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Sexual Precocity in a 16-Month-Old0 Z8 w9 [- v7 L/ v7 j; H# d
Boy Induced by Indirect Topical/ m+ b+ u- Q8 b. R: }; L0 x3 T
Exposure to Testosterone- {5 A1 Y$ z: Q* G
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
[5 ?9 ]! y# x0 ^and Kenneth R. Rettig, MD1
* X) B2 m! N- [1 L$ f9 s) Z% eClinical Pediatrics
3 L! \7 N7 L# rVolume 46 Number 6; D v: y$ Z" p8 V+ h% D
July 2007 540-543
/ _! E7 l7 z: B5 e© 2007 Sage Publications
( r3 u- M& O( ^8 k1 _0 N* D2 B, r/ X10.1177/0009922806296651
3 u( S6 o# w; q3 |% K1 E4 vhttp://clp.sagepub.com: U& v( `" U0 o% ]. G
hosted at
' |, m1 ]/ W! y8 k& |8 vhttp://online.sagepub.com- ~2 |- A. }1 z
Precocious puberty in boys, central or peripheral,' J I4 t/ V! f( G1 y' N C
is a significant concern for physicians. Central% Z) d9 h3 ^5 Z9 M" l {/ o. K) U5 [
precocious puberty (CPP), which is mediated
$ M7 E8 e, v* Q, V1 {6 X0 |through the hypothalamic pituitary gonadal axis, has3 A& t7 H+ Q5 S) ^+ M5 D/ }% L( H
a higher incidence of organic central nervous system
3 w" U9 {' k. Mlesions in boys.1,2 Virilization in boys, as manifested
( v4 o! l. A( w3 N4 nby enlargement of the penis, development of pubic
* L. _5 ^" `2 i- bhair, and facial acne without enlargement of testi-: R9 L4 _6 T' o1 f% p
cles, suggests peripheral or pseudopuberty.1-3 We
" q K/ }* ~0 S% Y& C# Zreport a 16-month-old boy who presented with the
$ s4 i5 r4 v9 u, R- q1 q: c5 denlargement of the phallus and pubic hair develop-( W' C% v9 t6 T/ [6 m; S3 g1 c
ment without testicular enlargement, which was due; \9 {6 x3 q0 m: |2 g! h
to the unintentional exposure to androgen gel used by
' s4 h9 q) m8 p4 f" K* R1 Rthe father. The family initially concealed this infor-
" _6 j+ a! J& i) B! a9 D. `mation, resulting in an extensive work-up for this
Y% p, G1 p1 E& p( G# Z schild. Given the widespread and easy availability of5 l, w6 x9 p7 z3 @4 }; P; P- Y, K. c
testosterone gel and cream, we believe this is proba-
1 n2 c$ Z% z3 P1 v1 Obly more common than the rare case report in the: I# D& A0 ^4 [) ~9 O
literature.40 x" T: ~& e5 c' x. u
Patient Report
1 R& H( U& p t9 o2 J! F6 ]A 16-month-old white child was referred to the
# I0 r$ b5 L; Pendocrine clinic by his pediatrician with the concern3 E* f, v$ [ h
of early sexual development. His mother noticed
3 r! C# S8 D* R6 x( j/ jlight colored pubic hair development when he was
& D. u8 e" X: d1 @' aFrom the 1Division of Pediatric Endocrinology, 2University of
4 `; o. L) U1 kSouth Alabama Medical Center, Mobile, Alabama.
, Y7 J+ K1 T# |Address correspondence to: Samar K. Bhowmick, MD, FACE,
" U" V" ~& ]8 F5 O+ {Professor of Pediatrics, University of South Alabama, College of+ k8 d; m" p0 n
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 U \# f! c% |7 @
e-mail: [email protected].
1 f9 v, }5 S+ g4 Wabout 6 to 7 months old, which progressively became
! U" S9 n( X, O2 x3 Udarker. She was also concerned about the enlarge-
1 N5 z; {2 U v" p; oment of his penis and frequent erections. The child- ^4 t6 e9 F3 F6 S; W# c
was the product of a full-term normal delivery, with
2 C+ c: N! p' f% p7 B ja birth weight of 7 lb 14 oz, and birth length of3 l d) l, c& i4 C0 u U
20 inches. He was breast-fed throughout the first year3 A0 `( V/ g& F& ~
of life and was still receiving breast milk along with$ |1 F9 f; W3 v. b7 V
solid food. He had no hospitalizations or surgery,
3 ^; [; w8 J8 H6 _and his psychosocial and psychomotor development
, v3 P2 A2 s6 P) t6 ^, b& @. K4 {2 Ewas age appropriate.
( u6 o, i, x+ cThe family history was remarkable for the father,% Y8 A8 b+ X7 w1 Z& [3 c
who was diagnosed with hypothyroidism at age 16,
0 n" J3 C, J+ b5 e U1 \. y: Uwhich was treated with thyroxine. The father’s
; {3 N) j6 t6 N0 P$ Kheight was 6 feet, and he went through a somewhat
# d B* @ r6 B3 E1 jearly puberty and had stopped growing by age 14.
8 O3 Y% ?2 K+ _% S1 jThe father denied taking any other medication. The
5 n2 l5 S. q" h6 b$ u, y& c+ schild’s mother was in good health. Her menarche
6 ]; v9 `3 [- R, Z- }/ o- G8 Ewas at 11 years of age, and her height was at 5 feet
% i$ w$ |9 X) X, Q0 a- u5 inches. There was no other family history of pre-" w6 M Q. N: H p
cocious sexual development in the first-degree rela-
0 \9 c( D2 H: J9 |tives. There were no siblings.
5 }: K. U% _ XPhysical Examination
+ s8 m+ x8 ^' j& p& T8 ?9 |The physical examination revealed a very active,9 V) | R: h% v! L: X2 C9 ]
playful, and healthy boy. The vital signs documented! a+ X% W4 T5 V
a blood pressure of 85/50 mm Hg, his length was
9 q( o- M' [1 @* Z0 B- j3 r90 cm (>97th percentile), and his weight was 14.4 kg
. _6 L( J0 u3 w(also >97th percentile). The observed yearly growth
; n& O2 f; V. m' [) E2 X- Ivelocity was 30 cm (12 inches). The examination of
' ^% t3 e/ R/ p1 \4 w$ wthe neck revealed no thyroid enlargement.* t( J# ~ p; z1 F M
The genitourinary examination was remarkable for% o; N$ |4 w4 ^. R, I
enlargement of the penis, with a stretched length of: |: f( G' ~& m9 a* V8 n3 q/ ~# ]
8 cm and a width of 2 cm. The glans penis was very well; T5 x$ ]* M0 V" ^# y' W6 Z7 ^
developed. The pubic hair was Tanner II, mostly around
P- k& f3 n2 M: c540
. t3 b8 [. s0 y9 L7 K K- Vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 w- p( y$ }% K6 j4 F% H
the base of the phallus and was dark and curled. The& C) V- b. l" g1 }
testicular volume was prepubertal at 2 mL each.
6 k: q7 y2 n, b/ jThe skin was moist and smooth and somewhat
) v5 t7 R e) x {# y6 ^! coily. No axillary hair was noted. There were no: [ |, ^5 I* U3 K2 E
abnormal skin pigmentations or café-au-lait spots., X+ F+ x2 W% n0 n7 a( I1 ^
Neurologic evaluation showed deep tendon reflex 2+) b x [6 g/ G
bilateral and symmetrical. There was no suggestion G& R7 c( s( W6 u- R
of papilledema.3 }0 c" R- ^9 S9 @$ U# M
Laboratory Evaluation
: V7 C7 \! j7 k2 p9 bThe bone age was consistent with 28 months by
; O7 h& A" Y9 t1 G" {using the standard of Greulich and Pyle at a chrono-
( i) O' [' m$ P* J0 x' U; N+ Alogic age of 16 months (advanced).5 Chromosomal- w4 O% H! F1 C1 r' O: f+ \$ G% D
karyotype was 46XY. The thyroid function test
9 }4 O) R% D* T/ E, p' Ushowed a free T4 of 1.69 ng/dL, and thyroid stimu-+ e7 o9 f$ `0 ^/ b+ `( t- Q/ c! M
lating hormone level was 1.3 µIU/mL (both normal).3 O" E! `$ y3 h% s2 D q
The concentrations of serum electrolytes, blood
& j3 M0 C) c$ h: ^9 _urea nitrogen, creatinine, and calcium all were& |' ^6 u9 ~; r2 i
within normal range for his age. The concentration
4 x4 B6 ?, R- Y& L# _- }. Nof serum 17-hydroxyprogesterone was 16 ng/dL3 d7 X- H/ S. M5 j9 m" @
(normal, 3 to 90 ng/dL), androstenedione was 20
) f& J1 a7 i" tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 X, x* | t, M1 a9 C6 r
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
! F* j9 ?: A% y0 y" ]3 ndesoxycorticosterone was 4.3 ng/dL (normal, 7 to
% ~6 d# ?7 p. \; I3 t1 G5 h# p49ng/dL), 11-desoxycortisol (specific compound S)
m9 n- E5 u4 y8 K9 b/ V `+ y( ywas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
) ?$ j6 x4 O3 o/ X7 ~1 Z( S+ p0 U1 Qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' _, u$ {$ H7 t/ {1 H* D# k/ B
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 _4 ]$ m- w% O% d* s+ H# mand β-human chorionic gonadotropin was less than
! s( B. S# ~( w! h* j9 n; D/ T5 mIU/mL (normal <5 mIU/mL). Serum follicular
. L/ H1 j1 b+ K) e7 Ostimulating hormone and leuteinizing hormone
9 ?2 T6 f+ Y! Qconcentrations were less than 0.05 mIU/mL
H0 a, s" _7 @' x(prepubertal).
/ v) `7 n6 j( o; H2 y+ FThe parents were notified about the laboratory
8 e- M2 F6 I5 o8 q1 }results and were informed that all of the tests were
* _, v |/ ~) Z& S: ], ?! unormal except the testosterone level was high. The4 a/ K$ Y* S8 c! N% J( r
follow-up visit was arranged within a few weeks to4 g% ~- S& [3 O7 N: o% e( H( F" o" h) X
obtain testicular and abdominal sonograms; how-
9 O1 V0 {5 @4 ^# yever, the family did not return for 4 months.: B( J3 o# }$ f1 g3 d) p
Physical examination at this time revealed that the; k% G1 h" Y; Z u# S
child had grown 2.5 cm in 4 months and had gained
0 a6 W8 Y5 A, `( `2 kg of weight. Physical examination remained
+ X' @# d; E2 m1 funchanged. Surprisingly, the pubic hair almost com-2 A3 k6 Z' v3 v$ R* X# Y# x
pletely disappeared except for a few vellous hairs at
4 N' x. `( e# x0 W, }the base of the phallus. Testicular volume was still 2
6 G* B% z9 K8 \" Q3 OmL, and the size of the penis remained unchanged.5 v- |7 j" N7 k' }4 j/ X3 i9 M- c
The mother also said that the boy was no longer hav-
' \2 l, U" K+ u. h6 king frequent erections.
* |) r, g+ l# {" T- A( ]Both parents were again questioned about use of2 V3 J5 T6 O+ l+ ]5 ?
any ointment/creams that they may have applied to, _" ^' m/ n7 G# E. j3 t/ q" O
the child’s skin. This time the father admitted the
9 ~) a( y/ P* X4 |4 n/ g( ^' t* }Topical Testosterone Exposure / Bhowmick et al 541
6 C+ i' z6 {* Fuse of testosterone gel twice daily that he was apply-! g7 G6 f! x4 a" G+ ~' a: R) J D- W
ing over his own shoulders, chest, and back area for/ _6 |1 M9 U9 Q) s' J1 W) p
a year. The father also revealed he was embarrassed
$ r* i' o1 G1 _/ K7 {) rto disclose that he was using a testosterone gel pre-
, h6 ]# Y2 G+ ?2 @4 _5 P1 fscribed by his family physician for decreased libido. i8 P1 f; o, e
secondary to depression.
1 ^+ z d! A8 {- h9 dThe child slept in the same bed with parents.
% t) }/ \- B' X7 u* [- lThe father would hug the baby and hold him on his
3 r* B3 a# [( P1 m( S7 ~) {chest for a considerable period of time, causing sig-" \& j5 u: d" E0 N' b
nificant bare skin contact between baby and father.
- w9 v8 f7 b* \$ v9 @2 H2 vThe father also admitted that after the phone call,
" M2 d/ }0 s5 b3 ^when he learned the testosterone level in the baby4 h2 N# q8 M8 m9 [- g# m
was high, he then read the product information
7 f3 F+ c) {8 t; P0 _1 cpacket and concluded that it was most likely the rea-8 X; @0 q S! f1 L# \7 ^
son for the child’s virilization. At that time, they5 f& K" D3 P1 [# v5 T
decided to put the baby in a separate bed, and the
& x, J E$ F/ R! r1 Qfather was not hugging him with bare skin and had/ V8 @! Q" v& _8 Y4 i
been using protective clothing. A repeat testosterone
# T& K, o6 P: O. I+ dtest was ordered, but the family did not go to the
1 J: a1 ^& u3 n$ x/ Claboratory to obtain the test.
% r1 d9 C3 i( U8 ] F1 C( `" VDiscussion
9 f. ~& l5 l' g* d5 ]- X. _Precocious puberty in boys is defined as secondary: @; O4 j% I1 n6 r t0 l
sexual development before 9 years of age.1,45 h: a- T- d# l9 K' c
Precocious puberty is termed as central (true) when4 O" Q( x1 r3 l J. z
it is caused by the premature activation of hypo-
- u0 L1 K y- K: vthalamic pituitary gonadal axis. CPP is more com-, P8 {4 x0 U, B t; J m+ n/ I& K
mon in girls than in boys.1,3 Most boys with CPP
5 b3 l' a( b, j# u4 Zmay have a central nervous system lesion that is; E7 d+ I/ a* d$ P v/ R
responsible for the early activation of the hypothal-9 ~: l7 D8 h# ]8 {! S
amic pituitary gonadal axis.1-3 Thus, greater empha-5 d o" {) K5 W% q- l8 G
sis has been given to neuroradiologic imaging in
9 S( o# V" N: z, m1 n a: m& Fboys with precocious puberty. In addition to viril-
: D" C9 [: @* K6 \6 l8 d+ t- h2 z0 Pization, the clinical hallmark of CPP is the symmet-
5 {4 h5 l& O0 ?; ?rical testicular growth secondary to stimulation by
7 f/ K4 _) G9 f) d0 k& z O! Lgonadotropins.1,3
7 [5 `8 m/ U+ g1 z0 b( g8 pGonadotropin-independent peripheral preco-2 V* r. g( P' E, F9 U9 C8 V6 s
cious puberty in boys also results from inappropriate6 t$ {* Q3 j1 Q/ b
androgenic stimulation from either endogenous or
/ q/ z* J3 J6 {2 {4 }5 Nexogenous sources, nonpituitary gonadotropin stim-
# Q T T6 d4 w7 Yulation, and rare activating mutations.3 Virilizing
5 Q' ^9 h5 \1 ycongenital adrenal hyperplasia producing excessive
; i+ U) l1 ~! A% j* N/ z/ U: vadrenal androgens is a common cause of precocious9 g% m( u4 E1 ]3 i* [
puberty in boys.3,4
( o7 z/ ?# [# {) T" `4 tThe most common form of congenital adrenal/ u" }+ A: ^) Q u# c! {7 n4 T
hyperplasia is the 21-hydroxylase enzyme deficiency.
6 h \* ^9 b' w. n( D5 d' e" WThe 11-β hydroxylase deficiency may also result in$ ~, ^, G/ p3 P
excessive adrenal androgen production, and rarely,
0 f! q) I1 |' A" r! M# Jan adrenal tumor may also cause adrenal androgen/ f/ R5 s1 Y1 a/ z& G$ M3 ?
excess.1,3
6 F1 } t, H+ o @1 n6 G; q0 G* T. p Wat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, y/ N. o: {( q
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007; Q' {+ p9 N% @3 Y" y+ P! O, k2 F
A unique entity of male-limited gonadotropin-
' |2 J& T' a( s% I0 W" L: b* ?5 Y5 sindependent precocious puberty, which is also known
2 M' q9 d- a# v$ E# Tas testotoxicosis, may cause precocious puberty at a. W. r; u7 O2 d; N# L, C4 i# \
very young age. The physical findings in these boys
* n9 T, T- k5 b7 P# H4 a& Ywith this disorder are full pubertal development,
9 E5 W, ~7 X6 J s9 K, y/ H8 d* }including bilateral testicular growth, similar to boys' z( T C- x) B$ ~
with CPP. The gonadotropin levels in this disorder6 E# J( d' M; B' P: ], D3 t
are suppressed to prepubertal levels and do not show. J# \/ a1 Y' C$ _4 q9 R/ g
pubertal response of gonadotropin after gonadotropin-
1 J+ l1 ?* o6 M/ g. g2 G% l) Zreleasing hormone stimulation. This is a sex-linked$ ]1 E5 P5 r7 e$ y6 D
autosomal dominant disorder that affects only
" Y% g: K$ d" I7 F: H5 w$ J# pmales; therefore, other male members of the family' X5 [; X6 v9 k" g
may have similar precocious puberty.3
* N3 h/ I. {0 Y7 \In our patient, physical examination was incon-
$ R- ~) ?- R7 i$ ysistent with true precocious puberty since his testi-
9 b5 \0 q' q! Ncles were prepubertal in size. However, testotoxicosis3 k; ~, o4 N( _. ~2 Z
was in the differential diagnosis because his father" p, [- t9 L, ~2 Y& w
started puberty somewhat early, and occasionally,
1 B) l+ o" l" R: ftesticular enlargement is not that evident in the" B2 ] y( R2 i' S; l# N
beginning of this process.1 In the absence of a neg-
, u; h3 ]) v5 w+ g; l9 m5 Dative initial history of androgen exposure, our
6 p+ m$ z4 ^& o8 d' d2 V8 mbiggest concern was virilizing adrenal hyperplasia,
7 _' P- x- v& |% Jeither 21-hydroxylase deficiency or 11-β hydroxylase0 a( _9 h& d) ^6 _
deficiency. Those diagnoses were excluded by find-3 g& [7 L0 C. y" M9 ]* q! h* h
ing the normal level of adrenal steroids.
6 C1 M0 {3 C" y$ T7 e; ^The diagnosis of exogenous androgens was strongly
. z7 I2 ~7 M7 s9 |suspected in a follow-up visit after 4 months because: W0 @. F( ]: X0 i; ]$ `
the physical examination revealed the complete disap-
0 I+ \- Y. Z1 G8 `! dpearance of pubic hair, normal growth velocity, and7 ^8 s7 g, ?0 `$ d& C
decreased erections. The father admitted using a testos-4 e( L7 \! K0 x
terone gel, which he concealed at first visit. He was O5 }: H0 b( i
using it rather frequently, twice a day. The Physicians’
4 \0 O% O( O, I8 U. O# p# lDesk Reference, or package insert of this product, gel or
! @7 X! f+ @4 s4 ~: ?% }; \3 tcream, cautions about dermal testosterone transfer to
. v: }- T3 d& I s0 Vunprotected females through direct skin exposure.
# G4 t6 w X- T9 V# _! kSerum testosterone level was found to be 2 times the: t- ? P+ p1 `( d
baseline value in those females who were exposed to6 e# y7 E# V: z. X' B; @! Z
even 15 minutes of direct skin contact with their male( e' B2 e0 M4 C
partners.6 However, when a shirt covered the applica-% r* l, ^5 s* C+ Q% z0 f
tion site, this testosterone transfer was prevented. ~2 H E! T3 J: l. W6 Y. \+ @
Our patient’s testosterone level was 60 ng/mL,
* x5 i- _, N r0 ^6 f1 k: z8 ewhich was clearly high. Some studies suggest that
) z# W5 A' E z8 Q, jdermal conversion of testosterone to dihydrotestos-
5 E9 \) b( z+ [6 f; X" p U2 _terone, which is a more potent metabolite, is more( H/ u- b7 k- }2 t+ y6 a
active in young children exposed to testosterone1 A1 k4 l/ k) G
exogenously7; however, we did not measure a dihy-
0 ^% r( W, v" \* ~drotestosterone level in our patient. In addition to
6 e5 V C" q2 a! A: vvirilization, exposure to exogenous testosterone in
" S- Q$ G9 ?- H( t8 k# z/ D$ Ychildren results in an increase in growth velocity and
$ P0 e* Q0 E) {0 Madvanced bone age, as seen in our patient.$ m6 [, f* ^3 L2 W- S( t+ W+ u
The long-term effect of androgen exposure during# `/ S5 Z2 ~8 c4 }4 R- ]
early childhood on pubertal development and final
$ ], a1 o6 B' ]' A9 J, Oadult height are not fully known and always remain! _% _5 C- u7 Z; V+ R W7 }5 k
a concern. Children treated with short-term testos-
' D' b% d1 A' E, ^8 l2 u; C* \terone injection or topical androgen may exhibit some
- q+ H" ]0 c( y, C9 k: _2 sacceleration of the skeletal maturation; however, after# i, l& G# O" K- i/ a- ?
cessation of treatment, the rate of bone maturation4 T# e2 c9 l# \* ?/ s& u
decelerates and gradually returns to normal.8,9
( T5 F7 U5 c/ P0 o! p- A8 [# AThere are conflicting reports and controversy
0 l$ I3 o) Q5 S$ \over the effect of early androgen exposure on adult# x% g+ v5 U- [6 t( ?
penile length.10,11 Some reports suggest subnormal
! U, J2 W! i3 L( j* xadult penile length, apparently because of downreg-. m- c. T5 h: p, j/ B- D2 o8 S
ulation of androgen receptor number.10,12 However,3 y! i0 _7 y( c3 h
Sutherland et al13 did not find a correlation between
; i- H& ~1 g9 L ?- Z+ nchildhood testosterone exposure and reduced adult$ [9 |! e1 |9 c7 i) p/ l& e2 G
penile length in clinical studies.
% S, R' E+ h8 f/ K4 c6 WNonetheless, we do not believe our patient is% J2 [. `7 t/ a0 A7 ^+ S
going to experience any of the untoward effects from
$ E' A' S( N1 A/ A+ X; z+ ~testosterone exposure as mentioned earlier because: s/ y5 a/ {6 ^
the exposure was not for a prolonged period of time.* E7 L5 I# t M
Although the bone age was advanced at the time of
! t/ ]1 ~, g8 X6 ^, G, hdiagnosis, the child had a normal growth velocity at' E- z2 T- ^, k" P2 D) u% v
the follow-up visit. It is hoped that his final adult
6 H( E" q; T, `* l* _height will not be affected.$ y( r8 s4 O; I$ I! ^
Although rarely reported, the widespread avail-4 w6 D) R6 h# H; I0 _: N% b3 [1 i
ability of androgen products in our society may
. l- \8 H2 L8 Kindeed cause more virilization in male or female
* o0 @9 X8 l, o5 }5 tchildren than one would realize. Exposure to andro-
/ v" T+ {$ _: Sgen products must be considered and specific ques-* X1 [2 `* f6 l/ J# I1 q
tioning about the use of a testosterone product or# Q$ J, A0 q% x
gel should be asked of the family members during
* _% [' l. B" Gthe evaluation of any children who present with vir-! S* F* D* m @2 a5 @& ]+ H
ilization or peripheral precocious puberty. The diag-
# r: Y o) w6 L$ W! @/ ~nosis can be established by just a few tests and by
/ q0 ^% g' S$ _3 O& F/ Wappropriate history. The inability to obtain such a
3 _* B0 c. p/ t: G9 h: O9 w% Mhistory, or failure to ask the specific questions, may; k$ l1 {: \, o: w& k2 m1 a
result in extensive, unnecessary, and expensive
! m, q) w9 Y0 K8 h' v$ d. Xinvestigation. The primary care physician should be3 Y7 ]' J0 h- |3 H* g" \
aware of this fact, because most of these children9 N* j% n& K. h9 y9 k5 @, u
may initially present in their practice. The Physicians’
4 M. \. f E k9 pDesk Reference and package insert should also put a
, z; ~" R! b0 R& V6 xwarning about the virilizing effect on a male or
) F3 E9 E. f! v) Jfemale child who might come in contact with some-4 l2 ~2 }" z3 @# R+ |/ _& V- G& p
one using any of these products.
9 R9 w0 k% Q% |4 V' v* ~References1 ?8 a3 U& `9 t v# @$ l
1. Styne DM. The testes: disorder of sexual differentiation) z/ Z8 x' a8 G
and puberty in the male. In: Sperling MA, ed. Pediatric; y: p7 P* |- G) P/ l
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 z' D. i2 L; I0 _+ [0 @
2002: 565-628.3 j' Z8 M- C0 I$ ^
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious: K% M3 `* T0 F3 U9 C- b. F! J
puberty in children with tumours of the suprasellar pineal |
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