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Sexual Precocity in a 16-Month-Old9 a7 _" C0 y' L4 U# Y* E$ p* r
Boy Induced by Indirect Topical6 f* e/ u: a' E% R5 @( z1 W
Exposure to Testosterone, `' N0 X: Y; T" p* T0 ?8 G
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ E2 C$ h9 G E) W3 L' X1 c1 Tand Kenneth R. Rettig, MD1
7 F: ~5 Q& @5 [/ X% ~' D3 d* qClinical Pediatrics' U' B/ A* G% @" L; i
Volume 46 Number 60 k, T" b5 h8 K0 f
July 2007 540-543/ [% V0 d7 i+ u8 E
© 2007 Sage Publications
& E5 t' h: o" M% X5 Q4 Q' F10.1177/0009922806296651* E# P Y/ }- ?
http://clp.sagepub.com7 z# D* }' I4 t# _6 _
hosted at
( ^$ j, m" {6 E3 E9 {2 ~ fhttp://online.sagepub.com" T" f) p$ f! M8 p6 F- X/ l. Z
Precocious puberty in boys, central or peripheral,
2 @5 u% u1 t/ f6 b+ w% [is a significant concern for physicians. Central
3 A9 }$ h3 f+ xprecocious puberty (CPP), which is mediated" \6 i. d- e, ]1 E
through the hypothalamic pituitary gonadal axis, has
. t' r; t2 T! e+ [a higher incidence of organic central nervous system
. L) p: T* K q) Xlesions in boys.1,2 Virilization in boys, as manifested
) s$ ?; v( o1 Pby enlargement of the penis, development of pubic: ?% o- u( f+ X; j" J# R
hair, and facial acne without enlargement of testi-
$ i" t' i5 Q9 | z0 Qcles, suggests peripheral or pseudopuberty.1-3 We+ {: [* [! ~" t
report a 16-month-old boy who presented with the
! F8 ]9 Z; T) P$ @% P1 ]# renlargement of the phallus and pubic hair develop-
2 x; C2 e, {! l" C1 W; o1 @ment without testicular enlargement, which was due
2 h4 J+ T5 u, a uto the unintentional exposure to androgen gel used by
5 E2 p+ ~% w6 `, J5 [' vthe father. The family initially concealed this infor-
1 q1 o) B3 }& x8 j1 e; omation, resulting in an extensive work-up for this# |9 j! i2 J) C3 Y0 L4 x' B/ |
child. Given the widespread and easy availability of
# ~; [, w" N4 Y4 x9 Ltestosterone gel and cream, we believe this is proba-" i2 ~2 j3 d! s# C# t1 ] T
bly more common than the rare case report in the
5 Z3 q8 G& n2 n" _literature.4
7 U% t; V5 P; w) E" dPatient Report
( V' P4 [! ^- bA 16-month-old white child was referred to the, q% A A" I/ e" y Z
endocrine clinic by his pediatrician with the concern
9 c! k$ g) ^( [* rof early sexual development. His mother noticed! Z: G$ A. u2 Q- B2 a5 C
light colored pubic hair development when he was
. @8 Q$ g7 {: j @8 ^" j- V& |+ N2 [From the 1Division of Pediatric Endocrinology, 2University of3 @: z1 Y2 w% z: k$ X& G1 B6 m
South Alabama Medical Center, Mobile, Alabama.
' j! [6 y/ K5 G ~! nAddress correspondence to: Samar K. Bhowmick, MD, FACE,
' F% T% M$ s0 k, F% k2 m) iProfessor of Pediatrics, University of South Alabama, College of) c; z8 M& Y( L
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297; Y0 { S, R/ y& R$ S
e-mail: [email protected].
2 O- c8 y3 m$ S4 tabout 6 to 7 months old, which progressively became
! j2 x+ J8 S$ {0 kdarker. She was also concerned about the enlarge-0 \& q) M; ]( G& t
ment of his penis and frequent erections. The child6 q( L1 k& n; `+ d% c! G7 a% d; i& p6 @
was the product of a full-term normal delivery, with
' `2 W+ l' j Y0 [a birth weight of 7 lb 14 oz, and birth length of" `; }8 l4 k# K) o& M! O
20 inches. He was breast-fed throughout the first year6 Y$ G. \* b2 g0 P$ {1 B8 @
of life and was still receiving breast milk along with
: G& a% z+ I" I0 dsolid food. He had no hospitalizations or surgery,$ F; ? \6 u/ _" _" i# g6 X
and his psychosocial and psychomotor development1 L' I4 {6 v% f
was age appropriate.
0 v$ O1 }+ B5 m) h* O+ `& R) DThe family history was remarkable for the father,
/ J. ?# [: c/ h% \+ Dwho was diagnosed with hypothyroidism at age 16,
) |5 W) O1 O& Pwhich was treated with thyroxine. The father’s
: t4 O4 e( {/ [/ ~! U, Wheight was 6 feet, and he went through a somewhat; K9 }1 G, S5 Q3 }
early puberty and had stopped growing by age 14.
# m$ x9 l/ s, _9 r% V" s# d1 ZThe father denied taking any other medication. The8 t% B5 v( F' c/ F2 I2 N( p- V9 n: Z& l4 D
child’s mother was in good health. Her menarche
3 u# \/ [, B3 |7 r( L9 vwas at 11 years of age, and her height was at 5 feet9 |% [; |4 P5 k a* B6 T$ @
5 inches. There was no other family history of pre-
m0 W! s5 B+ ^2 scocious sexual development in the first-degree rela-
" v" Y, O/ h ^4 O1 \tives. There were no siblings.5 u/ f9 B) h6 d: n' v; k( {2 r
Physical Examination, d; U5 I% K4 G& p v
The physical examination revealed a very active,
z5 O7 e, @, _+ A9 H% p _' l$ qplayful, and healthy boy. The vital signs documented
6 J0 b1 ^9 R) Y! y% S0 M% v3 }a blood pressure of 85/50 mm Hg, his length was
$ n6 M) n" S* q( x/ \+ F$ \90 cm (>97th percentile), and his weight was 14.4 kg
$ U- m9 K; Z! w1 c9 m7 v! ?(also >97th percentile). The observed yearly growth/ Y- D8 V, ?0 k$ I! B& n
velocity was 30 cm (12 inches). The examination of3 {) Z/ S+ c- H
the neck revealed no thyroid enlargement.+ [5 r0 F. p* N9 O H& ]& R
The genitourinary examination was remarkable for
2 A2 t$ o! E9 M, h/ z( Eenlargement of the penis, with a stretched length of l8 ?5 F8 f& {
8 cm and a width of 2 cm. The glans penis was very well
6 L$ k3 a- t/ Edeveloped. The pubic hair was Tanner II, mostly around$ G3 @* o- \8 |1 W: @" O( ^' j
540: z& l5 r/ f+ q8 U/ B' T: k: \+ H
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; O) C2 |, ]" M) O. _2 r- }
the base of the phallus and was dark and curled. The; _: d% D0 j" D
testicular volume was prepubertal at 2 mL each.
- y ]5 h% v9 oThe skin was moist and smooth and somewhat
: A+ W3 c7 |' ]& G) V4 v. p# moily. No axillary hair was noted. There were no
^$ s) F2 |6 Y+ S& u. P, W+ e \. Rabnormal skin pigmentations or café-au-lait spots.
- l1 ]1 ?/ w5 A) ]# V6 B* Y# ANeurologic evaluation showed deep tendon reflex 2+, s& d) v, J5 x; E. o6 V t& F; g
bilateral and symmetrical. There was no suggestion( s1 w8 p9 m0 P5 S
of papilledema.
% ]* }; ^6 j# a7 a5 a: uLaboratory Evaluation) t0 u: G7 _# w' E% |, n
The bone age was consistent with 28 months by
( r8 D: O, ?5 cusing the standard of Greulich and Pyle at a chrono-
7 g1 C0 t) v" D* A6 i* ^logic age of 16 months (advanced).5 Chromosomal: v {' o6 m7 @/ k% U6 U
karyotype was 46XY. The thyroid function test
" d) n9 p% b& i& f. l7 z- ^showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. |: c- Z- c/ n( G& hlating hormone level was 1.3 µIU/mL (both normal).5 C* E- Z. }$ a# F6 Q6 j
The concentrations of serum electrolytes, blood
/ O& V/ T2 a0 G, E7 curea nitrogen, creatinine, and calcium all were
/ j- R! @: L# { p0 X0 ?within normal range for his age. The concentration7 ]; `5 K. W8 B# ]( f" L: h1 O
of serum 17-hydroxyprogesterone was 16 ng/dL
8 [1 R) M, B0 j+ u9 n C8 K5 g(normal, 3 to 90 ng/dL), androstenedione was 20
! ]+ e- z/ ]# f) t, q4 Jng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; ]; r) G1 @9 Y2 `* h8 o) x
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
, b8 o3 ^, {9 A1 C% ddesoxycorticosterone was 4.3 ng/dL (normal, 7 to2 N' @2 |2 s; q6 N; o
49ng/dL), 11-desoxycortisol (specific compound S)( Z6 |" J3 o. t4 { e; _
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 W5 _' N7 a3 Q' i
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total% u4 I) @: L% Y3 r# n' u
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),. F; c [. i) d5 s3 V: ^2 O
and β-human chorionic gonadotropin was less than% C' u4 |) m8 d* w4 f P9 ?
5 mIU/mL (normal <5 mIU/mL). Serum follicular
/ _6 g7 x' N9 b* |stimulating hormone and leuteinizing hormone
_: v* ^( H0 Y) j0 kconcentrations were less than 0.05 mIU/mL
- ?) @* ? ^# d/ \1 m(prepubertal).0 C% V9 X! F' i
The parents were notified about the laboratory
' ]$ A8 J# `! _7 H: ^: q* aresults and were informed that all of the tests were4 V+ t4 I1 I4 m, l" c/ v2 A
normal except the testosterone level was high. The
( o- M1 N! G# Xfollow-up visit was arranged within a few weeks to
3 L% T: c5 e5 t0 s, ]" j( _3 Qobtain testicular and abdominal sonograms; how-( t* r/ l% M3 Y/ z
ever, the family did not return for 4 months. K9 r6 n* D) l) E
Physical examination at this time revealed that the
# V7 I4 E- T2 F" u( uchild had grown 2.5 cm in 4 months and had gained! P, r6 p1 A5 l3 ]' U8 U8 w
2 kg of weight. Physical examination remained
+ K4 l. K/ \# m% Z) @unchanged. Surprisingly, the pubic hair almost com-
' n [% t2 J( Z: ypletely disappeared except for a few vellous hairs at
7 _1 T4 S6 c. J( v/ [the base of the phallus. Testicular volume was still 2
0 M; t- e. O* b6 t1 u8 bmL, and the size of the penis remained unchanged.
1 k- [5 T x b2 e4 ]. RThe mother also said that the boy was no longer hav-
r- O: T) H/ R+ l4 g' H1 z; _ing frequent erections.+ F+ N" X) K) p
Both parents were again questioned about use of
$ i% z! j# J' f4 _3 I/ e$ sany ointment/creams that they may have applied to
5 ~- `0 o6 |9 I3 d- }/ _! X, athe child’s skin. This time the father admitted the
/ a3 B" K1 X9 c8 J& l+ UTopical Testosterone Exposure / Bhowmick et al 541
) V( W9 ?0 C N6 ~3 ?use of testosterone gel twice daily that he was apply-' C! D' D0 x: S3 Q4 Y6 t5 j+ `
ing over his own shoulders, chest, and back area for' u3 ?" {7 P9 r" F& F' y
a year. The father also revealed he was embarrassed
0 H- ^( o4 ]: M" {0 p- R8 sto disclose that he was using a testosterone gel pre-
|7 m( {- `) q1 R# {+ T( v* Z0 lscribed by his family physician for decreased libido
2 Z' K- g" X; y- osecondary to depression.
$ P8 ?: d/ _) S0 pThe child slept in the same bed with parents.$ n/ [, j+ o/ Q) P x
The father would hug the baby and hold him on his4 }4 `! @" V( T
chest for a considerable period of time, causing sig-
+ N* Q& m- ]/ G' A/ mnificant bare skin contact between baby and father.9 R; s5 c, y0 ~2 J/ [' R5 m
The father also admitted that after the phone call,
( p. C+ ?7 u* c) H V6 Y, swhen he learned the testosterone level in the baby1 o# @0 v+ m# U
was high, he then read the product information4 U2 G6 M4 O4 i
packet and concluded that it was most likely the rea-
' U% c( [% I" U5 B. X7 K* oson for the child’s virilization. At that time, they
: W4 o+ v/ U- w7 R; n3 x7 Idecided to put the baby in a separate bed, and the
K. E6 A& h& M- i4 @% V/ _/ bfather was not hugging him with bare skin and had5 X8 l5 c/ a" W- x! A" p
been using protective clothing. A repeat testosterone" c" W% k& |6 r. D. v6 ~- k' e
test was ordered, but the family did not go to the N+ Z; q" X: X9 K9 X
laboratory to obtain the test.
8 |) x8 L4 g+ B. X) F- s i1 M# EDiscussion9 W t8 E8 u1 [
Precocious puberty in boys is defined as secondary
! A% U: Z) ]3 f7 P0 b wsexual development before 9 years of age.1,4% M' l2 ~: q% i3 p/ w( E/ w& c) D, t" I
Precocious puberty is termed as central (true) when4 j" ?- y ?7 x% V
it is caused by the premature activation of hypo-
2 W2 a1 X. [0 J2 q$ ~: Hthalamic pituitary gonadal axis. CPP is more com-
9 P; Y6 o1 y, B% S8 Jmon in girls than in boys.1,3 Most boys with CPP
) Z! s9 [* _+ x. {+ X( ]2 Cmay have a central nervous system lesion that is6 Q ?* p2 [: W3 t/ }
responsible for the early activation of the hypothal-6 C0 F+ ?% R4 w* F) m
amic pituitary gonadal axis.1-3 Thus, greater empha-
. G' i" ~: a) ]2 C+ H( h; tsis has been given to neuroradiologic imaging in$ p, [9 `7 x& B( b
boys with precocious puberty. In addition to viril-! h+ z# [$ J5 u- s# J) b
ization, the clinical hallmark of CPP is the symmet-3 H c! K# P6 I' Y7 x5 v5 y
rical testicular growth secondary to stimulation by
( d6 M0 e' J7 O! Igonadotropins.1,3/ Z7 N& b" z6 \1 a
Gonadotropin-independent peripheral preco-2 K' E3 f% | }: g( f
cious puberty in boys also results from inappropriate6 q2 ~! E- m0 d% ^5 \ n& n
androgenic stimulation from either endogenous or& t) P- l' D! {; m3 [& l1 ~ L( H
exogenous sources, nonpituitary gonadotropin stim-2 c" }, E# }. B- `2 k5 b1 ?) G( U- k
ulation, and rare activating mutations.3 Virilizing
- {" ?6 ]( H( ~. V: i9 ycongenital adrenal hyperplasia producing excessive! P* ?8 N A& Q$ }' Y } d
adrenal androgens is a common cause of precocious; S7 n! j3 d6 m- S1 ?
puberty in boys.3,4' R5 I0 O% J9 X4 m* J) X$ k! t
The most common form of congenital adrenal
0 g6 S( A4 J/ J/ Z* R& v+ C! g7 fhyperplasia is the 21-hydroxylase enzyme deficiency./ Y! r+ J' r5 G$ g! n$ @/ d
The 11-β hydroxylase deficiency may also result in$ a1 O# ~0 p3 Y& c8 a# T) s
excessive adrenal androgen production, and rarely,
" P; ]! e- p( H+ @- u N5 [an adrenal tumor may also cause adrenal androgen; s) Y; O \/ l) [% q9 C3 |3 d! R
excess.1,3$ F4 L' Y2 ]/ u8 q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 W8 I( x% q6 u8 A# [2 i
542 Clinical Pediatrics / Vol. 46, No. 6, July 20071 u4 J! \( Y+ p2 C2 B
A unique entity of male-limited gonadotropin-
2 h+ O7 S" G _0 H k/ K6 b7 l5 hindependent precocious puberty, which is also known
3 J0 t; ~/ c* K/ i* z0 jas testotoxicosis, may cause precocious puberty at a' Q T' b) b4 t) g0 A; v$ J0 Q/ U
very young age. The physical findings in these boys
?7 f$ m, j6 V9 g9 Ywith this disorder are full pubertal development,$ T) Q4 S+ U2 g1 a
including bilateral testicular growth, similar to boys
( V3 \0 |+ l0 J: G; \+ `with CPP. The gonadotropin levels in this disorder
5 G* ]8 ~9 u! E) Y/ B2 w0 mare suppressed to prepubertal levels and do not show
# ^9 Q1 `( T0 e4 j* `& }pubertal response of gonadotropin after gonadotropin-
6 k/ X3 w7 X* e. m: v! G" Wreleasing hormone stimulation. This is a sex-linked/ s& x% H! J( E* p" A% P$ I8 z
autosomal dominant disorder that affects only
" R$ z& _% w3 Q" i, y* imales; therefore, other male members of the family
% B: j( F6 i: V- _may have similar precocious puberty.3
% ^/ U, Z; X* p& N1 [. T RIn our patient, physical examination was incon- u4 i% d) K& G" h1 `2 d
sistent with true precocious puberty since his testi- b4 g! n& A, ^
cles were prepubertal in size. However, testotoxicosis" \) i$ j ^! M+ y% d' f2 U: a6 w) i
was in the differential diagnosis because his father
7 b# p u! q! Q4 Hstarted puberty somewhat early, and occasionally,
1 u- k+ e! v( p" v- mtesticular enlargement is not that evident in the
- S' T) N m3 Abeginning of this process.1 In the absence of a neg-- ~+ o- U/ b% R
ative initial history of androgen exposure, our; W& p5 h6 l4 c. a/ _
biggest concern was virilizing adrenal hyperplasia,4 G* F3 H3 W% X( k7 D6 r( W+ \! K0 \9 {
either 21-hydroxylase deficiency or 11-β hydroxylase
+ ^1 }) e. U+ y0 }deficiency. Those diagnoses were excluded by find-6 F0 z9 }) {. N) Q) {0 F
ing the normal level of adrenal steroids./ q8 O- i Y$ N2 `6 o
The diagnosis of exogenous androgens was strongly# _0 e' m; c: u/ |! \) A2 y
suspected in a follow-up visit after 4 months because
/ d' E3 T2 o6 P8 O# ^the physical examination revealed the complete disap-- a% `& e; @+ q* L5 P" v
pearance of pubic hair, normal growth velocity, and
2 i4 ]9 p# v0 ^: \decreased erections. The father admitted using a testos-8 @/ P+ ^: U* c9 N* G- }0 R ~" {
terone gel, which he concealed at first visit. He was& S$ j7 v) c2 X. S+ j
using it rather frequently, twice a day. The Physicians’
+ S; E9 ?* @8 O% @/ F: W: Z% c; ODesk Reference, or package insert of this product, gel or+ K. J6 L! a% O$ R! v, J
cream, cautions about dermal testosterone transfer to7 B L" j3 U- q% h$ W g
unprotected females through direct skin exposure.
# P, G f* K+ z0 ~2 k2 t3 g! T& C2 oSerum testosterone level was found to be 2 times the3 _' Y) m8 r: M0 Z/ z# b
baseline value in those females who were exposed to' o' T5 @7 Q6 ~! k. O1 c# t! \: L
even 15 minutes of direct skin contact with their male
4 F8 y7 M+ e0 l( X/ L W( _- zpartners.6 However, when a shirt covered the applica-
M ]/ O) y% E2 m( g; stion site, this testosterone transfer was prevented.
3 i" j7 r1 @( i9 ? rOur patient’s testosterone level was 60 ng/mL,
+ A+ A6 o6 f3 I' `which was clearly high. Some studies suggest that
" U& f! K& t; m' Tdermal conversion of testosterone to dihydrotestos-
8 p) k& P _8 e0 }& h# Zterone, which is a more potent metabolite, is more
9 u1 T7 N( ~8 K3 Tactive in young children exposed to testosterone
, r$ K7 r; E, z- o. hexogenously7; however, we did not measure a dihy-5 ?( C3 _( L2 C3 G- Z
drotestosterone level in our patient. In addition to
: K x _& x2 m0 P: {( @( ^4 ivirilization, exposure to exogenous testosterone in
2 Z. Z- i7 D/ ?children results in an increase in growth velocity and
6 {( k, e/ u! A+ A% U4 b/ k7 }advanced bone age, as seen in our patient.
, L9 |& r$ V1 L. W; _The long-term effect of androgen exposure during
) R2 M( D) F( n2 A4 T# a: `! z6 Oearly childhood on pubertal development and final
. S4 |5 b W7 A9 q/ Qadult height are not fully known and always remain- F8 E3 V$ C; E; [; j$ t! a2 N b7 H
a concern. Children treated with short-term testos-
8 \' y2 S& m" Z' c Mterone injection or topical androgen may exhibit some' c& l! M8 v/ N7 A6 L
acceleration of the skeletal maturation; however, after3 D2 _, D2 e' l. z0 y
cessation of treatment, the rate of bone maturation
5 ]- x- K" d& v7 C0 H% `9 }: ~7 z) Rdecelerates and gradually returns to normal.8,9+ \3 ~- m8 w/ U; r* b
There are conflicting reports and controversy( I7 B- ^4 \9 l/ p8 ^0 z! o
over the effect of early androgen exposure on adult# D# ]' | o$ r
penile length.10,11 Some reports suggest subnormal
' o G! Q9 W; v/ d1 gadult penile length, apparently because of downreg-
P0 g, [5 e1 Dulation of androgen receptor number.10,12 However,
* _9 O' M0 X8 j2 ?: \Sutherland et al13 did not find a correlation between
2 _/ i k4 @+ ^. O8 q* P, _" @childhood testosterone exposure and reduced adult
6 e+ z; T. K; L$ Dpenile length in clinical studies.: `0 p' N" _2 K2 {0 U( H( U4 P0 |* D
Nonetheless, we do not believe our patient is
* f4 u; a# W) F9 Ygoing to experience any of the untoward effects from
1 w+ A! p' v; B7 I7 gtestosterone exposure as mentioned earlier because
! W& t8 b6 @6 g! n" k8 O" v) Rthe exposure was not for a prolonged period of time.; t) T% `+ Z, j$ O! K" ]+ o
Although the bone age was advanced at the time of0 [' T& ~" ~+ I- Z
diagnosis, the child had a normal growth velocity at+ X% |; t' O/ Z R+ x J
the follow-up visit. It is hoped that his final adult
6 [) P! C5 i3 l3 c' d& W1 I7 L5 c( uheight will not be affected.+ W' j5 W1 K$ M7 [
Although rarely reported, the widespread avail-5 ?6 _/ @, ^9 F2 t$ c5 e& F+ k
ability of androgen products in our society may a' Z; z4 B, _+ @) I
indeed cause more virilization in male or female. K3 u( r3 O }
children than one would realize. Exposure to andro-7 R w6 B. A( c# x- N# {2 V- p% {
gen products must be considered and specific ques-
* G7 q1 f3 h2 y4 u" O) i! |) Ationing about the use of a testosterone product or. H; J/ V" z6 ~3 V
gel should be asked of the family members during
3 q- D. T$ b; dthe evaluation of any children who present with vir-+ j2 |. j, ~% i* c* @
ilization or peripheral precocious puberty. The diag-
, \3 l; ~- y' D9 d, r O& ]nosis can be established by just a few tests and by
/ q# E8 C& R! L9 R' j$ vappropriate history. The inability to obtain such a: n& g0 e4 i4 J" R3 Y% W- P- Z
history, or failure to ask the specific questions, may( i* @4 I" W* l1 I5 o
result in extensive, unnecessary, and expensive
& k1 P5 i. X9 d6 v- |investigation. The primary care physician should be
7 _ w+ C9 q4 `8 L ~3 Haware of this fact, because most of these children
* }! k4 H3 j; H' cmay initially present in their practice. The Physicians’) @0 C' d2 j k- n
Desk Reference and package insert should also put a$ h( Q* r5 W' E3 D$ A" y
warning about the virilizing effect on a male or
6 d( f, ?) H1 W4 nfemale child who might come in contact with some-/ a: q( T$ X5 X Y# v$ D
one using any of these products.
! z7 a! J( W( G3 k5 ]References! M! M' _9 `9 O2 v' Y: T
1. Styne DM. The testes: disorder of sexual differentiation/ M5 G6 l1 {! l! A& c5 O; u$ ]
and puberty in the male. In: Sperling MA, ed. Pediatric
: Y" y/ p- Z8 Q" SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 }, R9 U- t9 O& h
2002: 565-628.. B, W% q9 X3 p
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 c+ ~( E! @/ K; gpuberty in children with tumours of the suprasellar pineal |
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