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Sexual Precocity in a 16-Month-Old0 l2 v! C+ \! i$ d3 Y3 F& l
Boy Induced by Indirect Topical
6 M b- u! j- PExposure to Testosterone+ F2 i( B* A% r, f3 m
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; T8 N4 l8 v, K; h' `and Kenneth R. Rettig, MD1
0 F% }" T: n1 y$ FClinical Pediatrics; f# h1 T6 L" j% D# D
Volume 46 Number 6
$ G. z% A, F V! D! M: G$ SJuly 2007 540-5434 M' l+ @- v) H# b& x8 C5 O8 R) ?; y
© 2007 Sage Publications
3 ^0 b2 q1 B% l2 f10.1177/0009922806296651
8 j! d) G8 R# w9 ohttp://clp.sagepub.com# W; k! t, W+ j e
hosted at3 ?- J X, N& t+ R3 @9 u
http://online.sagepub.com2 x) |" F( W: ]3 ~, u$ B
Precocious puberty in boys, central or peripheral, x, k3 ^% J! f( [9 [4 {4 p3 k
is a significant concern for physicians. Central
; l, e O. Z1 z( xprecocious puberty (CPP), which is mediated" {( r, U! Q, I. }" Z/ w7 |+ y
through the hypothalamic pituitary gonadal axis, has
m2 l2 L: J3 D* r9 ^# K% h; Wa higher incidence of organic central nervous system
+ ^: k) N( n( l: I2 @: f& ylesions in boys.1,2 Virilization in boys, as manifested
7 t& v) q) B4 o) T! n, kby enlargement of the penis, development of pubic* p1 Y9 n D0 L/ x" B0 K2 y
hair, and facial acne without enlargement of testi-5 |. r9 P4 S( \) x7 j% L8 R
cles, suggests peripheral or pseudopuberty.1-3 We
: s# ?' B+ l2 ?) \" I7 k, T* S( Greport a 16-month-old boy who presented with the5 Z6 M9 N) z6 ^$ `
enlargement of the phallus and pubic hair develop-+ `+ R$ j' d# j# L+ v/ F, z
ment without testicular enlargement, which was due C, N* {' S' n5 l
to the unintentional exposure to androgen gel used by
9 Z# f; f- `: Kthe father. The family initially concealed this infor-
# |9 F& |9 d1 r* b& Q; q6 ~2 Jmation, resulting in an extensive work-up for this. g' T' u# y8 X1 C% @% [/ A
child. Given the widespread and easy availability of) Y6 D+ ]1 n W7 l
testosterone gel and cream, we believe this is proba-+ U2 J# N! W$ w0 r5 P2 i6 @1 O
bly more common than the rare case report in the0 H. N0 }' {9 h. s2 \( V0 A* p8 O
literature.48 d. f2 f/ p9 ?9 o9 u
Patient Report
0 g: ?- A! ?3 ]5 s9 k: V7 N" `A 16-month-old white child was referred to the0 p* e- z" r; h3 O
endocrine clinic by his pediatrician with the concern9 R5 w: }* z3 j; h4 _: O% m
of early sexual development. His mother noticed
, F* q g2 E, Y0 y) w" slight colored pubic hair development when he was% V& E( ~2 E! M8 n
From the 1Division of Pediatric Endocrinology, 2University of
! f: ~* O6 D! M$ f4 Z0 V. Q" P) wSouth Alabama Medical Center, Mobile, Alabama.
Z4 P9 W$ K8 f$ K4 {Address correspondence to: Samar K. Bhowmick, MD, FACE,% u( |1 U7 i/ V- ~4 {
Professor of Pediatrics, University of South Alabama, College of
6 x5 H- z% @5 \3 VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 t/ y* T6 a' H6 B c i5 @e-mail: [email protected].
$ c* z4 t% n4 W& U" I9 wabout 6 to 7 months old, which progressively became
# n% h7 }* \' T' sdarker. She was also concerned about the enlarge-: ?; K% w8 E4 ?) a7 V, ~
ment of his penis and frequent erections. The child# E( L- U5 r' m* [; n e: i4 S! ~3 i
was the product of a full-term normal delivery, with% K6 P7 }" ~. Y6 `( |: H
a birth weight of 7 lb 14 oz, and birth length of& W) W2 i, V: U* ]0 h# d
20 inches. He was breast-fed throughout the first year/ L: j5 x) J; p+ _9 i
of life and was still receiving breast milk along with
& c. c" e; Q+ S% Ksolid food. He had no hospitalizations or surgery,3 r7 F2 K( G# x: {
and his psychosocial and psychomotor development. A$ n9 x, a- B; u' [
was age appropriate.3 E% W( q0 m, i- l, T/ C$ }
The family history was remarkable for the father,
& h5 A. u9 f0 ewho was diagnosed with hypothyroidism at age 16,; S) x/ S# Q! P9 S7 P
which was treated with thyroxine. The father’s
E D @! E( M% z1 m' g2 V5 f% uheight was 6 feet, and he went through a somewhat2 l+ _" A H* x J# r" \- r
early puberty and had stopped growing by age 14.
( Z# R+ ]4 Q0 f7 r0 h1 M! p. cThe father denied taking any other medication. The
3 c$ e& E z1 O) @4 Y( zchild’s mother was in good health. Her menarche8 q$ I; b% b7 q/ U
was at 11 years of age, and her height was at 5 feet
0 M, k1 Y: s- Z0 I5 inches. There was no other family history of pre-
- J7 j7 K$ ~5 V" V M' Mcocious sexual development in the first-degree rela-8 C* Q4 z/ W9 e1 A8 J/ }( ^
tives. There were no siblings.
# w; C/ B( |+ {$ b! s5 q8 I2 tPhysical Examination
! h: s; k1 U+ F* C- ~. ^The physical examination revealed a very active,6 t3 F$ q& M+ x6 R9 g' L( [" d" _; k- Q
playful, and healthy boy. The vital signs documented& E9 Z% m! c% I6 Q9 F* p( L0 a
a blood pressure of 85/50 mm Hg, his length was7 ?4 ^$ T& Y# i; ~
90 cm (>97th percentile), and his weight was 14.4 kg. U- W+ i1 C. f4 g
(also >97th percentile). The observed yearly growth
1 M, G# A% p$ | X8 q7 `velocity was 30 cm (12 inches). The examination of
) l+ |1 q: q) R1 u5 qthe neck revealed no thyroid enlargement.
8 Q% n: y- H6 l, R- eThe genitourinary examination was remarkable for
! U8 t* E" X& ?9 ]$ O: G# t5 z' Cenlargement of the penis, with a stretched length of/ o8 p4 W' \$ C9 u
8 cm and a width of 2 cm. The glans penis was very well3 u4 p& |, I8 n- B. q( A q; V/ b
developed. The pubic hair was Tanner II, mostly around
/ i) r$ ~ @; y9 h2 S5 I2 }5402 p- g" {! S2 p3 p4 E$ ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; N1 V O/ F) O" j6 Hthe base of the phallus and was dark and curled. The
) \7 d& ]2 `2 |+ p# dtesticular volume was prepubertal at 2 mL each.( d) k. F1 I3 F& \
The skin was moist and smooth and somewhat8 K5 N G5 ~: I7 o; D
oily. No axillary hair was noted. There were no7 K9 ~1 V# j) e2 L/ @$ N% |' D
abnormal skin pigmentations or café-au-lait spots.) M9 a2 Q9 Y ?8 ]) b
Neurologic evaluation showed deep tendon reflex 2+6 A# g% n% h8 y3 j- H
bilateral and symmetrical. There was no suggestion
8 j, M E$ w) U+ E0 Wof papilledema.
5 j- m$ e* {& o$ A2 `Laboratory Evaluation
4 u' W* I+ v" ]) q0 vThe bone age was consistent with 28 months by' e' _& F- M8 D, j& f9 {: e T" G" M
using the standard of Greulich and Pyle at a chrono- k. \9 G5 b- S" z% n1 B8 ^$ |8 e
logic age of 16 months (advanced).5 Chromosomal
3 b3 Q: [ @ E; O2 j6 h4 hkaryotype was 46XY. The thyroid function test2 H$ f* ?3 J6 b; S, x
showed a free T4 of 1.69 ng/dL, and thyroid stimu-, Z2 @0 j" B) p# Y# p% F5 T# ~ V
lating hormone level was 1.3 µIU/mL (both normal).9 d- v* K+ O4 W9 j/ }9 v( r7 D
The concentrations of serum electrolytes, blood
; e* ~; v1 }5 }. Z7 g) Qurea nitrogen, creatinine, and calcium all were
$ A" [! B$ V5 @, N, c* m$ fwithin normal range for his age. The concentration
- d/ W- a8 T0 I9 t3 d' Iof serum 17-hydroxyprogesterone was 16 ng/dL
Q. l' ~& m( c) C8 y2 T(normal, 3 to 90 ng/dL), androstenedione was 20
' W3 y* `" Q! T7 N& ^8 _ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: N% [9 w3 u3 B2 c2 m* J. w3 v
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
" g9 x: z+ z' Odesoxycorticosterone was 4.3 ng/dL (normal, 7 to0 W, O* H% d z2 q1 L9 ]% ?
49ng/dL), 11-desoxycortisol (specific compound S)' X5 U! r, K4 ?2 g/ i* X
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 j% _" x8 ^: a3 B Ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 H' {- {5 J7 v( a6 b# ?
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ O$ i4 t# P$ @# cand β-human chorionic gonadotropin was less than
1 F' S+ G, Z4 ~& M$ Q- r- R6 q5 mIU/mL (normal <5 mIU/mL). Serum follicular+ ^5 J# v2 k* \% k' D6 O0 |" R _
stimulating hormone and leuteinizing hormone
V1 \9 j3 e! q( x, |concentrations were less than 0.05 mIU/mL' k0 H; @! C$ k3 ^
(prepubertal).
, O% u1 r; Q/ }) P. LThe parents were notified about the laboratory3 R- |/ f2 O' t4 N5 o
results and were informed that all of the tests were" I, f2 M) Q3 _0 v- A
normal except the testosterone level was high. The. ]- l0 ~$ v7 B8 }" F2 T
follow-up visit was arranged within a few weeks to. {4 U- @( S, t; K( T3 A
obtain testicular and abdominal sonograms; how-
3 D5 p5 {, X% C9 zever, the family did not return for 4 months.
3 [' u- t7 k' R- P% CPhysical examination at this time revealed that the
" s- |; Z/ P, t2 S: j& tchild had grown 2.5 cm in 4 months and had gained
9 h( |: }! Q2 A) ^2 \2 q0 t; q5 T2 kg of weight. Physical examination remained, E! y, ?. [ m, Y6 r
unchanged. Surprisingly, the pubic hair almost com-& U4 _ p6 F) V$ E/ V* L
pletely disappeared except for a few vellous hairs at/ @' ~3 s* g% O8 ?. j8 Z
the base of the phallus. Testicular volume was still 2
+ A; m. I$ N' [2 l M1 \* [mL, and the size of the penis remained unchanged.
, b# P9 n% M% B( b3 s" z- fThe mother also said that the boy was no longer hav-! O7 |8 k/ V) n! k/ a% `9 |
ing frequent erections., p$ @( W) K0 G6 ]. Z
Both parents were again questioned about use of
9 c- h# w* n# ~any ointment/creams that they may have applied to" q- [+ ~5 o' b0 x- n
the child’s skin. This time the father admitted the
, ?" O3 e9 f, G6 ~4 g( cTopical Testosterone Exposure / Bhowmick et al 541
/ d. q* _2 \3 Q. D% ause of testosterone gel twice daily that he was apply-- y: e8 x7 U: b% d1 l E5 e0 o5 m
ing over his own shoulders, chest, and back area for) E+ i5 @, D9 T
a year. The father also revealed he was embarrassed! G- [' N0 d/ K: Q
to disclose that he was using a testosterone gel pre-
- `0 ?3 } f0 y8 i! lscribed by his family physician for decreased libido
0 j' n' s. L) w; y/ E0 W6 f3 jsecondary to depression.
+ L. C( }+ a- @ x( j" k) uThe child slept in the same bed with parents.7 H8 B& j4 L! I( i' j
The father would hug the baby and hold him on his
% D: F* Z% U6 k3 Y! t F+ Ychest for a considerable period of time, causing sig-
% k/ C& y; _0 P: E, N7 A+ qnificant bare skin contact between baby and father.
3 U' {' o7 P7 g; z! f% aThe father also admitted that after the phone call,7 ~0 R* n# b# G! d( A! } z/ s
when he learned the testosterone level in the baby! O8 R4 l6 f: w
was high, he then read the product information% h' B5 M3 S3 [* \+ g; a# i; |
packet and concluded that it was most likely the rea-" G" O8 x2 y9 ]# Q
son for the child’s virilization. At that time, they/ C; P. o9 e+ p
decided to put the baby in a separate bed, and the
8 T) G2 p3 a% u1 W/ nfather was not hugging him with bare skin and had
9 s& B$ ?4 t5 B3 @: Mbeen using protective clothing. A repeat testosterone
: t% Y6 _5 L6 H7 w4 etest was ordered, but the family did not go to the
- r) V# x% T. K8 j% V$ Blaboratory to obtain the test.
3 Y4 u& N2 }5 a) TDiscussion& j( @# C% _! B- S) n
Precocious puberty in boys is defined as secondary
0 u: ^: W i) ^5 f6 m2 A$ j1 Usexual development before 9 years of age.1,4
6 w" K8 J O8 j9 v) e$ rPrecocious puberty is termed as central (true) when0 Q, H1 X, q- {: K7 Y& P; g
it is caused by the premature activation of hypo-
/ q; }6 d5 P3 u; k. Wthalamic pituitary gonadal axis. CPP is more com-
2 K% \9 W9 d; B& \$ Dmon in girls than in boys.1,3 Most boys with CPP0 i/ O: u- y: z9 e- w) I
may have a central nervous system lesion that is! C* N9 v: L: c) {+ s( r
responsible for the early activation of the hypothal-( a: E+ O7 @. i/ r
amic pituitary gonadal axis.1-3 Thus, greater empha-& p; |! z7 ~1 a [( {
sis has been given to neuroradiologic imaging in
+ S2 C/ i" A% mboys with precocious puberty. In addition to viril-
/ e& w; Q$ n$ h" C. K; Bization, the clinical hallmark of CPP is the symmet-) A" Q, W+ [3 `% t# @; E2 D6 l
rical testicular growth secondary to stimulation by
9 F" l# t) M; r. r: j3 dgonadotropins.1,3
8 ~! x- A; m8 ?( A+ F2 y( w3 L. @2 a0 SGonadotropin-independent peripheral preco-! ~3 r5 ^) X* R8 L. \- p
cious puberty in boys also results from inappropriate
8 p8 v& `/ R9 D( N$ B% b1 B Landrogenic stimulation from either endogenous or
! B; I* N# O2 o5 s4 fexogenous sources, nonpituitary gonadotropin stim-7 U6 J$ Y+ I# J# _& c
ulation, and rare activating mutations.3 Virilizing
3 f5 j/ W: ]; y% o/ t1 ~congenital adrenal hyperplasia producing excessive
$ e; ]3 {0 @$ dadrenal androgens is a common cause of precocious- _' p0 m0 S1 T+ W# v8 J
puberty in boys.3,4
$ k% W9 b4 r% {: O: p' C" eThe most common form of congenital adrenal
5 \& S+ z" i5 n9 M$ @4 a2 ]hyperplasia is the 21-hydroxylase enzyme deficiency.. z2 I' F# t% ^8 e% |0 ~; ^9 _
The 11-β hydroxylase deficiency may also result in# F5 N3 Z* \) j# e
excessive adrenal androgen production, and rarely,
# H9 W4 F C" x0 jan adrenal tumor may also cause adrenal androgen) E B4 _$ e) P4 s; ?) K3 i( e4 z
excess.1,3
8 }, K) B; o4 Q- b3 z/ t: \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& K4 X3 \8 m" U1 Q542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ s! |! Q: |" j! j) R8 GA unique entity of male-limited gonadotropin-
# ^6 J0 |' S# l3 L4 aindependent precocious puberty, which is also known
3 U( ~/ S( n' S/ \5 xas testotoxicosis, may cause precocious puberty at a' A( J# K, e4 h
very young age. The physical findings in these boys5 P M; ?0 g; B/ b0 M5 }3 h7 c3 R- c
with this disorder are full pubertal development,
' C$ z1 C: d, vincluding bilateral testicular growth, similar to boys
- M1 _; }# M" Q+ q" E+ vwith CPP. The gonadotropin levels in this disorder
: T3 a l5 | k- X6 b6 care suppressed to prepubertal levels and do not show" o9 B( t+ W- J9 i0 q4 l) Z' s& z
pubertal response of gonadotropin after gonadotropin-
1 Z1 `* ?3 Q# w* P: \6 Nreleasing hormone stimulation. This is a sex-linked
( i* M: k) O& @5 Iautosomal dominant disorder that affects only9 p: P$ F3 T# \8 f9 D! }
males; therefore, other male members of the family: S6 O' I* \6 T& m* \5 P1 ~8 e
may have similar precocious puberty.3
6 H7 n( W0 D! eIn our patient, physical examination was incon-, C; z4 c; i: v* z @7 R( A0 n
sistent with true precocious puberty since his testi-) q6 N0 \ I+ y6 d5 Q) [4 {4 ~0 L
cles were prepubertal in size. However, testotoxicosis7 y5 q" y) y0 O- `
was in the differential diagnosis because his father
+ s0 R& y7 U$ j/ N3 q5 Kstarted puberty somewhat early, and occasionally,. M9 h1 `/ K% o& \4 A( A
testicular enlargement is not that evident in the
: c# ^- N$ P/ w5 D K4 Fbeginning of this process.1 In the absence of a neg-
. {3 N& \7 u5 b1 y2 T. h! X8 u+ @ative initial history of androgen exposure, our
, E& z3 e" e# R* [$ j5 ~2 n- ~biggest concern was virilizing adrenal hyperplasia,
$ j: I, R5 X. z& s# I$ ]+ i$ leither 21-hydroxylase deficiency or 11-β hydroxylase
7 L# z- \: |) {8 S5 ]deficiency. Those diagnoses were excluded by find-$ A: n+ K7 v* A, k8 U
ing the normal level of adrenal steroids.
& y6 @5 V' F2 t- EThe diagnosis of exogenous androgens was strongly$ l# b6 Q+ K/ Z; T+ o' Q
suspected in a follow-up visit after 4 months because' g& D/ H$ b3 s+ f
the physical examination revealed the complete disap-
/ y) d# ]1 J. }; ^pearance of pubic hair, normal growth velocity, and
, N; ^$ W% w/ S: J3 Z: _5 sdecreased erections. The father admitted using a testos-
& O P6 O5 c& d, Q* yterone gel, which he concealed at first visit. He was7 F5 `3 R% h4 e$ i
using it rather frequently, twice a day. The Physicians’) [$ w Q- U0 i7 V: p
Desk Reference, or package insert of this product, gel or& n- u( c% L! i) q- l/ Z' j
cream, cautions about dermal testosterone transfer to
. B, ^1 x6 W1 t, f, Hunprotected females through direct skin exposure.: f5 {1 i Q$ u
Serum testosterone level was found to be 2 times the
# P1 J! m- m+ W. k; q9 y: Ybaseline value in those females who were exposed to
l* _6 ?! j4 C. s" l* f5 Heven 15 minutes of direct skin contact with their male
0 [1 L0 }8 K" Z; B5 c1 Qpartners.6 However, when a shirt covered the applica-+ }7 q) ?" t! r6 z. Y' q. r# h
tion site, this testosterone transfer was prevented.
9 `* ]8 d6 s! F$ jOur patient’s testosterone level was 60 ng/mL,5 Y$ V8 g+ b, q4 b. ]" ~/ ~4 ]
which was clearly high. Some studies suggest that, G' @" ]6 }& A! f! L. ]
dermal conversion of testosterone to dihydrotestos-
+ c$ e' X$ m7 [; K) Q: t& Dterone, which is a more potent metabolite, is more
8 ?, W4 u3 ?7 S6 m ^active in young children exposed to testosterone
( j9 u& ]: U. q7 b+ F% ?exogenously7; however, we did not measure a dihy-" H% I ^( r$ b# `0 @% F6 q
drotestosterone level in our patient. In addition to
9 Z0 V2 Y% d' W9 P |- ovirilization, exposure to exogenous testosterone in
. x; w6 a% P: v! `- G Hchildren results in an increase in growth velocity and
( D. H# z: z# u. Oadvanced bone age, as seen in our patient.
/ g0 w7 f5 R% H" [2 hThe long-term effect of androgen exposure during
5 H2 S5 P J, O" y# [$ i# searly childhood on pubertal development and final% ^6 {/ @) X. r5 `# v+ w& L
adult height are not fully known and always remain6 o1 ?0 d9 M/ ?) x
a concern. Children treated with short-term testos-
8 ?+ ]1 z$ M l( P. p' }3 uterone injection or topical androgen may exhibit some
$ u) r- ]' o, H6 U; r1 p* ]6 bacceleration of the skeletal maturation; however, after& U2 C; D" P3 G& ~
cessation of treatment, the rate of bone maturation8 u& x" g; e D+ E( l0 f
decelerates and gradually returns to normal.8,9: s0 c! F# Z# W& M, D
There are conflicting reports and controversy
; F" \5 N6 h0 Z# o( n. L! Cover the effect of early androgen exposure on adult& o0 Q; W+ u H. V
penile length.10,11 Some reports suggest subnormal
+ A) W# A& B7 m: iadult penile length, apparently because of downreg-7 Q. N) V5 B, v5 w
ulation of androgen receptor number.10,12 However,
1 }3 c1 y2 r2 E$ ~6 pSutherland et al13 did not find a correlation between
: s8 ~. F' ?# o; b3 c+ t1 ?childhood testosterone exposure and reduced adult
' H' g+ ~; X. @# ^! |1 P9 [penile length in clinical studies.
- s) u4 w3 q$ A: [( p1 b# aNonetheless, we do not believe our patient is
3 y' T; ?& M6 t& M# Xgoing to experience any of the untoward effects from' T+ L0 X4 |) H* t1 l
testosterone exposure as mentioned earlier because3 S9 i) o" L( L( B2 V/ j# p) S
the exposure was not for a prolonged period of time.
2 T, X8 w4 D& ~% C0 WAlthough the bone age was advanced at the time of8 {8 F" F5 ]+ e; V6 c
diagnosis, the child had a normal growth velocity at
4 Y7 F2 a/ q. x- w8 R" M8 gthe follow-up visit. It is hoped that his final adult
2 Y3 t, d& A; c# Xheight will not be affected. M; h+ a' q/ E: [+ J( F
Although rarely reported, the widespread avail-
E3 b% ^7 S8 N% Dability of androgen products in our society may$ F: }: S4 O: k
indeed cause more virilization in male or female
( x. f9 E0 B" \6 r, b( f) s0 C- e# tchildren than one would realize. Exposure to andro-9 J; p. ?2 E3 ]
gen products must be considered and specific ques-
8 U* d" {! v# j* |" T/ Rtioning about the use of a testosterone product or
2 g3 d" z5 V$ R9 R1 L* r' Vgel should be asked of the family members during
5 O4 b. ]. Q. G9 N0 e& ithe evaluation of any children who present with vir-( s! t# Y; Q d" y
ilization or peripheral precocious puberty. The diag-& ]4 U5 d) L" Y4 t
nosis can be established by just a few tests and by. y- d# o( H- L/ B
appropriate history. The inability to obtain such a8 s1 g5 ?: s5 {2 o2 I% T6 P
history, or failure to ask the specific questions, may
7 ~2 c$ t. e* L, Gresult in extensive, unnecessary, and expensive
% S, T) T2 X8 Oinvestigation. The primary care physician should be
/ z% a! a4 W( ]1 h4 F- m* }' w# p" Kaware of this fact, because most of these children& S/ F# Y9 J1 y; `
may initially present in their practice. The Physicians’
, W9 D& `6 R7 x! k/ \6 EDesk Reference and package insert should also put a. `1 v- f. Y6 Y9 h
warning about the virilizing effect on a male or: Q0 F' K8 Z! s9 V# p' K
female child who might come in contact with some-
8 B9 t5 m* _3 i9 D2 ^( H' d: uone using any of these products.4 A t3 ^7 O* ~0 f* z \8 |6 g
References- v% s. h* b, M7 q; b7 c9 [
1. Styne DM. The testes: disorder of sexual differentiation9 T2 ~2 y3 u: A/ x! A, C; `4 A0 Q# H n
and puberty in the male. In: Sperling MA, ed. Pediatric
8 F1 C1 K7 m# P6 U3 u% j; wEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( \" T! W1 N: R* W2 z) ^ X2 l
2002: 565-628.
$ ^) M3 e2 E9 ^' V2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious+ u) D0 V, M9 n, e6 \; X7 d
puberty in children with tumours of the suprasellar pineal |
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