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Sexual Precocity in a 16-Month-Old" p0 N X9 D6 L3 B! E2 F
Boy Induced by Indirect Topical8 _& c7 e( ]! F* i# ]$ W
Exposure to Testosterone
4 N; m2 F% N; k5 o; [- w$ m; z: ^Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ {: P6 ?0 d/ Aand Kenneth R. Rettig, MD1
0 s0 i. _5 R; D) {/ }Clinical Pediatrics
3 y Z3 W* k0 h! oVolume 46 Number 6' p7 F" _; B: i, |- E. U+ s: I
July 2007 540-543
# _" O5 K% E; H' }" u/ k© 2007 Sage Publications
4 r! c z5 r" w% O! y10.1177/0009922806296651& B, O! r' F; J- o' F
http://clp.sagepub.com4 O0 [9 |) B9 y: {# w0 z
hosted at
2 I% y O# z& D& R8 R+ Khttp://online.sagepub.com; |$ A3 ]4 h! C4 K! Y% h" g
Precocious puberty in boys, central or peripheral,
( u, \" u9 k2 w/ R4 V/ ]is a significant concern for physicians. Central
p. V% m1 h3 ]( vprecocious puberty (CPP), which is mediated: C3 o# ^% [9 f# W( ?
through the hypothalamic pituitary gonadal axis, has
+ E+ q, \" c5 q9 E W" m! L* p/ Va higher incidence of organic central nervous system7 q, ~+ ~. o) B
lesions in boys.1,2 Virilization in boys, as manifested* x \, |& Z, Q" H
by enlargement of the penis, development of pubic5 A. D8 m: x2 {% I' W; h
hair, and facial acne without enlargement of testi-( w3 q* O( j* J: j. r& p# \3 C
cles, suggests peripheral or pseudopuberty.1-3 We O, E f9 ^, D8 f* `6 \9 v: p
report a 16-month-old boy who presented with the0 \% h0 h6 a* V: E
enlargement of the phallus and pubic hair develop-' W( M. n6 P3 X# q5 H
ment without testicular enlargement, which was due- H/ _8 {0 c- j3 t2 c
to the unintentional exposure to androgen gel used by
5 q+ T& v# G* l5 Y3 sthe father. The family initially concealed this infor-
9 }7 F# l5 i; v5 q7 Hmation, resulting in an extensive work-up for this/ X) s! i% `+ T* u. F' M& l$ w! D
child. Given the widespread and easy availability of
% `6 w' C8 F8 Wtestosterone gel and cream, we believe this is proba-
- `: G5 {6 ~4 v1 hbly more common than the rare case report in the
- P d0 B) B. x; v4 g6 D \9 xliterature.4
$ Z) T9 t: b5 qPatient Report5 Q1 S. ^) [: s! h
A 16-month-old white child was referred to the7 f9 R$ V5 B: \7 l4 Y6 d' E' a0 c
endocrine clinic by his pediatrician with the concern" S/ e4 Q2 v; ^, Y9 j
of early sexual development. His mother noticed6 E' `, l9 G' C+ x) G7 N8 x
light colored pubic hair development when he was
- A( y& q* y# y6 BFrom the 1Division of Pediatric Endocrinology, 2University of$ {! N" E/ t) d1 G' L8 d. {
South Alabama Medical Center, Mobile, Alabama., |4 x y3 l0 k A. N0 L& I5 W
Address correspondence to: Samar K. Bhowmick, MD, FACE,7 a3 L4 l/ q- M- I0 V% n
Professor of Pediatrics, University of South Alabama, College of
4 [; D, X) k; x% fMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
, p8 ~* K3 v; V# x) C+ v% Ge-mail: [email protected].
8 c$ Z8 f/ a) Z, A) E3 \. Tabout 6 to 7 months old, which progressively became9 J' Q5 D- `: c; n8 A/ d S
darker. She was also concerned about the enlarge-
* p- k: x, Z9 a5 Wment of his penis and frequent erections. The child
# i7 [; B0 y9 [6 T g1 fwas the product of a full-term normal delivery, with$ T2 U% N+ N1 s- t! P
a birth weight of 7 lb 14 oz, and birth length of
% t3 E: c5 W' f20 inches. He was breast-fed throughout the first year
: ~/ G2 o0 v) b( S/ t0 N _of life and was still receiving breast milk along with1 L" S9 e V$ O5 o3 W/ J& `& L( c0 i! `
solid food. He had no hospitalizations or surgery,% {- k! t4 Y# v ]9 ?
and his psychosocial and psychomotor development- _; i' T& W, l! |- e! q. J* g
was age appropriate./ E# p2 X' \2 k; d5 ^9 `
The family history was remarkable for the father,& I$ B& R# V7 C5 G2 Y
who was diagnosed with hypothyroidism at age 16,
( C( V0 \+ X8 z9 n: {; @5 n. i; ^& Pwhich was treated with thyroxine. The father’s% {' J3 ? Q9 }$ ^/ m
height was 6 feet, and he went through a somewhat2 D/ D0 ]9 q% h2 G+ f X. \
early puberty and had stopped growing by age 14.. s7 E& G& D' K' F# w
The father denied taking any other medication. The
2 @! b' ?% j8 v: z/ vchild’s mother was in good health. Her menarche& o. n* N- S2 }7 }" @$ Z; K, _4 d
was at 11 years of age, and her height was at 5 feet2 T# `! j" o: S8 ~) O
5 inches. There was no other family history of pre-* [( e4 B" L8 d0 G! w8 X
cocious sexual development in the first-degree rela-8 t: F- x5 C9 @
tives. There were no siblings.
: E6 r2 ?" ?# h7 |7 \( rPhysical Examination" j* M$ \7 L7 m' ?0 x8 d
The physical examination revealed a very active,
# p4 z' W3 Q; q# rplayful, and healthy boy. The vital signs documented
: m+ l& i h0 w- @a blood pressure of 85/50 mm Hg, his length was+ S: `8 T' f; W+ a M. u4 }9 A
90 cm (>97th percentile), and his weight was 14.4 kg# R" K9 B$ [) s6 ^
(also >97th percentile). The observed yearly growth1 i5 n& @# P; `, c+ s
velocity was 30 cm (12 inches). The examination of
6 I1 L% w" ?$ a1 c# Jthe neck revealed no thyroid enlargement.
( r- J% {! z% M: O+ U KThe genitourinary examination was remarkable for
: n; g6 T# [1 Eenlargement of the penis, with a stretched length of V1 A: |9 c* l4 D7 W
8 cm and a width of 2 cm. The glans penis was very well
: q, q% {/ A( r. fdeveloped. The pubic hair was Tanner II, mostly around! r" H. h! c" b) V* P" e& z
540: r" j1 f. K- Q7 V# n! g/ A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* k p8 K" i! i+ Q* o6 {" }7 athe base of the phallus and was dark and curled. The
0 `5 a5 @6 A: wtesticular volume was prepubertal at 2 mL each.
, J" B4 e$ B+ \: N: AThe skin was moist and smooth and somewhat+ P V5 R& F1 k* }: i+ i
oily. No axillary hair was noted. There were no
2 l: r3 f% h' f9 eabnormal skin pigmentations or café-au-lait spots.
) d$ I1 H; |4 t$ ]Neurologic evaluation showed deep tendon reflex 2+
" G* K( x0 B. c6 P! U5 Cbilateral and symmetrical. There was no suggestion
* { e8 \- A7 N( Tof papilledema.
( `9 c2 Q' @2 j6 s' t0 f* y4 ~Laboratory Evaluation! ]. u% s) F' h7 ~+ s2 U
The bone age was consistent with 28 months by
0 q7 \0 u' d6 \7 y" S0 z Rusing the standard of Greulich and Pyle at a chrono- s( F# k% \6 H- t, p/ n& z
logic age of 16 months (advanced).5 Chromosomal
# r* p( U9 t8 `( T5 k& l Bkaryotype was 46XY. The thyroid function test4 w! ~& ^: c4 ~5 M k& G5 k' e
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
0 [ z, h' ~: o# R y, qlating hormone level was 1.3 µIU/mL (both normal).& s. |, \! q7 o$ A. j2 g
The concentrations of serum electrolytes, blood
6 b+ j8 W7 U, R4 ^! M, p! C: W6 [urea nitrogen, creatinine, and calcium all were+ L( g( y: G$ H3 a# _
within normal range for his age. The concentration, U$ C& j# H7 P; a0 N6 u6 ~ F
of serum 17-hydroxyprogesterone was 16 ng/dL: q3 N' Z( n# V! v8 h% S: u
(normal, 3 to 90 ng/dL), androstenedione was 20
* }- Q7 v* F2 v( jng/dL (normal, 18 to 80 ng/dL), dehydroepiandros- j8 A* u0 x7 ?& p& T7 k
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
: R* Z% |7 ]/ p) Q" n/ a4 ^5 jdesoxycorticosterone was 4.3 ng/dL (normal, 7 to+ c! A9 e7 ?; s: K+ a$ X. q
49ng/dL), 11-desoxycortisol (specific compound S)
1 P. D9 m/ f2 {2 d( p1 m3 ?was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 {. N' r5 P$ P' m; C# O `8 O, L# O5 a
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total+ k. O% K0 h _, j2 D7 d2 n/ H' K' X
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),/ {' C3 n6 Z( t1 N7 v3 n
and β-human chorionic gonadotropin was less than' T3 m6 Z/ Y! j8 o w2 Q) h
5 mIU/mL (normal <5 mIU/mL). Serum follicular
|/ K. c% w4 o( e" _stimulating hormone and leuteinizing hormone4 k, v& M, E) t8 _5 O
concentrations were less than 0.05 mIU/mL j4 S" }/ f; g# N) U5 p
(prepubertal).
+ E- g7 e |, w5 E m+ f3 G* PThe parents were notified about the laboratory) M/ H- l( D- B3 t: I. ?2 v
results and were informed that all of the tests were8 z% G' i: e% B6 n. ?1 B
normal except the testosterone level was high. The. H( [1 ~* G" W) L
follow-up visit was arranged within a few weeks to
, y+ e' P- G% i' v: d- iobtain testicular and abdominal sonograms; how-
1 K4 i! E- k' t; r1 Tever, the family did not return for 4 months.( U: O) L% U3 j0 I1 g& `6 ~, g) H
Physical examination at this time revealed that the/ j1 K" @8 m4 {1 b) i: `, D
child had grown 2.5 cm in 4 months and had gained
) }9 g& N) ^4 z2 r# X2 kg of weight. Physical examination remained
" s- y$ X( [" O7 Tunchanged. Surprisingly, the pubic hair almost com-
9 X* c* _( I# x& f2 v5 ?7 qpletely disappeared except for a few vellous hairs at
( D8 v( R: o- s6 D _' z. f( C0 mthe base of the phallus. Testicular volume was still 2
5 J! u' _% T0 Y% H$ l, pmL, and the size of the penis remained unchanged.6 a! r, c: n1 G
The mother also said that the boy was no longer hav-+ z1 ^* E: Z M9 z
ing frequent erections.. r# y K( h6 O; n
Both parents were again questioned about use of
" P* l5 y5 f: O. }any ointment/creams that they may have applied to
2 p2 a+ W! O6 Q; L, @1 o, xthe child’s skin. This time the father admitted the
- Z& z" M0 V" R' m7 ]2 iTopical Testosterone Exposure / Bhowmick et al 541
" B- B5 T! @2 `( y- uuse of testosterone gel twice daily that he was apply-
+ V, J4 c$ N5 H& Ting over his own shoulders, chest, and back area for
) `5 ^( D1 i8 L( a/ B# sa year. The father also revealed he was embarrassed: E7 @+ _9 Q& R Q4 A3 L
to disclose that he was using a testosterone gel pre-
" N% P: u9 A# T+ ]2 | `) G7 Escribed by his family physician for decreased libido
% X/ m- [; r# G$ B Ssecondary to depression.
4 T+ n3 i, d! U0 O- |The child slept in the same bed with parents.$ V. `4 w2 U, [8 M; U4 Q, a5 `3 [
The father would hug the baby and hold him on his2 q; {1 r v0 t- F' d/ G
chest for a considerable period of time, causing sig-! A0 Z: v. P: }& `; \5 U! Z; \: D* Z
nificant bare skin contact between baby and father.
. E* g: b; {, K+ s; O& PThe father also admitted that after the phone call,5 a# P; |+ U, K7 v& X1 ?; D
when he learned the testosterone level in the baby
0 i; g3 P; W7 _3 _was high, he then read the product information
7 u8 J: y% ~0 c: Jpacket and concluded that it was most likely the rea-7 `6 F/ r7 e3 D
son for the child’s virilization. At that time, they
R" b9 b; [: u" I" g0 sdecided to put the baby in a separate bed, and the" E/ Z8 w+ A/ }* }
father was not hugging him with bare skin and had6 C7 w1 Z* j" j7 M2 _2 @: W
been using protective clothing. A repeat testosterone
: J! h6 s- v/ F2 `test was ordered, but the family did not go to the
, M l8 Q. Z- ~5 A/ G4 F+ Jlaboratory to obtain the test.
$ G$ K+ M# ]$ t' V. I1 f0 `+ d& ^; C( sDiscussion
' V Y& f* l- [0 k9 F8 ^" T8 jPrecocious puberty in boys is defined as secondary& H5 J9 J' f# M/ w* K- e
sexual development before 9 years of age.1,4
5 T5 D! ]/ p& N$ P( g7 R" I. H6 \) lPrecocious puberty is termed as central (true) when
" B; F$ C# }3 U( @it is caused by the premature activation of hypo-4 y1 U* H+ j0 M# Y z8 T1 ]& e
thalamic pituitary gonadal axis. CPP is more com-' S9 L5 F' L7 n4 [2 i
mon in girls than in boys.1,3 Most boys with CPP0 \8 h( ?! n. s* R) r' W# H1 B
may have a central nervous system lesion that is" o/ e) K2 i4 T7 r
responsible for the early activation of the hypothal-
# \( ], S& O; \+ P+ o! yamic pituitary gonadal axis.1-3 Thus, greater empha-! S# ^8 p- W, T5 D
sis has been given to neuroradiologic imaging in% \ d" C4 V0 r- t4 ^
boys with precocious puberty. In addition to viril-
7 O0 h* y- A, k, k* P/ O7 b- Vization, the clinical hallmark of CPP is the symmet-
! A" Z8 v8 m! Brical testicular growth secondary to stimulation by
$ e2 M3 U0 j+ K/ s2 z' ?gonadotropins.1,3
; I& f5 b0 p8 [9 E1 mGonadotropin-independent peripheral preco-' s, Q5 U# O' H, c
cious puberty in boys also results from inappropriate3 z, L/ U; I4 C6 o' J$ }0 ~. {
androgenic stimulation from either endogenous or6 r* \# Q: [8 }1 O t* L8 [- L; D, v
exogenous sources, nonpituitary gonadotropin stim-$ ?, _9 M3 k+ h2 p2 H
ulation, and rare activating mutations.3 Virilizing
1 [& D7 H" B" e2 c |. _congenital adrenal hyperplasia producing excessive
6 i @) K+ n2 [: _; `adrenal androgens is a common cause of precocious
% I: H$ M) q9 Y. D! p. q8 mpuberty in boys.3,4
4 O1 _* p' A# u1 O" zThe most common form of congenital adrenal! ?' c3 T7 d# C% J. V
hyperplasia is the 21-hydroxylase enzyme deficiency.
, P; y, k# i# t4 b8 B9 TThe 11-β hydroxylase deficiency may also result in: v0 D) u c& j+ n I, J, k' z
excessive adrenal androgen production, and rarely,
7 p2 p7 Z9 b$ q9 C9 @7 M+ g4 \& z, san adrenal tumor may also cause adrenal androgen
, @# a7 o; Q7 zexcess.1,34 I7 i2 X$ Z9 L2 p! v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% a7 {) L) m* h; g0 M& p
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 \6 U, V9 \: e& aA unique entity of male-limited gonadotropin-
- c- F5 f5 U, t0 O) @+ iindependent precocious puberty, which is also known$ A7 a# o, g, w6 x0 m
as testotoxicosis, may cause precocious puberty at a
4 w* p/ } j6 F/ k; G, i; svery young age. The physical findings in these boys
& q5 o% x% v. Ywith this disorder are full pubertal development,
4 |! X$ f, a1 n! j2 f5 zincluding bilateral testicular growth, similar to boys8 T' O% p K- l* V9 P9 n4 Y6 Z
with CPP. The gonadotropin levels in this disorder
( z; M" M8 o$ S$ dare suppressed to prepubertal levels and do not show
+ m6 j0 B4 d) Qpubertal response of gonadotropin after gonadotropin-
) }: S; b! C1 b# v1 d, Qreleasing hormone stimulation. This is a sex-linked7 A0 C; _8 t6 ^# C/ s6 e
autosomal dominant disorder that affects only
. F- o0 ^. b( d$ Y1 L2 ^males; therefore, other male members of the family
5 E# G% u# Y; \may have similar precocious puberty.3" q9 f- L2 x* f3 I* C6 G
In our patient, physical examination was incon-
, C e5 E$ r5 V5 q/ n8 Rsistent with true precocious puberty since his testi-
1 P+ U' O$ h/ U1 x/ K: u% Vcles were prepubertal in size. However, testotoxicosis3 w* u3 K& Z2 R0 ^$ O. h0 f T
was in the differential diagnosis because his father2 U3 H' ?* a; a& T u9 ~
started puberty somewhat early, and occasionally,
" z4 h( {4 W! N/ Ltesticular enlargement is not that evident in the
3 e6 a. m Z. O. a7 ? ~7 {' Jbeginning of this process.1 In the absence of a neg-
, x \0 C' m8 W, ~; w& Y4 xative initial history of androgen exposure, our
7 Q( g# E, m4 k* [0 `3 ibiggest concern was virilizing adrenal hyperplasia,
9 d) k; W t6 aeither 21-hydroxylase deficiency or 11-β hydroxylase
% u o; ~# z# {* h; Mdeficiency. Those diagnoses were excluded by find-2 z$ M* z( {5 z% J
ing the normal level of adrenal steroids.
1 M U5 e8 [' S2 _) VThe diagnosis of exogenous androgens was strongly5 A, ^9 ?8 k- i. V2 X# X: S
suspected in a follow-up visit after 4 months because) `6 y, |# u, ?. Q( ]7 R8 K; S
the physical examination revealed the complete disap-6 [7 C/ N6 R* u+ b8 _0 h
pearance of pubic hair, normal growth velocity, and! c& W( m: a4 K$ x
decreased erections. The father admitted using a testos-
% X; N9 r: C- r% Y0 i' M; b* q2 Hterone gel, which he concealed at first visit. He was
9 Z9 ^- O" f, f" rusing it rather frequently, twice a day. The Physicians’" i/ J/ \/ B7 \0 X0 q3 A1 _, M7 Z
Desk Reference, or package insert of this product, gel or
, P5 _" E, h7 H, e" S! m* jcream, cautions about dermal testosterone transfer to
' C; `; Z0 I* | z/ e( f! `$ Aunprotected females through direct skin exposure.
( G5 g. v0 b& j; J1 r! l+ QSerum testosterone level was found to be 2 times the
# E, S- j* \. X$ B6 Y- _* Pbaseline value in those females who were exposed to0 Q5 h9 P' n4 |& `) h, m" t
even 15 minutes of direct skin contact with their male5 j% Y2 h+ M. y9 H# p0 P
partners.6 However, when a shirt covered the applica-% Z9 I7 p2 I! j7 ]: g: p
tion site, this testosterone transfer was prevented.4 s% L) f3 R/ i- ~
Our patient’s testosterone level was 60 ng/mL,1 O6 N2 Z; r# a2 ~
which was clearly high. Some studies suggest that
6 r! M/ D. N2 G& z& r5 g/ Z/ qdermal conversion of testosterone to dihydrotestos-
5 \) F3 u+ W% H! d$ f, iterone, which is a more potent metabolite, is more
m8 o& X5 B: _1 F U0 @active in young children exposed to testosterone
$ ~$ M7 |( W$ N7 D/ S; Cexogenously7; however, we did not measure a dihy-
6 _7 C% s" E! j" h8 F2 K1 U( [2 c+ kdrotestosterone level in our patient. In addition to
% L6 o* J; ^! \3 t" M9 gvirilization, exposure to exogenous testosterone in
) M2 j& q$ g" ?" z# Q3 V2 r+ zchildren results in an increase in growth velocity and
M6 ?/ K) m: n. d A% y vadvanced bone age, as seen in our patient., E! }* x: ^- r, C+ ]
The long-term effect of androgen exposure during4 n9 |/ c, G$ ~( v4 G2 w
early childhood on pubertal development and final
: c, w* ]( x7 X% U3 J! ]adult height are not fully known and always remain
* m1 ]7 p% O4 B; i4 O& D# F! ua concern. Children treated with short-term testos-* v$ X7 u/ b& t1 k& \9 [
terone injection or topical androgen may exhibit some V* q! t% O* g
acceleration of the skeletal maturation; however, after
, G& t& S) \4 Jcessation of treatment, the rate of bone maturation! E* e4 r3 o" p; s& D
decelerates and gradually returns to normal.8,9
/ |6 d" X+ t5 P9 n6 ~; `3 K* x1 MThere are conflicting reports and controversy# P+ p/ D9 Y& ]8 j$ R, \- [4 l' R
over the effect of early androgen exposure on adult5 ^: z- Z3 t: S2 d6 g2 u2 R3 ~
penile length.10,11 Some reports suggest subnormal
. K! _) M; |9 Ladult penile length, apparently because of downreg-
6 }- F* O: d- \ulation of androgen receptor number.10,12 However,7 l, v# a8 F3 ^2 Y/ C3 `
Sutherland et al13 did not find a correlation between# M+ K3 x& A0 R- c' Z
childhood testosterone exposure and reduced adult. f A8 y5 c' @+ ~! a9 R
penile length in clinical studies.
, Y5 o) b" ?/ U ?6 l8 X' `Nonetheless, we do not believe our patient is
7 W8 @$ g" M* [' A4 e( `going to experience any of the untoward effects from
" r7 o, ]2 v9 l# m1 b# V0 k6 d; Utestosterone exposure as mentioned earlier because
+ N0 X9 g. ^4 [2 `the exposure was not for a prolonged period of time.
" Y& d1 Z/ U) |( j* vAlthough the bone age was advanced at the time of
, u0 d: ~ C% hdiagnosis, the child had a normal growth velocity at
* R9 ]+ ~! h1 W% o2 k4 Q \) ~the follow-up visit. It is hoped that his final adult
3 J& r' X3 d; {- B* j( g4 T4 xheight will not be affected.& ]" Y" E3 G3 ^. ^. \( [
Although rarely reported, the widespread avail-, x$ { K$ x. @$ O2 Z9 D( Z; k) H) Y
ability of androgen products in our society may) o W7 q6 h( e+ x' O$ I
indeed cause more virilization in male or female8 q* s g/ W+ T* X
children than one would realize. Exposure to andro-) q! B/ G- Q$ ?7 t* Q, E
gen products must be considered and specific ques-3 g/ W! R4 Y3 ]
tioning about the use of a testosterone product or
. Y* ]6 M$ E$ ~( B% lgel should be asked of the family members during, @6 P. ~9 X9 ]! J& M5 ]( K6 s7 i
the evaluation of any children who present with vir-
( v5 i% r( O) ^ilization or peripheral precocious puberty. The diag-1 _& z$ x% i- d) K& z% Q9 Z
nosis can be established by just a few tests and by9 K* F2 r. O+ A8 k# U0 X
appropriate history. The inability to obtain such a
( O' t6 ^3 K( O' ?1 V! Z1 xhistory, or failure to ask the specific questions, may
* R) ~+ j! e/ i4 C+ nresult in extensive, unnecessary, and expensive2 K3 s8 u: L3 {4 t! ]* a
investigation. The primary care physician should be# }3 Q" \8 D. w3 ]5 m
aware of this fact, because most of these children8 W- { V. h6 t7 f0 D
may initially present in their practice. The Physicians’
3 Y0 @1 F6 ^) N4 J! Y" d; wDesk Reference and package insert should also put a
1 J+ h4 v, Y( F L9 X5 D1 Fwarning about the virilizing effect on a male or
' B, U* q: l6 ?6 {# o7 u; Q! V+ Vfemale child who might come in contact with some-- T2 j! j% H" N! Y
one using any of these products.
) U1 ?- r, s* l/ Y- ^References
+ {6 x' O! m. b" o2 ?; X/ Z1. Styne DM. The testes: disorder of sexual differentiation* `8 P( `! d0 G' r$ I
and puberty in the male. In: Sperling MA, ed. Pediatric
0 H/ w8 {1 G$ z: M* Y* ^Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 c! s5 }* r( r" @' O+ l2 I2002: 565-628.
0 k' B H' c, I2 W2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious @6 }( U6 s8 v! T2 Z' h& Y0 s
puberty in children with tumours of the suprasellar pineal |
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