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Sexual Precocity in a 16-Month-Old
" J* r1 V5 e. SBoy Induced by Indirect Topical: w; O7 f# x( ]* h- y' i# @
Exposure to Testosterone
4 ^8 s. H8 s" ?9 v4 WSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
+ [, h. ^- S( ?) C+ y. xand Kenneth R. Rettig, MD1
& Q# `+ j" ~; g/ jClinical Pediatrics
8 \; C: v1 t. e3 U0 g* BVolume 46 Number 65 e) h: U2 Q& B7 t) d
July 2007 540-543
! H7 S; t P% J( C6 c; H: C& P% w© 2007 Sage Publications$ B# |$ @# s3 p- V
10.1177/0009922806296651
% w4 D" L! d4 z3 S3 m9 Z8 \http://clp.sagepub.com( s$ h0 g7 @, H- u
hosted at
& Z; b) l. ^- A* P5 O! s3 Ahttp://online.sagepub.com
y( M4 W. y5 j- H/ UPrecocious puberty in boys, central or peripheral,
# D. o, @" n' t& o, C: J& ?% F" D: [is a significant concern for physicians. Central! T3 i3 F: S6 o3 X% l1 A; Z" m
precocious puberty (CPP), which is mediated
8 E- i% w8 S8 A2 b1 \through the hypothalamic pituitary gonadal axis, has P" r: y6 x1 z9 T# V) G5 O7 a
a higher incidence of organic central nervous system5 o% S, C- F* y9 t$ _
lesions in boys.1,2 Virilization in boys, as manifested) n1 f. J+ k$ ]* \( i& i4 g
by enlargement of the penis, development of pubic
; {! H7 u" R( ]4 o, X) nhair, and facial acne without enlargement of testi-- E! O7 m1 V9 t4 u7 a h
cles, suggests peripheral or pseudopuberty.1-3 We+ A5 Z+ K, ]& G: P. k. l7 s
report a 16-month-old boy who presented with the
, D3 w( \% o& [1 A0 s8 b! Xenlargement of the phallus and pubic hair develop-% q' c- I& ]7 a* w
ment without testicular enlargement, which was due
1 v/ R: k+ l# r7 A dto the unintentional exposure to androgen gel used by
* g8 C3 X# W$ d- Jthe father. The family initially concealed this infor-
. n- v( y8 Y( B4 q6 [4 bmation, resulting in an extensive work-up for this. r( I. z# N L
child. Given the widespread and easy availability of' I. r3 O" ]9 @9 Z8 M
testosterone gel and cream, we believe this is proba-
/ ]- n1 z' x* }/ F3 b0 ?bly more common than the rare case report in the9 r0 o3 `) W* z) }9 c( p
literature.4& ^( T+ R3 W- u
Patient Report
5 ^1 p/ Q, f4 RA 16-month-old white child was referred to the, Z9 ~. F" p( q, P0 ~2 Y& q; u$ v; L6 u, \
endocrine clinic by his pediatrician with the concern
1 c2 G" H* q+ |! Kof early sexual development. His mother noticed: `$ _+ b0 S6 |2 c" ~1 D* Y' A
light colored pubic hair development when he was* {9 \2 L4 E1 e) j3 |" v
From the 1Division of Pediatric Endocrinology, 2University of- |) \& G) _8 P0 j, X% m
South Alabama Medical Center, Mobile, Alabama.2 M* {- p" \$ S' A" o- H
Address correspondence to: Samar K. Bhowmick, MD, FACE,# U, [ B( e* B# g, m
Professor of Pediatrics, University of South Alabama, College of$ x" y+ C8 G' W0 ?; H
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( n F0 ^0 N+ f% a: }
e-mail: [email protected].; w6 s6 t$ W. X" W
about 6 to 7 months old, which progressively became
! ] @9 w8 J9 l0 }- k. Y4 H, Hdarker. She was also concerned about the enlarge-9 E/ h I$ p7 N/ E
ment of his penis and frequent erections. The child" \+ A* X1 @$ R3 A5 w
was the product of a full-term normal delivery, with" o- | D; [9 \7 j1 _- N9 ?- [& D
a birth weight of 7 lb 14 oz, and birth length of
& Z! t$ D0 X: F8 j' s- @20 inches. He was breast-fed throughout the first year
% d8 c4 C- \8 X6 ^' S/ m! m) o. sof life and was still receiving breast milk along with4 l7 i( `& w' f6 ?$ k! k
solid food. He had no hospitalizations or surgery,, t, `/ w* g* {
and his psychosocial and psychomotor development5 t4 A$ v$ O' M- U2 k9 j3 f+ u- l
was age appropriate.
8 G+ D- A% p! h1 JThe family history was remarkable for the father,9 Q# Q! j" g9 c: }1 ^
who was diagnosed with hypothyroidism at age 16,
3 E7 O% V8 b: Z: Q4 Ywhich was treated with thyroxine. The father’s: Z' v0 I+ j# Z. |
height was 6 feet, and he went through a somewhat1 O4 x7 L3 @8 k( t- p$ o$ n
early puberty and had stopped growing by age 14.
. Q. R/ v, a _5 P8 e2 d0 r. w% U2 sThe father denied taking any other medication. The' h0 @. Y/ m2 Z
child’s mother was in good health. Her menarche
" [; h% n+ X9 R. Fwas at 11 years of age, and her height was at 5 feet
" o& b1 @7 e1 _5 _. K, g, ]5 inches. There was no other family history of pre-3 h9 {9 Q. }3 h, n2 q* O/ A
cocious sexual development in the first-degree rela-
( C% `2 e8 Q5 a* ^$ Wtives. There were no siblings.- S8 t$ E: P% n. `- q# ^
Physical Examination
! \% r+ f# q* ?The physical examination revealed a very active,4 g& B# y7 i$ l6 b
playful, and healthy boy. The vital signs documented/ Y! l& T- {9 J: r1 c; x
a blood pressure of 85/50 mm Hg, his length was
) @6 O) x& Q0 I* t r90 cm (>97th percentile), and his weight was 14.4 kg6 L- }6 G( Z' M' E: E9 d% I
(also >97th percentile). The observed yearly growth# \( ~# s, X' R/ }9 M
velocity was 30 cm (12 inches). The examination of" k) D/ j: ~% \3 k% C
the neck revealed no thyroid enlargement./ k# q( e; b* [. m$ N
The genitourinary examination was remarkable for
- m. N5 C- C/ O) `: v6 Fenlargement of the penis, with a stretched length of) |: e4 e# b6 `3 k' Q
8 cm and a width of 2 cm. The glans penis was very well
" \! g$ ^( K+ V. C" ~developed. The pubic hair was Tanner II, mostly around
; V% R2 B$ g3 X* z" F- h540
( u4 f* i4 |/ N# [# H2 hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 X, \1 n) e9 Mthe base of the phallus and was dark and curled. The
: b1 ]- \1 B$ L- _5 V7 q$ z7 X' ~testicular volume was prepubertal at 2 mL each. U, F+ o( [" z) x
The skin was moist and smooth and somewhat F& c0 x5 ~2 O
oily. No axillary hair was noted. There were no
) s# X+ i4 D$ k$ o+ W# oabnormal skin pigmentations or café-au-lait spots.) H" R3 H4 M0 Z8 i- k" Y
Neurologic evaluation showed deep tendon reflex 2+3 n6 V W- y8 m/ Y0 ~8 P( N
bilateral and symmetrical. There was no suggestion
. |5 w- N- F+ M) Eof papilledema.* ~ s) @4 g/ F. E$ w
Laboratory Evaluation! l& e1 Q9 u& M' L
The bone age was consistent with 28 months by
) b# b; m, c4 N+ o5 e4 ?' Yusing the standard of Greulich and Pyle at a chrono-+ P$ C* U- c& t* G4 Q2 l8 }! ~
logic age of 16 months (advanced).5 Chromosomal. s( t9 v2 d2 f/ Q1 b
karyotype was 46XY. The thyroid function test* W' U. ]* Z6 Y7 B1 T" I! J8 ~- j
showed a free T4 of 1.69 ng/dL, and thyroid stimu-6 ~4 B- c/ B. O6 \: h5 t# d
lating hormone level was 1.3 µIU/mL (both normal).$ m S" r3 l2 d# P; r$ \
The concentrations of serum electrolytes, blood
7 {9 X, ^3 u& w" G9 U durea nitrogen, creatinine, and calcium all were) p2 Q$ N8 L% l- }5 H
within normal range for his age. The concentration4 P' i8 l/ P# a7 n9 ^) P
of serum 17-hydroxyprogesterone was 16 ng/dL1 s" a/ U7 t8 o- t2 q
(normal, 3 to 90 ng/dL), androstenedione was 20
- s1 x2 \+ L2 G" ?( Q, D4 G* D1 Qng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
0 Q/ n, G1 j# Qterone was 38 ng/dL (normal, 50 to 760 ng/dL),' L" ?0 F' P1 e9 Q2 ?) ]- w, [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
2 B# N4 b% f5 Z9 ?6 u49ng/dL), 11-desoxycortisol (specific compound S)2 X1 e% Z7 F' |9 B
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-/ T! }! y0 z& u
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total( o2 ~- \0 F0 b
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),: Q: h5 N0 `$ ^+ P
and β-human chorionic gonadotropin was less than
% ^4 t" O$ r, ^5 mIU/mL (normal <5 mIU/mL). Serum follicular
! S: x: O' W# q0 Tstimulating hormone and leuteinizing hormone
! G9 i% T' {6 S% J& Mconcentrations were less than 0.05 mIU/mL
. m1 J9 z7 J5 e5 o0 y(prepubertal).
1 B- D# f |6 w& f- e- {( y( y1 mThe parents were notified about the laboratory
2 q: b9 P V: a- R$ d1 @results and were informed that all of the tests were H4 U0 Q) D6 u0 W) q8 R, r
normal except the testosterone level was high. The |" V0 `) |4 x0 e
follow-up visit was arranged within a few weeks to
/ h1 v( e0 v( L7 n6 I' ^$ ]obtain testicular and abdominal sonograms; how-
0 U2 h" }% s4 f& F6 @' A9 x( V0 t8 never, the family did not return for 4 months.
9 m7 B3 |; p- U. q3 |$ pPhysical examination at this time revealed that the. C2 Z/ Z+ J7 l1 h1 F
child had grown 2.5 cm in 4 months and had gained% Q9 u0 X# `5 B/ F5 Y7 O
2 kg of weight. Physical examination remained* ?( N7 S" W6 F' \+ \/ W# S
unchanged. Surprisingly, the pubic hair almost com-7 l3 v' Z5 L' E
pletely disappeared except for a few vellous hairs at/ @" q8 z3 O' N. S) ]( Y9 f# G
the base of the phallus. Testicular volume was still 20 r1 R$ i! O+ s; l6 z
mL, and the size of the penis remained unchanged.
& E5 G2 [, s" k0 Q' V) x6 sThe mother also said that the boy was no longer hav-7 @3 u# R% M5 g
ing frequent erections.- x" b F: k. N1 g* X, ?( O
Both parents were again questioned about use of
" @( @% G% F9 {- J% ~any ointment/creams that they may have applied to
" L2 E! J/ z7 g1 s* n: R, |- Gthe child’s skin. This time the father admitted the
. ~- w, E' b6 d F8 A. |Topical Testosterone Exposure / Bhowmick et al 541
& |. e9 O- S; Ruse of testosterone gel twice daily that he was apply-, r- @" W+ f" L: C! V Q
ing over his own shoulders, chest, and back area for
4 P: I. a1 H) F7 ^8 ]+ j! I. aa year. The father also revealed he was embarrassed2 G- [3 T3 ?/ p0 Y6 X
to disclose that he was using a testosterone gel pre-
' {% p m) z& y, ^scribed by his family physician for decreased libido+ Q; \# ~* |9 o4 S
secondary to depression.5 T8 O1 i3 C. v9 V/ ^
The child slept in the same bed with parents.9 @7 J4 T4 ?' @6 h5 C8 H
The father would hug the baby and hold him on his
$ o) E* u. x+ |, ], kchest for a considerable period of time, causing sig-* ]0 N. J' n2 E7 \4 Y
nificant bare skin contact between baby and father.5 w/ O @; w( c0 ^$ K& g- G% n
The father also admitted that after the phone call,
$ K9 {- M1 ~% ywhen he learned the testosterone level in the baby
c) o7 r- h2 t3 Hwas high, he then read the product information
8 }( f, r2 u, k+ _packet and concluded that it was most likely the rea-
, r$ [! d) o9 oson for the child’s virilization. At that time, they2 n* ~ G9 I* ^8 S2 r) C# k
decided to put the baby in a separate bed, and the
/ M& e) B3 N; Q! H& rfather was not hugging him with bare skin and had
- r& Q6 M$ Y; n7 Sbeen using protective clothing. A repeat testosterone
0 @& [- b4 H1 u* mtest was ordered, but the family did not go to the
4 J, g$ J. B, \5 E* L5 Claboratory to obtain the test.
' v2 k* E" L5 ?7 PDiscussion
* R5 S* S/ H4 B1 M' |2 ^$ mPrecocious puberty in boys is defined as secondary
3 E; o! h2 c* p, Bsexual development before 9 years of age.1,4+ m! f% p E6 }$ ]
Precocious puberty is termed as central (true) when& r; d# ~9 \. {& z5 Z
it is caused by the premature activation of hypo-% ]- ^2 ^. M. u
thalamic pituitary gonadal axis. CPP is more com-
/ S! W: i0 K; n1 tmon in girls than in boys.1,3 Most boys with CPP' d& a' b. D8 h
may have a central nervous system lesion that is7 r3 f/ Z7 y4 z$ o X1 V
responsible for the early activation of the hypothal-
- b; Y+ ^4 l! P- m8 w+ K, Famic pituitary gonadal axis.1-3 Thus, greater empha-
2 c, R$ c3 }7 g6 b6 v$ c! nsis has been given to neuroradiologic imaging in
& f6 c' a8 G* i; x; Sboys with precocious puberty. In addition to viril-' k8 t, L# k6 W
ization, the clinical hallmark of CPP is the symmet-
9 S' m/ L0 }0 E7 T/ @3 G& x, [$ ], I- A Rrical testicular growth secondary to stimulation by
# S4 g3 C/ ^" @2 e+ ngonadotropins.1,3+ q' T; T9 z" ]) y+ }/ }% T: V
Gonadotropin-independent peripheral preco-. x" d! [* M u( z
cious puberty in boys also results from inappropriate
7 E$ B- W- w9 P0 h% s; G' u* i1 Dandrogenic stimulation from either endogenous or2 s2 {: P8 n" J4 Q! U: P* T9 l
exogenous sources, nonpituitary gonadotropin stim-
) M& _+ [$ k, L4 ^ulation, and rare activating mutations.3 Virilizing8 x( J. P5 l6 [
congenital adrenal hyperplasia producing excessive
) @7 p% t+ ~0 d/ T, Tadrenal androgens is a common cause of precocious
3 V+ p" D7 [1 c1 W2 Tpuberty in boys.3,45 q1 {1 S# v. a/ H
The most common form of congenital adrenal
, }* T6 e1 A/ t; y6 _hyperplasia is the 21-hydroxylase enzyme deficiency.
8 c4 {9 h; K0 x2 r }6 }6 Z1 y5 OThe 11-β hydroxylase deficiency may also result in/ e% _& ^, Y9 ~4 \
excessive adrenal androgen production, and rarely,, l) A0 K% F3 ~' L
an adrenal tumor may also cause adrenal androgen* J9 V9 U5 k9 Q3 W/ C! t
excess.1,3
& ~$ l6 W' `0 p9 P. [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 y& K, N, t2 l) [' q& L/ R542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 E1 o, A; r2 h8 y- c5 P0 ]/ @1 B
A unique entity of male-limited gonadotropin- W; o0 F) u! U) R* Y, t/ }3 d
independent precocious puberty, which is also known1 t" T6 T7 c0 [& Q1 W
as testotoxicosis, may cause precocious puberty at a
E! N) ]6 c) ^7 w% }7 Zvery young age. The physical findings in these boys, H# p( b: K( p1 R
with this disorder are full pubertal development,
5 w$ M2 a+ w( b2 uincluding bilateral testicular growth, similar to boys' t0 `$ f3 T- K: Q5 M' W4 D
with CPP. The gonadotropin levels in this disorder
7 o& C# {% ?( a0 `. ~% c3 n+ s: I5 Care suppressed to prepubertal levels and do not show$ ]9 R7 D, z7 t+ U3 e3 G
pubertal response of gonadotropin after gonadotropin-
6 r" Q0 c6 z6 P# x4 b& Y& v7 creleasing hormone stimulation. This is a sex-linked
) v; S% F5 A$ ^4 r! A( U/ Qautosomal dominant disorder that affects only+ C( H+ d" c3 r# x& G6 z
males; therefore, other male members of the family
' P8 C! J3 j2 m% _may have similar precocious puberty.3 a9 F. z/ @8 L* ~4 ^) D! s
In our patient, physical examination was incon-3 j( X9 a7 h3 H- v* K1 C% [# }
sistent with true precocious puberty since his testi-" k6 j4 M& X/ i# t" P' `
cles were prepubertal in size. However, testotoxicosis
: K/ @1 Z \0 j# W5 V7 C9 ^. Jwas in the differential diagnosis because his father
$ B+ {) J# J( y: g% Z" Kstarted puberty somewhat early, and occasionally,
2 ~! R9 B/ g: O) c% U+ rtesticular enlargement is not that evident in the
# h& A, j0 A2 y7 q# D2 Sbeginning of this process.1 In the absence of a neg-
3 g; ]# O/ E& p1 T9 J2 n5 yative initial history of androgen exposure, our, q$ M9 f( w* }/ z. h3 e
biggest concern was virilizing adrenal hyperplasia,% A. p" q2 {4 M$ u& v, k& Y
either 21-hydroxylase deficiency or 11-β hydroxylase$ m1 {$ W9 e' L6 j5 f6 ]
deficiency. Those diagnoses were excluded by find-' A5 }, t- Y, ^$ P
ing the normal level of adrenal steroids.6 F) g) l6 O! E7 X: ~ T5 X
The diagnosis of exogenous androgens was strongly2 Z l) _) F# s! Z0 U2 [9 b4 q
suspected in a follow-up visit after 4 months because( I7 k, k8 B+ h, j, [
the physical examination revealed the complete disap-
+ V2 |/ S$ I& T' J3 {+ _; ^8 A/ Npearance of pubic hair, normal growth velocity, and
2 A p8 ]( d/ |8 B) }& ~decreased erections. The father admitted using a testos-
4 g8 h9 S3 b2 O. fterone gel, which he concealed at first visit. He was
( t j. S* c @using it rather frequently, twice a day. The Physicians’# A2 Q! x$ i' n$ J- z2 |3 Z
Desk Reference, or package insert of this product, gel or% k& y9 K2 S- f0 {0 e
cream, cautions about dermal testosterone transfer to
* u' u2 ]% h( Q7 t" b! a( X( ~( Hunprotected females through direct skin exposure.5 `( A6 f0 B- m) K
Serum testosterone level was found to be 2 times the8 H! e8 Y! @# P6 e, u# v. Z+ _
baseline value in those females who were exposed to
& D3 g: K+ |! J' N) |even 15 minutes of direct skin contact with their male9 M" E* J% H/ L$ w
partners.6 However, when a shirt covered the applica-" f1 z! o( a% R
tion site, this testosterone transfer was prevented.
7 m* ~3 C/ o& AOur patient’s testosterone level was 60 ng/mL,4 f" {0 [& s& w: ^
which was clearly high. Some studies suggest that
' X& J r( s4 P' j5 v# Bdermal conversion of testosterone to dihydrotestos-$ d- y9 b/ |$ J J8 A( i1 @. t) ~
terone, which is a more potent metabolite, is more; B3 U$ o3 X" F& D) `9 P
active in young children exposed to testosterone5 I) B( j* r( w) N0 t" o
exogenously7; however, we did not measure a dihy-6 K. Q6 e! b5 G1 q/ e; v
drotestosterone level in our patient. In addition to
% i) @5 g* ~% D% ]# {' G2 d. L- Lvirilization, exposure to exogenous testosterone in5 Z3 _4 u- N1 E) V
children results in an increase in growth velocity and
1 a9 d1 D' E! o, ?advanced bone age, as seen in our patient. ]- M' ^$ Q9 B. \1 o
The long-term effect of androgen exposure during
! T# O: a1 _; x2 d5 I1 O3 x; Nearly childhood on pubertal development and final
/ j e/ {2 Z; {9 [. {$ radult height are not fully known and always remain
# E5 K( p5 h( i6 H; F3 ?, da concern. Children treated with short-term testos-
9 O6 X% Z- W4 [' s$ l; r( vterone injection or topical androgen may exhibit some
# j; t3 D' `1 q/ |+ R: _( T( ]acceleration of the skeletal maturation; however, after0 r3 d/ j! y p( ~/ Z0 x9 l1 i
cessation of treatment, the rate of bone maturation x4 @- P% N3 N
decelerates and gradually returns to normal.8,9
* ^6 W! t$ S4 @5 e8 A! E5 A9 nThere are conflicting reports and controversy0 v& ^7 k9 \! T2 v4 D
over the effect of early androgen exposure on adult
$ q* f/ ]# Z: c9 U. n0 xpenile length.10,11 Some reports suggest subnormal% b& ?8 Y. c3 O4 N" E4 b( e
adult penile length, apparently because of downreg-
. [6 W' @( H, K$ Q# m e9 @- M5 g, h2 Eulation of androgen receptor number.10,12 However,
( H! x6 [1 b5 L) S5 P1 O; nSutherland et al13 did not find a correlation between
1 ]( O) r! H% Z, C; Y0 a7 echildhood testosterone exposure and reduced adult
) F" h6 p; p( [$ R; Apenile length in clinical studies.$ x9 F- S5 ?, Y; W0 J, l, T! J
Nonetheless, we do not believe our patient is
, n0 ?0 B+ v8 ygoing to experience any of the untoward effects from5 R$ z- s- G" D$ j
testosterone exposure as mentioned earlier because U, L. A: ]7 a# A
the exposure was not for a prolonged period of time.% ?, d& K0 J: g/ i/ N- N' C% o
Although the bone age was advanced at the time of
; O$ K7 @, B* S# V3 p3 [* ]0 Z* idiagnosis, the child had a normal growth velocity at
5 H* H# g; S5 ~ K6 a1 m p! Vthe follow-up visit. It is hoped that his final adult- y& _7 N; h1 ]3 O2 ~8 X
height will not be affected.
! z5 p$ v; E( J/ f/ L( P0 ]Although rarely reported, the widespread avail-0 S6 L7 j" G" ]; _4 `
ability of androgen products in our society may. W$ W% m1 m, E2 z% N6 v/ J
indeed cause more virilization in male or female1 U2 y, c& V8 t! f$ p$ D) X8 Z- Z
children than one would realize. Exposure to andro-
: n) {8 N1 S' n, Agen products must be considered and specific ques-
/ q2 P$ ~; V1 u! ]5 ~tioning about the use of a testosterone product or5 g% p- p# I4 p+ H8 E4 q" A4 ~
gel should be asked of the family members during
4 b$ K2 |4 }% ^% T5 \the evaluation of any children who present with vir-$ j6 U. l% |9 v9 M$ V [3 G& D8 p
ilization or peripheral precocious puberty. The diag-
3 K5 R1 p/ u$ P. J/ onosis can be established by just a few tests and by
9 q/ b8 S2 Q& Pappropriate history. The inability to obtain such a
5 H9 j9 O; m. g9 Q" `& e& ^. Yhistory, or failure to ask the specific questions, may
; d- L8 v9 K: S2 J# Mresult in extensive, unnecessary, and expensive
1 z: {4 h+ m6 \2 Uinvestigation. The primary care physician should be$ f7 t( G( `8 I4 Y
aware of this fact, because most of these children
& X/ w( ~4 K6 w, F3 j; d! Imay initially present in their practice. The Physicians’- a7 L# O# q: {5 h$ W D$ t) W
Desk Reference and package insert should also put a6 ?* \4 Y F* x: y- ?" n- \3 d
warning about the virilizing effect on a male or
# B, [! _5 z/ @female child who might come in contact with some-
4 w$ Q1 G0 L& Q+ d; Done using any of these products.
+ N R* F7 o, [1 ]* q* ~References
, D0 n6 U7 [* I- A1 j+ N1. Styne DM. The testes: disorder of sexual differentiation
4 h$ _9 v0 D. m: I7 b: i `& c9 D. Xand puberty in the male. In: Sperling MA, ed. Pediatric
4 S. h$ q9 y0 Z0 i6 j6 K Z, l/ rEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;" C( e8 c% S: w# q+ n4 n# u" X
2002: 565-628.7 N+ I9 k% X( V$ r' `9 P0 V+ p
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 }* ] w$ }. ^% z# hpuberty in children with tumours of the suprasellar pineal |
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