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Sexual Precocity in a 16-Month-Old6 J8 q9 b$ F, K. d3 }3 L$ I
Boy Induced by Indirect Topical6 Y+ ]8 [! S p
Exposure to Testosterone
& B/ s6 @! }1 U" \1 T) R/ wSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2; w: V" \! S( [- }) x/ f
and Kenneth R. Rettig, MD1
1 R( ^) h; W6 a* ?Clinical Pediatrics) R. W( [$ D8 A/ b3 S/ r/ q6 x0 N$ N
Volume 46 Number 6
& ~; X1 }) N, J' A; e! R9 Z# MJuly 2007 540-5433 e# Z# x* V' R# U8 z
© 2007 Sage Publications5 U& J6 p: `$ F$ s1 S" l% J+ S( q
10.1177/0009922806296651) l+ o) ~% R ^, z
http://clp.sagepub.com5 N; l- T% Z. s
hosted at
9 Z6 a* R/ r1 e( Ahttp://online.sagepub.com
2 h$ g. f9 ~, A3 LPrecocious puberty in boys, central or peripheral,
2 I# s: G% ?! M* Z8 ~is a significant concern for physicians. Central& \& i) i9 b+ s2 y* o! D+ b! g8 [
precocious puberty (CPP), which is mediated
9 P8 L2 Y0 k) }7 Tthrough the hypothalamic pituitary gonadal axis, has8 h: {8 E6 {- ^
a higher incidence of organic central nervous system2 U- u5 E* [' K; h6 B; l
lesions in boys.1,2 Virilization in boys, as manifested8 y; D$ H0 @2 |; [$ f; r7 u( I
by enlargement of the penis, development of pubic
' D/ d: v, O1 Q( m7 phair, and facial acne without enlargement of testi-8 Z7 @3 _7 s+ q& q/ m. o
cles, suggests peripheral or pseudopuberty.1-3 We
% h# P5 f+ _' S- l! X) \. X; H8 xreport a 16-month-old boy who presented with the
* ^& w. Z3 @8 D: A+ o9 Venlargement of the phallus and pubic hair develop-
& P4 w/ a$ d+ ~& F: }7 Z% Vment without testicular enlargement, which was due
+ y, z0 w( h% B& V: k5 m" {3 ito the unintentional exposure to androgen gel used by6 R* P% v$ B5 | }
the father. The family initially concealed this infor-
/ ~( V, @$ A/ D3 Q% smation, resulting in an extensive work-up for this# L9 Z7 C# i3 n4 f4 Y0 M* M% d4 n
child. Given the widespread and easy availability of
* t* h" Q- e% h) V! h( D) Ttestosterone gel and cream, we believe this is proba-! z- I- Y4 Q* v6 b
bly more common than the rare case report in the! A) O$ ]. B3 t! s
literature.4
( @; h0 v5 s( \1 ~Patient Report
8 m# ~8 C9 B/ D, M- X jA 16-month-old white child was referred to the
$ F* P$ z2 o. E4 O( @/ hendocrine clinic by his pediatrician with the concern
$ L* ]3 K* W& |) O* ^. t# Zof early sexual development. His mother noticed
/ O3 q8 g/ l( I( `& P: clight colored pubic hair development when he was
" j/ l- D9 Q0 `. ~7 M$ BFrom the 1Division of Pediatric Endocrinology, 2University of& r+ N N8 p6 q5 G; O
South Alabama Medical Center, Mobile, Alabama.
% l. o6 g: n3 D, k% _Address correspondence to: Samar K. Bhowmick, MD, FACE,# O! T9 |6 N! }) s9 W
Professor of Pediatrics, University of South Alabama, College of- t$ l& |7 l" r8 F# J# v. ?
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- K4 @- [- Z0 F5 be-mail: [email protected].. P; _3 o4 U8 V, h/ w8 [, f& y! U
about 6 to 7 months old, which progressively became
+ ^9 \" _& G6 @+ r4 j \1 Wdarker. She was also concerned about the enlarge-
& J4 I3 m" U6 n' ^+ M6 l6 N% S" i- yment of his penis and frequent erections. The child H- `9 m) O" o/ X$ \
was the product of a full-term normal delivery, with4 z$ p$ X* x* V5 a- Z; m
a birth weight of 7 lb 14 oz, and birth length of$ b. n" n! |/ G# U% ]3 L& T3 P
20 inches. He was breast-fed throughout the first year
( T; U/ t0 a% B n5 Uof life and was still receiving breast milk along with
. `2 O7 j8 L! ]9 E6 W0 v8 ]solid food. He had no hospitalizations or surgery,
6 g# h4 i2 ~1 _, B6 gand his psychosocial and psychomotor development: i' H& _* q) V4 p8 ^5 ]" r
was age appropriate.# Y3 g ?- s& {) l8 X2 o
The family history was remarkable for the father,: ~4 m! v8 h7 L( w; d7 N
who was diagnosed with hypothyroidism at age 16,
1 k) ^' @. g# gwhich was treated with thyroxine. The father’s L) z8 t1 W1 `# t
height was 6 feet, and he went through a somewhat8 o: U- t0 y e- N
early puberty and had stopped growing by age 14.
6 Q* k# S8 F% y0 |4 \* D6 j* pThe father denied taking any other medication. The6 v/ ?# F6 x1 x6 K0 V0 p
child’s mother was in good health. Her menarche" r+ x! q- Y6 j
was at 11 years of age, and her height was at 5 feet+ n2 R( q% p( a! y
5 inches. There was no other family history of pre-
. d' f: q. }8 V* t3 H2 \9 c! Scocious sexual development in the first-degree rela-
1 T$ {0 I+ _7 F( y' {3 J+ Ltives. There were no siblings.9 T, }! V& f1 T5 ~) i
Physical Examination- M' l* c8 v' t* d1 B$ F
The physical examination revealed a very active,
& W; G4 M+ T/ y8 eplayful, and healthy boy. The vital signs documented
: j0 G' {$ K9 F" v1 T8 Q6 I, ^+ Ea blood pressure of 85/50 mm Hg, his length was4 U# T) q H" U* ]
90 cm (>97th percentile), and his weight was 14.4 kg+ s# [1 U, l, _) e: Z' f( x' B
(also >97th percentile). The observed yearly growth
3 w. H A" @& b1 N+ xvelocity was 30 cm (12 inches). The examination of
$ S# {6 D' a0 {2 x2 A- D! E& tthe neck revealed no thyroid enlargement.
/ A& y8 K* @& T. G$ MThe genitourinary examination was remarkable for
' [# u! r* B/ q; X- s' Jenlargement of the penis, with a stretched length of
6 v$ c( H6 e" b* T* ~/ k( f# M+ M8 cm and a width of 2 cm. The glans penis was very well
h8 e+ ?- r4 ddeveloped. The pubic hair was Tanner II, mostly around
! a2 W7 K8 N" y- t4 {4 H( V6 ^- z540
: P3 D* ~6 [, Q iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' [' [9 K u! I& zthe base of the phallus and was dark and curled. The. l0 @- X0 s1 k$ w
testicular volume was prepubertal at 2 mL each.1 o6 A9 R, Z$ W( S
The skin was moist and smooth and somewhat
; M. Q9 B, \% J7 A# Foily. No axillary hair was noted. There were no& [3 m6 v5 T( ?
abnormal skin pigmentations or café-au-lait spots.
+ B' X9 Z- p! K* B2 {Neurologic evaluation showed deep tendon reflex 2+
/ b& u5 A1 R6 v% T" r: Y) kbilateral and symmetrical. There was no suggestion
; I2 k% g" x5 q! Wof papilledema.$ W" v4 s0 r1 N4 ?
Laboratory Evaluation9 f+ \* W+ G( v9 C. {6 c
The bone age was consistent with 28 months by
' n4 m0 X* N3 q h5 w, {" ]using the standard of Greulich and Pyle at a chrono-1 l2 q# g4 j# l( g, G4 u) L
logic age of 16 months (advanced).5 Chromosomal/ W( S5 J0 x3 X \: ~4 A8 }% d4 f
karyotype was 46XY. The thyroid function test1 z* e5 U1 D0 D& G
showed a free T4 of 1.69 ng/dL, and thyroid stimu-9 }# `/ \, w7 ^
lating hormone level was 1.3 µIU/mL (both normal).
8 U7 |3 y4 q* D' nThe concentrations of serum electrolytes, blood
" d, Z3 d \9 Y) ~6 z* }! Rurea nitrogen, creatinine, and calcium all were! @5 N d5 ]8 q, K$ K9 l
within normal range for his age. The concentration
6 }8 w+ h0 V, E+ Mof serum 17-hydroxyprogesterone was 16 ng/dL
" r9 Y8 E" S' g9 {2 t) v( k' S(normal, 3 to 90 ng/dL), androstenedione was 20+ |1 e0 H0 h2 V* d5 |- C( P% ]1 W5 c' h
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
2 r( n, i6 x `: r- ]+ c, i1 ?" pterone was 38 ng/dL (normal, 50 to 760 ng/dL),
0 G3 u- s6 B3 o8 fdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
* J" }6 E3 A! l7 C3 x49ng/dL), 11-desoxycortisol (specific compound S)! X, E- p3 p! I0 r3 I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 G/ c$ C; ]& V8 A! w$ k1 B' E/ v# wtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 J- x( ~5 `* ]: z7 R$ _6 z( x
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! @. [0 g$ w" k6 G% T: uand β-human chorionic gonadotropin was less than9 q) e& x3 S, K' ~, K. I
5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 c( }& u7 j5 ]6 ]- D( [+ r5 I1 o' ~- ^" |stimulating hormone and leuteinizing hormone* i. p% Z% l" P- }8 ?- B4 J$ V
concentrations were less than 0.05 mIU/mL6 F+ e# b z X5 o4 b1 t4 u
(prepubertal).: x7 @9 n9 M5 Z) w
The parents were notified about the laboratory
& V) M& `2 O1 o, r+ Bresults and were informed that all of the tests were
% n8 x/ w6 g2 [# X8 y( f$ n" ynormal except the testosterone level was high. The6 b" Y* o: {4 ?& L4 |- R' _" [0 K5 k
follow-up visit was arranged within a few weeks to
" y5 F. I& s9 Z: [+ K8 V1 gobtain testicular and abdominal sonograms; how-6 @% H6 `8 O; G9 {; V# r
ever, the family did not return for 4 months.4 L+ Q) h% T+ M, P5 f' b% g) w
Physical examination at this time revealed that the' \ G( h9 s8 e/ X7 I+ B5 P
child had grown 2.5 cm in 4 months and had gained
9 C |. V0 ]; ^! E% R4 @% o; }5 s$ i2 kg of weight. Physical examination remained# w, ~; s1 E! i, K! O( D
unchanged. Surprisingly, the pubic hair almost com-2 t. M4 M4 L/ k/ N) @ ~" K
pletely disappeared except for a few vellous hairs at9 _, Q5 G+ \( ]9 v
the base of the phallus. Testicular volume was still 2
( B' N# f8 o, l0 @; cmL, and the size of the penis remained unchanged.
9 K/ n5 H9 Z- gThe mother also said that the boy was no longer hav-: x1 l% R* r% y% ?; F- E& R, \
ing frequent erections.
' z) V5 a2 o+ g4 [Both parents were again questioned about use of
H4 v) A! y7 dany ointment/creams that they may have applied to
+ `/ U. u* E5 z; \& {7 vthe child’s skin. This time the father admitted the+ f, }: J: A; w% G" ^; r( q
Topical Testosterone Exposure / Bhowmick et al 541
7 k5 o, m" V1 @( ~use of testosterone gel twice daily that he was apply-
# _) G) ?1 A- z# h2 p E4 K: b, wing over his own shoulders, chest, and back area for2 {% u$ B: d7 [* l
a year. The father also revealed he was embarrassed7 I7 t, ]" c: `) d9 C: w: E4 I
to disclose that he was using a testosterone gel pre-) D* |' I- f( w# ?
scribed by his family physician for decreased libido
+ c' Q( J7 V& m: ?: M4 w" Usecondary to depression.: }' a/ l) F4 n3 ~# M
The child slept in the same bed with parents.1 |% v4 Z, ?% U9 b( Z
The father would hug the baby and hold him on his( |( }* z: }( ?, g {, ^
chest for a considerable period of time, causing sig-
' b6 S$ |0 d4 p snificant bare skin contact between baby and father.. t! L" U, u' r+ f$ ]
The father also admitted that after the phone call,
3 S) F* Z+ B$ J- N+ _$ Twhen he learned the testosterone level in the baby
' W6 X- ?: i- ~# x$ y: [, y$ x: q qwas high, he then read the product information
- Q1 w, o5 X" Y- P3 `' E- Dpacket and concluded that it was most likely the rea-
' I2 b( g: z9 sson for the child’s virilization. At that time, they
) J6 V! E6 q( X: j% L- o5 o' _7 Pdecided to put the baby in a separate bed, and the" A$ |. q" @# [) U
father was not hugging him with bare skin and had
1 b% E2 z* }$ P* s+ U& fbeen using protective clothing. A repeat testosterone
. g2 i7 x6 z9 ^, xtest was ordered, but the family did not go to the
) _* ^4 l6 H- L$ G8 z/ Ulaboratory to obtain the test.+ L/ ~# v( S2 h8 w8 G: M
Discussion
2 K- p1 w( m; n7 e( b6 t. QPrecocious puberty in boys is defined as secondary
1 M% m* V- k, i8 H# d$ u4 u' gsexual development before 9 years of age.1,4- u& e: T5 Y4 b" L' D2 P. r
Precocious puberty is termed as central (true) when, t/ ~+ {0 Z. h: q! c) e2 U$ Z/ f
it is caused by the premature activation of hypo-/ t. ~ w$ D- v
thalamic pituitary gonadal axis. CPP is more com-2 ?& ^; X, L$ `) w3 `, F
mon in girls than in boys.1,3 Most boys with CPP
' l- A* U6 X7 W8 dmay have a central nervous system lesion that is) Z! E$ X/ }* L/ U# @
responsible for the early activation of the hypothal-
! z1 U: P+ R! i @, x+ h1 V) Samic pituitary gonadal axis.1-3 Thus, greater empha-
, T8 `) G# L0 p d8 jsis has been given to neuroradiologic imaging in
, |; v5 s, ^ G: p5 D4 z0 Nboys with precocious puberty. In addition to viril-- s) Z& H6 j7 q* O, t5 j! q
ization, the clinical hallmark of CPP is the symmet-
: E$ S4 O3 a& Krical testicular growth secondary to stimulation by
( v. D: ~& y! Y: d8 \7 K3 i% egonadotropins.1,3
0 V4 H* | i& j D% X# E) PGonadotropin-independent peripheral preco-4 R" j/ S( k! _0 x8 x Q6 {
cious puberty in boys also results from inappropriate
1 R& S% K g$ p9 d: fandrogenic stimulation from either endogenous or
$ A+ V$ I0 @5 G4 M: n4 a$ eexogenous sources, nonpituitary gonadotropin stim-
5 c+ B6 r! y0 Q" Zulation, and rare activating mutations.3 Virilizing" R+ L( C+ s2 O) K8 u
congenital adrenal hyperplasia producing excessive
$ u0 T% x! K: {1 M0 l+ Z4 xadrenal androgens is a common cause of precocious
F. f1 X* c7 X% \# N$ H, _1 Upuberty in boys.3,4
8 R7 l3 t7 v+ @# v: U9 MThe most common form of congenital adrenal
g/ n. J9 m9 G, x4 b4 V3 Phyperplasia is the 21-hydroxylase enzyme deficiency.
4 a8 O0 F9 J' x! qThe 11-β hydroxylase deficiency may also result in
3 }% _6 b: V% bexcessive adrenal androgen production, and rarely,$ s: T8 e% C5 h' q8 A2 D+ z
an adrenal tumor may also cause adrenal androgen
6 U* f9 {2 }5 Lexcess.1,3
! D* D' S9 c+ m- i2 K6 ]) n+ m% `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. ~+ O( ]" ] R5 ^, C1 J( D
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007- d# Z3 V! Y2 a4 z$ \9 B
A unique entity of male-limited gonadotropin-
. V! x5 m/ I; K6 s: b" c1 aindependent precocious puberty, which is also known% b* w* E. b1 I- G9 y
as testotoxicosis, may cause precocious puberty at a
' S' f- b+ k1 ^# Bvery young age. The physical findings in these boys
% \* W; S0 r5 C- rwith this disorder are full pubertal development, W0 X6 { @3 r* |
including bilateral testicular growth, similar to boys5 E* @! H! `4 @8 @1 E9 D' T
with CPP. The gonadotropin levels in this disorder
# w- K5 W. s) a/ M- yare suppressed to prepubertal levels and do not show
* g" a! l& _5 T* c \' K/ u& W) ppubertal response of gonadotropin after gonadotropin-; P5 w+ a$ r2 b# c/ T2 k9 k4 G7 ~) O
releasing hormone stimulation. This is a sex-linked
|" u Y# `( S, D% P7 c$ K( sautosomal dominant disorder that affects only
# g8 ~- I' `# O4 O( {+ Vmales; therefore, other male members of the family, \1 ]5 M9 G3 a: V2 x3 k ]. C
may have similar precocious puberty.3: t5 B3 V( \8 I: S( O
In our patient, physical examination was incon-! [0 N: h) f) A4 f
sistent with true precocious puberty since his testi-* w9 T4 s8 X& } w% A
cles were prepubertal in size. However, testotoxicosis
4 Z( y/ n" _0 j# Q; Y3 `was in the differential diagnosis because his father
z& t# j% p1 Nstarted puberty somewhat early, and occasionally,
' b8 B% M5 w7 m- Qtesticular enlargement is not that evident in the! [4 O! @3 r- f$ \+ N
beginning of this process.1 In the absence of a neg-
( m* L: G S( Q) X7 Y# _ative initial history of androgen exposure, our; ~, L! p2 i' [$ x
biggest concern was virilizing adrenal hyperplasia,3 R3 @' ~! Q, P X# F1 w
either 21-hydroxylase deficiency or 11-β hydroxylase; m; e# \# K) B; {5 X( n
deficiency. Those diagnoses were excluded by find-
+ b8 T7 C$ k! B1 Uing the normal level of adrenal steroids./ i' O7 n# Q9 s" T
The diagnosis of exogenous androgens was strongly, B, q0 ^5 r. Z2 Y2 P9 \
suspected in a follow-up visit after 4 months because, y9 ^9 t+ F, R1 ~
the physical examination revealed the complete disap-" }% g+ n6 `6 }( T _' r! q' _: \
pearance of pubic hair, normal growth velocity, and% H) j& v+ n$ _) D& Y0 F+ A ]
decreased erections. The father admitted using a testos-
' Z. K- Q! V) H1 @) F/ m! A, Cterone gel, which he concealed at first visit. He was# p; F* v$ Q7 j) ?0 w
using it rather frequently, twice a day. The Physicians’
* J/ D4 g8 K2 _( W7 E" ]( FDesk Reference, or package insert of this product, gel or# U& y1 O3 j2 t7 m( K3 Q
cream, cautions about dermal testosterone transfer to
1 I; T& d9 Y7 W2 L x! [unprotected females through direct skin exposure." U1 Q6 Z1 R# ?4 f h
Serum testosterone level was found to be 2 times the9 L* V' a) y! S" I; x% |6 R, W. t" d: R0 v
baseline value in those females who were exposed to& Z: g! {% q( \1 y
even 15 minutes of direct skin contact with their male$ X X1 N! S; q8 @% x
partners.6 However, when a shirt covered the applica-
0 V+ }# ]7 ^9 x0 ltion site, this testosterone transfer was prevented.
[7 w2 s% s3 U' uOur patient’s testosterone level was 60 ng/mL,
- f; j- r- A( e& X8 g4 uwhich was clearly high. Some studies suggest that
4 t$ b2 K- N" A4 F) {4 n5 s" pdermal conversion of testosterone to dihydrotestos-
! D& M& @/ A, }: f/ |* f6 n' ^: Uterone, which is a more potent metabolite, is more# h9 [. Q0 s b2 @4 {1 i7 s) I( ?
active in young children exposed to testosterone& @2 e6 \! u8 j, g3 t( ?$ j
exogenously7; however, we did not measure a dihy-
* x+ S7 }% {( C1 F- E" q% Z& Udrotestosterone level in our patient. In addition to' L3 W4 k* \4 \) `: v
virilization, exposure to exogenous testosterone in
! T8 @( @, |0 e" tchildren results in an increase in growth velocity and; A z0 z9 s% V
advanced bone age, as seen in our patient.
' G+ u) G* I! V) z0 U! ~The long-term effect of androgen exposure during
/ ]. Z/ p' X. g! N" Yearly childhood on pubertal development and final9 K3 Y6 I/ r+ {1 r( w
adult height are not fully known and always remain; b3 k* j6 y- v; L, c
a concern. Children treated with short-term testos-
) M" M" l" o5 [% B& aterone injection or topical androgen may exhibit some/ K# C4 v: D' M, |6 K! G
acceleration of the skeletal maturation; however, after
S: a- f& H3 |3 F9 Bcessation of treatment, the rate of bone maturation
. ~7 B* K- N+ vdecelerates and gradually returns to normal.8,9- i& N* s8 Q: p2 O4 J0 g2 c
There are conflicting reports and controversy
; ~2 ^0 @- s8 o0 n; Xover the effect of early androgen exposure on adult. J x& t6 @) A$ ?9 Q+ q( e+ T
penile length.10,11 Some reports suggest subnormal- L I) y1 b* B: [: R* R
adult penile length, apparently because of downreg-; j0 s+ G2 l$ T( {& x
ulation of androgen receptor number.10,12 However,3 q3 v4 N! F+ I$ ?
Sutherland et al13 did not find a correlation between _6 g' L# E, q
childhood testosterone exposure and reduced adult
/ r+ i# k: G2 B" q4 `1 t7 V1 U9 Ppenile length in clinical studies.
, H1 I% n* F' g) l5 u' uNonetheless, we do not believe our patient is
, b3 q8 B* ^; t+ g8 S) p( d2 `4 pgoing to experience any of the untoward effects from
- G( o2 W j8 C. D/ o3 atestosterone exposure as mentioned earlier because
0 `) p+ _2 S% t9 @! A( ithe exposure was not for a prolonged period of time.
% }8 p+ ~ E7 x8 W" nAlthough the bone age was advanced at the time of, I/ O$ n/ t @$ J
diagnosis, the child had a normal growth velocity at3 K- b" h( T: a+ i3 [
the follow-up visit. It is hoped that his final adult: M% U/ w1 z# r/ b; f
height will not be affected.
) \" n) ~6 K5 I% w+ gAlthough rarely reported, the widespread avail-: h8 r8 k7 z( w% m; I
ability of androgen products in our society may9 e" u% ~ m4 n& V' b" m
indeed cause more virilization in male or female$ z& ~, w& _1 J9 q9 ]% {
children than one would realize. Exposure to andro-% D# U8 n( J' \, C
gen products must be considered and specific ques-
7 S, n2 W& ]! Ltioning about the use of a testosterone product or* F# Y8 _1 {6 N4 W
gel should be asked of the family members during0 y+ ?3 b1 a6 D
the evaluation of any children who present with vir-
3 _% C- \$ I' {" M6 Z1 x- R% Hilization or peripheral precocious puberty. The diag-
8 h8 q# q. j: [' p* Z& jnosis can be established by just a few tests and by& O* k+ U' ]' i# ?. s0 K1 U9 l
appropriate history. The inability to obtain such a: v# ~9 v/ D$ ^
history, or failure to ask the specific questions, may+ w; @5 l/ w. n' q1 t2 E
result in extensive, unnecessary, and expensive
; T# ?4 m$ f2 P3 x y" r8 winvestigation. The primary care physician should be
* l( F# C6 _; uaware of this fact, because most of these children$ y p8 P0 |& @1 a1 e
may initially present in their practice. The Physicians’
" R. _. E6 N4 L C: |3 ~. V% wDesk Reference and package insert should also put a
+ j: e+ O( T* u" q2 Hwarning about the virilizing effect on a male or, H9 j$ ]7 ]6 i4 K3 a, e6 @
female child who might come in contact with some-
# `. ~) i5 S0 K3 J# o* ?; @one using any of these products.3 ~3 Q7 d1 F# {* w+ D4 q8 ^
References
* H( p1 ~& M) h6 U1. Styne DM. The testes: disorder of sexual differentiation6 u" L5 X+ Z0 E9 z( t: C9 `
and puberty in the male. In: Sperling MA, ed. Pediatric$ {* p5 X: Q0 g, @0 p F; b8 J) q
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
9 a1 Q1 |7 G e7 a. U+ g- ^/ f2002: 565-628.
/ P$ c, f+ n1 X% u, A6 g$ K2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious v4 r3 _* H2 A% g! {
puberty in children with tumours of the suprasellar pineal |
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