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Sexual Precocity in a 16-Month-Old
3 r# |, H$ a9 r, M& aBoy Induced by Indirect Topical
. [6 A L1 g: K/ L: _1 q7 CExposure to Testosterone
/ ?2 E6 R9 g# `3 L, X. }Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2 q+ R2 w# i2 ]/ A; G9 d# W5 p
and Kenneth R. Rettig, MD1
* G/ y& y; u3 q- O- P$ gClinical Pediatrics: g* _$ d; w7 Q: x; t
Volume 46 Number 6% s# b7 ^) G7 [# H
July 2007 540-543
$ r. G, Q7 b8 C+ d© 2007 Sage Publications" P5 h: T, f, q0 ~& F' C
10.1177/00099228062966511 Q$ h1 u3 [" r$ `0 k0 F3 Q
http://clp.sagepub.com) u0 W/ y& d4 c: R% ]
hosted at5 @9 }! {# ]% Q u& C2 U
http://online.sagepub.com
, ^- _5 W) P/ A aPrecocious puberty in boys, central or peripheral,3 Z2 g- W$ P& @8 i0 H) d! A
is a significant concern for physicians. Central- [8 Z) b) L! s5 q7 R
precocious puberty (CPP), which is mediated# ?/ A' r" O$ k3 n( i
through the hypothalamic pituitary gonadal axis, has
8 V: ?3 l: [$ K$ d1 Z$ _) r; I/ n3 ka higher incidence of organic central nervous system
+ d# j {) P: Z% r: G9 \lesions in boys.1,2 Virilization in boys, as manifested4 ^: F9 y' X: z( T" i- C2 R
by enlargement of the penis, development of pubic( W0 A1 F6 D2 }: k" N! y2 g- n
hair, and facial acne without enlargement of testi-3 R# j5 S5 m0 ~; D/ m- Y* Y0 }
cles, suggests peripheral or pseudopuberty.1-3 We
! I' {6 V5 s4 V! W mreport a 16-month-old boy who presented with the# z: E3 h; M% w5 C# n2 \! x; F
enlargement of the phallus and pubic hair develop-
5 c8 m+ ?" q, A# ^+ R2 Yment without testicular enlargement, which was due
2 E3 d, C/ e# Q6 w J& u) C5 Jto the unintentional exposure to androgen gel used by
0 z3 M6 L7 A# M$ \: j5 |the father. The family initially concealed this infor-
8 j2 k4 \: y; N+ Emation, resulting in an extensive work-up for this
& w- G3 O6 ]1 P; J5 @: echild. Given the widespread and easy availability of, ?) x! O# b+ H: z5 d6 [
testosterone gel and cream, we believe this is proba-
9 ^" {! z7 c. G0 L3 @bly more common than the rare case report in the7 A) W. F# ?5 A0 j5 q
literature.4
# ]: q9 B* i! d# ZPatient Report
- T0 c* N' C7 m" K. W" k6 JA 16-month-old white child was referred to the1 K! h6 L a) o
endocrine clinic by his pediatrician with the concern. d* `. q8 ^) Z& B8 K( f
of early sexual development. His mother noticed2 Q0 F1 _' F% a% |
light colored pubic hair development when he was/ s1 {5 d) L! G: o2 z/ l5 U
From the 1Division of Pediatric Endocrinology, 2University of
" Q1 d# s+ U4 T' ZSouth Alabama Medical Center, Mobile, Alabama.7 o1 H, h- j+ \' K* P
Address correspondence to: Samar K. Bhowmick, MD, FACE,; f& c* U% M5 r; R. L0 h" A
Professor of Pediatrics, University of South Alabama, College of- M4 ]6 X5 V" s2 \0 d$ H+ I
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
7 o- l7 V) U3 ?$ ~e-mail: [email protected].
: v. j+ O' y+ mabout 6 to 7 months old, which progressively became
, \) d9 }( [ m) E7 @+ ndarker. She was also concerned about the enlarge-2 f1 h+ S3 }" ]# x: u, p
ment of his penis and frequent erections. The child0 K* L; K- r4 L
was the product of a full-term normal delivery, with
# r" y8 a+ [( }a birth weight of 7 lb 14 oz, and birth length of
/ V' B! v4 L8 i! `- ], x$ V20 inches. He was breast-fed throughout the first year5 U( P! f8 i' S/ H& f0 n
of life and was still receiving breast milk along with5 _0 u; s7 j2 T- K# B
solid food. He had no hospitalizations or surgery,
, `( s7 Z2 ^( v z0 ^, o- eand his psychosocial and psychomotor development
6 a3 ?' K/ P5 B6 @! [$ Uwas age appropriate.5 q7 ^/ u1 q: L# O
The family history was remarkable for the father,, P+ N* U, b: r+ l9 R3 [
who was diagnosed with hypothyroidism at age 16,
4 P/ d: I+ W$ u2 l t& U! x- kwhich was treated with thyroxine. The father’s
1 a. [: B2 I/ L& l. V9 G/ gheight was 6 feet, and he went through a somewhat. ~1 p$ B5 g& ` @# M. E+ k- j" r" Y
early puberty and had stopped growing by age 14.- p: o7 l7 l. m) f! V! @. ~( |
The father denied taking any other medication. The4 l: }0 W s" t, ~; `1 d
child’s mother was in good health. Her menarche5 k$ T6 u5 ? y% p* |+ Q
was at 11 years of age, and her height was at 5 feet
! O3 Q0 N1 I# p; j L0 `6 ?5 inches. There was no other family history of pre-$ \: x5 v4 q" _0 V: r
cocious sexual development in the first-degree rela-
1 m2 i Q0 h1 ~/ Rtives. There were no siblings.
' p* ], w- B0 O2 Y' QPhysical Examination
& W# F9 W+ ?& X6 y D" r' UThe physical examination revealed a very active,
, Y& m) ^; `6 G! Splayful, and healthy boy. The vital signs documented( k' y. B w4 R, q' {3 s! J" P
a blood pressure of 85/50 mm Hg, his length was; K" H7 ?! Z4 p4 r
90 cm (>97th percentile), and his weight was 14.4 kg8 Z* J8 ^! e* U
(also >97th percentile). The observed yearly growth4 m* K6 W3 f) [/ F
velocity was 30 cm (12 inches). The examination of/ v( E$ I" p7 _8 M1 B
the neck revealed no thyroid enlargement.6 o3 M. m6 c0 E+ \ ^! y
The genitourinary examination was remarkable for! q1 v2 T3 y% |; a0 g3 o2 ]; |
enlargement of the penis, with a stretched length of
% W* ]4 `8 A4 A6 J+ U8 cm and a width of 2 cm. The glans penis was very well8 Z) f, b' X; n7 V- l+ u
developed. The pubic hair was Tanner II, mostly around
1 p( [8 d ]# q- E5407 x" [( |2 {4 z$ h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 e: j+ ^7 \0 y6 u0 r4 ]- o
the base of the phallus and was dark and curled. The2 \, ~: `) l+ N% c
testicular volume was prepubertal at 2 mL each.* R/ W) U' a1 {$ G" ~# O4 b
The skin was moist and smooth and somewhat- k4 z" J4 \9 Y
oily. No axillary hair was noted. There were no
) u' U" F9 h C1 Pabnormal skin pigmentations or café-au-lait spots.* C W V$ l+ I. |8 A7 e. f
Neurologic evaluation showed deep tendon reflex 2+
6 s8 l3 P8 K# L& d" o- Ebilateral and symmetrical. There was no suggestion
% K7 E" D& q" w- |of papilledema.
, _8 l6 C8 H; m& o: R8 u$ c: RLaboratory Evaluation
/ T! o6 \. F' m! f3 aThe bone age was consistent with 28 months by
% J5 X' p! e4 [1 r+ Susing the standard of Greulich and Pyle at a chrono-3 l d8 Z- I5 b0 E- Q
logic age of 16 months (advanced).5 Chromosomal: e6 t+ h1 w( N
karyotype was 46XY. The thyroid function test
; X+ a$ D: O8 t8 X- Zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-7 V- o9 D5 ^2 d
lating hormone level was 1.3 µIU/mL (both normal).0 h" ~5 Z. Q! u+ N7 f0 Y, E! B
The concentrations of serum electrolytes, blood Y6 N# v: z* B
urea nitrogen, creatinine, and calcium all were2 B# v9 n3 \3 s/ E# _4 W
within normal range for his age. The concentration8 {3 a' m; i& [0 D; P
of serum 17-hydroxyprogesterone was 16 ng/dL
1 b/ P: f4 @: ` p(normal, 3 to 90 ng/dL), androstenedione was 20
" N! Z, g/ r9 J0 n7 M5 Ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
* g% H# l% l3 v8 nterone was 38 ng/dL (normal, 50 to 760 ng/dL),
, {0 G& N( B0 \1 v2 y( g# mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to2 @" t7 o7 @* N' f* S
49ng/dL), 11-desoxycortisol (specific compound S)
: L f% e, L. t1 I+ y- C6 ewas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 E: c! ^& C) [1 Q2 L. |% u% P, Gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 s, I2 k# n* Y: Y( E
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
& y! ^* U! _. `6 q5 b) ?6 Y4 E2 z5 \and β-human chorionic gonadotropin was less than
5 y0 q# G2 I2 J, [+ x, |7 c5 mIU/mL (normal <5 mIU/mL). Serum follicular
7 u8 l) O' R- Z2 q/ t. astimulating hormone and leuteinizing hormone
" Y( x, E( [ Yconcentrations were less than 0.05 mIU/mL4 c# Q* {6 g. L/ p( }5 J! P& I5 ^
(prepubertal).4 y( g; ]- d6 F: A
The parents were notified about the laboratory0 P! d8 V6 M. ~8 r
results and were informed that all of the tests were2 [2 Z2 e- {/ m7 I% f( v0 m& R
normal except the testosterone level was high. The3 h g: G: k% w% G/ r0 e1 f
follow-up visit was arranged within a few weeks to
, m' P5 h# a- \4 k/ e& ^: q; U& Gobtain testicular and abdominal sonograms; how-
3 _- H. y) n( _ `ever, the family did not return for 4 months.
6 p& ?3 J6 J# P# ~6 r" _Physical examination at this time revealed that the4 b1 b% j1 {, g" ~
child had grown 2.5 cm in 4 months and had gained
" [% s! l' e) L) N! x2 kg of weight. Physical examination remained
" D0 r+ l* M" X" Aunchanged. Surprisingly, the pubic hair almost com-5 W. o' m, P O
pletely disappeared except for a few vellous hairs at7 ]6 c1 W# \9 B/ q: V
the base of the phallus. Testicular volume was still 21 ~" @& \3 b @, o) I
mL, and the size of the penis remained unchanged.) q. p3 g2 O! Q- K( t- K
The mother also said that the boy was no longer hav-$ \- P$ T; y( Q$ g! e1 |. Y
ing frequent erections.- _3 A( B, z. }. W6 w: G) C3 _
Both parents were again questioned about use of
7 o9 n5 ^ C& H+ Cany ointment/creams that they may have applied to
0 q( X: q7 o8 l( `! Q$ u( B# H. bthe child’s skin. This time the father admitted the& N' y4 _- k; w7 b$ H; S
Topical Testosterone Exposure / Bhowmick et al 5418 ?1 W* M$ d; f4 [" o- I
use of testosterone gel twice daily that he was apply-0 e4 C; A. \3 O% T! K3 l& h. i$ T- D
ing over his own shoulders, chest, and back area for
3 q7 g( C1 D b2 ba year. The father also revealed he was embarrassed
7 J8 P6 r$ v9 r; p7 \8 Q& Yto disclose that he was using a testosterone gel pre-* ^% \: ^6 C- f9 J/ O8 T
scribed by his family physician for decreased libido
5 i" q$ L6 z% s/ }- m7 ]secondary to depression.$ K4 \( q& n" |+ Z
The child slept in the same bed with parents.2 p, G: J# U4 P! ^ @
The father would hug the baby and hold him on his3 ~0 I! y8 A2 d$ A
chest for a considerable period of time, causing sig-3 c8 S$ X" ]! j* e) P! k' q
nificant bare skin contact between baby and father.
9 I8 o. s# ]9 V! X UThe father also admitted that after the phone call,- \6 [5 t: ]7 k9 Y" o# b
when he learned the testosterone level in the baby
9 K$ a% P0 ^6 L9 T6 D; j! G2 \was high, he then read the product information+ j/ J# {" w9 `& t
packet and concluded that it was most likely the rea-. c7 Z5 Y4 N0 s5 A* ^( j
son for the child’s virilization. At that time, they
/ Z9 L! u3 q9 d" a( N9 ~% C5 Pdecided to put the baby in a separate bed, and the/ q2 S* @' v6 h
father was not hugging him with bare skin and had
& a( C& B7 g: ]4 e! l% M9 T2 Pbeen using protective clothing. A repeat testosterone
% t5 v! C0 l0 Rtest was ordered, but the family did not go to the
! h% a+ F2 D6 E2 Qlaboratory to obtain the test.
$ _$ w& ]. M0 d+ X/ W# z, ]Discussion' ^& T( g6 T6 Y! Z0 `6 D6 x
Precocious puberty in boys is defined as secondary/ `; D! i0 A: W( `9 m) `
sexual development before 9 years of age.1,4# d* i% ?$ \( V% v6 }$ R" A( h4 d
Precocious puberty is termed as central (true) when
, N. O. m, A8 I' h5 t! K S' W7 lit is caused by the premature activation of hypo-
8 N% C" W/ J1 J- F& Kthalamic pituitary gonadal axis. CPP is more com-. K1 z/ O$ j1 Y% ^9 {
mon in girls than in boys.1,3 Most boys with CPP5 M* x" g0 h) N7 {; ]
may have a central nervous system lesion that is
$ `! l6 S8 \$ }& G0 a/ S+ Vresponsible for the early activation of the hypothal-
9 K3 q5 |: }1 T; U8 r" Xamic pituitary gonadal axis.1-3 Thus, greater empha-$ a8 \. G+ s7 u3 ~6 u6 Y
sis has been given to neuroradiologic imaging in7 N6 z0 a. [9 s) w8 n
boys with precocious puberty. In addition to viril-
6 y5 Q6 E2 h& Y4 | u( l/ o7 W9 H" ]) uization, the clinical hallmark of CPP is the symmet-4 F5 d1 j' [- h% ]4 o2 J$ I
rical testicular growth secondary to stimulation by: g) j" E: G; H. a I
gonadotropins.1,3
/ {% [' K' v$ m+ d/ K0 |4 ~9 ~Gonadotropin-independent peripheral preco-: _+ Q/ a$ n; Z+ d
cious puberty in boys also results from inappropriate
1 ?* A' k" V* L+ M% @1 Vandrogenic stimulation from either endogenous or0 i2 R6 _( W* Y$ x6 |% x1 ?& N" }
exogenous sources, nonpituitary gonadotropin stim-
; v+ \5 u6 J/ x4 m& f" [1 rulation, and rare activating mutations.3 Virilizing
& `7 f: @) m! m xcongenital adrenal hyperplasia producing excessive
; q& U+ Q) \; x( j3 gadrenal androgens is a common cause of precocious
' h* q5 N" |, M1 S9 D; Q0 w5 W" Hpuberty in boys.3,4
! t; |: j- O7 r5 uThe most common form of congenital adrenal
: V! Y+ _2 ]# D! ?0 vhyperplasia is the 21-hydroxylase enzyme deficiency.' o7 ~3 ^" T2 d2 P6 G
The 11-β hydroxylase deficiency may also result in: n" Y7 L e$ v( r5 f$ y, n
excessive adrenal androgen production, and rarely,1 v& E) \% d" Q x' R
an adrenal tumor may also cause adrenal androgen) t% d E* |; @. w
excess.1,3
9 l0 O# p* T* G6 ^# }- x+ Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, Z/ M; w1 A" }( K9 f
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007+ }9 ^+ ^/ O% H8 {) [
A unique entity of male-limited gonadotropin-
) N2 _& l4 G2 {independent precocious puberty, which is also known4 X5 H) F1 I! ^0 G
as testotoxicosis, may cause precocious puberty at a
5 r, g: R& q! p- ~very young age. The physical findings in these boys+ H6 p, t! U2 I% g
with this disorder are full pubertal development,
+ O& r* L0 |4 ?including bilateral testicular growth, similar to boys- t! i& D# m: T
with CPP. The gonadotropin levels in this disorder
/ A2 P* C! b6 Z2 R- mare suppressed to prepubertal levels and do not show) h+ s. v. n$ X
pubertal response of gonadotropin after gonadotropin-
5 k% ~& e9 c- i% c) z& |! Yreleasing hormone stimulation. This is a sex-linked3 k: i( k3 `5 M! y: F' x
autosomal dominant disorder that affects only# |* v* b) K* J% ?3 t& A0 k
males; therefore, other male members of the family3 \, _: K' I2 H! k1 M- K0 U% H& P
may have similar precocious puberty.3! M7 d8 ~ M2 A. r. S
In our patient, physical examination was incon-- V- p( A: w9 B
sistent with true precocious puberty since his testi-! t$ ]8 j) K# |: Z0 h
cles were prepubertal in size. However, testotoxicosis
# l+ s) [+ A2 P' l' b3 V4 dwas in the differential diagnosis because his father) G5 |6 C4 e. i2 `7 K9 b
started puberty somewhat early, and occasionally,5 q9 X% W: K0 N7 d/ U
testicular enlargement is not that evident in the
' S7 w& D5 B6 I; ubeginning of this process.1 In the absence of a neg-# M+ J% {9 C1 J7 g9 f
ative initial history of androgen exposure, our
( t# m) a' a+ Y* @; ]biggest concern was virilizing adrenal hyperplasia,
" t1 F5 @9 d0 | T4 h1 ^8 b2 Veither 21-hydroxylase deficiency or 11-β hydroxylase( R/ H0 R* k# a; a, b! t" g2 j0 K
deficiency. Those diagnoses were excluded by find-) C. `% ^( K$ U9 ]3 U5 f# H
ing the normal level of adrenal steroids. [: L4 H- O" f! n) P+ y+ r( K
The diagnosis of exogenous androgens was strongly
9 O1 u% ?% O3 {8 Tsuspected in a follow-up visit after 4 months because' d0 I) x, C2 W, a- L
the physical examination revealed the complete disap-
( M& o( q# G1 l" Wpearance of pubic hair, normal growth velocity, and
- L* |" G. X& d+ ^) C7 p( x, wdecreased erections. The father admitted using a testos-
& |$ Z3 ?- u- o \terone gel, which he concealed at first visit. He was1 J, j* ]7 e$ _8 y( J f u+ e: ~: r
using it rather frequently, twice a day. The Physicians’
$ [' q* O m/ \+ _5 G. c4 ^Desk Reference, or package insert of this product, gel or
& ]" q7 I7 Z6 d6 r1 A4 `/ U: F/ q( @cream, cautions about dermal testosterone transfer to }8 Q7 M U9 Q% J1 R3 o
unprotected females through direct skin exposure.
: Q6 ^2 d0 I4 W8 d0 C! j. uSerum testosterone level was found to be 2 times the
2 U& V! {: r. _baseline value in those females who were exposed to
5 b8 |9 Y0 Z' |+ Z: z! x3 N3 Peven 15 minutes of direct skin contact with their male: w. Z5 S$ R3 W! @( E+ ]" {
partners.6 However, when a shirt covered the applica-
! S4 o, E* Z, Vtion site, this testosterone transfer was prevented., c N% I: K- D0 P" Q6 ]7 o s& l
Our patient’s testosterone level was 60 ng/mL,) c' ~! K* `. v) h3 \9 B
which was clearly high. Some studies suggest that
0 x! K) ]7 U Q) ?$ F# B }5 L( Rdermal conversion of testosterone to dihydrotestos-
' t+ n) t$ }& J6 Gterone, which is a more potent metabolite, is more3 o& E4 v% V7 I& s0 L) R9 W
active in young children exposed to testosterone
: M0 E" Z& w0 L5 l" ? e- Pexogenously7; however, we did not measure a dihy-
' ?4 ]' i; T0 X3 jdrotestosterone level in our patient. In addition to- C& {: F/ U: A$ k6 @7 v& K8 b
virilization, exposure to exogenous testosterone in2 m" f# h5 M: T5 [1 O/ R7 L
children results in an increase in growth velocity and0 c1 B- J8 I' ?' m
advanced bone age, as seen in our patient.9 E6 R: c7 {8 d3 D! E* Q" J
The long-term effect of androgen exposure during
2 t8 W4 A! B- _, A5 f$ Pearly childhood on pubertal development and final
- u' d0 O; ^0 q% @& [6 Y% q5 x" Xadult height are not fully known and always remain. j7 O% H% N4 |+ F5 ]- O! q4 O
a concern. Children treated with short-term testos-4 Z8 c I" J+ Y
terone injection or topical androgen may exhibit some8 M, c: a# ]8 r: I7 v. \
acceleration of the skeletal maturation; however, after* x3 F8 w7 a. ^. k
cessation of treatment, the rate of bone maturation
' B( o7 H) `: q( d) u2 P( i' H( A& \decelerates and gradually returns to normal.8,9
2 {+ d2 [# Y: C7 Q& `There are conflicting reports and controversy
! m; v; x- k H! q9 X- _3 Y) Jover the effect of early androgen exposure on adult2 @ n6 I7 n% t* ^
penile length.10,11 Some reports suggest subnormal+ q# N2 H. J" t" K( h8 x
adult penile length, apparently because of downreg-! f# Q* h7 y) y) k; h
ulation of androgen receptor number.10,12 However,
; `/ o, v( s: O; i. ~Sutherland et al13 did not find a correlation between
# f2 R/ G& j6 Z$ J, Bchildhood testosterone exposure and reduced adult
/ w- t. \: ~/ d v4 c' h, Y$ T a$ e7 rpenile length in clinical studies.$ u6 E/ W5 G$ y% e/ b+ e
Nonetheless, we do not believe our patient is& A, P- y# d$ C/ g& ^
going to experience any of the untoward effects from3 G% S! ~+ m2 j g5 y3 w1 Q( E
testosterone exposure as mentioned earlier because
3 z$ ?- }. ?" P# j5 nthe exposure was not for a prolonged period of time.
. h" n1 T' N5 e* {8 f1 ?! qAlthough the bone age was advanced at the time of+ R1 ]; I5 A# V r
diagnosis, the child had a normal growth velocity at
# u5 G+ Z0 a& m8 Q$ w; mthe follow-up visit. It is hoped that his final adult
8 @" n4 Y/ K c; H% F! }8 ^height will not be affected.
8 }7 t: @2 c2 {8 l$ TAlthough rarely reported, the widespread avail-/ E# d5 D6 O) ]/ }
ability of androgen products in our society may
' a6 x. `) a' q8 [# Nindeed cause more virilization in male or female
2 o; i" u$ S& b) j$ Achildren than one would realize. Exposure to andro-7 ]) k, B& o' }+ K! C
gen products must be considered and specific ques-
" F# ~6 P4 R. O" _tioning about the use of a testosterone product or
/ Q& M- z5 L4 i) D( q- _gel should be asked of the family members during
{0 |1 [5 p) j& `2 t I7 Wthe evaluation of any children who present with vir-
, z: s6 n" r$ f r1 zilization or peripheral precocious puberty. The diag-
Q# u* f& }2 O! p3 t3 N& U$ enosis can be established by just a few tests and by
/ p) h7 |* N9 B4 {% fappropriate history. The inability to obtain such a
& P% |& b) M% O/ v1 X3 W' uhistory, or failure to ask the specific questions, may
. i8 D, S$ L# q' }* \0 j2 g" Uresult in extensive, unnecessary, and expensive
8 p; z" W n) ]) H4 x% o3 k3 `investigation. The primary care physician should be
& q+ v3 _. y6 |7 _4 Uaware of this fact, because most of these children N- B) w7 r3 w6 J% H* [' f
may initially present in their practice. The Physicians’
4 i. C+ j, d# Y' Y. u E1 a; S- E9 HDesk Reference and package insert should also put a
, h; g% d- i, b D# L1 W7 t( ~- x" D8 \warning about the virilizing effect on a male or2 y/ w6 q# A( p) q
female child who might come in contact with some-- ?: s; e' `$ ?$ [7 H. P
one using any of these products.# F9 u6 n8 f9 e
References
' o. d# H; Y8 n1. Styne DM. The testes: disorder of sexual differentiation; ]; b& G, q$ L: U
and puberty in the male. In: Sperling MA, ed. Pediatric' \1 _. w3 m9 _7 W, q- l
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;# S# x- b6 z2 T9 t! @
2002: 565-628.
& N r& d- D- B; p2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" C. t- B( Z2 i g7 T
puberty in children with tumours of the suprasellar pineal |
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