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Sexual Precocity in a 16-Month-Old, K* P: j" U8 _4 O# y2 I' z2 e
Boy Induced by Indirect Topical
9 b* q) l$ b& E. SExposure to Testosterone3 }) K# f' s |2 U8 o0 a+ c% S
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,27 N' b( F+ F/ J o5 M* h$ r
and Kenneth R. Rettig, MD1
& W) b4 _) D' E) ?! |7 DClinical Pediatrics; o' X+ _1 G4 j# F& D
Volume 46 Number 6+ ]) l; J, J7 E- F& h& T/ H, k1 m
July 2007 540-5438 V# V) b7 O0 ] [4 C9 }+ A& |
© 2007 Sage Publications5 Q- B/ F! B) M7 R
10.1177/0009922806296651# h) T9 ^1 o# t+ d+ f8 y" X
http://clp.sagepub.com6 }# ?) R! Y4 h, e( T* F* j. s) C( v
hosted at
; o* Z! x* T2 c$ ~& T- ?http://online.sagepub.com) g2 ^* c0 V( ~/ ~' \ @& `8 m
Precocious puberty in boys, central or peripheral,' B3 O6 @5 D. J! [* d' X
is a significant concern for physicians. Central
; V6 c9 g; p4 s$ R1 @% sprecocious puberty (CPP), which is mediated
5 O) L0 Z8 l0 D. S* }9 G0 h9 cthrough the hypothalamic pituitary gonadal axis, has
. w7 ]/ ?: x* aa higher incidence of organic central nervous system1 U* ]6 F5 p7 `( [9 r W
lesions in boys.1,2 Virilization in boys, as manifested
6 \# J6 `8 l# F5 `by enlargement of the penis, development of pubic: _) E, a; z& i3 X; G' s
hair, and facial acne without enlargement of testi-
8 L2 C# [) @/ \- L0 w3 d% vcles, suggests peripheral or pseudopuberty.1-3 We
; y& R, Y: x9 } \3 qreport a 16-month-old boy who presented with the
) i- r. T& j. [enlargement of the phallus and pubic hair develop-
9 a% R, H H. ?. Cment without testicular enlargement, which was due
7 a. Q' v& [+ E' K0 R4 sto the unintentional exposure to androgen gel used by
3 q" t- ?: a P* D7 m; i+ { s o7 Gthe father. The family initially concealed this infor-
9 W. m# b3 `2 `9 F; F7 Fmation, resulting in an extensive work-up for this
3 R6 t+ T) e8 q, X" Pchild. Given the widespread and easy availability of
" x D* F! A: i: v0 xtestosterone gel and cream, we believe this is proba-
, g0 c: F: L2 \( D& ^$ m0 Rbly more common than the rare case report in the
, ?3 l$ b# G$ iliterature.46 W |3 P$ }5 j( s9 L/ @9 t Q$ D
Patient Report3 h, K7 i0 K: l) a: I2 @% u/ {- d
A 16-month-old white child was referred to the
* D A/ | L7 Y! w$ `6 Y3 hendocrine clinic by his pediatrician with the concern
3 C, P& w2 @5 m- G2 vof early sexual development. His mother noticed) O7 G& c4 I" k" [9 M
light colored pubic hair development when he was* [! _3 c! f' V' c2 z5 C
From the 1Division of Pediatric Endocrinology, 2University of* `' ^7 s) W# i: c! ]2 Q7 c
South Alabama Medical Center, Mobile, Alabama.
( ~5 x5 S0 o' n! XAddress correspondence to: Samar K. Bhowmick, MD, FACE,
5 b1 k4 @- _* IProfessor of Pediatrics, University of South Alabama, College of. H" p/ r, N' K3 f5 E5 L) y- N
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* d9 T$ x6 B, x' M; u) R
e-mail: [email protected].
p6 C. p6 X# q: b7 Q3 C) ?* oabout 6 to 7 months old, which progressively became4 }: \1 G# D$ E' e, q
darker. She was also concerned about the enlarge-7 Z. B$ y# L/ D7 s* M+ O
ment of his penis and frequent erections. The child
. ^% ]4 O3 V3 p/ R( f2 Iwas the product of a full-term normal delivery, with
# x" ?) o- n& H2 D la birth weight of 7 lb 14 oz, and birth length of
2 h/ W6 i1 k% j& h4 \; y20 inches. He was breast-fed throughout the first year+ {# g! H) K, }% e
of life and was still receiving breast milk along with# B- u9 P' b5 F* j5 V
solid food. He had no hospitalizations or surgery,
$ ?2 i, V8 c7 D( t6 Q, A; \) o$ ~and his psychosocial and psychomotor development# A1 [" b% E- P! X+ V
was age appropriate.
1 ], R& z# @9 T3 lThe family history was remarkable for the father,3 s2 L' D* t) v- f- s6 c: v
who was diagnosed with hypothyroidism at age 16,
& }: U! L' q* [3 {) [" v. ^which was treated with thyroxine. The father’s
% s" Z% y. S4 U& ~% ]5 sheight was 6 feet, and he went through a somewhat1 r" G) d9 G. C/ T! I
early puberty and had stopped growing by age 14.* A! V3 R% ~: f. J% v# z
The father denied taking any other medication. The3 ]7 ^, x3 P0 {# n. O
child’s mother was in good health. Her menarche
4 V/ n* x: B+ \/ M0 i. g/ v6 y9 Twas at 11 years of age, and her height was at 5 feet
4 g/ ?) Z4 q; t) [4 x- i$ w$ |5 inches. There was no other family history of pre-
9 D! J9 J! @1 X! w) tcocious sexual development in the first-degree rela-/ g: y& |: t7 q5 [) z$ P
tives. There were no siblings., _& [! f9 q( U5 y8 e- M& F, }/ {
Physical Examination
; ]6 D. o" l |0 jThe physical examination revealed a very active,
9 ]9 X' T# Y) {! s1 e& Bplayful, and healthy boy. The vital signs documented; @" W9 d0 G- D
a blood pressure of 85/50 mm Hg, his length was
$ k* } P7 O5 _) v4 v! C90 cm (>97th percentile), and his weight was 14.4 kg0 c& o: [ M9 B& N2 m
(also >97th percentile). The observed yearly growth7 ~% A3 p+ }$ R' u' \ A! U
velocity was 30 cm (12 inches). The examination of! G$ [% w9 A/ [" e$ Q4 _4 W
the neck revealed no thyroid enlargement.' `/ r# k! N* @7 h9 B
The genitourinary examination was remarkable for
: X7 m% H8 I* c' kenlargement of the penis, with a stretched length of7 a5 q% M5 T/ Z$ }+ N; j( v, P: C
8 cm and a width of 2 cm. The glans penis was very well
: c- V9 Q7 U2 `* }& f/ {2 d+ v ^' pdeveloped. The pubic hair was Tanner II, mostly around
1 |9 w) y5 _% m. M$ o540
8 {. b3 }) u6 E( ~2 @7 {& w6 tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( T) W, ?3 S. O7 e3 E. U/ n& @7 B% Nthe base of the phallus and was dark and curled. The
: B5 x4 Y( S$ l$ Z$ Vtesticular volume was prepubertal at 2 mL each.
- U, O( j8 n# `# M d, B" N) qThe skin was moist and smooth and somewhat) d; Z* |- d9 Y
oily. No axillary hair was noted. There were no
0 J$ k0 \) K: w5 cabnormal skin pigmentations or café-au-lait spots.
9 x. p% E( C( y7 l# g8 XNeurologic evaluation showed deep tendon reflex 2+
: @9 C- |5 R+ ?0 [ d- h) fbilateral and symmetrical. There was no suggestion
( h8 u/ O0 ~7 t1 h4 j! B8 Eof papilledema.
1 l) |/ C' W. w- aLaboratory Evaluation
! z, F2 x( Z2 J- U1 mThe bone age was consistent with 28 months by2 q' x$ e" f; n6 b/ S; A' O! l
using the standard of Greulich and Pyle at a chrono-* T& ^+ r8 u: x% i/ b( c {
logic age of 16 months (advanced).5 Chromosomal. ^# ^$ s& z4 b7 V
karyotype was 46XY. The thyroid function test
" {5 C0 S6 ?. e9 gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
7 M: `- n8 \) C% olating hormone level was 1.3 µIU/mL (both normal).
; P4 q. _( A) F$ q$ _6 LThe concentrations of serum electrolytes, blood
2 Y8 w6 |+ s9 }' w$ |3 rurea nitrogen, creatinine, and calcium all were
; z1 J5 _, u s, T. dwithin normal range for his age. The concentration: A4 C/ Y4 `& ]2 f# y* J+ B, o
of serum 17-hydroxyprogesterone was 16 ng/dL
) N1 c$ |- d' `(normal, 3 to 90 ng/dL), androstenedione was 20
+ Z$ H% y; m, ~, d' ~" B! T7 s+ nng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
& m$ ^+ w# k4 D, Kterone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 k" G$ E: ~# U2 e/ kdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 ]' f) E0 @% |% B6 [. O3 h4 n2 W) q+ C49ng/dL), 11-desoxycortisol (specific compound S)8 s0 _" C1 J: E' ?! N; I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-9 p8 u1 O( g6 P
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; c9 F. Z0 I3 N" G- M7 [
testosterone was 60 ng/dL (normal <3 to 10 ng/dL)," m4 Q6 J9 n2 V# D ~4 N
and β-human chorionic gonadotropin was less than
5 C% S4 J; i1 H% l$ i. ^5 mIU/mL (normal <5 mIU/mL). Serum follicular
7 _3 A. R& T3 p' o0 Xstimulating hormone and leuteinizing hormone6 R( O$ z& F7 ~2 t
concentrations were less than 0.05 mIU/mL
& r1 X$ i c3 g8 g2 O(prepubertal).9 t9 l9 o! T% ~. e0 x
The parents were notified about the laboratory5 e' U, q# ~+ g: `
results and were informed that all of the tests were
2 U9 L9 _. L; pnormal except the testosterone level was high. The
! E* H+ g/ |& Tfollow-up visit was arranged within a few weeks to$ p+ r# U. g8 V* O
obtain testicular and abdominal sonograms; how-1 `5 _4 s% E' C2 ]( R8 y" b4 ]5 N
ever, the family did not return for 4 months.
1 p6 O7 P( x+ k) lPhysical examination at this time revealed that the
3 N5 B4 O$ h/ k0 H; achild had grown 2.5 cm in 4 months and had gained
+ c5 F8 J; F8 r6 k* y2 kg of weight. Physical examination remained" K, O/ `" L7 }
unchanged. Surprisingly, the pubic hair almost com-7 }2 u/ H0 ^) E
pletely disappeared except for a few vellous hairs at2 s: i$ S4 z5 _8 ^. I# h2 R7 A
the base of the phallus. Testicular volume was still 2. X7 v! ^% ], G# v7 Q! i. {) L
mL, and the size of the penis remained unchanged.3 Q3 ^5 }* a) Q0 Z
The mother also said that the boy was no longer hav-
' w" y k' ~8 Oing frequent erections.7 ^; f! Y5 k# {- D# @$ \" A' F
Both parents were again questioned about use of
4 d3 o( w4 |( i* g2 e3 iany ointment/creams that they may have applied to! E4 C# W! _- @+ J+ E4 m
the child’s skin. This time the father admitted the& t" o F1 f$ x4 H' V: Q" F8 B
Topical Testosterone Exposure / Bhowmick et al 541/ T+ g) ?5 {# {2 X
use of testosterone gel twice daily that he was apply-
& a, y& E, U0 B8 k+ J* U/ H# Ding over his own shoulders, chest, and back area for
- n& M7 U. _" g2 C7 ~a year. The father also revealed he was embarrassed- U+ t3 X- [4 w) R* T9 n/ F
to disclose that he was using a testosterone gel pre-
$ t7 o+ ?0 M, i7 V% i+ t7 Z. F' S3 u0 Oscribed by his family physician for decreased libido
5 t m4 @: ]$ f) u3 I% {6 xsecondary to depression.
. o0 _- W2 `$ }# TThe child slept in the same bed with parents.
3 x& _( c8 [7 c' h# e/ c( ?The father would hug the baby and hold him on his5 E' D2 N; Y! e
chest for a considerable period of time, causing sig-
5 b, P3 q0 g4 t# q, V% Hnificant bare skin contact between baby and father.
% l% ^1 S3 c+ I" p2 Q( T+ M% ZThe father also admitted that after the phone call,
* D# P9 w* r, ?8 F+ Xwhen he learned the testosterone level in the baby8 J R" ]4 U P5 N2 T/ R
was high, he then read the product information* Z. a2 ^6 N5 ^6 b$ N2 G
packet and concluded that it was most likely the rea-+ L+ a- g- L+ Y5 q$ t( @
son for the child’s virilization. At that time, they& v* g) h4 k6 k, m3 ~! I& y, ^
decided to put the baby in a separate bed, and the. C( |7 ~- f5 S7 g! C
father was not hugging him with bare skin and had
) o; }! _3 n0 ^+ A% v6 z: hbeen using protective clothing. A repeat testosterone
' c; U) U. C% W. wtest was ordered, but the family did not go to the
0 `3 t* M4 P: mlaboratory to obtain the test.
4 D) E2 ^9 ~: }% c! R, |Discussion
( M# g& A! c8 K, u+ O+ D" [4 b' y7 u6 nPrecocious puberty in boys is defined as secondary5 n7 I* A+ s3 Q/ g; K% N
sexual development before 9 years of age.1,4& T" N- H c2 x7 a9 X+ F: s- ?
Precocious puberty is termed as central (true) when, ^$ f4 ~3 O2 X# K! t
it is caused by the premature activation of hypo-( [6 J0 v( O5 q, r2 Y/ Q
thalamic pituitary gonadal axis. CPP is more com-0 J0 z3 L$ n# t( Q/ ?* t8 U- g
mon in girls than in boys.1,3 Most boys with CPP: H$ T9 w+ ]. T' o
may have a central nervous system lesion that is
3 B! w4 ?9 F$ \$ h1 Iresponsible for the early activation of the hypothal-) s4 g3 Y$ P" j& c9 z! P
amic pituitary gonadal axis.1-3 Thus, greater empha-3 t2 u* w& J7 n; r: T1 h
sis has been given to neuroradiologic imaging in
. G) K0 j6 i2 s5 Mboys with precocious puberty. In addition to viril-
1 x9 s7 E" E3 sization, the clinical hallmark of CPP is the symmet-
: \; N- A+ P( k, nrical testicular growth secondary to stimulation by& m% y1 j- z( g3 `& ?( r
gonadotropins.1,3, n0 A+ o/ z' I1 U+ R
Gonadotropin-independent peripheral preco-
& P% d( {+ x% l; Fcious puberty in boys also results from inappropriate* w# S; j# @* l4 |
androgenic stimulation from either endogenous or4 u9 e, p% B& E) H- r
exogenous sources, nonpituitary gonadotropin stim-
* ?! \4 B1 M5 C, i: z9 wulation, and rare activating mutations.3 Virilizing6 J. z5 q* w7 R+ o0 ]) I
congenital adrenal hyperplasia producing excessive% j0 q. u3 I4 _
adrenal androgens is a common cause of precocious
( E& ~& g" s1 C1 Dpuberty in boys.3,4
# g' ]. B7 X( x1 }+ R. \3 QThe most common form of congenital adrenal8 S% I/ x. H3 B% p7 b0 _9 \
hyperplasia is the 21-hydroxylase enzyme deficiency.7 [# } Y' T2 Z" ]- |& S' @
The 11-β hydroxylase deficiency may also result in8 m6 a# j: Z x8 {
excessive adrenal androgen production, and rarely,1 y* ?$ O1 [5 W( v# s7 L
an adrenal tumor may also cause adrenal androgen" t+ L# i% `5 _4 _
excess.1,3
- a0 D- E. [0 O' Q) h a/ K% N" \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from# N7 h. ?; Y( p1 ?4 n
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007/ f; }+ z( X6 N5 J3 [6 `
A unique entity of male-limited gonadotropin-# L* l h7 D* R( ?8 ^
independent precocious puberty, which is also known
6 j/ z& M0 Q2 M7 y) d0 b! Das testotoxicosis, may cause precocious puberty at a
+ S6 o* S. H' G" q6 svery young age. The physical findings in these boys
3 y5 L3 Q5 p/ p: Rwith this disorder are full pubertal development,) C' P% s& C' V, }1 e' |4 o
including bilateral testicular growth, similar to boys
6 k5 \* ?& D( j! S- [with CPP. The gonadotropin levels in this disorder$ j( b, h U* e5 w
are suppressed to prepubertal levels and do not show1 _- ^. F5 I7 Z8 k
pubertal response of gonadotropin after gonadotropin-
! y) ~( J, U6 N$ w* G% M' |releasing hormone stimulation. This is a sex-linked
- C8 a2 _# r* `/ Hautosomal dominant disorder that affects only
+ X5 p+ Q+ a. U1 \7 Z# B" Wmales; therefore, other male members of the family
- q8 B7 e5 d$ l& S* Gmay have similar precocious puberty.30 d. o# [( h% d; @; {% Z6 p; }
In our patient, physical examination was incon-
. r; j! f1 [2 Fsistent with true precocious puberty since his testi-
1 p0 _6 M4 _) bcles were prepubertal in size. However, testotoxicosis
3 y" |. S. g5 O# M" |" ?% n8 Ywas in the differential diagnosis because his father
( F5 O+ u5 r ~5 Pstarted puberty somewhat early, and occasionally,
( r- Y+ a7 j! W) xtesticular enlargement is not that evident in the8 z2 \& C$ }' Y% {$ m
beginning of this process.1 In the absence of a neg-
7 |3 M$ s& `1 bative initial history of androgen exposure, our
$ ?4 J3 p1 o7 c8 m7 [8 rbiggest concern was virilizing adrenal hyperplasia,- Y) H* \3 s1 n! b$ R6 q, O
either 21-hydroxylase deficiency or 11-β hydroxylase. t$ B, ~1 a6 `! D
deficiency. Those diagnoses were excluded by find-
0 _; O3 v1 H9 [) [7 }ing the normal level of adrenal steroids.
% {$ e' O7 _9 z8 A% ~4 uThe diagnosis of exogenous androgens was strongly
- O, d0 @5 E, y5 q* Lsuspected in a follow-up visit after 4 months because
% B' D6 j0 T$ R# H' sthe physical examination revealed the complete disap-
7 ?7 n {& z2 R: h4 K$ fpearance of pubic hair, normal growth velocity, and9 E# `7 Z8 B9 t2 r- y
decreased erections. The father admitted using a testos-; f( S5 B e" Z. z
terone gel, which he concealed at first visit. He was
# ] ?$ l0 Y; s' W# }' jusing it rather frequently, twice a day. The Physicians’
: f- Q/ o4 H6 N" {2 {Desk Reference, or package insert of this product, gel or5 V# M9 B4 u( e
cream, cautions about dermal testosterone transfer to- {9 b3 @7 |3 r% C
unprotected females through direct skin exposure.
! O$ m2 ?; |4 P9 M6 x3 j5 a, CSerum testosterone level was found to be 2 times the+ U: N2 f4 G% s$ k; ]' [+ Q# x/ w& Z
baseline value in those females who were exposed to, H7 k! S7 i7 u8 x
even 15 minutes of direct skin contact with their male
7 }7 a) {$ K: b, r6 vpartners.6 However, when a shirt covered the applica-
+ f* c7 ?4 M1 y f9 ?! D5 Ztion site, this testosterone transfer was prevented.
@: E. ]) T C3 uOur patient’s testosterone level was 60 ng/mL,: H3 R t: V* k P
which was clearly high. Some studies suggest that7 M. W! [4 {7 G/ |
dermal conversion of testosterone to dihydrotestos- Y) i8 O8 I, d% R/ u/ G. h( U
terone, which is a more potent metabolite, is more J- M) u. W/ Q2 B1 S7 R
active in young children exposed to testosterone
1 v+ r2 K; G- w, S" ]7 ~ g+ rexogenously7; however, we did not measure a dihy-' |8 ], B/ o6 b/ k
drotestosterone level in our patient. In addition to4 d: V Y; q. D- B! B2 [3 W/ _( \; p
virilization, exposure to exogenous testosterone in
7 E6 j( e. l2 {* D3 d7 vchildren results in an increase in growth velocity and
# a. k+ ?0 k+ ?- ladvanced bone age, as seen in our patient.
/ m$ ~" Z, P" j s/ _The long-term effect of androgen exposure during
: }2 i$ {7 O7 ]' u8 h7 |/ A! yearly childhood on pubertal development and final
) v) `& i+ y$ Q7 I! ^" ^; yadult height are not fully known and always remain# V _7 a* r& X6 Q% q+ M
a concern. Children treated with short-term testos-0 c, O/ \& J! b, @
terone injection or topical androgen may exhibit some
' e4 j9 C* e' l2 x% Y. f7 Cacceleration of the skeletal maturation; however, after
8 y% b# L$ J' u8 F" F3 x- d. ~cessation of treatment, the rate of bone maturation# v7 |) v7 A" y' g6 `
decelerates and gradually returns to normal.8,9
4 G2 ]0 `. ]! I0 ~$ B6 I) fThere are conflicting reports and controversy
# _+ N% S! D7 f } x7 Nover the effect of early androgen exposure on adult+ a' a1 v; i+ f! b# a
penile length.10,11 Some reports suggest subnormal
/ D, }! D! _/ O$ zadult penile length, apparently because of downreg-
4 D: Y9 p- V3 G% P# }ulation of androgen receptor number.10,12 However,
4 |) A/ \ h& x7 lSutherland et al13 did not find a correlation between
; h7 A$ U ^9 i6 t: n6 zchildhood testosterone exposure and reduced adult
9 U' u: n) [' [5 C8 v. Apenile length in clinical studies.( _( A. V4 }9 \ s* o
Nonetheless, we do not believe our patient is1 Q1 \' d% h- P* I9 \* {5 ^, r" l
going to experience any of the untoward effects from
e! |4 e1 U7 Dtestosterone exposure as mentioned earlier because
u$ m5 a& }7 I4 lthe exposure was not for a prolonged period of time.5 `" ]- r" M% ?5 m
Although the bone age was advanced at the time of
1 d+ \ r5 ]# Q" C+ Q9 xdiagnosis, the child had a normal growth velocity at
- o% l7 O- J Dthe follow-up visit. It is hoped that his final adult% D7 Y1 U$ W& `
height will not be affected.7 S1 S& x% N8 A* d/ N1 d
Although rarely reported, the widespread avail-) }! s+ D* i L8 x/ F0 |# x, H
ability of androgen products in our society may
! y4 K( M: i5 R c2 w$ T' cindeed cause more virilization in male or female
- I6 v4 t4 K+ M9 [& Bchildren than one would realize. Exposure to andro-
" D2 V8 B! z* `: Z7 A& T; Ngen products must be considered and specific ques-
) k/ i6 s. I* m) W+ P! G2 Etioning about the use of a testosterone product or
% D& g& E) v5 y; R# \- C; E8 i* rgel should be asked of the family members during, v7 S0 _6 t7 Q, i
the evaluation of any children who present with vir-
* z4 w! d% E& \. e$ s7 @# Y( Xilization or peripheral precocious puberty. The diag-
0 \" t( b, b3 t) ]" F p( c' Knosis can be established by just a few tests and by
# L3 l9 r& h( W8 f* }5 Sappropriate history. The inability to obtain such a
# `# u3 T8 x2 T, R% f. T6 o* ~' r# ehistory, or failure to ask the specific questions, may
: ?. L+ x. `& t( f5 V* ?( Mresult in extensive, unnecessary, and expensive
* N+ ]& I+ @; `$ O! w! E& u/ yinvestigation. The primary care physician should be5 C% A# n, Q( A3 l u, ~1 W
aware of this fact, because most of these children. Q) h# ^/ E7 V
may initially present in their practice. The Physicians’; L1 G4 {# p4 U+ v k: B3 C% B
Desk Reference and package insert should also put a
4 I8 N g3 k3 F7 \( M1 u/ y4 p Ywarning about the virilizing effect on a male or
/ ~( U% a5 j h" H4 J# I' ffemale child who might come in contact with some-. S; j; d% ~+ x. }/ Y
one using any of these products. v: F7 C# \) ]) [' A. W
References
6 m) W; h% k) {4 Y+ l1. Styne DM. The testes: disorder of sexual differentiation" I2 q# ?( ] l" ~* v+ _
and puberty in the male. In: Sperling MA, ed. Pediatric1 b- u; |! K1 `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;8 o0 `- Y+ I4 D1 k+ M5 _* M% u
2002: 565-628.
% N. |3 `6 a6 Z- B* R2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 S. g4 D2 Q. W' C% ^puberty in children with tumours of the suprasellar pineal |
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