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Sexual Precocity in a 16-Month-Old: T% w; H& V9 n5 c6 Q7 j
Boy Induced by Indirect Topical/ g# o: w% \, d
Exposure to Testosterone
9 N: q( l( y O0 [) T: R: ISamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
6 ]( B0 x* ]4 Dand Kenneth R. Rettig, MD15 u$ [ u# J: v" p" f% v
Clinical Pediatrics0 p8 B& `$ E" |- v3 o
Volume 46 Number 6
& }! X6 b% } W- G7 q6 V EJuly 2007 540-543
5 t& A( a7 r: }+ _5 s( W! E© 2007 Sage Publications( I* ]1 A0 X" ]
10.1177/0009922806296651
1 l j$ Q7 z! A% S% Mhttp://clp.sagepub.com1 L% ]* s8 u: R& W2 I2 T" P
hosted at
8 x. V, [, w: p# r! r" v0 ohttp://online.sagepub.com: g3 E! S# a- i( n
Precocious puberty in boys, central or peripheral,
3 V8 {& F7 Y0 I; A, o& Ois a significant concern for physicians. Central4 s, |/ U+ G: B+ o. O" A, d
precocious puberty (CPP), which is mediated w) Q- u2 R9 \' m9 t* C
through the hypothalamic pituitary gonadal axis, has
+ W2 v2 Y7 C* e- M: ]a higher incidence of organic central nervous system% y2 ^' E& t+ g
lesions in boys.1,2 Virilization in boys, as manifested
. f& [& ^" X( _7 S4 z \9 ^by enlargement of the penis, development of pubic% y! \; u3 Q- ` U3 {# m
hair, and facial acne without enlargement of testi-
% @3 L% y' E) `cles, suggests peripheral or pseudopuberty.1-3 We
7 V, a$ Z' K0 k$ `" q& d. Ireport a 16-month-old boy who presented with the: _& E( q- z* L9 N. c G
enlargement of the phallus and pubic hair develop-
2 i* t) G9 d8 i% }ment without testicular enlargement, which was due9 w# _3 ^5 t2 x6 g, ^; B
to the unintentional exposure to androgen gel used by8 O/ y0 }. O( G! v* [: t
the father. The family initially concealed this infor-/ @4 }5 [) P8 v3 y7 D5 e9 B- J( i
mation, resulting in an extensive work-up for this
/ Y6 Y# |3 F' c ]child. Given the widespread and easy availability of
- L( ^; P$ q$ x& v& ztestosterone gel and cream, we believe this is proba-+ J8 @0 Z) h0 N1 }2 M: s' L# p
bly more common than the rare case report in the
# l; Z8 Y: X# Zliterature.4# B+ _; O( e% H- x v
Patient Report
$ k" J& ^' G$ VA 16-month-old white child was referred to the, r2 n( u, m) G2 V. S8 `4 n( U' |3 v
endocrine clinic by his pediatrician with the concern
3 w, d, A" ?, \! H. d+ Z1 Hof early sexual development. His mother noticed* E' z% w9 n8 z c. S9 l! ]
light colored pubic hair development when he was* K+ j- n, r+ j, h3 l
From the 1Division of Pediatric Endocrinology, 2University of8 V- o3 m/ ^3 E/ e5 |
South Alabama Medical Center, Mobile, Alabama.: Y+ o* O1 c2 W @- |* G7 z( q
Address correspondence to: Samar K. Bhowmick, MD, FACE,
* n( @- V% C' {) n! P& p0 F& OProfessor of Pediatrics, University of South Alabama, College of
' ^) @( M& C! |% }Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" ~) e, A; m% T8 ie-mail: [email protected].% l" n1 e, t8 R+ y: X
about 6 to 7 months old, which progressively became- K# I- @5 K- k/ ~& S2 k0 ^
darker. She was also concerned about the enlarge-
1 n% I9 _5 k' |6 C) Z6 v2 kment of his penis and frequent erections. The child; Q( |; l* j9 z; B
was the product of a full-term normal delivery, with- d$ m, o K) F: f' B
a birth weight of 7 lb 14 oz, and birth length of/ s+ ~% L6 v& c8 ^9 x4 T% L
20 inches. He was breast-fed throughout the first year
; f) [& {) q3 ~+ x6 Mof life and was still receiving breast milk along with
0 ]: x) U' I1 s: J: ]% Nsolid food. He had no hospitalizations or surgery,
. Z' c# w( G1 f Q: G' band his psychosocial and psychomotor development
; a9 ~" E M! s! S/ I: ]/ jwas age appropriate." k5 W5 A/ q: l, ]( _( ?
The family history was remarkable for the father,
1 f' V. n4 f* Z! C) T) @, uwho was diagnosed with hypothyroidism at age 16,
" E4 W: M- W8 [: w ywhich was treated with thyroxine. The father’s
u& j5 ~5 m; F) Aheight was 6 feet, and he went through a somewhat
# \! P8 F! I( Iearly puberty and had stopped growing by age 14.* _: V6 H# |9 A. _
The father denied taking any other medication. The1 J! {2 J% y( n. f/ M! E( o$ Y& h3 n+ q
child’s mother was in good health. Her menarche" i0 a" }* U! g/ O; S/ H& t( K) U
was at 11 years of age, and her height was at 5 feet: u ]+ F8 z- M( T4 h
5 inches. There was no other family history of pre-
- a0 Z& _* n0 \" E3 _cocious sexual development in the first-degree rela-
* H; h% V" H' }tives. There were no siblings.
% Z' n ? \- Z0 a' MPhysical Examination: q+ a% _/ y! Y; J5 O! r( V
The physical examination revealed a very active,
! P& R) D5 c# r- B q1 |* eplayful, and healthy boy. The vital signs documented
$ u* f" u+ M/ i' ?# Q8 }$ U0 W: ~1 Ea blood pressure of 85/50 mm Hg, his length was
5 T. x& T) {& P- p$ ` x' `3 Y8 ?90 cm (>97th percentile), and his weight was 14.4 kg
# Q) J7 F5 ?2 N. s(also >97th percentile). The observed yearly growth
2 u+ k% z9 r0 h/ |) g J- Qvelocity was 30 cm (12 inches). The examination of
0 H, G1 v' m# o4 x! t2 Zthe neck revealed no thyroid enlargement. \' x# l* F) k
The genitourinary examination was remarkable for; |+ V" l6 Q& t& E1 ?. m
enlargement of the penis, with a stretched length of/ S2 A& v, Y2 j) X) A, J b
8 cm and a width of 2 cm. The glans penis was very well
9 |4 F4 x; T6 c) G4 ?) A% ]developed. The pubic hair was Tanner II, mostly around
2 t! f$ W5 m' D, b540
2 [2 j) B* R( f* K6 I6 Mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( O3 N( L- H* bthe base of the phallus and was dark and curled. The) V+ I# U2 O* }6 K) \1 P
testicular volume was prepubertal at 2 mL each.
+ ^2 ^" A; }; C: k O: BThe skin was moist and smooth and somewhat5 Z( [0 l2 O6 N# P) `+ C
oily. No axillary hair was noted. There were no! h# V5 X+ u, T/ N4 _: \! F7 n
abnormal skin pigmentations or café-au-lait spots.
6 z8 j* o. ^+ u; z; V) VNeurologic evaluation showed deep tendon reflex 2+
0 t9 F r, V6 C, B9 G# O7 [7 ]bilateral and symmetrical. There was no suggestion
9 w/ t' n, a- }) A0 f# Xof papilledema.9 I: P5 ?. O9 Z% E) ], m( w3 A& F+ y e
Laboratory Evaluation
1 Z/ c) p" ^: \/ j6 PThe bone age was consistent with 28 months by4 |( Y! w/ Z' u% u2 e0 i
using the standard of Greulich and Pyle at a chrono-" g! G p' r( v9 ]! X6 i5 z% |
logic age of 16 months (advanced).5 Chromosomal& _) ]4 G( K4 O* p3 d) a
karyotype was 46XY. The thyroid function test$ F9 `" O5 {! g
showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 A6 n2 h' V7 s+ E2 N
lating hormone level was 1.3 µIU/mL (both normal).* _8 Q0 n" P. {' T; _
The concentrations of serum electrolytes, blood
; B( N+ N; [4 S; ]+ r* ourea nitrogen, creatinine, and calcium all were( B. T# ~( w _/ I ?
within normal range for his age. The concentration
0 R; o" E) \* r1 K+ }/ o8 Jof serum 17-hydroxyprogesterone was 16 ng/dL: r5 M, ?2 F6 U1 ~/ f
(normal, 3 to 90 ng/dL), androstenedione was 20- l$ O4 }' k/ l, G5 k- b+ Q, S+ _
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 T* \! I% A- G0 `; y+ o! u& k7 W qterone was 38 ng/dL (normal, 50 to 760 ng/dL),
. j/ p) A2 Q9 _" Z7 g& f3 Qdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
# b% l' m: g9 l3 \* C( h) b49ng/dL), 11-desoxycortisol (specific compound S)% l9 x5 V, |/ E0 P( H5 r# _
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" }5 T; u& I U
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
( o/ l, K% O# n% ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
" g" Q1 W3 B. K% V3 f! gand β-human chorionic gonadotropin was less than
5 b$ T6 n8 K& t2 d' T5 mIU/mL (normal <5 mIU/mL). Serum follicular
; ~! x) u& ~4 V! X+ S1 ystimulating hormone and leuteinizing hormone c/ t: D; ~9 Z
concentrations were less than 0.05 mIU/mL
3 @9 {5 Q$ X9 S$ ^(prepubertal).
4 ^, ]* w; c! R, Q+ iThe parents were notified about the laboratory3 j/ i2 Y% ~( I( t. J d2 S
results and were informed that all of the tests were- q" m; k% K1 y% f+ J# N: s0 ~
normal except the testosterone level was high. The
( C* W' M) c! }$ c$ dfollow-up visit was arranged within a few weeks to+ ~. T3 P6 q( @+ R7 w4 N8 z+ W
obtain testicular and abdominal sonograms; how-, |$ `/ c% J/ k/ m% ^; V
ever, the family did not return for 4 months.
6 t/ C. n2 S( r8 w; s3 r; zPhysical examination at this time revealed that the
$ _$ J! @1 C6 w1 L* Q- Lchild had grown 2.5 cm in 4 months and had gained$ c* ~3 m4 ?* [. c
2 kg of weight. Physical examination remained6 w7 f0 {" c- I
unchanged. Surprisingly, the pubic hair almost com-
1 {* H. c/ j1 ^pletely disappeared except for a few vellous hairs at
( r3 K4 b7 h* C: p6 f5 k. [- U5 ~the base of the phallus. Testicular volume was still 2
% L& A2 C( b" m, p( F+ i1 dmL, and the size of the penis remained unchanged.2 ] G$ @5 G& ~* x* i: Z
The mother also said that the boy was no longer hav-
- H8 C: q6 r, J/ q1 Ting frequent erections.) p i# s. E) f' o5 A) |
Both parents were again questioned about use of* N7 B3 v9 x; y5 r
any ointment/creams that they may have applied to3 Y* W5 e3 ~# c
the child’s skin. This time the father admitted the' p- f: q b M% c' J' g
Topical Testosterone Exposure / Bhowmick et al 541
. R% U0 I/ e9 g; `use of testosterone gel twice daily that he was apply-
$ p" x c: P$ O9 ], ning over his own shoulders, chest, and back area for
8 l. p1 d; ^0 Q# a0 @8 O; a' Na year. The father also revealed he was embarrassed
6 W M3 F0 q# z" @to disclose that he was using a testosterone gel pre-
. p* }4 x8 }( L8 _+ xscribed by his family physician for decreased libido
! N9 K' y( \1 w+ D% v; n4 p" {, P" Ysecondary to depression.
8 b7 @% N, D* n- ?The child slept in the same bed with parents.
) h4 O+ _ r6 Y3 ?The father would hug the baby and hold him on his
1 Q, c* g! L/ V8 }. `' {chest for a considerable period of time, causing sig-
@; q9 n+ {# @) R. J% rnificant bare skin contact between baby and father.9 Q/ w; V; D9 h
The father also admitted that after the phone call,
: g- {- O( [) V( r. r9 iwhen he learned the testosterone level in the baby. u+ x. q' e! o8 \
was high, he then read the product information
% K" {% r& `* @% T9 ipacket and concluded that it was most likely the rea-
: H# Q, h+ t0 L6 O5 ~* ]( zson for the child’s virilization. At that time, they* q7 g7 V4 e# x, Y
decided to put the baby in a separate bed, and the
( R3 j0 A# d, G; i3 g4 R$ Mfather was not hugging him with bare skin and had
# B4 c: _* }$ e( _9 I% J4 k4 ~been using protective clothing. A repeat testosterone
4 Y1 P3 r4 I9 t$ k# z: ]test was ordered, but the family did not go to the
( a; j) F+ {; Z" {5 B5 P7 }) r3 ]laboratory to obtain the test." q8 @: p7 @$ D+ e5 i. M( ?0 H
Discussion2 ~; q' U2 S% k& c+ V; G4 j
Precocious puberty in boys is defined as secondary5 t& W# B$ W) w$ y7 x# {
sexual development before 9 years of age.1,4( f2 N2 L, A( L' g( @* y- C
Precocious puberty is termed as central (true) when5 p! q) x7 v# K5 L
it is caused by the premature activation of hypo-# e _: Y8 f/ S+ T( O
thalamic pituitary gonadal axis. CPP is more com-: |2 y) Q& \! T+ q2 c4 q8 h+ t+ B6 Q: X
mon in girls than in boys.1,3 Most boys with CPP& Y, u' T0 `1 ]5 f( [ Y- p& B
may have a central nervous system lesion that is
5 u- {; ]' v( G- E" tresponsible for the early activation of the hypothal-# H; t# y- m5 S1 s0 e. ]4 M
amic pituitary gonadal axis.1-3 Thus, greater empha-
9 e/ o" Q4 D7 `* t* Lsis has been given to neuroradiologic imaging in
6 P, p3 j' U2 r) m/ z5 J7 ]# g Iboys with precocious puberty. In addition to viril-% }4 r: v& x. k) p5 O- c+ @& h Q
ization, the clinical hallmark of CPP is the symmet-
0 C" y6 P: W8 ]8 {+ ~; srical testicular growth secondary to stimulation by
: ^* I( H# V- C$ dgonadotropins.1,3
9 j5 j. \' g5 ]" q wGonadotropin-independent peripheral preco-
5 b8 e$ B" U/ h, E+ K, |2 scious puberty in boys also results from inappropriate
4 I8 K) {# `5 Z: V ]8 randrogenic stimulation from either endogenous or
# ^& u B% b% V: c2 i+ y; Texogenous sources, nonpituitary gonadotropin stim-6 d# F) g8 R9 ~: X; A- q, U
ulation, and rare activating mutations.3 Virilizing
% i$ G0 C! D$ r9 S' @9 F7 Gcongenital adrenal hyperplasia producing excessive9 S+ o% Y% ~' D! ~+ R o& L) X
adrenal androgens is a common cause of precocious e2 ^9 h4 h9 O
puberty in boys.3,4
0 ]4 ^! k8 ~; d& CThe most common form of congenital adrenal+ E8 T5 y5 D! k7 B3 A& |
hyperplasia is the 21-hydroxylase enzyme deficiency.0 N J+ r" i9 a+ }& m8 r9 w0 H
The 11-β hydroxylase deficiency may also result in
/ V7 k5 \6 Z' M# [. b3 K( @" `: Vexcessive adrenal androgen production, and rarely,% A$ {& T! }9 T' C
an adrenal tumor may also cause adrenal androgen( F- Y3 F h! ^7 i( [# S0 E
excess.1,3
! b0 _" j/ W' Y) }$ P1 jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- T: H6 a& N: C- T, ^
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007: r+ x! w8 {' n' ~& r0 U
A unique entity of male-limited gonadotropin-. O6 m L6 q0 t4 S# T: j
independent precocious puberty, which is also known
- _( }) f8 m' |9 v2 ^* s: \, Las testotoxicosis, may cause precocious puberty at a$ L) @" T+ q; `( h8 R7 \! q: l
very young age. The physical findings in these boys( u9 D( ]% D$ C0 \
with this disorder are full pubertal development,# j0 I# }4 F. V! x/ b
including bilateral testicular growth, similar to boys
i8 ]- U' p- Z5 B0 vwith CPP. The gonadotropin levels in this disorder8 g+ z3 Q+ A7 x. c1 E+ a9 G* {
are suppressed to prepubertal levels and do not show
, F0 z) ~, O U+ I1 Ypubertal response of gonadotropin after gonadotropin-
4 h8 J' @" r# M6 T3 k7 Vreleasing hormone stimulation. This is a sex-linked
; |1 x6 a, S! n5 Y9 nautosomal dominant disorder that affects only% j; Y; r1 \3 m% ]
males; therefore, other male members of the family4 x( \& ^. c9 `0 ?0 A, |
may have similar precocious puberty.3
9 h+ p% f/ x2 g) KIn our patient, physical examination was incon-" T+ |. A' D1 Z2 P7 M( }$ k
sistent with true precocious puberty since his testi-* ]) y& [+ f; f$ S
cles were prepubertal in size. However, testotoxicosis3 G8 |9 @$ R7 d, ?3 q( t7 K
was in the differential diagnosis because his father) w( n! D# {2 ^: _0 F' f3 b' \
started puberty somewhat early, and occasionally,$ a0 F4 P% J- c1 G
testicular enlargement is not that evident in the& m* G6 Y: U r) b
beginning of this process.1 In the absence of a neg-
+ Y* }2 y( U- M1 Rative initial history of androgen exposure, our
* j8 ^/ y+ A! ]2 }6 D. B' x! D# J3 wbiggest concern was virilizing adrenal hyperplasia,
% C* e$ E1 B1 [; I7 i5 oeither 21-hydroxylase deficiency or 11-β hydroxylase6 J9 b# {" X q, @% g
deficiency. Those diagnoses were excluded by find-7 j( I/ O, k: O3 x6 ~; {
ing the normal level of adrenal steroids.
0 V! D. a I, kThe diagnosis of exogenous androgens was strongly# K- [: i( X7 L* h" L0 P2 @. V
suspected in a follow-up visit after 4 months because: O% P' j+ q; `1 B- y9 }
the physical examination revealed the complete disap-
C* B% h M Z5 N; J2 Lpearance of pubic hair, normal growth velocity, and
% F1 ]) c' @6 t+ O: B! p) I4 zdecreased erections. The father admitted using a testos-
5 H9 U$ e$ W( [terone gel, which he concealed at first visit. He was
0 t/ h1 X; g; w! }7 U+ x# A/ ousing it rather frequently, twice a day. The Physicians’
7 T' v/ W* D8 p+ N5 IDesk Reference, or package insert of this product, gel or
2 ^$ _# }% N8 }1 O, O8 E% r. G# zcream, cautions about dermal testosterone transfer to0 B* R7 U3 |" C
unprotected females through direct skin exposure.
" g% X, F4 y4 l# ^' TSerum testosterone level was found to be 2 times the
+ v0 _6 C" g( ~9 T+ `) k9 O5 E3 ?baseline value in those females who were exposed to
7 ~$ T% [- @% Eeven 15 minutes of direct skin contact with their male
) {. |* |! V1 w5 M* l9 X6 Hpartners.6 However, when a shirt covered the applica-
1 ?0 N; b; l. ^" ltion site, this testosterone transfer was prevented.
4 [4 U# |) t9 m4 V: vOur patient’s testosterone level was 60 ng/mL,6 q. e6 |. Z' q+ Y1 V5 L& _
which was clearly high. Some studies suggest that- @* y7 g8 C6 }1 l: m/ I
dermal conversion of testosterone to dihydrotestos-3 k- h; u6 q8 a- e- ^4 X
terone, which is a more potent metabolite, is more
9 I6 x, M5 k) U- hactive in young children exposed to testosterone- m$ M4 W8 n6 a( v' ]
exogenously7; however, we did not measure a dihy-/ N' e( @9 j1 J# I! b! h2 z
drotestosterone level in our patient. In addition to
' R ?! Z9 Q# C9 ^+ V- w' vvirilization, exposure to exogenous testosterone in7 l1 i& O' X1 T; ?: e! I7 D
children results in an increase in growth velocity and
3 c- n8 W% G: Y# P; ]advanced bone age, as seen in our patient.
- K" V# e) d4 V9 e/ Q1 c, yThe long-term effect of androgen exposure during% E$ n. ]& h- J0 Q
early childhood on pubertal development and final
/ Y3 t" e0 @* R$ ~4 K% l8 \: Aadult height are not fully known and always remain+ q5 {* c- U0 e- p( m
a concern. Children treated with short-term testos-2 r3 x' r. b: `3 a/ I7 k4 ^% R
terone injection or topical androgen may exhibit some
" e! q2 |* S$ ^; U, uacceleration of the skeletal maturation; however, after
4 H v: M6 \' h0 V3 D. I9 j5 I# Qcessation of treatment, the rate of bone maturation) A: w5 ]6 N2 T9 Z
decelerates and gradually returns to normal.8,9
, k4 u( M3 a7 f- s7 j8 V# w# u! bThere are conflicting reports and controversy
: Q+ r: U4 g) Q/ d5 }- D2 J _0 T, Vover the effect of early androgen exposure on adult* w9 {! Z! V4 t0 k
penile length.10,11 Some reports suggest subnormal# n! U+ J. J: u5 E! I: p2 V
adult penile length, apparently because of downreg-
3 d' f9 }5 i y5 N1 e. A; _1 q: k- Qulation of androgen receptor number.10,12 However,3 d8 k# q7 g& Q6 Y" o
Sutherland et al13 did not find a correlation between- c) |$ {' u/ K3 z7 n `5 q
childhood testosterone exposure and reduced adult
* L$ x% G3 n1 H3 _( wpenile length in clinical studies.* } t! {+ Y: V; [
Nonetheless, we do not believe our patient is
1 C: t# O v5 Rgoing to experience any of the untoward effects from0 i0 e- i& ^* K. V& a
testosterone exposure as mentioned earlier because
* t$ q4 Y( s% ]) _* O6 ^$ Cthe exposure was not for a prolonged period of time.
4 y. U7 ~- F! B* |) UAlthough the bone age was advanced at the time of
$ s! V- {9 [$ @0 I! idiagnosis, the child had a normal growth velocity at
5 z( _7 @- v j9 n; c; H! s. Dthe follow-up visit. It is hoped that his final adult
: k8 X/ q: M4 u0 Q, z6 G; Pheight will not be affected.8 h' p" [" G- a) @- u: b
Although rarely reported, the widespread avail-& D8 o$ ~6 ~% p
ability of androgen products in our society may1 A+ C/ N; F- g, K: Z
indeed cause more virilization in male or female+ j: e8 L' P! w; H9 S. A
children than one would realize. Exposure to andro-
! R* H, u+ H2 h3 w Ggen products must be considered and specific ques-2 a4 N/ r, K A
tioning about the use of a testosterone product or/ O( h4 e7 \9 j0 B5 O
gel should be asked of the family members during
5 _- o; T$ j6 F2 j: R9 U: b; dthe evaluation of any children who present with vir-5 H# u) X3 L% I% }4 [( K7 `. O
ilization or peripheral precocious puberty. The diag-
# j! w. K1 V7 Mnosis can be established by just a few tests and by
+ k0 J% W- I5 R$ [appropriate history. The inability to obtain such a; L$ a; @; O( H g+ O( Y8 y- [% }
history, or failure to ask the specific questions, may
0 a- m! }* F F/ D6 X' U/ A/ U6 ~result in extensive, unnecessary, and expensive
2 |/ d0 w2 P1 M$ d4 Ainvestigation. The primary care physician should be3 s) M; Z/ A3 L0 R# l1 d! i
aware of this fact, because most of these children
& \( g4 H& s) }; k2 _may initially present in their practice. The Physicians’
# U* c; [( ^8 G3 t# O7 {Desk Reference and package insert should also put a6 t; P2 o2 e* k0 v M H' w& H* ^
warning about the virilizing effect on a male or
7 ]5 q. V! K& t5 f8 U+ L" pfemale child who might come in contact with some-" o" t# t, e/ i- o* }3 Y: D! ~
one using any of these products.$ G, Q# m& N2 w E7 M
References/ ~+ p9 G5 @& e4 V2 u u3 y2 D) r
1. Styne DM. The testes: disorder of sexual differentiation
* p! e* t: x$ u5 X* z+ h; N& s, oand puberty in the male. In: Sperling MA, ed. Pediatric6 M; V& v. K; E! C3 P. C+ q: ]
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: K0 P5 r( l2 R4 i5 V C2002: 565-628.
' c8 L- q) W7 K4 Z" X2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious6 U7 E8 e) q7 R
puberty in children with tumours of the suprasellar pineal |
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