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Sexual Precocity in a 16-Month-Old
' |5 D' S6 [9 f- j; ^Boy Induced by Indirect Topical2 z% H- F; }1 v( O1 _( O! Q) Z
Exposure to Testosterone4 K0 r1 v, P5 ?# r) N
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
I4 b2 ^$ j. R. y1 a8 Oand Kenneth R. Rettig, MD14 v" O; k* b! D* A1 P6 _# Q
Clinical Pediatrics$ ?) }8 e8 x' ^' k6 @
Volume 46 Number 66 n4 v; L/ o5 i1 _) H6 q
July 2007 540-5437 A% T" n4 H/ l2 q
© 2007 Sage Publications
% D ]' _; T: s: T# d10.1177/0009922806296651
6 `5 Y/ v: w- S4 ~8 H. `http://clp.sagepub.com
6 R* U g4 Z- h" P' \hosted at
; B! C& j$ N) w+ u0 Thttp://online.sagepub.com
$ u' S2 l a0 C4 Z, R' }, W9 H/ {Precocious puberty in boys, central or peripheral,
7 h2 z$ l) B; F0 r% y& g$ uis a significant concern for physicians. Central. n5 l! |$ F7 M* B3 |1 A! s3 O, X
precocious puberty (CPP), which is mediated; j$ ~2 c o3 U6 t j; o# u
through the hypothalamic pituitary gonadal axis, has1 [ z- e& K$ Z% a
a higher incidence of organic central nervous system
/ }+ r9 G& C; o7 Plesions in boys.1,2 Virilization in boys, as manifested
" S3 j0 `) \9 h- \. }by enlargement of the penis, development of pubic
% p( E) j i9 V& ehair, and facial acne without enlargement of testi-
6 y2 W0 }8 e7 P# |8 V3 `* Pcles, suggests peripheral or pseudopuberty.1-3 We. y+ E1 o6 S. L0 L% H
report a 16-month-old boy who presented with the
. X1 X/ r u8 g u# d/ u) Denlargement of the phallus and pubic hair develop-
$ o, y8 g2 F a s+ y: G( Vment without testicular enlargement, which was due
, ^ G9 S9 o; D% x) p3 fto the unintentional exposure to androgen gel used by. e; N8 ?8 O0 V4 z
the father. The family initially concealed this infor-
6 d+ F6 \& h# s& I" |mation, resulting in an extensive work-up for this: y* X! O* e4 _, G; z+ Z" @
child. Given the widespread and easy availability of: B! m9 o T$ C. m2 D
testosterone gel and cream, we believe this is proba-$ \1 P+ {' L U9 ?- X2 ^ o( L
bly more common than the rare case report in the
1 S5 u. x$ r. S) m6 Q3 Dliterature.4" L/ Q0 @& f3 Q. [4 o- u0 E+ u7 P
Patient Report
; I2 X) f1 ]. ?4 A3 FA 16-month-old white child was referred to the8 u3 o6 @$ F; v
endocrine clinic by his pediatrician with the concern
! n- U1 \) M+ ?/ R; g2 y1 hof early sexual development. His mother noticed
4 p& g& ?! E& Xlight colored pubic hair development when he was
) n0 e5 R* [ n- V: @9 _From the 1Division of Pediatric Endocrinology, 2University of0 B) w z0 Z. V" L5 |8 A
South Alabama Medical Center, Mobile, Alabama.
' o9 M7 F" c5 x& O9 VAddress correspondence to: Samar K. Bhowmick, MD, FACE,: v* l- D2 \ C' f$ p# e
Professor of Pediatrics, University of South Alabama, College of
/ j: l# A! | L2 L+ uMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
c& V" K; A5 ~: \e-mail: [email protected].
+ {7 J) c$ q2 |2 T! \& m( X, ]about 6 to 7 months old, which progressively became
3 v3 d8 c3 k4 Odarker. She was also concerned about the enlarge-
" s u6 P) Y% F$ Q K: w+ J1 {ment of his penis and frequent erections. The child& d) R) x2 j1 H5 `5 Z! u. {
was the product of a full-term normal delivery, with
3 p9 y* ]1 U* t. `* oa birth weight of 7 lb 14 oz, and birth length of8 l: w3 P0 O5 |# K3 I7 J
20 inches. He was breast-fed throughout the first year
7 Z) L3 P, B) r) u1 Dof life and was still receiving breast milk along with
+ v: X8 ]5 p0 A5 i8 ^solid food. He had no hospitalizations or surgery,/ F0 \ G, `, u$ B* B6 W# [: V
and his psychosocial and psychomotor development0 c% J4 P, u& X7 s6 V7 O9 J: h
was age appropriate.
, l6 ]! N2 ~# A/ ]8 e' x. d; d% YThe family history was remarkable for the father,
6 t9 x2 W \. xwho was diagnosed with hypothyroidism at age 16,
3 R p8 s8 ^, ~' z. awhich was treated with thyroxine. The father’s
9 F6 u! _# J3 o7 ~3 qheight was 6 feet, and he went through a somewhat
- l/ C, {8 b/ S% |8 p# T x! E L* Searly puberty and had stopped growing by age 14.
g3 _8 ]9 z) z% F. M; XThe father denied taking any other medication. The
9 ~4 N1 C, j/ Schild’s mother was in good health. Her menarche9 D g; X! L" I" L
was at 11 years of age, and her height was at 5 feet
; g% k, a. S, b/ E6 f5 inches. There was no other family history of pre-, X7 E" J# C6 N1 Y; n
cocious sexual development in the first-degree rela-
, c- m% E5 T% A2 R0 Ptives. There were no siblings.
6 l2 \8 O$ S: S2 m9 j3 m' EPhysical Examination, @$ F6 a/ p5 M
The physical examination revealed a very active,
, u" `6 A* G8 f/ _5 @) uplayful, and healthy boy. The vital signs documented
8 A. C e P$ C5 z4 na blood pressure of 85/50 mm Hg, his length was1 s& ?% Z9 Q0 d" L1 _5 R
90 cm (>97th percentile), and his weight was 14.4 kg0 O2 T8 o+ g" C, Z/ B% _1 g" _3 k8 O
(also >97th percentile). The observed yearly growth1 ?2 [; h9 w7 ^7 u8 I3 j1 P
velocity was 30 cm (12 inches). The examination of
0 b; @8 x- a Uthe neck revealed no thyroid enlargement.
* e- d# a1 q8 x2 CThe genitourinary examination was remarkable for
% X: Y3 }- L, |* Q1 _% Uenlargement of the penis, with a stretched length of
$ H/ z/ j" x* Q" t- h6 h8 cm and a width of 2 cm. The glans penis was very well
- @# d# G& ~+ ^ tdeveloped. The pubic hair was Tanner II, mostly around/ G, H- u7 B% E ^
540 C4 a0 x( i* q7 p* J8 P/ E5 ?
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: ^0 F6 Z4 R1 B4 W( {1 n9 }
the base of the phallus and was dark and curled. The
+ B, D) c! u( K. e7 H9 V' otesticular volume was prepubertal at 2 mL each." ~/ J2 [9 v2 C ^3 R$ ^
The skin was moist and smooth and somewhat4 c7 ]; Q( }8 ~+ ]& W
oily. No axillary hair was noted. There were no+ M* m" ~; h: ^1 v+ W; H2 c, j9 k
abnormal skin pigmentations or café-au-lait spots.
& @: B. m$ M" }# Q$ l% |- F" INeurologic evaluation showed deep tendon reflex 2+1 P H9 ?* {5 j9 {7 g7 T, V
bilateral and symmetrical. There was no suggestion" b" g2 B3 o! G3 b' ? ^2 W5 q9 L
of papilledema.
& o! {9 p3 ^( `$ d% S0 Q- qLaboratory Evaluation9 C/ s* c( |% M' H/ z( U$ q2 n6 n
The bone age was consistent with 28 months by
# Q- U3 p; I# |, e) s o/ a0 Yusing the standard of Greulich and Pyle at a chrono-
, i+ L2 y4 U% G' T' \logic age of 16 months (advanced).5 Chromosomal( k. k/ W2 `# j! _' [
karyotype was 46XY. The thyroid function test! T- G+ Y1 E$ G- }) s$ M
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
2 \: A9 i \# n) v9 alating hormone level was 1.3 µIU/mL (both normal).
, R, y2 ^( b$ i$ d3 i: `3 {The concentrations of serum electrolytes, blood
" L5 t, l. E% E; m# m, }urea nitrogen, creatinine, and calcium all were
, x, n8 `# i3 xwithin normal range for his age. The concentration4 K1 C3 D/ k" A3 e& v
of serum 17-hydroxyprogesterone was 16 ng/dL
& h Y4 J5 u6 ?(normal, 3 to 90 ng/dL), androstenedione was 20
- C* _8 P) X+ N- m8 H! z, F) Cng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-# t7 R; K1 R3 H, q" c G) Q
terone was 38 ng/dL (normal, 50 to 760 ng/dL),/ O" \: j+ [: @
desoxycorticosterone was 4.3 ng/dL (normal, 7 to, s8 ]8 m) z& F% ~/ g
49ng/dL), 11-desoxycortisol (specific compound S)
( L" i* y' Z0 Awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- W g4 ^. e0 z) H
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& ?% ^! \6 H9 D; l! A, z; {testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
9 V1 u5 s8 k% x j# f- ` N% Dand β-human chorionic gonadotropin was less than
5 n- }" V3 U' W5 mIU/mL (normal <5 mIU/mL). Serum follicular
! w: V" ]# a$ F1 W8 u4 @6 cstimulating hormone and leuteinizing hormone; {( o2 b4 w& x: M6 |8 \) f
concentrations were less than 0.05 mIU/mL
|6 z9 b3 n# t$ y( ~(prepubertal).7 P' z6 ?. \3 j- f R
The parents were notified about the laboratory
) D- R1 U' k) [9 E% w. ]9 ?4 L2 I( Iresults and were informed that all of the tests were5 ]- F5 p& ~3 e) _8 Y
normal except the testosterone level was high. The8 ~! {4 B+ d' @6 ~3 |' P+ G
follow-up visit was arranged within a few weeks to9 [+ [0 I2 ?7 R; }
obtain testicular and abdominal sonograms; how-
, f/ n5 k) |8 |, T! u! Iever, the family did not return for 4 months.4 U/ Y$ m7 @$ S/ d
Physical examination at this time revealed that the6 ^+ n0 N R D, R
child had grown 2.5 cm in 4 months and had gained6 N" d* o) d6 |* L2 Y* ]
2 kg of weight. Physical examination remained
& B, Z1 _2 c5 r+ w3 h3 O/ Eunchanged. Surprisingly, the pubic hair almost com-
9 h3 `' r$ v1 W0 s* r# Xpletely disappeared except for a few vellous hairs at
, ~( ^( b% x! w3 s& vthe base of the phallus. Testicular volume was still 2, D. f) I& ]1 V% \" u' t W
mL, and the size of the penis remained unchanged.
: Q2 v y# \* {9 I c4 \0 _1 t/ @The mother also said that the boy was no longer hav-
$ V2 \$ R1 l3 A! N+ x4 f! ~ing frequent erections.1 d' R+ |! P9 l' Y* X c& w8 L
Both parents were again questioned about use of
, J. t/ k { C8 e0 ~% t' ~' L0 p0 qany ointment/creams that they may have applied to5 v/ l$ _6 y. h* @! \
the child’s skin. This time the father admitted the) P& U3 M5 i' q
Topical Testosterone Exposure / Bhowmick et al 541
+ W$ i, q! Y' W* }: Q9 g9 Cuse of testosterone gel twice daily that he was apply-/ Y) `) o. c9 I4 o/ I% n" Z2 d
ing over his own shoulders, chest, and back area for1 K6 h& z" t& f4 {3 M6 q8 q( W
a year. The father also revealed he was embarrassed
4 R$ ~' m$ |% d% b9 ^ ito disclose that he was using a testosterone gel pre-3 D* {, J! @- m1 ~7 g
scribed by his family physician for decreased libido
* P @3 u) p! D/ e2 O- N# msecondary to depression.8 }& Q4 I+ ?7 @+ E1 W
The child slept in the same bed with parents.( }" p l+ u1 Y7 J# \7 ~+ J! N5 P
The father would hug the baby and hold him on his8 c& O1 Y% T, |; d6 i" W- _. C
chest for a considerable period of time, causing sig-( D$ t' ^9 ?& `8 }' j
nificant bare skin contact between baby and father.
# P- U7 {0 a6 }) l3 n. u i, ^The father also admitted that after the phone call,9 B3 l, B. M+ c0 M+ w9 O" n
when he learned the testosterone level in the baby
7 x% t7 Q7 s; T" T" U4 Bwas high, he then read the product information
& {$ P: ] G0 V5 t2 fpacket and concluded that it was most likely the rea-
5 }% T j( p8 B$ ~$ m: Yson for the child’s virilization. At that time, they
0 `! ^; p* u. y8 G, V# ~* ~3 Gdecided to put the baby in a separate bed, and the
- a% }9 b/ k. f3 Z1 kfather was not hugging him with bare skin and had$ l: d5 d$ {4 Z! b
been using protective clothing. A repeat testosterone
. X, f) B+ Z ^) ]2 Z. q# e1 C: ktest was ordered, but the family did not go to the
+ k/ o0 ]2 a' @- v! `9 b) Claboratory to obtain the test.
i8 c3 O* P% D$ B1 K! T' ^0 @Discussion
8 m" i) M( H9 o+ h4 ~Precocious puberty in boys is defined as secondary
; o5 x6 j @0 k; I9 p1 dsexual development before 9 years of age.1,4
" J+ }4 n# F& c; fPrecocious puberty is termed as central (true) when, ?; v8 k0 h L+ \5 s
it is caused by the premature activation of hypo-
% a# k# ?( x: M; ?+ Z$ [1 jthalamic pituitary gonadal axis. CPP is more com-# d. v/ ^: F: d' k$ e
mon in girls than in boys.1,3 Most boys with CPP
. v* L3 k% s+ ?5 |may have a central nervous system lesion that is
! X8 H% [) E# D+ q$ }3 }responsible for the early activation of the hypothal-
# B4 b1 r d, ?( uamic pituitary gonadal axis.1-3 Thus, greater empha-
* B7 Q) m1 \0 v* o- Csis has been given to neuroradiologic imaging in8 d3 d8 x& c1 P* H/ a; `
boys with precocious puberty. In addition to viril-
. [- ]; f0 `% v4 t/ e3 Eization, the clinical hallmark of CPP is the symmet-
. l+ V4 m1 n. D& |rical testicular growth secondary to stimulation by# U! E8 j- b8 s' [ z
gonadotropins.1,3 [& o8 F' q# E1 |, ~; L6 V
Gonadotropin-independent peripheral preco-
3 b% I% w; u; h+ } m- tcious puberty in boys also results from inappropriate9 E+ c3 e8 G0 t8 [- h
androgenic stimulation from either endogenous or8 \3 h2 b4 Q* h! w2 a: Y* h
exogenous sources, nonpituitary gonadotropin stim-
4 F4 J" w( q$ }9 h! g6 O, lulation, and rare activating mutations.3 Virilizing
^/ E" N5 F& b: g+ `0 ncongenital adrenal hyperplasia producing excessive+ H: }! U v1 m" X, \, {& c
adrenal androgens is a common cause of precocious# U: f6 _. i! ?" u; R b
puberty in boys.3,4
7 V2 V8 u7 b4 j6 jThe most common form of congenital adrenal
1 V1 T* i- k$ Q7 jhyperplasia is the 21-hydroxylase enzyme deficiency.
% `8 m$ U# r+ {& E/ Z6 wThe 11-β hydroxylase deficiency may also result in+ C* d* Y& K8 P( `3 F
excessive adrenal androgen production, and rarely,
& x; v" ^8 x0 b S+ x0 Uan adrenal tumor may also cause adrenal androgen
/ }7 |) V) g3 [6 cexcess.1,3
4 M2 J0 K q4 K; hat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 W7 q# f+ Y7 s5 ?8 r
542 Clinical Pediatrics / Vol. 46, No. 6, July 20077 e9 B( R! Y" G% C7 [
A unique entity of male-limited gonadotropin-! N/ _2 i+ r; I$ n5 ^; ?9 _6 P6 k
independent precocious puberty, which is also known4 ^+ t: X& C5 v2 M1 E
as testotoxicosis, may cause precocious puberty at a/ R* K, e- n( w/ s: \& Q- i9 {
very young age. The physical findings in these boys
6 ]# s4 p# Z9 P0 t! w: Lwith this disorder are full pubertal development,, N, e! [. Y' `& p b2 V6 f" \7 X* \
including bilateral testicular growth, similar to boys7 M% d/ u5 X, _/ b4 b( ^
with CPP. The gonadotropin levels in this disorder9 F2 F( Z5 h/ K/ C2 u9 l4 p/ y7 ?
are suppressed to prepubertal levels and do not show6 Z( z$ o& ^5 a% N; D5 S
pubertal response of gonadotropin after gonadotropin-; e& I; f0 @& f# u5 ]# b- h5 f
releasing hormone stimulation. This is a sex-linked
; e& {+ G3 v4 \ ^autosomal dominant disorder that affects only% U: {+ D0 G' J2 S0 t
males; therefore, other male members of the family5 ~! @+ ^6 T2 X3 \% d1 |9 l/ J
may have similar precocious puberty.3
% S1 c2 L; Y% ^7 WIn our patient, physical examination was incon- ]( l, z4 S; ~7 j
sistent with true precocious puberty since his testi-
, C4 S; M1 W# D- Ycles were prepubertal in size. However, testotoxicosis f1 I7 ^% K* p1 e
was in the differential diagnosis because his father* r; N. @, S# ]" ^% T
started puberty somewhat early, and occasionally,+ A+ m8 ?1 x* B" H: C/ N( J
testicular enlargement is not that evident in the
" z8 u) C g2 K: A: p8 N: g* M3 |! g" Ubeginning of this process.1 In the absence of a neg-
+ b; U; u: J9 l6 d+ I( kative initial history of androgen exposure, our
4 d) ]9 a) h! kbiggest concern was virilizing adrenal hyperplasia,
: M$ B- W g2 S4 F$ O. Seither 21-hydroxylase deficiency or 11-β hydroxylase( @- |/ t! U8 V- x
deficiency. Those diagnoses were excluded by find-
- Y* @! y$ F9 i* Ring the normal level of adrenal steroids.
' \! z5 E; n6 F3 zThe diagnosis of exogenous androgens was strongly) _9 T4 H2 F+ t U; ~& Q
suspected in a follow-up visit after 4 months because
3 j+ ]) M7 t0 j6 D k+ F8 q$ ^the physical examination revealed the complete disap-7 |8 T( R/ m' [# ~, S; c/ j
pearance of pubic hair, normal growth velocity, and! }$ U3 W+ O9 x4 f& \' H
decreased erections. The father admitted using a testos-
* u7 `# O3 D7 o- g( lterone gel, which he concealed at first visit. He was( R5 d! B) F3 a; t
using it rather frequently, twice a day. The Physicians’
, P9 ?" [+ m( Y) ADesk Reference, or package insert of this product, gel or5 ~3 S( L5 W, k, I
cream, cautions about dermal testosterone transfer to0 H9 d( E% ?3 G" A `
unprotected females through direct skin exposure.9 S( y: t6 F/ O5 V7 K
Serum testosterone level was found to be 2 times the) s: F1 o* u# R- k
baseline value in those females who were exposed to
5 l0 o" |7 R: d! @& F. n; {! L0 Meven 15 minutes of direct skin contact with their male
/ D3 G9 E2 r. c# spartners.6 However, when a shirt covered the applica-
$ {1 q F+ g7 U# M5 L# ktion site, this testosterone transfer was prevented.
: U$ o$ S1 B0 O! [4 COur patient’s testosterone level was 60 ng/mL,5 h' m3 U' C d: }
which was clearly high. Some studies suggest that5 D4 H* f+ Z& q7 d( i: X
dermal conversion of testosterone to dihydrotestos-
) _6 e) m) W) b. T* hterone, which is a more potent metabolite, is more: w5 ~" ?1 ~# }9 E) {) C
active in young children exposed to testosterone5 {: p+ `+ [0 F7 J
exogenously7; however, we did not measure a dihy-
- z8 g- U! ?% ? T" C& fdrotestosterone level in our patient. In addition to
- G* M/ R8 w. \! z; w! @% xvirilization, exposure to exogenous testosterone in
' \: }9 E$ q- l$ ]8 o* C$ Echildren results in an increase in growth velocity and
( z% e) F* p% R9 V7 F4 w) ~0 Sadvanced bone age, as seen in our patient.
3 T2 k, Z* j3 |' F2 S9 HThe long-term effect of androgen exposure during
( P! `& Q2 B2 G; U3 z$ Hearly childhood on pubertal development and final! U* l3 O q7 O/ U/ \5 ]
adult height are not fully known and always remain
. _! ^1 ^) F% k A# E8 q, e/ g* B; Ba concern. Children treated with short-term testos-
6 y0 T3 b8 _8 w: Lterone injection or topical androgen may exhibit some3 I% g V4 \- _3 t4 m* J
acceleration of the skeletal maturation; however, after$ ~$ N( ?+ C/ m+ R. l) d
cessation of treatment, the rate of bone maturation2 C2 A. F3 d+ G! C# t; y+ ]! V
decelerates and gradually returns to normal.8,9
1 T3 z' }* ?6 N3 i- ^" kThere are conflicting reports and controversy
; Y8 {5 ?3 d1 L, b3 `4 iover the effect of early androgen exposure on adult, C. R2 v( I8 v1 Z/ w
penile length.10,11 Some reports suggest subnormal! h n( H& O1 }0 z7 n. V# t
adult penile length, apparently because of downreg-7 B, N8 ]1 f7 N4 b, N+ {
ulation of androgen receptor number.10,12 However,* s" x) D7 C7 Q% e8 U
Sutherland et al13 did not find a correlation between! j7 N. R4 ^# v) W1 D- j
childhood testosterone exposure and reduced adult
4 {7 T" Q8 s* \2 o8 h0 q5 ~penile length in clinical studies.
* G4 F( N, A, u, O. cNonetheless, we do not believe our patient is
6 C) c f7 Q- ~" W# W8 ugoing to experience any of the untoward effects from5 b( ?; M8 r- J
testosterone exposure as mentioned earlier because
# C( D* h( P7 [2 h1 y! |the exposure was not for a prolonged period of time.
. K% G( N4 r- h7 V2 F1 ]Although the bone age was advanced at the time of# B6 G: j0 d1 p* Q1 @% w
diagnosis, the child had a normal growth velocity at
2 |( }* y. f, Tthe follow-up visit. It is hoped that his final adult
) k; r" E1 @6 q( }: C% jheight will not be affected.
+ S) G* c+ h( U AAlthough rarely reported, the widespread avail-
! I2 l( }" k3 t# x( L4 Z l$ o @ability of androgen products in our society may
$ t! }6 W% k8 Q, N0 X0 g6 J; }6 Dindeed cause more virilization in male or female
{5 [1 _2 X; ^6 K9 `* ~children than one would realize. Exposure to andro-
' ?. h; q& i# X: T, ugen products must be considered and specific ques-+ V4 C8 m8 S/ x* F% q) D4 |4 b
tioning about the use of a testosterone product or
! y/ Z4 u. U$ N- _" @gel should be asked of the family members during: O6 k# ], U! ` P2 @7 P
the evaluation of any children who present with vir-
2 U# b4 \& M4 {% r* s% Tilization or peripheral precocious puberty. The diag-
# w8 _& N: {1 y3 \7 ]* Z' \nosis can be established by just a few tests and by
3 z) R2 g$ Q* v( C& t# l9 eappropriate history. The inability to obtain such a
% S- x' x9 F' C, q7 yhistory, or failure to ask the specific questions, may. [8 j: d% O$ ~1 R: \: h6 U X' H: p. K
result in extensive, unnecessary, and expensive
/ w( {# q1 f0 e0 xinvestigation. The primary care physician should be
( j/ G! z+ r6 s: I8 oaware of this fact, because most of these children
" ~6 ^5 x' C p; R9 h; q C( wmay initially present in their practice. The Physicians’
5 v" E: m& }% _5 M% v* t- _. Y" vDesk Reference and package insert should also put a
6 B: q3 N( |* b O/ ^. ?warning about the virilizing effect on a male or: M7 G5 Q) D# j+ E
female child who might come in contact with some-4 p7 X; p, z) d% |- ~, ]2 T
one using any of these products.2 c* N5 Q* P* K& |
References: Z3 q V2 \: D( K
1. Styne DM. The testes: disorder of sexual differentiation
' M# T" e( V0 H- |7 K; Gand puberty in the male. In: Sperling MA, ed. Pediatric# J6 B, |8 H8 |& H) B
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
[ @! H( v0 _- \! B e2002: 565-628.' U+ F' A T" H1 B! @% x1 I) A* [
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious" G7 h0 d& `9 B5 }% w, t
puberty in children with tumours of the suprasellar pineal |
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