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Sexual Precocity in a 16-Month-Old% m- A1 C/ T0 }' S
Boy Induced by Indirect Topical
/ r! Q# |+ B2 F! N9 JExposure to Testosterone& z" e& P: A3 j; A) y2 s( g! J+ ~" M
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,22 s \" h0 y- G& g& L+ t: |* \
and Kenneth R. Rettig, MD1
" h% r* F% Z4 o1 M1 w' \+ e: @Clinical Pediatrics
, L& X4 }5 V4 b# I/ C/ L! x. b( j) rVolume 46 Number 6
$ Q7 C: S: s& r+ ~: kJuly 2007 540-543. W5 C! S i5 [2 R( Q
© 2007 Sage Publications
6 _/ u+ M2 |6 X3 s5 k7 j10.1177/0009922806296651
9 J/ p, D+ A5 W8 zhttp://clp.sagepub.com$ A9 r& @8 T6 ~
hosted at
1 Y, W- r5 t( L; Bhttp://online.sagepub.com
& b5 C: \4 \( [ C9 yPrecocious puberty in boys, central or peripheral,
+ T9 ~0 w1 L& [is a significant concern for physicians. Central
$ R! g' \& U3 F; C$ B$ f% mprecocious puberty (CPP), which is mediated- u- E& J* n8 |' M X
through the hypothalamic pituitary gonadal axis, has
3 i( ?, R4 q$ x6 P5 f3 Ea higher incidence of organic central nervous system0 k& x6 d5 g) E2 B1 [8 L
lesions in boys.1,2 Virilization in boys, as manifested# w K8 _3 j! g- o, O! w6 ?8 P f) _' K
by enlargement of the penis, development of pubic6 t5 e+ f3 |1 k* Q- g
hair, and facial acne without enlargement of testi-. G7 Z G0 F2 L0 S& X
cles, suggests peripheral or pseudopuberty.1-3 We: G$ y4 I$ h U+ n
report a 16-month-old boy who presented with the; Z2 W7 E. q4 ]. j; z$ |
enlargement of the phallus and pubic hair develop-
! l2 Q, L8 V8 j7 oment without testicular enlargement, which was due8 k4 Z) L0 X" G$ |
to the unintentional exposure to androgen gel used by
/ j' |. s) j1 C6 L$ Athe father. The family initially concealed this infor-. d' q) B& [" x2 P& r: c
mation, resulting in an extensive work-up for this1 r- x. u# x8 s* Z1 d9 y9 W
child. Given the widespread and easy availability of
' D0 Z1 o4 @; K; A- F1 mtestosterone gel and cream, we believe this is proba-' B- J, Q2 P7 k v% r5 o1 w5 l
bly more common than the rare case report in the
) }5 y! ]/ x8 F$ j, wliterature.4% f) S7 o- S) q( B- k; a9 ]* I( e7 p
Patient Report
9 u& S* O. d3 l& Y, @A 16-month-old white child was referred to the$ ?/ | r) J4 e- ^ c$ l
endocrine clinic by his pediatrician with the concern5 N+ |6 Q" P* W. l" }
of early sexual development. His mother noticed, `& a$ L# W2 y9 [7 g0 U0 [
light colored pubic hair development when he was
+ N& Q) [2 Q7 N$ {From the 1Division of Pediatric Endocrinology, 2University of
1 x4 d- B9 Y2 o1 y U* hSouth Alabama Medical Center, Mobile, Alabama.
1 Z5 F) _. P7 m5 ?; P) n5 nAddress correspondence to: Samar K. Bhowmick, MD, FACE,
5 \1 j5 e& q% F$ `5 Z7 oProfessor of Pediatrics, University of South Alabama, College of }/ g; K$ O; H0 I
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
/ n# H3 e; M" ~7 L" ye-mail: [email protected].
8 j( o$ m% M- Z& v. g% qabout 6 to 7 months old, which progressively became8 L9 P# t5 B, \2 }9 m6 W) k
darker. She was also concerned about the enlarge-4 C7 b" [0 B% U0 l% s7 G
ment of his penis and frequent erections. The child
# f4 j a+ n) o( c/ Cwas the product of a full-term normal delivery, with! D' ^( n: Z6 k( q8 E9 V0 G' w1 }
a birth weight of 7 lb 14 oz, and birth length of5 R( g, l; P5 ~7 D3 [
20 inches. He was breast-fed throughout the first year
7 z. S0 X- A" cof life and was still receiving breast milk along with
3 }% T7 `+ s, j) p% qsolid food. He had no hospitalizations or surgery,
, b/ R/ `9 O! y( B Band his psychosocial and psychomotor development2 K; b. \* r; I* K
was age appropriate.
: R4 l! a" a9 f: g: P4 {% u" Y( u: K4 iThe family history was remarkable for the father,
' A# X+ S% g! N; _) I* wwho was diagnosed with hypothyroidism at age 16,
) ~" c: `" y( l* k$ p# ~ B6 pwhich was treated with thyroxine. The father’s8 m. e- w3 i' W$ y
height was 6 feet, and he went through a somewhat: @) q& U2 S4 W# ]' k) Q6 x
early puberty and had stopped growing by age 14.
6 Y6 H2 m- w' D D0 CThe father denied taking any other medication. The$ u6 Z' G" r2 C5 N; f: I; B* ~
child’s mother was in good health. Her menarche7 V; C$ p: f3 E; ?$ `+ A j; d6 [
was at 11 years of age, and her height was at 5 feet; x- p) @* {3 v. w \% @' }( w# Y
5 inches. There was no other family history of pre-
& _* R& \" p2 }/ Ucocious sexual development in the first-degree rela-4 ~) K) d* T$ ?& p
tives. There were no siblings.
5 _8 V5 U* p( F2 hPhysical Examination
- f& Q6 S8 Y2 d, g/ \. WThe physical examination revealed a very active,' D9 A9 j- W' I M+ [% ~
playful, and healthy boy. The vital signs documented" j/ a% n8 ]' t0 \& y$ u5 n3 _ u
a blood pressure of 85/50 mm Hg, his length was' L; c/ u6 T) Y$ K! n& ]
90 cm (>97th percentile), and his weight was 14.4 kg% ~: X; } M+ f) w
(also >97th percentile). The observed yearly growth
4 J- [5 t: G+ i! V% K5 kvelocity was 30 cm (12 inches). The examination of
% `% m, P1 g! C; D/ Vthe neck revealed no thyroid enlargement./ a' Z5 ~8 F. F! _8 ^9 S0 ^
The genitourinary examination was remarkable for! ]/ G& ~" p8 a) Y' q5 k4 W
enlargement of the penis, with a stretched length of
; |# }8 O) q8 _, O" C2 f$ X9 H8 cm and a width of 2 cm. The glans penis was very well& P' i; e- r4 W) s# b1 R ? ?) L0 t; `
developed. The pubic hair was Tanner II, mostly around
" o, d/ {* _; W8 Q1 u! t# w. u540. e7 x, x1 Z* V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
: s: l9 d6 F: \4 Uthe base of the phallus and was dark and curled. The
5 Q9 R6 A1 G& [* O4 q: f9 j F: Mtesticular volume was prepubertal at 2 mL each.
6 B# N9 c/ L5 ]7 h$ ^! y8 {The skin was moist and smooth and somewhat+ i: C) I" {; \0 e2 X
oily. No axillary hair was noted. There were no
% I, C+ w/ ~8 g+ I) Jabnormal skin pigmentations or café-au-lait spots.
1 \! m' T9 c* s2 Z9 R4 KNeurologic evaluation showed deep tendon reflex 2+. i- |8 @9 {& e6 U& a! t. z
bilateral and symmetrical. There was no suggestion) r2 p9 v4 N* r+ Q3 r8 y( q
of papilledema.
% z3 R0 U% F4 [1 Y+ LLaboratory Evaluation: r- b& |! i4 Z
The bone age was consistent with 28 months by' d4 ?. `9 u. I* M5 |+ r
using the standard of Greulich and Pyle at a chrono-
- O+ C: e0 i+ t3 k3 `logic age of 16 months (advanced).5 Chromosomal3 X% k: E& R1 C D ~; v
karyotype was 46XY. The thyroid function test
1 [9 s0 z8 m, n% kshowed a free T4 of 1.69 ng/dL, and thyroid stimu-% e2 ~8 S: z; K: C9 g7 t1 i% C
lating hormone level was 1.3 µIU/mL (both normal).
, R+ F) Z5 O, W& [) d2 E& A5 fThe concentrations of serum electrolytes, blood4 W" {+ j9 C1 M" U+ h# C: Q: R
urea nitrogen, creatinine, and calcium all were: R" q7 v6 S2 ^9 A
within normal range for his age. The concentration' [/ e1 f1 P* W+ X. ]
of serum 17-hydroxyprogesterone was 16 ng/dL/ z* R$ L- y4 {( @8 p
(normal, 3 to 90 ng/dL), androstenedione was 20- D1 L" U/ i2 P& H1 ^* n$ A* U
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
U1 X0 z! {" m* M- ?terone was 38 ng/dL (normal, 50 to 760 ng/dL),7 U6 A) I+ `% I/ a/ H. {
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
) o4 z) H4 ?* N0 [2 S; ~49ng/dL), 11-desoxycortisol (specific compound S)
1 U: |8 c& g: Q* m e6 d7 fwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 F" d9 F+ R$ J, H! ~
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& A. u" M$ k) _/ Q& E1 Xtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 l. z4 M- T& H4 E
and β-human chorionic gonadotropin was less than
2 F' v. P! _0 S( }5 mIU/mL (normal <5 mIU/mL). Serum follicular
' n; e/ z# _6 j' d& Wstimulating hormone and leuteinizing hormone0 d2 G: m. G5 K; c# o ~
concentrations were less than 0.05 mIU/mL7 S( _5 r: R& @; W4 t P
(prepubertal).6 V ~( @" ]1 G1 ^
The parents were notified about the laboratory1 F' [$ l4 L9 e7 y$ X3 G0 R
results and were informed that all of the tests were \7 P% }$ c* B' W! f
normal except the testosterone level was high. The: c" H: ]$ I/ Q- K! D
follow-up visit was arranged within a few weeks to
5 D+ f2 I' u* v7 n8 Iobtain testicular and abdominal sonograms; how-" N9 [- K! S. z' S }. e" R
ever, the family did not return for 4 months.
: s- z9 ]( }3 v$ B2 @- L+ yPhysical examination at this time revealed that the, F: h8 Y4 P- ~; E$ _
child had grown 2.5 cm in 4 months and had gained
# i9 P6 s$ Y- U) e2 kg of weight. Physical examination remained
% U% U; ~. S- H: ~unchanged. Surprisingly, the pubic hair almost com-9 z r6 R0 r% C% z" M+ B
pletely disappeared except for a few vellous hairs at4 H; d7 K/ H r. |; Y
the base of the phallus. Testicular volume was still 2
- l/ t7 \6 o* n& ^mL, and the size of the penis remained unchanged.% N: p% v8 G* }/ o% k" m
The mother also said that the boy was no longer hav-
' H+ H% Z8 u" e: f$ t1 ]ing frequent erections.
# B: j% L+ M/ `0 b- B' u2 v; I' XBoth parents were again questioned about use of& ]5 T; a3 V% {& u/ s4 ?
any ointment/creams that they may have applied to
o8 Z3 F' W1 Q' \: W$ dthe child’s skin. This time the father admitted the% J: n+ f' _; J$ n# K3 ?2 S
Topical Testosterone Exposure / Bhowmick et al 541
; u% O0 u* c; l6 g8 puse of testosterone gel twice daily that he was apply-
4 y. H4 P; D7 ~ e1 Qing over his own shoulders, chest, and back area for
) z, ~! H$ f& W! K, Ra year. The father also revealed he was embarrassed
/ O( s8 C0 B% i7 r! _to disclose that he was using a testosterone gel pre-
0 k+ z; ~) v9 c' }" |4 S1 X7 Bscribed by his family physician for decreased libido
9 h# U* z# F7 L c+ J+ nsecondary to depression.
e# }- M9 P! JThe child slept in the same bed with parents.
& V0 ^/ o, G6 d" R9 B$ ]8 gThe father would hug the baby and hold him on his8 `: C+ J" E. r0 J& {5 [
chest for a considerable period of time, causing sig-& N1 O1 m' c) O7 u- y0 I
nificant bare skin contact between baby and father.
& h' g! S( ^, b% EThe father also admitted that after the phone call,4 k9 Z: U( a& _
when he learned the testosterone level in the baby. A9 b$ t# Q- K' v; ]% v2 d; s* |
was high, he then read the product information
/ S: j1 F3 a& c8 g% q, Y/ bpacket and concluded that it was most likely the rea-- P! o5 i2 ]& d
son for the child’s virilization. At that time, they% m1 V8 t; G* C' [5 \
decided to put the baby in a separate bed, and the
2 J9 Q' W F1 w% r1 c2 C0 `9 ]father was not hugging him with bare skin and had; Y- J% j; U$ i' L; b
been using protective clothing. A repeat testosterone
9 |2 W! D0 j& a3 I! B+ V) ~test was ordered, but the family did not go to the8 u* N+ f: P$ g4 k5 R. P# Q
laboratory to obtain the test.
; m+ n6 m* z& ADiscussion; r' L) F* Q4 ?3 s
Precocious puberty in boys is defined as secondary' i$ {8 u' c0 X
sexual development before 9 years of age.1,47 p9 v% f6 ^; S! R. z
Precocious puberty is termed as central (true) when
* p8 Y+ \% ^; sit is caused by the premature activation of hypo-
1 i! }; { g/ K' Athalamic pituitary gonadal axis. CPP is more com-& p. F' C# g1 w5 Q. S
mon in girls than in boys.1,3 Most boys with CPP
) g" R- x1 N" B+ c' bmay have a central nervous system lesion that is6 |8 I, F( z; o( l1 Y8 F
responsible for the early activation of the hypothal-
+ U9 ?4 D o3 _& x& \amic pituitary gonadal axis.1-3 Thus, greater empha-0 r0 U* N3 n1 C2 J, b+ l/ \
sis has been given to neuroradiologic imaging in+ x, p; d' O# \0 a
boys with precocious puberty. In addition to viril-0 ?- U; a& F: } M$ u
ization, the clinical hallmark of CPP is the symmet-, r+ B5 m8 Z/ u' f3 Q2 e2 L' |
rical testicular growth secondary to stimulation by9 o9 z5 k) t. b& g. K5 R! U
gonadotropins.1,37 A: _0 V d$ ^, l
Gonadotropin-independent peripheral preco-
, y# W. r; b5 T& m1 o: Z+ D; Dcious puberty in boys also results from inappropriate
3 D( s& K4 Z6 L6 I; l- {2 }5 m( pandrogenic stimulation from either endogenous or- P z% a5 u1 `5 {8 G$ {# j- {
exogenous sources, nonpituitary gonadotropin stim-, t% g. ^ R! U2 Z
ulation, and rare activating mutations.3 Virilizing
" G; Y( y( u' N; f* Zcongenital adrenal hyperplasia producing excessive
0 g- J9 n6 ~, |( Gadrenal androgens is a common cause of precocious
; t( n! L* G1 _7 @) fpuberty in boys.3,4
# i+ Y- i p! {. o1 E& k! E; X$ mThe most common form of congenital adrenal8 I$ n& t0 m0 \" L4 V
hyperplasia is the 21-hydroxylase enzyme deficiency.; {3 x4 C; q i6 e: I7 [
The 11-β hydroxylase deficiency may also result in# ^; s: w2 J4 L- D3 h" g7 i5 t
excessive adrenal androgen production, and rarely,1 ]% N. T/ X! ?/ g( ^8 a! n7 J6 N
an adrenal tumor may also cause adrenal androgen, b8 y9 Y! \4 u
excess.1,30 X* _' X2 v$ G9 b
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from2 q0 q' v2 @2 m$ b' Y2 G
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007! R6 }% l; \% T% E. L; E0 Q1 G* W7 @
A unique entity of male-limited gonadotropin-
" T) T! b3 _5 _3 w8 [! mindependent precocious puberty, which is also known1 G5 J2 T* G5 b: @$ @6 l* x* R
as testotoxicosis, may cause precocious puberty at a
. W+ S) W( M$ B/ tvery young age. The physical findings in these boys9 p% i3 u. h6 y2 [+ K
with this disorder are full pubertal development,
5 @1 X/ | n, r0 z) _$ i# \/ bincluding bilateral testicular growth, similar to boys
' `/ H9 V+ c9 V' Uwith CPP. The gonadotropin levels in this disorder" P* H4 c; ~3 |+ S
are suppressed to prepubertal levels and do not show6 P- R/ P" a; r( n( b* D6 E( z6 {
pubertal response of gonadotropin after gonadotropin-
+ n! ?3 z1 u/ Z' ~8 D- hreleasing hormone stimulation. This is a sex-linked; L) x3 S" H6 p
autosomal dominant disorder that affects only- Y. s' n' E' S% G8 K: ^
males; therefore, other male members of the family, O: X6 C: ^$ t% V! m9 |
may have similar precocious puberty.3% {* f9 q; }% ]# g
In our patient, physical examination was incon-
1 f: m/ f% P. m7 z, Vsistent with true precocious puberty since his testi-
( E) C% @9 }6 g# j( Bcles were prepubertal in size. However, testotoxicosis
6 B) G4 w( L2 Rwas in the differential diagnosis because his father# l3 w+ F. ?$ I! } ~$ p
started puberty somewhat early, and occasionally,
# G4 ]+ D& m5 G* _! ~testicular enlargement is not that evident in the5 d/ ^: @+ j& l4 w* t) A% K& G( n
beginning of this process.1 In the absence of a neg-
6 l8 g% p; K5 G- G1 mative initial history of androgen exposure, our8 l) N. H1 @. P/ U. D( v3 c/ t$ L
biggest concern was virilizing adrenal hyperplasia,+ z3 S9 `/ u/ ?: z7 V( x" L' z; j7 K
either 21-hydroxylase deficiency or 11-β hydroxylase# M2 j) b8 u1 }: C; e" n/ A
deficiency. Those diagnoses were excluded by find-
# f3 \% G7 r! F" ting the normal level of adrenal steroids.$ |6 A+ e' x. y7 Z
The diagnosis of exogenous androgens was strongly7 P) T( ]8 \& T: n6 b3 v& w
suspected in a follow-up visit after 4 months because
; b8 D+ X b9 h7 \ D) \the physical examination revealed the complete disap-4 C% \" s, u3 u
pearance of pubic hair, normal growth velocity, and
, c7 F4 X0 A4 g! z3 }' t; ^* Ddecreased erections. The father admitted using a testos-
5 d8 r. f& }5 x5 ^$ _7 ]6 B/ hterone gel, which he concealed at first visit. He was
) \/ R" W' Z1 l+ y$ ]2 ]% b% @using it rather frequently, twice a day. The Physicians’1 ]/ D2 o$ y, w
Desk Reference, or package insert of this product, gel or
' X% V9 ?! @9 S! ^cream, cautions about dermal testosterone transfer to0 i r2 T* B5 w* _' E. m
unprotected females through direct skin exposure.* Z! e9 f4 T1 X. d9 t1 K, A8 {
Serum testosterone level was found to be 2 times the* ]' h- ?1 b7 o- j0 `4 s- w
baseline value in those females who were exposed to
- A- l9 e4 t1 K' S% ~even 15 minutes of direct skin contact with their male
! b- q' r. c% N( [& d) b# cpartners.6 However, when a shirt covered the applica-: z+ k$ U. Q5 C
tion site, this testosterone transfer was prevented. _' r t8 z4 R3 K+ \0 _
Our patient’s testosterone level was 60 ng/mL,6 ?# ^2 D$ u1 w4 A
which was clearly high. Some studies suggest that# }9 w( J p v" \$ D$ m
dermal conversion of testosterone to dihydrotestos-% E1 [$ q8 v1 [2 X5 b
terone, which is a more potent metabolite, is more2 B5 W6 V! ^ U; C) C
active in young children exposed to testosterone
7 `0 y4 `( \- J$ ?9 Vexogenously7; however, we did not measure a dihy-
9 N' ^ M8 W* U# Q$ t, ]. M3 bdrotestosterone level in our patient. In addition to) K: f7 f% v4 {0 y" K$ q
virilization, exposure to exogenous testosterone in: K# |* W/ {( C- x E7 o
children results in an increase in growth velocity and( {+ U+ O! ~5 N; i; t K. { {4 a
advanced bone age, as seen in our patient.
* `0 e* \( c3 t; O% t/ ]2 oThe long-term effect of androgen exposure during
& P" l$ ]* _+ Oearly childhood on pubertal development and final
( n) c3 }2 T" nadult height are not fully known and always remain
8 ]/ ~( Y0 K- za concern. Children treated with short-term testos-& z6 P$ X, x, X4 J
terone injection or topical androgen may exhibit some
4 [ W/ i7 I; Uacceleration of the skeletal maturation; however, after* \ \$ C/ m! T) c) P
cessation of treatment, the rate of bone maturation
) b) v& {6 c# `: Ddecelerates and gradually returns to normal.8,97 p3 p) M; N$ T& Z$ j
There are conflicting reports and controversy
% e# M! a% N+ m- D$ i6 E6 R1 a; oover the effect of early androgen exposure on adult9 r! o1 i2 y1 O. P3 G/ b
penile length.10,11 Some reports suggest subnormal* p) w* ?& X. }! }8 h. w0 V
adult penile length, apparently because of downreg-" f0 G7 m* ~, [+ l4 a2 ]) w4 t( a- U
ulation of androgen receptor number.10,12 However,1 U2 V4 f; J5 |4 Z, R0 \4 b3 ^9 |$ `
Sutherland et al13 did not find a correlation between
- X% S, @( f1 g5 C, bchildhood testosterone exposure and reduced adult
6 P- k7 }; o* y( Y" a0 U, jpenile length in clinical studies.+ V. W( G( U( r" N& J
Nonetheless, we do not believe our patient is% b+ |" p$ u' ^5 k, Q! A; D% E$ h
going to experience any of the untoward effects from: V( J: y0 B2 |; v1 q3 m
testosterone exposure as mentioned earlier because
+ q3 k; r; i4 z' _( S+ F) \8 E" P$ mthe exposure was not for a prolonged period of time.
3 |+ T/ G) p) f* k; k+ P" kAlthough the bone age was advanced at the time of+ Z' ^+ q: b/ `' Q
diagnosis, the child had a normal growth velocity at/ w+ z; }* d) G+ \+ K- y4 y6 k
the follow-up visit. It is hoped that his final adult
( z7 D5 Y# l/ n4 _height will not be affected.8 L+ D S$ H% y- g3 m% P
Although rarely reported, the widespread avail-8 B6 s& V& H" Q
ability of androgen products in our society may9 o# Q; y; b* b1 k! i8 }. ~3 p
indeed cause more virilization in male or female
+ ]- q& D, S; F; Q' F8 @children than one would realize. Exposure to andro-
: y1 R1 ~1 c3 X% G0 l# p: Ygen products must be considered and specific ques-) L0 K2 k5 n+ V) p) D/ J
tioning about the use of a testosterone product or0 {7 T' B/ p/ X8 _$ F8 E! b6 t
gel should be asked of the family members during
) s6 p3 f4 x) U5 ?the evaluation of any children who present with vir-; m& J& _- R, a0 n F* m
ilization or peripheral precocious puberty. The diag-
; B" E# ]' F* @' U2 bnosis can be established by just a few tests and by
* o# e' D& T, Q& F9 g7 _& h5 M' X. L' Lappropriate history. The inability to obtain such a
6 D$ L( p% x& s; ]history, or failure to ask the specific questions, may3 i- e/ D' `- D7 i- \
result in extensive, unnecessary, and expensive9 m% \6 v; \1 Y/ o/ g
investigation. The primary care physician should be
9 T4 p) m( Q) E5 Faware of this fact, because most of these children
) a1 H& ]5 |2 S5 r7 z. rmay initially present in their practice. The Physicians’
2 ?) ]) s( C) o4 p3 X3 {Desk Reference and package insert should also put a4 r0 J( a+ j3 i/ C" l e
warning about the virilizing effect on a male or
) h7 {% P7 o5 L, ^' r4 afemale child who might come in contact with some-
' r& H" x- j q9 f# I+ sone using any of these products.2 V% ?. Z' F7 J$ R( j4 d, i, |
References
4 e4 m# E- B% e. t1. Styne DM. The testes: disorder of sexual differentiation: ^/ Y8 q/ F& O$ V8 ^
and puberty in the male. In: Sperling MA, ed. Pediatric
/ m: F; H. p5 Q: z5 tEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: B" f3 t/ s1 _. T# K2002: 565-628.( Y. L$ x) {7 W( s
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 r2 e2 _* {$ s6 {% ^
puberty in children with tumours of the suprasellar pineal |
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