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Sexual Precocity in a 16-Month-Old
U: [) M$ g: U2 T0 x6 x6 ^Boy Induced by Indirect Topical y1 E3 h1 Y. a! {
Exposure to Testosterone
& n' E, f2 Y0 @" J# v1 OSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
+ K7 J6 J9 n/ fand Kenneth R. Rettig, MD1, q7 Q+ d. q5 C4 [$ \$ Q
Clinical Pediatrics
& M" [ m/ Q1 m4 Z# ^1 PVolume 46 Number 6
R- t7 _ w9 T1 DJuly 2007 540-543% H, x/ j0 h, A$ a
© 2007 Sage Publications6 [6 v. y2 U0 c* S2 Y
10.1177/0009922806296651" Q+ R9 B$ Z' w1 O6 X( A
http://clp.sagepub.com
* {2 }' s4 t9 ^- c% X! F$ {hosted at
4 ]7 o8 w% o9 Xhttp://online.sagepub.com
. m' D7 h% \- j7 X( w$ DPrecocious puberty in boys, central or peripheral,8 ^, d! [$ }6 v- J
is a significant concern for physicians. Central' h1 {% p4 u5 E
precocious puberty (CPP), which is mediated/ G w4 c; [# i& }
through the hypothalamic pituitary gonadal axis, has
' c$ P3 E' r" P4 K6 r$ g7 D* J% k) Aa higher incidence of organic central nervous system) w! E5 i; V; k5 y1 s f
lesions in boys.1,2 Virilization in boys, as manifested2 M! F$ W \9 K6 l: j9 A
by enlargement of the penis, development of pubic
% c) B9 Z4 d+ I, o) }- M4 Ahair, and facial acne without enlargement of testi-( S$ g& j, F' V
cles, suggests peripheral or pseudopuberty.1-3 We/ N$ S% _1 x) M; \, u
report a 16-month-old boy who presented with the- F5 y* N# X6 R, e- @: b, I9 n6 t3 l" ^0 E
enlargement of the phallus and pubic hair develop-
+ F9 h3 [% p, ?) i' Fment without testicular enlargement, which was due
1 x) a: {# `$ h+ Q! D6 bto the unintentional exposure to androgen gel used by
4 i" F8 k# Y3 t- F4 ]the father. The family initially concealed this infor-$ B6 P( V. r4 A
mation, resulting in an extensive work-up for this
, i# v( Y& c: ichild. Given the widespread and easy availability of/ k8 y7 J" t' {8 a. M- u: Q1 k" M
testosterone gel and cream, we believe this is proba-" I+ Y5 F4 \/ m4 K7 u) S, S7 _
bly more common than the rare case report in the# s. J6 c _3 s5 t' O& x# ?2 u
literature.4
0 V! [$ i0 Z8 d$ j# |Patient Report, [; ?/ u. g% }, N; a
A 16-month-old white child was referred to the
4 O7 x. q3 f# @" e8 R$ Lendocrine clinic by his pediatrician with the concern
/ }: a3 u) C, ?8 {- J1 Dof early sexual development. His mother noticed
2 r- V9 s( T$ _6 j+ I# p; t; glight colored pubic hair development when he was5 P- Y% j4 V( }% x1 O) X
From the 1Division of Pediatric Endocrinology, 2University of
7 }. Q2 \* }" D" w" |9 ~8 BSouth Alabama Medical Center, Mobile, Alabama.
2 @: m G. S _* Z4 v5 fAddress correspondence to: Samar K. Bhowmick, MD, FACE,* I$ {- m5 ]" J1 V) K0 w5 k2 J, w
Professor of Pediatrics, University of South Alabama, College of5 d9 t0 Z8 c$ V: m
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;) b2 ?1 r" V1 O- K
e-mail: [email protected].
* l9 o/ R5 v1 B* p7 B; F- Rabout 6 to 7 months old, which progressively became* M6 x4 w1 g6 C( | u2 j2 m* ?
darker. She was also concerned about the enlarge-
% e1 |+ H, O8 M! T( W, P& v! Wment of his penis and frequent erections. The child
* R& H! z; F: K: gwas the product of a full-term normal delivery, with
1 p9 q. K# P/ C& ^: W2 fa birth weight of 7 lb 14 oz, and birth length of
8 m9 \0 `' F, L+ ~2 B20 inches. He was breast-fed throughout the first year
$ [; s @( @$ Y2 W* C$ ^9 N9 ^* \of life and was still receiving breast milk along with0 v( N) d6 Y Y
solid food. He had no hospitalizations or surgery,& r* P: f' \. s& N B/ |: e
and his psychosocial and psychomotor development- @7 T# o8 i0 [
was age appropriate.- d1 o$ A$ \0 N4 j. Q: g) V" K
The family history was remarkable for the father,. `' F) N8 I% O3 A4 G, g
who was diagnosed with hypothyroidism at age 16,
5 O# a. q# T M. I4 S* J2 ywhich was treated with thyroxine. The father’s
6 Z, y5 K. Y) U9 G+ C3 bheight was 6 feet, and he went through a somewhat7 k8 R8 v" P: @; k6 a
early puberty and had stopped growing by age 14.1 P- u; A) | B" m; t
The father denied taking any other medication. The
. V2 U& J* g# W( cchild’s mother was in good health. Her menarche
; q9 u( c9 E6 c7 e7 Nwas at 11 years of age, and her height was at 5 feet
9 E$ z& ~ H- F1 H# l+ U7 l5 inches. There was no other family history of pre-
s! j3 n2 |8 F5 K2 y9 P7 scocious sexual development in the first-degree rela-
0 H! }+ `' f) F3 y/ I. Z/ }tives. There were no siblings.' N+ R( D# }* u+ _' a2 T
Physical Examination
# J5 u7 C% F' l; S) D7 DThe physical examination revealed a very active,- \ j* ^$ M1 z1 n. p6 c) l9 M
playful, and healthy boy. The vital signs documented
4 U, o0 G) n6 U. g7 sa blood pressure of 85/50 mm Hg, his length was4 b' \. e, X6 r7 c" C
90 cm (>97th percentile), and his weight was 14.4 kg
1 m7 v3 r$ P; n(also >97th percentile). The observed yearly growth2 M9 ]5 C6 s6 M* S/ a$ V% K
velocity was 30 cm (12 inches). The examination of) m c9 |& J+ H
the neck revealed no thyroid enlargement.
8 B4 ~# V* Y- BThe genitourinary examination was remarkable for6 I1 C: G; u1 @1 B3 L! }9 u
enlargement of the penis, with a stretched length of
* n4 d9 g% k4 G P7 I5 {$ f8 cm and a width of 2 cm. The glans penis was very well, }) ]+ F: k- A% f; l/ F8 K. X- E
developed. The pubic hair was Tanner II, mostly around8 H9 ^! D7 t r8 ?
540
7 W, H( @# J" `at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 H5 |3 V+ `9 D, T! A" E
the base of the phallus and was dark and curled. The
; w" h9 h' m" I; ftesticular volume was prepubertal at 2 mL each.
' H2 q' L( n. K" ~. oThe skin was moist and smooth and somewhat
1 U. s) V6 B5 z+ _: boily. No axillary hair was noted. There were no: y, E/ g; V3 K' P$ Y& }1 m
abnormal skin pigmentations or café-au-lait spots.
+ q8 u2 q5 m$ x' W, T) H( @Neurologic evaluation showed deep tendon reflex 2+# m K7 W9 r, n$ \5 D
bilateral and symmetrical. There was no suggestion! \" p8 y6 z! C& i8 N
of papilledema.
6 T$ B K& ?* k; ~! YLaboratory Evaluation
9 I/ y6 J% o( `4 SThe bone age was consistent with 28 months by
8 F" {* F' M! _+ N4 ?using the standard of Greulich and Pyle at a chrono-
/ U/ g9 m* w0 X% p5 S0 glogic age of 16 months (advanced).5 Chromosomal1 _0 V2 n% e+ v
karyotype was 46XY. The thyroid function test. P" R5 S6 s$ z( ]
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
. J: u* ~! w0 P- Q! ^lating hormone level was 1.3 µIU/mL (both normal).
7 A7 Y# q9 h% T( }$ \/ ]The concentrations of serum electrolytes, blood
( [! I8 Z6 f' n$ Aurea nitrogen, creatinine, and calcium all were+ y' c* b8 @0 q+ t
within normal range for his age. The concentration
5 l5 ?0 r; ?, I6 F+ Kof serum 17-hydroxyprogesterone was 16 ng/dL/ b' n5 y, S* ]1 n. F8 w! Y
(normal, 3 to 90 ng/dL), androstenedione was 20$ ?$ p3 b6 A# H6 s& S" D
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-; R0 J% G( |1 b* M* G' d3 P
terone was 38 ng/dL (normal, 50 to 760 ng/dL),0 C! t$ `' g" g7 M$ C
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
! J6 w8 ~+ ]' v C49ng/dL), 11-desoxycortisol (specific compound S)
1 L+ O/ k2 [0 C% |was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-* T+ q4 V9 L* ]9 {
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& q4 ?& ?" b' }1 A9 O( Ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ u0 o0 u0 n" u2 N: \5 i
and β-human chorionic gonadotropin was less than$ J$ F/ G, I$ b% S& s- U! K" A
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 p, y' v+ W* ?+ O3 ]* K' w" F
stimulating hormone and leuteinizing hormone
' O) V0 ?3 Z2 z% j+ W* R3 x. a( Q8 aconcentrations were less than 0.05 mIU/mL
( H+ ?/ `' R" g; L(prepubertal).* ~/ x7 g. b* r
The parents were notified about the laboratory# Y6 X. s; O5 T
results and were informed that all of the tests were
6 x+ e( w3 c/ b4 Z. t8 S7 vnormal except the testosterone level was high. The6 |# |; e5 U* P4 A3 \$ k
follow-up visit was arranged within a few weeks to
4 h, w" h9 R4 Uobtain testicular and abdominal sonograms; how-9 f& s- Q: u4 D, F& C
ever, the family did not return for 4 months.+ q: s' F: F' T' V M' A
Physical examination at this time revealed that the
) w. U9 ~, Q2 Ochild had grown 2.5 cm in 4 months and had gained
: Y3 }! U5 O8 v3 S- @8 y/ l" ]2 kg of weight. Physical examination remained+ V. j. v' M- t5 K, P/ Z2 {
unchanged. Surprisingly, the pubic hair almost com- _# b/ J4 H5 G/ D; t+ |7 z
pletely disappeared except for a few vellous hairs at
8 W* G2 W0 }: t) L' fthe base of the phallus. Testicular volume was still 2
4 O% R5 q" n: y" M3 m/ C" ymL, and the size of the penis remained unchanged.- e. q! q# O) T+ y
The mother also said that the boy was no longer hav-) s" w& X& o* H! F! o0 R5 f& D
ing frequent erections.
6 s6 ]' X% b# g4 dBoth parents were again questioned about use of
# Q; i$ a+ H) m. zany ointment/creams that they may have applied to- y2 u% T4 b8 p$ e0 Y
the child’s skin. This time the father admitted the$ q% x/ x# \2 v" `* _1 c
Topical Testosterone Exposure / Bhowmick et al 541
7 _) `$ u& p$ T7 i# g) duse of testosterone gel twice daily that he was apply-1 t/ d2 P2 y0 {' f
ing over his own shoulders, chest, and back area for8 v' u/ z. S6 H, R9 |- r, l
a year. The father also revealed he was embarrassed
" r& D9 @2 _9 a1 e: l' Uto disclose that he was using a testosterone gel pre-7 G) N1 `7 K, U2 j% c- \
scribed by his family physician for decreased libido: x2 S6 p5 Q3 W* c8 i" V; f
secondary to depression.
A3 Q) T. M# S" Z5 ~+ @The child slept in the same bed with parents.
1 V* b6 V1 r3 l; ]/ aThe father would hug the baby and hold him on his1 f7 g: h( w* M( [/ f: |
chest for a considerable period of time, causing sig-# e4 N; f/ y3 ?) h# V) V, ^/ m7 j
nificant bare skin contact between baby and father.
5 D, {- }" }: S4 ]' x e* J# O; ~The father also admitted that after the phone call,. E) E2 ^ l$ W9 A' p1 r) n
when he learned the testosterone level in the baby
! Y; Y9 O1 C, W$ ?$ o9 Q2 D# twas high, he then read the product information! W7 A0 {( S- E5 l
packet and concluded that it was most likely the rea-
# c* K: P2 t9 I9 lson for the child’s virilization. At that time, they6 Y" ~5 |" O4 ~* Y0 h2 Y
decided to put the baby in a separate bed, and the( C) R9 z( N' r" y
father was not hugging him with bare skin and had% U- S3 j8 \8 |0 G, e
been using protective clothing. A repeat testosterone# B; C: H1 g/ i& {/ a2 z6 t, `$ V
test was ordered, but the family did not go to the4 o6 T3 X1 H8 N |2 o; d& V2 l
laboratory to obtain the test.( T- \$ ~8 X4 h) M$ M h o
Discussion! U0 h) X" z2 b% N
Precocious puberty in boys is defined as secondary
4 ~- @* s4 W; `& y0 @sexual development before 9 years of age.1,4: J: g9 |. L3 F k9 w, O0 t0 }
Precocious puberty is termed as central (true) when, x6 s) V& S3 g q( Q, n6 U' b9 q) _
it is caused by the premature activation of hypo-0 W( L2 W% ]9 q- J" B
thalamic pituitary gonadal axis. CPP is more com-( f9 R" D: h0 W, H
mon in girls than in boys.1,3 Most boys with CPP# A, y) j: ?' K, `# J7 B! L( v
may have a central nervous system lesion that is- s7 s" i" ]6 f; H! v, u1 _
responsible for the early activation of the hypothal-' t6 R# X, V9 q$ n4 j% b
amic pituitary gonadal axis.1-3 Thus, greater empha-
% g) ^* o/ c3 [$ ]/ |4 W- Zsis has been given to neuroradiologic imaging in" d9 I+ d7 e4 t
boys with precocious puberty. In addition to viril-) k. A: X9 E e$ ?5 Z- X
ization, the clinical hallmark of CPP is the symmet-0 y4 ?6 ~6 l; q$ D; S/ ^1 k, G3 p1 Y
rical testicular growth secondary to stimulation by1 \. @& E: w7 M# @: d" U
gonadotropins.1,3
% V* m4 u4 ~4 L# M1 S3 gGonadotropin-independent peripheral preco-1 M4 r/ \/ ] L6 t! Y
cious puberty in boys also results from inappropriate
- z3 R* ?# s, b- Tandrogenic stimulation from either endogenous or
8 i+ q7 e# R: t5 c- m1 _exogenous sources, nonpituitary gonadotropin stim-4 W3 w' g2 \3 u. ^- r
ulation, and rare activating mutations.3 Virilizing
0 u9 k3 q, @+ s# o) n0 f" k; \congenital adrenal hyperplasia producing excessive' Y/ b1 s0 W' o1 o: l
adrenal androgens is a common cause of precocious
% [- d: w6 M! |: Wpuberty in boys.3,4! P( O5 G0 M+ q! d9 a
The most common form of congenital adrenal/ m7 M: G* m: O
hyperplasia is the 21-hydroxylase enzyme deficiency.
/ ^9 h/ X( z \, x% d# g: dThe 11-β hydroxylase deficiency may also result in) S2 \" i; [+ Q/ m
excessive adrenal androgen production, and rarely,: a% N Q% m1 B$ Z+ L% f6 X
an adrenal tumor may also cause adrenal androgen
! H% v% Z; W6 l" Z" g8 ~3 ^; hexcess.1,38 ~( K. _2 h9 T5 m: C( f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ _9 t& e! z, C+ m542 Clinical Pediatrics / Vol. 46, No. 6, July 2007 Y2 {; y1 g% w1 W
A unique entity of male-limited gonadotropin-6 D: h9 M+ S7 X/ N* G
independent precocious puberty, which is also known) |/ T5 g* w8 E7 V6 ~$ l m4 {
as testotoxicosis, may cause precocious puberty at a# _5 d* ~" [9 O& ?# I
very young age. The physical findings in these boys$ V2 i/ O* M' B
with this disorder are full pubertal development,
) y O, k% W9 N1 kincluding bilateral testicular growth, similar to boys& V# O- M9 j' w. q& s9 O
with CPP. The gonadotropin levels in this disorder
; L) f: B( [; ?. Uare suppressed to prepubertal levels and do not show+ V1 U9 ^9 L. N5 a1 V
pubertal response of gonadotropin after gonadotropin-
D6 n Q6 F- r, p8 P0 Lreleasing hormone stimulation. This is a sex-linked
* s: _6 N; g" E7 d9 Hautosomal dominant disorder that affects only
8 W7 B! C% m& d; {males; therefore, other male members of the family
! q, b# v8 _' vmay have similar precocious puberty.3
8 ?- |0 q2 r& ^- B, A% _In our patient, physical examination was incon-
- C: t, D& S; ]8 Ksistent with true precocious puberty since his testi-* A8 g' `& q0 C# `/ U/ Q
cles were prepubertal in size. However, testotoxicosis
* V2 F7 U' n0 u6 Y- Ewas in the differential diagnosis because his father F+ q/ ]5 l" x; t4 G+ ?! H
started puberty somewhat early, and occasionally,1 `* [+ m Z" w: B
testicular enlargement is not that evident in the
4 [ q5 F6 b1 c$ }beginning of this process.1 In the absence of a neg-5 q: r8 v/ G9 Y0 \% k4 X/ C \7 u& P$ D
ative initial history of androgen exposure, our: c3 P: Q( q/ L$ c- y7 F9 s1 \% [
biggest concern was virilizing adrenal hyperplasia,
2 ~/ \, H5 A0 @1 Y3 Y, o8 meither 21-hydroxylase deficiency or 11-β hydroxylase/ v1 p! v v0 I/ C9 S
deficiency. Those diagnoses were excluded by find-( h- N* v! r1 x( V$ r: ~
ing the normal level of adrenal steroids.
5 `' _5 U5 ?1 D* `9 WThe diagnosis of exogenous androgens was strongly* l+ j' M# b$ m/ k6 I
suspected in a follow-up visit after 4 months because
8 P) }" t/ E; U' ~# rthe physical examination revealed the complete disap-7 @7 t! Z; a, H" k/ ?. L
pearance of pubic hair, normal growth velocity, and8 _ x+ J4 a4 N" _& c/ a" W! C
decreased erections. The father admitted using a testos-
; \6 n+ y- t. B- rterone gel, which he concealed at first visit. He was
. q6 L0 z/ T% u1 f, l) fusing it rather frequently, twice a day. The Physicians’2 P; Q0 K" ?2 A6 d" A5 R7 a# T
Desk Reference, or package insert of this product, gel or, ?# n8 n, H ~# a/ ?: @6 n
cream, cautions about dermal testosterone transfer to
7 h7 E4 y V0 Gunprotected females through direct skin exposure.! ^% b+ f% U/ q1 s
Serum testosterone level was found to be 2 times the0 v& }8 u w7 ?# G
baseline value in those females who were exposed to
& o( ]; r1 F$ t* b, V: u2 Seven 15 minutes of direct skin contact with their male- O2 c0 x+ K8 { ?
partners.6 However, when a shirt covered the applica-
' |+ g2 Q7 s0 ~2 b4 Q4 ]+ [) }& dtion site, this testosterone transfer was prevented.
: c3 B, H' e& k$ j) Y0 ^% }- h5 JOur patient’s testosterone level was 60 ng/mL,
3 I. v& x4 l) y& O$ H; rwhich was clearly high. Some studies suggest that
; @! Z( c* c8 x5 W: X" Gdermal conversion of testosterone to dihydrotestos-
* m& N/ o0 S+ e! z9 Z) W9 ^# Gterone, which is a more potent metabolite, is more
5 k- ?* _7 ]5 M( Y' Dactive in young children exposed to testosterone' g" P' o/ ~0 Z7 H/ m
exogenously7; however, we did not measure a dihy-6 o, \" \8 {9 s6 [% j
drotestosterone level in our patient. In addition to
9 M# P- R/ v) O+ kvirilization, exposure to exogenous testosterone in
* [8 Q3 r* D! ~$ O) {; schildren results in an increase in growth velocity and
' ]: s* U0 k* R* M% z6 ladvanced bone age, as seen in our patient.5 f2 e2 s/ n, E }: o+ E6 } U
The long-term effect of androgen exposure during$ \/ D. @2 r9 z% h/ |
early childhood on pubertal development and final2 `1 I8 L0 ?: u8 I5 y
adult height are not fully known and always remain% j9 Z/ v! B2 i3 B7 |
a concern. Children treated with short-term testos-
+ z( ~6 [' N: v$ R( Dterone injection or topical androgen may exhibit some, B6 g v, X$ K
acceleration of the skeletal maturation; however, after
9 i" R$ o+ L+ T& o; w. ccessation of treatment, the rate of bone maturation& x$ Z" A8 a5 |- I7 `7 p& x1 w
decelerates and gradually returns to normal.8,9( A& [9 K6 W5 r' V4 g
There are conflicting reports and controversy
1 W( `; T9 q0 \$ e# V5 E: H7 [over the effect of early androgen exposure on adult5 G2 d# T. {6 {
penile length.10,11 Some reports suggest subnormal
! ?3 W" ^/ T% i( ]9 Q! F& wadult penile length, apparently because of downreg-: p% o$ s3 U; D/ ?, j
ulation of androgen receptor number.10,12 However,
# a3 }5 N0 E9 L5 O/ N( f+ qSutherland et al13 did not find a correlation between- e' z9 ]$ Q6 q# I7 J1 P
childhood testosterone exposure and reduced adult* d9 k9 w% h5 d5 g& q8 h( O) l
penile length in clinical studies.) h) d! L2 q( Q) [, Q
Nonetheless, we do not believe our patient is
: U4 \ L% g* @' ygoing to experience any of the untoward effects from. W9 S! o6 ~1 f7 Z
testosterone exposure as mentioned earlier because- C* H& S7 I' z& ?2 [ {
the exposure was not for a prolonged period of time.- R" L& B: R$ s; r z% ~
Although the bone age was advanced at the time of
% t* s# G7 s6 M5 m, f, M: Z/ z) q' S6 Mdiagnosis, the child had a normal growth velocity at
/ C# O8 c% h0 S [9 }8 C* Athe follow-up visit. It is hoped that his final adult
; X: A1 B1 p/ Z# Eheight will not be affected.5 V) V7 V9 p& G$ @; g9 [2 ?; |9 x, K
Although rarely reported, the widespread avail-
! T$ {* H g. l, U! z8 j1 Fability of androgen products in our society may* x7 f* i; s" z" t4 K$ k
indeed cause more virilization in male or female
* w; ~3 d0 U) h* @' s: v+ _2 jchildren than one would realize. Exposure to andro-- t& x! j: P) I4 h( [# ~
gen products must be considered and specific ques-* J4 s& G4 a! t! y
tioning about the use of a testosterone product or
$ r. \( H5 V* ]gel should be asked of the family members during
' `+ t7 @( F5 n4 ?) N3 d$ [: @6 Mthe evaluation of any children who present with vir-! o1 m& f+ m! N- l& i9 K1 A8 K. I
ilization or peripheral precocious puberty. The diag-
8 _3 G" A0 x9 b5 e, Hnosis can be established by just a few tests and by
. q3 N, ~" e. ? c0 O) K$ _* H1 \! dappropriate history. The inability to obtain such a/ F! n. z4 v5 _( Y. Y+ L
history, or failure to ask the specific questions, may
$ n6 m! J* A! Z, Tresult in extensive, unnecessary, and expensive
5 A4 S# s% B2 v6 u. Dinvestigation. The primary care physician should be+ Y9 l7 Z1 v% y, K) t' D# g; Z( y- M
aware of this fact, because most of these children* J% @; l" G; v- G+ ^1 d
may initially present in their practice. The Physicians’
" b1 W. I1 S% FDesk Reference and package insert should also put a5 g o0 _9 b6 z: |$ H$ }9 v, ?
warning about the virilizing effect on a male or$ I* J4 F6 N3 c" o7 m% a: R
female child who might come in contact with some-: ]8 Y' k8 ^9 k
one using any of these products.3 v2 x; L3 y1 S2 j L( h
References
& V L# r3 F' l6 }% B1. Styne DM. The testes: disorder of sexual differentiation
& y# }# G$ L! B! ] F4 R- mand puberty in the male. In: Sperling MA, ed. Pediatric
$ C4 Q% w0 t4 v1 FEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 }4 V' y, S' _; P) b7 M5 f
2002: 565-628.
+ R9 H: q, A$ J$ {2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious/ Y1 D0 G, p- D s2 o/ i! L5 P
puberty in children with tumours of the suprasellar pineal |
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