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Sexual Precocity in a 16-Month-Old1 o3 }" C( y) E; v9 _
Boy Induced by Indirect Topical
* @" a+ f0 Z4 m3 Z6 r+ |4 D+ @7 ^5 HExposure to Testosterone
0 p4 o9 P- F9 o$ b# g# ^( J) ESamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
7 B: y' P; S3 Z0 R6 n* _2 i6 dand Kenneth R. Rettig, MD1
y5 E) E. \, v5 i* A9 g& k. D" F3 vClinical Pediatrics5 D0 c, V1 z: S) A
Volume 46 Number 66 M1 E! K- j( ^8 P( _
July 2007 540-5431 B/ U" O. F% @+ q
© 2007 Sage Publications
- B# v0 Q% s& k [$ V% `2 E10.1177/0009922806296651% L2 `0 R) p0 f. ^
http://clp.sagepub.com# u, h8 h. j$ P- O
hosted at
# j4 a- U5 z- ?& D1 b5 M) whttp://online.sagepub.com
1 ?! X4 b8 s6 G: D, n( V. H6 Z4 cPrecocious puberty in boys, central or peripheral,
0 y! e8 t; P# G+ gis a significant concern for physicians. Central
. B5 u) W& _: Q- \" p. M" Mprecocious puberty (CPP), which is mediated
# M$ q7 Z9 Y' T8 Q+ `6 wthrough the hypothalamic pituitary gonadal axis, has% W m+ h/ C, H6 b
a higher incidence of organic central nervous system
) ?5 x; n: }( x0 K( b& e8 wlesions in boys.1,2 Virilization in boys, as manifested
5 V( n/ r' m! `; tby enlargement of the penis, development of pubic( {0 |" w3 ~) C! d4 U# f* O
hair, and facial acne without enlargement of testi-) r0 ~9 D9 U) ?& C
cles, suggests peripheral or pseudopuberty.1-3 We x4 Y4 M* z0 R- ]5 h* _
report a 16-month-old boy who presented with the
" }# n; z1 n9 d y0 oenlargement of the phallus and pubic hair develop-
7 D0 B3 Q/ j& h) mment without testicular enlargement, which was due( k) E/ m( l7 |" a+ T. V
to the unintentional exposure to androgen gel used by+ q# A. f3 E1 `
the father. The family initially concealed this infor-
" E2 t5 ~* [4 Z1 ?5 `mation, resulting in an extensive work-up for this
1 R6 n# [4 U+ B7 H3 b7 Pchild. Given the widespread and easy availability of
+ D( G) B0 F1 ^6 ]8 stestosterone gel and cream, we believe this is proba-( Y) `0 S4 y$ Y$ U
bly more common than the rare case report in the
, j8 b- M7 Z; c9 E6 Zliterature.4
o/ [5 u( h) B$ V: LPatient Report& J1 X1 g; m* S/ ~
A 16-month-old white child was referred to the4 f' {) d) Q+ U- a+ V6 m' A
endocrine clinic by his pediatrician with the concern
3 _: p8 Y& X5 L$ C, @+ tof early sexual development. His mother noticed; ]0 u2 ]+ X$ L# m" v
light colored pubic hair development when he was7 L! M9 w) @- h: K
From the 1Division of Pediatric Endocrinology, 2University of8 O3 @4 {1 p1 G# ^: \. ]" B
South Alabama Medical Center, Mobile, Alabama.
3 E- w3 x3 U0 K3 gAddress correspondence to: Samar K. Bhowmick, MD, FACE,
[5 \0 u# M% d1 lProfessor of Pediatrics, University of South Alabama, College of
$ }, ]0 J& u7 Z! e# p' n4 dMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;; j3 l. [ _ }" j
e-mail: [email protected].
* O' l5 Z2 m$ h8 zabout 6 to 7 months old, which progressively became
. b0 x$ S9 h# j8 E8 udarker. She was also concerned about the enlarge-9 U' f" I4 w& I
ment of his penis and frequent erections. The child3 `: y: [ n; E. W6 f" F
was the product of a full-term normal delivery, with" `1 B0 e! }- S6 }% b
a birth weight of 7 lb 14 oz, and birth length of6 m- [* a6 o: u# {
20 inches. He was breast-fed throughout the first year
1 D# L8 Q# r% {: I7 M6 uof life and was still receiving breast milk along with" p/ h% T+ i( r- w: \
solid food. He had no hospitalizations or surgery,+ x: q; J5 A6 r
and his psychosocial and psychomotor development
. P8 n, c* D% Ywas age appropriate.
7 r7 t C3 e* x, X; B# qThe family history was remarkable for the father,
i( f \5 `9 c5 M6 _who was diagnosed with hypothyroidism at age 16,
* D1 R6 o, k7 fwhich was treated with thyroxine. The father’s! A3 h/ [8 E* q% s \( m, i
height was 6 feet, and he went through a somewhat4 ]6 x& x3 c3 p+ ~
early puberty and had stopped growing by age 14.& c4 I( d, t! d7 o& Y" ~ {
The father denied taking any other medication. The
- U1 T9 b, B# f s1 E7 Z1 ochild’s mother was in good health. Her menarche
( v+ W8 N4 D1 w w( H* gwas at 11 years of age, and her height was at 5 feet X. N, s! p5 y. A7 s
5 inches. There was no other family history of pre-6 X: I; @- f ]% r3 ?* q
cocious sexual development in the first-degree rela-
4 j! Z% G' k: r! d* a+ qtives. There were no siblings.7 b2 j* I9 N) f8 B, _/ \* J
Physical Examination
* p! e' x5 X7 tThe physical examination revealed a very active,
( y; z( q. |- V5 h4 _+ eplayful, and healthy boy. The vital signs documented" Y; \2 n; F3 k& _: ~
a blood pressure of 85/50 mm Hg, his length was
4 _: `7 n' b& X, ~90 cm (>97th percentile), and his weight was 14.4 kg% [% ~# b5 t1 k! B4 T+ e0 y
(also >97th percentile). The observed yearly growth
1 Q7 J& c- g2 U8 r+ Dvelocity was 30 cm (12 inches). The examination of/ T6 ], B5 ]. d7 V6 U) H
the neck revealed no thyroid enlargement.5 U( C8 e2 j* U9 A6 m2 \- x" F. r
The genitourinary examination was remarkable for
4 T1 y# Q/ d' r( uenlargement of the penis, with a stretched length of4 n2 v6 Q7 n/ J6 Q* t
8 cm and a width of 2 cm. The glans penis was very well
' R/ f7 w2 `( b* e: v6 }developed. The pubic hair was Tanner II, mostly around
# Q0 f# ?5 I. t) p( c" D5408 W; y. R. ~' G& [4 b/ ]4 U
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from ?4 S4 j" m! x7 z6 e, J
the base of the phallus and was dark and curled. The
& T5 D9 _! _, @- `% Y. k8 ]testicular volume was prepubertal at 2 mL each.7 E5 [. s! ~5 |& h
The skin was moist and smooth and somewhat' [! U' F+ s% k% k" F
oily. No axillary hair was noted. There were no, B1 e+ T+ K% Y. _7 F0 {
abnormal skin pigmentations or café-au-lait spots.3 A u7 S9 c3 W% c6 |
Neurologic evaluation showed deep tendon reflex 2+
0 x1 u, P* ?1 ^0 ubilateral and symmetrical. There was no suggestion8 \- \- r/ P& O8 e# ~
of papilledema.
2 @4 r) P4 c; ~* FLaboratory Evaluation# ^/ f7 |7 Q3 l) |5 n" N8 B) z
The bone age was consistent with 28 months by E% w8 f' H/ @3 N9 O; v
using the standard of Greulich and Pyle at a chrono-
% v7 M) u- i3 G& Qlogic age of 16 months (advanced).5 Chromosomal
0 Z6 X) }( G1 |karyotype was 46XY. The thyroid function test
5 Y& Q3 B3 ^# e* T% Gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 S" O& }, x) A5 Qlating hormone level was 1.3 µIU/mL (both normal).3 e6 d5 c! s+ @: |6 J3 K% N
The concentrations of serum electrolytes, blood' I7 N% t: i) w" F9 u+ n2 ` h
urea nitrogen, creatinine, and calcium all were
6 k5 E: B# A. n5 m6 B1 ^within normal range for his age. The concentration
3 @% y l: _' ~6 E6 ?' l& i& jof serum 17-hydroxyprogesterone was 16 ng/dL
1 z1 f2 I. C' A8 W" }+ R' d7 R- _$ A(normal, 3 to 90 ng/dL), androstenedione was 20
) h$ A6 b! ?9 v0 L, ong/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 n; H" j7 [* ?* c. U+ v
terone was 38 ng/dL (normal, 50 to 760 ng/dL),5 `1 F0 X5 v8 x: Q8 }
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ x# w+ R g' r% ^5 h49ng/dL), 11-desoxycortisol (specific compound S)$ K! P% s' J1 b9 c" G4 u
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- ?/ e. y4 N* R- P* Q. B7 g
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) k. l1 a* j: \# k5 g F% vtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),. p! `- ]+ D9 W, q7 t
and β-human chorionic gonadotropin was less than$ X" b0 l6 Q. Q1 d; q
5 mIU/mL (normal <5 mIU/mL). Serum follicular$ B, G: Z7 d- X& [6 J# q
stimulating hormone and leuteinizing hormone5 c! s) L( ^8 r7 p" z, t
concentrations were less than 0.05 mIU/mL
' i$ ?7 P+ I( P. k(prepubertal).3 \# e! Z: a6 t6 v, V4 c8 [ [
The parents were notified about the laboratory
' k( O( z% M& S: @% m7 e& Jresults and were informed that all of the tests were; ? R! z" F: I/ Q- [5 Y0 Q U
normal except the testosterone level was high. The6 q# n; y9 [* `$ R5 d
follow-up visit was arranged within a few weeks to) k+ w5 J c: r2 E9 f% K
obtain testicular and abdominal sonograms; how-
& B% e- E9 w. [6 q7 j4 iever, the family did not return for 4 months.! ?* i' D/ X& ` k
Physical examination at this time revealed that the
" {& c5 e* ?% w) R3 [9 Qchild had grown 2.5 cm in 4 months and had gained$ f% ]) k4 N! A+ J/ q
2 kg of weight. Physical examination remained
% t. i* r! b' M! \6 L! i2 funchanged. Surprisingly, the pubic hair almost com-$ U2 C* B8 |1 k& I2 x2 j
pletely disappeared except for a few vellous hairs at4 p: P* F1 W% u# @* Z7 }* T, Z
the base of the phallus. Testicular volume was still 2
, v+ L4 ?2 z6 s0 C3 d( G s- AmL, and the size of the penis remained unchanged.! T1 D8 x$ @+ v4 ?3 N
The mother also said that the boy was no longer hav-; [6 d B% U8 @4 T( i
ing frequent erections.
, ]; o$ H2 A8 K+ z; x$ c2 MBoth parents were again questioned about use of8 E+ a* X+ E$ z/ Q. b5 p) t
any ointment/creams that they may have applied to* @2 o0 w, c( n8 F" O; U- z+ H- m
the child’s skin. This time the father admitted the
0 u; M O& t' A! S9 MTopical Testosterone Exposure / Bhowmick et al 541
3 \8 S* c1 k, c" Z! z6 b I3 c* U4 guse of testosterone gel twice daily that he was apply-
P) l# {7 P( Y! t- H* ~: ging over his own shoulders, chest, and back area for! M' ]: g/ X3 b. y. |+ z7 a
a year. The father also revealed he was embarrassed
0 B- j$ B) d( @to disclose that he was using a testosterone gel pre-& A0 e$ H1 @; z
scribed by his family physician for decreased libido
- r [4 Q4 u: L' s6 }4 I; zsecondary to depression.
9 ]# Z/ [! N" y$ J! L% l5 c) gThe child slept in the same bed with parents.
9 O3 |& Y* U) f; w( o4 yThe father would hug the baby and hold him on his
- C2 l: m8 G- f( `chest for a considerable period of time, causing sig-
: j8 {9 v w6 F4 Anificant bare skin contact between baby and father., A/ q$ l0 |+ o. A% T
The father also admitted that after the phone call,5 x- c4 P( T, `; p3 |2 x& T
when he learned the testosterone level in the baby
$ \8 v0 V6 E5 Y* Lwas high, he then read the product information
" T5 l0 O. Q$ Ipacket and concluded that it was most likely the rea-% p h5 i7 i8 @1 N( ?. D
son for the child’s virilization. At that time, they+ d! K) ]4 z0 x& M, m8 d
decided to put the baby in a separate bed, and the
' I4 S) R6 P. kfather was not hugging him with bare skin and had
5 ~: a" v# ^1 h5 K4 x( X0 Y% U8 L t& Vbeen using protective clothing. A repeat testosterone
9 f' \$ D5 N0 m* `8 vtest was ordered, but the family did not go to the7 [0 ?# U+ M/ C: ]7 ]& J
laboratory to obtain the test.
- n0 i9 ?: H! v% ~6 u N. sDiscussion
/ x0 K& E9 q7 _1 ?. lPrecocious puberty in boys is defined as secondary
% ]1 A2 P8 z9 R, ~0 Ksexual development before 9 years of age.1,40 P y8 a5 \% A/ y6 n0 o' G
Precocious puberty is termed as central (true) when
# A: f/ S' R: Yit is caused by the premature activation of hypo-! N- U) W: D3 w; ~9 N" c! T
thalamic pituitary gonadal axis. CPP is more com-( V1 O0 @# {! o- k& o7 {
mon in girls than in boys.1,3 Most boys with CPP1 z; J2 X% o G7 }# e
may have a central nervous system lesion that is/ W* Q) k6 E+ O, m8 d* a* X# `4 `; s
responsible for the early activation of the hypothal-4 @$ k5 r; T7 b* _+ o3 Z
amic pituitary gonadal axis.1-3 Thus, greater empha-
/ z+ V# c5 H. E( M1 rsis has been given to neuroradiologic imaging in
9 {2 |- W% r8 O5 l( B( C9 _' ~boys with precocious puberty. In addition to viril-
, c j1 B* T* D( Mization, the clinical hallmark of CPP is the symmet-; `% Q% c1 z% L. K: q
rical testicular growth secondary to stimulation by t: F' q! P! x1 h& S( P* ~
gonadotropins.1,3( n. h2 M/ M+ O5 ?0 E6 \
Gonadotropin-independent peripheral preco-5 ~8 Z( V6 ~/ p5 Z4 O
cious puberty in boys also results from inappropriate8 j( Y4 ~6 m7 n# N: k) K9 e
androgenic stimulation from either endogenous or
8 [, i+ g/ M" S( K" |0 q( Pexogenous sources, nonpituitary gonadotropin stim-0 O* i( ]. z1 a. p" ?3 S/ ?
ulation, and rare activating mutations.3 Virilizing
+ F9 M& U: ^+ d6 R+ h* @+ ocongenital adrenal hyperplasia producing excessive
( G. {/ f' c* w( s d5 N4 Gadrenal androgens is a common cause of precocious* D9 n I& h' v5 c# b- d
puberty in boys.3,40 b& w1 G& X- H, F( ?- l4 v
The most common form of congenital adrenal; [$ R0 x' d' y) K
hyperplasia is the 21-hydroxylase enzyme deficiency.
: d: ?7 x0 b8 D, M; ?6 f9 P" d$ CThe 11-β hydroxylase deficiency may also result in
: W( f# q8 W9 q2 U% E- eexcessive adrenal androgen production, and rarely,, i0 {; F9 _) S( d* B* T1 X# a3 N
an adrenal tumor may also cause adrenal androgen
; c$ v0 U6 L; t. @1 s' c6 x. Lexcess.1,3) f6 i5 b: H$ H; r, e8 `
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
, y5 G, k# |# l8 K$ v542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ o% Y! G: j$ v9 L; r0 M
A unique entity of male-limited gonadotropin-8 \. ~3 @5 E8 d+ h8 g; Y, J
independent precocious puberty, which is also known$ c' E9 D1 ~/ L- [' }) [, ^# X( g
as testotoxicosis, may cause precocious puberty at a
. n( S2 I: _+ \# {% H- Overy young age. The physical findings in these boys$ s) c* j Q( Z& ?+ C4 n& q3 Z
with this disorder are full pubertal development,7 \$ C6 {# a2 i* y+ {% Z
including bilateral testicular growth, similar to boys
3 p( M& H$ S! M, Y6 Q7 gwith CPP. The gonadotropin levels in this disorder4 h7 L' E% l8 J+ V9 n1 T- [ ^
are suppressed to prepubertal levels and do not show+ ~# N. ?3 m9 h
pubertal response of gonadotropin after gonadotropin-
1 B i4 D4 S- S9 _& sreleasing hormone stimulation. This is a sex-linked
$ z2 Y7 a$ v L6 X n: P/ A+ aautosomal dominant disorder that affects only
2 B7 Z2 c" B; R% _) H8 m2 Jmales; therefore, other male members of the family/ t2 E! i' i4 h) X0 Z' ^
may have similar precocious puberty.39 g8 O+ m. `0 {) b! s1 m
In our patient, physical examination was incon-2 E" ?* s% a+ k4 s+ T- U: F
sistent with true precocious puberty since his testi-# b9 r4 [( D( R8 i/ Q+ }8 y6 S
cles were prepubertal in size. However, testotoxicosis$ q* t% b s( u& D! q: V
was in the differential diagnosis because his father6 P H- @0 v7 F- ]
started puberty somewhat early, and occasionally,3 b3 l* t/ A- B8 y$ A- i f- k
testicular enlargement is not that evident in the
1 A4 u" T9 I5 b# \6 R, Mbeginning of this process.1 In the absence of a neg-
: R: n& N4 m+ J/ {1 n4 ^7 A5 A& v* X7 yative initial history of androgen exposure, our0 X O: }* A1 U: \. a
biggest concern was virilizing adrenal hyperplasia,, X8 [! Z1 X7 [* v: P$ C( H
either 21-hydroxylase deficiency or 11-β hydroxylase3 y4 v& O- Q; Z
deficiency. Those diagnoses were excluded by find-
+ p& q7 A; x( qing the normal level of adrenal steroids.- K( e! d0 a7 A
The diagnosis of exogenous androgens was strongly
! i6 _7 s+ g5 k+ M: y8 H, O' Hsuspected in a follow-up visit after 4 months because0 b4 v9 K( N' Y4 h
the physical examination revealed the complete disap-
! ^, h0 t$ m. X$ R# Zpearance of pubic hair, normal growth velocity, and' T2 |4 x; i1 ~$ U$ K/ m8 t; c- q, l
decreased erections. The father admitted using a testos-
' _6 k z3 U7 _/ p* m7 ^terone gel, which he concealed at first visit. He was
: t1 z* B" l9 q5 s2 G+ ~, U( n8 }using it rather frequently, twice a day. The Physicians’) Y" u! G; a0 I* {6 |$ i
Desk Reference, or package insert of this product, gel or
: {& f9 \: R( s9 Scream, cautions about dermal testosterone transfer to, U0 o# m5 B9 D$ P2 I: g3 L
unprotected females through direct skin exposure., l1 y; [8 v$ v9 G! n& l
Serum testosterone level was found to be 2 times the5 j% J" m' m7 r
baseline value in those females who were exposed to, C, ^7 b* b* A0 | w! g" L
even 15 minutes of direct skin contact with their male2 C0 U5 k9 i" w3 r( y
partners.6 However, when a shirt covered the applica-
, L- l) u, X- btion site, this testosterone transfer was prevented.
9 H1 F6 \2 L+ WOur patient’s testosterone level was 60 ng/mL,
( }2 B( b, f; a9 _which was clearly high. Some studies suggest that% W& ?( o; J O: _1 i4 {# k1 Y
dermal conversion of testosterone to dihydrotestos-
! R9 G- O) Y# ~% T% Oterone, which is a more potent metabolite, is more1 H- {" J! q3 d. K1 Z! _4 J9 w/ C' J
active in young children exposed to testosterone" V3 c$ Y8 z3 h! H& S
exogenously7; however, we did not measure a dihy-
, u% g+ w! O, T2 p6 Rdrotestosterone level in our patient. In addition to
& \" O3 b. u7 m: E5 M ^4 Cvirilization, exposure to exogenous testosterone in4 c% g5 D( N7 O- }6 |) P
children results in an increase in growth velocity and
) ^2 Y' V0 P) r$ K. P7 T! Kadvanced bone age, as seen in our patient., c+ f2 d' Z. {# X; \) j0 K+ v
The long-term effect of androgen exposure during
; w- e8 W1 Z* u6 u( C Qearly childhood on pubertal development and final# V! t0 a7 Z1 {& W& k V9 x) x
adult height are not fully known and always remain
6 f& p( }) T2 k# Y. O, a0 [) oa concern. Children treated with short-term testos-1 U" N+ D% F; M( Z& _7 J9 X
terone injection or topical androgen may exhibit some
, i$ R$ O0 k, k" X% x- jacceleration of the skeletal maturation; however, after/ j0 ~& {; Q! J) F- a
cessation of treatment, the rate of bone maturation/ N/ K: X& b& h) {8 j
decelerates and gradually returns to normal.8,9
" Y9 M6 Z5 ^$ ~* m) B$ hThere are conflicting reports and controversy
: e% C5 h O; J# w7 w5 M1 G. Aover the effect of early androgen exposure on adult" m0 N. ~; P. s7 ~2 c
penile length.10,11 Some reports suggest subnormal6 [" u( J& h& A9 Q
adult penile length, apparently because of downreg-0 o. N$ x3 B' a" s5 W) C
ulation of androgen receptor number.10,12 However,
& h9 Q6 p3 c( |6 V4 a* m, oSutherland et al13 did not find a correlation between. w; y9 I4 B1 ~) i
childhood testosterone exposure and reduced adult, {$ J) g5 k% Z* r, C* D
penile length in clinical studies.
# n) _, e% l' Z8 s5 v) y, xNonetheless, we do not believe our patient is/ a, y5 B- O, l, J, Y
going to experience any of the untoward effects from
5 k' q R1 z9 [ U& qtestosterone exposure as mentioned earlier because @' z6 v+ `5 j/ K, \
the exposure was not for a prolonged period of time.
J* G$ v" s# N# R4 ?Although the bone age was advanced at the time of6 f, l9 V" J! I @6 p
diagnosis, the child had a normal growth velocity at# U; s4 T/ o/ d0 E& T
the follow-up visit. It is hoped that his final adult7 D. V" X( k& Z; @) O1 [1 {2 ]4 A
height will not be affected.
, J# i% M/ m) \& a+ A, b- ?Although rarely reported, the widespread avail-
- A9 ~+ Z+ S1 c Z) t7 ~ability of androgen products in our society may8 D' {3 g& Z; w1 ?: ~
indeed cause more virilization in male or female
" f5 P/ r" l, K1 j2 e! hchildren than one would realize. Exposure to andro-
$ s0 N# |1 _0 |. cgen products must be considered and specific ques-: i W8 y9 q% `5 ~+ H3 @
tioning about the use of a testosterone product or" V4 L2 I, Q& W/ I
gel should be asked of the family members during
- U0 s" H) j# r# Nthe evaluation of any children who present with vir-
: K! E3 H! Y# {ilization or peripheral precocious puberty. The diag-3 K1 y$ i s c( Y1 E- Q) C$ ?
nosis can be established by just a few tests and by
$ @0 S9 L9 a) U* e6 A+ _; Qappropriate history. The inability to obtain such a
I1 A0 z% N. |1 phistory, or failure to ask the specific questions, may+ ^5 y7 i) X* _( v, m% ~ Y8 b
result in extensive, unnecessary, and expensive" c) u, o. M- Z8 l, W8 f! ]
investigation. The primary care physician should be
( q; Y3 J: K) g/ E1 D" E& ^& Caware of this fact, because most of these children
" ^$ G2 u3 Y! I7 ]9 pmay initially present in their practice. The Physicians’7 M: _/ p% G( V; R
Desk Reference and package insert should also put a
0 Z/ m: `; c# Z. R2 x: vwarning about the virilizing effect on a male or
* E* b' {; T# d5 Q0 S) dfemale child who might come in contact with some-; \2 y) J+ ?9 Z& T% \
one using any of these products.
) t Z, E& b" V N0 Y% vReferences# a0 C- b- ?- Z7 U' z, e
1. Styne DM. The testes: disorder of sexual differentiation
' n* k, W& ]0 S* _/ pand puberty in the male. In: Sperling MA, ed. Pediatric% x* S& N; N$ M
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& c. p1 A% u/ G2002: 565-628.
6 M( ^* A0 ~' B1 U( {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious' C0 d/ {, u2 C* y3 W+ z
puberty in children with tumours of the suprasellar pineal |
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