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Sexual Precocity in a 16-Month-Old9 Q2 a3 `: W( V7 \9 F
Boy Induced by Indirect Topical
4 F# O* c9 s) Q0 Y2 mExposure to Testosterone( |7 u8 Q9 Z; o% N! Z. ~
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
1 B$ E' M; {/ B3 vand Kenneth R. Rettig, MD12 I+ _1 j+ O. u: h
Clinical Pediatrics' F0 D! r0 d, g! Z4 H
Volume 46 Number 60 h# ?0 D! n: y3 j! S
July 2007 540-543, H4 Z- ~% I. s( z* B
© 2007 Sage Publications
0 }( N a; v \; q9 z. x v10.1177/0009922806296651
7 I7 [5 _* H1 M2 Uhttp://clp.sagepub.com, G$ w8 _2 b* ^3 H1 X$ @% j
hosted at/ D% v. g6 o9 W# K( f2 c& T
http://online.sagepub.com; M. Z: o% s) ?- `7 I9 _4 y# E) Z
Precocious puberty in boys, central or peripheral,
4 [1 Y& ]6 n) H" C/ Kis a significant concern for physicians. Central
; f/ H" ^' p, n# `: v4 hprecocious puberty (CPP), which is mediated
# v; m7 K0 \8 D" ~1 E% @( C& Jthrough the hypothalamic pituitary gonadal axis, has' H2 |; W5 y+ l- }
a higher incidence of organic central nervous system
3 j l6 I- u, B1 k! W3 clesions in boys.1,2 Virilization in boys, as manifested
8 c$ x+ D. v0 J* [by enlargement of the penis, development of pubic
4 a! Z( o; y; ^( d; ^hair, and facial acne without enlargement of testi-" L& Z; K; S/ c7 ^9 b; }! d
cles, suggests peripheral or pseudopuberty.1-3 We
9 X4 \9 _8 t* d) sreport a 16-month-old boy who presented with the$ V. W i$ T+ U, C$ ?
enlargement of the phallus and pubic hair develop-# ]- g9 F9 S' X {: h
ment without testicular enlargement, which was due4 h, m1 x& H/ @/ G" R
to the unintentional exposure to androgen gel used by3 I2 u1 F; |; z+ t- Z1 P8 N
the father. The family initially concealed this infor-
: _0 D$ m: ]2 q) {) W/ Imation, resulting in an extensive work-up for this
9 f& X" V" r6 k g1 [" r4 dchild. Given the widespread and easy availability of
* b# K' ?+ p% k" R9 E/ ~) H& vtestosterone gel and cream, we believe this is proba-" o z7 S7 q3 w9 x7 `
bly more common than the rare case report in the7 f l9 O+ R8 m8 b' v5 ]9 n, n0 o
literature.4
- r- p4 i+ \. ^' ?$ W! h% nPatient Report$ g; E: }9 c: y0 g1 z
A 16-month-old white child was referred to the- u- |) S- U: i4 c m1 {& k+ K
endocrine clinic by his pediatrician with the concern
, y+ v; a* }1 u( l5 oof early sexual development. His mother noticed- _$ H& g% Z. z
light colored pubic hair development when he was. _5 M, }& n# ~+ C, v( [5 ]8 [
From the 1Division of Pediatric Endocrinology, 2University of
+ c* ?1 U. y: [+ XSouth Alabama Medical Center, Mobile, Alabama.! x$ K4 W2 {- ?* n. h7 q
Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 A& N9 f3 Y/ z1 m' oProfessor of Pediatrics, University of South Alabama, College of
9 Y) M1 T& b) j7 P9 N8 ?2 VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;8 h- ^: t$ J3 h S5 S
e-mail: [email protected].
2 J+ \) u2 ?' ?- M- |about 6 to 7 months old, which progressively became
1 V+ o( w! I3 E6 Sdarker. She was also concerned about the enlarge-( K. m \# W# i) }/ v" ? ^' w
ment of his penis and frequent erections. The child
: D5 R3 Z \2 z6 x* F/ _- vwas the product of a full-term normal delivery, with
G& S7 O3 J" v# a+ N5 @ ma birth weight of 7 lb 14 oz, and birth length of
; X' ]/ U1 t* _' @* }6 p+ H( G2 X. P20 inches. He was breast-fed throughout the first year
8 N( F& n$ l1 r" {of life and was still receiving breast milk along with- u( z% | C$ J& Z3 ?% ^# r5 G
solid food. He had no hospitalizations or surgery,8 T7 M& N1 E) H/ ]
and his psychosocial and psychomotor development+ G: I0 h" w- Q [7 B
was age appropriate.0 y' A2 B/ V4 ^4 u8 P4 q( d. `
The family history was remarkable for the father,
) ~4 W. ?' s# r) a! Y D" ewho was diagnosed with hypothyroidism at age 16,
2 W' O$ ?& \; y# w! |& Kwhich was treated with thyroxine. The father’s
. L: f" M. T: o; ?height was 6 feet, and he went through a somewhat
, J6 V% y7 ~' Dearly puberty and had stopped growing by age 14.
2 S5 ~* k; \: k3 h; j5 f2 y) s% PThe father denied taking any other medication. The* x5 }& O {$ J% g$ L8 H' g: i
child’s mother was in good health. Her menarche! {7 l' _2 \' {$ ^+ d
was at 11 years of age, and her height was at 5 feet8 y# A7 W4 c6 w, K0 n, H
5 inches. There was no other family history of pre-5 ]; s4 h" o4 h U M3 T% F' X0 g
cocious sexual development in the first-degree rela-! `5 h# L6 R4 }& V; O
tives. There were no siblings.
0 A9 g$ n7 s( E2 TPhysical Examination" C+ X- |$ r: d" L
The physical examination revealed a very active,
. n9 m1 i& E: m9 o$ S H# y7 tplayful, and healthy boy. The vital signs documented
( i& ~' z5 z4 W, G- xa blood pressure of 85/50 mm Hg, his length was- X5 F! I% K6 j# N Y1 |6 }: v
90 cm (>97th percentile), and his weight was 14.4 kg( i' A7 D: E* J& J2 f
(also >97th percentile). The observed yearly growth
8 {, y' p0 p2 S( t3 B& _9 tvelocity was 30 cm (12 inches). The examination of
' k) `5 K; }, N8 Dthe neck revealed no thyroid enlargement.0 G0 |; s h ^8 F4 _& ^ m
The genitourinary examination was remarkable for
% a* w3 ~. x/ C( F8 x% Tenlargement of the penis, with a stretched length of
6 J0 @( B) z' s8 cm and a width of 2 cm. The glans penis was very well' Z3 G; T# Q7 L9 W1 w5 ` {+ e
developed. The pubic hair was Tanner II, mostly around, Z* p2 I5 h, M1 ^2 F+ C; F
540
0 R l. k3 t2 p1 L; G7 n2 e9 gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) @' A8 k# `" J$ [1 a4 O( F' _3 i' e3 J& ?the base of the phallus and was dark and curled. The0 i9 j4 Y& U/ }# Z
testicular volume was prepubertal at 2 mL each.
# x0 c |4 W! k' [The skin was moist and smooth and somewhat
* C0 r, n# j9 M+ \3 [6 }# K* Y# w; goily. No axillary hair was noted. There were no
8 R! {$ E. p, m0 H# T+ ]abnormal skin pigmentations or café-au-lait spots.
3 l6 r3 d7 e: @: c, _- j5 R4 W3 pNeurologic evaluation showed deep tendon reflex 2+8 C1 f9 A# b- o) j
bilateral and symmetrical. There was no suggestion+ u8 D+ L8 T+ H/ Z1 J2 @# K* k
of papilledema.
* d) k3 {" J' L1 j0 x/ A, j$ u ULaboratory Evaluation
% x( M% H# q$ _5 _- RThe bone age was consistent with 28 months by% F2 l+ i" |6 Y, w
using the standard of Greulich and Pyle at a chrono-
3 W- }) s, h8 I" [logic age of 16 months (advanced).5 Chromosomal) P, }+ ?8 J$ n! f5 S
karyotype was 46XY. The thyroid function test
- ^7 ]/ i- i& @ xshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
6 U# H- ^3 y' i1 s5 Tlating hormone level was 1.3 µIU/mL (both normal).; q3 b/ D7 ]% [
The concentrations of serum electrolytes, blood
8 J2 U/ }& C, Z' d6 turea nitrogen, creatinine, and calcium all were. n; j: }' S( P( b
within normal range for his age. The concentration
r6 J+ S! X- R+ V9 q, ^/ Aof serum 17-hydroxyprogesterone was 16 ng/dL
# c% J# Q% p. U(normal, 3 to 90 ng/dL), androstenedione was 20; e. W: B; M4 M5 I
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
`# O9 ]9 U0 W, S/ r6 Aterone was 38 ng/dL (normal, 50 to 760 ng/dL),
* O" d; l" T5 n" l0 C6 Ldesoxycorticosterone was 4.3 ng/dL (normal, 7 to
3 A2 m% A, o, @! M0 y49ng/dL), 11-desoxycortisol (specific compound S)
! E) {2 M& y8 s* X& l+ _5 Y$ Zwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% |+ T" Q: z: C4 Z$ h
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. v Z5 ?% O3 h* H z2 T
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& I1 g. M; E! w7 z' }7 [0 `
and β-human chorionic gonadotropin was less than
: M8 A t# Y: d$ M' |7 r5 mIU/mL (normal <5 mIU/mL). Serum follicular% S `& ]2 W/ N1 X1 D {2 o4 r# w5 Z
stimulating hormone and leuteinizing hormone
, K& j% G6 o, Qconcentrations were less than 0.05 mIU/mL y! d" l) h5 Y
(prepubertal).
! `5 z; o! `+ E3 q4 ^3 @The parents were notified about the laboratory
9 ~ L) a, G4 f% q/ o2 x- _, {4 Vresults and were informed that all of the tests were
$ {3 T" j. g! L! d1 M. |normal except the testosterone level was high. The d, z: F, c3 |
follow-up visit was arranged within a few weeks to+ B$ _ o9 Z- r
obtain testicular and abdominal sonograms; how-, L0 b/ Q5 w; N; v
ever, the family did not return for 4 months.: u6 C% J8 y# L! |, R( V4 g X. N
Physical examination at this time revealed that the
" d, y) t4 u7 @child had grown 2.5 cm in 4 months and had gained
. ]6 m- }9 o: O2 p- j) z2 kg of weight. Physical examination remained
9 K5 k9 S5 k' \$ z( nunchanged. Surprisingly, the pubic hair almost com-
4 A2 e0 m) d4 F% Ppletely disappeared except for a few vellous hairs at/ f7 Y) |/ z& p2 A: g4 C$ Z
the base of the phallus. Testicular volume was still 2
; G& a0 y3 r4 \mL, and the size of the penis remained unchanged." c0 B8 ^3 X: A) P
The mother also said that the boy was no longer hav-
* H; R& m3 a/ H3 \$ x, Jing frequent erections.
" M: X+ C: H- J9 m; F6 @3 pBoth parents were again questioned about use of
5 U; a% m) C, {3 ^- gany ointment/creams that they may have applied to
7 N# ]# r* g' T3 b: Vthe child’s skin. This time the father admitted the
$ w6 }$ s' u5 l K% h& pTopical Testosterone Exposure / Bhowmick et al 541
0 c5 w8 ]' s1 U# V* b, i- euse of testosterone gel twice daily that he was apply-
! O- [) z L4 oing over his own shoulders, chest, and back area for. l1 Y+ K. l2 V1 T' S8 e$ i6 z
a year. The father also revealed he was embarrassed7 K0 x' ^" y+ _, m
to disclose that he was using a testosterone gel pre-
4 B/ t3 x9 j/ \# E# fscribed by his family physician for decreased libido2 s9 S& X& p8 c, C2 i) I6 ~6 L
secondary to depression.
, b+ Y& J! o L! mThe child slept in the same bed with parents.
4 a: d. K" }' D# t6 TThe father would hug the baby and hold him on his
! s1 k7 E0 H9 T O( N6 F/ }2 |# _chest for a considerable period of time, causing sig-
P6 X( |; n, O# b; k9 r! V8 D5 knificant bare skin contact between baby and father.
' S2 f' M) I5 U2 m- S+ t4 pThe father also admitted that after the phone call,. c* H E* T9 i& _! f. F, D2 c
when he learned the testosterone level in the baby( F4 Z: P4 j) T9 d$ J# }
was high, he then read the product information
" s5 Z: g; R. Xpacket and concluded that it was most likely the rea-
/ F! f# {( R J; N/ ^son for the child’s virilization. At that time, they9 U& [% G8 C6 [$ @+ O, L. m
decided to put the baby in a separate bed, and the
5 d C9 q$ ^9 v% E2 ofather was not hugging him with bare skin and had" B ^3 I# I* O+ A
been using protective clothing. A repeat testosterone
. h& B# T7 v& s+ v |2 d2 l2 Stest was ordered, but the family did not go to the: w5 \9 {$ i# W! g- X% Q+ d
laboratory to obtain the test.
5 m) i6 L6 @1 i. R; a( F, zDiscussion
1 m( _$ w+ E5 t" I( a8 x1 vPrecocious puberty in boys is defined as secondary( U" y& S0 ?7 Z" ?) I# k, p
sexual development before 9 years of age.1,4
, G( E; [' Y. Q) ~0 p9 z. h" y9 X( DPrecocious puberty is termed as central (true) when) w$ b+ N0 H1 ^! _ Y9 O$ y
it is caused by the premature activation of hypo-! A5 `% _! Z \$ Z. X
thalamic pituitary gonadal axis. CPP is more com-; _% y; x; U& _+ T& I. n' x5 M( X
mon in girls than in boys.1,3 Most boys with CPP2 t. B/ K4 ]4 S! k. c3 t7 @5 s
may have a central nervous system lesion that is
; l* ~ h: Y( w8 yresponsible for the early activation of the hypothal-& B3 j1 M* w( B1 c( c: z
amic pituitary gonadal axis.1-3 Thus, greater empha-. h9 V' t7 i; w m" n
sis has been given to neuroradiologic imaging in
& s5 \" W4 u7 [7 Gboys with precocious puberty. In addition to viril-
# T6 f7 l9 W- X4 Z4 I$ D) i |ization, the clinical hallmark of CPP is the symmet-
7 W9 X/ ~( d4 Y( b8 rrical testicular growth secondary to stimulation by; J5 v' m2 I2 B0 I$ _
gonadotropins.1,3
& e# O+ L# W3 j2 Q+ [8 g+ ~4 B YGonadotropin-independent peripheral preco-
9 _: L4 j: g! G! lcious puberty in boys also results from inappropriate+ r6 e5 c0 S; Z" u8 C' p
androgenic stimulation from either endogenous or0 e# r7 I" C0 y5 c0 E( O
exogenous sources, nonpituitary gonadotropin stim-
% ^3 D: {& |9 x G, Z z7 ^ulation, and rare activating mutations.3 Virilizing
: P# I; l9 ^. A6 K' \- G' J' jcongenital adrenal hyperplasia producing excessive4 U6 J7 g1 \0 h/ ]' b
adrenal androgens is a common cause of precocious9 Y, ]0 n5 p. d1 |6 U: h9 m. o/ A
puberty in boys.3,4
3 j+ Z9 H5 [: F7 H DThe most common form of congenital adrenal# R+ X0 c W! {" }& H! a
hyperplasia is the 21-hydroxylase enzyme deficiency.' ], ?9 K1 ?5 M
The 11-β hydroxylase deficiency may also result in) } t6 I$ e6 s6 ]# f: R c
excessive adrenal androgen production, and rarely,
! F: J6 W. E7 U% x' d/ _an adrenal tumor may also cause adrenal androgen+ I; h/ b# Q" t
excess.1,39 z$ i( x# H% @ k0 H) G: T% H
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 I% p; r. s7 V8 z* s
542 Clinical Pediatrics / Vol. 46, No. 6, July 20076 j% b* W3 u4 ]$ b$ y. T
A unique entity of male-limited gonadotropin-; ^- `& h$ v' J/ G1 m' Y
independent precocious puberty, which is also known
# P; I5 L; H! O' }as testotoxicosis, may cause precocious puberty at a1 P+ q! z& w* p( b: Q' N" W. }
very young age. The physical findings in these boys4 {6 Z' e* p3 G i0 ^' b' [0 q
with this disorder are full pubertal development,$ z* [8 ]+ {1 w3 N: E5 @
including bilateral testicular growth, similar to boys% s1 x) g2 ]2 e
with CPP. The gonadotropin levels in this disorder- B% h$ W, J& H! L( A2 _9 j
are suppressed to prepubertal levels and do not show' P0 }3 |: \9 C% W' h3 Y- Y7 z
pubertal response of gonadotropin after gonadotropin-9 ]; f* Y8 ]( n! D6 f3 v7 I& S
releasing hormone stimulation. This is a sex-linked
& f: b4 i* ?/ A) L. I' m2 k, dautosomal dominant disorder that affects only
: q) y' ^0 T; I( Nmales; therefore, other male members of the family' u9 ^- D( `/ d7 r
may have similar precocious puberty.3" o, }& ^9 r9 ]9 z" d2 ?
In our patient, physical examination was incon-2 V; g) D# w6 f* z- z9 q
sistent with true precocious puberty since his testi-/ f6 }" U+ O2 e2 U% F
cles were prepubertal in size. However, testotoxicosis/ D) k4 X; u+ ?5 N/ x* [2 o
was in the differential diagnosis because his father
- w: d4 C% [; \& [/ m9 jstarted puberty somewhat early, and occasionally,5 J3 k' Y8 c3 w# X( h6 m
testicular enlargement is not that evident in the& R# H$ ?( w0 _8 l
beginning of this process.1 In the absence of a neg-
9 y" U' W, p# U7 X3 ]. @" U+ W8 Jative initial history of androgen exposure, our
, s! {* ^: j+ Jbiggest concern was virilizing adrenal hyperplasia,
' g( l+ ~6 e' U S' Deither 21-hydroxylase deficiency or 11-β hydroxylase
" O: ` ?" @! M1 V: c$ Q$ fdeficiency. Those diagnoses were excluded by find-
& t7 s, A) `/ C& ]3 V" b/ Sing the normal level of adrenal steroids.
9 C5 W8 n) k. BThe diagnosis of exogenous androgens was strongly7 S( @. ]/ K A" s9 A% f
suspected in a follow-up visit after 4 months because/ L5 d: C% `, H% R) m. X
the physical examination revealed the complete disap-
8 @7 W R0 w+ ~' s. `pearance of pubic hair, normal growth velocity, and
0 G. |& t% l. B2 Hdecreased erections. The father admitted using a testos-
$ o5 u+ O: {5 Q( j3 ?7 H$ rterone gel, which he concealed at first visit. He was$ O* ` b; Q8 r2 }/ q
using it rather frequently, twice a day. The Physicians’3 ? K& x# l" Y4 O h6 }+ N
Desk Reference, or package insert of this product, gel or+ v0 q; \( y# C& x* Z2 r0 C
cream, cautions about dermal testosterone transfer to3 a9 E; Y8 d* A. d9 E5 p6 }
unprotected females through direct skin exposure.
* s! U- Y. n/ m; d P7 b; Y4 C( I; p1 uSerum testosterone level was found to be 2 times the) O- \; K" m+ Z! O; E% H" u
baseline value in those females who were exposed to$ N) F( J1 S0 I1 t7 I. S+ U
even 15 minutes of direct skin contact with their male7 N) m. Q& s; p7 g- ?1 h
partners.6 However, when a shirt covered the applica-
- M; ~5 d b! y- ?7 p" Ztion site, this testosterone transfer was prevented.
2 R# H3 a1 ~/ a. r' TOur patient’s testosterone level was 60 ng/mL,
! K# y! m( i' A6 R& k5 b: }- {9 J2 Swhich was clearly high. Some studies suggest that
4 Y* I3 n7 L6 y: ^8 S0 ldermal conversion of testosterone to dihydrotestos-! E$ A4 b8 V* C% f! f
terone, which is a more potent metabolite, is more- p0 J0 j) q# \
active in young children exposed to testosterone
: _) D& T3 V( U, ]2 gexogenously7; however, we did not measure a dihy-
* I, l+ n0 H" q& }; h0 jdrotestosterone level in our patient. In addition to
3 r7 S3 h) f lvirilization, exposure to exogenous testosterone in
\' {3 N& k+ F5 H! U, Jchildren results in an increase in growth velocity and
& O5 |# Z+ i1 Q4 ~- vadvanced bone age, as seen in our patient.
, I7 n7 J- L+ m9 N& G& \7 [) p. l1 ^The long-term effect of androgen exposure during
, c7 n4 U7 Q1 @$ A: r( h; rearly childhood on pubertal development and final6 M# r% b( B3 U
adult height are not fully known and always remain
1 y/ v- K" b7 ta concern. Children treated with short-term testos-9 S6 B) _% }( \& {
terone injection or topical androgen may exhibit some
. Z) }) v6 c2 V. P/ p/ K1 zacceleration of the skeletal maturation; however, after
9 N9 g/ g! C; ]) ^; jcessation of treatment, the rate of bone maturation
& l; @. k% L. _8 r4 p! Jdecelerates and gradually returns to normal.8,9
% ?/ N7 U: u& e& h' Q/ IThere are conflicting reports and controversy8 v2 O, @' @) ?3 x# q
over the effect of early androgen exposure on adult0 ], o7 o" Q# T% z5 B/ _9 E8 ~
penile length.10,11 Some reports suggest subnormal
) {/ |3 `% ~: Qadult penile length, apparently because of downreg-' S6 _$ P8 g& _- M3 w% e" @$ K2 w
ulation of androgen receptor number.10,12 However,
, B) T$ H7 x2 _* [/ j+ }8 GSutherland et al13 did not find a correlation between
, T3 {$ G7 d! n! `$ ]: Vchildhood testosterone exposure and reduced adult$ w) ~2 X6 m5 F0 @# I; b6 i0 Y; C, ?! i
penile length in clinical studies.
8 r& V# q! z. sNonetheless, we do not believe our patient is
2 L' j6 \' @* A( R# \6 Ygoing to experience any of the untoward effects from
. C5 x( ]- i# I6 m7 Stestosterone exposure as mentioned earlier because2 a m5 Q" n- J* _# {2 p
the exposure was not for a prolonged period of time.
0 I, i3 ^2 R5 j e9 }Although the bone age was advanced at the time of3 \7 Y3 U9 I/ J* q/ l( y
diagnosis, the child had a normal growth velocity at0 }/ l; k0 P% }" O T
the follow-up visit. It is hoped that his final adult7 p& W6 R) B; I2 j& b! o
height will not be affected.
' J1 ~% c. B) {" Y6 lAlthough rarely reported, the widespread avail-5 a W( n. w; B+ B& b
ability of androgen products in our society may: o3 E5 D3 u' ^% H9 Z3 o
indeed cause more virilization in male or female( {) t) f7 U6 G9 b' e
children than one would realize. Exposure to andro-
/ R; N; ]; |" C: x% T }9 dgen products must be considered and specific ques-9 B% ~+ ~" L) j$ f, V- E
tioning about the use of a testosterone product or
3 L) `! R) d: w! }2 _gel should be asked of the family members during
$ s2 E% G+ Z1 ethe evaluation of any children who present with vir-
' N* n7 p% |/ V- U' bilization or peripheral precocious puberty. The diag-
" m) L2 w: v Z1 S, fnosis can be established by just a few tests and by
2 }7 j3 Y( p$ X; C( |appropriate history. The inability to obtain such a
) X1 g e3 Q% I+ ^/ dhistory, or failure to ask the specific questions, may! ]$ f* I: b! l9 ^
result in extensive, unnecessary, and expensive+ b6 f2 U0 o6 x2 u) Z
investigation. The primary care physician should be
" e/ T& q/ D1 ^" P% ^aware of this fact, because most of these children5 r6 @" b/ ]- S# h
may initially present in their practice. The Physicians’8 u i; z# R" q: t6 ?" v; K
Desk Reference and package insert should also put a7 h/ \/ B! ^ C5 q/ E5 O8 b9 C
warning about the virilizing effect on a male or
* t5 b* H4 I3 m$ K6 I- z9 rfemale child who might come in contact with some-% ^% C2 d9 x0 N8 Q" p7 G) N( |
one using any of these products.
/ J3 F. Y. F) k% i8 ~References& L/ D) g ?. u# ~8 V, K3 F u& }8 E
1. Styne DM. The testes: disorder of sexual differentiation- N% s Y: {* P- p
and puberty in the male. In: Sperling MA, ed. Pediatric
6 r( I& j" w# a+ ^Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 F( E6 ?. v' H8 T9 `# v3 ^+ z) Q
2002: 565-628.
0 w4 F( `; \1 }6 Z* B1 J2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious+ R, C8 v; Q" ~' \
puberty in children with tumours of the suprasellar pineal |
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