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Sexual Precocity in a 16-Month-Old5 t0 q2 ? @+ O- M! Y+ e `
Boy Induced by Indirect Topical
c! R. L& r! i9 m+ [Exposure to Testosterone+ c# c# m$ H! Z8 u
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# R7 I) N' Z- U8 y" g9 t* }4 Cand Kenneth R. Rettig, MD1
$ W, a0 R+ R0 X. I* [' K4 x$ j! ?9 c6 c, _Clinical Pediatrics( _# i# m: o. A b
Volume 46 Number 6
' d3 N% P- N: L& \1 H5 y# M2 fJuly 2007 540-543
( _$ N( l1 V" g5 L1 t& D© 2007 Sage Publications
4 j' Z- K* R( Z, Z' P( s10.1177/0009922806296651
4 ~/ E9 x7 B/ Z$ s/ I Phttp://clp.sagepub.com U+ Q9 v; Z2 ~+ u$ h
hosted at
7 e7 M" a- ?3 w+ ~http://online.sagepub.com. \* F4 [; ]8 U5 z4 E. V
Precocious puberty in boys, central or peripheral,) M. q" _) Q4 t3 V% K" [9 C# A8 j
is a significant concern for physicians. Central
. M4 R2 [, z7 y2 J" D) \: uprecocious puberty (CPP), which is mediated* @, H4 k) f& ]
through the hypothalamic pituitary gonadal axis, has6 ^( m7 p/ {! c% e! _
a higher incidence of organic central nervous system
: l; x6 L& ]; z& W n5 D% }5 klesions in boys.1,2 Virilization in boys, as manifested
. d$ ^* U$ I- P8 _0 Tby enlargement of the penis, development of pubic
( A6 s# ^; l' m, g* qhair, and facial acne without enlargement of testi-
% N4 k7 O( L& m$ Z1 ncles, suggests peripheral or pseudopuberty.1-3 We
7 a0 B0 g( W' |4 u7 j g9 Qreport a 16-month-old boy who presented with the- o( X3 I2 g$ X& d, w/ ~
enlargement of the phallus and pubic hair develop-
8 P7 y, A; X9 Tment without testicular enlargement, which was due' c1 I0 k& v: v k$ I5 s* k$ G8 Y6 T
to the unintentional exposure to androgen gel used by' |2 x8 s; e7 s
the father. The family initially concealed this infor-- R* Y: }' j/ p; c
mation, resulting in an extensive work-up for this3 b" W# G. `5 [' W
child. Given the widespread and easy availability of) ?* f% Z0 ?6 p! K
testosterone gel and cream, we believe this is proba-% d2 V- H, r5 i. v- L+ ~( L9 p
bly more common than the rare case report in the: X7 b1 ^& g1 ?
literature.4
" }& Z, L3 m+ r7 gPatient Report+ h6 k* @/ n0 G/ y2 ]
A 16-month-old white child was referred to the) C" M, k d. e5 v, O8 ~) [
endocrine clinic by his pediatrician with the concern
+ H8 X$ u& Q8 J- Mof early sexual development. His mother noticed
" H# r! D& K# U" x( zlight colored pubic hair development when he was
: ]" U) X; n& S, {# O tFrom the 1Division of Pediatric Endocrinology, 2University of" f3 u4 V: ]- a* K
South Alabama Medical Center, Mobile, Alabama.: X2 ^4 C0 u3 N
Address correspondence to: Samar K. Bhowmick, MD, FACE,
/ j7 T, a& A9 N3 E5 x& K- sProfessor of Pediatrics, University of South Alabama, College of
+ e/ b7 H3 o' X. l' R( F7 F* `5 W* AMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
) Z, i4 a7 I7 H# n/ D) |( ie-mail: [email protected].) ]0 w3 r. i( H7 w0 o
about 6 to 7 months old, which progressively became# q7 y! W% H! q+ A, D- x
darker. She was also concerned about the enlarge-. C) I3 o' E' t Z
ment of his penis and frequent erections. The child
- R+ T8 Q/ _: ^' g( Qwas the product of a full-term normal delivery, with
5 ~* N' `* @4 } }, w: q2 R/ Za birth weight of 7 lb 14 oz, and birth length of
5 `( R' m% _* x5 r( s7 i" Z$ J20 inches. He was breast-fed throughout the first year- x3 [7 _" ?7 P6 q" S
of life and was still receiving breast milk along with/ z( p. o! g# S2 {
solid food. He had no hospitalizations or surgery,$ A! a1 b- ^' f: i# A5 O6 p0 X" Y
and his psychosocial and psychomotor development
9 q) x( M9 C% n8 f: y! Jwas age appropriate.; @, @, i1 T6 F, C) t# b1 p
The family history was remarkable for the father,! W0 E7 L, H- ]0 t. B
who was diagnosed with hypothyroidism at age 16,
7 a7 G3 W2 g: X5 [% Twhich was treated with thyroxine. The father’s
& e; r0 e( _7 ]; r' ^) G* h3 Jheight was 6 feet, and he went through a somewhat2 Q# b, }4 u: S" Q) K. z
early puberty and had stopped growing by age 14.
! i; Y+ N5 T4 h2 F; f) IThe father denied taking any other medication. The
& j* t9 E* H- f4 m$ a- |" R, tchild’s mother was in good health. Her menarche8 @- H7 N8 K3 ]# A: q* k$ q+ ?
was at 11 years of age, and her height was at 5 feet
2 Z. `5 _& \5 \: T$ h5 s. |4 t) |5 inches. There was no other family history of pre-; {4 e" H) C6 k# o4 T q
cocious sexual development in the first-degree rela-
6 y; m1 h- ^% n; V, _tives. There were no siblings.1 e5 v G5 w1 n( X* ^ ]; h
Physical Examination
( { L* P- p( N4 J5 J$ e/ Z' CThe physical examination revealed a very active,# R1 |8 P; a+ {) }) k% R
playful, and healthy boy. The vital signs documented
$ c9 s: u/ j7 o T; R3 V( _a blood pressure of 85/50 mm Hg, his length was; o: l/ p' V9 N0 F
90 cm (>97th percentile), and his weight was 14.4 kg
# l* I. P5 s! A6 Z(also >97th percentile). The observed yearly growth9 ?+ N, p! G9 F( b( F O5 \( k
velocity was 30 cm (12 inches). The examination of
6 V3 s! t( n6 Z& `1 \- C6 Vthe neck revealed no thyroid enlargement.8 J- W0 d" X% @# r
The genitourinary examination was remarkable for+ D( S" u! l% N* a; r0 {. R
enlargement of the penis, with a stretched length of5 x6 e U, D) W/ s, s# q
8 cm and a width of 2 cm. The glans penis was very well6 e) \" t/ g+ b _, Y% @" ]
developed. The pubic hair was Tanner II, mostly around5 q2 \( g5 ~. f% T; [- o
5408 ?2 A9 @9 Y1 v) \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 L0 Z0 B4 W8 L8 {2 {( @3 T4 s: B2 Bthe base of the phallus and was dark and curled. The# e5 D$ R8 h2 Y8 o& z# `7 W0 o
testicular volume was prepubertal at 2 mL each.
$ \ @( G. i, B4 ?4 n/ ?0 dThe skin was moist and smooth and somewhat5 C& K* \$ r0 J9 q/ Z! f0 [+ ~
oily. No axillary hair was noted. There were no
; g8 d, A* @& c+ Habnormal skin pigmentations or café-au-lait spots.
8 u' j3 u0 C dNeurologic evaluation showed deep tendon reflex 2+/ @* h8 L) m7 z8 k
bilateral and symmetrical. There was no suggestion
: H4 F3 W& b* f0 Gof papilledema.
, _5 ] N4 h B% K0 q7 u d! ~Laboratory Evaluation
% o0 c2 d; [# v9 n! WThe bone age was consistent with 28 months by
# w7 h; Y! L p$ W6 e3 {using the standard of Greulich and Pyle at a chrono-( R- P, n4 u9 O6 ^/ v" I+ R
logic age of 16 months (advanced).5 Chromosomal+ k# D" \8 q7 |8 G! A
karyotype was 46XY. The thyroid function test
( O" o3 T& x& zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-3 P% ]' O- g" r S: q
lating hormone level was 1.3 µIU/mL (both normal).
2 ]: ]; c4 F9 b6 C$ v4 \% ~) j7 C5 SThe concentrations of serum electrolytes, blood% b: m/ S. `7 {3 [1 M
urea nitrogen, creatinine, and calcium all were" T$ _5 K# ~: F$ z4 U' {& X) {) b9 _
within normal range for his age. The concentration
; B- {* r3 J* N; v6 @: tof serum 17-hydroxyprogesterone was 16 ng/dL
2 D9 p& S$ @6 U" U1 o6 i$ r(normal, 3 to 90 ng/dL), androstenedione was 20$ n8 p: y# q" y$ `0 n5 h7 @: W% M
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-3 q# G$ X4 E3 f8 {: \ {+ b
terone was 38 ng/dL (normal, 50 to 760 ng/dL),/ g- y, B9 z9 V, z. i5 q; _) M
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ V; x$ r$ }. \1 a49ng/dL), 11-desoxycortisol (specific compound S)3 _% d% o' B. y
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-& n7 i9 Q. T( `8 o8 H" R
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 v6 ~/ _* N ^ l' u& v
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),# j+ f2 S0 M7 Q( l
and β-human chorionic gonadotropin was less than
, Y; J( F5 q; e. y* X( l5 mIU/mL (normal <5 mIU/mL). Serum follicular
. d4 `+ A4 p. F2 _stimulating hormone and leuteinizing hormone
) N2 J( j! K, S, D: ?concentrations were less than 0.05 mIU/mL
2 d$ T: k9 Y* X. O4 }4 h, J5 U(prepubertal).6 B1 P: {% ]3 f- Y4 h+ S v! m9 }- J
The parents were notified about the laboratory& k; _7 U( t/ D
results and were informed that all of the tests were& E, f: ]3 d1 a" ~1 S, m4 \
normal except the testosterone level was high. The
# z; m9 R+ B1 x& Ufollow-up visit was arranged within a few weeks to
- X4 r' B' p0 Nobtain testicular and abdominal sonograms; how-
# `& v% v0 X4 R0 R5 o! Z0 S0 y8 s% l( ~ever, the family did not return for 4 months.
3 V6 X7 E. e3 G; @' X) S6 X+ uPhysical examination at this time revealed that the& N: u, G Z( o
child had grown 2.5 cm in 4 months and had gained
! j. N6 E1 n2 t% d$ d4 D2 kg of weight. Physical examination remained8 v' o; m, Q% h# j
unchanged. Surprisingly, the pubic hair almost com-
2 T/ M; w4 x/ x* opletely disappeared except for a few vellous hairs at' o3 U9 y9 }. Q* S1 X |
the base of the phallus. Testicular volume was still 2! ^$ V Z' }/ l% G7 X
mL, and the size of the penis remained unchanged./ v, Q+ Q+ ]. V" J0 \
The mother also said that the boy was no longer hav-
; M( F1 ]7 u7 Bing frequent erections." D! ~8 v$ B1 j2 N
Both parents were again questioned about use of; E. \* Q& ?& W# r! T9 q
any ointment/creams that they may have applied to. p _! L$ o) [/ @0 N6 a
the child’s skin. This time the father admitted the
0 h, q$ q& k0 ?/ vTopical Testosterone Exposure / Bhowmick et al 541! _: S& q: ?4 E C$ L7 t
use of testosterone gel twice daily that he was apply-
& q: r T% _4 s [: n- king over his own shoulders, chest, and back area for& W3 u" ^( q+ B! Y
a year. The father also revealed he was embarrassed
6 d# r: }0 Y4 @$ ]0 ~: W; `to disclose that he was using a testosterone gel pre-+ E" K/ L: [% }; E: q" W9 _
scribed by his family physician for decreased libido
5 H K6 F* y8 w+ b+ P" _8 U( isecondary to depression.
: H$ W: u' G2 J+ g( }/ pThe child slept in the same bed with parents.
, s- g! |3 \% R3 M5 BThe father would hug the baby and hold him on his
! |8 A3 l. F, U; _chest for a considerable period of time, causing sig-
# ]" i a3 L# c; v7 Pnificant bare skin contact between baby and father.
! J$ ~5 {3 G4 B6 F: ^6 t6 OThe father also admitted that after the phone call,
) _1 q4 E+ I* E- R% O8 Twhen he learned the testosterone level in the baby. A9 s* q' N$ v0 z9 X W% {
was high, he then read the product information" Z; I# q! L8 K" p* o; G- E+ @& k
packet and concluded that it was most likely the rea-
+ a; O8 z+ \6 Eson for the child’s virilization. At that time, they5 Y) M2 X' B t) |# `" T
decided to put the baby in a separate bed, and the6 k' Y5 b% f9 n/ d. M# s1 o
father was not hugging him with bare skin and had
' W6 i" R) c8 v C; p. \been using protective clothing. A repeat testosterone, @6 m; z0 K1 q& }
test was ordered, but the family did not go to the
) `; A! a& n% f( s1 wlaboratory to obtain the test.
' C2 {+ H% Q1 L d3 A& EDiscussion6 N2 }, h9 ~% X3 d+ Q- E3 R; R5 |
Precocious puberty in boys is defined as secondary3 N' e6 [+ N0 }5 P6 x+ i
sexual development before 9 years of age.1,45 M1 E4 }% q+ m4 Z6 n
Precocious puberty is termed as central (true) when9 a$ k/ D, s7 ~
it is caused by the premature activation of hypo-
6 X5 ^; `) {2 p) tthalamic pituitary gonadal axis. CPP is more com-
8 K+ M6 K6 K1 U/ o& ?% gmon in girls than in boys.1,3 Most boys with CPP
. U9 p7 M! J' w$ h$ r5 ^may have a central nervous system lesion that is
1 v* k0 B) g& h1 D7 l/ E9 ^# Dresponsible for the early activation of the hypothal-
- c$ s% x! `% d# O |$ }amic pituitary gonadal axis.1-3 Thus, greater empha-# P8 c( `( J2 ?( A* @2 M2 S
sis has been given to neuroradiologic imaging in2 _3 A& o$ P+ E8 g8 s5 ^7 Y) j4 T
boys with precocious puberty. In addition to viril-
5 S5 I/ U3 |( R( nization, the clinical hallmark of CPP is the symmet-
# p1 w# P$ V! p: @ d# q; Mrical testicular growth secondary to stimulation by* u y* n! Q& K- O9 v0 M( O( ?( C
gonadotropins.1,3$ t9 I. _; B G0 e# P7 n/ S
Gonadotropin-independent peripheral preco-
& T, x# D5 s% Y; t+ M& W+ P2 F: @cious puberty in boys also results from inappropriate
( e+ F3 A' T4 v1 k Eandrogenic stimulation from either endogenous or2 w2 W6 M- Q, y8 {
exogenous sources, nonpituitary gonadotropin stim-/ Q4 p) P, f8 C! ^
ulation, and rare activating mutations.3 Virilizing9 I+ _/ y, o) _# w
congenital adrenal hyperplasia producing excessive8 \! ^) T9 H, i* d
adrenal androgens is a common cause of precocious9 ~9 S' \" ^( p2 K) g
puberty in boys.3,4
+ |/ K* J: a* t$ n' e2 [* I: |4 \0 IThe most common form of congenital adrenal
1 J' Y3 B: J3 rhyperplasia is the 21-hydroxylase enzyme deficiency.
& m; I- a/ w! I( S" m% TThe 11-β hydroxylase deficiency may also result in( E! ]7 T- C% J% U- t1 X8 f! [
excessive adrenal androgen production, and rarely,
( D* Y6 P: T) A, P0 Fan adrenal tumor may also cause adrenal androgen
1 q+ T$ q# E; ^! Z8 }, z) ~7 Xexcess.1,34 r& y: n3 `; y/ }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
F; ^0 n' N% d4 H542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 ~! ?4 A8 l1 A" \6 S% L9 K2 VA unique entity of male-limited gonadotropin-8 J$ J0 x6 q! a* z4 S
independent precocious puberty, which is also known
* t% [+ i b: \0 ?, j) Mas testotoxicosis, may cause precocious puberty at a
7 k( r8 A: K! T) k Z xvery young age. The physical findings in these boys. t1 h; B3 n# _3 P
with this disorder are full pubertal development,
4 |# N# m% X% F; Oincluding bilateral testicular growth, similar to boys% t; S) w# `" |& @! Q" Q
with CPP. The gonadotropin levels in this disorder
5 x+ E9 ~1 _; M& {+ Ware suppressed to prepubertal levels and do not show& C1 ]) G" {& n0 e+ X
pubertal response of gonadotropin after gonadotropin-/ b( t4 Q+ M4 k7 O7 E
releasing hormone stimulation. This is a sex-linked5 |5 U6 `9 c8 F6 S$ H) [
autosomal dominant disorder that affects only
& G% |! q; v c2 K5 b& o8 u/ smales; therefore, other male members of the family/ F( u/ t" U" @2 S. V0 m
may have similar precocious puberty.3
$ t$ A) {/ r9 x8 u, f: C) yIn our patient, physical examination was incon-
% E q& N5 b) Z- q5 @6 p, Wsistent with true precocious puberty since his testi-
* t3 V' ^" V+ h7 xcles were prepubertal in size. However, testotoxicosis$ ]0 X! P7 Y6 r+ h ^
was in the differential diagnosis because his father/ Q. Q$ @8 I7 Z5 X: @1 \' M
started puberty somewhat early, and occasionally,
4 @* S; C; g* U+ M. g6 Ktesticular enlargement is not that evident in the- R, Y$ ~( x6 q9 ~) I
beginning of this process.1 In the absence of a neg-
2 p# w7 [4 e% O% x3 F! Q9 F9 r8 Wative initial history of androgen exposure, our
* B% ` B/ }1 Y \6 |: hbiggest concern was virilizing adrenal hyperplasia,3 O" W$ ~% l/ R. M5 g+ r
either 21-hydroxylase deficiency or 11-β hydroxylase
2 P: T1 |5 L% _) H9 Zdeficiency. Those diagnoses were excluded by find-
) _4 S+ |! |& N- Z& }7 aing the normal level of adrenal steroids.! X7 z# N* T, g+ N. \
The diagnosis of exogenous androgens was strongly
4 `5 C! o8 o9 a) N1 Qsuspected in a follow-up visit after 4 months because
8 f% }; g; F' x9 D6 ~/ @" P' Qthe physical examination revealed the complete disap-
( B' O7 p* W0 \pearance of pubic hair, normal growth velocity, and5 b- l% }% ]# H5 _0 m# C8 x' \$ `9 s
decreased erections. The father admitted using a testos-3 h: ]6 q+ F1 P/ s/ o
terone gel, which he concealed at first visit. He was# i( [, r/ b; {% T2 i) W9 t" k
using it rather frequently, twice a day. The Physicians’' Z$ O1 v4 P3 T& x) K8 \; }
Desk Reference, or package insert of this product, gel or' i2 j) x! @& ^% _) V2 {
cream, cautions about dermal testosterone transfer to
4 _) m- D2 j* N. U; Qunprotected females through direct skin exposure.
4 e- f- R0 E: c# }Serum testosterone level was found to be 2 times the
/ O( K& _# i# j- G; Kbaseline value in those females who were exposed to
2 f/ [6 `2 _; ceven 15 minutes of direct skin contact with their male1 v# z& b9 T7 B$ x
partners.6 However, when a shirt covered the applica-0 H) |3 n/ S6 b) L2 g: c$ L6 p
tion site, this testosterone transfer was prevented.7 y3 I( V; m. Q8 I/ f6 k
Our patient’s testosterone level was 60 ng/mL," |9 a3 @, u* N* E: q
which was clearly high. Some studies suggest that* v) m; N1 _2 F* ?5 U, ^; D
dermal conversion of testosterone to dihydrotestos-
6 _7 C/ `7 S* U+ i& L, G7 J: Pterone, which is a more potent metabolite, is more# O$ ^7 h$ F$ ]
active in young children exposed to testosterone4 Y9 J! }# U/ g- W1 G8 D1 s
exogenously7; however, we did not measure a dihy-4 M: V' \ m8 b. ~. g" `/ a7 q
drotestosterone level in our patient. In addition to) |. I0 u9 c4 w
virilization, exposure to exogenous testosterone in0 D9 f# T; J+ T
children results in an increase in growth velocity and( {9 Q) c0 c, J/ H; \
advanced bone age, as seen in our patient.: l: B8 {5 e" Y- ?
The long-term effect of androgen exposure during
8 e! A7 g( b$ {: S+ rearly childhood on pubertal development and final6 j0 K6 F) j+ \% V. W
adult height are not fully known and always remain
. V/ s: l2 X+ F/ U$ X( Ta concern. Children treated with short-term testos-: L3 ^9 h" b) ]4 ]# F
terone injection or topical androgen may exhibit some
5 L7 U* x% O) }, \acceleration of the skeletal maturation; however, after0 l- ?3 r' S* u7 q
cessation of treatment, the rate of bone maturation
/ ]+ R( e r# p7 mdecelerates and gradually returns to normal.8,95 g; M9 Q. w5 ]5 I
There are conflicting reports and controversy
" p2 i; h1 B: _over the effect of early androgen exposure on adult8 V0 D* [4 l4 h5 n% i
penile length.10,11 Some reports suggest subnormal6 A2 K2 }. x7 N' r! F. [; x' j
adult penile length, apparently because of downreg-
1 W# Y# Y2 |. T5 sulation of androgen receptor number.10,12 However,$ T. m& z; \ p* u
Sutherland et al13 did not find a correlation between/ @% o- N4 m* `7 L/ Q& A
childhood testosterone exposure and reduced adult; n! z0 I3 X* ^3 n/ M% U& I9 ~
penile length in clinical studies.
" ~. c: Q5 y$ @9 ANonetheless, we do not believe our patient is
0 P, s# r- x4 j. k! ~( W1 b/ Q3 ?8 ~going to experience any of the untoward effects from7 S; ? ~1 T1 P1 Z* r
testosterone exposure as mentioned earlier because
% v* i1 f: ~* e0 gthe exposure was not for a prolonged period of time.
; @) _( m, ]) g4 {5 \4 LAlthough the bone age was advanced at the time of6 z+ J9 s' E! L: _" }; p: J
diagnosis, the child had a normal growth velocity at& U& l$ i9 [% X `: }
the follow-up visit. It is hoped that his final adult$ w9 ?# [$ u$ L" [5 `; Y
height will not be affected.
; v# N T1 L, e0 p* a# bAlthough rarely reported, the widespread avail-" e0 Y( Y6 s- j$ ? I2 _3 N
ability of androgen products in our society may
' M: u+ N. O$ _6 @( ]. V# uindeed cause more virilization in male or female& W8 k |0 D! S r
children than one would realize. Exposure to andro-* r0 w0 V; m1 p/ Z1 e
gen products must be considered and specific ques-( U, W+ z8 n( t
tioning about the use of a testosterone product or( N0 x3 q6 q8 Y5 \; R3 m# w2 l
gel should be asked of the family members during
- ^7 `* r, l, Z, t% Y) P Q9 Gthe evaluation of any children who present with vir-2 v5 j2 I' a& C; O( ~+ [
ilization or peripheral precocious puberty. The diag-
( [0 ]0 z# h6 _* T h- r0 V& knosis can be established by just a few tests and by
1 f$ B+ B6 J' Pappropriate history. The inability to obtain such a
: E3 a# q; m& H; R, X" w; uhistory, or failure to ask the specific questions, may( O& N5 Q/ r4 v0 _# Z. i
result in extensive, unnecessary, and expensive
K& O0 X0 ^( ?; Q: D: Jinvestigation. The primary care physician should be- f8 x! t4 m6 @, S; b
aware of this fact, because most of these children8 Y" t! b9 p0 H; _' N+ m' P9 B; ]
may initially present in their practice. The Physicians’
0 z6 ~; }$ m" f, k" M, S# V. }Desk Reference and package insert should also put a1 x' B6 N. K. Q: T" A( r, |( G6 a
warning about the virilizing effect on a male or# d! w+ }3 ?2 I. j- s) A% w
female child who might come in contact with some- l. \8 j& y) ~/ L- m+ W S
one using any of these products.
9 t9 |1 B. n( q( k6 ^7 b- c SReferences
( o! x: i, x5 X- ^. s" q1. Styne DM. The testes: disorder of sexual differentiation
6 N' S6 t- d0 g9 f7 t- |4 Rand puberty in the male. In: Sperling MA, ed. Pediatric
/ [3 J V, r8 ^8 Y% n' }Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
$ j4 X% _ u( K% g2002: 565-628.
, D( {! m9 N- r2 S, G2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
% z/ _; w) m8 |8 s* z) cpuberty in children with tumours of the suprasellar pineal |
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