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Sexual Precocity in a 16-Month-Old/ R# r+ j, F* p3 k0 G2 w! V
Boy Induced by Indirect Topical7 J s# i' z, P% s* u
Exposure to Testosterone
' d! [; u) j4 N' F( A, _7 ~3 USamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,21 R) z, r- E- Q* _7 i
and Kenneth R. Rettig, MD1
" n$ Y Y1 q( aClinical Pediatrics) K4 ?2 E6 K" P5 e- d2 o8 C
Volume 46 Number 6
9 T! b3 W5 Y1 l8 C+ \6 kJuly 2007 540-543) T, {: {' I3 c8 [" Q, A8 d
© 2007 Sage Publications. x# C% q$ q* a$ G( a# L- M1 D
10.1177/0009922806296651
% J. I* X0 f$ b, ohttp://clp.sagepub.com
% R& v9 \4 }/ i0 Yhosted at
5 E5 Q2 ^# S4 f0 r. g* chttp://online.sagepub.com
, ~9 W+ ~( q, u P0 g! S: I, P* N8 vPrecocious puberty in boys, central or peripheral,
1 A9 I+ B, n: b9 K! i/ Gis a significant concern for physicians. Central
1 ?( s$ h, K6 S% Q( k1 ^) q5 K# cprecocious puberty (CPP), which is mediated
2 Q& Y; _2 l+ [9 z. _! R8 S& gthrough the hypothalamic pituitary gonadal axis, has
6 `) n7 ]3 L) g' V4 m( Ea higher incidence of organic central nervous system
: f2 p8 U' \; Q z5 `& N) @ slesions in boys.1,2 Virilization in boys, as manifested) `9 G- a+ `4 p1 r6 s
by enlargement of the penis, development of pubic- A3 I% S! _5 U) x
hair, and facial acne without enlargement of testi-
% @% R6 [; x1 qcles, suggests peripheral or pseudopuberty.1-3 We
+ ?3 U; A! p% f- @. g% `report a 16-month-old boy who presented with the4 s5 l) D* L0 P! e& w
enlargement of the phallus and pubic hair develop-/ F) w8 D' h4 U
ment without testicular enlargement, which was due
7 s* e) Y# e; S0 [to the unintentional exposure to androgen gel used by
u/ G5 T- V( T* x( c$ Tthe father. The family initially concealed this infor-- [' K* _- d# p: \2 z
mation, resulting in an extensive work-up for this
: X/ f# m* B: |child. Given the widespread and easy availability of/ Y% `1 c _, n+ B# J
testosterone gel and cream, we believe this is proba-
; }# b* w# E4 q% L% i& L9 xbly more common than the rare case report in the( ~% S: I# W" T" ^" r% `3 f4 E# J" x
literature.4
/ E% s6 J; Q; [; j$ z G; y5 rPatient Report
7 V; E) y- D! I: `5 ]9 y9 h$ k1 m8 sA 16-month-old white child was referred to the
5 s' r/ W$ |+ Z& e4 D: Q# Bendocrine clinic by his pediatrician with the concern
% g/ o2 y; n2 b. lof early sexual development. His mother noticed
$ ~9 J& ?; ~ V, g' glight colored pubic hair development when he was
3 b9 Z" v5 [9 O/ Q# d. FFrom the 1Division of Pediatric Endocrinology, 2University of
2 t! x% V4 y5 x4 uSouth Alabama Medical Center, Mobile, Alabama.
7 E- ?. G# F0 B$ _ x k% K5 eAddress correspondence to: Samar K. Bhowmick, MD, FACE,* y2 D& i- E8 P- @! x, b- t
Professor of Pediatrics, University of South Alabama, College of6 k$ w' @' X! g5 j9 j! E
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;. x8 |/ {; U6 j: M$ s5 C
e-mail: [email protected].% ^! V4 _' t0 w8 @0 E- g4 I3 [
about 6 to 7 months old, which progressively became
7 W- Q& _) J# y7 ?2 u7 S! tdarker. She was also concerned about the enlarge-
) l0 w$ {6 |2 I# g0 C; yment of his penis and frequent erections. The child/ E6 k- e" R& ]2 v* P8 l
was the product of a full-term normal delivery, with
- F% s; f7 T2 |- ]. P Z1 Aa birth weight of 7 lb 14 oz, and birth length of+ S5 F* ?0 k. v7 {7 q" {& D: s
20 inches. He was breast-fed throughout the first year
# l; p6 P- w" k4 \7 R2 dof life and was still receiving breast milk along with7 Q8 B7 D5 P- a, j! l# S6 J" f
solid food. He had no hospitalizations or surgery,
! a5 q; S- X! l2 s* v9 xand his psychosocial and psychomotor development5 H1 c W& r) ]; Y
was age appropriate., L$ I/ I; x$ m9 A- Z1 T0 H
The family history was remarkable for the father,4 y6 E8 Q5 i7 U* `
who was diagnosed with hypothyroidism at age 16,
5 E6 S3 r7 b- F [0 R) fwhich was treated with thyroxine. The father’s
$ C O% S/ B/ V, |( p+ dheight was 6 feet, and he went through a somewhat
/ L4 T5 Q' P7 Bearly puberty and had stopped growing by age 14.
' O0 F! n, ?9 P4 C4 FThe father denied taking any other medication. The
$ [& _& f( ~0 d( A) lchild’s mother was in good health. Her menarche
& x; v! s. @( iwas at 11 years of age, and her height was at 5 feet
# |: n0 ?$ b3 v" C) @5 inches. There was no other family history of pre-+ }7 W; Z( ]- e% ~5 `, ^, Z
cocious sexual development in the first-degree rela-' y. Q5 [( t+ z" d7 C+ _
tives. There were no siblings.8 {' G6 a; ^! l/ G
Physical Examination( t% K `0 i! R) w/ S" l7 n
The physical examination revealed a very active,' O# `# Y' w! D$ Q0 j- _
playful, and healthy boy. The vital signs documented: q3 l: z% ?/ g( g/ K/ c+ C
a blood pressure of 85/50 mm Hg, his length was
& g) N$ a# Z- d; q90 cm (>97th percentile), and his weight was 14.4 kg
; f. L' Z, z6 T, w/ C( v(also >97th percentile). The observed yearly growth
$ K& d# v" V5 S! z% ]# Wvelocity was 30 cm (12 inches). The examination of
) U1 G1 a$ r/ q$ Ithe neck revealed no thyroid enlargement.
; ]" \, Q/ _6 u% t1 W ^7 S2 vThe genitourinary examination was remarkable for
$ r/ S4 l2 j- U) E$ ?! Lenlargement of the penis, with a stretched length of
# p* Y) f( f3 Q; D8 cm and a width of 2 cm. The glans penis was very well" h$ c7 E( D! M: {
developed. The pubic hair was Tanner II, mostly around
8 f( G7 g+ i9 M& }' B. Q2 Q( B8 J& x540
% F3 P5 a8 K8 f# F" n; [8 L/ Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 w1 }6 h9 C$ X- Q. D
the base of the phallus and was dark and curled. The8 g+ c6 s2 G8 Y: m: @- i
testicular volume was prepubertal at 2 mL each.
7 @7 D8 D$ v6 e4 v1 k; bThe skin was moist and smooth and somewhat
# M g- `- a X' ~" k6 soily. No axillary hair was noted. There were no
- e. f% ~' p, x; | ?abnormal skin pigmentations or café-au-lait spots.
, A! z* Z7 n2 _7 h7 xNeurologic evaluation showed deep tendon reflex 2+% R6 C3 z) x' m Z1 n$ C+ @% _
bilateral and symmetrical. There was no suggestion
9 C0 p! d! |8 A! T. K0 k7 W" ^of papilledema.
8 V2 Z8 q7 y7 K' O. MLaboratory Evaluation
, E1 M* J' K" ^& R. BThe bone age was consistent with 28 months by
8 M' O) n% @6 u% [* I/ z' \0 @using the standard of Greulich and Pyle at a chrono-3 M% \" l) y4 Q+ p; q$ \
logic age of 16 months (advanced).5 Chromosomal8 \: c5 N- p, p' B! _
karyotype was 46XY. The thyroid function test3 `; {' J' A* x% v0 g1 x
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
, X h( x( W" |- k; U8 L- o r/ _lating hormone level was 1.3 µIU/mL (both normal)./ l2 |4 D% [& c8 k, L2 J( m
The concentrations of serum electrolytes, blood9 c( {7 B3 c& {
urea nitrogen, creatinine, and calcium all were. A9 x& ?! j) e% k4 b
within normal range for his age. The concentration
2 W- O; ]8 Y3 M2 y Pof serum 17-hydroxyprogesterone was 16 ng/dL
3 J, g( K8 s2 e$ Z& j; U(normal, 3 to 90 ng/dL), androstenedione was 20
b8 I7 a- w! N5 b+ ^ a! Y% Eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 ]! r" v: G) V1 t
terone was 38 ng/dL (normal, 50 to 760 ng/dL),5 I L- O' ]- o- q; [6 B
desoxycorticosterone was 4.3 ng/dL (normal, 7 to" }. q S, Q. Q, _
49ng/dL), 11-desoxycortisol (specific compound S)
) r, X; X. K# L/ Wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-' N8 e5 d0 I. x# H
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
4 L, v( k J- |6 g9 q( X4 wtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, w/ h9 T. ?8 o1 d( \2 n* u) jand β-human chorionic gonadotropin was less than; ?) o! ~1 H. s4 r- t
5 mIU/mL (normal <5 mIU/mL). Serum follicular( l3 O1 u' \; v, }' W
stimulating hormone and leuteinizing hormone+ M/ L0 L, t% Y+ E5 L
concentrations were less than 0.05 mIU/mL B4 }& t; _) |" U& w( q9 P+ H
(prepubertal).
8 v4 Y M! n$ X7 e, n: k5 q9 mThe parents were notified about the laboratory
% e# L* t7 S2 e6 E5 Aresults and were informed that all of the tests were
; V9 e `" f7 g! Qnormal except the testosterone level was high. The4 Y% Q( D; a' ?7 B
follow-up visit was arranged within a few weeks to
. k, f# p+ W( _4 eobtain testicular and abdominal sonograms; how-/ b' b$ x6 `8 H# P/ H
ever, the family did not return for 4 months.
+ ^, N6 m. b2 X9 Q' M' f1 E6 qPhysical examination at this time revealed that the
. Q) K" r* v: ~# n8 ^) F4 M3 k& Uchild had grown 2.5 cm in 4 months and had gained9 s0 s- {# \! T) M0 s+ [3 l6 ~
2 kg of weight. Physical examination remained9 p4 S) ~- F. p4 {% F2 O9 r
unchanged. Surprisingly, the pubic hair almost com-5 v0 T3 O9 O( p
pletely disappeared except for a few vellous hairs at
6 n& \2 @) ^/ @the base of the phallus. Testicular volume was still 28 ]0 K* T7 z0 Z1 W- k6 b/ y
mL, and the size of the penis remained unchanged.
# A$ N4 n& D9 [The mother also said that the boy was no longer hav-. a2 ?1 W/ d/ e1 e6 h
ing frequent erections.2 i9 E8 _* E- i( Z2 |
Both parents were again questioned about use of
! J% @1 g8 N" Tany ointment/creams that they may have applied to2 ^3 i5 N4 [* f% C* F, ]; h+ n# e
the child’s skin. This time the father admitted the" [/ F7 p# {8 i9 m$ |: j
Topical Testosterone Exposure / Bhowmick et al 541
$ `, o% R+ T4 y; M4 g! f+ Uuse of testosterone gel twice daily that he was apply-
: K2 x( E5 Z( X# f, I: King over his own shoulders, chest, and back area for
+ b$ _! ]! X9 {a year. The father also revealed he was embarrassed
. }( e4 |0 U, |$ Rto disclose that he was using a testosterone gel pre-, h7 z3 G8 J K
scribed by his family physician for decreased libido
/ l" G( T; N+ Osecondary to depression.
6 H' p- b4 k' c7 N+ p% CThe child slept in the same bed with parents.
: U' B: @; d8 P; `0 X$ gThe father would hug the baby and hold him on his, P; h$ C" h" G9 a
chest for a considerable period of time, causing sig-9 \/ v* G% [9 E) J- V2 I
nificant bare skin contact between baby and father.
, E% a: k; O# ]# h* B2 P6 ^6 `( IThe father also admitted that after the phone call,) {4 M- @' y" o1 q. a K' X9 o z
when he learned the testosterone level in the baby8 A9 F, w* C0 `) k" r; F- g8 V
was high, he then read the product information
" E- W" x) k* r2 q+ k" K }packet and concluded that it was most likely the rea-
+ p$ O' x9 N& X5 Yson for the child’s virilization. At that time, they
/ |) d: J4 D j# Z" c8 a- Bdecided to put the baby in a separate bed, and the9 Y' c9 o4 S! ^
father was not hugging him with bare skin and had
. K8 W9 F; |0 b! ?- xbeen using protective clothing. A repeat testosterone5 H9 P8 H8 L' L/ a4 Q$ j. l. b
test was ordered, but the family did not go to the. l3 e/ @! q% h7 R; |! @9 `/ n- ~
laboratory to obtain the test.
! q3 d9 e. z& R/ M* @Discussion, O0 d [3 |( I6 b
Precocious puberty in boys is defined as secondary
( D% A) M1 m- A: M8 h$ ssexual development before 9 years of age.1,40 E0 P$ ? I0 ]4 G$ }: j
Precocious puberty is termed as central (true) when
7 a. X$ I. o& K( o9 rit is caused by the premature activation of hypo-
% l- \9 p! E1 O( S; ~thalamic pituitary gonadal axis. CPP is more com-. \3 j1 N. K @0 ], \% H
mon in girls than in boys.1,3 Most boys with CPP
$ ]; d# a5 A# F6 P& C$ Bmay have a central nervous system lesion that is
; @5 l+ z% x0 {( t6 H: y7 m# ]responsible for the early activation of the hypothal-
' H6 R+ D5 ]/ t5 U& x7 Bamic pituitary gonadal axis.1-3 Thus, greater empha-0 t& h/ ` v Q; _3 h
sis has been given to neuroradiologic imaging in$ A1 Q( X* r! Q0 ^
boys with precocious puberty. In addition to viril-! s+ r6 r1 S% U9 ?; C$ b
ization, the clinical hallmark of CPP is the symmet-
( a/ k% h3 l1 Frical testicular growth secondary to stimulation by
7 @( [9 L9 i- `3 _0 igonadotropins.1,3
9 T& v& i4 s8 @' X3 YGonadotropin-independent peripheral preco-8 \* U- w ^1 i; w1 H" k
cious puberty in boys also results from inappropriate3 C. r3 m/ h2 M* S- K7 i* g
androgenic stimulation from either endogenous or9 ]2 g+ Q! s1 ]
exogenous sources, nonpituitary gonadotropin stim- F8 B) Q. f! }3 I5 c/ S
ulation, and rare activating mutations.3 Virilizing8 D7 q$ ^' z( J- s. x
congenital adrenal hyperplasia producing excessive
" K$ `" n/ n; G1 o3 Z$ U2 Xadrenal androgens is a common cause of precocious+ ~, H, ?4 N8 \7 D
puberty in boys.3,4, L; ~ j; v" b' M; x3 {) p
The most common form of congenital adrenal1 v/ d. Y( J8 V) O6 p) j$ }! Z
hyperplasia is the 21-hydroxylase enzyme deficiency.
* w1 O& M: a1 U# W3 jThe 11-β hydroxylase deficiency may also result in% t* ^. Y( D) c5 ~
excessive adrenal androgen production, and rarely,6 p+ j1 N4 _3 m* E. e, E- v
an adrenal tumor may also cause adrenal androgen. ]4 X$ N& e5 j6 }( d! j* P
excess.1,3. G$ J0 u( s8 |: s1 o
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 v) b% a( k. q& o$ g* i542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! K y O6 `# ]5 ^# c( V
A unique entity of male-limited gonadotropin-
; ^6 p8 T1 T/ ~# A1 v, C# _1 N% Bindependent precocious puberty, which is also known7 I) J, A }7 {- _6 C" x$ L% C
as testotoxicosis, may cause precocious puberty at a
3 ~) g( P" b& [4 t4 d/ l8 K5 }very young age. The physical findings in these boys/ t+ T0 A. O! E
with this disorder are full pubertal development,7 S9 z- F9 h, n$ J) J% N) X, k/ c& I
including bilateral testicular growth, similar to boys( V! N! D ^! ~) g
with CPP. The gonadotropin levels in this disorder
4 k2 Q2 ~# u& k! o$ R/ ?( oare suppressed to prepubertal levels and do not show
8 \+ m$ A8 n. w; {$ ~* xpubertal response of gonadotropin after gonadotropin-
+ z: z( X" A/ m: P( l V) nreleasing hormone stimulation. This is a sex-linked
; k" h! c. u/ x+ Nautosomal dominant disorder that affects only0 n% A. P/ D4 e1 X+ d' Q" _! t
males; therefore, other male members of the family
: @2 f( s& ~7 D' }9 i6 fmay have similar precocious puberty.3
+ @: e) W9 W9 L8 m ~7 oIn our patient, physical examination was incon-
c" t' k$ q( _1 Y' J6 A' nsistent with true precocious puberty since his testi-: W- Z) C5 z3 U5 ]' d. W( s
cles were prepubertal in size. However, testotoxicosis
6 |4 B/ ?" Q5 xwas in the differential diagnosis because his father c$ ]4 W) C4 c. E# F
started puberty somewhat early, and occasionally,: L* H- f# G- F* T$ u: p' h& w
testicular enlargement is not that evident in the [8 s- Y, B# R) J' H0 q- d
beginning of this process.1 In the absence of a neg-
/ n( |% t1 D" ~% s4 b' g7 C mative initial history of androgen exposure, our! j4 U6 O' N+ l$ x$ V# r3 l& j) J
biggest concern was virilizing adrenal hyperplasia,+ p. W! O) `0 y+ ^9 s! N- I
either 21-hydroxylase deficiency or 11-β hydroxylase
' i& B/ I" h6 Z, [deficiency. Those diagnoses were excluded by find-* M4 z+ L1 U4 D. }9 S' |( g) ?
ing the normal level of adrenal steroids.
* i5 `- N# e% p% [The diagnosis of exogenous androgens was strongly
& c" X, x# c$ Y4 p; ksuspected in a follow-up visit after 4 months because7 q* k. }. V/ R. M! A
the physical examination revealed the complete disap-! D* q6 }- x* P; h; H4 i4 M$ n
pearance of pubic hair, normal growth velocity, and6 R4 |- X( q7 Z& d5 V& }+ Z+ q% c
decreased erections. The father admitted using a testos-
+ k8 q" |) h |# x0 Uterone gel, which he concealed at first visit. He was! W% Y4 R* y4 F$ y$ j
using it rather frequently, twice a day. The Physicians’
9 V# a& c; ~; K1 |6 s6 nDesk Reference, or package insert of this product, gel or
8 k0 h0 {1 o; }( Fcream, cautions about dermal testosterone transfer to* d& \6 p& z/ e* E3 {
unprotected females through direct skin exposure.3 ]; N$ a: P3 U% ^/ |) t
Serum testosterone level was found to be 2 times the. Q) C' G+ x$ O4 |- `3 ?4 _
baseline value in those females who were exposed to
, n. k0 R1 b3 d" M! ueven 15 minutes of direct skin contact with their male+ L7 _7 }2 d) `
partners.6 However, when a shirt covered the applica-
; K/ w7 v1 ]: N u# v% X' o" v$ ition site, this testosterone transfer was prevented.) a$ K0 W, G. J( C' g0 g3 o, k
Our patient’s testosterone level was 60 ng/mL,
# P! \+ h8 i; R& s U* Iwhich was clearly high. Some studies suggest that' d! t3 ]' y7 U. M+ w
dermal conversion of testosterone to dihydrotestos-
- j5 M# i5 E$ Y" u. [' ?( jterone, which is a more potent metabolite, is more
b/ t' r3 Y6 z- R( V( ]active in young children exposed to testosterone
# ~3 D+ S+ z& Q* Z: T6 G1 D' Hexogenously7; however, we did not measure a dihy-
6 S2 ~8 M5 @* T2 Idrotestosterone level in our patient. In addition to3 R& Q. Q$ U0 P. j( E: a1 U
virilization, exposure to exogenous testosterone in
1 m/ r( L8 o! p4 _7 K: uchildren results in an increase in growth velocity and
/ _0 ^* z, V( Fadvanced bone age, as seen in our patient.5 ^1 H9 q. O" v7 b; B
The long-term effect of androgen exposure during
! m& b% ~' K5 |+ c' h+ |early childhood on pubertal development and final
O" T( _8 @" h7 m9 T$ P7 F" c+ Cadult height are not fully known and always remain( d- r. Q! _+ S
a concern. Children treated with short-term testos-
2 S) E1 ^2 y: I @: ~2 `terone injection or topical androgen may exhibit some9 H2 Z( I, w1 Y& j& |) q$ h
acceleration of the skeletal maturation; however, after; G2 {' N2 o3 X1 j1 o' Q) i* T
cessation of treatment, the rate of bone maturation
3 v" H; @' s( _, [' X8 X+ O0 Ydecelerates and gradually returns to normal.8,99 _# m9 R" P5 I, z
There are conflicting reports and controversy! M; n9 h v5 x% ^( j; f) J
over the effect of early androgen exposure on adult3 M5 j3 d( H8 |8 C8 q
penile length.10,11 Some reports suggest subnormal# G# k. p4 G5 ]" B& ?: V
adult penile length, apparently because of downreg-
+ }( Y/ t( C2 k0 `2 `) J1 p5 W2 v. gulation of androgen receptor number.10,12 However,
4 ] ~0 v8 l1 s- RSutherland et al13 did not find a correlation between
; V9 d2 s; F. l ~& hchildhood testosterone exposure and reduced adult
: O: w% Q' l( U+ wpenile length in clinical studies.
; m. H4 j+ u) [; H+ VNonetheless, we do not believe our patient is
( @: v, z3 x" w# L" Z2 s6 hgoing to experience any of the untoward effects from/ ?( N. p6 s- C9 V1 C
testosterone exposure as mentioned earlier because
3 h" B8 y, A* xthe exposure was not for a prolonged period of time.
- x: u/ E( ?8 d" aAlthough the bone age was advanced at the time of b- e3 \' ~! c' T1 B! G+ S$ B
diagnosis, the child had a normal growth velocity at' B4 i- E/ v! \/ [
the follow-up visit. It is hoped that his final adult
w' i1 M; U! `: o# i2 rheight will not be affected.
# N V f+ u) U7 O( ^9 iAlthough rarely reported, the widespread avail-. M. E2 z+ ~' G( i$ ]/ X/ i+ j
ability of androgen products in our society may' B* ~4 j* a0 z% n
indeed cause more virilization in male or female9 T' _" m, h& k3 K8 x
children than one would realize. Exposure to andro-0 h' R* @7 c% O8 h1 g5 z1 ^
gen products must be considered and specific ques- J4 I# l4 B! c" n5 O% H
tioning about the use of a testosterone product or
$ `1 | K) l0 z9 i; _& Y0 i) w" ogel should be asked of the family members during T! m3 z, R& T
the evaluation of any children who present with vir-) h8 F( u6 J- f; a6 s1 v2 u6 C/ k
ilization or peripheral precocious puberty. The diag-
6 X' G5 t t( f& G9 W1 }1 ynosis can be established by just a few tests and by( V& j* P/ q8 ?5 {+ o! T- N
appropriate history. The inability to obtain such a
, W1 U( t0 y% z9 i4 v( W% o* _history, or failure to ask the specific questions, may( @/ D; P1 d6 ?) Z$ o
result in extensive, unnecessary, and expensive0 R3 f7 D, C: J/ R) _
investigation. The primary care physician should be
& C6 m6 z9 a9 K1 T* z. @aware of this fact, because most of these children+ V: M Z& R }% v* J* p$ U; X
may initially present in their practice. The Physicians’
* L3 P( m/ }( S5 q6 @8 IDesk Reference and package insert should also put a
, [: p6 H* ?0 w7 Nwarning about the virilizing effect on a male or
2 m3 d3 h' U9 f" Hfemale child who might come in contact with some-
7 N' `6 p. k( m& j. g* v% `one using any of these products.
6 ~; F* k' j/ _, e* S! g& k, uReferences- Q- p. I$ E( m2 O. i) u% S: |
1. Styne DM. The testes: disorder of sexual differentiation
7 N2 L6 J. Z% q, {; O! @and puberty in the male. In: Sperling MA, ed. Pediatric
1 g8 P4 u& y# w9 b! wEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 p' _' m% a# S4 a9 {2 |% p }
2002: 565-628.1 W ~& L A2 i: i6 M
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& E$ [: i5 b+ Npuberty in children with tumours of the suprasellar pineal |
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