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Sexual Precocity in a 16-Month-Old1 d+ H6 c ?5 `/ }# t3 u3 b+ v
Boy Induced by Indirect Topical Z5 B, C: {) r3 }8 \
Exposure to Testosterone. O2 Z5 O% e/ Y- f
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* s* g. z5 H& y) Q0 r
and Kenneth R. Rettig, MD17 V. I( G3 ]7 r( P: T8 e
Clinical Pediatrics- S1 H* H; F2 D( v( @1 B
Volume 46 Number 6$ E/ ^4 Z4 q/ E" Q5 S! y
July 2007 540-543
: T# H( g* Z4 E" e+ T$ r+ c© 2007 Sage Publications
# M$ F9 W/ l" ^10.1177/0009922806296651( H3 P0 G" K1 W* q+ u
http://clp.sagepub.com
' E4 o k: N* `1 C( F0 Zhosted at9 J1 C3 V' q6 S0 k' }" \5 i
http://online.sagepub.com
# V! ~; u% z- c% q' mPrecocious puberty in boys, central or peripheral,
- n M, o( X( W3 e7 N6 u5 yis a significant concern for physicians. Central; K, p' v) @; K# f$ y' c. G1 k4 ]+ E
precocious puberty (CPP), which is mediated
/ J) G" ^) r/ b( }$ }through the hypothalamic pituitary gonadal axis, has
1 R1 v) J8 t z# va higher incidence of organic central nervous system0 c* I( ~1 s* g8 a7 O* `
lesions in boys.1,2 Virilization in boys, as manifested
9 }! |7 P9 z- U8 i$ Hby enlargement of the penis, development of pubic( o9 a: z* l" B8 L$ N, V2 `2 Y
hair, and facial acne without enlargement of testi-$ B- I; Z$ g7 D0 H7 Y
cles, suggests peripheral or pseudopuberty.1-3 We0 I" V6 h0 B) t2 W' U% x
report a 16-month-old boy who presented with the. M$ Y I- M D- H Y- t
enlargement of the phallus and pubic hair develop-% @8 t. H. x2 t5 ^0 \, O; |/ t
ment without testicular enlargement, which was due( q ^9 ~& l1 v! \; `9 t: l
to the unintentional exposure to androgen gel used by6 a! J5 e2 ?; m, R2 M
the father. The family initially concealed this infor-. i4 ? C* z" o! k8 s& P' |, X! |
mation, resulting in an extensive work-up for this
7 {' o4 c$ M0 Q) E, zchild. Given the widespread and easy availability of
' b4 M9 O6 U- f: w) ]0 Wtestosterone gel and cream, we believe this is proba-1 ]+ m- n b! N: u
bly more common than the rare case report in the
" Q8 R. V& B c: b) pliterature.4
6 \+ o: C( Q9 B& APatient Report0 R- A' r# s- M" C( }6 W
A 16-month-old white child was referred to the2 H# l7 A8 j1 c, i# u( P+ B
endocrine clinic by his pediatrician with the concern/ O3 t6 m) ~5 ~- ]: o' {* b# o
of early sexual development. His mother noticed
, _$ A h' V2 H* C7 n7 ilight colored pubic hair development when he was
5 ~$ U; v2 Z" f" R7 W4 [, w' vFrom the 1Division of Pediatric Endocrinology, 2University of2 e, |4 k- n& T7 u8 H
South Alabama Medical Center, Mobile, Alabama.
7 u A& {0 N" }! z* CAddress correspondence to: Samar K. Bhowmick, MD, FACE,
! \% f4 I2 B1 W% Z" C6 ^Professor of Pediatrics, University of South Alabama, College of
. Y) e6 {; s9 M$ i1 a: eMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) m% x1 S# O$ L+ W& v: [
e-mail: [email protected].! C$ D+ |7 V' P
about 6 to 7 months old, which progressively became/ N% l7 d1 `; l* [. }' m D
darker. She was also concerned about the enlarge-8 s# n! S) z6 U r3 r1 m; n% l
ment of his penis and frequent erections. The child3 f5 z) v. S2 a4 {, i; \# m, V
was the product of a full-term normal delivery, with$ w" N+ n5 ~1 o. y
a birth weight of 7 lb 14 oz, and birth length of
# U* K; I1 ^! y20 inches. He was breast-fed throughout the first year6 N _' H! Y o; E) y' ^; x+ f6 W
of life and was still receiving breast milk along with
4 k. K/ d6 H5 F7 d0 {' usolid food. He had no hospitalizations or surgery,* w$ i" s# _/ R8 T4 R
and his psychosocial and psychomotor development+ o' _- M( W; V# z% ~
was age appropriate.
# C6 u+ ~/ l. l# }, T# mThe family history was remarkable for the father,
' K; [4 u: M$ E& Qwho was diagnosed with hypothyroidism at age 16,) |% \3 }# [1 Y
which was treated with thyroxine. The father’s
& S7 K" U5 _ Z2 @3 Kheight was 6 feet, and he went through a somewhat( C% y6 I- s1 q" f8 m
early puberty and had stopped growing by age 14., H$ \1 ^4 [ Z0 ?) C
The father denied taking any other medication. The
4 Q& a. I; X4 F% n6 A, E+ N7 schild’s mother was in good health. Her menarche: y8 ?( b3 B+ W; i" L
was at 11 years of age, and her height was at 5 feet
9 [$ ]) x+ {% _) H' R! [. K5 inches. There was no other family history of pre-
! _* F! O- B9 h7 ncocious sexual development in the first-degree rela-
9 ?" W% c' x! O0 ]# f5 z9 C) N2 htives. There were no siblings.3 r1 m; S5 Q3 E' Q- u; h4 G1 f
Physical Examination
/ W4 o4 e& j7 G! _' LThe physical examination revealed a very active,) o; T' ]2 V* i
playful, and healthy boy. The vital signs documented$ ]6 r3 G. ?7 k
a blood pressure of 85/50 mm Hg, his length was
0 s' ?+ |. C3 {2 ` G90 cm (>97th percentile), and his weight was 14.4 kg
9 P+ N6 @% y. G7 O/ `(also >97th percentile). The observed yearly growth
p- e; v3 _) rvelocity was 30 cm (12 inches). The examination of
: P6 m! j1 j5 z: ^the neck revealed no thyroid enlargement.- L& i' u' [$ ~
The genitourinary examination was remarkable for3 @3 i3 ~% |6 I+ N( a* S
enlargement of the penis, with a stretched length of2 M& x$ k; i. w/ @6 f( a k
8 cm and a width of 2 cm. The glans penis was very well/ Q9 W! Q0 J; A# i8 A
developed. The pubic hair was Tanner II, mostly around
4 F$ P. ?8 G0 I" m) {. S540
* w {6 Y) C) F7 ]at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% P+ C% m; h. w/ j" T3 qthe base of the phallus and was dark and curled. The
7 c- R2 v; z/ ^8 g0 R- V0 i+ j7 Rtesticular volume was prepubertal at 2 mL each.
, o1 ^, K5 q% D3 U# n& N+ v" r+ v" `The skin was moist and smooth and somewhat$ b8 z9 }9 s; F7 T4 d4 J
oily. No axillary hair was noted. There were no
8 s* f1 q0 D- ?abnormal skin pigmentations or café-au-lait spots.
" S9 }% w/ M9 ~: N) \- x$ iNeurologic evaluation showed deep tendon reflex 2+% }" k+ v; k- o
bilateral and symmetrical. There was no suggestion# L* F, c: O6 p, u% D5 q
of papilledema.
7 Z# h! y2 k' p& U% R! g- f. nLaboratory Evaluation4 W2 v) S6 N' y; ~9 S& d- t# _; H" c
The bone age was consistent with 28 months by; E9 V' T/ t' i+ d6 `! B, ^
using the standard of Greulich and Pyle at a chrono-
) a, M' V; s, ?: v5 Y: A0 }logic age of 16 months (advanced).5 Chromosomal, |% c2 G9 h5 V( Q
karyotype was 46XY. The thyroid function test; h( [4 F5 c' J$ C. I
showed a free T4 of 1.69 ng/dL, and thyroid stimu- [( P6 ? Z7 I
lating hormone level was 1.3 µIU/mL (both normal).
* o3 e8 @5 X+ B5 G& x, l9 ^7 b3 `The concentrations of serum electrolytes, blood4 d2 |; N7 A. _5 i! m3 ]+ a. `
urea nitrogen, creatinine, and calcium all were, j" |+ A' S: r7 B
within normal range for his age. The concentration
4 c( f! ^: k6 t0 ?2 B3 J; vof serum 17-hydroxyprogesterone was 16 ng/dL
& A* L9 d# e% b! n2 P5 ~(normal, 3 to 90 ng/dL), androstenedione was 20
0 x1 G& `/ u) `2 a0 _3 w! \ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
' O( A* ?) J4 ?7 g# D6 Wterone was 38 ng/dL (normal, 50 to 760 ng/dL),; ^4 H+ L$ Y g2 e
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
% U9 K4 ?# I. R; K+ d49ng/dL), 11-desoxycortisol (specific compound S)
. x* i+ m+ t3 R4 ^1 |* H3 N1 jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. I0 [6 O6 s+ `- r$ K/ O: J
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# {; h, D: K6 [7 n; I
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ B( l# R+ y9 ?6 D R% k) @
and β-human chorionic gonadotropin was less than4 t. x9 W2 c/ F8 R4 \/ Z9 x
5 mIU/mL (normal <5 mIU/mL). Serum follicular( L& Z' [4 t1 u% l# c7 K
stimulating hormone and leuteinizing hormone6 M5 d2 t8 k4 h' {
concentrations were less than 0.05 mIU/mL# _. x S: `, [: ]$ B) T
(prepubertal).' ?4 ^8 v# a* @
The parents were notified about the laboratory, g+ P& ~. Y) h' J% M
results and were informed that all of the tests were5 p2 T5 y# r9 P5 U% c) R
normal except the testosterone level was high. The
1 m0 } F/ n( G R9 ?1 f# ^9 c9 }follow-up visit was arranged within a few weeks to- @$ J, U3 G- X+ ~( I# q
obtain testicular and abdominal sonograms; how-3 ~; z; M7 v5 I. V0 z
ever, the family did not return for 4 months./ `# s( Y- V& q( |) l) j9 n- _8 c
Physical examination at this time revealed that the q7 X! N1 r- Q+ X# i
child had grown 2.5 cm in 4 months and had gained$ ~, p& C. S' u7 B, [6 O
2 kg of weight. Physical examination remained( A# z( m( S5 x$ |# v
unchanged. Surprisingly, the pubic hair almost com-
) X! e1 Y. m1 G, n& r& g$ @0 Rpletely disappeared except for a few vellous hairs at, X; e F. l% a$ Q4 r
the base of the phallus. Testicular volume was still 23 R' `5 D E+ L5 N6 m3 \
mL, and the size of the penis remained unchanged.7 m3 e5 J) [: {( L
The mother also said that the boy was no longer hav-% ^, b0 Q6 W. l* h
ing frequent erections.4 c6 b- D0 v9 K* f+ n
Both parents were again questioned about use of2 W4 ]' H1 ?5 P" K% X, y
any ointment/creams that they may have applied to! T+ \# e7 x4 i. m. o
the child’s skin. This time the father admitted the
8 l e3 d( T" \2 ^Topical Testosterone Exposure / Bhowmick et al 541 H+ R9 G7 F" P1 S2 h
use of testosterone gel twice daily that he was apply-
) `* B/ q) V! f7 y( u8 I! Ging over his own shoulders, chest, and back area for. D" \# ?9 z3 L/ J7 g
a year. The father also revealed he was embarrassed
* L2 i( E* L4 ^- j3 C- vto disclose that he was using a testosterone gel pre-
$ z7 v: |( W; S+ X+ Escribed by his family physician for decreased libido
; a" t5 R* c( ?secondary to depression.* f l9 [& w# }. `+ r; K
The child slept in the same bed with parents.9 I1 w/ f- ]3 q0 `
The father would hug the baby and hold him on his, k; b3 r# Y4 m
chest for a considerable period of time, causing sig-% T6 h' l6 `2 I+ }; p ]
nificant bare skin contact between baby and father.* f. U S" r/ m2 ^" Q0 I, H+ l
The father also admitted that after the phone call,$ L4 L7 _3 z- ]# ^( K/ Y, M Q
when he learned the testosterone level in the baby
, J7 H7 t! o% V/ E, swas high, he then read the product information& a: ~! ] e% [
packet and concluded that it was most likely the rea-7 C/ k6 h: j+ J! n0 I; ~+ v0 m
son for the child’s virilization. At that time, they, S8 {7 j1 m" \8 l1 ?7 H, F
decided to put the baby in a separate bed, and the
2 ~1 l1 \1 l; v- Q6 wfather was not hugging him with bare skin and had
. \( f( O; W9 m" B0 ^7 Zbeen using protective clothing. A repeat testosterone
% V4 o/ }& |* c3 U' ttest was ordered, but the family did not go to the
% U9 D7 ?* s0 h. Z3 llaboratory to obtain the test.) v9 V6 D0 d, |% e# ~
Discussion" o2 X# Q" v! k1 x2 q
Precocious puberty in boys is defined as secondary3 a4 {; h) @) Q) x0 H# o
sexual development before 9 years of age.1,4; m; ? ]- y0 E1 _' c/ y
Precocious puberty is termed as central (true) when
' z+ L8 b% E2 \! i, ^! Qit is caused by the premature activation of hypo-# w. q D# d( Y: s; {
thalamic pituitary gonadal axis. CPP is more com-2 d. L! t1 i) g! p( j( Z C1 {, s
mon in girls than in boys.1,3 Most boys with CPP" o/ Z5 @2 \* j
may have a central nervous system lesion that is
8 ]% R0 @- m6 d0 [- E3 Q$ Lresponsible for the early activation of the hypothal-4 O/ d: i: P. ], I
amic pituitary gonadal axis.1-3 Thus, greater empha-
# C0 A! i' C" i. x: csis has been given to neuroradiologic imaging in. [ r# p! C% b8 p
boys with precocious puberty. In addition to viril-6 L4 l, k! d0 x" t
ization, the clinical hallmark of CPP is the symmet-; I. v, C+ N7 L1 ?( T8 ?% e
rical testicular growth secondary to stimulation by8 T3 p* ^' G8 z6 t. T6 A
gonadotropins.1,3
# i+ [3 z1 u3 ]Gonadotropin-independent peripheral preco-
0 C6 h; u; j5 M- H8 r' V9 a1 @( Hcious puberty in boys also results from inappropriate3 l5 M5 K& b5 s& l G* Y- Q+ H
androgenic stimulation from either endogenous or
8 R: u$ v+ J, Yexogenous sources, nonpituitary gonadotropin stim-9 d! n9 b* [, r3 c
ulation, and rare activating mutations.3 Virilizing1 l* T/ A# y* m& Y2 o# c1 r
congenital adrenal hyperplasia producing excessive$ d/ Z0 N& B( ]1 J0 W. b* U3 D
adrenal androgens is a common cause of precocious
3 N- D& P* O' K' H7 ~$ Ppuberty in boys.3,4; m: M: o4 h0 x0 a2 V) H
The most common form of congenital adrenal% |) T" X% Z+ H# O d
hyperplasia is the 21-hydroxylase enzyme deficiency.. Z, P; Z7 E; k) l' r
The 11-β hydroxylase deficiency may also result in
2 A; L2 g: q$ }& x" {excessive adrenal androgen production, and rarely,; X* O- ]5 T% o( q8 T2 v/ r" H0 V
an adrenal tumor may also cause adrenal androgen6 O" O3 |% c! g* J# r" g+ [
excess.1,3
4 a! }6 Y) L1 B6 C8 O5 w+ Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 M& P9 m0 h+ t: c7 N( M
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007 P7 [8 a6 u% y
A unique entity of male-limited gonadotropin-
$ S! A) i+ c6 f2 a- Pindependent precocious puberty, which is also known9 M' s0 ~9 T" B
as testotoxicosis, may cause precocious puberty at a% `; Q7 e \* X* I8 l1 R
very young age. The physical findings in these boys
' H$ q0 K( f2 D( _with this disorder are full pubertal development,5 \# N- I2 L9 N" c) q
including bilateral testicular growth, similar to boys
( G: {" }8 i9 E6 O$ q" C! W4 Ewith CPP. The gonadotropin levels in this disorder0 b& K& |: }- I( W9 B
are suppressed to prepubertal levels and do not show
( u# A+ o e. R) \/ Fpubertal response of gonadotropin after gonadotropin-
! F: h) A+ Z" Q0 {+ a5 Y' c, greleasing hormone stimulation. This is a sex-linked/ {5 p% ~. R% f& s0 I8 q! u
autosomal dominant disorder that affects only# Z) N6 l- }* Q7 T% F
males; therefore, other male members of the family" j4 `8 }; x% K( M# \4 C
may have similar precocious puberty.35 D5 v7 ` h; Q( ?
In our patient, physical examination was incon-8 ]& ?7 C% ^# n! h# [
sistent with true precocious puberty since his testi-2 a' d# N, ?: c* P+ u& a
cles were prepubertal in size. However, testotoxicosis6 a- x5 d2 F6 h6 d, Y0 u
was in the differential diagnosis because his father
6 f5 F s7 R E) {4 ^started puberty somewhat early, and occasionally,% E! K9 A# R2 l: S$ E
testicular enlargement is not that evident in the8 `4 z( z4 m$ L' P R1 F
beginning of this process.1 In the absence of a neg-
4 E4 |; f1 X/ N6 N/ S# @7 |ative initial history of androgen exposure, our
/ P2 f8 L% v( f' E+ t- tbiggest concern was virilizing adrenal hyperplasia,. p. n1 `& w. Q0 X# B1 j+ w
either 21-hydroxylase deficiency or 11-β hydroxylase
7 O- P* |) F0 Z: ?% P6 u' xdeficiency. Those diagnoses were excluded by find-
6 x' d5 n, U ] S! l0 p! y# ying the normal level of adrenal steroids.
- q9 D5 `; q9 G) f5 _5 R7 ~The diagnosis of exogenous androgens was strongly+ V4 Y( ^0 w+ p" b
suspected in a follow-up visit after 4 months because1 f$ O- A9 n ]. j' J5 m( D
the physical examination revealed the complete disap-4 |( M5 _- g- Y1 N
pearance of pubic hair, normal growth velocity, and8 U8 Y% C& l7 _- f! R; n
decreased erections. The father admitted using a testos-) ^$ i4 s A& G O0 {- y/ T: t
terone gel, which he concealed at first visit. He was
; {9 G" N& j3 R( Y4 F% I8 Z4 }using it rather frequently, twice a day. The Physicians’
& g0 C) T8 c* n6 [8 P: G0 gDesk Reference, or package insert of this product, gel or1 z; z6 Z( D+ n* `$ g: U7 F4 o" U
cream, cautions about dermal testosterone transfer to
; v* X5 \ g$ zunprotected females through direct skin exposure.0 Z4 e* G7 \ P4 a3 B7 J3 |" ~
Serum testosterone level was found to be 2 times the( Z- S9 b1 }) u
baseline value in those females who were exposed to
, t# t Z5 B) x2 ~/ _9 `7 q0 J- yeven 15 minutes of direct skin contact with their male4 Q5 T' w1 G& \6 J. }" ]; }
partners.6 However, when a shirt covered the applica-
s$ D9 m" b. z. g) `0 ^7 ption site, this testosterone transfer was prevented.- z6 r( ?" b2 H- r% ~! ^8 Y0 V
Our patient’s testosterone level was 60 ng/mL,
6 x8 X8 u5 ~5 s3 V8 E7 ]which was clearly high. Some studies suggest that! R& j$ @* t2 q- ]
dermal conversion of testosterone to dihydrotestos-
+ @& G- d6 B3 N: Uterone, which is a more potent metabolite, is more# j0 M4 _$ |/ M4 z' L, ?
active in young children exposed to testosterone
$ r7 ^- U0 ~- z! B( E* H7 K, G" xexogenously7; however, we did not measure a dihy-
0 x8 e! g3 Q; \9 s5 ~" p; z! y& A4 Rdrotestosterone level in our patient. In addition to( q8 T& k1 i( \
virilization, exposure to exogenous testosterone in1 ^" K# @) D0 w2 `3 O
children results in an increase in growth velocity and( a: j1 z5 S( o' S2 q
advanced bone age, as seen in our patient.# G- m$ p5 H# ~% S y$ v% _
The long-term effect of androgen exposure during+ S% I# M0 h7 W4 V3 a
early childhood on pubertal development and final9 O `* I5 ?( q
adult height are not fully known and always remain
, J% K! I6 q; s# R' f- P9 o) ?a concern. Children treated with short-term testos-
* h$ e5 w- m. E( y/ n" \4 ^3 x4 [% tterone injection or topical androgen may exhibit some
3 J8 Q7 i. f& P. l4 @) racceleration of the skeletal maturation; however, after( a9 r" S9 a# }$ N
cessation of treatment, the rate of bone maturation
! p( k* c* _6 j5 g% ddecelerates and gradually returns to normal.8,9
: A3 s6 K( v: x4 g; t6 g2 @2 hThere are conflicting reports and controversy
6 S5 J0 F& Z# K2 dover the effect of early androgen exposure on adult: K$ _' { F' J# N
penile length.10,11 Some reports suggest subnormal
5 ~, \+ }+ t2 O4 A) @% j7 uadult penile length, apparently because of downreg-
% }, @ x: N1 b- rulation of androgen receptor number.10,12 However,
* `# O, ^" `$ U9 ]1 N& |' @( P- D7 B$ bSutherland et al13 did not find a correlation between
5 I. e: `' b1 j& xchildhood testosterone exposure and reduced adult
' S( A+ l7 z" q$ y# dpenile length in clinical studies.
9 h! Q% L8 k$ r( r3 Q/ m+ e$ b! bNonetheless, we do not believe our patient is9 ^% x. P+ Q+ p2 s3 r1 n/ r
going to experience any of the untoward effects from
; x# C4 V% f' n$ I+ N3 ztestosterone exposure as mentioned earlier because
( `8 f) n' ]' [) s$ A$ othe exposure was not for a prolonged period of time.
/ E2 G7 |+ R/ O* rAlthough the bone age was advanced at the time of
) G- _ O1 I5 }0 j- |' Ndiagnosis, the child had a normal growth velocity at, D: s1 e6 v8 q H5 P* U9 K4 b
the follow-up visit. It is hoped that his final adult5 J3 s6 G2 {& P
height will not be affected.: Q- t- G! H3 C) j0 \! }
Although rarely reported, the widespread avail-; ]& Y0 } T" n: q5 K. J
ability of androgen products in our society may
) k, V0 K$ S( }. [; F1 ^indeed cause more virilization in male or female" G2 c% P5 L" g5 h) O! `- X; ~5 R
children than one would realize. Exposure to andro-( r8 W# r u3 B
gen products must be considered and specific ques-; `6 D' L4 N2 ]1 g( Z' M
tioning about the use of a testosterone product or
9 u/ j6 d' _5 U" C6 v5 M, H8 N6 ^gel should be asked of the family members during( ?4 [1 H- z, l: R+ ~; j
the evaluation of any children who present with vir-) \2 j$ H `1 [: F0 o9 _% Q9 b3 _' J
ilization or peripheral precocious puberty. The diag-- t- Y, F' j/ ^" [
nosis can be established by just a few tests and by+ i+ Z$ k2 A' I+ t; g
appropriate history. The inability to obtain such a7 A0 W. M" y Z$ w: Y$ ~
history, or failure to ask the specific questions, may
8 {; i% `) p- G0 Z$ n, ?1 vresult in extensive, unnecessary, and expensive, ?6 H% m4 d" J3 o y' b& q) [% l8 K
investigation. The primary care physician should be1 v ~! \7 a$ x9 C6 A3 t/ q4 h
aware of this fact, because most of these children
% a" G( V- Q* F! {% ]" dmay initially present in their practice. The Physicians’
& v6 z: A, K! u. G/ `; r4 X! cDesk Reference and package insert should also put a
/ B/ F$ i; i+ \ w/ U% `warning about the virilizing effect on a male or) R( w2 X: j0 Z% O5 b
female child who might come in contact with some-. x( C$ ^! s& H1 Z4 |- d s
one using any of these products.: q* O1 ^' T; e8 e8 F
References
6 j4 p# Y0 U3 v0 t( h3 L1. Styne DM. The testes: disorder of sexual differentiation5 l7 J9 c, r9 Z$ Y3 G: _. Z. ]+ X
and puberty in the male. In: Sperling MA, ed. Pediatric
. Z% d, o+ @: ]" _$ bEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. i5 H6 Q- r# N+ d2002: 565-628.) d. M9 S% @6 x5 ]! X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 E' b1 q0 r! }0 i7 K
puberty in children with tumours of the suprasellar pineal |
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