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Sexual Precocity in a 16-Month-Old
0 p, g7 P' G- A+ vBoy Induced by Indirect Topical
3 Q8 W7 D/ t9 |7 H- o4 B- WExposure to Testosterone3 q9 b0 r H; ^7 |5 t
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
1 _+ D, {, }) `$ t* Cand Kenneth R. Rettig, MD1: e2 x- a! {) P* T O! N6 L
Clinical Pediatrics5 F2 [/ c* b+ \; `# S
Volume 46 Number 6 E! c% h. @8 J1 M8 ?
July 2007 540-543
3 s4 j5 a, x4 C© 2007 Sage Publications
- _% Q& G3 Q2 f+ U: p! o& r10.1177/0009922806296651
" ~# M0 S6 t {3 Ohttp://clp.sagepub.com2 U& H3 b$ w9 t) B+ ?* f3 ?: m7 u
hosted at% a& Z2 ~' X' D4 V* z8 z8 N5 F/ e
http://online.sagepub.com8 i9 v9 f* D, a4 U
Precocious puberty in boys, central or peripheral,6 ]% y/ Z" k: j7 L, O- S6 h/ |
is a significant concern for physicians. Central" l' k: F! W" G6 @
precocious puberty (CPP), which is mediated
5 ]5 l( k) A- k0 x9 q: tthrough the hypothalamic pituitary gonadal axis, has& {2 E, h* S1 _' A
a higher incidence of organic central nervous system9 t- D, J$ y% C' e# C
lesions in boys.1,2 Virilization in boys, as manifested
$ R$ `4 C1 b4 z, X& d# Rby enlargement of the penis, development of pubic
5 U6 g1 m5 M% W V0 y' a+ {7 a4 _' qhair, and facial acne without enlargement of testi-
4 o* D" N6 G4 V' Mcles, suggests peripheral or pseudopuberty.1-3 We T* \! I7 k( o4 N" v( Q. A
report a 16-month-old boy who presented with the
$ c0 i# C- X4 U) A/ Aenlargement of the phallus and pubic hair develop-
3 @" n6 V( k! \1 g0 t! Rment without testicular enlargement, which was due
' t7 K# \$ e6 O, P5 N3 B- Jto the unintentional exposure to androgen gel used by
" C, W1 f5 _* a+ y# I, @3 p6 Gthe father. The family initially concealed this infor-
( }/ b# h2 |" U1 _$ @+ }mation, resulting in an extensive work-up for this
* U/ `3 i7 j# i- ?9 ^* z% z: S S- gchild. Given the widespread and easy availability of
M4 |8 Q8 q# R Otestosterone gel and cream, we believe this is proba-6 h6 k* A& @7 N) E, K, q
bly more common than the rare case report in the
9 Q, h+ d0 L* m* J* {) a3 lliterature.4
7 D- V) C( j2 n( l' W8 yPatient Report
8 o1 f$ ?" n: r; hA 16-month-old white child was referred to the
7 g3 z3 k% } g! Zendocrine clinic by his pediatrician with the concern" ?1 I% e3 Y2 o: R
of early sexual development. His mother noticed# h* |! F8 E; w1 t$ o9 N+ j5 e
light colored pubic hair development when he was9 V! l* d2 m% n) y! }
From the 1Division of Pediatric Endocrinology, 2University of N% M3 p! ]5 r% L! p7 v1 j+ |4 i
South Alabama Medical Center, Mobile, Alabama.
1 B0 k J; t) E4 X3 n3 D" SAddress correspondence to: Samar K. Bhowmick, MD, FACE,6 |4 r: V7 N9 @$ }0 W
Professor of Pediatrics, University of South Alabama, College of
: x! m3 x5 m1 kMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
4 ]+ ~- k6 K0 ?) s# \e-mail: [email protected].5 }+ a, a# A" ]; l* f. r! {1 X
about 6 to 7 months old, which progressively became
: |% K; U. X: p; a9 \ Qdarker. She was also concerned about the enlarge-: A' C8 W% R: V" e0 l$ z
ment of his penis and frequent erections. The child7 q- M3 u, z! Q' w4 x/ y$ n4 Z
was the product of a full-term normal delivery, with' z6 y2 [' Q g# ?7 h
a birth weight of 7 lb 14 oz, and birth length of* k, k0 `& k* z! r
20 inches. He was breast-fed throughout the first year
0 J, `3 ]3 w$ |of life and was still receiving breast milk along with0 _1 @# Y# u S' Z4 u/ K
solid food. He had no hospitalizations or surgery,
* D3 j$ ?5 A" A4 k) Kand his psychosocial and psychomotor development& M& \- v" U4 Y1 i7 G
was age appropriate.$ j* J- P' T: Z8 ]. \, y3 ~# e
The family history was remarkable for the father, z9 N" u. z( p% f% I
who was diagnosed with hypothyroidism at age 16,4 ^9 Y$ F4 B. [( O3 L& E' m
which was treated with thyroxine. The father’s
7 L9 K0 s6 X1 x' @height was 6 feet, and he went through a somewhat
. w2 v, Q( ?( O5 [ O' learly puberty and had stopped growing by age 14.% n0 ^2 g9 \ C# w, S/ m; A \
The father denied taking any other medication. The* W# n% |; v' `7 R ^
child’s mother was in good health. Her menarche; X, k/ p7 I4 w Z8 R/ W$ r3 O6 k
was at 11 years of age, and her height was at 5 feet
! x9 s9 O- |, X" x! d5 inches. There was no other family history of pre-
# X( O8 F6 T7 Xcocious sexual development in the first-degree rela-
9 A4 X3 z& Z, |2 btives. There were no siblings.
\" M! X2 \6 {3 {0 \3 H, r, WPhysical Examination
1 [# q$ i+ N, J4 U' p2 tThe physical examination revealed a very active,1 F, O5 I: J2 s5 f7 Y
playful, and healthy boy. The vital signs documented9 V4 X3 a5 c+ M. ~+ i- u5 ~" U6 I
a blood pressure of 85/50 mm Hg, his length was& g0 F# C# \7 A1 k/ F4 z! C3 f8 U
90 cm (>97th percentile), and his weight was 14.4 kg
( B" C, h0 ?& T! X1 R2 C* n(also >97th percentile). The observed yearly growth
* K1 T2 Z8 e& C; Cvelocity was 30 cm (12 inches). The examination of ~' S( ~0 y! z. { a
the neck revealed no thyroid enlargement.
& E" i3 Q7 j5 FThe genitourinary examination was remarkable for
/ g$ {6 ?6 V5 h+ D( u* z" k4 |enlargement of the penis, with a stretched length of% }% `$ f; n# o, T- g5 y
8 cm and a width of 2 cm. The glans penis was very well7 k$ b1 O8 Z8 v! K. L
developed. The pubic hair was Tanner II, mostly around' \! p! {2 X/ P& r2 Q5 g7 P }
540# I) n* o& t$ }( ~/ g. y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 ]7 d5 O" G5 U9 X
the base of the phallus and was dark and curled. The
# y" L8 }' G+ P5 ?" {' F: @: \testicular volume was prepubertal at 2 mL each.
' ]7 y! f: Q3 i% i9 HThe skin was moist and smooth and somewhat5 U6 C4 C& c' p/ T. m' N2 G9 S
oily. No axillary hair was noted. There were no
8 F6 m6 {+ o6 ~1 I' b. Xabnormal skin pigmentations or café-au-lait spots.1 p/ Y+ E9 c: {1 u) l
Neurologic evaluation showed deep tendon reflex 2+
( d. l( v' k9 c& Ybilateral and symmetrical. There was no suggestion" R$ a4 d- o+ W# Z& P3 U3 p
of papilledema.( T! c( |* I( W& }: X% m4 x$ }
Laboratory Evaluation9 n! d: Z% |( b1 l
The bone age was consistent with 28 months by8 g3 l- k: \( B" u( p7 n
using the standard of Greulich and Pyle at a chrono-6 H# q3 g& g3 _7 v
logic age of 16 months (advanced).5 Chromosomal q8 u2 M6 `( D
karyotype was 46XY. The thyroid function test
( t. @2 ^& Z/ g$ f' v D0 q9 bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 u# j+ \0 M& @- _lating hormone level was 1.3 µIU/mL (both normal).
( M0 R* P! q& |: S; V8 BThe concentrations of serum electrolytes, blood9 H8 [4 C/ l' v4 ~3 a
urea nitrogen, creatinine, and calcium all were: X. ^) f, N/ B6 |
within normal range for his age. The concentration. w- c+ L4 w$ K1 C5 u
of serum 17-hydroxyprogesterone was 16 ng/dL
& H* j" r Q! D0 `9 o% y# z# h9 f(normal, 3 to 90 ng/dL), androstenedione was 20 u$ G" j; K- R5 V v
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* |+ W8 _! u2 Y/ I e p: s
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
. V( t! z+ H- r. @6 y. L1 A& pdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ D8 }8 `: e1 Z2 T; {3 ?5 \49ng/dL), 11-desoxycortisol (specific compound S)& L! k6 |9 q2 |+ V% z' S# C8 Q
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& m$ V9 r" z6 N- d/ J& U- P: otisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
1 r7 K+ F! d4 v6 atestosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 }6 q2 F( @! M1 V8 A
and β-human chorionic gonadotropin was less than" V; Y6 j" c2 X( N
5 mIU/mL (normal <5 mIU/mL). Serum follicular ?6 A0 U! [- K! p3 w
stimulating hormone and leuteinizing hormone
2 c% M% H% G7 O e0 Vconcentrations were less than 0.05 mIU/mL+ \- }4 g5 a. u& P. ^( J
(prepubertal).
# I: d) x: Z: nThe parents were notified about the laboratory0 m* i' z9 @) m D: R% s
results and were informed that all of the tests were& Q8 I( I, ~# d& `
normal except the testosterone level was high. The
" t) A t# R% ~: W+ K" `follow-up visit was arranged within a few weeks to& `! |4 @5 e H4 Q1 ], f5 W' m
obtain testicular and abdominal sonograms; how-
9 j. f( ?, c6 b H6 `0 g: J; yever, the family did not return for 4 months., V3 t# \+ W3 x& G/ P3 ]. A/ V6 O
Physical examination at this time revealed that the
( q) q: T" C+ K& U- Q+ R @& ?- zchild had grown 2.5 cm in 4 months and had gained
2 b* V! _8 n3 I6 Y, L4 `7 Q2 kg of weight. Physical examination remained1 X* X- `( N/ I2 {* i
unchanged. Surprisingly, the pubic hair almost com-
+ D& L( Y$ X( [6 Ypletely disappeared except for a few vellous hairs at6 Y& l2 q* S! a5 R- j( F% c- V
the base of the phallus. Testicular volume was still 2
8 W5 b2 k, Y; y8 x6 x* }mL, and the size of the penis remained unchanged." k: @$ L( e( k i4 k! v& a
The mother also said that the boy was no longer hav-: u1 c, Q3 u+ S! |1 Q
ing frequent erections.. O ?( q0 I6 ~% u, {2 _
Both parents were again questioned about use of
6 S3 v# e! e: R1 ^+ aany ointment/creams that they may have applied to
: H- X' m: y _& ?' ?the child’s skin. This time the father admitted the
' p1 m5 f5 g0 {) n r6 i+ wTopical Testosterone Exposure / Bhowmick et al 541% a! r. [7 r: I& ~4 @
use of testosterone gel twice daily that he was apply-
2 X1 i1 G& o e9 ~: F1 hing over his own shoulders, chest, and back area for1 r$ ^- y5 J5 e% h( b
a year. The father also revealed he was embarrassed8 g2 j/ y8 \) Y: ?
to disclose that he was using a testosterone gel pre-
0 l G4 o* X+ v4 oscribed by his family physician for decreased libido
( z- {% E0 k. ]; ?secondary to depression.
9 R6 Q% p o7 m! y1 [0 j6 n) pThe child slept in the same bed with parents.5 \, R K: m1 i! b2 v; a- U
The father would hug the baby and hold him on his
; E) o: h" D/ e7 g& T* q5 Rchest for a considerable period of time, causing sig-7 a' d, x1 ], [) B G' O
nificant bare skin contact between baby and father.# e6 c4 I, |/ r
The father also admitted that after the phone call,# J- u7 L; H/ _! U3 ?
when he learned the testosterone level in the baby
, L7 w6 C! i' U6 e9 O# I+ rwas high, he then read the product information" x: |2 Q# I1 ]# R! Q
packet and concluded that it was most likely the rea-
, R7 h. b* ~6 a/ Bson for the child’s virilization. At that time, they
2 N# p+ ^3 }/ R8 \1 |0 a/ \, X! T1 xdecided to put the baby in a separate bed, and the
& b: j+ K( A" X% sfather was not hugging him with bare skin and had
2 a3 T, L4 v! q. Tbeen using protective clothing. A repeat testosterone
' Y* V. `" c# T1 N9 g1 d8 Y1 {test was ordered, but the family did not go to the/ ~- n4 K' ~. O2 i/ y8 i7 T
laboratory to obtain the test.
* D+ P: n5 A. @/ M8 a5 PDiscussion# C3 M6 h' [3 ?! F' H3 R
Precocious puberty in boys is defined as secondary2 h* Q/ D8 B2 y
sexual development before 9 years of age.1,4# B6 b. U' @% M0 }
Precocious puberty is termed as central (true) when
2 G" K) Q: R* K# U+ d& G Eit is caused by the premature activation of hypo-
( o( H6 F' B- u' l/ u7 _( `thalamic pituitary gonadal axis. CPP is more com-9 ?6 ~& X3 R" W ~7 E& Y
mon in girls than in boys.1,3 Most boys with CPP
' }) R1 b0 X4 b9 V dmay have a central nervous system lesion that is# ~+ l, H# k$ [9 B
responsible for the early activation of the hypothal-
8 N( |" c k9 ^7 A- o' \" d& ^% namic pituitary gonadal axis.1-3 Thus, greater empha- V- B! p% `0 ^: z
sis has been given to neuroradiologic imaging in
9 V4 P: j) _ n! z# fboys with precocious puberty. In addition to viril-
. F$ g# R! k" p) o Q) Y# ^! R8 Q o; L7 Dization, the clinical hallmark of CPP is the symmet-
! V# u$ O9 L9 M5 H7 J6 N' |, c8 ^rical testicular growth secondary to stimulation by
4 ~: X! w, H- [6 ^; ^/ d* Y5 kgonadotropins.1,3. t/ n3 S7 R0 B' w" t
Gonadotropin-independent peripheral preco-* ?4 T. e! u* Q3 ^( s; O
cious puberty in boys also results from inappropriate7 m$ P1 P. S6 {
androgenic stimulation from either endogenous or. l6 y A3 ^% R" ^6 N1 e8 F+ n& n
exogenous sources, nonpituitary gonadotropin stim-
4 X+ \- \+ J+ p/ f K! \- kulation, and rare activating mutations.3 Virilizing
% G5 x; ]7 @7 G& Y! rcongenital adrenal hyperplasia producing excessive. l4 n2 @) u" h) M* l% N7 F
adrenal androgens is a common cause of precocious
+ x3 T4 `. }8 M2 O/ |" Mpuberty in boys.3,4
4 G. Z* n# H( u- I; x9 }0 KThe most common form of congenital adrenal6 q4 P T O- Q8 B* ~% q( t
hyperplasia is the 21-hydroxylase enzyme deficiency.
3 F% o/ r5 m0 S( b/ ^8 JThe 11-β hydroxylase deficiency may also result in
5 M0 r9 F. m6 a. g: {0 Jexcessive adrenal androgen production, and rarely,% H( r& D& a- a3 C: T1 {0 M
an adrenal tumor may also cause adrenal androgen/ s( n( U/ A" ]2 ]! L
excess.1,34 g6 N2 \- Z2 d
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 Y; q7 n# b# `$ x! R
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 I0 o* V; f5 Y' }- cA unique entity of male-limited gonadotropin- _1 G/ A" s a e
independent precocious puberty, which is also known8 d+ N- z% H1 ]8 ^: o
as testotoxicosis, may cause precocious puberty at a
3 N ~, ~- F2 L* d* F+ xvery young age. The physical findings in these boys0 {+ L8 C# Z. Y, z' {
with this disorder are full pubertal development,; B) P) L. s/ V; e
including bilateral testicular growth, similar to boys
# G2 ?; S. I1 P0 T6 {- Zwith CPP. The gonadotropin levels in this disorder0 Q3 s0 m# ^. J7 f9 H! _0 a- K
are suppressed to prepubertal levels and do not show
n8 E, t+ Z" o. h5 epubertal response of gonadotropin after gonadotropin-. h$ n8 T: b; u3 y- ^& Q5 l
releasing hormone stimulation. This is a sex-linked- g0 b3 H) V/ t' ?" v) \
autosomal dominant disorder that affects only
9 }/ I( g7 q b# \+ y3 W0 Rmales; therefore, other male members of the family% b; j* o9 y( r; Z8 W+ b% g
may have similar precocious puberty.3
( G' M6 Y8 _( B2 V6 ^3 EIn our patient, physical examination was incon-( T& e% J+ W* W& i$ x& Q. m; Z" q
sistent with true precocious puberty since his testi-/ `& {; J2 r2 a5 l; b, f
cles were prepubertal in size. However, testotoxicosis
1 h0 J% Y. V. pwas in the differential diagnosis because his father: q* b% D: l7 f# ~" m) h
started puberty somewhat early, and occasionally,) P8 B, m8 f5 P& `( d: k2 m
testicular enlargement is not that evident in the
" p& p% \ x7 Z# p( S, xbeginning of this process.1 In the absence of a neg-: d( {/ c* S, I# J
ative initial history of androgen exposure, our) y$ H* y$ z x
biggest concern was virilizing adrenal hyperplasia,' s" X, t# j4 s/ a3 K3 Y7 o
either 21-hydroxylase deficiency or 11-β hydroxylase% s9 G, R2 u" Y/ g4 L: a/ l
deficiency. Those diagnoses were excluded by find-+ c* G# s, r6 j
ing the normal level of adrenal steroids.1 o8 Y, {" S( i) ~ U" I' J6 |
The diagnosis of exogenous androgens was strongly
) V, B9 o! v( W) [7 hsuspected in a follow-up visit after 4 months because
3 g4 T- ]2 c5 O! }9 Mthe physical examination revealed the complete disap-
% r3 `" H' H9 r% [6 Epearance of pubic hair, normal growth velocity, and; ~$ s% d0 o1 W
decreased erections. The father admitted using a testos-6 @9 L9 D* X& R7 t9 b
terone gel, which he concealed at first visit. He was. y0 T4 O5 K, e! ], r" X& G Z
using it rather frequently, twice a day. The Physicians’1 t/ T" v) k9 `+ v) v- g7 L6 g
Desk Reference, or package insert of this product, gel or
* z/ n& C, z5 }- |cream, cautions about dermal testosterone transfer to0 L8 l1 J0 W( [6 i
unprotected females through direct skin exposure.
{. N" { ~2 s' b* E' B/ T& j, BSerum testosterone level was found to be 2 times the
0 Z( @) u3 S8 C3 b. W: ebaseline value in those females who were exposed to, o- a, z- _' F* q$ t
even 15 minutes of direct skin contact with their male9 s: _1 Q1 u+ c$ `* j% c& M$ Y: L# A/ P
partners.6 However, when a shirt covered the applica-5 R$ g" [) b6 s f$ b
tion site, this testosterone transfer was prevented.. p% f0 Z" g) r" ~* e' i
Our patient’s testosterone level was 60 ng/mL,! o4 m E, A& T! W1 s0 ^# {
which was clearly high. Some studies suggest that
6 x( G2 @! o# n+ U6 l% N! ~dermal conversion of testosterone to dihydrotestos-
1 K8 y6 \0 v1 E% ^terone, which is a more potent metabolite, is more
& m1 J9 X. J5 O; dactive in young children exposed to testosterone
( I0 L+ r/ M4 T% B; ~exogenously7; however, we did not measure a dihy-
3 n: y, M5 O6 n; u; qdrotestosterone level in our patient. In addition to
9 c* g9 B) R. i2 H5 _virilization, exposure to exogenous testosterone in
+ O- w1 V) {: G. Lchildren results in an increase in growth velocity and& E1 W+ ^9 p' g3 ^
advanced bone age, as seen in our patient.! y. ^- [2 X/ p$ i2 T% ^& G9 H" n
The long-term effect of androgen exposure during
" u' |6 z/ u R1 i$ X! tearly childhood on pubertal development and final" O2 `. H, ]0 l1 ~8 ~. m3 v; b, k
adult height are not fully known and always remain5 j' d3 n; ?( k( d" u; D
a concern. Children treated with short-term testos-
) i! b+ D# V$ }2 x; K3 Eterone injection or topical androgen may exhibit some
. } o' ]7 V' E% l" dacceleration of the skeletal maturation; however, after+ J. b; `) I7 t% Y
cessation of treatment, the rate of bone maturation6 c, g7 g4 L1 k' _5 f% p) `2 _
decelerates and gradually returns to normal.8,9
; G: H! m! E+ _1 |There are conflicting reports and controversy
5 C% @2 a( e' kover the effect of early androgen exposure on adult
, c! x( b! ^( H) L' R; l0 wpenile length.10,11 Some reports suggest subnormal7 g* h( ^2 V$ | C, h! j
adult penile length, apparently because of downreg-
# e5 x8 Y. A& O; |% w$ F8 Q2 Gulation of androgen receptor number.10,12 However,
3 p- r$ @7 A# l( [) c4 j: HSutherland et al13 did not find a correlation between. f0 N/ O" w; Q4 ~8 J. r) X
childhood testosterone exposure and reduced adult. A8 G! \7 E& C8 }* U( a
penile length in clinical studies.( x6 e) ?$ x4 o" |" Z. H5 L
Nonetheless, we do not believe our patient is- r& ]3 ~! ?' @ u5 ]+ z
going to experience any of the untoward effects from4 c4 N! X% r4 z S7 i7 d: h8 Z8 l
testosterone exposure as mentioned earlier because$ o" C. u5 T1 ^4 F" p
the exposure was not for a prolonged period of time.
" c3 @# U! j- i" q- e3 l& {9 KAlthough the bone age was advanced at the time of
( V- h8 X6 R& x% w! ^* ^( u" Z* Zdiagnosis, the child had a normal growth velocity at4 A: U. t9 N1 q5 N, _+ p* l% E
the follow-up visit. It is hoped that his final adult, @: d& C0 }9 g4 S' g! r
height will not be affected.
a: I8 f) f$ F3 K# }8 ^Although rarely reported, the widespread avail-
8 U9 T. @& l$ ]# n8 ?" hability of androgen products in our society may
& Y9 r* g' L3 \8 m8 A- {' uindeed cause more virilization in male or female
1 v% w, N4 k& X- a% `, _children than one would realize. Exposure to andro-, B( R1 _# K3 p3 r
gen products must be considered and specific ques-
) p I$ t: v- l( Y7 L: F" _tioning about the use of a testosterone product or4 f' G% e Z e* C. f4 m5 {; e
gel should be asked of the family members during& h' b* z1 n: ~3 |, a
the evaluation of any children who present with vir-
* _" t$ u9 b+ l7 @+ pilization or peripheral precocious puberty. The diag-
9 i2 P& Y7 q7 m, K& R4 c* Wnosis can be established by just a few tests and by
H; I) J4 X* m" k' _) iappropriate history. The inability to obtain such a7 R0 t8 A' P) N7 z& o
history, or failure to ask the specific questions, may
) g1 q! }- l; A5 o+ y6 @result in extensive, unnecessary, and expensive6 x7 t/ |5 |. h X: n
investigation. The primary care physician should be
2 [! G% k9 U( }1 y5 xaware of this fact, because most of these children! v' e+ i3 k+ |1 U5 Z( y* U
may initially present in their practice. The Physicians’
+ F& I1 [4 `; G2 V% uDesk Reference and package insert should also put a1 [9 A9 }5 _2 [7 ]
warning about the virilizing effect on a male or- B$ I3 v" t: e! m! \1 C: U
female child who might come in contact with some-! O' @9 [5 f. s1 k9 j$ p3 ]
one using any of these products.
5 t: g: k8 S Q8 oReferences) |0 T" Y1 _6 Z& x- j
1. Styne DM. The testes: disorder of sexual differentiation
1 I& U+ |% V. Z' R3 X+ pand puberty in the male. In: Sperling MA, ed. Pediatric+ N3 O& G' E' a j6 U
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;- o I) p, e- Q4 y$ T/ I1 A2 ?
2002: 565-628.8 j8 ^+ b6 V7 ^# K
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- `( P# J3 Y4 W: }' e) Fpuberty in children with tumours of the suprasellar pineal |
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