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Sexual Precocity in a 16-Month-Old
5 v, O1 b7 A8 J6 X. W! {% `Boy Induced by Indirect Topical
* i8 p: a. G' L0 A5 KExposure to Testosterone1 R0 r3 W9 P* T, _5 A W7 k
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 H8 p7 U$ `8 S% b2 \8 hand Kenneth R. Rettig, MD1
& I7 I) w8 w! Z" AClinical Pediatrics, N9 g( V# Z8 \
Volume 46 Number 63 ^* e: U7 a$ P, j
July 2007 540-5439 T5 p" K; F7 x( u; u1 e* l8 p! h
© 2007 Sage Publications
! z, Z7 P3 y$ `, Q3 j1 Y6 v10.1177/0009922806296651/ R/ K0 }9 a' ?/ W
http://clp.sagepub.com. V- ~ F: X- ^- N- [
hosted at6 L, ?! C4 a" U. z+ C) E5 k5 I, G
http://online.sagepub.com# w6 I) Y+ n% y$ m6 O
Precocious puberty in boys, central or peripheral,
# k! a2 r* S! j7 d# Y+ `4 iis a significant concern for physicians. Central, N6 Z/ ^: a* `9 x- q- k
precocious puberty (CPP), which is mediated! D. r6 [' R* @/ B+ D$ \, x; V
through the hypothalamic pituitary gonadal axis, has7 z$ m5 E# a) |* p' y
a higher incidence of organic central nervous system- M: l. ?* `( G1 B w
lesions in boys.1,2 Virilization in boys, as manifested4 ~$ k' |! |& U; n
by enlargement of the penis, development of pubic
& {' _* D1 }; V1 e" t% Chair, and facial acne without enlargement of testi-9 g/ Y7 j* N! n1 z; c+ G0 N
cles, suggests peripheral or pseudopuberty.1-3 We% `. E V( P( j" O
report a 16-month-old boy who presented with the
3 y& h3 R' g$ f) i" ]' d( x% denlargement of the phallus and pubic hair develop-3 a2 J2 o9 C) `7 u) {
ment without testicular enlargement, which was due. r6 {" `4 R8 R6 Q$ n( t
to the unintentional exposure to androgen gel used by
) A( e/ A* X5 m2 H% ^* I3 K( hthe father. The family initially concealed this infor-3 j4 m5 X6 ?1 m9 l1 A3 k. O
mation, resulting in an extensive work-up for this
4 |3 g" L7 d/ \% d! {) e2 w& ~child. Given the widespread and easy availability of; h: w/ F- X. p. O' y# v
testosterone gel and cream, we believe this is proba-
0 W5 V( y u8 N& z1 L. mbly more common than the rare case report in the
( M; v" c6 o+ d" G8 W7 cliterature.4
# @5 p( C, u4 J0 M1 R- M. w: WPatient Report7 d; e3 T1 i. r6 R. U4 c# e
A 16-month-old white child was referred to the
8 ^$ `2 A0 {7 A# `- \endocrine clinic by his pediatrician with the concern( V+ s% u4 }% h5 J @& c
of early sexual development. His mother noticed% x1 A- Q/ O! ^% l
light colored pubic hair development when he was
' e: ~9 e) y- n. VFrom the 1Division of Pediatric Endocrinology, 2University of4 V( L k) `) G( y
South Alabama Medical Center, Mobile, Alabama." h( s; m+ T0 A3 S& B: X
Address correspondence to: Samar K. Bhowmick, MD, FACE," u& A6 _: F& G1 Y
Professor of Pediatrics, University of South Alabama, College of
' L: l. m: U( V. a5 O% fMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 p1 |& L0 K: }) ~7 J0 V+ H1 a
e-mail: [email protected].. r% X; J4 n _1 U: l
about 6 to 7 months old, which progressively became
0 T) f8 }. I7 |darker. She was also concerned about the enlarge-9 v5 f g6 Y- n; F( B3 a
ment of his penis and frequent erections. The child
1 d- m' K3 Y( A( Kwas the product of a full-term normal delivery, with/ A- K4 \, [' u- ?' E1 y V1 E
a birth weight of 7 lb 14 oz, and birth length of8 X/ t9 ?& Q0 \5 u: M/ k2 j+ {
20 inches. He was breast-fed throughout the first year
4 y: E3 n8 Q, Pof life and was still receiving breast milk along with1 H+ z2 V& {: |8 r+ K3 ] {) p
solid food. He had no hospitalizations or surgery,- s. C4 j" [# c; k6 i1 c/ M
and his psychosocial and psychomotor development
4 i; g; X5 P, c" S; F/ {0 awas age appropriate.* m( L$ f* K+ u. I6 B" P, T
The family history was remarkable for the father,4 ^( D& |) |- I B" e7 j: R# j+ n- H
who was diagnosed with hypothyroidism at age 16,# ]4 K% U: A) s
which was treated with thyroxine. The father’s8 c1 a1 j+ b4 `5 n
height was 6 feet, and he went through a somewhat5 L- }* W+ Z m* Y
early puberty and had stopped growing by age 14.
- D3 v v5 G* i6 q' r# hThe father denied taking any other medication. The- \# p' L8 V" l
child’s mother was in good health. Her menarche
+ v- c& T& a4 Swas at 11 years of age, and her height was at 5 feet1 D2 r7 X5 y. l0 z z3 X3 w
5 inches. There was no other family history of pre-
r! G; v9 ?% ]9 ]cocious sexual development in the first-degree rela-
! V: Y2 B# x6 V3 v3 ?3 x' y2 V% e1 f3 c/ jtives. There were no siblings.4 S8 g' U# D# r0 [% i! k$ L
Physical Examination) Q: g$ |" R# M m
The physical examination revealed a very active,/ `5 p9 D2 v$ O. k S0 D
playful, and healthy boy. The vital signs documented5 a" _- ?* X, j+ B! R
a blood pressure of 85/50 mm Hg, his length was
2 G& D5 Z2 O1 g' C90 cm (>97th percentile), and his weight was 14.4 kg
2 o$ e1 \1 ^3 a(also >97th percentile). The observed yearly growth+ i+ r1 |; q: e& o2 |
velocity was 30 cm (12 inches). The examination of9 Y; K& Y5 U4 ^: t! X& l
the neck revealed no thyroid enlargement.
7 ]/ _- q; F0 h0 kThe genitourinary examination was remarkable for% J- w: X* [7 ^
enlargement of the penis, with a stretched length of2 v( i1 w% m- m' M
8 cm and a width of 2 cm. The glans penis was very well1 z5 N! d9 f1 c
developed. The pubic hair was Tanner II, mostly around
1 e. I# j& I% J# G6 l7 e; ^6 E540
' ^( R1 J7 s2 V' F4 jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 F' l5 R& B" T/ ]the base of the phallus and was dark and curled. The
- ^( m/ R$ l; J* n" @ P4 N6 ^testicular volume was prepubertal at 2 mL each.
$ l' _* B, w# @% {, I, W. v9 LThe skin was moist and smooth and somewhat
: G0 D4 Z2 K1 v- Toily. No axillary hair was noted. There were no) c" V, h8 A6 @- f, H- y
abnormal skin pigmentations or café-au-lait spots.7 B) R: g: I% k( f
Neurologic evaluation showed deep tendon reflex 2+' L3 s) J6 R4 j g5 k! J
bilateral and symmetrical. There was no suggestion& |# H5 L# [8 o, b' Q
of papilledema.
0 S, ?6 ?2 u" t6 aLaboratory Evaluation% ~- V3 ]2 u1 J2 n0 {
The bone age was consistent with 28 months by- v. X5 P( c* }( c0 {
using the standard of Greulich and Pyle at a chrono-
! l- h2 a% K( b9 x wlogic age of 16 months (advanced).5 Chromosomal
* ~. y$ \% l0 c1 R" ]: t) Xkaryotype was 46XY. The thyroid function test
. }0 f7 @8 t$ X7 R' F- Qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-8 q0 |: ^) k# V& b9 A& [
lating hormone level was 1.3 µIU/mL (both normal).
! [! P* j5 a! d$ C* SThe concentrations of serum electrolytes, blood
5 k; r7 g9 l# r. n; f5 \! V5 xurea nitrogen, creatinine, and calcium all were, i+ C) c; g6 a2 G. V9 r/ a) G
within normal range for his age. The concentration
0 s4 ^* _( e% [6 N: ^, Lof serum 17-hydroxyprogesterone was 16 ng/dL$ R+ M$ w# ~+ H
(normal, 3 to 90 ng/dL), androstenedione was 20
) F: ?# w& k! c' c, _) J# n' Lng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, }6 V X+ I3 F5 hterone was 38 ng/dL (normal, 50 to 760 ng/dL),
& {, B5 B4 u* z" Y: u1 y( R0 i adesoxycorticosterone was 4.3 ng/dL (normal, 7 to3 T2 X2 ?( ]; O( G, E+ G
49ng/dL), 11-desoxycortisol (specific compound S)
) s- g. u& B0 H. Cwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 c' r5 _9 w- j3 E2 E% _! [1 htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; l3 w- a! K0 t- P, ]# {4 N5 T( E* {
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
$ w% I( m9 k. E& |, {and β-human chorionic gonadotropin was less than: W* x7 G+ g' R2 |9 S0 n
5 mIU/mL (normal <5 mIU/mL). Serum follicular
3 H9 r( i0 W( f6 Q+ ^) G. ystimulating hormone and leuteinizing hormone
" L* ?9 z. }: T- v- y. econcentrations were less than 0.05 mIU/mL
( E) i s1 b6 b4 `- E8 ?$ Y. m, ](prepubertal).
: g2 g5 \6 O) m2 UThe parents were notified about the laboratory
( O1 P; H% f% L0 Z, H" vresults and were informed that all of the tests were
; j8 b9 t3 X; a1 M9 s0 V) x; lnormal except the testosterone level was high. The
5 e1 h+ M" ?+ n$ h. kfollow-up visit was arranged within a few weeks to
" m: \% C* o1 L$ E6 Tobtain testicular and abdominal sonograms; how-
' j2 P! S7 B/ s gever, the family did not return for 4 months.7 i8 N( X3 P( b/ l; Q
Physical examination at this time revealed that the
2 \; {: S) p+ {0 C1 `8 _" x' T" Fchild had grown 2.5 cm in 4 months and had gained. d0 e% i+ J$ E' L) ^
2 kg of weight. Physical examination remained3 Y9 V0 J% q! ^7 i" P) i! f
unchanged. Surprisingly, the pubic hair almost com-
$ s* {) @: L- L- s2 b! Ypletely disappeared except for a few vellous hairs at, W3 e/ Q. ^& o* ]% f
the base of the phallus. Testicular volume was still 2( i7 m8 `5 L5 ?2 Y4 y
mL, and the size of the penis remained unchanged.
, ~( G Q7 \$ ^5 `5 z$ q' z$ x: y2 X$ RThe mother also said that the boy was no longer hav-* m% x- U9 N$ r, {- `
ing frequent erections.
- X% H' h) v1 e1 r |Both parents were again questioned about use of
+ D* p' z9 c' z# L+ hany ointment/creams that they may have applied to9 @& I7 e3 w N4 P
the child’s skin. This time the father admitted the
4 R: |5 y: w- m3 n RTopical Testosterone Exposure / Bhowmick et al 541( }/ T2 C5 E2 Z6 S5 z# b& q
use of testosterone gel twice daily that he was apply-2 }2 i$ e6 K8 w& x# Z- D; F/ R/ b
ing over his own shoulders, chest, and back area for
1 Z9 n3 n1 T; a, H' A& q: B4 za year. The father also revealed he was embarrassed8 a- ^5 Q) }0 ~5 j$ q: A; A/ [- M
to disclose that he was using a testosterone gel pre-
( u0 S' ?6 p" u, E. m% V; cscribed by his family physician for decreased libido8 o& l. F# n" g- P" y) z- a) Y
secondary to depression.: U4 ^( q7 E0 a( C( `$ u; n7 w
The child slept in the same bed with parents.
5 Y6 H1 t' e8 K9 k/ cThe father would hug the baby and hold him on his/ s( Z" I! m9 f
chest for a considerable period of time, causing sig-; [. e8 Y1 C7 N8 X; W. b3 {& b% S
nificant bare skin contact between baby and father.. w% k' I$ y) n! \2 m
The father also admitted that after the phone call,
% h* H/ N& t& g! ?: K, z4 U$ k2 jwhen he learned the testosterone level in the baby
q/ {3 p% I5 Xwas high, he then read the product information7 c9 J5 ~! `; [& n" ~$ F- D5 G
packet and concluded that it was most likely the rea- d4 V+ F) G1 j& s% T, A. O# l
son for the child’s virilization. At that time, they
: |, c2 \9 O$ q* S6 }2 j7 b! G. I6 L/ @4 @decided to put the baby in a separate bed, and the
3 Y3 c5 z1 N$ j0 B$ V2 U" p9 _# }2 [father was not hugging him with bare skin and had& }1 E8 L+ s# d" R
been using protective clothing. A repeat testosterone8 V: R) x) P" u2 K; }3 a) T
test was ordered, but the family did not go to the
) D6 l4 Y" V8 I9 B7 hlaboratory to obtain the test.6 F0 U4 o k: I+ Q6 M. S- d0 {
Discussion
) L! o4 f4 [# [+ _' l9 uPrecocious puberty in boys is defined as secondary
9 A: |) W9 t0 K. @sexual development before 9 years of age.1,4
* B' g1 O. U. b. r; uPrecocious puberty is termed as central (true) when
5 D s9 |# B$ O% l+ m' a5 x/ kit is caused by the premature activation of hypo-
% h* o0 f8 ?! d$ p" f( {1 H! T Q, Qthalamic pituitary gonadal axis. CPP is more com-
+ f# l4 U* A# ?4 ^, ] V4 ]mon in girls than in boys.1,3 Most boys with CPP, z6 J! g# h$ _# w
may have a central nervous system lesion that is
6 @" p4 P6 M' \6 {2 e. i* Y8 G# _, G" n$ rresponsible for the early activation of the hypothal-$ w7 a4 ^5 Z+ v# c- m* }1 ^1 ]
amic pituitary gonadal axis.1-3 Thus, greater empha-
4 Y: C7 [$ X( F7 [0 f2 k2 Z+ Usis has been given to neuroradiologic imaging in. m/ i) b5 W# n2 y7 A
boys with precocious puberty. In addition to viril-
4 z- [; p6 K) l% v4 yization, the clinical hallmark of CPP is the symmet-
: F, [- }6 @6 m7 \% Erical testicular growth secondary to stimulation by
5 v1 u1 i ^# w# b/ i( ]gonadotropins.1,3
b# L% |& Z F; `& IGonadotropin-independent peripheral preco-
1 `5 e, ]5 H8 ?) A5 j2 R0 ~5 {cious puberty in boys also results from inappropriate/ G7 a+ q: j+ j# q
androgenic stimulation from either endogenous or3 B: L6 Z5 ]) i
exogenous sources, nonpituitary gonadotropin stim-
) a( ]8 Q6 M. H$ {3 c4 Qulation, and rare activating mutations.3 Virilizing
7 s0 u+ V0 J3 A% F7 o6 gcongenital adrenal hyperplasia producing excessive( J/ o& }4 Z: ?9 e; u
adrenal androgens is a common cause of precocious
: T% F- Z$ U t2 \1 {) A9 m( Jpuberty in boys.3,4% x( X) Z8 Q) ~* n8 d, c- {
The most common form of congenital adrenal0 T. g' H+ E: W0 c4 m) b4 y
hyperplasia is the 21-hydroxylase enzyme deficiency.
! z9 I% H- l" ?The 11-β hydroxylase deficiency may also result in3 r. J' x" L/ j$ I/ A3 W1 p
excessive adrenal androgen production, and rarely,% @& R: H# f2 l S% z
an adrenal tumor may also cause adrenal androgen; r( ^# c9 v, @$ _
excess.1,3% I& T' q. k4 \7 M$ y2 Y1 J. S. I
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 ]4 g4 @% a# ?, _2 R! T
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 t7 C% N6 }0 i" ]A unique entity of male-limited gonadotropin-$ E* I1 @/ j- q7 u0 X- r8 s
independent precocious puberty, which is also known2 N! L$ G% R( R5 d
as testotoxicosis, may cause precocious puberty at a
/ z7 o" M% O1 U! overy young age. The physical findings in these boys6 I' x, ?/ `) T f2 M) n
with this disorder are full pubertal development,
5 k9 Z! o# M f% t% x0 a6 \including bilateral testicular growth, similar to boys
: c I! k+ D% H3 L, L9 s0 zwith CPP. The gonadotropin levels in this disorder& [! a$ x' A% @+ W4 @, g
are suppressed to prepubertal levels and do not show
' Y# U! C6 Z- A5 b& q' [& e1 }pubertal response of gonadotropin after gonadotropin-' X; i9 N/ G: f7 n6 C
releasing hormone stimulation. This is a sex-linked
! }/ c) {; d' hautosomal dominant disorder that affects only) f- R7 C3 W, c: p
males; therefore, other male members of the family3 @4 O& ^3 {- V( z4 B1 y6 m5 M" ]
may have similar precocious puberty.3
P# `- C) {. f8 W! }9 rIn our patient, physical examination was incon-, W# e8 P q1 }0 m: Y
sistent with true precocious puberty since his testi-
6 R. X2 H: P! t9 A) E8 Rcles were prepubertal in size. However, testotoxicosis& H+ [" R/ J8 I6 W
was in the differential diagnosis because his father
4 w8 B2 z( Y4 o4 z+ ?# o( `/ gstarted puberty somewhat early, and occasionally,
! c2 k$ v% d2 b7 h8 t) W: jtesticular enlargement is not that evident in the
0 [. W$ c3 q" a# |8 a E: ?, J. Z9 W& F1 qbeginning of this process.1 In the absence of a neg-
0 z( z% p: b8 s, pative initial history of androgen exposure, our
+ [- B; T" P' h- J9 e3 _biggest concern was virilizing adrenal hyperplasia,
9 y* j$ t, k. W' H7 u2 Peither 21-hydroxylase deficiency or 11-β hydroxylase8 t& F0 v0 E& X0 c
deficiency. Those diagnoses were excluded by find-( G6 H" u$ x. P% E1 u# A1 a
ing the normal level of adrenal steroids.3 A( ?" v% }2 |, ]' p" s
The diagnosis of exogenous androgens was strongly/ h) C: y7 Q( i8 ~! o; S* \/ T I
suspected in a follow-up visit after 4 months because8 v z* D$ N; ]$ g: _3 f
the physical examination revealed the complete disap-7 M% K) n W- c9 i6 ~$ j
pearance of pubic hair, normal growth velocity, and1 O+ A% m- ?$ T
decreased erections. The father admitted using a testos-
" F B) o. w( O+ Oterone gel, which he concealed at first visit. He was
! l1 a- t" N. ?( O0 a! Gusing it rather frequently, twice a day. The Physicians’
: U1 S# Y! o2 V8 F9 HDesk Reference, or package insert of this product, gel or/ I: o! {4 [$ j' Z/ X9 t
cream, cautions about dermal testosterone transfer to. c: \+ v- c, r1 q: G" P- T
unprotected females through direct skin exposure.
- n$ K" W# w& r0 K# y/ b( nSerum testosterone level was found to be 2 times the* H# b4 k* l t2 ?6 b p5 T. d
baseline value in those females who were exposed to+ k0 I& `% a5 z0 H ?" i' M
even 15 minutes of direct skin contact with their male1 t9 m7 A5 `6 n5 U# Z* G4 w
partners.6 However, when a shirt covered the applica-7 w* j% `1 ]( P) l4 }
tion site, this testosterone transfer was prevented.' T4 C& O; T, ?2 {/ A* x
Our patient’s testosterone level was 60 ng/mL,7 y$ V$ G/ R' |) Y' @6 X; }0 z$ Z
which was clearly high. Some studies suggest that* l+ Y5 d1 P; m- b- U* m1 N7 f
dermal conversion of testosterone to dihydrotestos- P5 b$ h/ F$ s0 S( n& |8 {
terone, which is a more potent metabolite, is more
+ a5 Y, z6 l1 t: x" a: u. v/ aactive in young children exposed to testosterone
% }% L; f1 P" d( `exogenously7; however, we did not measure a dihy-- R9 i# I+ `; j
drotestosterone level in our patient. In addition to
- ?: `9 Q0 M8 S- Y8 w# V- Vvirilization, exposure to exogenous testosterone in) l3 ]! I" Q3 M
children results in an increase in growth velocity and# N9 t( G$ i+ p2 E! ~2 y
advanced bone age, as seen in our patient.7 k) O* @! |. _: q0 v. M8 `
The long-term effect of androgen exposure during
! j4 v1 p6 v$ N' K- Bearly childhood on pubertal development and final
! T. c& x5 W' q3 _& x5 vadult height are not fully known and always remain& J9 L& M1 {! e6 w9 p7 @$ B, U
a concern. Children treated with short-term testos-
% d. h$ n% Z5 t1 M, vterone injection or topical androgen may exhibit some
" m: s- \) j/ l) k- M$ C# [4 gacceleration of the skeletal maturation; however, after" v9 X x0 `9 f
cessation of treatment, the rate of bone maturation# D z. v# D* X2 |, A! K
decelerates and gradually returns to normal.8,9! z0 P' w' d2 f: g% P) m5 Q% H
There are conflicting reports and controversy
) Z. t. S" e7 O& I" \5 fover the effect of early androgen exposure on adult
' _, U# a( x' I8 Rpenile length.10,11 Some reports suggest subnormal3 i/ m1 f4 X i+ u( n1 p, P
adult penile length, apparently because of downreg-1 R$ p8 f5 S( w, y9 t
ulation of androgen receptor number.10,12 However,
, [# J$ I+ }5 Y; b& o( x: j& P; {Sutherland et al13 did not find a correlation between
9 B0 K2 f3 ]* D& Kchildhood testosterone exposure and reduced adult, p7 ]8 l8 c9 D4 a
penile length in clinical studies. t! V6 t& s3 T/ X5 L+ x' E3 N
Nonetheless, we do not believe our patient is5 j9 C4 X. x% r: K0 E. H; f
going to experience any of the untoward effects from# |+ X3 V1 n( @& ]1 l
testosterone exposure as mentioned earlier because
* D7 ]! i+ |2 ~* f: C) }4 F2 |& ethe exposure was not for a prolonged period of time.. A9 A+ B# B: ^+ A; w! W- z" n
Although the bone age was advanced at the time of# l0 _' A* E& O6 p; A/ e# J
diagnosis, the child had a normal growth velocity at- X3 [5 v% y+ h# q" `
the follow-up visit. It is hoped that his final adult
; \, J- D1 U8 X; |9 [height will not be affected.
' x8 T1 [% D) v& J( H4 YAlthough rarely reported, the widespread avail-
0 D0 y T3 x2 k3 Y+ zability of androgen products in our society may0 l$ y+ j; [9 C0 }$ E- ]
indeed cause more virilization in male or female5 ^# u% Q9 e7 G8 S! c C4 X
children than one would realize. Exposure to andro-
; m0 m6 \2 F: {3 v8 hgen products must be considered and specific ques-
- _& x* Q# e6 A' Z$ h* ?+ z7 Gtioning about the use of a testosterone product or' s; B( j3 R, T6 J) ?
gel should be asked of the family members during: l# f" v# j/ e$ g6 r7 e9 g" J/ K
the evaluation of any children who present with vir-
6 w, F% ]* F9 M* Z. cilization or peripheral precocious puberty. The diag-
% E& h$ i& L1 j/ Anosis can be established by just a few tests and by, W8 x0 n/ H* u" J! ?
appropriate history. The inability to obtain such a1 ]( g" x b% ]
history, or failure to ask the specific questions, may
0 v. {. c( K# ?! K( Z6 }' oresult in extensive, unnecessary, and expensive
, W) d( e$ E" E' xinvestigation. The primary care physician should be& u/ Y( C" A, ?9 F, W
aware of this fact, because most of these children' O: f, ]: y5 B
may initially present in their practice. The Physicians’- o: j3 f/ l, L! K3 h2 V: w
Desk Reference and package insert should also put a2 O u; _+ n/ ?8 o) D& a4 E5 B
warning about the virilizing effect on a male or
6 m7 X" n: M5 D' l1 K" e) Lfemale child who might come in contact with some-- ~- _( I( Q4 w) B7 T" J/ W
one using any of these products.
4 R0 a5 E0 W8 Z8 N8 H( P4 {0 j tReferences( {- _+ O X( W b/ u6 _
1. Styne DM. The testes: disorder of sexual differentiation
6 L' p$ [2 E/ @2 L1 z, Pand puberty in the male. In: Sperling MA, ed. Pediatric9 @- {1 G, L/ m) x P
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 a3 j. W8 y8 K) U' m2002: 565-628.
, L1 _" ^4 R0 o5 b/ R2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 n* a9 X, t. fpuberty in children with tumours of the suprasellar pineal |
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