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Sexual Precocity in a 16-Month-Old
0 o$ H( N, j$ A& @* M# w4 _Boy Induced by Indirect Topical$ ]/ s, n8 z: z8 t
Exposure to Testosterone- D2 z; m4 M5 }% o: D9 q; h
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ ` _0 S1 H, U; c$ z4 mand Kenneth R. Rettig, MD1
7 A; b5 m# [( D" Q; GClinical Pediatrics9 X7 z0 L# w* o$ P( V
Volume 46 Number 6
* d1 o# D9 g( GJuly 2007 540-543
4 c) }1 W! m8 T( u© 2007 Sage Publications
0 |- i- G- B6 ~10.1177/0009922806296651. T2 b( _0 s8 m. {1 K! @* |: `6 c6 A
http://clp.sagepub.com9 m& y5 ^5 x! ^# `, @" S
hosted at" J; s* K t( l" F9 l
http://online.sagepub.com
8 k* ], |( n: V: V$ Q0 j$ wPrecocious puberty in boys, central or peripheral,9 @ D# F" R8 {& ~6 x u, b0 \
is a significant concern for physicians. Central( u9 n; d6 W5 n: _$ g
precocious puberty (CPP), which is mediated
; ^6 j& I8 e% E/ E: U- nthrough the hypothalamic pituitary gonadal axis, has; N. x* H! a! |
a higher incidence of organic central nervous system/ F/ N# o7 _9 ], t* F9 C1 H7 ~3 v
lesions in boys.1,2 Virilization in boys, as manifested
8 y ?, |5 T" H. `* gby enlargement of the penis, development of pubic. z- w4 C/ @. c$ Z7 ?6 ~
hair, and facial acne without enlargement of testi-
. ?% n! x6 Y9 }cles, suggests peripheral or pseudopuberty.1-3 We/ t) c, R/ w5 B) x# D f* _) C
report a 16-month-old boy who presented with the% y9 r& g, b5 V3 f C* `+ j, K
enlargement of the phallus and pubic hair develop-
0 d- `+ i$ d T) hment without testicular enlargement, which was due
& L0 h! [' _; i% e3 _to the unintentional exposure to androgen gel used by
5 c( p0 a1 i! Y+ r9 t% A; n( r0 Cthe father. The family initially concealed this infor-0 r, i& i0 n' z P% B* L; ^
mation, resulting in an extensive work-up for this
& u- y" N5 J0 P$ m; S- @: F4 Fchild. Given the widespread and easy availability of
8 ?3 T9 {( K2 U+ } k1 q* ^/ S; d- v* ztestosterone gel and cream, we believe this is proba-( T$ k/ @) A9 l4 f
bly more common than the rare case report in the
2 e$ q6 D: z [* Tliterature.4
# D: K1 v4 M$ o$ g* r+ qPatient Report$ X# g( m. e0 O! G+ f% Y7 s4 S' ]
A 16-month-old white child was referred to the: E0 x/ l' M8 z" O! e* n
endocrine clinic by his pediatrician with the concern
! n1 l6 S1 ? u9 `& a) n: Zof early sexual development. His mother noticed
8 ]: c) |: R* N- y/ k' K" elight colored pubic hair development when he was: h$ e2 a' t% W- U) N+ A
From the 1Division of Pediatric Endocrinology, 2University of
3 `( F7 [* K8 X. C* ]/ q1 f( ], JSouth Alabama Medical Center, Mobile, Alabama.# p2 E+ c. c6 }: T# j: s: ]
Address correspondence to: Samar K. Bhowmick, MD, FACE,
1 y5 S3 @5 \6 {3 l& n' C& CProfessor of Pediatrics, University of South Alabama, College of
/ A6 p0 | l+ Q' QMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 x) a8 }) F& n* K$ c7 _( o: p
e-mail: [email protected].+ ~4 R3 A0 O- \+ Z2 l
about 6 to 7 months old, which progressively became
. n0 c5 V7 M/ {8 L: e; g3 r: v3 gdarker. She was also concerned about the enlarge-
% Q& u" Z1 C/ A* Z e& |( Ument of his penis and frequent erections. The child
& I/ z! B; F L* W+ O5 r- Owas the product of a full-term normal delivery, with
2 v; Y& R* s' }/ Za birth weight of 7 lb 14 oz, and birth length of
% L$ O9 `9 Z% ]' x$ s. g20 inches. He was breast-fed throughout the first year
: S8 O( x' t! |, |2 c# pof life and was still receiving breast milk along with1 b) M- j: a, c% a0 N7 G3 K$ H
solid food. He had no hospitalizations or surgery,- x( [/ g* L# b, D* |4 i8 b
and his psychosocial and psychomotor development: w: d4 Y z. }1 a2 {2 {1 L
was age appropriate./ p4 \# X9 a4 Q+ ^# G! _3 ?6 _8 U8 z
The family history was remarkable for the father,
5 E4 a! M' s( W& u$ Swho was diagnosed with hypothyroidism at age 16,! T5 X& f4 w# |# u% B6 h
which was treated with thyroxine. The father’s
f! p! P& ^$ o% eheight was 6 feet, and he went through a somewhat
$ h: v; ]- _8 f: X! Learly puberty and had stopped growing by age 14. A% x0 X8 G% ]4 @' l) r6 \
The father denied taking any other medication. The; D# B0 J8 m1 V
child’s mother was in good health. Her menarche/ m1 e) ]- g' G9 N2 w
was at 11 years of age, and her height was at 5 feet6 r8 g' U! a$ g& a1 a
5 inches. There was no other family history of pre-0 E5 e9 k& M3 {8 Z1 b
cocious sexual development in the first-degree rela-4 J4 R0 d+ o7 {% F7 ~9 I) a
tives. There were no siblings.
, G2 B) b- i) n+ zPhysical Examination
9 M/ {7 Y' F: L1 O+ CThe physical examination revealed a very active,
5 z4 g- B* l& O$ K5 Y% aplayful, and healthy boy. The vital signs documented
& o& m, ` m- S/ g- V, ?( {4 la blood pressure of 85/50 mm Hg, his length was; H' | t. w z* b
90 cm (>97th percentile), and his weight was 14.4 kg
# @1 @* N) B6 D! X& U(also >97th percentile). The observed yearly growth
5 L4 R- c; a- Mvelocity was 30 cm (12 inches). The examination of: Z; g) Z# j: J
the neck revealed no thyroid enlargement.
- m5 r4 H7 U7 C% hThe genitourinary examination was remarkable for C3 E7 ]3 S! A0 B
enlargement of the penis, with a stretched length of
4 O) \3 `/ h" p9 ^% A: L8 cm and a width of 2 cm. The glans penis was very well
& k( F$ A& C4 y1 O2 K7 o& Kdeveloped. The pubic hair was Tanner II, mostly around! k' I0 m1 E7 j, \
540* f7 w! i1 J7 \' {3 T0 L
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 |/ J* }4 X+ ]. U# e; \9 t% b
the base of the phallus and was dark and curled. The
% w* }' l9 l0 {4 Wtesticular volume was prepubertal at 2 mL each.
: A8 A2 s$ ]/ M4 kThe skin was moist and smooth and somewhat) H9 U5 K; P' E v2 Z" \
oily. No axillary hair was noted. There were no
9 R9 q% W! v6 f" `9 o7 X- }2 Dabnormal skin pigmentations or café-au-lait spots.8 I# G, e0 o/ i' S3 z2 r: r( u
Neurologic evaluation showed deep tendon reflex 2+; y- u/ U9 W; p* C( s1 |" P
bilateral and symmetrical. There was no suggestion- G1 \0 s- T/ ]# s; ^
of papilledema.
: }) `: M8 Z; z0 c0 ~' @- d! d. FLaboratory Evaluation
! _; Q- W2 J8 fThe bone age was consistent with 28 months by( s4 u& L ^- ~% i
using the standard of Greulich and Pyle at a chrono-
6 ^2 `4 g* J# l' z/ G" Alogic age of 16 months (advanced).5 Chromosomal
) D# C' Q- g4 Hkaryotype was 46XY. The thyroid function test
7 ?% W6 Y7 L; j; C) r5 wshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 ~# o6 w( u9 R& E: E4 s: R+ Plating hormone level was 1.3 µIU/mL (both normal).
& t1 d4 X2 Y7 O v, U q W& [8 |' t, eThe concentrations of serum electrolytes, blood# P7 n! o7 s% ] B# `, ^
urea nitrogen, creatinine, and calcium all were
, A, Y7 ~9 i3 i+ iwithin normal range for his age. The concentration
4 P* |7 i$ [5 c6 Nof serum 17-hydroxyprogesterone was 16 ng/dL
- C# Y9 |0 g R(normal, 3 to 90 ng/dL), androstenedione was 209 j( g! e" a- q# ^7 q9 I6 Y
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
: [4 c$ h) j& d5 _/ X0 Dterone was 38 ng/dL (normal, 50 to 760 ng/dL),- j; {: {7 n3 T- O0 c
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
; P& s# O2 t0 M$ l, L ^49ng/dL), 11-desoxycortisol (specific compound S)6 l' i' ~. p7 ?. q+ ]; d0 |/ ~" }
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
# D- p; _2 \" v2 @tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 h( S' s! P' ^4 ?
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) q2 _8 J8 S+ t* N, e0 nand β-human chorionic gonadotropin was less than
7 Y+ b, b. N; O" }5 mIU/mL (normal <5 mIU/mL). Serum follicular
# ^. u5 P! [* B( A: o6 P9 a% nstimulating hormone and leuteinizing hormone
$ n! @- n: o9 _3 v) cconcentrations were less than 0.05 mIU/mL
: d( E3 j- E$ K1 J" r7 m(prepubertal).
1 a+ K1 j1 p5 {% @3 aThe parents were notified about the laboratory
7 x$ d8 X* k% E7 Oresults and were informed that all of the tests were
" R1 b |$ x) l5 H( ~# n B2 Gnormal except the testosterone level was high. The
: q, n7 t& a# ^. N' lfollow-up visit was arranged within a few weeks to3 E2 p" j h( v7 D
obtain testicular and abdominal sonograms; how-
8 ?& T. v: p' C0 Zever, the family did not return for 4 months.3 [) c. a0 z6 I$ s9 e& l
Physical examination at this time revealed that the
# D+ |# I/ s5 d+ I0 T2 Uchild had grown 2.5 cm in 4 months and had gained
+ ~! |& r. k8 o Y$ D! c5 k2 kg of weight. Physical examination remained
" n0 A a) \- x0 a$ aunchanged. Surprisingly, the pubic hair almost com-1 [) S x3 E5 d( Q0 e
pletely disappeared except for a few vellous hairs at
: b) V& s$ ?, K- s' @% kthe base of the phallus. Testicular volume was still 2: i9 p7 ]2 n) t: [0 s
mL, and the size of the penis remained unchanged.& b4 K9 \) v) |# m
The mother also said that the boy was no longer hav-$ v$ O3 N$ h& r" }1 E, G+ x
ing frequent erections.
7 t+ \( s T3 x! ]$ @% _Both parents were again questioned about use of
- T- Q6 Y3 `8 a Z/ gany ointment/creams that they may have applied to
8 ]5 r0 D8 P2 Y" ithe child’s skin. This time the father admitted the! N3 E3 P" [7 s+ Q8 T9 D5 a. v
Topical Testosterone Exposure / Bhowmick et al 541
2 p3 j; B- f- _$ Y) Puse of testosterone gel twice daily that he was apply-& i; z$ ^9 l! R% u6 B
ing over his own shoulders, chest, and back area for
) C! P' v; v- I* O8 t% u! @a year. The father also revealed he was embarrassed
( [8 i2 N+ w* z( wto disclose that he was using a testosterone gel pre-+ U) u! @2 g8 E3 E
scribed by his family physician for decreased libido
5 P7 r2 }' Y7 G/ p( F8 }secondary to depression.
3 G+ Y- m! y0 ?, L% nThe child slept in the same bed with parents.5 U7 k; t4 m& ]0 k
The father would hug the baby and hold him on his
/ I) \3 L) R% m) |chest for a considerable period of time, causing sig-
+ l! T( _4 L/ C" x. pnificant bare skin contact between baby and father.3 I# T+ b' Z3 d) N, h M o/ V
The father also admitted that after the phone call,
0 R: p. l3 J+ u$ N# R. S+ z: Ewhen he learned the testosterone level in the baby
) r' a0 z, g$ bwas high, he then read the product information
7 v+ |) l& }0 `: \6 [! lpacket and concluded that it was most likely the rea-6 w* w2 }+ w" i' y
son for the child’s virilization. At that time, they1 Y; c8 r3 B1 o4 h0 V1 P: B. K8 R4 K
decided to put the baby in a separate bed, and the
) u1 K! b5 X/ u( p% M% Hfather was not hugging him with bare skin and had) t; p) u4 V2 K, p# V" F# Z8 l
been using protective clothing. A repeat testosterone# G% g$ \, Q% Q5 J3 f
test was ordered, but the family did not go to the
' k, E) p- t) U! {; H/ Dlaboratory to obtain the test.
* h% [8 s7 e* _, {Discussion
8 U, c/ T/ a8 l% }3 jPrecocious puberty in boys is defined as secondary
5 D# s- Q9 |) |& w3 @. Dsexual development before 9 years of age.1,4
$ D$ W# W& g3 P+ M4 KPrecocious puberty is termed as central (true) when8 w6 k- d8 W' z$ a
it is caused by the premature activation of hypo-, z- | T7 r) o. A: q, F8 F2 n
thalamic pituitary gonadal axis. CPP is more com-% N6 v! \$ p; T% G5 V
mon in girls than in boys.1,3 Most boys with CPP; Q$ w; ]" y* Z- Q6 |! L( }
may have a central nervous system lesion that is
* g$ Q# J6 O/ m1 _1 ]responsible for the early activation of the hypothal-
9 w J$ f9 i: zamic pituitary gonadal axis.1-3 Thus, greater empha-& b _4 i9 ~4 S _
sis has been given to neuroradiologic imaging in, j3 `1 M, @2 N/ f5 G0 Q) c& x
boys with precocious puberty. In addition to viril-
7 }4 n0 F/ W0 h! o: B. k* O3 K+ @ization, the clinical hallmark of CPP is the symmet-; O* F" n1 v1 ^# h' a& r* M R# I2 A+ w
rical testicular growth secondary to stimulation by( P" d! y/ } P8 F% m5 c
gonadotropins.1,3
+ b8 I' u. K& d- `Gonadotropin-independent peripheral preco-
- d" T2 F% y6 o0 V/ h$ `cious puberty in boys also results from inappropriate
' A- S* u& S3 L/ n) W5 s) V7 fandrogenic stimulation from either endogenous or
9 L( G) k) e6 \# E- qexogenous sources, nonpituitary gonadotropin stim-
- ?/ S5 R) F6 j2 a Eulation, and rare activating mutations.3 Virilizing
: \1 k6 t4 ^" t0 k( u! Ncongenital adrenal hyperplasia producing excessive
$ H& h! H& o' sadrenal androgens is a common cause of precocious. x$ P* W4 ?! _$ I
puberty in boys.3,4- l! L0 s, T+ K1 Y d
The most common form of congenital adrenal. `$ ~+ g q) d! \( K* Z% {
hyperplasia is the 21-hydroxylase enzyme deficiency.
' y; a3 O* g6 _The 11-β hydroxylase deficiency may also result in2 y5 y3 q6 v0 h% `' H& g" Z( E" f
excessive adrenal androgen production, and rarely,
! K7 J9 v O( D- N4 [an adrenal tumor may also cause adrenal androgen
# j x, [; ^0 ^3 V$ Q5 p& O/ hexcess.1,3
" @' q# w. G! N( Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: O# g8 U- j6 z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% x+ }& y" F* l# d) KA unique entity of male-limited gonadotropin-
1 }/ S) @4 p9 R) A* Rindependent precocious puberty, which is also known% w K$ l( S' u' G8 b
as testotoxicosis, may cause precocious puberty at a/ j6 Y4 ^3 U( |, q
very young age. The physical findings in these boys
* G( u: w% H- \1 Xwith this disorder are full pubertal development,2 Q% a2 B) R! E% A2 z; d9 l
including bilateral testicular growth, similar to boys
$ m& k1 A" L2 z' _! Xwith CPP. The gonadotropin levels in this disorder$ ?+ t+ p, q! N% D# a+ J
are suppressed to prepubertal levels and do not show
* c {: i# z% M9 qpubertal response of gonadotropin after gonadotropin-5 X4 S! Q) S! P8 s* O: q
releasing hormone stimulation. This is a sex-linked" m; n2 `, U1 M: u' W
autosomal dominant disorder that affects only2 |5 H$ |/ v) y" z8 }# Z
males; therefore, other male members of the family$ q! m' s3 O( k8 C" p8 {6 A. p }
may have similar precocious puberty.3; H/ G! @! J+ ~
In our patient, physical examination was incon-$ y/ X" h/ ^$ ]: k( b1 b: y. [
sistent with true precocious puberty since his testi-
8 j3 x. \) L3 P% t, S+ i9 I) lcles were prepubertal in size. However, testotoxicosis8 ~) V3 J p! x+ E6 h
was in the differential diagnosis because his father
! t( ?( ^" S" m) j) istarted puberty somewhat early, and occasionally,. w3 I7 g9 J# D- N
testicular enlargement is not that evident in the' g% r- s5 J6 k% d. m; v
beginning of this process.1 In the absence of a neg-
: u- w: \, H7 e( p7 aative initial history of androgen exposure, our8 {3 p8 I: z# [, D, D6 I# f
biggest concern was virilizing adrenal hyperplasia,2 h6 ?: M9 F. _& a
either 21-hydroxylase deficiency or 11-β hydroxylase+ c1 | W& G3 e5 q
deficiency. Those diagnoses were excluded by find-+ ?' [# e" \/ d& G1 P: ~, s
ing the normal level of adrenal steroids.
" Y) q5 A' @. M7 m* W: t7 r6 i4 `The diagnosis of exogenous androgens was strongly; T3 W Z3 L, H4 ?5 u/ b
suspected in a follow-up visit after 4 months because
r, x$ I- b" L; S& Othe physical examination revealed the complete disap-3 X4 J+ ^, Z5 Y
pearance of pubic hair, normal growth velocity, and! m& X1 w. C$ i% c5 h9 n
decreased erections. The father admitted using a testos-
" G* n: }0 T: ~) vterone gel, which he concealed at first visit. He was
^) E9 }6 B1 u/ [5 susing it rather frequently, twice a day. The Physicians’4 _4 c- Y. |& H! _* N- ~
Desk Reference, or package insert of this product, gel or
9 S( O, Q& `" Z. {+ Y1 ^$ q) Qcream, cautions about dermal testosterone transfer to
. z5 B! o; p, R5 ]unprotected females through direct skin exposure.
6 D) [2 j M2 N0 {. b6 n1 ]Serum testosterone level was found to be 2 times the k* \: S( K7 ?* J+ D( \
baseline value in those females who were exposed to7 ~9 A( w" H9 T# N! I6 |9 _, @
even 15 minutes of direct skin contact with their male
r( q+ `: C" N! v$ gpartners.6 However, when a shirt covered the applica-. Y5 d3 F/ V. D' `3 u5 ]
tion site, this testosterone transfer was prevented.
0 M) X* b2 g7 z/ ^: z1 s) K6 ~- mOur patient’s testosterone level was 60 ng/mL,
S( K7 a1 s8 ~9 mwhich was clearly high. Some studies suggest that1 @( @- E& Q+ e8 T+ y* w: e1 _8 C
dermal conversion of testosterone to dihydrotestos-
+ G+ w# V$ r H# X# j2 R9 @terone, which is a more potent metabolite, is more9 R# _0 y" V+ B3 L; M9 @
active in young children exposed to testosterone
5 b; P N' A; Q6 \- ^0 Bexogenously7; however, we did not measure a dihy-
) x8 z' ?4 m+ x8 R hdrotestosterone level in our patient. In addition to
8 K( S3 ~/ q8 }& h6 h' {7 \9 {virilization, exposure to exogenous testosterone in+ K W2 m- I- G3 W9 C0 N' b
children results in an increase in growth velocity and
2 |" J) n* d1 h+ D) L3 [/ [$ Tadvanced bone age, as seen in our patient." a5 p" m/ F/ v. T* I) Y/ V. ~
The long-term effect of androgen exposure during# v' J6 C3 ~6 n0 j. q, q3 h/ x
early childhood on pubertal development and final
1 D8 p( n( j" m# _( f" Y% @adult height are not fully known and always remain
+ H2 t- \% B) Na concern. Children treated with short-term testos-
8 {/ J4 T. m. m( _6 e# qterone injection or topical androgen may exhibit some
* N0 ], J5 C J7 Uacceleration of the skeletal maturation; however, after3 p! N* T& N/ d% I' R
cessation of treatment, the rate of bone maturation. Q* z8 _; Z0 F, m' y
decelerates and gradually returns to normal.8,9
$ W& o4 @! w6 jThere are conflicting reports and controversy4 Z* [6 z' A+ y2 }$ y
over the effect of early androgen exposure on adult
" y2 ~8 S: ?/ n# D4 o4 `3 gpenile length.10,11 Some reports suggest subnormal
" E$ q: n6 j1 ?; T _adult penile length, apparently because of downreg-
8 D9 ]6 ^) o ?1 lulation of androgen receptor number.10,12 However,
; ?, i1 X' ] M8 L" x5 |6 \Sutherland et al13 did not find a correlation between
! L% {4 l |: T k2 o0 z) H% `childhood testosterone exposure and reduced adult% X( D1 _5 F5 D9 f) O/ E+ K
penile length in clinical studies.
* K$ x( Z8 }: V/ V6 Q4 b8 rNonetheless, we do not believe our patient is
" K& U, T8 }% n. @going to experience any of the untoward effects from
6 f& V$ w9 ^- {" xtestosterone exposure as mentioned earlier because
/ k- ^) `8 O3 o% `4 {* w6 [the exposure was not for a prolonged period of time.4 d5 k+ r8 X: u3 ?, V/ l5 x
Although the bone age was advanced at the time of, M0 T, t7 t' A, v7 ]% d
diagnosis, the child had a normal growth velocity at# Y$ `4 E! n* s. B$ B6 c
the follow-up visit. It is hoped that his final adult
: s. k* G! m8 |, |1 p8 dheight will not be affected.
n7 K/ Y: H+ A8 r$ u/ r1 RAlthough rarely reported, the widespread avail-
- ?3 }0 {$ F% v0 Pability of androgen products in our society may0 V: E9 y$ i" p. P l
indeed cause more virilization in male or female
6 Q' c6 C! z4 O# E% M Vchildren than one would realize. Exposure to andro-
6 J( p* c6 ]' P, q( ?gen products must be considered and specific ques-- k9 v$ G: d, N' M7 q- s
tioning about the use of a testosterone product or
; ~( Q) E9 k- w4 Q/ X @5 kgel should be asked of the family members during* |/ @! V2 ] G9 q
the evaluation of any children who present with vir-1 K) h/ ~- ? ^% ^/ P/ C" `
ilization or peripheral precocious puberty. The diag-( @! P. \$ m: S, M1 ~3 u, B' Z$ \
nosis can be established by just a few tests and by+ j7 ]6 ]) q8 X$ Q$ p/ E# G8 b( Q. z" O
appropriate history. The inability to obtain such a
+ U f% e) ]7 a4 ?history, or failure to ask the specific questions, may
- z) ]' E9 c! u, Z8 cresult in extensive, unnecessary, and expensive
# B# Y% }" }8 C" [" p. |investigation. The primary care physician should be
- C( h9 @. J! M/ _1 s7 J9 q" R8 ]aware of this fact, because most of these children
# _9 F, @4 d( X m1 \9 h X8 x) }% bmay initially present in their practice. The Physicians’/ m; S; k' H& t' A8 R3 ?
Desk Reference and package insert should also put a
8 P9 q1 z1 b) Q5 Vwarning about the virilizing effect on a male or
3 C6 @; N; z$ M' J0 N Nfemale child who might come in contact with some-
& N3 |5 g0 T% G5 hone using any of these products., i$ C% `6 Y' N/ D+ y2 x
References
4 C3 ]/ X1 a) s4 t# _! j1. Styne DM. The testes: disorder of sexual differentiation B; A$ m0 ?) y0 S$ ?
and puberty in the male. In: Sperling MA, ed. Pediatric
+ s* N; @! W$ r' AEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) J. `& t" {1 E' i4 Y2002: 565-628.
$ i# t% l4 ?5 w5 Q2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- J. M, L6 r$ r4 `+ ]* }5 j& \puberty in children with tumours of the suprasellar pineal |
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