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Sexual Precocity in a 16-Month-Old
( Z3 }% ~; T# n- _. CBoy Induced by Indirect Topical
: c$ B0 k! o4 G' A5 p* U$ P# l0 {Exposure to Testosterone
/ ]0 X, B) z6 \. ^Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
2 a; B! v* b7 w1 \. Vand Kenneth R. Rettig, MD1
# i0 ?+ j" T: l7 B$ d( l kClinical Pediatrics
) v" M: M' ^' ]( [ UVolume 46 Number 6
7 q% ~" | S7 V8 g# f/ e8 k1 `July 2007 540-5438 I, I' i a& m/ N L8 j8 d' _
© 2007 Sage Publications
) Q1 {7 `6 m; O+ d) C, q/ f10.1177/0009922806296651
/ L4 G3 t7 Y; w, _http://clp.sagepub.com- I9 f/ i* b9 Y3 v+ i4 O& b0 Y
hosted at8 o1 c3 s6 A6 p7 E
http://online.sagepub.com
$ o. `$ T8 q4 E' ^' y. [. b9 j4 cPrecocious puberty in boys, central or peripheral,4 e3 _* ]: |4 l; }$ u1 F* S
is a significant concern for physicians. Central
7 _/ l6 x! \$ c$ o1 Z4 h! o, D2 eprecocious puberty (CPP), which is mediated I( w8 |3 k4 _3 y c& N. }8 o
through the hypothalamic pituitary gonadal axis, has
$ u; r7 D/ {9 _5 u7 ha higher incidence of organic central nervous system y8 x/ J* `) k! f6 Q* g0 \% ^
lesions in boys.1,2 Virilization in boys, as manifested
" L* z/ y3 E% Q m( bby enlargement of the penis, development of pubic# D3 x4 [) R7 R/ v# Z C
hair, and facial acne without enlargement of testi-
' a6 n9 c( `6 C5 icles, suggests peripheral or pseudopuberty.1-3 We
* |. k+ r0 t: @: e/ Sreport a 16-month-old boy who presented with the
& }& X$ D% |- t. z- \! @. Yenlargement of the phallus and pubic hair develop-; f9 {9 B! k( Y$ S
ment without testicular enlargement, which was due. M8 R# _1 `# l1 M: y, \! ]
to the unintentional exposure to androgen gel used by
0 ]% Z: D; W& }/ y6 ~* `the father. The family initially concealed this infor-
5 V+ d9 q. ~" M* {mation, resulting in an extensive work-up for this) ]/ Z6 f8 G1 W$ q/ L0 N
child. Given the widespread and easy availability of$ S5 ~8 i9 `. _* T' [
testosterone gel and cream, we believe this is proba-
2 E; x2 s. ~! M( Ubly more common than the rare case report in the
& X6 `6 b/ l- H$ A( Y; o' |literature.4
& V' R- T; c B4 yPatient Report
* |) [/ M! s, m- bA 16-month-old white child was referred to the6 I4 \ s- N- z9 N( z" p7 Y
endocrine clinic by his pediatrician with the concern
" P$ Q+ q2 T6 f! aof early sexual development. His mother noticed1 P0 y9 e; P0 L- C! \8 j" l$ S5 F
light colored pubic hair development when he was
4 y- V: d+ U3 s$ x4 ~From the 1Division of Pediatric Endocrinology, 2University of
3 v0 L+ m: ~+ W, h. C% G) T- iSouth Alabama Medical Center, Mobile, Alabama.% {/ @( n0 q0 |' s* p# p4 G# E
Address correspondence to: Samar K. Bhowmick, MD, FACE,
4 D9 l# s& J' r AProfessor of Pediatrics, University of South Alabama, College of3 v8 b3 A: v! P" f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 s3 }. h/ f1 re-mail: [email protected].
2 J! b: ~7 N4 T% x# Fabout 6 to 7 months old, which progressively became
$ v3 H8 e9 f3 b% A; Y) |$ ddarker. She was also concerned about the enlarge-
, ^( _! V# Q3 e+ Yment of his penis and frequent erections. The child& c0 P- n4 B* i3 t$ q4 z- J+ j9 u9 L
was the product of a full-term normal delivery, with
# p6 x2 \" T) l: sa birth weight of 7 lb 14 oz, and birth length of
8 g( g2 p; {# G" ]3 z1 v6 n0 o20 inches. He was breast-fed throughout the first year3 y" \+ B* {& T. M
of life and was still receiving breast milk along with
+ k9 q, @4 ]( W/ j Dsolid food. He had no hospitalizations or surgery,
$ ]. P1 A$ b6 O* Uand his psychosocial and psychomotor development
! c' ~* E' n' x& B% M3 `was age appropriate.
6 I2 r; z$ D# R' t3 XThe family history was remarkable for the father,
" M3 o |3 G C: M& h }who was diagnosed with hypothyroidism at age 16,
8 ?- l2 F7 S3 e4 I( X; h8 h% _2 awhich was treated with thyroxine. The father’s3 P. K' y4 b4 F8 m) P! y
height was 6 feet, and he went through a somewhat
# y1 I+ h; p6 k2 h5 m7 dearly puberty and had stopped growing by age 14.2 g- Y9 \; O8 `% s+ o$ s. l
The father denied taking any other medication. The
9 a' N# U* y4 {! I! M" |1 V9 bchild’s mother was in good health. Her menarche
- A% _& v! _" Iwas at 11 years of age, and her height was at 5 feet
& v* n. d8 ~( r/ k! ^3 Y5 inches. There was no other family history of pre-
$ P* |) ^9 I! ]: V2 O8 e$ Zcocious sexual development in the first-degree rela-# E) E8 U' A8 b' W* K5 Q
tives. There were no siblings.
% X4 r, Y' Z# l, IPhysical Examination, [* r; T* E2 J* Q$ L
The physical examination revealed a very active,
/ W" c" a8 }6 [2 w0 `3 W- Splayful, and healthy boy. The vital signs documented
. F# d1 T& _$ T# F, {+ ]a blood pressure of 85/50 mm Hg, his length was
( \* \/ m7 d5 x& V$ B+ _90 cm (>97th percentile), and his weight was 14.4 kg
: L" Q: P7 ^. \3 G( b' X(also >97th percentile). The observed yearly growth K- S3 O7 X) V6 l
velocity was 30 cm (12 inches). The examination of
, p+ j- |6 q" X0 [3 v/ p0 `. Mthe neck revealed no thyroid enlargement.
9 I: N# c4 U0 W" [5 |The genitourinary examination was remarkable for
8 H8 R. U$ {% _7 p& S, Kenlargement of the penis, with a stretched length of
. @& A) O0 O* I8 cm and a width of 2 cm. The glans penis was very well
: x( T% l0 {8 K! t5 b b5 ~developed. The pubic hair was Tanner II, mostly around
- z! P$ F, E' J4 ^: r4 r% S3 C- H u540( D. U. _' f0 Z9 f" u3 \- ^3 c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* y" G( ?/ _0 `. s5 G4 j) uthe base of the phallus and was dark and curled. The
) F9 Q, `0 @2 \, R1 w+ F4 rtesticular volume was prepubertal at 2 mL each.. j+ {' C& v: _9 q- m+ _
The skin was moist and smooth and somewhat
0 W' U7 e3 Z( p% w- J5 p6 ioily. No axillary hair was noted. There were no
/ t! _2 j( F" s- G4 Sabnormal skin pigmentations or café-au-lait spots.5 J* v+ _; a# p
Neurologic evaluation showed deep tendon reflex 2+5 B) I9 y/ q& F8 B# q
bilateral and symmetrical. There was no suggestion
' a; l; S" n3 M! r7 u/ qof papilledema.0 x0 `1 F8 ~+ V$ D. Z9 d
Laboratory Evaluation
$ A+ N2 R3 ?/ WThe bone age was consistent with 28 months by
( A" b. c0 C/ Z; f& X; J$ Eusing the standard of Greulich and Pyle at a chrono-, T# D5 N- M' A, e7 G5 \" c
logic age of 16 months (advanced).5 Chromosomal* e8 s/ @% Q. a1 ]
karyotype was 46XY. The thyroid function test% P5 A, u# ?0 l: M# T
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
$ Y7 y" \* c9 plating hormone level was 1.3 µIU/mL (both normal).' a2 }- w0 N$ g3 R7 j4 c- N/ [
The concentrations of serum electrolytes, blood
/ }4 W; O4 M9 Nurea nitrogen, creatinine, and calcium all were
4 d- D' m/ l2 n! f5 w7 V2 lwithin normal range for his age. The concentration$ {1 b. S$ Z6 I% Q
of serum 17-hydroxyprogesterone was 16 ng/dL
% O& p- }$ ]' ?& o. Q(normal, 3 to 90 ng/dL), androstenedione was 20
c5 W, _" j1 k+ f9 s3 r2 Mng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
( k/ _6 X; G; \: E8 z; i2 R! X2 uterone was 38 ng/dL (normal, 50 to 760 ng/dL),
" t1 L- G, A% v+ i9 Odesoxycorticosterone was 4.3 ng/dL (normal, 7 to
/ z( p$ t9 I7 E p) Z. r R" [49ng/dL), 11-desoxycortisol (specific compound S)
& @5 P1 t3 j/ N6 ~9 v- awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 `8 q& @ r2 l$ g4 `+ H5 u7 @/ jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
+ `& l7 ~( L6 H8 e: x4 C3 y/ Ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ `) P$ X/ Y* j' {0 I) l
and β-human chorionic gonadotropin was less than) c$ I+ E2 y( @$ D4 y8 K
5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 c3 V0 ]# V* Fstimulating hormone and leuteinizing hormone, Y0 C6 n% |* ?" }2 n6 `- [
concentrations were less than 0.05 mIU/mL
- A+ f# j) ~5 T2 J9 i(prepubertal).
+ q" d5 K; K p! B; ^! Y, t5 u3 uThe parents were notified about the laboratory8 Q) u% p- K! S6 z8 ~
results and were informed that all of the tests were5 _1 n$ s0 q2 k+ @
normal except the testosterone level was high. The- Y) @& o& U& A% Z" l: w
follow-up visit was arranged within a few weeks to; G: e7 \0 {+ P( U4 n% E
obtain testicular and abdominal sonograms; how-
( L$ r" r$ }, ]% v4 zever, the family did not return for 4 months.
$ V8 H: R, ?. A8 @) v' IPhysical examination at this time revealed that the
# L( r7 n) v7 I: j9 _$ _0 nchild had grown 2.5 cm in 4 months and had gained
1 L F" @2 I0 q) p! c; P: P2 kg of weight. Physical examination remained; k) v3 m( C. x
unchanged. Surprisingly, the pubic hair almost com-
- l7 M" r" ] j/ I% Gpletely disappeared except for a few vellous hairs at$ X+ D. L! f+ F) S/ R
the base of the phallus. Testicular volume was still 2
" H* F. O3 i( N; {$ @! OmL, and the size of the penis remained unchanged.
3 c1 f1 g" E% |7 p# c- a2 V& FThe mother also said that the boy was no longer hav-( r7 S$ j$ A1 R0 [, ]3 i8 L
ing frequent erections.
/ x% s4 q. i7 CBoth parents were again questioned about use of
6 h- X, P0 \5 X: @ tany ointment/creams that they may have applied to: ^' i" N% w- \6 N! `
the child’s skin. This time the father admitted the
( ` _+ d. Z' s+ ^. TTopical Testosterone Exposure / Bhowmick et al 541( k% v5 ` v- s2 Q
use of testosterone gel twice daily that he was apply-
! S7 U$ }- A5 R" i; j$ Z3 K `ing over his own shoulders, chest, and back area for
@6 m1 v) m, N# Ta year. The father also revealed he was embarrassed
* z7 I, a9 V, T( c& ]2 ^, Uto disclose that he was using a testosterone gel pre-6 }, a# c8 i e) A; g/ Q9 C: Y2 Y
scribed by his family physician for decreased libido
$ B) D$ ]+ U' Ysecondary to depression.
. w" w( H1 V- sThe child slept in the same bed with parents.
9 f: `" o' _- g" Q1 WThe father would hug the baby and hold him on his, J' a5 c% Y# a$ b
chest for a considerable period of time, causing sig-6 p5 C, z7 I+ g3 H
nificant bare skin contact between baby and father.
: a. l/ d2 |# l+ Y: PThe father also admitted that after the phone call,
9 F+ w) I; }. kwhen he learned the testosterone level in the baby
' {% k7 E0 j8 j$ o4 \8 T- Ewas high, he then read the product information" I9 m3 Z) E& a" H
packet and concluded that it was most likely the rea-
. V* k# d3 J0 v- Ason for the child’s virilization. At that time, they( K1 T# _' |' R% z+ A8 U# U
decided to put the baby in a separate bed, and the" X6 ` ]# C# h. V1 f0 [
father was not hugging him with bare skin and had1 n* `( P5 \* V- `4 `# Y, U
been using protective clothing. A repeat testosterone
' ^# Y5 U7 r9 c* U9 S; i% stest was ordered, but the family did not go to the
3 Z# `' |. ?: W- \2 g: ^' d9 Dlaboratory to obtain the test.
$ o, F6 r3 e! j9 i j2 R; r, `4 iDiscussion/ R2 g! \9 N1 O2 a& Y) K. L: E
Precocious puberty in boys is defined as secondary
^6 ?. E% n" M4 ysexual development before 9 years of age.1,4
( }6 F9 ?" p5 L8 @7 g! UPrecocious puberty is termed as central (true) when
+ s8 H K s) E& Jit is caused by the premature activation of hypo-
! W% C! Z e2 qthalamic pituitary gonadal axis. CPP is more com-1 L3 Z; N5 f+ c
mon in girls than in boys.1,3 Most boys with CPP
( x+ b9 D6 m$ ^! F9 gmay have a central nervous system lesion that is. Y1 }$ }' s) p3 o
responsible for the early activation of the hypothal-% Q0 m5 f' G3 F$ q$ J- _
amic pituitary gonadal axis.1-3 Thus, greater empha-
# ^/ }9 j- ~1 Gsis has been given to neuroradiologic imaging in# ]) J9 E& V* Y A6 z9 Z0 d4 W
boys with precocious puberty. In addition to viril-) R! x. w o; Z8 I6 S( n6 C' b
ization, the clinical hallmark of CPP is the symmet-
2 Q( L; R `& u- _rical testicular growth secondary to stimulation by5 [' R C( h* g0 H$ n
gonadotropins.1,3
; \2 b$ V8 ~( t; T: V7 a$ i7 `Gonadotropin-independent peripheral preco-
1 A( e. |7 C/ U/ V1 O3 ^% lcious puberty in boys also results from inappropriate
, f& q! R' {2 l. @3 Wandrogenic stimulation from either endogenous or
# [2 E! m: F% b9 cexogenous sources, nonpituitary gonadotropin stim-
3 c3 I: n2 L! k; N! H# ]ulation, and rare activating mutations.3 Virilizing2 R- m, W) N8 j1 h, O# ?9 R
congenital adrenal hyperplasia producing excessive) v4 \+ L7 a8 p# S& X0 o
adrenal androgens is a common cause of precocious
2 |" b! c/ X0 i( a R+ ~1 d$ [; y% Fpuberty in boys.3,4
, w. b/ r W; G8 ~# ^2 ZThe most common form of congenital adrenal* X% Y3 k- [$ W2 F j& `! B
hyperplasia is the 21-hydroxylase enzyme deficiency.
' L- ^0 D. i9 {. }The 11-β hydroxylase deficiency may also result in5 [) P8 _2 Z$ C5 u
excessive adrenal androgen production, and rarely,
4 I8 d1 \# f! E7 M" Can adrenal tumor may also cause adrenal androgen
; a4 N6 O5 r/ x, p6 ^) sexcess.1,3- u3 G6 ^) i( t7 p( E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from& a$ G' L+ \& T
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
: w: d. x7 T, q8 x7 h4 UA unique entity of male-limited gonadotropin-
* \" ?2 P! z' O- d. O: \) Dindependent precocious puberty, which is also known# \' Q( I! G# W) I# d. D" x! O
as testotoxicosis, may cause precocious puberty at a
$ u) P, \7 a4 {" Uvery young age. The physical findings in these boys
. m- [! J" O) Twith this disorder are full pubertal development,
- ?7 I3 `9 Z1 @ t; {including bilateral testicular growth, similar to boys
9 n' I; ]" f. i2 S! I; t4 ~with CPP. The gonadotropin levels in this disorder4 g5 ?( g: X5 A, p5 C4 K
are suppressed to prepubertal levels and do not show9 z S* e. N/ s, M/ k6 B
pubertal response of gonadotropin after gonadotropin-
; w6 l9 p7 [6 mreleasing hormone stimulation. This is a sex-linked
. ^+ l& o/ n4 h. M5 ^: N& Uautosomal dominant disorder that affects only$ d/ k0 X: N4 I& t( ~; c
males; therefore, other male members of the family
6 M! K* h" Q2 h1 smay have similar precocious puberty.3
9 Z+ v* _- t* Z. F# lIn our patient, physical examination was incon-
% C0 T, X5 G. `, D- D* s$ J# k8 Vsistent with true precocious puberty since his testi-
0 I; o4 e5 P' g4 T) Acles were prepubertal in size. However, testotoxicosis
( O1 Y( q8 T6 `) Twas in the differential diagnosis because his father* e/ F, y8 ?2 j3 \
started puberty somewhat early, and occasionally,
$ Z, x; t$ u0 [- L! |8 Atesticular enlargement is not that evident in the3 m6 n; E+ B, |9 p, t( w7 c4 v9 t' ?. v
beginning of this process.1 In the absence of a neg-* \! X- y* ^1 x D
ative initial history of androgen exposure, our1 Q( d8 z6 }2 z9 a
biggest concern was virilizing adrenal hyperplasia,, N- ^: L, S4 x7 k, C
either 21-hydroxylase deficiency or 11-β hydroxylase
3 {8 m0 O+ F/ d0 C: y$ ?" Pdeficiency. Those diagnoses were excluded by find-
, b9 c1 U* D4 p! i; U6 Ding the normal level of adrenal steroids.( i1 ?+ c4 q9 V* c$ ?9 b' ^* n
The diagnosis of exogenous androgens was strongly
" c& V4 X5 W6 g4 Csuspected in a follow-up visit after 4 months because
1 ^3 m2 }* T- M- B% v8 w8 k5 `. ithe physical examination revealed the complete disap-2 O! O; U2 D& l, i# J) z' B- d r0 B
pearance of pubic hair, normal growth velocity, and8 Q! k9 M9 w6 p" s& ?9 M- p
decreased erections. The father admitted using a testos-
& x+ Z- O9 ]% y$ s$ O6 h1 |. Kterone gel, which he concealed at first visit. He was
. n$ C% g8 r/ ^) p/ o6 [using it rather frequently, twice a day. The Physicians’
3 Z4 G. z" p: S1 p# L6 vDesk Reference, or package insert of this product, gel or0 W5 O2 Y" N1 L! u7 f+ Y
cream, cautions about dermal testosterone transfer to
0 M! S, J8 W* C, P; ? U7 tunprotected females through direct skin exposure.
6 W4 U& N3 X) D- b" ^3 w& OSerum testosterone level was found to be 2 times the
7 Y3 }: Y" { K e5 X) @$ ]baseline value in those females who were exposed to
6 f1 k( g, w; a3 g, n$ weven 15 minutes of direct skin contact with their male
" B0 O# l2 C' r, v$ qpartners.6 However, when a shirt covered the applica-3 x) F1 L* i3 S
tion site, this testosterone transfer was prevented.7 N) f2 m' f0 Y1 j
Our patient’s testosterone level was 60 ng/mL,9 _. o5 x6 O# N$ }; U$ r$ V4 x
which was clearly high. Some studies suggest that
8 o4 S& Y3 I5 [) _. G4 Rdermal conversion of testosterone to dihydrotestos-
, H; h! b# ~# L/ c: u" g8 Qterone, which is a more potent metabolite, is more/ }( d/ C) ] ?4 Y0 ~
active in young children exposed to testosterone
. s# w" W) p+ R5 K% s- ]9 g' i* lexogenously7; however, we did not measure a dihy-* ~- h* T9 \+ z0 j# n, ~
drotestosterone level in our patient. In addition to
. x0 q+ H7 [7 p. R3 f( w/ ?; `virilization, exposure to exogenous testosterone in
5 m5 a0 m P" lchildren results in an increase in growth velocity and5 k# O; G7 A- o: \
advanced bone age, as seen in our patient.
# l8 O5 h+ S, e: c+ ?* rThe long-term effect of androgen exposure during
! k- E8 a; y9 bearly childhood on pubertal development and final
2 V# l7 O6 J" Z" Cadult height are not fully known and always remain
W% I5 Y, T0 M: z+ R3 ?a concern. Children treated with short-term testos-
* I+ q% {% R! tterone injection or topical androgen may exhibit some2 t0 Q. }& s( m! `/ U
acceleration of the skeletal maturation; however, after
& O( g: O) z) E5 g' Fcessation of treatment, the rate of bone maturation2 i, e; m1 L0 K& B# p4 C
decelerates and gradually returns to normal.8,9% R6 I5 c V$ y0 |
There are conflicting reports and controversy. G' Z( H2 y5 @4 Q+ R1 T' e2 D8 C
over the effect of early androgen exposure on adult
/ I# [' t- Q4 P4 Ipenile length.10,11 Some reports suggest subnormal
% O ^1 ?; I3 M# P- i' d8 radult penile length, apparently because of downreg-5 z7 I7 p2 E8 N; M0 M
ulation of androgen receptor number.10,12 However,
: n A$ _. [& Y+ h& N- u' j1 G9 pSutherland et al13 did not find a correlation between
: S Q I8 n. E7 N e6 e. n) T- r+ d; Rchildhood testosterone exposure and reduced adult n0 a+ \7 j! M1 |* ^
penile length in clinical studies., _7 R& p9 F' z" c. f4 K9 W% b7 {+ s
Nonetheless, we do not believe our patient is, @4 T2 }8 z! c; w# {5 ?
going to experience any of the untoward effects from7 ~& e% |0 r6 u" y0 r- w
testosterone exposure as mentioned earlier because
8 S1 W7 p) d# ?8 m9 V. i% ethe exposure was not for a prolonged period of time.3 k: `! W) C4 ~3 E5 M7 j1 P
Although the bone age was advanced at the time of
& m. _7 F& ~) j( Zdiagnosis, the child had a normal growth velocity at7 n6 h7 n {# A5 F; [. X
the follow-up visit. It is hoped that his final adult" ~+ V. V2 u9 b* n6 c% I
height will not be affected. Y/ q |+ ]5 H2 W) ~
Although rarely reported, the widespread avail-
% k8 S/ q: M7 |* e+ w7 D3 H: Kability of androgen products in our society may
. U4 f9 t7 e0 }. U6 D% G+ findeed cause more virilization in male or female
% n5 `4 D$ f9 xchildren than one would realize. Exposure to andro-5 Q3 y" b5 y0 g3 Z
gen products must be considered and specific ques-0 K! e) ?6 Y5 c
tioning about the use of a testosterone product or
1 ^/ A5 b. `5 }gel should be asked of the family members during
) Z7 R5 C' e+ W6 a- Zthe evaluation of any children who present with vir-
" b0 T4 X. k+ \+ ailization or peripheral precocious puberty. The diag-
& V6 H; P/ e5 K! Q. \nosis can be established by just a few tests and by0 ] X# K( S5 K' T" Y+ C. T+ ]" x
appropriate history. The inability to obtain such a
5 O7 A1 ^6 b7 a9 n- [, x6 @history, or failure to ask the specific questions, may
, c4 O" B2 W; m- Wresult in extensive, unnecessary, and expensive y- m; {0 \ D; k
investigation. The primary care physician should be" x: s. }" t: P8 T/ j
aware of this fact, because most of these children( J3 m2 T4 \( Q8 h% _; n; q
may initially present in their practice. The Physicians’
3 [. x# u2 z* g1 JDesk Reference and package insert should also put a
$ I0 O* G% Y1 a( l/ b8 g$ awarning about the virilizing effect on a male or
m% H9 F p0 g2 `female child who might come in contact with some-
: P$ i6 {3 i; ~$ G) C! A4 \0 ^# fone using any of these products.2 P! `% A/ S) ]: ~
References# q ~9 g9 E( w3 p6 ]( i7 H
1. Styne DM. The testes: disorder of sexual differentiation
. x3 _1 A- Q' hand puberty in the male. In: Sperling MA, ed. Pediatric
/ h; j D* f Z3 U+ j. k& [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;+ ^/ E: N! T# T8 J
2002: 565-628.
5 |, M' G- L1 { n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious# p7 ~( }4 L* J$ H: g Q. v, }
puberty in children with tumours of the suprasellar pineal |
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