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Sexual Precocity in a 16-Month-Old; {) u2 g- t, s- A( A I, B& `$ c% z" ^
Boy Induced by Indirect Topical
8 P) ]0 C- k' @4 f5 Q$ vExposure to Testosterone
' b6 f$ b: Z0 S% q6 H0 f+ xSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 H4 G8 i9 `% A3 t% c+ `and Kenneth R. Rettig, MD1
5 U `. m# I% kClinical Pediatrics
& c, }# Q! N% q2 y& R+ U4 W0 dVolume 46 Number 6
6 a9 Q' e8 T2 X+ r/ R0 x3 oJuly 2007 540-5432 r6 f/ G/ v" S3 |
© 2007 Sage Publications
\9 p7 O" o: e( j' z10.1177/0009922806296651
& d7 v0 f0 J* |8 Z% _; dhttp://clp.sagepub.com
! z: w% z' @3 {( D9 a( [1 ehosted at
2 c0 [8 h4 c# f; {- e3 p/ ihttp://online.sagepub.com
. O2 o7 V) c. Y5 RPrecocious puberty in boys, central or peripheral,
2 b" ~- _6 a9 ais a significant concern for physicians. Central
# r- c, h3 y; V; D( f4 g( qprecocious puberty (CPP), which is mediated
. F2 O% b( Z" D9 {2 Q" W3 Bthrough the hypothalamic pituitary gonadal axis, has# ^! N0 L/ o: I
a higher incidence of organic central nervous system8 s/ b! Q* w5 z! ^
lesions in boys.1,2 Virilization in boys, as manifested
* B& R) L' D# ~9 \. P+ m, ]+ Fby enlargement of the penis, development of pubic" |3 U; O" O* p6 P: I% N6 `8 l B3 c
hair, and facial acne without enlargement of testi-+ ^7 o: j+ l" H( C y# H
cles, suggests peripheral or pseudopuberty.1-3 We
0 H$ S s& h+ m! I; v2 [# `9 vreport a 16-month-old boy who presented with the
) S! m1 ~& S0 t& _enlargement of the phallus and pubic hair develop-: U% A2 i1 d' i8 l
ment without testicular enlargement, which was due7 B1 W& {0 G$ e3 M4 p/ o! C% D- e
to the unintentional exposure to androgen gel used by
# K" d0 ^; B9 A/ v C0 v! Jthe father. The family initially concealed this infor-# E- P; _4 Z8 S6 f+ L* l: A" ?
mation, resulting in an extensive work-up for this; P# D2 a6 m9 y4 {% E; I4 ~8 u
child. Given the widespread and easy availability of
- x9 W5 n: ~3 u! U \$ O# Ttestosterone gel and cream, we believe this is proba-
' F( P# o$ C) O% Y- r3 G9 e& v1 fbly more common than the rare case report in the
9 u& I/ b& h/ Fliterature.4- L5 s a8 `/ v4 A7 _
Patient Report+ C. B7 P+ h) m# f! E) I+ b4 L
A 16-month-old white child was referred to the7 i0 R( P0 L' z
endocrine clinic by his pediatrician with the concern
; A( k' g1 P- v. |4 T; f2 Dof early sexual development. His mother noticed
0 j3 s* x; M3 t: F7 a- Jlight colored pubic hair development when he was
0 a: c' j% k! |5 E9 \' v: sFrom the 1Division of Pediatric Endocrinology, 2University of
( U9 Q9 D' Y, f, k0 WSouth Alabama Medical Center, Mobile, Alabama.7 I) \; t3 e" I, U5 r o* O/ ]8 S* I( ~
Address correspondence to: Samar K. Bhowmick, MD, FACE,
6 ~- Z& E. E' h9 L- z3 \Professor of Pediatrics, University of South Alabama, College of
& Y: M! ?3 S7 U. ]$ D+ R: a2 F( ~) ? @Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 Z# ~. W0 o2 q: B
e-mail: [email protected].
" h" ^6 J) u7 l, @2 q1 ~about 6 to 7 months old, which progressively became. B$ g: W+ I. E+ d4 ?; Y
darker. She was also concerned about the enlarge-
+ x2 v5 c# f/ l. n; }+ x' y6 ?ment of his penis and frequent erections. The child9 \/ U0 u Y6 J5 d: M8 h
was the product of a full-term normal delivery, with
& G% O V" B6 A% ?. u( ca birth weight of 7 lb 14 oz, and birth length of
! P% ]8 H# @# b- B20 inches. He was breast-fed throughout the first year
. ]8 u& D$ K+ n, `of life and was still receiving breast milk along with
% P* T: b" J' f0 o% qsolid food. He had no hospitalizations or surgery,1 g+ {: i% a2 h9 P$ k' E
and his psychosocial and psychomotor development! e6 w8 X6 F$ s$ {) ?5 C) U
was age appropriate.
+ H8 a% L* Q/ SThe family history was remarkable for the father,
0 V! A2 P P3 W* Y* s6 Dwho was diagnosed with hypothyroidism at age 16,# O& g# @8 O1 J: t# y
which was treated with thyroxine. The father’s
+ ]# @8 z9 V: p, ?. s% j, Theight was 6 feet, and he went through a somewhat
" [7 J/ N: ^" u* O2 j: m( Gearly puberty and had stopped growing by age 14.
3 Z: c, u; I' Z. G& CThe father denied taking any other medication. The
1 g& t; C$ E6 {. x0 Achild’s mother was in good health. Her menarche. m F3 l5 A/ y8 w
was at 11 years of age, and her height was at 5 feet" S* B4 R, n+ h$ P s: L- l( Z
5 inches. There was no other family history of pre-
' N/ P, W. Z7 |! Q/ z0 V, Mcocious sexual development in the first-degree rela-# z, |$ Y' V6 \0 \) X
tives. There were no siblings.. K% }! [) t' e" j5 R$ B
Physical Examination
6 W0 S2 A9 k- { xThe physical examination revealed a very active,/ i- }( H" D( q. w
playful, and healthy boy. The vital signs documented
, o! |2 b; C* k0 a; H) \a blood pressure of 85/50 mm Hg, his length was" ], Y x5 O3 W$ m% c' _
90 cm (>97th percentile), and his weight was 14.4 kg
3 k9 \: Y3 k; v6 U! l( |; b(also >97th percentile). The observed yearly growth
& d& L, _6 I' p+ Y/ d) ~8 |velocity was 30 cm (12 inches). The examination of! o3 L8 d( [: c$ o4 J
the neck revealed no thyroid enlargement.
0 K+ |5 M3 o% x+ f5 XThe genitourinary examination was remarkable for
4 o% a& N1 q" A5 r) ?enlargement of the penis, with a stretched length of5 {* ^. Y" L' a; i8 P6 C" j2 f
8 cm and a width of 2 cm. The glans penis was very well; B4 Q) f/ O: Y# m h" o) w
developed. The pubic hair was Tanner II, mostly around
, g% V: E6 B+ [0 B540
! {. m' `. o1 v# r. V; hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 F1 [+ e9 V) `) o! ^! Bthe base of the phallus and was dark and curled. The% s! z/ O* O( l0 i) p6 C. U
testicular volume was prepubertal at 2 mL each.
9 {$ W d3 O* B" M6 I7 FThe skin was moist and smooth and somewhat
. a+ M h( {9 Q& v7 roily. No axillary hair was noted. There were no
' u7 |& V8 J4 b8 L9 p7 V q: b# q" Y8 tabnormal skin pigmentations or café-au-lait spots.
& s0 w" E0 h3 e( x( _& xNeurologic evaluation showed deep tendon reflex 2++ O, F: g! l% b# ^
bilateral and symmetrical. There was no suggestion
1 J( J2 U8 c$ a. z0 S- r: Yof papilledema.
* R% J5 s! j9 s- d6 \ g: nLaboratory Evaluation$ v" \; _8 A0 k/ Q1 j
The bone age was consistent with 28 months by8 ]. t* ]- g* O% Z
using the standard of Greulich and Pyle at a chrono-# Q q, V, l8 e9 Q. J6 G4 C
logic age of 16 months (advanced).5 Chromosomal
- F3 j2 x9 D" q. ]: pkaryotype was 46XY. The thyroid function test# h5 n! T( C7 D0 f4 ~) c
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 q+ V) d+ j+ _2 R0 J: Llating hormone level was 1.3 µIU/mL (both normal). [% p6 z$ @' E7 J2 b( E3 @
The concentrations of serum electrolytes, blood
& W s6 A- p# H7 P4 h' ^ L# ^urea nitrogen, creatinine, and calcium all were
' _0 m3 x9 Z8 m. {within normal range for his age. The concentration
5 t& p; ~- n: d6 Eof serum 17-hydroxyprogesterone was 16 ng/dL- D! F8 T+ {6 K
(normal, 3 to 90 ng/dL), androstenedione was 20
w( C, B/ M) m1 a5 kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' X' W3 l N2 n% x; H/ z" Vterone was 38 ng/dL (normal, 50 to 760 ng/dL),
: m9 F- c- I# n. Q7 ]desoxycorticosterone was 4.3 ng/dL (normal, 7 to. F* ]7 H) r \! P8 m
49ng/dL), 11-desoxycortisol (specific compound S)
# Q8 Y3 r; K5 D( G2 ]% Hwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
, u! J" i! w2 c" D7 u/ `; Ytisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total3 f4 K# `% S7 }
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
8 Q# N2 ~/ ?5 V" o' [' r, b7 Hand β-human chorionic gonadotropin was less than1 i" M7 A* r# h3 L
5 mIU/mL (normal <5 mIU/mL). Serum follicular+ _; C3 N( B4 d
stimulating hormone and leuteinizing hormone3 [& T6 h& v5 y r' y% u
concentrations were less than 0.05 mIU/mL
0 {! w+ }9 Q/ I2 ?(prepubertal).
J) J# m% k/ ]+ i9 U2 xThe parents were notified about the laboratory
( m0 G0 }) q/ g: ]" {' j% N# Yresults and were informed that all of the tests were: ]! _# c4 m% {9 C [5 E
normal except the testosterone level was high. The
2 a" h1 r/ i$ x$ O( Rfollow-up visit was arranged within a few weeks to
# |0 D) n3 S9 L2 H$ D* E7 r2 N+ kobtain testicular and abdominal sonograms; how-" d# ?8 v6 b' R; G. m" |' B5 b
ever, the family did not return for 4 months.6 q: i @8 w+ [: U
Physical examination at this time revealed that the8 Z$ k$ ^5 H& }9 d; q0 {
child had grown 2.5 cm in 4 months and had gained7 A* l3 V+ y6 c' P1 x6 N
2 kg of weight. Physical examination remained
3 g/ T8 T3 Q' c/ s- h5 punchanged. Surprisingly, the pubic hair almost com-
5 c, f: J' V0 [0 b* |' N6 |pletely disappeared except for a few vellous hairs at1 `2 t) F: {; ~3 A0 z# r
the base of the phallus. Testicular volume was still 2
% @- B( E3 H9 F$ r- DmL, and the size of the penis remained unchanged.
7 n7 A( Q9 Z% WThe mother also said that the boy was no longer hav-+ C# } W& r, M9 H! n
ing frequent erections.* G( Y G% Z3 [2 k% ^2 Y) T% ?$ v
Both parents were again questioned about use of8 Z7 O& b% |1 W/ B
any ointment/creams that they may have applied to) h+ r5 N+ _5 @' E5 @. P" h
the child’s skin. This time the father admitted the
+ o6 e0 a5 ]* F; O0 k( s0 XTopical Testosterone Exposure / Bhowmick et al 541
0 R( Y+ N' f# c$ s2 |) q7 [; puse of testosterone gel twice daily that he was apply-
5 G; ]. e7 Z! F' C' W+ L Ning over his own shoulders, chest, and back area for; {) ^3 J1 Z8 t; ?& A2 x9 w0 P, m
a year. The father also revealed he was embarrassed
( O, o( `: ]( Rto disclose that he was using a testosterone gel pre-
+ ^: l9 h4 b! w6 ~$ U! x9 y/ D* |scribed by his family physician for decreased libido: d O( p0 P; \% \
secondary to depression.
5 P, ?& w3 E5 M9 Y# J) j, k; @$ V8 FThe child slept in the same bed with parents.
1 S' R9 H: {) h. g8 PThe father would hug the baby and hold him on his
8 f% e0 N, v, ~* H# i4 O; r8 Uchest for a considerable period of time, causing sig-, g3 r; u" l/ B* V
nificant bare skin contact between baby and father.
* ~7 X" k( m8 d8 V* p$ I- KThe father also admitted that after the phone call,
$ n' f) N6 c% q/ F2 f# i6 iwhen he learned the testosterone level in the baby
3 S" p! L" `3 \( n, z" mwas high, he then read the product information7 y, V) s7 D5 p* e
packet and concluded that it was most likely the rea-
* c! d$ S% a% m: D' b- Vson for the child’s virilization. At that time, they, \, d) J" d4 p" Z5 K6 \
decided to put the baby in a separate bed, and the2 V0 F) A5 U/ i y" o9 [& i+ L0 F% b! I
father was not hugging him with bare skin and had# c+ c7 k$ K) h. L% e+ F% O+ D( D
been using protective clothing. A repeat testosterone
' m' D7 N9 m" `/ X8 Ltest was ordered, but the family did not go to the5 D6 [, Z4 u5 }# T: C) @
laboratory to obtain the test. X7 X" j a. Z
Discussion2 a. s2 E5 W, ]2 |( v
Precocious puberty in boys is defined as secondary
& R, x0 w# Z; [sexual development before 9 years of age.1,4" p1 P9 n) `3 i, n
Precocious puberty is termed as central (true) when
7 X9 D: S/ F, _# M. X+ ^2 fit is caused by the premature activation of hypo-% z+ I+ F: _0 z9 Z9 `. C
thalamic pituitary gonadal axis. CPP is more com-4 m2 r& J: J( @) {! G8 `, @
mon in girls than in boys.1,3 Most boys with CPP
7 u7 Y+ Q0 x2 F& L9 Mmay have a central nervous system lesion that is% m2 s# H$ D0 |- H2 _5 F0 x
responsible for the early activation of the hypothal-
9 T. b5 H7 t1 t; camic pituitary gonadal axis.1-3 Thus, greater empha-9 X! f+ ~. L1 M* n9 M+ M
sis has been given to neuroradiologic imaging in6 n7 T2 _2 F7 r# I5 r3 q8 @( N
boys with precocious puberty. In addition to viril-4 n, A) N% b6 Z5 P. [
ization, the clinical hallmark of CPP is the symmet-+ {! T- y) c; A1 `
rical testicular growth secondary to stimulation by
/ y# K; C6 S) c, r8 J% n7 Y% kgonadotropins.1,3' v6 E0 x* x1 Y8 t S7 B2 W# h
Gonadotropin-independent peripheral preco-
5 ~& W+ G! |. T0 @& s8 I/ jcious puberty in boys also results from inappropriate
7 F$ s$ N6 a& t1 `androgenic stimulation from either endogenous or
" l( @* E3 @( L4 ` f- f iexogenous sources, nonpituitary gonadotropin stim- `; E" Z* o3 Y' s
ulation, and rare activating mutations.3 Virilizing
% R/ G" b# [+ Y, u. s4 N7 y; ocongenital adrenal hyperplasia producing excessive
, ~/ l) Q- A+ V$ d" H. K* E2 _ {adrenal androgens is a common cause of precocious
& l; \9 J- {" m: _9 @! apuberty in boys.3,4
% p9 `3 ~* w4 |; R7 WThe most common form of congenital adrenal) k3 C1 C$ Y/ p! Y1 ^0 _ W
hyperplasia is the 21-hydroxylase enzyme deficiency.2 G, H2 K" Y+ I4 e' E' k! z
The 11-β hydroxylase deficiency may also result in
! c `$ ~$ d* z& a, T1 Nexcessive adrenal androgen production, and rarely,
5 m# X0 r. C8 l( K+ G, U) [an adrenal tumor may also cause adrenal androgen
7 Q! E) R: P8 {5 A( Sexcess.1,3
6 m1 O# E4 j9 P1 u4 d a% s: w9 N+ Qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( f j `8 E% r' G- e8 ?542 Clinical Pediatrics / Vol. 46, No. 6, July 20072 \0 C( Q4 q/ _$ v9 r
A unique entity of male-limited gonadotropin-) _- J+ e/ l' h6 K/ K
independent precocious puberty, which is also known
. i5 D2 x3 b/ ^4 I& B* jas testotoxicosis, may cause precocious puberty at a7 L$ l3 o1 u) m8 x) {' i; Y
very young age. The physical findings in these boys+ e! @2 k0 h3 E5 F, `
with this disorder are full pubertal development,
% [. D; g8 [+ h. D6 B! nincluding bilateral testicular growth, similar to boys, n6 R5 _; r9 r6 I+ p' f+ s9 Q
with CPP. The gonadotropin levels in this disorder
/ r$ I2 Z$ ]: o: Z- Rare suppressed to prepubertal levels and do not show
: M# H1 H6 y5 U Bpubertal response of gonadotropin after gonadotropin-6 d$ s& Y2 h: I. I- N4 r O
releasing hormone stimulation. This is a sex-linked0 F& {# ?+ x7 G
autosomal dominant disorder that affects only9 m& y2 G. F7 I n4 D
males; therefore, other male members of the family6 _3 X2 A$ B4 i/ ^0 v
may have similar precocious puberty.30 t E Z$ y$ C B
In our patient, physical examination was incon-
4 a0 f/ o% o S, S p0 }# Usistent with true precocious puberty since his testi-% a$ G% X' j9 L i& p( r
cles were prepubertal in size. However, testotoxicosis0 I& r9 g; F' H( g \3 O
was in the differential diagnosis because his father
6 o# i, A0 c' ]( Kstarted puberty somewhat early, and occasionally,
( P" K7 ~ t+ Z' w. ~testicular enlargement is not that evident in the/ W( u0 D7 @. B2 {2 V z. d9 U
beginning of this process.1 In the absence of a neg-
7 M( ?% h4 E; P; b* pative initial history of androgen exposure, our
. y |+ w3 V- ybiggest concern was virilizing adrenal hyperplasia,# \+ p+ @& J7 P+ e8 T+ X5 s/ e
either 21-hydroxylase deficiency or 11-β hydroxylase
% n$ ?4 o( E; y: s ]) edeficiency. Those diagnoses were excluded by find-
( O1 `! |0 }6 v2 K7 M9 F. ling the normal level of adrenal steroids.
0 u) C# B' U4 t% u' g9 t1 AThe diagnosis of exogenous androgens was strongly1 I8 q! M! k; a6 A+ o+ l/ ]
suspected in a follow-up visit after 4 months because
5 \/ L7 P) j9 J5 Bthe physical examination revealed the complete disap-
( Y' T' x5 r/ E! i( Kpearance of pubic hair, normal growth velocity, and- O/ J& b& y3 g0 S$ N0 ]4 L
decreased erections. The father admitted using a testos-& I; B1 F" p' S! Z) ~. s0 N
terone gel, which he concealed at first visit. He was
8 y' q3 n7 w+ ousing it rather frequently, twice a day. The Physicians’
9 n5 P; v3 K7 |" o9 S' o8 SDesk Reference, or package insert of this product, gel or O& K+ w6 e. `0 e F
cream, cautions about dermal testosterone transfer to. M1 t+ H% m8 q
unprotected females through direct skin exposure.. n' j; `) j- v1 J
Serum testosterone level was found to be 2 times the7 v3 {! b% N* m2 D# a3 u- p; F
baseline value in those females who were exposed to& U/ A/ i' u$ @& [/ \
even 15 minutes of direct skin contact with their male
8 H8 o' }9 ~2 v8 u( Upartners.6 However, when a shirt covered the applica-7 N' n' x( d' Q; }4 f, H
tion site, this testosterone transfer was prevented. l# g7 r9 X. D1 B6 j; _
Our patient’s testosterone level was 60 ng/mL,6 e& N* j" S: w
which was clearly high. Some studies suggest that
( f1 ?, R, Z. Bdermal conversion of testosterone to dihydrotestos-
' l, R3 V" v$ `terone, which is a more potent metabolite, is more! w* [ _! O4 a8 R% D
active in young children exposed to testosterone( r1 I* h- d2 k8 H
exogenously7; however, we did not measure a dihy-4 K. V9 @5 C( T
drotestosterone level in our patient. In addition to/ a- p$ _; P; X
virilization, exposure to exogenous testosterone in! I9 G: I% q, q( `! J5 ~
children results in an increase in growth velocity and5 v' k3 T- P* V( ?
advanced bone age, as seen in our patient.
3 W) {* {6 H7 }) h- `% F+ @The long-term effect of androgen exposure during2 l6 t+ y0 i. L8 P" Q' i* G
early childhood on pubertal development and final
9 W$ C% b( ]8 `: [adult height are not fully known and always remain- R& s8 f5 n; @' K' ^1 R' b$ v
a concern. Children treated with short-term testos-
! o( y& u+ B6 {2 j5 ^terone injection or topical androgen may exhibit some
3 Q' @8 N T+ A$ i. d, gacceleration of the skeletal maturation; however, after4 ~3 P6 N. t) ^& [! ]% j
cessation of treatment, the rate of bone maturation
3 b1 x5 _' D4 }/ q. C, Sdecelerates and gradually returns to normal.8,9: e+ f* D* o4 H( {
There are conflicting reports and controversy
& j0 Y5 i! I$ j2 Lover the effect of early androgen exposure on adult
5 ~9 V+ r- `: X& F/ apenile length.10,11 Some reports suggest subnormal
) Z& J$ \- ~; X9 _ \' uadult penile length, apparently because of downreg-
4 O, p8 I+ G5 x9 Z5 \6 ~+ eulation of androgen receptor number.10,12 However,
& j; L, Q9 }9 DSutherland et al13 did not find a correlation between8 ~7 v/ `/ \8 p4 Y( K
childhood testosterone exposure and reduced adult
% r5 N3 F8 k4 `8 G$ jpenile length in clinical studies.1 T3 ?; M5 _8 |; ^1 g9 m9 G' @4 k' z
Nonetheless, we do not believe our patient is
7 i# z# W4 t( l3 D& ~9 bgoing to experience any of the untoward effects from9 S+ T. D2 u: C3 G7 C; ~: S8 q7 L
testosterone exposure as mentioned earlier because
, w* _9 p# T' Kthe exposure was not for a prolonged period of time.
7 p; q; c8 ]9 Q2 K4 h6 xAlthough the bone age was advanced at the time of
8 v5 `3 q; u; B; w5 Rdiagnosis, the child had a normal growth velocity at3 m" q9 M9 M( F5 o
the follow-up visit. It is hoped that his final adult
! f" D- y, q2 R+ ` Y/ H+ |- t1 K; Hheight will not be affected.
9 ^- N( T B& v6 I0 yAlthough rarely reported, the widespread avail-' f ?* \8 o7 P. F
ability of androgen products in our society may
& P; A6 H9 P9 ]# {+ I3 pindeed cause more virilization in male or female
0 M# p+ [/ |" Ychildren than one would realize. Exposure to andro-
* z( _6 E% J, Q& L1 d# G7 ggen products must be considered and specific ques-* N4 H' |! C/ p. @8 L
tioning about the use of a testosterone product or" ~; p. R4 U4 M, A
gel should be asked of the family members during6 n1 P) U: r1 ?9 _- m
the evaluation of any children who present with vir-- R1 p, E$ w( u' W/ K/ k8 \
ilization or peripheral precocious puberty. The diag-
1 x+ O0 n. Q) S; C0 pnosis can be established by just a few tests and by1 f8 E' ]7 o) r0 m
appropriate history. The inability to obtain such a5 `' J! |2 w/ j% i% t2 c8 N9 V
history, or failure to ask the specific questions, may
# N7 j; k/ h! V ^8 Q" {result in extensive, unnecessary, and expensive
; u G, a9 O6 }, z/ q, N Rinvestigation. The primary care physician should be7 S* ]1 X; A1 ], v
aware of this fact, because most of these children- `7 t# P4 D: z* d7 A+ ^/ y
may initially present in their practice. The Physicians’
& N" `+ r- b3 b7 \+ b: h$ P/ P! v |Desk Reference and package insert should also put a
. U6 X/ b( ]# e+ t* u2 bwarning about the virilizing effect on a male or
/ r0 w. @/ G, w! ?6 Mfemale child who might come in contact with some-
7 r( t, s) Z* hone using any of these products.$ t# M+ Q4 I+ T$ W1 \- _4 H
References0 V* B9 f8 b. m C/ H9 { o# Y2 s
1. Styne DM. The testes: disorder of sexual differentiation
1 A( F8 b7 C! }0 U2 Fand puberty in the male. In: Sperling MA, ed. Pediatric
% o6 y I O7 p) N" O, Y1 h0 [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders; \$ b& c* G' S. v
2002: 565-628.- b+ S4 m: I# L5 Y
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' V; U$ r! ~+ |# C7 O
puberty in children with tumours of the suprasellar pineal |
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