c
© 2007 Sage Publications/ J) T( X8 v8 ]! b
10.1177/0009922806296651& a9 a; Z7 b. J% a7 U. a% V
http://clp.sagepub.com3 Y X% g& A& f2 A. u. X1 i7 E
hosted at4 K' I, D6 b0 `8 P0 ^
http://online.sagepub.com
! F- [1 p& |$ s) C0 L7 r- kPrecocious puberty in boys, central or peripheral,
# [: B. y: G, j; F6 [/ f' y8 yis a significant concern for physicians. Central
% T3 d7 Q2 |; m( p! H" v- h# qprecocious puberty (CPP), which is mediated
" _; ?) z9 n: bthrough the hypothalamic pituitary gonadal axis, has; \0 Q1 `! K/ n7 V! @9 P, F6 y
a higher incidence of organic central nervous system+ @5 ]0 G( K7 v7 m8 N6 i9 h* r# d
lesions in boys.1,2 Virilization in boys, as manifested
2 W1 G' h) n L; [by enlargement of the penis, development of pubic3 r& X6 N _7 Q" j; {! a: y
hair, and facial acne without enlargement of testi-
" F2 |& @$ v" N* N& a c5 kcles, suggests peripheral or pseudopuberty.1-3 We, ]2 j; a, n/ t) P( H& g
report a 16-month-old boy who presented with the
F) n; r5 t' _% s" Renlargement of the phallus and pubic hair develop-% r/ @, w% X* B
ment without testicular enlargement, which was due
. F; y& n4 W* [9 z( k% a- Ato the unintentional exposure to androgen gel used by1 c+ X5 q6 j- v8 H/ T1 Y( S
the father. The family initially concealed this infor-0 y( M' C- p( J6 p1 {4 A: k4 @4 @5 J
mation, resulting in an extensive work-up for this; [" x' z- `* ?# U1 ]
child. Given the widespread and easy availability of
* y. j4 @$ K u( |testosterone gel and cream, we believe this is proba-
E( ~/ v! V ebly more common than the rare case report in the5 ^- c/ q0 b% n
literature.4
2 v. Z& j. x4 d# IPatient Report
0 b+ x: e# T; ^) ^* \6 _A 16-month-old white child was referred to the# R- S/ \0 ]4 B- V$ J7 j
endocrine clinic by his pediatrician with the concern
8 b9 k' w* V2 y& g, y1 ?of early sexual development. His mother noticed
3 {& i6 _# C+ x; Plight colored pubic hair development when he was
* z* o) |+ e3 u n1 e( cFrom the 1Division of Pediatric Endocrinology, 2University of6 r/ F( }0 R) |* G1 s
South Alabama Medical Center, Mobile, Alabama.% [: c, g( m x4 K" R
Address correspondence to: Samar K. Bhowmick, MD, FACE,/ A& H h. E4 `! {/ a8 T W
Professor of Pediatrics, University of South Alabama, College of
4 O' `- n* f& ]7 R/ ]; J( Q5 GMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& B) Q! b5 {( {4 Z4 h. ]5 ce-mail: [email protected].
8 q, w, }8 E3 `8 \- Vabout 6 to 7 months old, which progressively became3 b9 G% ?) m/ l, f5 e& }4 ~
darker. She was also concerned about the enlarge-
% j/ K7 y L% n* ument of his penis and frequent erections. The child, {* z! S' T+ U7 @* a- [ \! u& e! ?
was the product of a full-term normal delivery, with* i. ~' l6 F( p1 [6 q
a birth weight of 7 lb 14 oz, and birth length of
Y" `6 E: M+ P9 b7 p20 inches. He was breast-fed throughout the first year0 Y7 N# J; N ^' o0 D* \
of life and was still receiving breast milk along with
: f/ ~9 _- \4 Dsolid food. He had no hospitalizations or surgery,, v3 v9 H7 Q& t% M0 o3 }
and his psychosocial and psychomotor development
; q) W5 B8 r6 j2 B. f9 a2 Bwas age appropriate.
4 T& W& t7 D+ I# ]The family history was remarkable for the father,
, D" V I A2 U# q5 O1 gwho was diagnosed with hypothyroidism at age 16,2 D, ?3 w" g) T4 R
which was treated with thyroxine. The father’s8 j* _) }) h3 u1 K8 V
height was 6 feet, and he went through a somewhat0 ^5 Q# {/ L. k5 i
early puberty and had stopped growing by age 14.# ^/ ]# r5 E7 x3 o( A$ t2 Y
The father denied taking any other medication. The
+ L( m) U! j! W8 y# z, z( _! J5 K4 Rchild’s mother was in good health. Her menarche
8 Q# G/ }' A( R" hwas at 11 years of age, and her height was at 5 feet' r. z+ ` f q. V% }
5 inches. There was no other family history of pre-
' p4 G9 n9 N/ R# Ncocious sexual development in the first-degree rela-
0 p j$ g7 v6 F8 s% r5 w, a& t1 mtives. There were no siblings.
& X& ^5 `/ I' O, k- aPhysical Examination, R H* V" i# t' u, ? k% Q% N
The physical examination revealed a very active,% x n, b1 |4 _' J
playful, and healthy boy. The vital signs documented5 S9 s. r# m3 i5 k
a blood pressure of 85/50 mm Hg, his length was! c/ ?& N( M+ u) ~2 P
90 cm (>97th percentile), and his weight was 14.4 kg' V! D' t, w! J W |! X
(also >97th percentile). The observed yearly growth
7 _- }) A% Y1 K+ Hvelocity was 30 cm (12 inches). The examination of7 ^4 l/ O, ]; {4 |
the neck revealed no thyroid enlargement.
, m' E' f* M. H- Q% J* `The genitourinary examination was remarkable for
) \, l* j7 W- D% j* y: d' oenlargement of the penis, with a stretched length of
* X6 {8 O, C z& o& U/ a8 cm and a width of 2 cm. The glans penis was very well
4 B' Y1 `$ m6 ^& ]- ~. F wdeveloped. The pubic hair was Tanner II, mostly around$ V, D" U7 N/ I6 m, T& B
540
% p5 E5 [$ H- B8 t+ C7 ?$ `$ p- Fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# G! O$ j' Z6 s$ z$ Q9 E; T
the base of the phallus and was dark and curled. The' |2 h4 u7 g2 |
testicular volume was prepubertal at 2 mL each.
# W+ Q4 E. d3 C" x9 t: `7 iThe skin was moist and smooth and somewhat
- i& _& t$ t1 t: \oily. No axillary hair was noted. There were no
/ \! K [. q) J) {# g0 i# U* @* Eabnormal skin pigmentations or café-au-lait spots.1 l$ h2 B6 ~1 X, L+ [
Neurologic evaluation showed deep tendon reflex 2+7 Y% {2 f& ^# A
bilateral and symmetrical. There was no suggestion' w$ y# w$ M$ C, X9 l
of papilledema.
. G! g! W5 |7 i( x" GLaboratory Evaluation
. X6 } ]7 x$ S; f8 u* Y* v2 z' Z5 TThe bone age was consistent with 28 months by
1 d2 Y* O) e' O( O; Yusing the standard of Greulich and Pyle at a chrono-
; }2 S* Y" j) \logic age of 16 months (advanced).5 Chromosomal
8 V! s% x b" V$ ?5 ]; o. Wkaryotype was 46XY. The thyroid function test
0 v s7 r% x3 ?: Sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-, B$ s8 y$ b, c$ I5 d& r V- m# f/ f
lating hormone level was 1.3 µIU/mL (both normal).# ]3 D' x/ H9 B, b7 a
The concentrations of serum electrolytes, blood
4 [8 a. [ e1 _( Burea nitrogen, creatinine, and calcium all were
) o8 t' v* _& ^! vwithin normal range for his age. The concentration
. y- Y' V9 r7 d6 H& B2 F" y1 _! eof serum 17-hydroxyprogesterone was 16 ng/dL
7 d& o% r/ k9 p- {% g O( ?/ i(normal, 3 to 90 ng/dL), androstenedione was 20
- P. B4 s3 W1 xng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 W- s) m1 c. ]. _- O7 C
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
& v; g m- E( r8 Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to0 k; N0 l4 I7 _, b
49ng/dL), 11-desoxycortisol (specific compound S) }% r3 n2 V! {5 a+ |
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ t6 K& y1 b: `tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
$ I$ g* g. }0 r6 ^/ Ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),% w( V2 e+ w) P: X3 a$ Z$ J2 p9 v2 C
and β-human chorionic gonadotropin was less than( b/ I. U, h/ w3 o% n% c/ {! P9 L$ g
5 mIU/mL (normal <5 mIU/mL). Serum follicular
$ v% ^! E# o% e" Astimulating hormone and leuteinizing hormone$ [, K8 R* g8 b; B7 G% u
concentrations were less than 0.05 mIU/mL
l; d6 G2 D0 G# h/ F(prepubertal).: K! o: c, A d6 Y
The parents were notified about the laboratory
4 ?/ ~* T. z& gresults and were informed that all of the tests were* L; q2 D2 s) W* U1 A
normal except the testosterone level was high. The* L1 h- q( T3 q( E% e
follow-up visit was arranged within a few weeks to3 Y. c8 g' c/ J6 Q: o, M% c+ A
obtain testicular and abdominal sonograms; how-8 d( y% B& i7 ^5 t2 U9 w8 ^+ T* I
ever, the family did not return for 4 months.; {+ ]/ N' Q O( s# w
Physical examination at this time revealed that the. m! _+ C* `. n' q2 M$ i4 a( F1 i
child had grown 2.5 cm in 4 months and had gained5 X7 d% G+ W9 C5 @' n' d7 V* A5 T
2 kg of weight. Physical examination remained
) E% g2 D( u6 S) }5 ]8 ?0 y8 Ounchanged. Surprisingly, the pubic hair almost com-
/ l' `" X+ l5 n* ], Z2 { ^pletely disappeared except for a few vellous hairs at3 v% c7 i) ^+ O7 S7 q- M9 u
the base of the phallus. Testicular volume was still 2
) t4 ]4 l) X" [" U" K7 u- e* _mL, and the size of the penis remained unchanged.' B4 h9 l8 Y+ j: @
The mother also said that the boy was no longer hav-
; T h1 I5 X* P: b& Y' D! m. W& @ing frequent erections.8 [6 r4 b: S% s- c, S `* J" x" m2 {7 F
Both parents were again questioned about use of
! C3 j; p5 e- q+ g6 k, p% s$ Sany ointment/creams that they may have applied to, {0 C1 B$ k6 B" K% {+ p# I0 e% [
the child’s skin. This time the father admitted the
, ~, d% T5 D5 P- c. W7 D- pTopical Testosterone Exposure / Bhowmick et al 541# J, C% k& ~7 r, o! p7 v$ o
use of testosterone gel twice daily that he was apply-
# H1 V+ x" v# |$ }& Iing over his own shoulders, chest, and back area for
1 |4 @% U& Q0 T7 Wa year. The father also revealed he was embarrassed5 H. V. P8 N1 s1 z3 e6 ^3 v! Z
to disclose that he was using a testosterone gel pre-
1 v* G+ W3 k; b. Bscribed by his family physician for decreased libido- X7 ~+ s8 t: p6 g7 S
secondary to depression.
! U+ x& u& g! L: @9 X0 P/ q$ bThe child slept in the same bed with parents.$ M' ~; k1 e7 Y0 {2 [- q
The father would hug the baby and hold him on his
$ q& b9 W. U r; I1 H; ichest for a considerable period of time, causing sig-1 K7 d1 |" s2 n( [; W9 F9 K8 t; Y0 Z
nificant bare skin contact between baby and father.
2 B8 O( ?0 u) [The father also admitted that after the phone call,
; h9 K/ L& D# M- r$ `when he learned the testosterone level in the baby
( a- U5 P) x* T+ j' Twas high, he then read the product information$ K9 ~5 u9 X: M' i. J0 ?/ v1 O$ x
packet and concluded that it was most likely the rea-, m6 n. X. ?9 Y: w! @% P7 N
son for the child’s virilization. At that time, they
1 w+ u! w5 c" n6 m G7 Y) ?& h: kdecided to put the baby in a separate bed, and the. S+ d1 s1 [% H6 x, i, `( j
father was not hugging him with bare skin and had
2 ^; `$ s$ a+ E# y0 W) d3 A4 C( O8 Sbeen using protective clothing. A repeat testosterone" D3 X% E* C# _ {
test was ordered, but the family did not go to the
0 ~7 J- U# l) z9 T' L5 x; glaboratory to obtain the test.) I V j( U6 ?. y: r$ _
Discussion
0 [1 G$ I# c. h& CPrecocious puberty in boys is defined as secondary
, z! [! @, R5 a; b, F) j% a3 X4 W" vsexual development before 9 years of age.1,4( B( x% c2 c' \# x
Precocious puberty is termed as central (true) when) l3 `4 \! H6 K+ f" X T
it is caused by the premature activation of hypo-
9 a Z: E1 a: g! @+ U/ ]: sthalamic pituitary gonadal axis. CPP is more com-
/ Y7 r: a3 C) a2 Z: k: {# Amon in girls than in boys.1,3 Most boys with CPP
* t& C Q! v+ Y, ymay have a central nervous system lesion that is
- n8 P8 v: T) x5 f% f% a& Vresponsible for the early activation of the hypothal-
& Y: F9 P0 h% N: qamic pituitary gonadal axis.1-3 Thus, greater empha-
& c3 p% \- X) ` c( vsis has been given to neuroradiologic imaging in
' P s# |$ \* b+ o6 j/ ~boys with precocious puberty. In addition to viril-& x7 n2 P# d0 B
ization, the clinical hallmark of CPP is the symmet-3 |) b X0 `+ d4 Z. d$ ~3 u
rical testicular growth secondary to stimulation by& A5 {4 |" e: a" P
gonadotropins.1,31 _) P- |# U$ N. o, i
Gonadotropin-independent peripheral preco-# B, y! q8 F) Z" N
cious puberty in boys also results from inappropriate, B! ^9 d! E0 S. ?
androgenic stimulation from either endogenous or1 ]. H; ~8 r5 F! w
exogenous sources, nonpituitary gonadotropin stim-
8 b4 w* [3 @8 W& g1 |. _7 u. |! zulation, and rare activating mutations.3 Virilizing4 ?. l' W; l; j2 y
congenital adrenal hyperplasia producing excessive
8 u6 H* |1 f4 c q. M& Oadrenal androgens is a common cause of precocious
$ C+ S# P; u3 P/ Qpuberty in boys.3,47 l; F- y$ i5 m- K3 K( ?& C
The most common form of congenital adrenal2 D; O" ?3 a8 }6 a$ u: {
hyperplasia is the 21-hydroxylase enzyme deficiency.$ x& s. @: v* K1 H
The 11-β hydroxylase deficiency may also result in
: G8 j4 Z$ c" L) C& m1 U: l$ Lexcessive adrenal androgen production, and rarely,
4 u [" V; Q/ H O6 H3 b0 Uan adrenal tumor may also cause adrenal androgen1 R c$ q: d$ ~+ k: l6 B
excess.1,3
5 `, U8 ^9 y4 ~6 w4 g6 K3 Z1 ?at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% D* J1 V9 {) @' F/ d
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007. s% ?. o5 w% G' {. O R7 [
A unique entity of male-limited gonadotropin-
7 s+ \9 @; f! j) mindependent precocious puberty, which is also known, a4 K+ l2 \+ B, Q
as testotoxicosis, may cause precocious puberty at a
, u: @8 \5 B/ i3 Xvery young age. The physical findings in these boys
9 ?# n, p+ j$ b5 d; gwith this disorder are full pubertal development,
. y7 a6 T9 e4 f4 u$ k$ q# Zincluding bilateral testicular growth, similar to boys+ Y; x& A1 }3 V0 Y3 ]2 R* }
with CPP. The gonadotropin levels in this disorder. j" `2 }$ |7 [2 j
are suppressed to prepubertal levels and do not show& [( r6 K8 x; r: J) W9 H! q0 ]- Z$ N7 z
pubertal response of gonadotropin after gonadotropin-
1 @) K/ H+ r/ N' n& J7 M1 Rreleasing hormone stimulation. This is a sex-linked
9 w. u' K, j1 Y4 n/ [autosomal dominant disorder that affects only
. S: T! `+ D- [1 P/ E, a5 Fmales; therefore, other male members of the family' s! L9 K- m5 U u$ j: N l8 X3 h. |
may have similar precocious puberty.3* m1 f+ S0 d7 h) G0 s3 M
In our patient, physical examination was incon-
; p) A/ \1 j9 R/ R L0 a8 h" {sistent with true precocious puberty since his testi- d5 ^$ b. w; F' A. k$ ]
cles were prepubertal in size. However, testotoxicosis- t8 o, e8 k& Y2 w
was in the differential diagnosis because his father
* Q/ q$ Z, w' Y. _. Qstarted puberty somewhat early, and occasionally,& v7 Z$ G. i9 M/ [+ f- A' B* S
testicular enlargement is not that evident in the
( g/ u Z0 t( \# I Rbeginning of this process.1 In the absence of a neg-
* @4 {. u& ~; y! e) c& \ative initial history of androgen exposure, our
5 S) b. t0 @5 Y$ obiggest concern was virilizing adrenal hyperplasia,
& I2 s) f8 P- `6 Q S+ qeither 21-hydroxylase deficiency or 11-β hydroxylase. _" Y3 N# Q$ v; t2 s
deficiency. Those diagnoses were excluded by find-7 C* N# I! M8 Q G' L% R% q6 T. O0 _
ing the normal level of adrenal steroids.3 t4 f8 \" T' y+ J7 F' @/ u; \6 g
The diagnosis of exogenous androgens was strongly
) o4 t0 Q' J2 R8 \0 ?% |% R- ^suspected in a follow-up visit after 4 months because4 z3 A7 ]* ^; {5 Y' X8 H; X4 g- U$ g: \
the physical examination revealed the complete disap-4 r" _" W7 C; Y* N9 u- ~
pearance of pubic hair, normal growth velocity, and
0 r( c/ _+ j& Y1 Mdecreased erections. The father admitted using a testos-4 J* h0 ]7 ~, L
terone gel, which he concealed at first visit. He was
3 P- D3 V% V; n6 U% g1 ~0 z" xusing it rather frequently, twice a day. The Physicians’& R# |7 |& S" D6 Z
Desk Reference, or package insert of this product, gel or( G0 p$ ?5 z H: {9 z7 q
cream, cautions about dermal testosterone transfer to+ A* ]+ q( N8 L- f* { s4 _- v
unprotected females through direct skin exposure.
2 u' E" J8 v+ PSerum testosterone level was found to be 2 times the
9 J$ ?) F" |! ]+ |2 j( m4 y; X5 ^/ xbaseline value in those females who were exposed to; w- T8 Z1 r5 n, a
even 15 minutes of direct skin contact with their male" }: M' m: |! Q" X4 h1 H
partners.6 However, when a shirt covered the applica-
6 l. S5 P3 ^4 {/ P6 Otion site, this testosterone transfer was prevented.8 B2 d0 g7 j' h1 S0 _
Our patient’s testosterone level was 60 ng/mL,' o5 ~* B0 ^; J, R/ Y# ]( a- [
which was clearly high. Some studies suggest that/ o1 x, D: n! K8 s. b
dermal conversion of testosterone to dihydrotestos-" G$ J$ Q) X. i& a7 T% Q
terone, which is a more potent metabolite, is more( ~6 L, c9 {. o$ U! f, i
active in young children exposed to testosterone
9 R8 H% K* h1 N) Gexogenously7; however, we did not measure a dihy-: z8 d4 W) D, E2 e! C m5 e
drotestosterone level in our patient. In addition to
9 k1 d! c& i8 c! I+ ]virilization, exposure to exogenous testosterone in
r5 a* z/ X1 m! s/ H4 x% ^. Echildren results in an increase in growth velocity and8 |4 C& ^- I4 h4 Q
advanced bone age, as seen in our patient.
$ I# P ]" d5 L! X3 `( E3 }The long-term effect of androgen exposure during
4 L, X" d, Q8 q9 A4 searly childhood on pubertal development and final( N/ A) K3 c! o8 e
adult height are not fully known and always remain5 s1 h B% a% H; @9 M
a concern. Children treated with short-term testos-) b) [" D3 u: f, [( Y
terone injection or topical androgen may exhibit some2 v/ _) n4 m4 s
acceleration of the skeletal maturation; however, after2 e5 ]; Z) T" n. j! G+ ?; R/ W
cessation of treatment, the rate of bone maturation$ e: k! T7 E" | T3 m4 |
decelerates and gradually returns to normal.8,9% q) s g1 L a# ]( P6 `! K
There are conflicting reports and controversy$ c; A8 d5 t. J+ @- [' w: y
over the effect of early androgen exposure on adult* Z; `/ i$ E: B" R) Y- f
penile length.10,11 Some reports suggest subnormal$ d# a8 @* D8 @
adult penile length, apparently because of downreg-
/ A1 _3 t& N1 Tulation of androgen receptor number.10,12 However,( m: E! g4 J, X) F0 c& y% p
Sutherland et al13 did not find a correlation between9 B0 F4 `7 h. c1 l+ E& r3 b
childhood testosterone exposure and reduced adult& s2 Q& }" f. B( r
penile length in clinical studies.4 c) L x/ T8 W& N
Nonetheless, we do not believe our patient is
" W0 `8 d) I" {/ F4 C* Pgoing to experience any of the untoward effects from( u1 r( N. l2 I. S
testosterone exposure as mentioned earlier because0 X, P0 }5 l+ I# u0 j: Z
the exposure was not for a prolonged period of time.
2 Q! L& N% N+ d2 l9 \Although the bone age was advanced at the time of0 I! a0 |! H) n+ Y
diagnosis, the child had a normal growth velocity at
/ W" ]' t; j2 _: Z. u7 F; c. Y9 F+ sthe follow-up visit. It is hoped that his final adult7 f: w, L3 ]$ g$ o4 A
height will not be affected.
/ h) {7 r8 ]' A5 GAlthough rarely reported, the widespread avail-2 S. {& n' W; y9 E2 g. A/ s
ability of androgen products in our society may: B% [4 u2 }* {- [
indeed cause more virilization in male or female7 m7 a- P6 b- I# c
children than one would realize. Exposure to andro-
0 c W; Z# c5 y; }3 k/ o3 Ygen products must be considered and specific ques-
6 A6 N; @8 f$ s" ytioning about the use of a testosterone product or
; P: S! y- m" M2 a- x2 F- T1 M) Tgel should be asked of the family members during! l1 a( S% F a/ `5 z$ c% \; i
the evaluation of any children who present with vir-. ^4 i% c4 | j! }
ilization or peripheral precocious puberty. The diag-& P# L4 C, J: ` e$ _7 Y3 u
nosis can be established by just a few tests and by
# t0 c- t; [* u2 c6 ~( E2 gappropriate history. The inability to obtain such a7 e0 D, E- ]; E6 v+ ~
history, or failure to ask the specific questions, may
& R6 r3 Y M8 t0 _; Oresult in extensive, unnecessary, and expensive
9 B. B, `0 c. M) c' g# L5 W4 |investigation. The primary care physician should be& v7 m! C# U2 j1 s/ ]/ N) m2 b
aware of this fact, because most of these children, {8 M3 ?. n$ p, L6 y! F/ y
may initially present in their practice. The Physicians’- Y7 ^( o5 b/ I5 f# p' K9 K
Desk Reference and package insert should also put a' }$ h! m( x! K# Z
warning about the virilizing effect on a male or
% p& c& g4 M6 E" W' C0 d2 Ofemale child who might come in contact with some-
+ T, c) L* ]) D! x# {4 t, f1 d$ A' eone using any of these products.; B: i% ]: Y) B( V4 e
References
2 m( u, c* k4 s) M2 }1. Styne DM. The testes: disorder of sexual differentiation+ k2 J( w0 `9 A8 n/ Q
and puberty in the male. In: Sperling MA, ed. Pediatric
+ p2 H" L N* T5 B/ j: CEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% t- g; S% |1 Z3 ]; s3 ~
2002: 565-628.7 U- N. d9 h" h; m4 m! {# g- Y% R8 m3 ^" F+ y
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 d* w4 {4 i8 K# ^* X4 |3 T8 B
puberty in children with tumours of the suprasellar pineal |
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