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Sexual Precocity in a 16-Month-Old
5 t4 I7 R. D% P L- A, `Boy Induced by Indirect Topical
- `( w! D! z. {Exposure to Testosterone/ z8 ^! Z; I! f' o% _
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
# s5 E. D) x# ^ |4 j1 _and Kenneth R. Rettig, MD1
( i$ N/ r8 _% x% C/ K2 SClinical Pediatrics- O, ?. U% P4 M0 ^( s3 L! c, \
Volume 46 Number 6: a( o& f$ F7 [4 e" I! q
July 2007 540-543. r2 {" x6 z0 V2 s; ?! ]7 ^
© 2007 Sage Publications* r& ?" W7 o# p- ~
10.1177/0009922806296651
8 M3 V# x5 }+ |6 L5 nhttp://clp.sagepub.com% d$ C7 @' D% C0 m: L0 M
hosted at
( D+ f" \5 [/ J6 C; Yhttp://online.sagepub.com5 b6 X) t3 q3 W' T+ ~, b
Precocious puberty in boys, central or peripheral,
; g9 Q2 ~& p- H* \! d- h1 Dis a significant concern for physicians. Central/ D$ ?" R0 t# h5 F
precocious puberty (CPP), which is mediated
2 E6 l/ O. j* p/ lthrough the hypothalamic pituitary gonadal axis, has
# I3 |! |: T7 Y) G# J, v. Ba higher incidence of organic central nervous system
. q' \5 a- |! }0 u* x* x0 ~- Qlesions in boys.1,2 Virilization in boys, as manifested
+ l; Z2 V9 B. Kby enlargement of the penis, development of pubic# i1 L. L) |# U- z4 g4 ^
hair, and facial acne without enlargement of testi-2 x# j8 K* J( T( q4 K. b5 L: v
cles, suggests peripheral or pseudopuberty.1-3 We* v+ h( i. r( x; _3 o U7 S
report a 16-month-old boy who presented with the1 o. a5 l- y; n$ v
enlargement of the phallus and pubic hair develop-& V. H% G; g) ?# h% h f
ment without testicular enlargement, which was due; h( O9 y1 o) s2 Y) q2 \
to the unintentional exposure to androgen gel used by
8 D; [. [9 |* _, v- A3 e" fthe father. The family initially concealed this infor-: }, E9 j$ }5 y
mation, resulting in an extensive work-up for this
; o2 i( l8 W& _/ L$ s* O9 hchild. Given the widespread and easy availability of
9 [7 J' B+ ^! z- }testosterone gel and cream, we believe this is proba-
) I) B, Z0 e! b; u2 Q2 zbly more common than the rare case report in the
5 V* `! V$ g: w! S9 X- nliterature.47 [+ w1 |, p3 S
Patient Report
( k# S2 s: g" j! _0 D9 Y* _# TA 16-month-old white child was referred to the0 Q7 t3 } k' B+ s0 c
endocrine clinic by his pediatrician with the concern
" y: c5 F+ @& p& j Z* r I: Yof early sexual development. His mother noticed+ k# Y- [9 w& A2 Q% u
light colored pubic hair development when he was
! _0 I+ s7 ~- Z% l0 e- A0 ~ N7 rFrom the 1Division of Pediatric Endocrinology, 2University of( V. f S' H* U( U5 R" m. E
South Alabama Medical Center, Mobile, Alabama.3 [; l/ h' r$ f* i
Address correspondence to: Samar K. Bhowmick, MD, FACE,; a+ G0 @7 T7 o& w# ], a _) d
Professor of Pediatrics, University of South Alabama, College of% n: z! c2 e6 A- a
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;+ ~6 C2 J' y/ |8 i: Z
e-mail: [email protected].
3 e8 Z3 E2 d% o+ u' q" Cabout 6 to 7 months old, which progressively became
: E+ h) X9 P4 y* s* F2 C* Edarker. She was also concerned about the enlarge-
0 x: d7 ]4 h0 k& R7 f! v/ Hment of his penis and frequent erections. The child
6 L/ T6 d9 g( t. b' {0 ]was the product of a full-term normal delivery, with6 S1 s, G3 X2 T1 {5 f8 ^
a birth weight of 7 lb 14 oz, and birth length of
; _! U3 l8 b& H7 W20 inches. He was breast-fed throughout the first year
! F8 n" {, h( ? @# Z7 C' J; Qof life and was still receiving breast milk along with/ J+ @; @+ N7 q( |8 z
solid food. He had no hospitalizations or surgery,; _6 M2 a" I7 c# L9 z
and his psychosocial and psychomotor development, r; E, j% W) S1 O
was age appropriate.1 w, v. {# F/ X; L0 H h8 d" x/ B" I
The family history was remarkable for the father,) k7 N) p( K) ?8 C
who was diagnosed with hypothyroidism at age 16,
5 u6 Q0 I* `9 s% h s# Rwhich was treated with thyroxine. The father’s% h) U2 _ e. L7 f+ T2 q
height was 6 feet, and he went through a somewhat$ V, K' P5 S: g7 v) Q
early puberty and had stopped growing by age 14.
, w( U+ q+ i( [+ @The father denied taking any other medication. The
0 Z6 _: ?3 h f2 s: A |8 echild’s mother was in good health. Her menarche
6 H8 u3 ~# u- _& l& O0 I' gwas at 11 years of age, and her height was at 5 feet
8 G$ O3 k/ R" F+ D# u, Y3 ^! T5 inches. There was no other family history of pre-
9 A3 [! \( c& u" z$ O# V$ @cocious sexual development in the first-degree rela-
& N- I" f1 E) s: p% Z; itives. There were no siblings.' Y# h# w$ }4 W" q6 L9 z: G5 f9 ^
Physical Examination
0 P7 V8 A6 M v, @* K9 ?The physical examination revealed a very active,
( u, @3 l! E. P5 o% _" x% ]% Yplayful, and healthy boy. The vital signs documented
& k1 z, z5 \1 s2 G2 oa blood pressure of 85/50 mm Hg, his length was
( X7 p4 I! P2 U2 Q90 cm (>97th percentile), and his weight was 14.4 kg
7 e! X- G# C# d2 T(also >97th percentile). The observed yearly growth/ T6 Y3 _. |; g, e$ x
velocity was 30 cm (12 inches). The examination of7 Z+ a6 V5 K) F# ]" g; T
the neck revealed no thyroid enlargement.$ Q$ w: ]* }! M. p1 K* t
The genitourinary examination was remarkable for
3 J) r4 I5 h' A r+ p; d4 \' Kenlargement of the penis, with a stretched length of
6 W; I, E' O4 Q/ v& c8 cm and a width of 2 cm. The glans penis was very well
2 L K' F$ A9 K: h% I ~( wdeveloped. The pubic hair was Tanner II, mostly around
' c/ v2 Q) y9 q) a& s5 D6 W# F540
) M* T! c$ q; b: [; r9 g5 p7 h& ~0 nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" o' ]2 Y* L. R! t, ]- s7 x( d/ a. }the base of the phallus and was dark and curled. The
" h9 t2 i0 F$ C* [6 L! Dtesticular volume was prepubertal at 2 mL each.# J3 |; Z7 {3 }
The skin was moist and smooth and somewhat' f1 l1 W- F$ i5 O: Z/ P! t
oily. No axillary hair was noted. There were no$ V; N2 |% w {, z1 O
abnormal skin pigmentations or café-au-lait spots.$ b2 v0 Y& N6 W1 C- u5 @: g6 M. n
Neurologic evaluation showed deep tendon reflex 2+
" ]& ^& d ?" B# [. _8 j" N6 ibilateral and symmetrical. There was no suggestion
! w* [8 S: Q) [; d/ Vof papilledema.. A, u) x- D0 R3 o1 k
Laboratory Evaluation
* n5 W' b$ n& d* I7 [ n% H* uThe bone age was consistent with 28 months by
8 y# x# g% ^$ c. I) w2 C3 Jusing the standard of Greulich and Pyle at a chrono-
2 u9 ?# B/ `9 ~. C# P0 wlogic age of 16 months (advanced).5 Chromosomal
6 L# L8 H5 O8 t0 lkaryotype was 46XY. The thyroid function test
" P0 i' O: Q/ ~8 e% l; v0 gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-1 a5 k# z v0 Y0 M+ T
lating hormone level was 1.3 µIU/mL (both normal).
4 h; P: r6 F2 o/ g/ a$ pThe concentrations of serum electrolytes, blood
* {8 O: D j- [. V# furea nitrogen, creatinine, and calcium all were
5 g# v2 S. A% T# {7 mwithin normal range for his age. The concentration
2 P, V: }5 b; ]5 ^; jof serum 17-hydroxyprogesterone was 16 ng/dL
# m ]( S3 [- @: T: a% @(normal, 3 to 90 ng/dL), androstenedione was 20- d0 z/ U4 R/ T7 C* j1 p M* r3 T
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 y' X( ^' J" Vterone was 38 ng/dL (normal, 50 to 760 ng/dL),& f* c8 p- N# i( K
desoxycorticosterone was 4.3 ng/dL (normal, 7 to5 t5 c4 N6 c; f
49ng/dL), 11-desoxycortisol (specific compound S)
9 A9 l! }' n* Y6 o9 Twas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 P! {, e, o! o1 k- C
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total! {: [7 B8 h& Z3 j P b& g
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),* n+ ^6 w* ?/ ~ z; Q6 L
and β-human chorionic gonadotropin was less than
7 d- H9 ?+ @. w1 B: G5 mIU/mL (normal <5 mIU/mL). Serum follicular2 l% L: |/ ]) k# {* K: }5 G) o0 |
stimulating hormone and leuteinizing hormone1 n$ I# A& x: R$ N
concentrations were less than 0.05 mIU/mL' u2 A: a- v/ k/ e+ o
(prepubertal).$ u5 _+ k X- h( ] t5 t
The parents were notified about the laboratory: g& q! ?: v, ]2 y: u
results and were informed that all of the tests were
( q9 x' N3 H- j& bnormal except the testosterone level was high. The
, H( [. R$ y/ A/ r, l+ ~7 ifollow-up visit was arranged within a few weeks to5 c3 X1 Z* o8 Z$ S7 M
obtain testicular and abdominal sonograms; how-
L8 ~) V% p2 dever, the family did not return for 4 months.4 M Z4 ]7 c$ C1 p0 }4 I+ r7 {0 w
Physical examination at this time revealed that the
1 j& i1 E7 U$ ?8 rchild had grown 2.5 cm in 4 months and had gained7 o5 ~/ A( D* |0 ^: k
2 kg of weight. Physical examination remained/ |$ s8 B$ Y6 d3 G: D9 x. D
unchanged. Surprisingly, the pubic hair almost com-
% ^9 t" M' Y* L# h& opletely disappeared except for a few vellous hairs at8 h* F1 G( W7 s, |
the base of the phallus. Testicular volume was still 25 E1 \2 X: n3 ^1 o# Q
mL, and the size of the penis remained unchanged.; Y( o# v' `8 r2 q" V6 u# l2 z% m
The mother also said that the boy was no longer hav-
* l$ K q* T& x! L' Bing frequent erections. ^8 q4 u) M. ?' Y' a, Y
Both parents were again questioned about use of1 ?" d! ]- H% I" g+ H& @" J& n* h3 h
any ointment/creams that they may have applied to
9 ?1 F% Y' u1 C Othe child’s skin. This time the father admitted the
9 [* W7 _) B. m/ Y6 Z& [" C1 ^' c% nTopical Testosterone Exposure / Bhowmick et al 541. h6 G; e6 L3 }+ w w
use of testosterone gel twice daily that he was apply-
, C: a4 @5 G! {' G8 s4 O8 I; Bing over his own shoulders, chest, and back area for
2 F+ v2 F1 t5 l- B7 R. `a year. The father also revealed he was embarrassed7 B2 z' p( w; W+ [ a
to disclose that he was using a testosterone gel pre-
# f+ v+ n. f( fscribed by his family physician for decreased libido/ e, e% w7 p, m; g+ n% F- w' w# B
secondary to depression.+ h- t$ L- b! O
The child slept in the same bed with parents.
/ }7 G4 x2 A) ~. i6 d) B sThe father would hug the baby and hold him on his* z1 w, x# c) }) g) o
chest for a considerable period of time, causing sig-
z: }# ^9 }6 B: I4 A# t6 hnificant bare skin contact between baby and father.$ i7 d- }8 |8 ^1 V
The father also admitted that after the phone call,: w# E& Q, A- E0 j# m F
when he learned the testosterone level in the baby
! u4 t1 H* ~) V" Iwas high, he then read the product information, k$ N- G& \9 h( X2 i" @
packet and concluded that it was most likely the rea-# S8 k. {5 M* p; ?4 X; r
son for the child’s virilization. At that time, they
7 l9 D# D4 s, \, y+ hdecided to put the baby in a separate bed, and the
8 o$ f( ^0 _ H- q1 lfather was not hugging him with bare skin and had( I- E0 B( d. m
been using protective clothing. A repeat testosterone
w( D4 Q% ?# ] ttest was ordered, but the family did not go to the
2 d4 ~/ j# E& l$ ?5 `' l9 l3 Olaboratory to obtain the test.
1 n! \1 c; P& Z% t+ qDiscussion
2 \0 S. V; o7 m+ k- o$ z4 k5 X, RPrecocious puberty in boys is defined as secondary$ D( I; `. K4 d9 c- K4 v4 l
sexual development before 9 years of age.1,4
. y' F7 B9 O9 ~& P. J, y4 _7 O4 WPrecocious puberty is termed as central (true) when
" J! _% |( ~1 Y3 z3 Vit is caused by the premature activation of hypo-
4 h, S$ E; I% o5 K* ^; [6 `thalamic pituitary gonadal axis. CPP is more com-& u; Q9 i& U# I# {4 c% m* D, Z1 ]
mon in girls than in boys.1,3 Most boys with CPP! i$ @! e& b3 F7 w9 j
may have a central nervous system lesion that is
, b+ {! M' b; Q; \0 bresponsible for the early activation of the hypothal-+ i% r0 F5 C' m9 A. k& O& L
amic pituitary gonadal axis.1-3 Thus, greater empha-
& g# d0 ~6 t* n$ H P8 `sis has been given to neuroradiologic imaging in. K W: j5 {2 o+ s2 ~
boys with precocious puberty. In addition to viril-
$ m$ L7 F H1 t: n& t L( ]ization, the clinical hallmark of CPP is the symmet-8 K6 c9 U" W$ f% ]3 {! M
rical testicular growth secondary to stimulation by, k: ^- a# q; O; ]. t( h; G
gonadotropins.1,36 o l, ]; I$ F' r
Gonadotropin-independent peripheral preco-
+ f2 D. K9 H' m7 ?! Q1 T. S! T% v+ Mcious puberty in boys also results from inappropriate
, z/ e8 I r- N$ O( ^0 Tandrogenic stimulation from either endogenous or9 A6 L3 m9 Y7 v' s1 U! Y: P ~; H: r
exogenous sources, nonpituitary gonadotropin stim-4 h1 {' x% ^( J9 Q
ulation, and rare activating mutations.3 Virilizing
( P* I9 w5 c3 l: econgenital adrenal hyperplasia producing excessive
# f: m) z. e' ]) Cadrenal androgens is a common cause of precocious x% q9 X _( m
puberty in boys.3,4
$ w6 B, l/ [& y) b) vThe most common form of congenital adrenal
! @$ E: R: L9 ~ chyperplasia is the 21-hydroxylase enzyme deficiency.
G4 r! `; i# O) M1 hThe 11-β hydroxylase deficiency may also result in
7 o; ^7 R" c' \ U, Eexcessive adrenal androgen production, and rarely,
: P& q, P- `- `an adrenal tumor may also cause adrenal androgen& ?7 @6 h# s9 J. c2 e% O7 Y& n5 R
excess.1,3- `! m: f8 S9 X% f3 @
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) m, P) M9 a8 ]2 Z& M. z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007& ]! f. Y3 { C& l0 J
A unique entity of male-limited gonadotropin-9 f- T. n; S6 s
independent precocious puberty, which is also known8 Q* ^3 {1 ~% ~) j
as testotoxicosis, may cause precocious puberty at a
" T! w: z2 C" l! P0 mvery young age. The physical findings in these boys: ?$ z6 V* ^# S/ r- T, F
with this disorder are full pubertal development,
* _% F0 g: \5 V2 ]3 s1 e: n1 qincluding bilateral testicular growth, similar to boys
5 M( ~) I- p: J* R$ vwith CPP. The gonadotropin levels in this disorder
# l" S/ ^9 {0 i- c- J- L7 Aare suppressed to prepubertal levels and do not show
* C# n( H# d4 G- r$ a0 k6 y+ Apubertal response of gonadotropin after gonadotropin-% I( |0 w- d( e1 n- f8 _1 N6 r: |, O
releasing hormone stimulation. This is a sex-linked
8 h* G- D4 ^3 M/ U% A) Q! ]autosomal dominant disorder that affects only8 F8 y8 P! o- b- y, b6 Z- q% h7 u% k) j
males; therefore, other male members of the family: ?4 H0 ^4 s- K, q+ [& `4 c" @
may have similar precocious puberty.3* Y& e& U* Y0 U8 K
In our patient, physical examination was incon- D+ B6 _4 k2 L* `+ \
sistent with true precocious puberty since his testi-; Y* {! Z& S" Z4 j5 w$ [
cles were prepubertal in size. However, testotoxicosis
E, P& T! }& ~7 @* G* L. Xwas in the differential diagnosis because his father
: `2 o2 g6 G! |0 T$ V: [. j) C8 Y# w& _0 qstarted puberty somewhat early, and occasionally,
3 U' v8 q0 B% u+ @3 \7 _testicular enlargement is not that evident in the
( Y8 u- T7 [0 jbeginning of this process.1 In the absence of a neg-' b" a& W3 s+ L8 W( r. ]1 C
ative initial history of androgen exposure, our; {6 J- [ z3 s8 k* R. ~
biggest concern was virilizing adrenal hyperplasia,
; a! c4 L" [# a- p ^* J% S! feither 21-hydroxylase deficiency or 11-β hydroxylase" G8 d8 q' h4 P5 s* G
deficiency. Those diagnoses were excluded by find-
" S4 r, Z5 o$ P% }ing the normal level of adrenal steroids.
1 n8 S, V9 r- J h% EThe diagnosis of exogenous androgens was strongly0 f. j) C- k0 ?9 ]& m6 y
suspected in a follow-up visit after 4 months because! J1 O( n `2 V* G% z: {. a
the physical examination revealed the complete disap- m/ _0 i! T/ k1 ?
pearance of pubic hair, normal growth velocity, and
3 n; G9 ?1 Z' ]3 s9 a# y* Xdecreased erections. The father admitted using a testos-
( u8 `: \/ }* Wterone gel, which he concealed at first visit. He was
4 e9 ~% N4 V+ i) @9 \2 q5 i9 {using it rather frequently, twice a day. The Physicians’
- I c" ^# {' s6 q4 q1 [2 l; y; R$ HDesk Reference, or package insert of this product, gel or
2 n. ?2 i# P$ ~( Z' ycream, cautions about dermal testosterone transfer to
' F0 r# C5 N. d4 x4 @+ ounprotected females through direct skin exposure.
0 r+ R- I* ~1 J/ ], _/ h/ mSerum testosterone level was found to be 2 times the
% V! T; U3 N3 L- ]: ?baseline value in those females who were exposed to+ V( v$ p8 q: X( b p1 b4 {3 {+ A: g/ ~
even 15 minutes of direct skin contact with their male! L h& o- W: X# B* e* p0 q
partners.6 However, when a shirt covered the applica-
{$ `' _1 D* m+ ~* ition site, this testosterone transfer was prevented.9 q* e" |% x" |# G) w
Our patient’s testosterone level was 60 ng/mL,
; i; u5 v$ k2 @+ e8 Ywhich was clearly high. Some studies suggest that4 b- Y" _. \- F" ^7 z6 r: o$ V
dermal conversion of testosterone to dihydrotestos-; m; [: t: H# U9 A8 ]: X8 J# R
terone, which is a more potent metabolite, is more
1 O/ ]. t/ G5 a2 j7 k: H; Sactive in young children exposed to testosterone M4 E0 J# d1 {. |
exogenously7; however, we did not measure a dihy-
" e: ?1 ?: t r* o4 Zdrotestosterone level in our patient. In addition to2 u7 k* G, D4 f. H( _: P
virilization, exposure to exogenous testosterone in
/ |. Z" s5 y9 r1 F; Y5 _9 achildren results in an increase in growth velocity and& {% f4 O9 N) V0 Q# i
advanced bone age, as seen in our patient.9 ~0 r6 L2 N N8 T8 O9 Y1 X
The long-term effect of androgen exposure during4 B: r. E0 u- F# J
early childhood on pubertal development and final
* T5 x& T* f( A! N6 L: |adult height are not fully known and always remain, p- F( o4 a$ r, r3 h( j& I
a concern. Children treated with short-term testos-
% _% {; q( G# h4 a+ Tterone injection or topical androgen may exhibit some
$ Z% l' Y; F" hacceleration of the skeletal maturation; however, after( A" ]/ ?) e" m* f2 j/ H o
cessation of treatment, the rate of bone maturation. E0 X( i9 ?' M# x: v% U
decelerates and gradually returns to normal.8,9; C K. a5 V0 ?* V% [) b
There are conflicting reports and controversy. \- q2 `( G3 m. W
over the effect of early androgen exposure on adult
5 H2 n/ x2 f) N' @9 @; o+ C, Upenile length.10,11 Some reports suggest subnormal
0 A7 w/ E; n7 M) c& h! c* Gadult penile length, apparently because of downreg-
( }6 F1 v S- j0 N4 m2 ^" xulation of androgen receptor number.10,12 However,& w" N5 v0 @5 N1 b% `% u, \
Sutherland et al13 did not find a correlation between
0 n$ h) N0 l4 d# Dchildhood testosterone exposure and reduced adult
3 f4 x |4 Q1 B+ Qpenile length in clinical studies.: K2 A$ o) J, p6 `+ [6 @
Nonetheless, we do not believe our patient is
8 y( k) h4 x8 @going to experience any of the untoward effects from
( ?% ?) Q, Q* D; R0 J3 J& n5 {0 ztestosterone exposure as mentioned earlier because
& k6 t$ S3 {, U; O1 y1 K: Sthe exposure was not for a prolonged period of time.1 ^. b2 a# y! H& y. t7 [
Although the bone age was advanced at the time of
2 v9 t6 Q" j- Rdiagnosis, the child had a normal growth velocity at
3 R- E4 X' u# ythe follow-up visit. It is hoped that his final adult# o" Q+ r: f9 \& U5 v
height will not be affected. s4 j! |: O* s* \& j1 W: \$ ^- S
Although rarely reported, the widespread avail-& S. g$ }. k7 Q3 S
ability of androgen products in our society may) a% l S, i0 c9 \7 d
indeed cause more virilization in male or female8 O. [" }6 r! A" ]" |
children than one would realize. Exposure to andro-
0 S) y: |: n" Y; r$ Y* t! `' Cgen products must be considered and specific ques-- }3 R A. R1 I" d( C
tioning about the use of a testosterone product or
9 p: [" S& A3 R3 Q+ vgel should be asked of the family members during
; Z8 c+ G* v4 r5 V4 H4 L- v+ d$ vthe evaluation of any children who present with vir-: F0 r# V% ?6 U) m- O
ilization or peripheral precocious puberty. The diag-
. y" d9 ?7 g# h* S$ h6 Gnosis can be established by just a few tests and by
/ y0 l/ _% @/ b+ U/ `appropriate history. The inability to obtain such a) R! v" |2 S7 l; b" _* W' _
history, or failure to ask the specific questions, may
) G. I" J* o, W1 x$ j4 Bresult in extensive, unnecessary, and expensive# V7 }4 `* |* h/ C" c
investigation. The primary care physician should be
4 \: z _( d, D8 U5 C" ~$ X: ]! h( m ]aware of this fact, because most of these children6 ~9 l* I# S9 U7 ~' t$ |
may initially present in their practice. The Physicians’
/ w4 w/ x) _0 ]# W1 _1 ADesk Reference and package insert should also put a
% l0 V- s; N8 T! f& o/ qwarning about the virilizing effect on a male or# y( z$ n7 q+ j- G' g0 }2 v
female child who might come in contact with some-
) y7 s( k3 F; r. Y3 i) \2 q# Rone using any of these products.3 G7 i- n- O& o1 C1 t4 f8 P' o
References
& t1 B$ Q# R8 v1. Styne DM. The testes: disorder of sexual differentiation2 ~* Q1 X+ g2 ~; B
and puberty in the male. In: Sperling MA, ed. Pediatric9 \2 |: o2 `; y3 F, _
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;; |* ^2 d+ f" h8 K# x
2002: 565-628." C% Y& H- k, e% W. B
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 T" ]! d% o7 i, y3 u
puberty in children with tumours of the suprasellar pineal |
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