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Sexual Precocity in a 16-Month-Old
: s: Y) v6 d2 r2 u4 }9 yBoy Induced by Indirect Topical: ]" B( O1 _) o5 ^% f
Exposure to Testosterone7 k" U" K- {3 L2 c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 r9 f' S& `: H. S0 `: r
and Kenneth R. Rettig, MD1. e: ^- u- l2 @2 K
Clinical Pediatrics/ | e# Z' F% a5 T; l! n/ e
Volume 46 Number 6
1 m4 z2 o+ _& \4 v- @July 2007 540-543
; S! l# s6 B2 D1 ^$ o© 2007 Sage Publications
' [' q* R7 k6 H* h# n9 ]0 g4 g10.1177/00099228062966513 M s; [0 A4 ~& ?
http://clp.sagepub.com
. ^+ f% a( C9 }2 ]% G! Ihosted at
" z1 ~! |' H9 P9 `4 m/ Nhttp://online.sagepub.com8 [& l9 V0 U# i2 c6 n+ U" a
Precocious puberty in boys, central or peripheral,/ f6 w/ Z: z. Z$ E; Z5 S
is a significant concern for physicians. Central
g, h$ p, J6 \* v: P# D& tprecocious puberty (CPP), which is mediated5 i3 ` g& ^! r/ U; M+ i
through the hypothalamic pituitary gonadal axis, has8 @6 d. ~; F3 S: X
a higher incidence of organic central nervous system6 z% G) R7 D# n k
lesions in boys.1,2 Virilization in boys, as manifested
7 A6 J8 u. ^2 S# z6 U0 Rby enlargement of the penis, development of pubic- |# u! x. e" V1 M
hair, and facial acne without enlargement of testi-7 ?9 G7 h8 k# ~, g
cles, suggests peripheral or pseudopuberty.1-3 We
& ]3 A. l+ `: I* t! G( treport a 16-month-old boy who presented with the0 B s' t3 ~6 z3 ~2 a) R. _
enlargement of the phallus and pubic hair develop-3 M! T V8 W' l
ment without testicular enlargement, which was due! r# J& |' C: s% f* p
to the unintentional exposure to androgen gel used by4 A1 z: u, V% v8 n0 u% f
the father. The family initially concealed this infor-
: G% ~. ^9 h9 ~' T! zmation, resulting in an extensive work-up for this& |3 c8 g$ H5 G( j
child. Given the widespread and easy availability of. d6 h2 [' J1 a T( K5 r3 n
testosterone gel and cream, we believe this is proba-7 _. D) r. T) }; o
bly more common than the rare case report in the
& R2 }# W: Y* _' v* a: N- V, dliterature.4: K8 e" a# ^8 T4 V, e- |
Patient Report6 ~2 q) O5 Z2 ^
A 16-month-old white child was referred to the
9 _/ c* t% G/ J8 P( F$ E" Nendocrine clinic by his pediatrician with the concern/ R- A5 d1 L( f2 w
of early sexual development. His mother noticed8 _# U5 @( }" Q+ y: q
light colored pubic hair development when he was' j- E" U! b8 a7 `$ W9 w
From the 1Division of Pediatric Endocrinology, 2University of
) s$ F- s* a( w# T$ l% e/ l! }. hSouth Alabama Medical Center, Mobile, Alabama.
; y7 n+ A1 _' P* n, iAddress correspondence to: Samar K. Bhowmick, MD, FACE,
+ J) \: n! X( h, X/ ^Professor of Pediatrics, University of South Alabama, College of
9 F* N$ F1 j( ]3 mMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;/ o, A4 k$ {1 }3 R) S ?" \; |
e-mail: [email protected].
1 E! V, r& G; a! a: j6 {about 6 to 7 months old, which progressively became
; S: J" l6 r" f6 r! ^. @darker. She was also concerned about the enlarge-
& i( O6 m5 m- x1 C" W) ]* `& `ment of his penis and frequent erections. The child# [" n1 C1 {6 m' B
was the product of a full-term normal delivery, with
4 f# u# e$ B& U1 v/ g) k+ W. xa birth weight of 7 lb 14 oz, and birth length of) N7 \8 u. N- r9 c1 _9 Q' Q N
20 inches. He was breast-fed throughout the first year2 Q+ D0 V e3 D) c/ A
of life and was still receiving breast milk along with
% R( a/ K0 X( P5 k5 hsolid food. He had no hospitalizations or surgery,0 x& G( i1 b+ a1 O- v3 L1 D* }4 u
and his psychosocial and psychomotor development
, l! r* F) u; lwas age appropriate.; l! V4 M* _; {6 F) R; H
The family history was remarkable for the father,9 S. t8 J- Y( A+ I+ G
who was diagnosed with hypothyroidism at age 16,
; W- i o+ K* v9 qwhich was treated with thyroxine. The father’s
6 r, V, ]' m. C6 |. yheight was 6 feet, and he went through a somewhat
. f6 X" u3 } E+ e0 ~6 @( G! qearly puberty and had stopped growing by age 14.
6 {3 [! W0 |; x9 a- HThe father denied taking any other medication. The
- G8 Y f+ v8 Jchild’s mother was in good health. Her menarche
5 X7 Z5 n+ \5 V. M9 ^: N* i9 Qwas at 11 years of age, and her height was at 5 feet
1 @- _ A+ F' ^- d0 X6 k5 inches. There was no other family history of pre-$ s" v; Y, }" B6 w# ^! _3 ]
cocious sexual development in the first-degree rela-& z" v, M. p, y0 }- d% w# a
tives. There were no siblings.6 j0 a0 `. \/ A. S
Physical Examination
5 @6 L! O8 L. Y8 k1 O8 ZThe physical examination revealed a very active,/ X# l4 p4 q% r
playful, and healthy boy. The vital signs documented3 h1 R3 J) A/ T
a blood pressure of 85/50 mm Hg, his length was2 Y/ W- ^2 g7 Q( `
90 cm (>97th percentile), and his weight was 14.4 kg
, |( \. |7 ^2 @ O- R(also >97th percentile). The observed yearly growth
- h8 F' S9 u( L/ ?- ~% r/ Cvelocity was 30 cm (12 inches). The examination of! l+ S* {0 D5 Z
the neck revealed no thyroid enlargement.
5 k5 j! u# {- `& n uThe genitourinary examination was remarkable for
S0 z! T/ N, p$ N! F2 e/ L [/ Tenlargement of the penis, with a stretched length of
; `( V B# h6 ~+ }8 cm and a width of 2 cm. The glans penis was very well# r8 Y* P3 ?/ \" a1 P) a
developed. The pubic hair was Tanner II, mostly around% y* i0 Q5 L) M& p {5 U
5403 R5 _8 b' J- S& e0 l9 `
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
e+ k% b) F+ a; t+ `( x4 ?, w- V2 ]the base of the phallus and was dark and curled. The
# n+ v6 J; A) h* Z! x: }testicular volume was prepubertal at 2 mL each.
5 l' k+ s2 b% m7 l; h6 uThe skin was moist and smooth and somewhat
/ R/ Y2 T( X- c, c, d; e4 j# r0 Xoily. No axillary hair was noted. There were no
* D8 r! } d2 K+ Z9 zabnormal skin pigmentations or café-au-lait spots.( Y: R! q" q; l! y
Neurologic evaluation showed deep tendon reflex 2+4 U# b; m. x# d9 x9 I o( v8 s
bilateral and symmetrical. There was no suggestion! R/ e7 I- n/ |0 k8 s3 A6 K9 M* p
of papilledema.
( m1 F0 h% w5 h4 MLaboratory Evaluation! N& s6 y( b; k- m5 y
The bone age was consistent with 28 months by
1 F" j9 U6 l1 g; C% `using the standard of Greulich and Pyle at a chrono-6 h/ `; N3 y) a( o8 @. l2 P% @
logic age of 16 months (advanced).5 Chromosomal7 R9 n! @# q5 o, ?5 Z
karyotype was 46XY. The thyroid function test
9 z N7 }' f0 M0 y0 r: mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
, ?, F6 k0 `0 R8 M- r5 S2 u! [lating hormone level was 1.3 µIU/mL (both normal).- h5 v+ V7 u. M; x" \8 z, U: K
The concentrations of serum electrolytes, blood# W {# B* n8 M; l' q
urea nitrogen, creatinine, and calcium all were
) Q7 N( `# j1 C k& w) fwithin normal range for his age. The concentration
6 x/ O1 z. H! ]. l! O2 d2 @5 B, d: Pof serum 17-hydroxyprogesterone was 16 ng/dL
, D" L: |5 O4 d+ {' A$ `(normal, 3 to 90 ng/dL), androstenedione was 20
# m! w) k2 x( ?0 r5 l5 lng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
0 Y( a; {& [% d! a& A# S5 O) D Rterone was 38 ng/dL (normal, 50 to 760 ng/dL),
# M) |, H6 U4 E" @" _: L8 mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to" j, ?( i. ]% R# f& W0 Q! F8 y
49ng/dL), 11-desoxycortisol (specific compound S)+ l& E7 k1 a, I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
, ^. P4 Q* c: `2 Stisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total8 ^* {- Q. }0 Q, q1 L Y
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),7 u3 K$ _; Y5 K4 u. l
and β-human chorionic gonadotropin was less than
; C' W3 e6 L u/ m5 mIU/mL (normal <5 mIU/mL). Serum follicular$ U6 Q5 {: [, A2 i- \6 c0 o
stimulating hormone and leuteinizing hormone
* b8 ~% h3 x2 K- e. C* C+ Vconcentrations were less than 0.05 mIU/mL
' O v+ ^) F7 A: }2 k r(prepubertal).+ A, {3 r& o( b
The parents were notified about the laboratory
8 h$ I2 o/ b6 ~9 ~) g: M' u5 b6 K. xresults and were informed that all of the tests were
4 a( v9 [$ ^& p$ wnormal except the testosterone level was high. The
+ V: a# W7 X" tfollow-up visit was arranged within a few weeks to
: S* E5 ?8 K2 T$ ]9 P6 l/ Xobtain testicular and abdominal sonograms; how-$ f4 _+ L; v! _# f
ever, the family did not return for 4 months.( f* r. [1 n4 w9 V6 Z
Physical examination at this time revealed that the
% @' Z1 J% p6 Vchild had grown 2.5 cm in 4 months and had gained. s) q6 x. P3 y- ?" \
2 kg of weight. Physical examination remained
" K/ v6 Q; r) Punchanged. Surprisingly, the pubic hair almost com-
5 f+ {0 }% R' i9 k3 v0 L% a3 Kpletely disappeared except for a few vellous hairs at
* B& s' R! F7 \* d1 D% Gthe base of the phallus. Testicular volume was still 2
2 ^0 ?! d: A* e+ q0 v5 t* ^mL, and the size of the penis remained unchanged.
# L- h5 `$ B9 e, T" Q k4 N3 JThe mother also said that the boy was no longer hav-# H5 `, r2 M3 {: y
ing frequent erections.7 Q3 I. G* y* M5 |0 C
Both parents were again questioned about use of+ K1 x+ A8 L& C! {5 b4 W4 H
any ointment/creams that they may have applied to+ U$ G( d T; q/ w1 q. t4 A9 _
the child’s skin. This time the father admitted the
! `8 D! I: f) Z: y5 t9 uTopical Testosterone Exposure / Bhowmick et al 541* v, h* ~9 N! ~, p: Z4 L) l
use of testosterone gel twice daily that he was apply-
+ N; ?/ R+ s& |- B# Ring over his own shoulders, chest, and back area for
- t, T4 B: \8 j. }a year. The father also revealed he was embarrassed, m3 M1 {; v2 \
to disclose that he was using a testosterone gel pre-
0 X( P4 m* e7 c! Q2 H5 y- B0 K. d! x! y) Zscribed by his family physician for decreased libido% M9 Q* F6 g2 s1 s W
secondary to depression.8 c! h& [( U4 s( q: d6 f
The child slept in the same bed with parents.
& ]2 `) O9 r9 T( S4 n; IThe father would hug the baby and hold him on his
7 o2 P/ m# Z, `' q7 Ychest for a considerable period of time, causing sig-7 @2 ~0 V1 |. s; J* _$ l$ I
nificant bare skin contact between baby and father.+ Y+ v z" k% {, q+ y+ D" Z6 }
The father also admitted that after the phone call,9 A+ v: R$ F4 f Q
when he learned the testosterone level in the baby
' a7 [* d8 A) g; r" \& Kwas high, he then read the product information
8 B/ Y [ N4 i% B( z& opacket and concluded that it was most likely the rea-# q- j1 Y& L3 \5 t4 ?& P, ~. w5 _
son for the child’s virilization. At that time, they
2 |" D6 B1 G( |3 j. fdecided to put the baby in a separate bed, and the
7 |$ [, ~/ E/ o* vfather was not hugging him with bare skin and had2 Q* [+ B' F4 y! r) L5 I
been using protective clothing. A repeat testosterone9 [) J' U0 T& h7 L
test was ordered, but the family did not go to the2 h+ f( m5 }" |
laboratory to obtain the test.
6 b$ Y' i4 f% y& o. g% ODiscussion4 m# q3 Q# Q$ | w1 A1 }
Precocious puberty in boys is defined as secondary
s* L/ w( e1 P$ h- Y$ nsexual development before 9 years of age.1,4, z6 q6 `3 N& [5 E6 I9 I
Precocious puberty is termed as central (true) when
( E' w l! \$ V; B7 S: P# eit is caused by the premature activation of hypo-
& l6 a8 {5 b2 f* W; d" Mthalamic pituitary gonadal axis. CPP is more com-& m2 o# a& `' N/ R! x
mon in girls than in boys.1,3 Most boys with CPP
9 u8 R) F8 s* D$ y; Rmay have a central nervous system lesion that is
* t* F8 d9 v( d3 [! Tresponsible for the early activation of the hypothal-
% t: O- q- h( v4 Hamic pituitary gonadal axis.1-3 Thus, greater empha-
* n1 ]' e$ [; Q9 p& fsis has been given to neuroradiologic imaging in
; z1 q% Z2 V$ n; N5 sboys with precocious puberty. In addition to viril-
. T8 t1 @% y/ Y3 c) F; G; Fization, the clinical hallmark of CPP is the symmet-
# e) a, g2 |1 w5 u" q- \rical testicular growth secondary to stimulation by
7 g9 r8 J$ F5 D8 ~) }# \gonadotropins.1,3
8 X5 b- U8 w. r) h& ^# DGonadotropin-independent peripheral preco-
* J) n6 l( d6 P" O& gcious puberty in boys also results from inappropriate+ r& ^: P @0 W0 ?) a" D
androgenic stimulation from either endogenous or4 t0 x& r7 M: }8 @
exogenous sources, nonpituitary gonadotropin stim-' u2 C, D& t* L% N4 W
ulation, and rare activating mutations.3 Virilizing
e; J$ A$ _: h& o$ k( @congenital adrenal hyperplasia producing excessive3 D" W4 @0 P$ P9 l1 A1 Z! C
adrenal androgens is a common cause of precocious
y+ r! L8 ?2 C9 D3 d4 A- d3 Z$ tpuberty in boys.3,4
) {1 Z2 _% R2 ]% \( m' [' J8 t6 kThe most common form of congenital adrenal5 ?* }- E# @: H/ Z1 v* r
hyperplasia is the 21-hydroxylase enzyme deficiency.
% o: h f$ N/ T6 oThe 11-β hydroxylase deficiency may also result in
. ?% u% r9 V. Kexcessive adrenal androgen production, and rarely,
6 E: {) ^: i: g7 t6 y! }an adrenal tumor may also cause adrenal androgen
7 e6 i L, ]- e) ^5 Z* n8 kexcess.1,3/ I2 M$ S( v: k: E, ? b
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" N- |; s3 q+ i( Z* W" x! \542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 o5 p) ]/ B& C* E! e# V- L# U! I
A unique entity of male-limited gonadotropin-, p. J# l* J& w& n, G& |
independent precocious puberty, which is also known
& A" e# W1 ]" {4 u" t2 jas testotoxicosis, may cause precocious puberty at a8 x' L: s; b0 ^, Y) Q8 _
very young age. The physical findings in these boys
- \4 T0 I. m! \8 ?; ]( I1 P3 dwith this disorder are full pubertal development,
' D2 ^& K4 F0 N. [1 T1 d$ s& tincluding bilateral testicular growth, similar to boys
( Y0 o4 P: b% [$ x: {, R9 gwith CPP. The gonadotropin levels in this disorder& ^* V% }! o/ s. y2 s! D
are suppressed to prepubertal levels and do not show7 c0 |% I- \% ?
pubertal response of gonadotropin after gonadotropin-+ C5 l& {6 A- e7 x" N7 e
releasing hormone stimulation. This is a sex-linked7 W$ z8 J! x( b$ ` m, s5 u3 n
autosomal dominant disorder that affects only% U% d$ c6 c, X- X1 Y
males; therefore, other male members of the family
( \( Q" ~& X3 \- \2 Y' W& umay have similar precocious puberty.3
' L4 M3 q e0 V& e8 k AIn our patient, physical examination was incon-& b8 S- h6 i' F
sistent with true precocious puberty since his testi-, v k! A, j' J5 p$ m
cles were prepubertal in size. However, testotoxicosis5 F" K6 V" r' F/ W7 ~' L+ @1 Y
was in the differential diagnosis because his father
; m0 {8 }. \! |2 cstarted puberty somewhat early, and occasionally,8 d+ ~ i9 ~# M# E
testicular enlargement is not that evident in the; ]! q# ?( M4 D8 S- k8 `7 F* t# k
beginning of this process.1 In the absence of a neg-. T: B u5 G3 p; s
ative initial history of androgen exposure, our: V: s( M I. r! O
biggest concern was virilizing adrenal hyperplasia,
! G$ K' w4 V" `: b0 A, |either 21-hydroxylase deficiency or 11-β hydroxylase, x7 u1 \1 U9 `8 ]$ x3 _: ^
deficiency. Those diagnoses were excluded by find-' K( E8 t m; J; e" s3 ~; u
ing the normal level of adrenal steroids.
1 p! M A4 y7 q3 E, X7 YThe diagnosis of exogenous androgens was strongly/ y, r: e! n' e% F. n8 z1 @# o
suspected in a follow-up visit after 4 months because
1 _; ^; \6 B7 h# athe physical examination revealed the complete disap-
( g" S8 d6 u3 G+ Lpearance of pubic hair, normal growth velocity, and
; S; P+ b+ j0 I6 K$ W, g' ~decreased erections. The father admitted using a testos-! ^+ g# {8 v8 Y) I5 \: q
terone gel, which he concealed at first visit. He was
( F4 P/ I7 r% b- N, t+ c9 Pusing it rather frequently, twice a day. The Physicians’! \9 w+ I' d- e* X8 g2 L
Desk Reference, or package insert of this product, gel or
9 B! @0 p& J7 g5 l* Ycream, cautions about dermal testosterone transfer to
+ m8 P) Y& o; _- G4 }unprotected females through direct skin exposure.* `7 I2 p' U! `; J* O. U, |6 q
Serum testosterone level was found to be 2 times the
3 D' _4 Z5 U" t0 T! Jbaseline value in those females who were exposed to2 h2 Q4 T, e% Y
even 15 minutes of direct skin contact with their male# T. v( B/ F2 u6 b) m+ f% _( l
partners.6 However, when a shirt covered the applica-# ~" [/ b3 j' y4 ^: {' R( m( g. [: }
tion site, this testosterone transfer was prevented.
3 `4 L; g; r% A# m' g- tOur patient’s testosterone level was 60 ng/mL,
) J T* g' W2 ?* G2 N& Nwhich was clearly high. Some studies suggest that
0 t; q, w4 h8 b" k& B3 ?dermal conversion of testosterone to dihydrotestos-
: Y" g: S3 `8 Y" Z. g H/ Rterone, which is a more potent metabolite, is more
; \7 j, u- u; U8 G6 z* R1 l- `active in young children exposed to testosterone7 Y: Y/ E9 t* q% V. P5 D
exogenously7; however, we did not measure a dihy-
: E2 v7 |8 T3 b1 C7 W, sdrotestosterone level in our patient. In addition to
" |: i/ `+ |$ F4 |7 U* Vvirilization, exposure to exogenous testosterone in" k3 f4 m5 u) T2 x l# W
children results in an increase in growth velocity and5 A, \ k) g1 x r6 c
advanced bone age, as seen in our patient.) ?& X& Z. [+ g+ j# X. V( Q6 r
The long-term effect of androgen exposure during* F- q. ?$ g5 @& \4 \
early childhood on pubertal development and final7 i( B- E8 Y$ ?# G' H- z% S+ Y
adult height are not fully known and always remain
8 K1 o) |' {! P% X9 ma concern. Children treated with short-term testos-) a: A; O# r$ p' D3 `
terone injection or topical androgen may exhibit some
' M" r$ L& V$ v1 J! oacceleration of the skeletal maturation; however, after5 ^0 [. L0 W1 m2 c0 R
cessation of treatment, the rate of bone maturation+ w9 f) z1 j7 f. V; f; K4 m# t/ x# r
decelerates and gradually returns to normal.8,9
$ B! y8 \- ~7 V* R. w7 n3 ^: cThere are conflicting reports and controversy7 [! o6 ?$ Y0 c
over the effect of early androgen exposure on adult$ ]$ ~; w( {1 [& q
penile length.10,11 Some reports suggest subnormal
* |; V8 F) a$ G8 ~adult penile length, apparently because of downreg-. a2 W9 i9 ^1 b/ h* u. t" S
ulation of androgen receptor number.10,12 However,3 a! G% H) t0 ?0 @$ j& j
Sutherland et al13 did not find a correlation between. `$ `# A4 I7 r: @" M) m
childhood testosterone exposure and reduced adult: v/ j. u( d3 V' L& Q/ r0 M' C
penile length in clinical studies.
# ^1 L! g. J/ f7 bNonetheless, we do not believe our patient is$ y! Z8 Z" C/ X& c0 Y7 O
going to experience any of the untoward effects from2 x: \& j9 E. m8 p
testosterone exposure as mentioned earlier because& q# _" F' m( y8 k9 I
the exposure was not for a prolonged period of time.' o( r+ V" u1 D' {8 }; P
Although the bone age was advanced at the time of
* G* h& ~+ Y& Q( v0 s& ] ?$ b* mdiagnosis, the child had a normal growth velocity at) U7 J0 E5 H$ B* g$ f5 C
the follow-up visit. It is hoped that his final adult/ f) [: ^8 y# d4 f
height will not be affected.6 s9 v( k+ B8 @ d3 P, U9 B0 H( k
Although rarely reported, the widespread avail-
( Q4 ?7 x; k6 F* X9 u M& Sability of androgen products in our society may& j0 o5 Y% v( O1 o
indeed cause more virilization in male or female) g) l& e, I; D
children than one would realize. Exposure to andro-
* f6 d5 L5 J7 C, L$ H6 P, y9 Zgen products must be considered and specific ques-
9 ~6 f! @! C+ l; }6 W1 i- e5 g+ V1 Gtioning about the use of a testosterone product or
) y9 ^2 W p! T+ ~8 T: }% i& I, Jgel should be asked of the family members during
5 T' w! d: J, {% B) v7 lthe evaluation of any children who present with vir-- N6 W: v4 U! H3 k; {& Q( b6 G
ilization or peripheral precocious puberty. The diag-
" ^* _( g1 J& f) J1 A% l, knosis can be established by just a few tests and by6 T5 G1 @9 P: F, U
appropriate history. The inability to obtain such a
( d8 l) l' r5 X+ t& v0 Uhistory, or failure to ask the specific questions, may
0 O" B. ^0 u( ^( zresult in extensive, unnecessary, and expensive
" H! [8 f' ~. Oinvestigation. The primary care physician should be
0 ^" X8 I4 h! maware of this fact, because most of these children0 n2 s* X: I2 j0 R- V+ ~
may initially present in their practice. The Physicians’
3 P) H4 S/ n6 ?3 y& k, B: K) C' VDesk Reference and package insert should also put a
5 [: a$ y% O! ?. g9 o* W2 Qwarning about the virilizing effect on a male or, T& q2 H( {9 A3 N9 \. [
female child who might come in contact with some-) z- `( M( P* y4 I; N' a
one using any of these products.
( C- |- O* J0 q. o$ y; I4 rReferences
7 u! F8 e' Q% D5 b' i1. Styne DM. The testes: disorder of sexual differentiation
6 s @" h- j. G! j0 y$ I2 C9 e/ Land puberty in the male. In: Sperling MA, ed. Pediatric
$ `0 a" o. U: V4 t& a$ a. T: sEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 v# }# _$ M) w& j! {$ z+ a2 A
2002: 565-628.
" ~0 U8 \0 C2 g# \- D2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 d/ x& B! `& u4 r
puberty in children with tumours of the suprasellar pineal |
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