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Sexual Precocity in a 16-Month-Old9 f: ? j3 g; ~4 J9 @
Boy Induced by Indirect Topical1 w+ G1 B' k9 |, A/ U; T/ Y) m1 P
Exposure to Testosterone/ h8 c0 k4 M, {. Q' ~
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
' I+ V% ^# Q' `4 G$ @- Y* T' ]. Band Kenneth R. Rettig, MD1
7 A+ G/ \; ^0 X! ^, s+ EClinical Pediatrics
1 a0 B, z6 H# ZVolume 46 Number 6, z! H9 N2 `$ b4 G6 o+ o Y& d% q
July 2007 540-543
" \ O1 @7 o5 N1 u" N+ \5 E( o' j© 2007 Sage Publications% t# R7 K; q! f# Z
10.1177/00099228062966514 T, u) S6 l- Z# J
http://clp.sagepub.com2 V1 [# ]- n$ N" R/ f6 [+ Q6 |
hosted at
: \9 w+ \5 F4 j+ ]3 a* \http://online.sagepub.com
- m+ c' N) X, j' P2 Z3 ePrecocious puberty in boys, central or peripheral,
8 A% s& i* W3 ?- t; x3 f x1 ~; Wis a significant concern for physicians. Central. `$ w0 ^9 o( l/ u/ M$ h9 y4 V
precocious puberty (CPP), which is mediated9 M2 U3 D) C/ N0 A5 C. ]$ A
through the hypothalamic pituitary gonadal axis, has
9 W0 H) T7 Z. [, m; \0 h& Sa higher incidence of organic central nervous system
6 h. v. r$ C/ N* [+ ?8 dlesions in boys.1,2 Virilization in boys, as manifested( \! {+ H, z& c8 E& I
by enlargement of the penis, development of pubic
: l# Y: A- R! y2 K+ @hair, and facial acne without enlargement of testi-9 e/ g0 \& f1 |& X3 @" ^+ Z% c4 x
cles, suggests peripheral or pseudopuberty.1-3 We. I6 r) }7 o7 o& | W& L9 N& i N3 G& z7 c
report a 16-month-old boy who presented with the
! g7 g$ S2 ?' \2 f# Zenlargement of the phallus and pubic hair develop-- J* k& z/ R! H( H! o
ment without testicular enlargement, which was due
3 @ D6 l9 {* K; Sto the unintentional exposure to androgen gel used by5 \% y& t7 r- Y$ s
the father. The family initially concealed this infor-
! x, K p4 Z$ xmation, resulting in an extensive work-up for this
# v: f. I; [- `child. Given the widespread and easy availability of3 A$ [# `# P' q* Z
testosterone gel and cream, we believe this is proba-
5 H7 L; {0 T# Tbly more common than the rare case report in the2 o3 b2 |: g# _6 h2 e
literature.43 i* a% J& v9 u, R/ L
Patient Report
Y: W, s$ }, q: ZA 16-month-old white child was referred to the! D) k- m$ d% m" X& J
endocrine clinic by his pediatrician with the concern
# O# J: G4 F0 U" }of early sexual development. His mother noticed4 ~- x& y, i2 R# i
light colored pubic hair development when he was5 L$ p: ~7 Z3 f4 t+ b/ w/ q s4 O
From the 1Division of Pediatric Endocrinology, 2University of# B7 Q6 U; D7 N! B- W+ A0 w
South Alabama Medical Center, Mobile, Alabama.4 j4 T" P5 G r3 T$ l7 |
Address correspondence to: Samar K. Bhowmick, MD, FACE,
* p: `$ Q- l6 C+ _8 Q2 HProfessor of Pediatrics, University of South Alabama, College of! a# X' ^/ z3 J
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" a; b8 S1 C$ B' b' I. N; Y
e-mail: [email protected].
4 Y% S7 `1 |: }2 B( Yabout 6 to 7 months old, which progressively became
8 @ i1 p" } D# T% xdarker. She was also concerned about the enlarge-
]- p8 N% @4 z- E! K5 O' Pment of his penis and frequent erections. The child
% f0 C# j( Q% L- ~& |! ?was the product of a full-term normal delivery, with3 b4 _* K0 c, ?6 Q) s
a birth weight of 7 lb 14 oz, and birth length of
1 Y, q9 X- y9 ? ?2 z8 v4 _4 e20 inches. He was breast-fed throughout the first year2 j+ u4 |/ D$ ?! D* o
of life and was still receiving breast milk along with
. R! F, m( Z, D3 N0 {solid food. He had no hospitalizations or surgery,
: o0 [$ S$ S2 F' t+ W5 j" iand his psychosocial and psychomotor development
' T/ i& X4 e% ~" J0 Wwas age appropriate.
0 y3 W+ y/ h: T' k9 w ZThe family history was remarkable for the father,$ A" m9 ]( W+ y( k( j
who was diagnosed with hypothyroidism at age 16," ]+ `3 k9 ^% ^4 O: b# ?
which was treated with thyroxine. The father’s4 G0 m/ r; P6 y
height was 6 feet, and he went through a somewhat0 h- r: k; F4 E6 R$ k5 A
early puberty and had stopped growing by age 14.
# P/ b' R7 P5 j# QThe father denied taking any other medication. The3 a( l6 C& C! o' y
child’s mother was in good health. Her menarche
+ W8 p+ T8 ]" l8 g3 s* Iwas at 11 years of age, and her height was at 5 feet6 [, S, ~) D9 a1 M$ z
5 inches. There was no other family history of pre-7 z9 ? b) H) S) o* v/ I
cocious sexual development in the first-degree rela-
1 t8 S2 W. L% U: Atives. There were no siblings.
6 k7 y0 l5 ]8 O* t+ a5 B/ {2 PPhysical Examination2 `4 L7 y- }4 ? M* L- t" U, X7 P/ D
The physical examination revealed a very active,: O8 l ~: G' I- p
playful, and healthy boy. The vital signs documented
) Z. A: l- _4 k; \. [; _$ Z4 O* Pa blood pressure of 85/50 mm Hg, his length was
2 D& ]+ y D9 I0 D8 @: `: m90 cm (>97th percentile), and his weight was 14.4 kg
1 A+ P, v" T9 R9 a(also >97th percentile). The observed yearly growth6 j( G, r4 Y/ f1 K8 i6 D: A
velocity was 30 cm (12 inches). The examination of
2 _4 E7 P# Q8 Gthe neck revealed no thyroid enlargement., D/ R( X' h/ |9 V5 q
The genitourinary examination was remarkable for
# g5 q8 ~# e) Menlargement of the penis, with a stretched length of1 v! R, E( J1 [ N U
8 cm and a width of 2 cm. The glans penis was very well$ e' m% X" A. G( b8 y2 J( B
developed. The pubic hair was Tanner II, mostly around8 G) o. R: t+ D( h' u
5400 E+ U$ Q9 i$ l: [
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; M* ?/ X% _6 c$ L0 ]
the base of the phallus and was dark and curled. The
$ q) f- d# n, g- c5 Etesticular volume was prepubertal at 2 mL each.6 d# S* f3 j$ z2 q0 d/ G
The skin was moist and smooth and somewhat S$ }, L" N1 [6 i- w
oily. No axillary hair was noted. There were no
6 ^# n1 Z g- ~2 C pabnormal skin pigmentations or café-au-lait spots. e( Z5 b! C; m
Neurologic evaluation showed deep tendon reflex 2+) k W) x) b8 q
bilateral and symmetrical. There was no suggestion
) z- q( `0 G6 _& g" yof papilledema., x" V/ w; M$ l3 b. E
Laboratory Evaluation
+ H& u z9 a. j$ xThe bone age was consistent with 28 months by. i3 U) V% x$ M& H! {/ [
using the standard of Greulich and Pyle at a chrono-
4 |3 w- D M3 f2 B7 }logic age of 16 months (advanced).5 Chromosomal& |' R1 Z7 J: I/ L' S$ Z+ l9 W
karyotype was 46XY. The thyroid function test* ^0 H$ \; k% f
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
- Y- r5 R. D9 F* c( {8 ]7 _- }lating hormone level was 1.3 µIU/mL (both normal).1 c+ o8 E6 d, ?8 b$ y! H
The concentrations of serum electrolytes, blood
* l7 G4 Q% ]2 w1 p" Uurea nitrogen, creatinine, and calcium all were. A1 m; D6 b7 n8 Y% x! Y+ s
within normal range for his age. The concentration! f7 @- d5 r$ }5 \, @9 f* o
of serum 17-hydroxyprogesterone was 16 ng/dL6 B0 d8 O4 `$ L
(normal, 3 to 90 ng/dL), androstenedione was 20
% s# V7 l; V" L2 b2 z/ F; y6 {( U9 e7 sng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 C- C* Z" l! M0 a# M# uterone was 38 ng/dL (normal, 50 to 760 ng/dL),! ~! |4 n' P( E+ ]: ?& c) s' _
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
: i# h% l+ H- V9 a49ng/dL), 11-desoxycortisol (specific compound S), _5 b3 b: H% m7 _4 b; w
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
" [7 Y9 x" G* E! _1 Ztisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total: e$ r5 I+ J( s
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),; t& s6 i$ @* ~- l9 M; H3 h
and β-human chorionic gonadotropin was less than
8 t# Z! i0 g1 R$ y. B% f5 L( {4 M# w5 mIU/mL (normal <5 mIU/mL). Serum follicular- ^, H- V$ d3 D# B" }$ p% O2 x
stimulating hormone and leuteinizing hormone4 }5 ^/ n8 V. V: H; M$ p1 }; T$ Q* H
concentrations were less than 0.05 mIU/mL+ [/ e4 B9 C; t9 A+ x ?. g
(prepubertal).: N5 r9 \6 R/ j* P* G
The parents were notified about the laboratory
4 }# z" V$ h1 R: E: }, ~$ D) Kresults and were informed that all of the tests were8 n) D$ m& l% m+ e; ~4 V2 v
normal except the testosterone level was high. The. l1 a/ o3 x* `7 i
follow-up visit was arranged within a few weeks to
$ {0 C+ c5 e5 q9 k% R' g7 O( |) C* dobtain testicular and abdominal sonograms; how-: Q* t5 G: m; H/ Y, w
ever, the family did not return for 4 months.; e2 ~2 q$ Q: m1 {3 K
Physical examination at this time revealed that the
2 [, f Q$ S9 T8 Lchild had grown 2.5 cm in 4 months and had gained
# u( W. p# L) t) f, ]! j2 kg of weight. Physical examination remained
2 b g8 H. `/ ^( V! Hunchanged. Surprisingly, the pubic hair almost com-
7 e1 B$ v# }+ b) ~+ z3 ^9 u$ upletely disappeared except for a few vellous hairs at
" y4 c: L! K# R1 U: u0 y6 Xthe base of the phallus. Testicular volume was still 2
- E& F, {2 n! \mL, and the size of the penis remained unchanged.2 s2 {8 M M8 d: ]0 @! K( U( l
The mother also said that the boy was no longer hav-
4 N$ U. z/ |7 S& a Iing frequent erections.
\' L( _6 r5 R+ SBoth parents were again questioned about use of# Y: Q! |' t1 D2 f7 Q# l0 A0 P
any ointment/creams that they may have applied to
! J' n! r" }" q: v! Q5 s; {the child’s skin. This time the father admitted the5 j7 J/ T; y$ j1 X! a6 f
Topical Testosterone Exposure / Bhowmick et al 541 {& V& Y1 r. W1 W; `
use of testosterone gel twice daily that he was apply-' U+ O0 }. @; x* ~* o5 s2 W9 w
ing over his own shoulders, chest, and back area for
3 O6 f1 v, r1 L& [a year. The father also revealed he was embarrassed4 H' Q1 H# P% D4 d+ K
to disclose that he was using a testosterone gel pre-
4 \7 u- B! v3 k; Z8 R& k3 Dscribed by his family physician for decreased libido- }0 Z* c- T6 {' b" i
secondary to depression.& N2 G) e- S( N4 W. z
The child slept in the same bed with parents.
9 p/ q, I, f: ]1 _: yThe father would hug the baby and hold him on his
4 E! s" Z* e; o! b! Z/ ] kchest for a considerable period of time, causing sig-) v( @& r0 N6 R4 l
nificant bare skin contact between baby and father.* B% T1 l2 f; h6 b+ \" J. V% {4 G
The father also admitted that after the phone call,
6 F2 l* Q2 }- Q) qwhen he learned the testosterone level in the baby3 i9 D! @; A2 Z+ Y0 K9 }
was high, he then read the product information
5 _5 l; J+ y1 ^. m* N5 V: z9 U% Jpacket and concluded that it was most likely the rea-8 r( [, y; N% c2 f- D
son for the child’s virilization. At that time, they0 U% x6 [* ^2 ]1 j5 u0 R" u
decided to put the baby in a separate bed, and the& t4 d1 X0 E; E9 C5 d A3 D
father was not hugging him with bare skin and had
3 K5 Y/ m: i# ^- {been using protective clothing. A repeat testosterone6 v5 a# y# h6 B2 B
test was ordered, but the family did not go to the
6 q& h& ~5 I7 @) G# blaboratory to obtain the test.$ f/ q; V3 z( U1 U* L- ^
Discussion( d+ l$ u2 `! y7 C
Precocious puberty in boys is defined as secondary
$ c o& P& h) a j: Ssexual development before 9 years of age.1,4
) z+ I9 T% L! U6 Z2 }3 WPrecocious puberty is termed as central (true) when
, t3 `9 Y- Y9 y9 n" \it is caused by the premature activation of hypo-
- L1 V' |5 @8 vthalamic pituitary gonadal axis. CPP is more com-
! Q9 g7 A( Z) y3 U/ h7 y: Fmon in girls than in boys.1,3 Most boys with CPP
, Q) v: ]. s! }5 {. Vmay have a central nervous system lesion that is* @3 }% r. a u# h9 |
responsible for the early activation of the hypothal-
+ A! u9 r2 ]( c$ ^amic pituitary gonadal axis.1-3 Thus, greater empha-6 R8 Y/ j0 n, S4 u, N* g
sis has been given to neuroradiologic imaging in
( w3 q! i* M$ T" t, eboys with precocious puberty. In addition to viril-/ e% q2 n% w6 O9 F" L; o9 [
ization, the clinical hallmark of CPP is the symmet-, j5 X' A4 v: U; F& O3 i
rical testicular growth secondary to stimulation by
5 w1 W1 I4 R# A* Ugonadotropins.1,3
9 X8 f1 a# B0 L1 `- i! YGonadotropin-independent peripheral preco-6 Q3 G w. _; l
cious puberty in boys also results from inappropriate! x2 T" v7 u9 N$ w
androgenic stimulation from either endogenous or
8 N7 ]! z1 Z0 ~0 `) Y3 {+ C4 ]: Bexogenous sources, nonpituitary gonadotropin stim-: @) Q/ B& [0 S1 ?
ulation, and rare activating mutations.3 Virilizing' c- v, g M) x9 n
congenital adrenal hyperplasia producing excessive; m* a# A4 F9 C5 t" T% Z/ B" V
adrenal androgens is a common cause of precocious' c# E$ B/ |. v
puberty in boys.3,4
& h9 R, F# C- Z$ o( V! EThe most common form of congenital adrenal
6 A1 e9 Y* V; o! Phyperplasia is the 21-hydroxylase enzyme deficiency.0 k. J" W6 l5 i2 Q3 P1 _
The 11-β hydroxylase deficiency may also result in
: c! s( y: }5 `+ }: x" Bexcessive adrenal androgen production, and rarely,
7 H4 B+ Q% s# nan adrenal tumor may also cause adrenal androgen& K5 Q) l F) ?2 E6 V- }
excess.1,3! x4 r& \6 Z5 @2 D1 L# b/ G
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
3 y, s1 Q2 Q" f9 `7 ?% |542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% v) o" d7 ^" y" ZA unique entity of male-limited gonadotropin-
" Z5 _! o! u4 J4 S" windependent precocious puberty, which is also known6 Z& g+ T+ R9 L5 i( o5 z5 @+ C6 D1 u
as testotoxicosis, may cause precocious puberty at a6 _/ j0 n! t9 |0 i, ?* S
very young age. The physical findings in these boys
$ n0 w3 o+ A, Swith this disorder are full pubertal development,1 z3 L9 D+ ~/ p( ? z e
including bilateral testicular growth, similar to boys
; H( A" _* H! s1 [( X9 T: lwith CPP. The gonadotropin levels in this disorder. p3 e/ m# _. ?7 v
are suppressed to prepubertal levels and do not show" z$ U$ ?' Q3 d
pubertal response of gonadotropin after gonadotropin-
2 m5 [$ j& `7 a/ A* W+ lreleasing hormone stimulation. This is a sex-linked
1 x+ C# \# ]" q! Dautosomal dominant disorder that affects only) h" i, @- Y* c4 {% g$ h1 Y) R: M
males; therefore, other male members of the family
0 g5 D4 ]( R6 [+ W# z* |may have similar precocious puberty.3# V8 k0 X0 x9 k# S- m4 a) [
In our patient, physical examination was incon-: v* P) ^- d6 a+ @5 x4 C
sistent with true precocious puberty since his testi-! ]* t( ~; [" V: Z
cles were prepubertal in size. However, testotoxicosis
# N ~8 y1 v/ h l# H: J( w% }was in the differential diagnosis because his father4 Y- Y0 j: r0 C, N8 ~- V1 \
started puberty somewhat early, and occasionally,
9 c3 f% R1 I0 k) etesticular enlargement is not that evident in the
4 B. H) l' }6 X8 i& @6 dbeginning of this process.1 In the absence of a neg-1 I0 g+ t8 [9 m- C6 R+ r: A5 L
ative initial history of androgen exposure, our& N; H' R7 A' M& F, H5 H
biggest concern was virilizing adrenal hyperplasia,: u+ n* m0 p8 |% q. _0 B
either 21-hydroxylase deficiency or 11-β hydroxylase' d9 O/ n. Z( j( p. _: E g
deficiency. Those diagnoses were excluded by find-
* e$ Q7 d8 b( g# jing the normal level of adrenal steroids.
- X4 q; e( |3 I4 S9 v$ T zThe diagnosis of exogenous androgens was strongly
2 f: n; P% i" ususpected in a follow-up visit after 4 months because
/ \+ {' E' p9 c& h2 @5 g$ L3 j5 W/ W( \the physical examination revealed the complete disap-
7 _/ p, V) }" R" t" j. n# Gpearance of pubic hair, normal growth velocity, and
+ R- V P: N. y/ B* _$ e% ~; wdecreased erections. The father admitted using a testos-5 p1 s/ I2 m9 A* y$ f- d' @+ Q! ]8 c
terone gel, which he concealed at first visit. He was) c" M5 v! L! K- R# F. V0 Z5 ^
using it rather frequently, twice a day. The Physicians’& Y' y% K1 V3 m
Desk Reference, or package insert of this product, gel or
' W# g d/ I* ?/ J3 R4 w+ xcream, cautions about dermal testosterone transfer to' R8 @$ T* C/ Q o8 A$ {
unprotected females through direct skin exposure.) m, T5 }4 H/ h6 E9 q+ L4 m t
Serum testosterone level was found to be 2 times the
# K3 {/ y s7 B, i6 K9 ?baseline value in those females who were exposed to
$ A- v3 f1 @- L* Zeven 15 minutes of direct skin contact with their male
6 X$ J+ ]- w6 fpartners.6 However, when a shirt covered the applica-4 C+ O, c: z) d& f E* Z* [# k7 n
tion site, this testosterone transfer was prevented.! h2 I9 S+ l) m; o
Our patient’s testosterone level was 60 ng/mL,
$ }# V0 W* @9 C* C6 @which was clearly high. Some studies suggest that
8 ~5 j& W' ], a ddermal conversion of testosterone to dihydrotestos-
) N q, ^% Y" s3 w6 b/ r" cterone, which is a more potent metabolite, is more
/ ]& U# f9 ?: v: p5 f/ h F Factive in young children exposed to testosterone4 z) y/ p* ~! _) L Y% H2 F7 v
exogenously7; however, we did not measure a dihy-
$ P# R% H9 G( L! {) \9 n2 t, N# cdrotestosterone level in our patient. In addition to% [1 [: B# e9 h9 k
virilization, exposure to exogenous testosterone in5 T N0 }$ j4 S( s% e
children results in an increase in growth velocity and
1 F$ i4 ^% R2 zadvanced bone age, as seen in our patient.4 n" V+ ^7 ]$ o5 q
The long-term effect of androgen exposure during* r8 y$ ]& `0 m1 e0 y" p
early childhood on pubertal development and final
3 f% U$ j0 `* H2 A/ a* v" eadult height are not fully known and always remain
9 u3 a5 x7 z% {" i, Q' N) Y: |a concern. Children treated with short-term testos-6 M8 r! Z! Q x/ C, F
terone injection or topical androgen may exhibit some" p( P$ n& W" z1 ~0 F
acceleration of the skeletal maturation; however, after; l* e" w- ~- X
cessation of treatment, the rate of bone maturation
* _( {! c+ k2 f: C- ndecelerates and gradually returns to normal.8,92 T: H. H6 S+ U7 L8 i# i% H
There are conflicting reports and controversy
- D+ B6 U9 d3 {# c( l3 C# Vover the effect of early androgen exposure on adult' Q& N4 }6 h; J- G; i' F1 `
penile length.10,11 Some reports suggest subnormal$ |) K5 i6 f7 S/ l9 l; k
adult penile length, apparently because of downreg-$ J' {* V* g% m5 R% C
ulation of androgen receptor number.10,12 However,
3 o u1 t$ j1 _* _1 p) F: p8 fSutherland et al13 did not find a correlation between7 N8 u) F( d/ l# W% P
childhood testosterone exposure and reduced adult
+ R/ S4 q' _3 Q# ]3 d- y' jpenile length in clinical studies.) q, j0 b. j0 Z4 l
Nonetheless, we do not believe our patient is
+ s- e- M- s9 f; |7 J, D& k3 Q5 @4 \" ugoing to experience any of the untoward effects from& B7 [( y. S4 j: E" c
testosterone exposure as mentioned earlier because: c0 P" p4 a- Z% {' N2 E2 c/ \' W
the exposure was not for a prolonged period of time.
7 G4 }3 k: ~# Z" L2 m/ C5 cAlthough the bone age was advanced at the time of
; p1 s. I1 C% ^diagnosis, the child had a normal growth velocity at5 o% t7 r5 z: n8 S: P7 _! ^3 E s
the follow-up visit. It is hoped that his final adult! z1 q( `0 ~: ]
height will not be affected.% O6 D- }2 [9 s3 |* v4 a1 p \1 t
Although rarely reported, the widespread avail-
2 J- k- s ]# Dability of androgen products in our society may
; D1 }9 P! o3 d9 h# ~* f( @6 Eindeed cause more virilization in male or female9 r. \9 Y+ ~5 K( G" U
children than one would realize. Exposure to andro-
! A! ?3 T7 M, `4 e M2 o4 Sgen products must be considered and specific ques-! v+ ]4 q! w. u7 P
tioning about the use of a testosterone product or
0 }8 h/ ^) F- X4 Q0 M) qgel should be asked of the family members during# G4 ]. C+ D& K p4 i, [0 @
the evaluation of any children who present with vir-; r1 Z; ^ ^1 Y! e2 p1 `
ilization or peripheral precocious puberty. The diag-3 f# d$ f8 p" U" S6 u* r
nosis can be established by just a few tests and by
' m+ T' t% S6 r' ]' A2 `3 uappropriate history. The inability to obtain such a9 Q/ G2 I9 X8 x% n8 o) X
history, or failure to ask the specific questions, may# x6 b: R; g8 n
result in extensive, unnecessary, and expensive! A* Z6 _" f0 y7 j6 J, a! V8 N/ c
investigation. The primary care physician should be8 [ u. I& A' a ^: K
aware of this fact, because most of these children1 Q8 b/ j4 ^7 c# J9 e( e
may initially present in their practice. The Physicians’
8 e6 n8 ]% @" }, l' G, lDesk Reference and package insert should also put a0 `- B1 Z9 [: J7 c5 J% O" ]: H
warning about the virilizing effect on a male or
7 D: b8 D) f/ G4 E \4 Wfemale child who might come in contact with some-, m7 [* w# J5 s( N0 b
one using any of these products.
s% k# R2 ^; n4 A6 N# e7 |References" }6 P8 o; Y2 k% g9 @# K5 ~6 c- C
1. Styne DM. The testes: disorder of sexual differentiation* ^3 v3 m3 n' K' ^' M
and puberty in the male. In: Sperling MA, ed. Pediatric
; E! _8 A# W: N6 O9 i8 HEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 q$ x+ O7 D( t% V/ b: c+ X
2002: 565-628.9 H7 Y2 V+ n+ z& c* ]
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious% ?8 \1 f3 x4 P* ~- c6 P: y! E6 h
puberty in children with tumours of the suprasellar pineal |
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