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Sexual Precocity in a 16-Month-Old
8 V' j7 P- ]4 Y KBoy Induced by Indirect Topical: z% h9 |- w% j
Exposure to Testosterone* z" w2 M" X; [. j* [) e
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 ?8 v! X+ T+ Z( J, N
and Kenneth R. Rettig, MD1: a; {3 o# p3 Y9 r! w; M d
Clinical Pediatrics1 `+ S- V% R& R+ _ ~) u+ \
Volume 46 Number 6
% @: \8 ^6 \) p$ g% m( rJuly 2007 540-543
" f; x7 Z& @) w+ H6 y7 g© 2007 Sage Publications' S3 x/ _; T2 b1 n; O( W
10.1177/0009922806296651
+ N+ @- x2 C, T! P" i" Shttp://clp.sagepub.com
' ?3 K2 U8 U. ihosted at
; S! Q8 S2 S0 k1 c2 ?3 w2 Ihttp://online.sagepub.com
1 a' P, v3 g! P. o3 \& o4 V; ~Precocious puberty in boys, central or peripheral,2 g$ g+ b: a" w) ^' N a5 `
is a significant concern for physicians. Central
, _0 P" B C# P4 c/ |- O! F# ]+ b% bprecocious puberty (CPP), which is mediated
+ z- i8 X* n2 g1 b; K6 j( pthrough the hypothalamic pituitary gonadal axis, has: G) Q/ K, t! W- c
a higher incidence of organic central nervous system- r3 a6 f6 m3 x4 |% y5 n: O) m
lesions in boys.1,2 Virilization in boys, as manifested
8 C# ^! l; }3 {$ iby enlargement of the penis, development of pubic
7 ^% |+ |1 x1 I% G, v# k9 mhair, and facial acne without enlargement of testi-0 L1 c' X* A( i) I! W1 ^
cles, suggests peripheral or pseudopuberty.1-3 We
* y3 |% q8 N, w0 w5 y Mreport a 16-month-old boy who presented with the
+ [& O# D) }5 Zenlargement of the phallus and pubic hair develop-9 ?2 ]' M% h8 B1 u
ment without testicular enlargement, which was due' A/ P, U. u# B5 y( V
to the unintentional exposure to androgen gel used by9 ]+ w8 \3 c5 i; T7 v* Q5 |
the father. The family initially concealed this infor-
& H2 S9 `( `$ l( Wmation, resulting in an extensive work-up for this# s9 p `! p0 \* M3 f/ v, ]
child. Given the widespread and easy availability of7 K* u- g4 P1 U: R$ W
testosterone gel and cream, we believe this is proba-$ Z5 _0 z& ]) w1 s4 W4 L k
bly more common than the rare case report in the
( k* J: k$ D8 q! o* L6 E1 \ I, ^literature.40 q; C( B/ K; N. v7 R
Patient Report
W N1 W2 F( T, _! MA 16-month-old white child was referred to the: z3 D) O# W4 D0 g6 s9 j
endocrine clinic by his pediatrician with the concern: H V. ~% A6 B+ t! s' `* Z
of early sexual development. His mother noticed o% j; N. G. U k9 @
light colored pubic hair development when he was' W" r. k3 `9 L }6 u5 _
From the 1Division of Pediatric Endocrinology, 2University of
; `# o& y* y, ~9 ?4 SSouth Alabama Medical Center, Mobile, Alabama.
& }. W# ^1 b* m2 J8 e6 ^/ Z4 FAddress correspondence to: Samar K. Bhowmick, MD, FACE,4 [$ S6 W* P; u7 _
Professor of Pediatrics, University of South Alabama, College of
0 e% p8 A+ U& C- ~Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 \1 I3 D/ u D$ Q* v7 w0 _! [1 }e-mail: [email protected].7 e% }+ {) o; J0 @( n
about 6 to 7 months old, which progressively became# W" [' m$ d7 R
darker. She was also concerned about the enlarge-
y! n" o/ K+ f' [2 s! gment of his penis and frequent erections. The child& }" v6 L5 Q8 n4 d4 _
was the product of a full-term normal delivery, with; F+ Y( g- \3 a' }) y
a birth weight of 7 lb 14 oz, and birth length of! g5 Z8 N s4 K- j# T& Z$ I6 }: b
20 inches. He was breast-fed throughout the first year
+ U6 _# Q) X9 X6 U" lof life and was still receiving breast milk along with/ U# E* A7 t. G; A9 Y9 K3 x0 F p
solid food. He had no hospitalizations or surgery,
* P; u% T( u3 B: Aand his psychosocial and psychomotor development
( @/ y: t9 u, a& `3 ]$ lwas age appropriate.: U+ w" b& l% c
The family history was remarkable for the father,2 U0 s! i. O# U3 M# i4 e) I Z/ `
who was diagnosed with hypothyroidism at age 16,
( L$ ~* d$ \/ g1 q) P7 \& [' |" k2 {0 lwhich was treated with thyroxine. The father’s
( g0 W5 D) D9 y: Rheight was 6 feet, and he went through a somewhat# @! ~; Q2 @- u9 M4 A, g3 W* M: [0 g5 z
early puberty and had stopped growing by age 14.
/ |: Y; q) A! A. r pThe father denied taking any other medication. The
' k% Z8 G% k( ~% ?- e! Vchild’s mother was in good health. Her menarche
T8 _7 N: B( v5 \2 x7 M x* P' b: Cwas at 11 years of age, and her height was at 5 feet
3 D( l8 m* H/ ^# N( B9 Q5 f5 inches. There was no other family history of pre-( f' ]# b& C: _6 |; s! `; L0 E2 E. C
cocious sexual development in the first-degree rela-. y, P4 m7 H% f; G
tives. There were no siblings.
7 U. e) }. i) v; ~) i$ G& vPhysical Examination
& _" m7 l1 m4 u' q9 g vThe physical examination revealed a very active," Z& G: ?, u7 z1 d3 r
playful, and healthy boy. The vital signs documented
% ]- {; }8 N+ ?6 [9 g, |, O2 `a blood pressure of 85/50 mm Hg, his length was* U; ]: o( w% b* H# F `, {" e
90 cm (>97th percentile), and his weight was 14.4 kg" y0 h) K8 L8 h1 q. l. t. w+ x
(also >97th percentile). The observed yearly growth+ u& g% u: D' X) W" A; |! i
velocity was 30 cm (12 inches). The examination of
' f+ r5 l0 w& k$ l7 V3 wthe neck revealed no thyroid enlargement.
. z5 R; r B7 @+ |The genitourinary examination was remarkable for% }8 Q0 Y, k" |$ _
enlargement of the penis, with a stretched length of$ r7 s# S! N, q
8 cm and a width of 2 cm. The glans penis was very well
" K7 Z( F0 G% R' l$ n2 F# jdeveloped. The pubic hair was Tanner II, mostly around S- ~+ ~+ s1 j7 ]( p
540
' x6 A$ |* B: M3 L5 w oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! i0 |3 W6 J: g
the base of the phallus and was dark and curled. The5 X$ O( X% U7 X; r- ^2 K2 Z" q
testicular volume was prepubertal at 2 mL each.
0 J, r" ]) h5 i( _# L& Z1 WThe skin was moist and smooth and somewhat
# M. n& L4 h Z, r# [* Koily. No axillary hair was noted. There were no
: |1 o4 k q+ e' a1 e# u' pabnormal skin pigmentations or café-au-lait spots.
) x$ n. }( ?+ m3 M4 rNeurologic evaluation showed deep tendon reflex 2+. g/ ^+ t; a3 @& u1 v) }" ?
bilateral and symmetrical. There was no suggestion' K1 N) V3 W9 Q
of papilledema.' } e/ u" n3 i/ e" {+ M/ e
Laboratory Evaluation* L' l( q) Q3 L1 q5 Y9 P t/ K6 o3 Q
The bone age was consistent with 28 months by
. {* F; W2 O$ v3 [& Xusing the standard of Greulich and Pyle at a chrono-& V0 h* j! s _5 j7 C
logic age of 16 months (advanced).5 Chromosomal/ U; ~9 z% t' E0 k; W( Q1 s
karyotype was 46XY. The thyroid function test
* Z/ q; G0 V1 b* r% J; D- @showed a free T4 of 1.69 ng/dL, and thyroid stimu-3 q- `) G) H( ~( \
lating hormone level was 1.3 µIU/mL (both normal).
" Y2 n2 b- f LThe concentrations of serum electrolytes, blood
8 d$ Y; F/ f+ I9 T) H5 f5 e ourea nitrogen, creatinine, and calcium all were5 p; P5 i- I+ W: I$ ^5 V& M
within normal range for his age. The concentration( C8 O5 K, q- l* }- G b9 F
of serum 17-hydroxyprogesterone was 16 ng/dL9 f: Y) x; ^: Q$ E( K# Q v a: J% A B
(normal, 3 to 90 ng/dL), androstenedione was 20
/ J/ P" q$ v4 p) nng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-& I H1 C1 R7 v* F" U) B" y
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
* t( o8 I0 s" s: {) s, o3 s6 o6 wdesoxycorticosterone was 4.3 ng/dL (normal, 7 to8 z" W8 D# {! H7 Y
49ng/dL), 11-desoxycortisol (specific compound S)
$ C/ _" b- z1 g2 x$ _2 e+ x( Mwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
9 ]- l: t$ S) t/ i/ `& wtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total$ j- ^9 r$ X1 `( W* J
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 t9 Z0 u" y% D9 ^& r, I" mand β-human chorionic gonadotropin was less than
* |0 ]3 V3 y3 i: ]6 S5 mIU/mL (normal <5 mIU/mL). Serum follicular
2 l. V' m( L* {/ U" pstimulating hormone and leuteinizing hormone6 G4 p( ~6 N+ h/ O7 q! C/ l8 [6 b
concentrations were less than 0.05 mIU/mL2 x! P5 V7 t/ ?" }$ @1 R. O" d& b
(prepubertal).2 C6 J# C3 q- U: Z0 r; ^
The parents were notified about the laboratory1 p5 d! S6 S1 L! d0 W+ n" U, ?7 H
results and were informed that all of the tests were
/ w a, _5 B- i Jnormal except the testosterone level was high. The
& x) l3 H) f3 W5 f6 m) f9 ^6 Bfollow-up visit was arranged within a few weeks to- z8 R3 u; m5 E, c3 I
obtain testicular and abdominal sonograms; how-2 r: R+ _4 x7 w2 V
ever, the family did not return for 4 months.
: y5 l. V- W" c( H5 o5 _2 xPhysical examination at this time revealed that the
2 h8 A$ Y+ U0 N" D- _child had grown 2.5 cm in 4 months and had gained1 X' `; O5 f, ^9 B! y9 j$ r$ W( O
2 kg of weight. Physical examination remained
, p- K; y9 \; u9 H- }5 Uunchanged. Surprisingly, the pubic hair almost com-
K9 |$ `( H8 [; b, e, `pletely disappeared except for a few vellous hairs at
7 j& `+ G* E- y- Uthe base of the phallus. Testicular volume was still 2
, N3 K4 n1 C1 B- S. T, r8 d& WmL, and the size of the penis remained unchanged.
7 I7 N a) G9 p. @8 EThe mother also said that the boy was no longer hav-
4 Q$ ?( F8 v4 U7 E( g& Zing frequent erections.
0 p( l' { I$ g. Z& RBoth parents were again questioned about use of
9 n- Q# {) i: P6 q7 n8 ]' Oany ointment/creams that they may have applied to
2 B+ ]& o% [' ]- Uthe child’s skin. This time the father admitted the
/ C8 M3 }$ _3 \' h2 w& @Topical Testosterone Exposure / Bhowmick et al 541
) A/ k2 o% q, ]use of testosterone gel twice daily that he was apply-
; Q* t W" W& J6 X% c' I; Z6 E1 `ing over his own shoulders, chest, and back area for' E6 g3 u6 u: u
a year. The father also revealed he was embarrassed2 f; N) ^5 a2 R/ T$ }
to disclose that he was using a testosterone gel pre-) b- G1 H [6 S$ D9 @; D
scribed by his family physician for decreased libido* i* K8 a# r+ F/ E; I/ U
secondary to depression.
$ H' W# A3 D( I$ @The child slept in the same bed with parents.
& K) Z2 Y! W; H' { T: G6 _The father would hug the baby and hold him on his5 }7 T: F, i* v$ M6 M. r+ U9 z
chest for a considerable period of time, causing sig-6 a$ Z, `) D8 j# W6 O
nificant bare skin contact between baby and father.
4 u$ A% n- }+ {7 {; A0 \8 O, pThe father also admitted that after the phone call,
+ d3 |& b1 T0 \8 Iwhen he learned the testosterone level in the baby
' m, {) C$ q- Ywas high, he then read the product information
% {) [5 k2 i6 a; M8 Z6 s: opacket and concluded that it was most likely the rea-
0 s, M6 \, H3 H6 t2 {. ~3 m6 oson for the child’s virilization. At that time, they
8 ~0 V7 C0 r& y, ldecided to put the baby in a separate bed, and the3 `) ^- F4 Q" n# E+ H
father was not hugging him with bare skin and had% V" J8 Q7 p& h2 T
been using protective clothing. A repeat testosterone
9 A! r! V7 u7 L, V: A, Ntest was ordered, but the family did not go to the
{0 f7 w! u, E: r& O7 [laboratory to obtain the test.& {* ?6 ^! q7 J( R
Discussion+ Y; o: [! ^; O( r( Z
Precocious puberty in boys is defined as secondary- `3 J4 Z4 f1 \) r2 |. d H
sexual development before 9 years of age.1,4
5 z; T" N8 n$ i$ _: V0 _Precocious puberty is termed as central (true) when
% r3 e* v0 h; L( M- z n) git is caused by the premature activation of hypo-
7 v) k: R2 X7 Wthalamic pituitary gonadal axis. CPP is more com-
: d1 m( }* _' S5 L0 Mmon in girls than in boys.1,3 Most boys with CPP
: p, Z3 b' Y7 J, f, b: ?& Umay have a central nervous system lesion that is) M, W& Z1 K: ]# V* O+ c
responsible for the early activation of the hypothal-
& g; L0 T- U0 x; Lamic pituitary gonadal axis.1-3 Thus, greater empha-
; V/ ~& R( M$ c$ A/ Psis has been given to neuroradiologic imaging in
( [# d6 B8 x) X2 {9 ^boys with precocious puberty. In addition to viril-4 t& @# n" o. E- K- |1 C, f, ?' q
ization, the clinical hallmark of CPP is the symmet-. V+ N$ X) O6 {3 O6 M6 n
rical testicular growth secondary to stimulation by
+ Y; n0 Q- b9 K R, u4 t+ k- {0 t; ggonadotropins.1,3
/ p3 N2 l* ]4 V7 `" h& J& r. b5 EGonadotropin-independent peripheral preco-7 Q( R& S% s. |& M' U
cious puberty in boys also results from inappropriate7 D) ^$ T2 _. q8 z, z
androgenic stimulation from either endogenous or
" S' ^& z) _! R d1 rexogenous sources, nonpituitary gonadotropin stim-# Y+ F5 g/ ?7 Z* ~' R
ulation, and rare activating mutations.3 Virilizing0 T/ L$ p# ~4 _3 u5 c
congenital adrenal hyperplasia producing excessive" X6 C- |$ ]0 e# u. ?% g
adrenal androgens is a common cause of precocious
$ i c- V8 b& t# I2 T4 A) V7 K, Hpuberty in boys.3,4
" u, ^6 j4 j7 C; OThe most common form of congenital adrenal
, K4 B2 {5 |5 p3 M! o4 L! lhyperplasia is the 21-hydroxylase enzyme deficiency.
# o1 \6 \# ~' mThe 11-β hydroxylase deficiency may also result in. i. i$ P O( D' B; } g0 {
excessive adrenal androgen production, and rarely,
. w3 V" m1 P; J* C9 Man adrenal tumor may also cause adrenal androgen
0 {/ m1 e9 Y. U; eexcess.1,3 g2 i; C. r+ B1 N# y- F% k
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: a/ P/ f: ~6 Z% n" M
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! Z3 w# Z1 ~$ @! RA unique entity of male-limited gonadotropin-
, Z# B) l B% D3 kindependent precocious puberty, which is also known
. m( m6 S& h8 U% T! \% J F( `as testotoxicosis, may cause precocious puberty at a
1 N8 r/ M* g( O* T: D* f( ~4 fvery young age. The physical findings in these boys" ~+ ?2 a A& E, x1 z
with this disorder are full pubertal development,1 l5 z# O3 Y( F! H9 G! J, M
including bilateral testicular growth, similar to boys: a- g4 f7 s" S2 T" ~! q1 x. `3 b
with CPP. The gonadotropin levels in this disorder
* l+ T3 ]$ o* k8 r/ \are suppressed to prepubertal levels and do not show P. `0 E( o, A8 V& p# a
pubertal response of gonadotropin after gonadotropin-
. S: p1 J; F6 o3 v& Preleasing hormone stimulation. This is a sex-linked) N1 d+ w5 P/ x4 J# g+ m
autosomal dominant disorder that affects only
2 x; Z& P' U+ o- G$ Q$ ^9 m) R+ A6 P( Xmales; therefore, other male members of the family: V# X; f- J8 C% _, |( i I
may have similar precocious puberty.3
( l' ~3 E! d: r8 \In our patient, physical examination was incon-
' K' v7 G$ R. G0 }, a z+ c0 E! h0 H' qsistent with true precocious puberty since his testi-
& l& F) {, g% B- h+ }6 j. hcles were prepubertal in size. However, testotoxicosis
; A0 E8 u Q5 e5 mwas in the differential diagnosis because his father
' u9 P; ?0 V$ d( ]started puberty somewhat early, and occasionally,! i+ z* H* g) ^5 R9 M4 D
testicular enlargement is not that evident in the
( t r9 ^; [: y' abeginning of this process.1 In the absence of a neg-
- d! F: r, u4 ^: bative initial history of androgen exposure, our3 O5 t5 o3 x9 q J8 a
biggest concern was virilizing adrenal hyperplasia,
4 t4 j7 ]) b B, Yeither 21-hydroxylase deficiency or 11-β hydroxylase
. C1 p7 p2 f1 Q: }) K! a7 Ldeficiency. Those diagnoses were excluded by find-
0 R1 F) T S4 j/ Z" i' ^5 h5 jing the normal level of adrenal steroids.4 y8 _" L. [0 j; p7 I
The diagnosis of exogenous androgens was strongly5 h' h: c, e* |* J& a* Z
suspected in a follow-up visit after 4 months because" y7 O( U% R6 W# @& ~+ @3 o
the physical examination revealed the complete disap-$ h0 P: j* @ E+ ]: t* A* w! M/ V
pearance of pubic hair, normal growth velocity, and
) r( @ }- G+ Tdecreased erections. The father admitted using a testos-
, A) i8 c$ w6 X4 g, \* i% g# o! hterone gel, which he concealed at first visit. He was6 |, N1 S& `: s/ B* J
using it rather frequently, twice a day. The Physicians’
5 t( Y @( G$ ?Desk Reference, or package insert of this product, gel or' D' P/ f9 ^* F: v
cream, cautions about dermal testosterone transfer to3 }/ X* J( `& y5 R9 ~
unprotected females through direct skin exposure.3 {8 M2 |0 }! M9 N
Serum testosterone level was found to be 2 times the
: e$ X z7 J- T0 j1 c5 B0 ^! ~baseline value in those females who were exposed to
9 l# I* _3 ~8 e0 Y3 @ Reven 15 minutes of direct skin contact with their male
; a' d+ W" Y! Cpartners.6 However, when a shirt covered the applica-. l2 j: L g9 N& \1 s
tion site, this testosterone transfer was prevented.
4 v+ t$ d" L5 y1 o6 H8 b' _$ _Our patient’s testosterone level was 60 ng/mL,. [# {, w4 T& D: [+ H$ ]
which was clearly high. Some studies suggest that" J/ k6 ?9 c. O. R4 O4 Q
dermal conversion of testosterone to dihydrotestos-
9 Y: p( H) `3 Aterone, which is a more potent metabolite, is more
1 z# C1 l2 O& l0 G/ x0 R+ Zactive in young children exposed to testosterone
+ z( ]* j$ v& E' ?, V9 Gexogenously7; however, we did not measure a dihy-! e- m2 R- k H6 h3 q2 `0 J
drotestosterone level in our patient. In addition to
$ n/ I% F8 w! C% ]5 \2 dvirilization, exposure to exogenous testosterone in
2 e/ x( P% \' F4 a$ G+ m/ b3 {- nchildren results in an increase in growth velocity and; M! g8 V0 I4 C/ T: \/ h
advanced bone age, as seen in our patient.
, {3 K: h4 W# x: s* w) hThe long-term effect of androgen exposure during
3 p/ e6 i* u; h7 v& dearly childhood on pubertal development and final' e* r% y$ P' V, O4 L$ C8 y
adult height are not fully known and always remain$ d$ z, \" b. S$ B
a concern. Children treated with short-term testos-; g) L, O3 f, ?
terone injection or topical androgen may exhibit some5 l) x& S4 p% F7 o5 E5 C
acceleration of the skeletal maturation; however, after7 u9 f# l2 ]( K! ~# V, w
cessation of treatment, the rate of bone maturation4 W0 I% k' W: Y, w$ W9 W5 c- X
decelerates and gradually returns to normal.8,9
6 h$ U, f# ]3 VThere are conflicting reports and controversy) H; z/ p' B# T( ]
over the effect of early androgen exposure on adult
9 z" {8 h! _: ?( d' I2 k( u2 upenile length.10,11 Some reports suggest subnormal
/ ]# e8 ?/ z8 K% U- uadult penile length, apparently because of downreg-
4 v" K: l# Z$ E- ?9 q! tulation of androgen receptor number.10,12 However,
+ }$ a$ R3 f" [' u; ]) U4 J# Q3 Y2 ZSutherland et al13 did not find a correlation between5 D3 P- }' I, A& e# l7 R
childhood testosterone exposure and reduced adult
0 S7 `: O( F& R0 cpenile length in clinical studies.
. I" k3 D9 C6 x& e3 M% c* g( UNonetheless, we do not believe our patient is
) }4 f- x4 _, tgoing to experience any of the untoward effects from+ B) b+ m: t6 f& a6 T* I4 G$ S
testosterone exposure as mentioned earlier because6 ^( _# g1 G# F( X" x1 Z Z7 K
the exposure was not for a prolonged period of time.
5 A h9 u7 u1 ?# o8 L S1 eAlthough the bone age was advanced at the time of% l- A3 q9 j% h2 F" g
diagnosis, the child had a normal growth velocity at
& H" M+ l: l, `( ^$ O# Qthe follow-up visit. It is hoped that his final adult
' l# p; o" p7 f" I4 L. q' eheight will not be affected.
4 N# K# G) E) a' _! x7 MAlthough rarely reported, the widespread avail-
- \9 m# Q# y9 [6 j9 Q+ j6 o0 bability of androgen products in our society may
3 S7 T A& `& g. }3 T7 `indeed cause more virilization in male or female
0 a8 V* P8 o7 i" J- }/ Cchildren than one would realize. Exposure to andro-
1 N8 v6 e3 z- z& b3 z3 lgen products must be considered and specific ques-$ i* N6 O1 P2 b7 H# a/ O! T
tioning about the use of a testosterone product or
q; q2 }/ U: J1 h+ Bgel should be asked of the family members during
& z7 k5 o( M, t, C: g/ Wthe evaluation of any children who present with vir-4 }/ e2 ~" f4 H& s- H+ Y
ilization or peripheral precocious puberty. The diag-3 q; d6 t0 d1 x9 ?
nosis can be established by just a few tests and by6 w4 E8 w' Q' N3 }
appropriate history. The inability to obtain such a8 W! l8 X: ?. C! K" S
history, or failure to ask the specific questions, may
( \5 W w0 M- l; N' nresult in extensive, unnecessary, and expensive
; g3 d2 L" u( w" P O" ^investigation. The primary care physician should be5 h8 t" V' I% f" |* y
aware of this fact, because most of these children) x( m e' n9 h" [# } M% y
may initially present in their practice. The Physicians’
' F" r) h0 Y+ F8 U HDesk Reference and package insert should also put a
, E% A7 `3 n) |; s/ W& p7 Mwarning about the virilizing effect on a male or
1 }2 A) e2 I% K5 Nfemale child who might come in contact with some-* L- w, S# C# G$ E: k- f4 [
one using any of these products.
% L. d- s% B4 B& R4 b, UReferences3 M# m- ^2 O3 I% S; y% [$ h
1. Styne DM. The testes: disorder of sexual differentiation
' M$ N9 @+ B- w) E9 ^) p! H% D) Tand puberty in the male. In: Sperling MA, ed. Pediatric9 D3 z& P# w" A! _& }/ B8 B
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
/ f: a0 W! E7 }2002: 565-628.+ w! y) \/ }* {. R( [
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
! \2 \: C- Q; dpuberty in children with tumours of the suprasellar pineal |
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