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Sexual Precocity in a 16-Month-Old- P5 W5 P( S5 i* `- p- e; H
Boy Induced by Indirect Topical
: T" D1 [* x( U( |4 V8 ?, @) QExposure to Testosterone
) C1 V+ `% M, x5 R }6 D. ESamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! l$ Z/ p# J8 E! V( d. I; [" q
and Kenneth R. Rettig, MD1
; N/ m, ]' h5 V, y1 U, O1 sClinical Pediatrics
2 r& j" X; B# {' d& |Volume 46 Number 6
8 i$ L3 f; t) i, l3 ~ W! [/ p* R/ F( aJuly 2007 540-543
9 g4 P& w4 [+ r6 y) l, @© 2007 Sage Publications
/ H9 i$ v" l2 `10.1177/0009922806296651
. w g1 {1 z+ p! E& t: ]: e# {% Qhttp://clp.sagepub.com( F! q2 Z8 o ?
hosted at$ |7 D" Y: t# ~& h- z+ x* q' e
http://online.sagepub.com0 |0 z9 i$ Z [: M7 f: v& k
Precocious puberty in boys, central or peripheral,
k1 x' N6 L# L, P5 Z4 O5 `is a significant concern for physicians. Central
* O2 s* t8 r0 Aprecocious puberty (CPP), which is mediated
3 Q: U) ^' L/ O9 ~through the hypothalamic pituitary gonadal axis, has
9 I% q5 p. k0 ba higher incidence of organic central nervous system
0 i' r! Z# T7 z. e& Plesions in boys.1,2 Virilization in boys, as manifested- k0 o7 @! n: a& T% J i7 O4 @7 }
by enlargement of the penis, development of pubic T" D0 E! J4 k, D/ @$ Z3 ?" }
hair, and facial acne without enlargement of testi- x2 @0 m0 Q, u# {0 ?' f" N2 J
cles, suggests peripheral or pseudopuberty.1-3 We
& U) k( {- v& H, P% Qreport a 16-month-old boy who presented with the
2 D" m' W2 k9 d6 kenlargement of the phallus and pubic hair develop-
4 b0 W$ W# z4 {ment without testicular enlargement, which was due2 \4 T4 T0 }; w& E3 K# I) P
to the unintentional exposure to androgen gel used by
, q1 F0 P' F) _: q" ~the father. The family initially concealed this infor-
# Y* Y% l* f) P- dmation, resulting in an extensive work-up for this
; i8 `4 L5 |& c$ x. Bchild. Given the widespread and easy availability of
! T, X C i% |: G& J7 otestosterone gel and cream, we believe this is proba-
0 e |2 J" e; ^0 lbly more common than the rare case report in the
! G3 q. H! T7 zliterature.4; l2 T3 i5 W* C. o9 `
Patient Report x) e- S; ]; ^- G4 P/ R
A 16-month-old white child was referred to the- \6 J. Y# c0 v
endocrine clinic by his pediatrician with the concern
2 Y0 P7 _: l( ^6 m; dof early sexual development. His mother noticed
' v5 T( G8 d/ z* Z1 i# x* [( {light colored pubic hair development when he was
4 c/ f+ \. ? s8 X0 ~* v, w( fFrom the 1Division of Pediatric Endocrinology, 2University of
9 I# ^* b; F2 b6 P; \" S3 q& H. K& O& QSouth Alabama Medical Center, Mobile, Alabama. m9 t3 h/ q* \
Address correspondence to: Samar K. Bhowmick, MD, FACE,
$ r- R) X; ^4 V6 H7 p1 \Professor of Pediatrics, University of South Alabama, College of
- C q/ }4 P' f( O) aMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) i- K G9 r. B: l6 t
e-mail: [email protected].: N2 D3 j4 }* v' o# q8 u
about 6 to 7 months old, which progressively became
. ]) a' C8 e" Q6 edarker. She was also concerned about the enlarge-
$ J7 W3 G1 N( Z; e0 K {% ament of his penis and frequent erections. The child
% n3 Q5 m% T+ Z i$ j/ {was the product of a full-term normal delivery, with9 Q% w( b7 G. p& ]" J
a birth weight of 7 lb 14 oz, and birth length of6 C' \8 A- Y* w% |; W9 ~- r5 D
20 inches. He was breast-fed throughout the first year
1 |9 W( J) T8 r8 e2 A5 W4 [of life and was still receiving breast milk along with
) e) ]% i0 q5 @4 usolid food. He had no hospitalizations or surgery,
! j5 k% t) `7 C5 b& j! Nand his psychosocial and psychomotor development
2 O* c* m1 d% bwas age appropriate.3 r! i( F6 g0 \2 [+ B
The family history was remarkable for the father,$ c& m& a" G8 _0 R' u
who was diagnosed with hypothyroidism at age 16,
v9 k( W6 L9 o& g+ O! E1 Owhich was treated with thyroxine. The father’s% P9 ] D% {3 i1 N
height was 6 feet, and he went through a somewhat% J( y# T$ q4 R1 ? B2 h4 l3 |. H, A$ F; C
early puberty and had stopped growing by age 14.& A- p7 R( R" Z# v. S" @
The father denied taking any other medication. The* [% E$ q& x- v- s9 P6 Z5 o
child’s mother was in good health. Her menarche
, Q( ^0 s8 h, I& c) Zwas at 11 years of age, and her height was at 5 feet
1 R% k" V2 _! f4 K9 X& J8 J6 L* C' ^5 inches. There was no other family history of pre-2 Z* J7 i7 O* [) _) M# w. V
cocious sexual development in the first-degree rela-) [+ g' R3 k! l
tives. There were no siblings.& {! ?5 g# R* h, \% x; w
Physical Examination( S3 E& @( x% m$ t2 d* n
The physical examination revealed a very active,+ T) c% m3 D8 Z" `7 h3 v- B
playful, and healthy boy. The vital signs documented0 s+ V% I7 S% p0 G: I0 X
a blood pressure of 85/50 mm Hg, his length was3 C+ m, }' t' [7 \
90 cm (>97th percentile), and his weight was 14.4 kg
9 W9 @' u( T. Y1 A2 z' X0 H/ v(also >97th percentile). The observed yearly growth8 V& q! ~* S: e$ Z8 G* V* Y9 ^( Q
velocity was 30 cm (12 inches). The examination of% C" Q9 E# d' M% B
the neck revealed no thyroid enlargement.
1 ]8 s8 [' y$ I( V) G0 qThe genitourinary examination was remarkable for
8 q- a' j, e/ m( y& W0 ^& E+ `enlargement of the penis, with a stretched length of$ g) z; \% O/ x4 m/ O% y* R. i
8 cm and a width of 2 cm. The glans penis was very well5 ]& G$ H6 C% N0 L/ d2 a
developed. The pubic hair was Tanner II, mostly around, m7 t) v, `" L6 b) t' E& {7 ~
540
+ l) z, C8 v/ b2 [( ~9 ?at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; t0 A [1 k* z' K& X N4 m2 R8 j
the base of the phallus and was dark and curled. The
# B0 G. @3 E; U( R- S5 ztesticular volume was prepubertal at 2 mL each.
5 a& d$ Y" t" ~% p6 ~The skin was moist and smooth and somewhat
6 y6 f) ?. I* w2 u; l. S- t8 l: foily. No axillary hair was noted. There were no! n# S) `9 c( f% S2 Y7 H
abnormal skin pigmentations or café-au-lait spots." w5 I' Y: _6 M# {4 a# A- U
Neurologic evaluation showed deep tendon reflex 2+
0 s) A0 {4 t6 A& {/ sbilateral and symmetrical. There was no suggestion
1 U) c! m% ^8 m" F0 H( y* M& M: _* ~of papilledema.
5 `1 _$ r% x( D- Z' Q8 iLaboratory Evaluation7 U! Z2 A: M% m/ q; c+ O
The bone age was consistent with 28 months by
/ F. S0 J: j* Vusing the standard of Greulich and Pyle at a chrono-
$ k' P5 V [$ F xlogic age of 16 months (advanced).5 Chromosomal
! Z% T9 _! I9 N" xkaryotype was 46XY. The thyroid function test+ F5 W" T* }1 U# t' d
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
?" W* @% u8 o6 A$ D2 [lating hormone level was 1.3 µIU/mL (both normal).9 I9 W0 J+ j6 `" B
The concentrations of serum electrolytes, blood
6 i& C y" L9 I( Eurea nitrogen, creatinine, and calcium all were( n: Q2 w, u3 F/ ]; i G5 y
within normal range for his age. The concentration
8 S0 ]9 T5 e+ Y9 `% _! r3 Y2 aof serum 17-hydroxyprogesterone was 16 ng/dL! g! @2 m. n) ]! ~% N. A" ]- \. I
(normal, 3 to 90 ng/dL), androstenedione was 20
; f2 d: f/ T; [% U1 Fng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 B8 d" w0 i0 u" @terone was 38 ng/dL (normal, 50 to 760 ng/dL),# K6 y' ]% C& P6 ?
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 A* Q3 \" X1 p5 P& X49ng/dL), 11-desoxycortisol (specific compound S)) z( m! `5 A$ B' @/ U3 L" o
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
( y& r+ g4 |" @# a6 q3 }! N. |+ Ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& R- A) J2 G; u; K: r( l+ Q4 y0 @
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),! O0 y8 Q, \# T( n
and β-human chorionic gonadotropin was less than" `* G% N- H, M+ h/ }
5 mIU/mL (normal <5 mIU/mL). Serum follicular; x, e7 w% u" |0 E4 x
stimulating hormone and leuteinizing hormone
' ^; s3 ]2 y1 nconcentrations were less than 0.05 mIU/mL5 [4 {5 G7 z- R1 C. V
(prepubertal).
* I, q6 ]- q6 d0 o5 m6 R! S! OThe parents were notified about the laboratory
2 O1 e# N5 @2 M" ?7 }results and were informed that all of the tests were' t! S; d! X% H% ~3 y
normal except the testosterone level was high. The D. u( T, Q4 q; i; P( X
follow-up visit was arranged within a few weeks to
+ w5 v' t3 z/ o; x: _obtain testicular and abdominal sonograms; how-' l' ^9 ]. s, G5 S* k" u0 N/ q1 ^
ever, the family did not return for 4 months./ N* r; U# A0 `
Physical examination at this time revealed that the2 a. W5 B4 f; q: A9 h1 u% ^
child had grown 2.5 cm in 4 months and had gained
) N9 o' K/ U; T% B5 [1 Q$ B2 kg of weight. Physical examination remained3 k$ S+ I2 p1 `4 l/ e
unchanged. Surprisingly, the pubic hair almost com-# R' z; w. O3 ^
pletely disappeared except for a few vellous hairs at+ P% p# Q6 A6 T! @4 e4 V8 u
the base of the phallus. Testicular volume was still 2- s5 E3 L4 }0 \" I: } U, ?4 I1 G F
mL, and the size of the penis remained unchanged.
Z' N4 d0 ~0 n% `* O+ IThe mother also said that the boy was no longer hav-
3 [! S" O0 ?( A/ u1 }5 ping frequent erections.; f% X$ D! d5 |5 x+ N9 N8 t
Both parents were again questioned about use of
* O# P* O' H- ^* g8 W2 N/ c! wany ointment/creams that they may have applied to z6 L9 @2 P( }; U. H
the child’s skin. This time the father admitted the
7 n9 k. N. F* ?" F% JTopical Testosterone Exposure / Bhowmick et al 541" h' X8 }/ f# ?8 m2 L1 M t
use of testosterone gel twice daily that he was apply-
6 l& ?1 u; g$ @( zing over his own shoulders, chest, and back area for9 H: I/ W3 k$ p! A2 Z& G, B: H
a year. The father also revealed he was embarrassed' N0 w5 N* o) O' c1 w
to disclose that he was using a testosterone gel pre-
( W% o$ {! N5 o5 _3 i- xscribed by his family physician for decreased libido
/ \. A6 r( o+ n7 a' O1 y6 F: O msecondary to depression.7 h+ ^) t* X8 z9 s/ g1 V* U7 c
The child slept in the same bed with parents.! d$ F2 |% n, D/ N. f# Z
The father would hug the baby and hold him on his' X: | L {9 T; s" E
chest for a considerable period of time, causing sig-$ |0 ~8 e; {' i0 r! q7 r8 z
nificant bare skin contact between baby and father.. W8 P) O* `: ]* y% E: S
The father also admitted that after the phone call,; c0 A" a; F6 R3 r
when he learned the testosterone level in the baby, B- L, n+ a8 J4 w1 c8 g
was high, he then read the product information0 m" N/ L3 h& N" j! z% X/ e+ f
packet and concluded that it was most likely the rea-: n5 L" J, ^4 } J
son for the child’s virilization. At that time, they
1 p- _. @) x; S# g/ Cdecided to put the baby in a separate bed, and the
) c5 { {# v+ R8 yfather was not hugging him with bare skin and had
# h2 s8 O& _; C) d/ lbeen using protective clothing. A repeat testosterone
/ g; W3 ?% t# R4 B5 x1 Otest was ordered, but the family did not go to the( m0 y6 d, L: q& D$ K/ N) N
laboratory to obtain the test.6 u" V5 U) m- d2 `, H0 o# g, L
Discussion1 I4 e2 J& H7 E" |4 \& o
Precocious puberty in boys is defined as secondary- R% }: T7 \/ t8 J# i
sexual development before 9 years of age.1,4
`5 \) y' k* xPrecocious puberty is termed as central (true) when0 }5 h4 r6 C: k- W: G
it is caused by the premature activation of hypo-4 k6 |* Z" H! \5 [5 @/ E7 Q( y4 s: q
thalamic pituitary gonadal axis. CPP is more com-$ Y& i3 z( Z% O: ~* p3 i
mon in girls than in boys.1,3 Most boys with CPP
% ?4 z2 L$ s+ c; ?3 } ~may have a central nervous system lesion that is
+ z3 o, {/ ]% u( R9 ?$ mresponsible for the early activation of the hypothal-
- g' ^6 ]7 R& \; L2 E- G& F1 [amic pituitary gonadal axis.1-3 Thus, greater empha-
! P2 O% [9 l9 o* o/ Asis has been given to neuroradiologic imaging in
. D3 t T2 O B* o7 [/ y8 l+ Gboys with precocious puberty. In addition to viril-4 t# F" u4 t" N
ization, the clinical hallmark of CPP is the symmet-
; T- f% M, ^: [1 f- w) ^- Xrical testicular growth secondary to stimulation by) b4 B. l( x/ i# ^
gonadotropins.1,3( m' B/ Q4 k* k3 g- e/ N% Y
Gonadotropin-independent peripheral preco-
9 P; q5 ^- ^# a# v. `cious puberty in boys also results from inappropriate
9 `6 I1 Q' Y% T5 Pandrogenic stimulation from either endogenous or D* Y5 M/ u1 b$ n7 `
exogenous sources, nonpituitary gonadotropin stim-! A! X$ [: ~. ?5 D) ]
ulation, and rare activating mutations.3 Virilizing# v4 ^1 A$ r3 P5 J% r
congenital adrenal hyperplasia producing excessive
* O' m! L! [0 g: O) D7 ?/ v2 Jadrenal androgens is a common cause of precocious
! h; W8 Q* E- o# T* I0 Upuberty in boys.3,4+ J- ~% w7 W# a. `' U, y) h- l
The most common form of congenital adrenal/ M6 C; r% r# M( G4 v8 B/ A
hyperplasia is the 21-hydroxylase enzyme deficiency.
1 h. q) T, r ZThe 11-β hydroxylase deficiency may also result in6 ?) a! P2 [8 }9 C* X
excessive adrenal androgen production, and rarely,
Q2 F* K) M$ r `) e4 P7 n yan adrenal tumor may also cause adrenal androgen
$ U* o1 q( A+ S9 \5 Q0 y! r- o& O3 ]excess.1,3
- `9 G0 }) z9 ~5 u2 E( }/ Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& J1 L6 z8 [8 X% e' |542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 r1 i/ S ~5 H2 f! x, _A unique entity of male-limited gonadotropin-
+ v2 [4 {# Z, L, jindependent precocious puberty, which is also known# z& e1 i# @ o J: f
as testotoxicosis, may cause precocious puberty at a) d6 ~! n+ }* ~* y) k0 e a, z
very young age. The physical findings in these boys. W# p! o' G) n& O' X1 ^
with this disorder are full pubertal development,
3 q; G" H( k5 xincluding bilateral testicular growth, similar to boys
8 D, [6 e! H9 J: Qwith CPP. The gonadotropin levels in this disorder8 U' J& m7 `: t$ b* j- e
are suppressed to prepubertal levels and do not show0 i6 H# B+ j" V' S. T- H
pubertal response of gonadotropin after gonadotropin-& |2 P$ r2 b! h. a$ k! \
releasing hormone stimulation. This is a sex-linked" i/ J" D& ]2 ?7 Y
autosomal dominant disorder that affects only5 j* B: o" w. T: r: m3 z
males; therefore, other male members of the family! F0 P3 i0 g7 M, ]; o, i
may have similar precocious puberty.3/ ?% Z4 c( Y# A! ]) q' N. @
In our patient, physical examination was incon-
! n) C6 `$ c4 o9 Dsistent with true precocious puberty since his testi-
1 Y' ]( J( s; b' L5 V7 H, Icles were prepubertal in size. However, testotoxicosis1 k. H( r2 X+ a1 J& `* c7 U! N h
was in the differential diagnosis because his father
" `+ H9 H" ], t x0 X8 m9 ^started puberty somewhat early, and occasionally," {2 w9 C: Y- I
testicular enlargement is not that evident in the/ U$ [8 Z* f1 m0 C# L$ C3 I
beginning of this process.1 In the absence of a neg-: N3 w" ], m1 L- Q& @/ g7 Z
ative initial history of androgen exposure, our
% r* g% R& _$ D% \biggest concern was virilizing adrenal hyperplasia,
% I: Z8 X, u; u- `1 t0 B- ?* {* K9 veither 21-hydroxylase deficiency or 11-β hydroxylase! g9 U/ r( e1 J3 ?1 f+ n% q
deficiency. Those diagnoses were excluded by find-5 X9 I9 q6 Y% \. e; L
ing the normal level of adrenal steroids.4 y; |% S. n0 |; X0 u. f0 z
The diagnosis of exogenous androgens was strongly
$ z( N6 Y& E# L0 M8 @suspected in a follow-up visit after 4 months because" c4 D5 N' h j) v0 C
the physical examination revealed the complete disap-- |9 T! `1 x+ ~7 l
pearance of pubic hair, normal growth velocity, and, h2 A% t5 ?0 G- A4 y8 h
decreased erections. The father admitted using a testos-
/ p( N1 P3 x& b: X) vterone gel, which he concealed at first visit. He was
" i4 { y7 U8 u5 J+ ]using it rather frequently, twice a day. The Physicians’
; v. d0 _" N: B8 ^Desk Reference, or package insert of this product, gel or" R, [/ l4 Q% A0 a7 ~
cream, cautions about dermal testosterone transfer to7 e+ c" W M+ n. x
unprotected females through direct skin exposure.
# _- ~: v+ s+ J+ p4 k bSerum testosterone level was found to be 2 times the6 A% Y L' D5 n/ B, {
baseline value in those females who were exposed to W6 F/ [4 J, L3 p+ {2 Z7 s
even 15 minutes of direct skin contact with their male
4 l* Y- f' K- |partners.6 However, when a shirt covered the applica-; V0 _5 @4 g9 D1 a5 |; {5 ]! r7 W
tion site, this testosterone transfer was prevented.5 s' X) i' Q0 N6 G
Our patient’s testosterone level was 60 ng/mL," ^. q( W5 @0 ~& x
which was clearly high. Some studies suggest that
# \& N, Z, t5 l; Ydermal conversion of testosterone to dihydrotestos-6 ^" E8 [! i6 z' U0 U
terone, which is a more potent metabolite, is more6 h' T3 h7 ]* }
active in young children exposed to testosterone* w/ A9 R# W7 R9 E/ S6 ], J
exogenously7; however, we did not measure a dihy-3 P! L, w+ U: v. ~2 w4 H
drotestosterone level in our patient. In addition to) a* ^ T) H9 T. a, @
virilization, exposure to exogenous testosterone in
E% b: C' p& @6 A7 M4 Wchildren results in an increase in growth velocity and6 O+ `$ ~1 |! R* A9 Q
advanced bone age, as seen in our patient.
! \3 d' K3 @$ A3 B# x% YThe long-term effect of androgen exposure during8 R2 ]1 A, y5 a/ ?% _2 k1 C
early childhood on pubertal development and final
" i! u' @* ~- Z5 y+ }8 M* G& @% wadult height are not fully known and always remain/ P% z% |. h# Z) L" L6 X4 d
a concern. Children treated with short-term testos-
' C2 Q- v" o! Lterone injection or topical androgen may exhibit some% |8 w+ R# p. ]+ [2 _5 I
acceleration of the skeletal maturation; however, after
( x5 k) R8 ]9 u0 R6 ~cessation of treatment, the rate of bone maturation
- |( ], p5 e% R; K5 [* z# X/ s4 [decelerates and gradually returns to normal.8,9" v; V( w# z( V0 M! y
There are conflicting reports and controversy3 Q$ T. m2 P1 H
over the effect of early androgen exposure on adult
* b7 L& t) J3 C- l& A, bpenile length.10,11 Some reports suggest subnormal
5 W5 Z7 T. A. \) J. yadult penile length, apparently because of downreg-0 e2 P$ e1 H& T: ]2 e' {- W
ulation of androgen receptor number.10,12 However,1 F; F0 ~" T, c/ L5 I% K. p) v
Sutherland et al13 did not find a correlation between7 v: o7 B5 G2 }, ]& e, e
childhood testosterone exposure and reduced adult
) S* ?& R( {/ W# t' J: rpenile length in clinical studies.0 [" ?& W2 F# h
Nonetheless, we do not believe our patient is
8 A) G( Q8 `# Q+ M! a- S$ ]; mgoing to experience any of the untoward effects from* b7 G: K4 O% g
testosterone exposure as mentioned earlier because
/ D2 Z/ a- T5 J& H/ Othe exposure was not for a prolonged period of time.- V3 F5 y- {3 }' { u
Although the bone age was advanced at the time of1 K4 P# }) o. w% X N, k& m2 {: ?
diagnosis, the child had a normal growth velocity at, g! D; k6 f& B7 X" X% I
the follow-up visit. It is hoped that his final adult" C* e) l% B' @$ \
height will not be affected.- `( p% n2 R, D* O; t( t
Although rarely reported, the widespread avail-! K3 d1 s) z9 R) e4 ]1 o
ability of androgen products in our society may- y2 Y: P3 e6 e! _% e
indeed cause more virilization in male or female
' l2 ~1 l- R9 i5 g0 U8 ichildren than one would realize. Exposure to andro-4 F3 n0 O2 S2 t) w4 H
gen products must be considered and specific ques-
, B4 Q) ^% O! I( T! Z. ytioning about the use of a testosterone product or8 I1 E: p2 g& P/ J7 X
gel should be asked of the family members during) U+ E) a, e' k8 Q# u' {
the evaluation of any children who present with vir-3 P% a$ e) c7 H- y
ilization or peripheral precocious puberty. The diag-
" H" g" T& S, e2 U4 wnosis can be established by just a few tests and by3 I5 S& ]0 e' Y+ L4 X1 z4 p* q
appropriate history. The inability to obtain such a
+ G& `7 Q6 j, S8 o8 c! E7 H3 v6 vhistory, or failure to ask the specific questions, may
7 {1 b4 A8 E# v Yresult in extensive, unnecessary, and expensive' h: t( K: H% H7 M3 Z
investigation. The primary care physician should be9 N% U( ^- l k7 w( v1 Q. L9 I$ t2 ^* W6 H
aware of this fact, because most of these children
. C+ `+ d( @# kmay initially present in their practice. The Physicians’# Q* e8 G- q; b4 e/ A9 g; p
Desk Reference and package insert should also put a4 ?# I# W& Z! V: u l
warning about the virilizing effect on a male or/ ?, r8 e# f4 j& g0 i
female child who might come in contact with some-- I9 [' b* R' ~- T) }% `
one using any of these products.. g2 j$ R. @3 N+ Q' W
References7 g/ D$ q* {, A- p' K( Z: Q4 G7 z
1. Styne DM. The testes: disorder of sexual differentiation
# F q9 e4 |8 r1 b' k0 Iand puberty in the male. In: Sperling MA, ed. Pediatric
* A6 r/ w3 M) g Y9 B6 F2 sEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
' h5 G4 M+ o" R2 J2002: 565-628.
7 i1 b+ |/ Z0 X1 R, s6 `5 w/ G' Y2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 Q. D7 v5 h0 J; ]* ipuberty in children with tumours of the suprasellar pineal |
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