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Sexual Precocity in a 16-Month-Old
- T" m+ |$ w+ I& ~/ s. qBoy Induced by Indirect Topical2 Q7 b. c# U8 \, Z4 a4 i
Exposure to Testosterone
( T! A5 ~1 s7 ~* k0 ?" ISamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 |- B3 j1 i% ~9 o, b( r7 t* |! [and Kenneth R. Rettig, MD1( P4 m6 Z9 D4 G
Clinical Pediatrics0 b3 a' L) F" K: X1 Q
Volume 46 Number 6. x& I$ R z' G, j
July 2007 540-543- k! f2 y* `/ }1 a4 [, N
© 2007 Sage Publications
* g1 ^' ]! W K" t4 A$ d10.1177/00099228062966511 Y2 z" o: o' T* n! m* X E1 ^
http://clp.sagepub.com
) Q7 N( I0 v8 V9 x4 K" i' X3 i Qhosted at9 G6 g2 g9 |# u4 D3 L
http://online.sagepub.com' W+ [5 N$ I* B( W7 b3 @
Precocious puberty in boys, central or peripheral,' K) \. d/ E! _: O, a( }0 I1 g
is a significant concern for physicians. Central P( x* c! A: Y% v* P O$ u& e9 c
precocious puberty (CPP), which is mediated- x* a- r n9 h$ N I
through the hypothalamic pituitary gonadal axis, has7 H8 @, ]6 b5 p, V7 t$ N
a higher incidence of organic central nervous system
0 ^2 n J) T C9 M& N! tlesions in boys.1,2 Virilization in boys, as manifested
9 p6 S; E8 w* m% {2 nby enlargement of the penis, development of pubic
5 H5 Q) I0 k! x' Khair, and facial acne without enlargement of testi-
- \3 {/ C0 N* v8 }cles, suggests peripheral or pseudopuberty.1-3 We
+ w A- U$ g+ c, I1 \$ Wreport a 16-month-old boy who presented with the
* O$ L+ Z& {1 e( d3 uenlargement of the phallus and pubic hair develop-
$ l6 ~! `6 C* [6 g# F3 X) Xment without testicular enlargement, which was due
; v3 u p e8 S' x, mto the unintentional exposure to androgen gel used by
+ t+ ~/ B# q. t0 pthe father. The family initially concealed this infor-0 A! C$ n2 {2 {$ X* I- L2 b
mation, resulting in an extensive work-up for this2 @5 N$ o% A' ?. g* o3 U
child. Given the widespread and easy availability of) S! W: I5 X/ S: ?' ^4 ~
testosterone gel and cream, we believe this is proba-9 Q L3 @6 }2 S6 I# q$ f- Q5 J
bly more common than the rare case report in the
) o- N5 x3 p: mliterature.4
/ S. }# |( p' p$ L# x j5 {( KPatient Report E6 p1 L+ [' R9 L! C/ J
A 16-month-old white child was referred to the, c( j9 E U8 W2 Z v1 I3 A
endocrine clinic by his pediatrician with the concern9 |: O5 P+ s0 X+ d* t, D
of early sexual development. His mother noticed
) _1 t; s$ J# ^. a( clight colored pubic hair development when he was
- ]( E5 ^! {- z6 ?7 b3 rFrom the 1Division of Pediatric Endocrinology, 2University of
: Y, x4 L# a. i. dSouth Alabama Medical Center, Mobile, Alabama.5 [' {- b- O1 M1 Y: x6 ~6 ]5 P
Address correspondence to: Samar K. Bhowmick, MD, FACE,
/ `0 c: w- E& y+ sProfessor of Pediatrics, University of South Alabama, College of
1 ?) `- Q" ~7 A* Q: I/ M2 }Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;0 q7 ?4 G! r9 O% o* U5 w% B
e-mail: [email protected].
5 X* J* V; S3 ~% h; z; N8 Habout 6 to 7 months old, which progressively became
- v( p# X* v, {: y, xdarker. She was also concerned about the enlarge-
/ L7 n8 v. `/ O7 j2 y3 }- z5 ?ment of his penis and frequent erections. The child& _6 T. Y2 m: A1 {" |
was the product of a full-term normal delivery, with. L: X* j7 V3 j8 F" n
a birth weight of 7 lb 14 oz, and birth length of% j9 g7 X, v2 w0 ?- ~6 z: ^' C
20 inches. He was breast-fed throughout the first year
/ `/ E$ O" A0 y% `) O6 }1 ~# hof life and was still receiving breast milk along with! y1 Y; T; J4 Z5 H% p: ~! [7 Q
solid food. He had no hospitalizations or surgery,8 G; {8 t) s1 l
and his psychosocial and psychomotor development, f) z, i, y8 |# N% t- s f) H
was age appropriate.
# f5 A* a0 g* D2 FThe family history was remarkable for the father,2 q# c2 Q- i: m% S
who was diagnosed with hypothyroidism at age 16,
; z% X& J1 Y! Y6 D+ `7 C8 ]which was treated with thyroxine. The father’s/ p4 f; f; t: r
height was 6 feet, and he went through a somewhat
2 M, w# }/ V- b# x+ iearly puberty and had stopped growing by age 14.
0 [6 j4 T' b3 ~/ ~2 f' B. bThe father denied taking any other medication. The# {$ K" A( W/ ~. h& m4 z
child’s mother was in good health. Her menarche
! P1 R& s: d/ r+ o* J8 d5 }was at 11 years of age, and her height was at 5 feet8 d' z7 A+ ?+ b
5 inches. There was no other family history of pre-
) ]% g& J8 t+ ]cocious sexual development in the first-degree rela-
z1 d! U a! A3 Ltives. There were no siblings.
7 O' i, x# l t( fPhysical Examination
4 I4 o' b% [# D9 b. z3 D) M8 T; [The physical examination revealed a very active,% n* ?# `9 f, _5 [
playful, and healthy boy. The vital signs documented
5 h- D0 U- o5 f& ba blood pressure of 85/50 mm Hg, his length was& b9 ?; g' C) j% r
90 cm (>97th percentile), and his weight was 14.4 kg
9 B3 x3 e) W) f: l, Q7 x(also >97th percentile). The observed yearly growth8 U$ O/ Q% x+ K4 V# s5 ]
velocity was 30 cm (12 inches). The examination of
8 z, t/ F8 z1 z5 gthe neck revealed no thyroid enlargement.
2 D( g: O7 z0 ]" X, OThe genitourinary examination was remarkable for
( a. z2 P7 S0 E. n" o7 _enlargement of the penis, with a stretched length of
* k4 y# \+ _* L. s% j. D! Z8 cm and a width of 2 cm. The glans penis was very well
% p9 B/ @8 n/ W# N' H! ddeveloped. The pubic hair was Tanner II, mostly around
$ Q+ ]; Z E1 E. @; Q+ Y/ n5401 f: n* X8 C+ i" g+ W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. o. r. y H4 {the base of the phallus and was dark and curled. The
' o% g {) p8 D+ s% \4 F: _testicular volume was prepubertal at 2 mL each.6 e3 |& C# D1 Q9 C" J! m+ A1 b
The skin was moist and smooth and somewhat/ a; j6 Y. ~4 l# p; ^+ Y8 U4 O! X( _
oily. No axillary hair was noted. There were no, i* ^' C1 g& N9 C$ ~" ~ j
abnormal skin pigmentations or café-au-lait spots.+ ~. g0 F' i! _4 w
Neurologic evaluation showed deep tendon reflex 2+
6 |: ], K4 }" N' fbilateral and symmetrical. There was no suggestion$ l. [& K/ V, `! x* X' [3 }4 B
of papilledema.. [. r5 y& ^' f2 j7 f
Laboratory Evaluation6 j1 }/ K$ O7 e* J, E; ?5 _ s
The bone age was consistent with 28 months by7 q- S4 ^& s" I
using the standard of Greulich and Pyle at a chrono-
3 @& ?2 R% |9 N% Z+ flogic age of 16 months (advanced).5 Chromosomal
$ D+ a- G4 i9 z: Kkaryotype was 46XY. The thyroid function test) Y, m8 M7 |) N+ A4 W
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
1 P2 Y7 C# r+ t0 a; Jlating hormone level was 1.3 µIU/mL (both normal).
, R5 ]4 D) c, D* x! y' H3 j! }; nThe concentrations of serum electrolytes, blood5 g( o5 `# L$ s- p$ U' `
urea nitrogen, creatinine, and calcium all were& s$ b" o1 G9 h9 \# i( V
within normal range for his age. The concentration6 |& j9 U) b" j* T
of serum 17-hydroxyprogesterone was 16 ng/dL
" I3 w- J4 l0 t1 c' Q* Y, b( R- {(normal, 3 to 90 ng/dL), androstenedione was 20
- e A& _. `2 L9 hng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 S$ w/ e5 l9 P O6 f
terone was 38 ng/dL (normal, 50 to 760 ng/dL),9 X( P8 f9 F0 ]: F. E
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 q7 w6 S+ |7 {1 A( M. {5 G3 E49ng/dL), 11-desoxycortisol (specific compound S)
! Q% b9 l: j' p: q0 W/ nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-/ X; w8 e) K, D% @
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 Q: h4 R: C3 ?& Etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),, G5 _8 d) ^" G5 d1 }9 N
and β-human chorionic gonadotropin was less than: i7 A2 ?1 X" j9 c# b, {- Y" T
5 mIU/mL (normal <5 mIU/mL). Serum follicular1 Q4 q3 V; u( m7 D4 O" B
stimulating hormone and leuteinizing hormone+ t h& @3 _ v( ~3 N' d
concentrations were less than 0.05 mIU/mL, r4 I7 d6 [& o7 D6 N
(prepubertal)., ]' E7 D, g! M9 @( y8 M0 N5 v
The parents were notified about the laboratory) u z8 ^& w" Y. @+ w: t% V
results and were informed that all of the tests were. |- q) P K. W* x
normal except the testosterone level was high. The k$ O# \. ~$ e( L- [2 n
follow-up visit was arranged within a few weeks to
6 J% U7 i4 A" B, Y# G) Bobtain testicular and abdominal sonograms; how-
" o- |/ |. |# Qever, the family did not return for 4 months.
( y3 j% x: ^5 O4 o4 L+ l5 dPhysical examination at this time revealed that the
0 J% Z) H7 U( D8 \; f5 c; Ichild had grown 2.5 cm in 4 months and had gained
4 d* a' T) }3 Z. {. U# J4 {2 kg of weight. Physical examination remained
/ y' q) {9 O2 vunchanged. Surprisingly, the pubic hair almost com-" k+ `3 b" X7 n" V
pletely disappeared except for a few vellous hairs at* P" V5 X* E! ^
the base of the phallus. Testicular volume was still 26 b$ Z# \7 P( |- u; ]/ U; I
mL, and the size of the penis remained unchanged.
/ v; d( J# p2 t8 \4 r3 p4 SThe mother also said that the boy was no longer hav-7 h6 V2 E# E6 b' Y
ing frequent erections.
7 W: ]+ H- v& K1 l6 z; uBoth parents were again questioned about use of
/ S( C% e+ g/ \8 rany ointment/creams that they may have applied to5 _- v: m+ h: u! ^6 A
the child’s skin. This time the father admitted the8 z5 Z, T: a" ]6 _2 |" I) T
Topical Testosterone Exposure / Bhowmick et al 5414 Z( N" ?& {* S y' Y U, v5 T
use of testosterone gel twice daily that he was apply-
9 P/ u& b" c2 {& B% `8 M' R7 wing over his own shoulders, chest, and back area for
8 J( ^. M# l' j5 O% _a year. The father also revealed he was embarrassed* b0 B: c) |7 Z6 X/ t
to disclose that he was using a testosterone gel pre-9 r# g* |" h' Q; k
scribed by his family physician for decreased libido
7 z& I7 h' ?! D. f2 fsecondary to depression.1 i. K$ |. A7 x
The child slept in the same bed with parents.* f8 Z) {+ x. g+ C( v
The father would hug the baby and hold him on his
* f9 w. @0 a# l5 v4 ?2 y' f5 J; Ichest for a considerable period of time, causing sig-
# Y/ C6 L) ]0 i- dnificant bare skin contact between baby and father.: N" H/ p! h0 W2 f0 ~8 v% m
The father also admitted that after the phone call,: _/ A" ]; j- ^
when he learned the testosterone level in the baby5 I0 N, q1 R& O+ E
was high, he then read the product information
& J @/ ~' k1 w7 O- xpacket and concluded that it was most likely the rea-
/ p. w$ E6 q7 }$ gson for the child’s virilization. At that time, they) ?% K2 [, @, ~' B* D
decided to put the baby in a separate bed, and the) d1 V/ W0 h& r- _
father was not hugging him with bare skin and had9 ^& n k' j" @; C
been using protective clothing. A repeat testosterone2 H6 C% y z& t7 l# L
test was ordered, but the family did not go to the# @% {; l- p, w4 s' k' I" S2 T5 M
laboratory to obtain the test.
5 _7 ?0 @% ~# n6 A- I" JDiscussion
" x1 V% [# N+ b& g1 {Precocious puberty in boys is defined as secondary3 ^4 c( ?5 N5 Q
sexual development before 9 years of age.1,4) L* C2 q- u6 L; K" R1 M
Precocious puberty is termed as central (true) when
5 n5 f8 u' u# ?; U* W0 m2 t+ Rit is caused by the premature activation of hypo-
" Y5 Q( v. B/ c* f0 C+ L. h& `/ Wthalamic pituitary gonadal axis. CPP is more com-
3 n3 p* i* C2 `; }8 hmon in girls than in boys.1,3 Most boys with CPP
8 ~- @. e; r& z' N# h, Imay have a central nervous system lesion that is
* ?8 S# r$ E A+ L& D+ Q* Dresponsible for the early activation of the hypothal-8 T' D1 v' v) b3 y/ ^
amic pituitary gonadal axis.1-3 Thus, greater empha-
2 C4 u; \+ P% Q6 c$ J, w9 Ysis has been given to neuroradiologic imaging in
1 Y" M( g" f/ k) kboys with precocious puberty. In addition to viril-
8 q4 e3 K7 Y% z! [ization, the clinical hallmark of CPP is the symmet-9 C' F; d0 k4 g. P
rical testicular growth secondary to stimulation by
$ y; j7 W: l, d. u9 J: I0 h4 Igonadotropins.1,3
) s& {# d9 n1 h4 n" E' s/ bGonadotropin-independent peripheral preco-9 ?( Q% q& k6 Z1 K
cious puberty in boys also results from inappropriate) K, W' e! W7 l" D& n$ W7 Q
androgenic stimulation from either endogenous or8 Y3 `! p5 n& H! a
exogenous sources, nonpituitary gonadotropin stim-
. [/ X' \0 ], Y2 [ulation, and rare activating mutations.3 Virilizing
/ y$ U/ P% o& qcongenital adrenal hyperplasia producing excessive
2 @0 \* s6 k; |" [+ y; ]# ~& qadrenal androgens is a common cause of precocious$ }- B+ O' I3 D* C. W8 z, S* _# ]
puberty in boys.3,4. l" X- h0 g7 S8 |- Z
The most common form of congenital adrenal
5 z& u! {1 y# I. Ghyperplasia is the 21-hydroxylase enzyme deficiency.) W! u9 ^( o9 o3 M( O% ]
The 11-β hydroxylase deficiency may also result in- t6 T! P; F. T: I9 h+ P! ]/ S6 ~
excessive adrenal androgen production, and rarely,
, n5 g2 X5 [! s4 E( San adrenal tumor may also cause adrenal androgen2 p. {3 P0 P) ]( g1 t6 n0 p5 C
excess.1,3
6 C1 O9 X/ Q7 I& k- Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) d5 `! R. n7 B6 Q4 f) f. B
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% N w* T! I+ U) s4 N' I+ {* z
A unique entity of male-limited gonadotropin-
' F% B f% U) E+ @9 M: I' S k$ _7 Xindependent precocious puberty, which is also known# O4 J3 w' C3 k* y$ e
as testotoxicosis, may cause precocious puberty at a
( R% k1 u, j+ p P9 Tvery young age. The physical findings in these boys2 \2 ?, ^9 j2 ?& p2 k7 L1 u" W
with this disorder are full pubertal development,& U0 ~* N# b5 F, @; I3 z
including bilateral testicular growth, similar to boys8 P) h! p* r$ B: u' q: A6 {
with CPP. The gonadotropin levels in this disorder3 |& i# @9 N1 E7 a' D
are suppressed to prepubertal levels and do not show
& E7 ^+ R/ E4 Gpubertal response of gonadotropin after gonadotropin-
4 z, c" }- E' J' V; Sreleasing hormone stimulation. This is a sex-linked
. V4 [. \6 O1 }autosomal dominant disorder that affects only
0 F1 T4 R+ G; z1 c4 H" c! Hmales; therefore, other male members of the family
3 b2 k. I s8 \. `+ j8 Wmay have similar precocious puberty.3 q, n% U* g9 ~' r9 g
In our patient, physical examination was incon-
4 R6 L& w( G+ f! N: esistent with true precocious puberty since his testi-
8 M% J0 Q" Z. Y [, scles were prepubertal in size. However, testotoxicosis: o' c1 P* f8 g6 C# j3 N
was in the differential diagnosis because his father/ H/ t% C0 U: A6 ]" Y5 p# O8 x
started puberty somewhat early, and occasionally,
5 b, { n, y0 y( i4 H Atesticular enlargement is not that evident in the
5 _& P1 x4 Y3 K7 D, U1 k+ |8 g. Lbeginning of this process.1 In the absence of a neg- v& [: O7 ]% b( } {$ t8 \% \
ative initial history of androgen exposure, our4 l- Y/ k( l9 m% Y j9 U7 }$ w0 g
biggest concern was virilizing adrenal hyperplasia, r h1 q6 y4 c) e1 t. B
either 21-hydroxylase deficiency or 11-β hydroxylase
# p# P2 ?7 J f7 H, o& b0 V1 Edeficiency. Those diagnoses were excluded by find-/ ~1 A! |" R4 Q; S* s
ing the normal level of adrenal steroids.6 ^: Z9 p" a0 e$ ^
The diagnosis of exogenous androgens was strongly
9 }# ?0 x6 H& R) y3 ^, G' v5 `% ysuspected in a follow-up visit after 4 months because1 j7 Q( [3 j0 s7 P( K7 n* G
the physical examination revealed the complete disap-
# I* r6 x2 B ^/ ]pearance of pubic hair, normal growth velocity, and
- d2 U& l H$ F! Y5 Rdecreased erections. The father admitted using a testos-
1 R4 E; r. ]: S1 j) F* G/ G$ ?terone gel, which he concealed at first visit. He was+ T/ T6 h+ b( W2 [' \# _: E' b5 D
using it rather frequently, twice a day. The Physicians’# Z+ C; E0 E1 k. l1 }( ~5 v
Desk Reference, or package insert of this product, gel or
( d2 B/ B/ Y, v" e7 ]cream, cautions about dermal testosterone transfer to& M: p# k) i. ]. \2 i, v$ e
unprotected females through direct skin exposure.' j" B* k! h8 q8 u/ ^
Serum testosterone level was found to be 2 times the7 h" V ^* W% F; ^. H( s- S
baseline value in those females who were exposed to U. u3 H$ n6 F0 A r
even 15 minutes of direct skin contact with their male6 u( `7 X! B5 c, Q6 q y/ e: E
partners.6 However, when a shirt covered the applica-5 G: |5 v3 P- U6 v
tion site, this testosterone transfer was prevented.
! v& b# Z; Q7 v$ N9 Q2 rOur patient’s testosterone level was 60 ng/mL,
[/ `# }( v0 z8 jwhich was clearly high. Some studies suggest that9 [: M9 |# l+ }& D, E3 b0 p
dermal conversion of testosterone to dihydrotestos-
' R& ~) ?: \$ u# Sterone, which is a more potent metabolite, is more4 D( m9 z* H3 O2 L3 f! W/ n6 ?: Y. b6 f1 t
active in young children exposed to testosterone
* Y, D, H& `0 o: a% D& B7 qexogenously7; however, we did not measure a dihy-
3 `4 m1 [7 c' q. Ydrotestosterone level in our patient. In addition to0 _( x3 w- Q6 h& K
virilization, exposure to exogenous testosterone in
* t7 k; M- ?; j: [children results in an increase in growth velocity and* O: I8 L6 O% |* X! T& Y
advanced bone age, as seen in our patient.1 ~, t, s# e& B) x, ~
The long-term effect of androgen exposure during U5 C" n' J; ]! j% X
early childhood on pubertal development and final" m8 a {9 `# M1 M) A* b' ?% X/ F
adult height are not fully known and always remain# S6 o8 L, V8 t0 C
a concern. Children treated with short-term testos-1 }# x, @2 M7 U0 ?
terone injection or topical androgen may exhibit some
5 s7 e$ Q1 ^1 uacceleration of the skeletal maturation; however, after
3 [' R5 e2 c+ F! c+ Zcessation of treatment, the rate of bone maturation5 v" h+ o8 y& q) h# u
decelerates and gradually returns to normal.8,9! U" a) [' s! D: A) o$ S u- I
There are conflicting reports and controversy* ^6 ^6 r& B. L- U; i
over the effect of early androgen exposure on adult
u6 w/ y8 R' ?5 \1 d& M; wpenile length.10,11 Some reports suggest subnormal' _6 G7 H5 Z9 T* S3 @
adult penile length, apparently because of downreg-* M' n1 v9 F6 P4 m. |
ulation of androgen receptor number.10,12 However,
+ J) R2 v3 [- X. r) D3 Z6 aSutherland et al13 did not find a correlation between' z, W& A9 q2 e2 [+ x
childhood testosterone exposure and reduced adult
- E3 |, F7 ~! i' Qpenile length in clinical studies.
* n/ p- S6 ^" `5 }; i$ oNonetheless, we do not believe our patient is0 W" D+ _' d1 Y1 S
going to experience any of the untoward effects from. R' @0 _1 y( ^/ x# C
testosterone exposure as mentioned earlier because
) x3 k2 D1 U6 z* |. k( J1 z( ?1 _the exposure was not for a prolonged period of time.% `8 P/ {) s. w# a5 Z5 t6 t; k
Although the bone age was advanced at the time of
) a' O; [$ w$ Y% ]& W# J& N) _diagnosis, the child had a normal growth velocity at5 }' m! c; l( E3 p4 e2 d7 x
the follow-up visit. It is hoped that his final adult1 A% q8 X9 X$ W; F' `* f
height will not be affected.
7 s" x3 f% [& C* U8 tAlthough rarely reported, the widespread avail-% N1 Z$ C Y& p" H; x& J5 e& R
ability of androgen products in our society may
0 C( n4 e7 o& [2 o! Vindeed cause more virilization in male or female$ c# ?: x+ L1 j% _5 O+ }
children than one would realize. Exposure to andro-
% p, N7 N( n" x. h4 Cgen products must be considered and specific ques-
8 X: |: y9 y. Z( k7 G* Stioning about the use of a testosterone product or
2 {0 N; I% v* Z j8 sgel should be asked of the family members during
- ]& ]/ ^5 d# f. @1 u4 Hthe evaluation of any children who present with vir-
* x8 q1 K# x; p4 x, ]ilization or peripheral precocious puberty. The diag-
! L6 H. p- P, I& Y$ m Rnosis can be established by just a few tests and by
2 y/ k0 Z* i" y+ `* [ t% E0 C qappropriate history. The inability to obtain such a6 N1 {& a# h$ g5 Z" ]! D
history, or failure to ask the specific questions, may: I3 ~; v7 G$ F- b& C+ f+ o' p4 w
result in extensive, unnecessary, and expensive
- j# p3 H, g. J. E( c7 X7 r6 \investigation. The primary care physician should be# D5 v y# I% v7 t3 w
aware of this fact, because most of these children; G- z; @* D" ?% o6 r' I
may initially present in their practice. The Physicians’
3 |+ M! I$ S0 U2 f. Z @' cDesk Reference and package insert should also put a% {1 v' h ^2 J
warning about the virilizing effect on a male or
0 N9 e( w: f2 \6 ^4 o: T$ Q) Sfemale child who might come in contact with some-( U' @, T+ W7 v0 S/ k9 u+ }" A
one using any of these products.
: j( X8 i, X! HReferences
% \$ u- o4 ], b0 @1. Styne DM. The testes: disorder of sexual differentiation9 b ]+ `) o7 n" e5 L' V
and puberty in the male. In: Sperling MA, ed. Pediatric- r* R) a7 h: y: _
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 r7 v. d5 g2 M; E2002: 565-628.2 a1 X5 F7 _9 c* A
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. |; W! X. r; P! g$ s* W, g* o
puberty in children with tumours of the suprasellar pineal |
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