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Sexual Precocity in a 16-Month-Old
4 J& C: }* L: b( IBoy Induced by Indirect Topical
Y+ l% N4 y+ MExposure to Testosterone
% W* f2 t4 f- s7 v) D& i$ ~Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 ~5 y9 f2 F7 V7 x" fand Kenneth R. Rettig, MD1& d9 E- I/ O0 [# I- _
Clinical Pediatrics& B, ^6 B8 i/ s3 a* m8 {, _$ N2 _- u
Volume 46 Number 6& @. m4 Y6 U) L, i6 b8 U
July 2007 540-543
3 k% l/ B& {# l9 a6 t6 I0 ~© 2007 Sage Publications
. F9 O+ f, a( Z8 W1 `10.1177/00099228062966510 q" R) C7 \; c8 [3 G
http://clp.sagepub.com
# H% u: j x R- P8 Z' a. Shosted at9 g, W+ a4 O% n3 q
http://online.sagepub.com
, H( g% D" N2 L! J0 p! | RPrecocious puberty in boys, central or peripheral,
7 I3 y( X( n% _% Z$ \3 G( ?" \6 tis a significant concern for physicians. Central
3 M, H8 ?/ [* Bprecocious puberty (CPP), which is mediated! {. N( ] X8 I
through the hypothalamic pituitary gonadal axis, has& _; ]) h/ G7 b2 w( u
a higher incidence of organic central nervous system+ J9 U2 ~& ]- X$ T' H
lesions in boys.1,2 Virilization in boys, as manifested0 `) O, n! E8 T# R" m& P. m- W
by enlargement of the penis, development of pubic: z3 s. r* P# v: {$ m9 I2 h+ e% @
hair, and facial acne without enlargement of testi-2 w/ A- x0 U4 l. q7 Y) l6 w
cles, suggests peripheral or pseudopuberty.1-3 We
5 _" A' c9 w& W* J( freport a 16-month-old boy who presented with the
* d' k1 S, e- h; s8 {+ `. Lenlargement of the phallus and pubic hair develop-
H8 L" z; t( D/ G# P" ament without testicular enlargement, which was due2 B# |. q# m1 `8 D* B0 e! v
to the unintentional exposure to androgen gel used by
% h, `! p& U0 b d; zthe father. The family initially concealed this infor-- p* N' |! \- G/ c' r
mation, resulting in an extensive work-up for this
" h" u5 T+ h9 c3 B! i0 S4 e7 O$ tchild. Given the widespread and easy availability of
/ y# q9 ?# l/ X5 g9 ?4 j8 b1 ~testosterone gel and cream, we believe this is proba-( ]1 M& M, y& P+ @
bly more common than the rare case report in the. i5 d3 `1 u! Q* c: D
literature.4
3 y2 [& K( S2 u9 z6 B3 OPatient Report
9 ]9 Q& } d6 a+ z( s6 F) Z1 T5 ^A 16-month-old white child was referred to the
. k/ z- Y; E$ y% ]* D' {endocrine clinic by his pediatrician with the concern
4 r' W4 F) d# o9 n2 I# pof early sexual development. His mother noticed
; s; [1 d! E: X( {light colored pubic hair development when he was( y! k$ }5 B8 v- a3 f
From the 1Division of Pediatric Endocrinology, 2University of
% P8 T0 d3 ], j* n) |South Alabama Medical Center, Mobile, Alabama.
) k" |8 o0 O0 q$ }$ P2 Z6 ?" yAddress correspondence to: Samar K. Bhowmick, MD, FACE,
# _2 X! u# a$ C8 P# HProfessor of Pediatrics, University of South Alabama, College of, }- u5 X1 x* m) ~3 U* y; {8 h
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
b7 l# j) @3 y* X+ }; c3 `e-mail: [email protected].0 X. O% W3 }2 p2 @6 L
about 6 to 7 months old, which progressively became6 H/ F$ K& w! O$ u- J
darker. She was also concerned about the enlarge-0 B! s; R5 z4 q" p/ _: p& ?- m
ment of his penis and frequent erections. The child% |4 h, G$ ^: P; V
was the product of a full-term normal delivery, with
1 n) K3 A& g( C5 d$ P) @: v, H4 H1 Ya birth weight of 7 lb 14 oz, and birth length of/ G9 v+ ]# w, V" B9 I3 s! T( \
20 inches. He was breast-fed throughout the first year
, P8 R- q2 I6 gof life and was still receiving breast milk along with
7 C8 [) i" l5 {solid food. He had no hospitalizations or surgery,5 w A+ Q" n- H8 \( k
and his psychosocial and psychomotor development
8 M. G; ^6 x* v; ^, ~was age appropriate.6 _3 L/ G! W% w6 R; i6 i
The family history was remarkable for the father,
* C' ]+ j8 b) swho was diagnosed with hypothyroidism at age 16,
4 ]- {+ l, p7 I+ s% M7 ?% O' {which was treated with thyroxine. The father’s& c- G$ z, M$ v5 @2 u) w% c
height was 6 feet, and he went through a somewhat" i, B& Y. O2 ^) _5 u* u9 u8 H
early puberty and had stopped growing by age 14.* f+ j# P( N4 N6 O( o; ^
The father denied taking any other medication. The, I H- j# M5 s# _9 D
child’s mother was in good health. Her menarche
* m# a3 N! }8 l2 ]was at 11 years of age, and her height was at 5 feet8 U. ^0 s1 v. D8 g% N6 Q
5 inches. There was no other family history of pre-4 ~" e! f* V1 c2 L2 q9 F
cocious sexual development in the first-degree rela-
+ T. B% v4 x' _! X* d( I0 J+ \4 Gtives. There were no siblings.
2 P: \" W( N6 S; L% ^Physical Examination$ m: {0 {0 i2 z8 i
The physical examination revealed a very active,! \# h5 X4 [ i; B& Y
playful, and healthy boy. The vital signs documented- Y4 _' ^. |" d y/ ^+ N
a blood pressure of 85/50 mm Hg, his length was$ ]8 j: L& r6 h* U( k
90 cm (>97th percentile), and his weight was 14.4 kg
" Z. c6 |1 [2 Q6 o5 [(also >97th percentile). The observed yearly growth
6 ]7 ~/ m) Y7 jvelocity was 30 cm (12 inches). The examination of& n9 o) q2 F; _9 `
the neck revealed no thyroid enlargement.
. ~7 T8 J7 K. {, F4 FThe genitourinary examination was remarkable for
% G) o9 Y) o- Z3 ?" \! N9 t5 k9 |" henlargement of the penis, with a stretched length of
: o7 V; n% w0 E2 A5 R- ?8 O8 cm and a width of 2 cm. The glans penis was very well! j+ @) U" ], m: m) \0 p
developed. The pubic hair was Tanner II, mostly around6 o0 p9 f$ s, V7 \$ d R( G
540/ E2 ^) h1 w5 c8 [3 r% A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: Y) n& j. q. B$ R: l! `the base of the phallus and was dark and curled. The: W( R9 U4 H2 ?* ?. X5 U1 ]
testicular volume was prepubertal at 2 mL each.1 H/ S( ^, m# e
The skin was moist and smooth and somewhat
! M% H; o' N2 \$ D1 I# n+ Woily. No axillary hair was noted. There were no/ A! k6 B8 j: g: F
abnormal skin pigmentations or café-au-lait spots.! g+ _' |! m# M4 n/ l: z. B( S
Neurologic evaluation showed deep tendon reflex 2+
7 |6 X. x" |8 d! a: u. w( J& @bilateral and symmetrical. There was no suggestion$ M- [' U( t' Y% N f* ]0 h3 N
of papilledema. o" y/ N3 u( W; h3 O, s
Laboratory Evaluation
l( E" h. s( J) m1 {The bone age was consistent with 28 months by
L. G' G% k/ |using the standard of Greulich and Pyle at a chrono-
! G! b- L8 x3 Z+ ]3 _+ H, l+ `' |logic age of 16 months (advanced).5 Chromosomal
4 G1 w9 X. L+ F: e6 T) W: Wkaryotype was 46XY. The thyroid function test9 V$ b& M. b* B% N0 j6 C1 j4 J
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 t8 h& w& J: V& @lating hormone level was 1.3 µIU/mL (both normal).. W, r( Q4 n2 z9 Y8 Q
The concentrations of serum electrolytes, blood
/ D- e7 S+ h. `9 f: Yurea nitrogen, creatinine, and calcium all were6 Y( I6 Q0 |7 _ R6 r
within normal range for his age. The concentration: c/ z& J( Q' B' J2 ~1 Y
of serum 17-hydroxyprogesterone was 16 ng/dL7 O4 {; U& s+ q! |6 [
(normal, 3 to 90 ng/dL), androstenedione was 20, u; R0 L* f+ \0 ~
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-" ^# h+ p1 j5 c p8 ~
terone was 38 ng/dL (normal, 50 to 760 ng/dL),* }" a+ ?* D/ D, n
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
3 T+ i8 A$ w$ Z49ng/dL), 11-desoxycortisol (specific compound S)& D @+ b& Z n3 o
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
& [' p1 D2 @5 b5 P$ Otisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 S8 U% D# ^7 d3 a, B! [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ G6 z3 t" J( S5 [and β-human chorionic gonadotropin was less than( u- F" y. \. W" b
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 O- A/ U* E1 D
stimulating hormone and leuteinizing hormone
$ o) v8 g1 t3 @; M4 t" `concentrations were less than 0.05 mIU/mL
0 q: n5 O! W0 i5 p, R2 ]0 R(prepubertal).
! f8 m, }2 i2 U! WThe parents were notified about the laboratory
. _* s$ p# \) tresults and were informed that all of the tests were3 O8 m# i2 v% G) k* V
normal except the testosterone level was high. The' o7 ~0 h8 l$ W) v3 ^" N" t
follow-up visit was arranged within a few weeks to
4 g% Q& {1 K3 P+ z: X0 ~obtain testicular and abdominal sonograms; how-
, |1 l! ?4 U4 ^9 M" [6 H% Q6 dever, the family did not return for 4 months.8 _% E- t8 X) N& J$ k# j
Physical examination at this time revealed that the1 `0 M) i. a& {, S( {6 Z
child had grown 2.5 cm in 4 months and had gained
$ b( d8 q; k+ u# b: u8 E# [4 J2 kg of weight. Physical examination remained1 {' `7 R! e7 l3 ^8 T& J7 f
unchanged. Surprisingly, the pubic hair almost com-
1 P5 `" p' y4 c g+ tpletely disappeared except for a few vellous hairs at
8 V7 w& n+ d. J) m; `! C4 m0 Fthe base of the phallus. Testicular volume was still 28 `" T' X" Y+ D( U: Z, C
mL, and the size of the penis remained unchanged.
( l! x! I, w1 M$ m$ @" F8 J+ C0 wThe mother also said that the boy was no longer hav-
# O, E" _" m" x9 t a- A: eing frequent erections.8 d$ V( d, T: U* r- P9 P% l8 _2 v% m
Both parents were again questioned about use of" D3 l% [6 [/ n. n: u& A% o: U
any ointment/creams that they may have applied to
2 _" p2 d+ O8 ?! G; Z; T0 J: othe child’s skin. This time the father admitted the
" Z2 c& o9 L; v) UTopical Testosterone Exposure / Bhowmick et al 541
8 u$ w1 l( O$ v! buse of testosterone gel twice daily that he was apply-/ k! [+ _, j" p u
ing over his own shoulders, chest, and back area for
* R4 @/ H9 C( z* _7 @a year. The father also revealed he was embarrassed- T! {+ F$ ?8 N9 N3 L V% Z" ]
to disclose that he was using a testosterone gel pre-/ Y: v, I" W0 X$ v/ B _9 E( H F/ V
scribed by his family physician for decreased libido/ v; {! T( k ^' g% d8 y$ J
secondary to depression.
0 ?& |; }1 J& J+ q1 M' X9 {* ~1 ^" V, wThe child slept in the same bed with parents.* J1 ?! Y, m" V
The father would hug the baby and hold him on his
! g- Q4 k3 _& h- jchest for a considerable period of time, causing sig-
9 k$ D6 x+ n2 p4 T# @nificant bare skin contact between baby and father./ |2 L$ L) S3 @
The father also admitted that after the phone call,
/ M( g$ L. p$ r/ m5 E j5 Wwhen he learned the testosterone level in the baby
) F/ s0 v+ m3 o& g; B Y: X, x0 m7 wwas high, he then read the product information' \( O8 y; [( D' n9 b: w# T! U
packet and concluded that it was most likely the rea-
; `3 f: J! p7 L# e! `son for the child’s virilization. At that time, they' v0 ?' l1 g: b2 D# r: N- F
decided to put the baby in a separate bed, and the# f( Y0 o7 ^- Y: e9 y
father was not hugging him with bare skin and had
) V6 n# I5 G% V7 tbeen using protective clothing. A repeat testosterone
+ C: s$ y7 I9 vtest was ordered, but the family did not go to the; T1 s# a1 @/ w% j8 w
laboratory to obtain the test.3 W1 [9 h! f" W2 M% R( y8 ~3 u
Discussion
' O' e% F( r" ^5 q" i9 I0 ~; G5 SPrecocious puberty in boys is defined as secondary# x! i) b0 X4 C+ @2 d6 z
sexual development before 9 years of age.1,4" G/ v2 f* t3 \' r
Precocious puberty is termed as central (true) when
! ~" p1 X/ Y$ h: |! Z% Y0 \' n+ Hit is caused by the premature activation of hypo-
4 W, c7 L9 ]% U* H: ~( L$ zthalamic pituitary gonadal axis. CPP is more com-
U% b" g/ P% M- ]mon in girls than in boys.1,3 Most boys with CPP
P$ p1 c, m z" h3 gmay have a central nervous system lesion that is" G- k' r. j3 d* s
responsible for the early activation of the hypothal-
9 L) U6 u& A* t% ?. b3 `amic pituitary gonadal axis.1-3 Thus, greater empha-
7 { _4 l" e4 j7 Y3 ~sis has been given to neuroradiologic imaging in
: _ V0 f0 a+ ^. }* Lboys with precocious puberty. In addition to viril-
" m# p% t- F: n6 d' T/ P2 j& A6 N1 jization, the clinical hallmark of CPP is the symmet-0 @4 ~3 G% [9 v1 g) _8 `2 T
rical testicular growth secondary to stimulation by$ u: E8 x: c) z+ c
gonadotropins.1,3
$ m# a( I$ V7 ^' MGonadotropin-independent peripheral preco-
. D I5 C- M$ h( y# a8 }7 m$ D* j7 Ncious puberty in boys also results from inappropriate( Z M& r3 Z: U" a
androgenic stimulation from either endogenous or: K5 J @$ `& W8 ?4 e
exogenous sources, nonpituitary gonadotropin stim-
, d) h# E( H7 r% k, Rulation, and rare activating mutations.3 Virilizing
: N* V/ J% i3 S0 T2 Ccongenital adrenal hyperplasia producing excessive
, U7 f9 K; K4 Xadrenal androgens is a common cause of precocious
t* k; N X( J, Z/ Wpuberty in boys.3,46 p4 [& F5 N, T1 m) S
The most common form of congenital adrenal1 [: ?4 b8 @3 E* k1 D# J4 A4 W
hyperplasia is the 21-hydroxylase enzyme deficiency.; p3 D6 k8 _8 p1 k
The 11-β hydroxylase deficiency may also result in
% R( i7 d5 _, Q" zexcessive adrenal androgen production, and rarely,8 ~" C/ p- E; b' x1 c9 b+ `
an adrenal tumor may also cause adrenal androgen1 P% H/ e% h ^$ K' r
excess.1,3
J2 @- _* u$ N0 @" P0 Q8 p+ Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: E+ a' r! I' K. x9 Q8 V- o( Q
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007$ Z6 \0 ?0 E, _& [
A unique entity of male-limited gonadotropin-
9 j) E9 |1 ?& M* Z" X0 S9 Pindependent precocious puberty, which is also known1 F4 Y A' [/ B. b
as testotoxicosis, may cause precocious puberty at a
( [# u! D4 J: ?) o4 w2 |very young age. The physical findings in these boys
/ l/ }" H4 `! p' ]. c f: Bwith this disorder are full pubertal development,/ R' z3 `4 x8 k8 k8 j% b9 X2 b" _
including bilateral testicular growth, similar to boys1 e! r$ m; V/ S5 j8 L$ W
with CPP. The gonadotropin levels in this disorder, u+ u0 l/ d2 k& \
are suppressed to prepubertal levels and do not show
5 V( ?5 c2 _+ T( l8 ]pubertal response of gonadotropin after gonadotropin-
8 w/ @# e5 ?# h1 s: Zreleasing hormone stimulation. This is a sex-linked
% s' l6 e8 b- N+ r8 ]& U" q& dautosomal dominant disorder that affects only# D4 \8 v$ v4 ^; G% ~3 [
males; therefore, other male members of the family
& J7 k f( l% y5 \may have similar precocious puberty.3, }- ?$ o7 H z
In our patient, physical examination was incon-4 _! G! g9 w. n' N
sistent with true precocious puberty since his testi- b% s) _. |9 y
cles were prepubertal in size. However, testotoxicosis/ g, S0 }9 {; ]5 _3 J0 r
was in the differential diagnosis because his father" M$ G5 Z$ g/ Y2 K
started puberty somewhat early, and occasionally,
* o3 ~9 q- J4 m% C: t2 B" K" Htesticular enlargement is not that evident in the
- t! }% j6 ~9 m" _beginning of this process.1 In the absence of a neg-' l0 N+ j( r& w, v/ n8 E
ative initial history of androgen exposure, our, w$ t; m6 O& I, l+ ~+ i# f0 B
biggest concern was virilizing adrenal hyperplasia,
8 @4 r# o: C9 O% H/ geither 21-hydroxylase deficiency or 11-β hydroxylase: g* ^4 u) W' g: q
deficiency. Those diagnoses were excluded by find-
! B Y/ M3 x6 F2 K9 E0 J) king the normal level of adrenal steroids.9 L2 z( E0 p1 o, Q! |1 ]+ ~1 }
The diagnosis of exogenous androgens was strongly
7 C1 O: ]% }9 M7 h' asuspected in a follow-up visit after 4 months because& G: \8 B1 f, {* ^ L: _( L* S
the physical examination revealed the complete disap-
9 z; i/ V {$ G' t7 o; n, ^+ mpearance of pubic hair, normal growth velocity, and! z1 _& ]' C) P& i, S! W6 I5 _
decreased erections. The father admitted using a testos-
7 w1 u; E9 z( t! b& t! P: }% Uterone gel, which he concealed at first visit. He was
; v3 K% m/ l5 G/ \5 l. m5 o Nusing it rather frequently, twice a day. The Physicians’
; I5 v$ @* }+ RDesk Reference, or package insert of this product, gel or/ s' ~& m! @6 D9 v. u' I
cream, cautions about dermal testosterone transfer to& w2 }2 O3 X" F2 k
unprotected females through direct skin exposure.
8 `& _. O; C9 f( KSerum testosterone level was found to be 2 times the# v: a% o- W4 j: `: ?. G
baseline value in those females who were exposed to' _5 x$ e) n& p7 `) N K
even 15 minutes of direct skin contact with their male: W/ r8 V& t* ^9 l! f7 |% t
partners.6 However, when a shirt covered the applica-
4 Y9 p$ C4 |5 {tion site, this testosterone transfer was prevented.5 F. h6 S1 Q) m2 l- I
Our patient’s testosterone level was 60 ng/mL, i/ b% N- Q; o
which was clearly high. Some studies suggest that% w0 y( q( L% q+ I) Y: g" Z Y
dermal conversion of testosterone to dihydrotestos-' | o1 B% |8 l4 V8 N* ~% A' d
terone, which is a more potent metabolite, is more7 i0 F9 c( }" ~" m* ^" V& n; \
active in young children exposed to testosterone
7 a+ ?! D4 l$ t5 \& o2 I, Mexogenously7; however, we did not measure a dihy-
" t$ e) y0 q: f/ Gdrotestosterone level in our patient. In addition to
7 b0 l# b- R5 [7 z6 R2 @. T" f3 h) ]virilization, exposure to exogenous testosterone in
9 Y& O. p/ N5 B! f9 I% ?children results in an increase in growth velocity and
# Y1 e+ f5 a% V+ T7 ~advanced bone age, as seen in our patient.. j5 }0 k/ U$ I+ `' T5 t$ [- I
The long-term effect of androgen exposure during
# c" c+ ] Z' h5 R! w0 U$ }early childhood on pubertal development and final! [5 E7 P2 l4 z$ _" c2 O
adult height are not fully known and always remain! j# V' a4 o* a6 I7 q# W/ F
a concern. Children treated with short-term testos-: N S& i! B1 B5 m; C$ l* v6 R' ~
terone injection or topical androgen may exhibit some# M$ D0 x; H& |1 k0 O9 N0 D
acceleration of the skeletal maturation; however, after# ?7 {2 ?+ N# }2 T
cessation of treatment, the rate of bone maturation& j; H9 h v5 [! F1 \, ]. C5 A
decelerates and gradually returns to normal.8,9
$ X0 g/ t* }' B! V1 SThere are conflicting reports and controversy6 Q# H9 N q- ?. k' H- M( ~. Q
over the effect of early androgen exposure on adult3 b; @$ g% k; A2 j4 y
penile length.10,11 Some reports suggest subnormal d- H) F! q& b* |: f! z0 ?
adult penile length, apparently because of downreg-8 Q2 n5 w( g# W6 ~4 L9 W J D
ulation of androgen receptor number.10,12 However,4 o% Q) P- v1 `2 H6 h0 [; y
Sutherland et al13 did not find a correlation between
8 p2 |* |# V0 p, l3 g/ d s3 k% X$ Qchildhood testosterone exposure and reduced adult
, k3 G6 v4 _) w' i% A w8 mpenile length in clinical studies.9 }4 o. E1 O$ }0 p3 L" @! I, k6 L' H
Nonetheless, we do not believe our patient is0 F6 p! q' c) \+ I- j
going to experience any of the untoward effects from% c; j0 X% v& l1 N/ s% m
testosterone exposure as mentioned earlier because
$ f' {! o4 A+ fthe exposure was not for a prolonged period of time.
. \: K+ ~% I/ ?- r( gAlthough the bone age was advanced at the time of
6 R2 p6 D! O% X' Vdiagnosis, the child had a normal growth velocity at+ P/ Q( M, j |
the follow-up visit. It is hoped that his final adult3 }& m! ]9 h9 p8 |* P
height will not be affected./ m$ E1 U7 p7 o" K; g4 g1 f
Although rarely reported, the widespread avail-
3 Y3 R( H* ?9 H! U: d4 lability of androgen products in our society may$ Q4 N) r# p. p8 I1 K y
indeed cause more virilization in male or female N0 w- U" j! z
children than one would realize. Exposure to andro-
" |. r: W4 n$ Bgen products must be considered and specific ques-0 Z) H8 K+ P" k* c* S
tioning about the use of a testosterone product or
. @5 D$ B7 I! W' f4 Q' J7 D zgel should be asked of the family members during
) h0 N" p; |5 lthe evaluation of any children who present with vir-# r3 Z# H( k i, t. t( l/ r5 l! u7 V
ilization or peripheral precocious puberty. The diag-7 e4 o, U; W0 i$ @
nosis can be established by just a few tests and by
9 b# K6 c& R. Q8 L- I3 z' n5 o8 |+ |appropriate history. The inability to obtain such a
# I8 P2 l0 c* c/ Q0 _! `( z \$ |history, or failure to ask the specific questions, may
' }+ Y# G9 y; {8 s7 \/ Wresult in extensive, unnecessary, and expensive
1 k- X. M. |3 b! |$ ~/ n, }investigation. The primary care physician should be ]" A7 X7 J5 d- W
aware of this fact, because most of these children
0 [$ o2 K2 }3 l: y; f5 y9 Cmay initially present in their practice. The Physicians’
1 v3 y# G: v6 ?; u zDesk Reference and package insert should also put a% l7 d0 U2 F. E% d, n. o% ?
warning about the virilizing effect on a male or- o3 y0 j; Q1 w2 W/ W! D% p
female child who might come in contact with some-
7 v% e2 ]8 J% ^one using any of these products.6 ?2 ~0 M r8 d) L4 W( s/ V
References: v0 H$ a9 ^; F1 d5 r, R
1. Styne DM. The testes: disorder of sexual differentiation1 S$ }; w% O' c: R% L p, \% O
and puberty in the male. In: Sperling MA, ed. Pediatric% S3 }' B D+ `5 P9 _; h1 o
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( v3 p7 ]' Z; Y8 d) H
2002: 565-628.
2 {+ x0 o/ N7 C; h1 \$ i8 u0 A2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious4 [; t5 k8 |9 H8 |5 p
puberty in children with tumours of the suprasellar pineal |
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