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Sexual Precocity in a 16-Month-Old
8 D6 `2 J! A6 o" j8 X8 `Boy Induced by Indirect Topical% E- ?+ P4 K+ n$ B ?6 y
Exposure to Testosterone
) O% k1 m5 D7 Q* K+ P' J0 i$ H, XSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 U3 Z5 Y" o* A# B F* |and Kenneth R. Rettig, MD1
1 f4 q$ s% S' F# Q% B1 IClinical Pediatrics
1 S# `' \5 O4 x% y$ p, c yVolume 46 Number 6) Y: a5 z$ A3 O7 n2 a
July 2007 540-5432 P; a! k( q5 {
© 2007 Sage Publications- j( H& \/ R9 L" v" b# L* q) x
10.1177/0009922806296651
. h" e2 ^! b" D8 ^8 y# khttp://clp.sagepub.com
; m5 V: a) e/ ohosted at
( R5 V% S& ?# O: p# chttp://online.sagepub.com# S7 N5 z/ M& X) a
Precocious puberty in boys, central or peripheral,
I1 R1 J3 h1 [0 a) Pis a significant concern for physicians. Central
& ?/ J" r( n8 Z. I0 j& Uprecocious puberty (CPP), which is mediated
$ H! g3 H, R/ q/ Q9 B0 Gthrough the hypothalamic pituitary gonadal axis, has
1 D s6 R! c1 f' y" ?+ ca higher incidence of organic central nervous system- ^ @- e7 y. \4 H1 v" k( Y) E
lesions in boys.1,2 Virilization in boys, as manifested
. `; G. J2 A' i4 f4 ~9 v) jby enlargement of the penis, development of pubic
" W9 z+ X% ?8 A! M* w; ghair, and facial acne without enlargement of testi-
9 P+ `8 z! T2 bcles, suggests peripheral or pseudopuberty.1-3 We( c, r- B+ H5 u/ Q
report a 16-month-old boy who presented with the
9 ?2 _: h* y3 G. Z- z% cenlargement of the phallus and pubic hair develop-
" o# u4 U ? w6 F$ dment without testicular enlargement, which was due
3 Y0 j3 L% v, C' z/ xto the unintentional exposure to androgen gel used by
# M) q2 L; ]7 ^; W' O( Y) _the father. The family initially concealed this infor-" ?1 ~" U( @$ {" g: V8 r9 M% ~7 r
mation, resulting in an extensive work-up for this
' a6 s" U' y* t1 P0 Q; Z; x9 K. L# Kchild. Given the widespread and easy availability of
7 S: j' u& `9 ctestosterone gel and cream, we believe this is proba-
: p" T& Y- O( Rbly more common than the rare case report in the
# _: q) e2 N/ c3 Nliterature.4
. B' Y5 }1 e7 S$ G4 U5 H( RPatient Report. |) O% |. r; E- ^
A 16-month-old white child was referred to the
: k6 G; V. k8 p9 @endocrine clinic by his pediatrician with the concern# d/ `3 U q+ T( f7 m& x
of early sexual development. His mother noticed
# l0 Z4 ]6 N! J! Xlight colored pubic hair development when he was2 H& r% v& i: |! ^$ d: v
From the 1Division of Pediatric Endocrinology, 2University of
8 j2 e+ a; A' ~South Alabama Medical Center, Mobile, Alabama.
) g2 M# P: C$ X4 o0 ^Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 X3 l0 N7 Q. u+ E9 p+ ~Professor of Pediatrics, University of South Alabama, College of
8 U6 U" m+ I0 [3 VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 d$ M3 p# c& ^1 S# s) X0 qe-mail: [email protected].
9 n7 L- L! F; F) uabout 6 to 7 months old, which progressively became( z2 J, [' a7 A/ p* Z
darker. She was also concerned about the enlarge-
5 a3 Q0 |7 b& R* v/ t% K8 N# Pment of his penis and frequent erections. The child$ g v5 Z$ ], m& {; t
was the product of a full-term normal delivery, with* [- y) L2 _1 v' o' |: b
a birth weight of 7 lb 14 oz, and birth length of
" a" y7 F, a+ g) I6 M2 c20 inches. He was breast-fed throughout the first year, Z! `! X, l( C9 v! a
of life and was still receiving breast milk along with/ G/ {& H! l3 |' f
solid food. He had no hospitalizations or surgery,2 b" r6 y" @' d G3 j
and his psychosocial and psychomotor development
4 H8 g a! s% e! ]! j* W9 f( Q$ wwas age appropriate.# t$ q& N v \# D, |. e
The family history was remarkable for the father,
# t8 ~1 X' R3 G9 g* c& vwho was diagnosed with hypothyroidism at age 16,! [5 \; J$ l: ^8 y. |
which was treated with thyroxine. The father’s/ m* z5 d* @( T! Z# z3 M: Y
height was 6 feet, and he went through a somewhat# b; P1 L. C1 o' `7 U6 I
early puberty and had stopped growing by age 14.1 w' o+ [- ]$ c( `! K* z
The father denied taking any other medication. The
& a! m8 M. }) M7 u' jchild’s mother was in good health. Her menarche3 q w, D# K& q/ r
was at 11 years of age, and her height was at 5 feet* n5 }, S3 X% j. @$ o
5 inches. There was no other family history of pre-
- D d/ ^) w- hcocious sexual development in the first-degree rela-5 n8 T Y. ~. p( C/ k0 `& w; s
tives. There were no siblings.
" G/ i$ E; v- }# a1 Q FPhysical Examination* Q* q" w S! R+ X3 }+ H
The physical examination revealed a very active,
@9 ^' |, `$ V) Xplayful, and healthy boy. The vital signs documented
7 G3 Z5 N R& F& X) j4 za blood pressure of 85/50 mm Hg, his length was
7 u7 F5 h# |* ]7 w6 V9 _/ m- J; k; @. x90 cm (>97th percentile), and his weight was 14.4 kg' d( E* p) C6 m; ^9 b6 K, `3 s
(also >97th percentile). The observed yearly growth& F6 F+ E- H! Y, T2 T
velocity was 30 cm (12 inches). The examination of
/ Y" H2 g' c3 k* Qthe neck revealed no thyroid enlargement.. _: r+ c6 c$ Z7 d
The genitourinary examination was remarkable for; X+ z" l5 E `
enlargement of the penis, with a stretched length of% V, q& q- K, k! G# Q5 L+ s
8 cm and a width of 2 cm. The glans penis was very well
' `7 m7 p3 V. Edeveloped. The pubic hair was Tanner II, mostly around
4 C0 @+ n2 Q, J; A1 h$ d540$ j% |) U3 v$ c' t* v& t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 U2 l! J4 @* m5 R9 Y0 S1 Hthe base of the phallus and was dark and curled. The
0 S0 ? F: X, L5 y; ~+ Otesticular volume was prepubertal at 2 mL each.! r9 n" w; c7 M$ {5 `! N
The skin was moist and smooth and somewhat
! x' Y' m3 b% E' \oily. No axillary hair was noted. There were no
/ X* ~. G$ t2 kabnormal skin pigmentations or café-au-lait spots.3 Y1 d! R4 o3 D. L+ g& _
Neurologic evaluation showed deep tendon reflex 2+, e6 M8 Q+ u) t, u
bilateral and symmetrical. There was no suggestion$ s0 p3 A3 P7 ~/ p6 i0 H/ Q
of papilledema.
* ?+ D/ \' Y8 D9 j8 Q" b7 qLaboratory Evaluation
1 `/ e- X1 L- i( A# j$ HThe bone age was consistent with 28 months by
: v0 N0 z& S+ G. susing the standard of Greulich and Pyle at a chrono-
7 D4 p6 i% _ Q) I' glogic age of 16 months (advanced).5 Chromosomal
4 s3 `- P4 e, a/ }, Fkaryotype was 46XY. The thyroid function test- a+ V! {: P% ~/ V5 g( I9 R. x
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 o. q' u2 ~6 `5 u! ~& f) m Llating hormone level was 1.3 µIU/mL (both normal).9 }: q7 H) u7 [" Y1 w G
The concentrations of serum electrolytes, blood
' Z6 x' P& S( zurea nitrogen, creatinine, and calcium all were! N. y. g; m5 G0 _- X& P2 {; b
within normal range for his age. The concentration
2 v U+ ~; [+ u- {! r7 pof serum 17-hydroxyprogesterone was 16 ng/dL
9 E9 y; M4 C6 B% e, T( n(normal, 3 to 90 ng/dL), androstenedione was 20- z! R+ v; Z0 v$ r8 x+ n
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 v* ]5 P7 X7 a0 x+ b
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 D: U& b' c' @/ E8 Mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
: E0 ]! `8 J @6 t49ng/dL), 11-desoxycortisol (specific compound S)# g7 t2 A# ?+ Q, J
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-7 z C) m, e8 q' ~4 Q) r d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 I W) ]/ I, `# J* ptestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 H! |! \2 g! Y8 {9 p2 O* \and β-human chorionic gonadotropin was less than, e$ S+ [! Z! c1 u% Z7 {: q3 N8 C
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 n! @1 A$ d" A! d& W' }/ pstimulating hormone and leuteinizing hormone
0 u( U W; G9 _concentrations were less than 0.05 mIU/mL
* A! l" Y6 E- i- Y4 \8 ?+ J( [0 B(prepubertal).5 v' {$ q$ s$ E W/ d& E. R" n
The parents were notified about the laboratory
4 Q3 F) w! r) d* N: B3 mresults and were informed that all of the tests were; P* i$ W7 J7 L6 b; o1 O0 ^
normal except the testosterone level was high. The
2 X; T0 C! H9 u( Z. Hfollow-up visit was arranged within a few weeks to; v- ], O; _4 Y9 x! O2 q+ g
obtain testicular and abdominal sonograms; how-. c) n" ~! o+ K, z& m) M
ever, the family did not return for 4 months.
' r) B& y }9 x0 RPhysical examination at this time revealed that the9 j; ~% v; ~3 g! c' @
child had grown 2.5 cm in 4 months and had gained
+ |+ @; ~* L$ g3 O3 N1 w: i' f2 kg of weight. Physical examination remained0 u, }- u1 a3 I! H
unchanged. Surprisingly, the pubic hair almost com-; C: b* @5 G. K' R) Y# l A; {2 e. q0 z
pletely disappeared except for a few vellous hairs at
' u7 j' o9 k% z {the base of the phallus. Testicular volume was still 2" w# E% Q; }7 i6 B2 {9 A |
mL, and the size of the penis remained unchanged.
- b, G" l5 ]+ ~5 T; P: |' u6 fThe mother also said that the boy was no longer hav-7 ^# h2 F" [5 s# T+ M; Z
ing frequent erections." @" _3 R, a& V' R2 M j! c8 X
Both parents were again questioned about use of$ V2 E- d6 t( X) a- ?% ?5 s
any ointment/creams that they may have applied to- s9 u7 k- s" a# @
the child’s skin. This time the father admitted the/ {# S; s) j4 d- o' E1 s
Topical Testosterone Exposure / Bhowmick et al 541
$ H4 Y& |! @. e' i) L9 y7 uuse of testosterone gel twice daily that he was apply-
/ y- c* J: E- \2 D8 T1 @ing over his own shoulders, chest, and back area for
/ j5 Q, u* ~3 fa year. The father also revealed he was embarrassed0 W2 b) y/ J( u. O4 g0 f' u
to disclose that he was using a testosterone gel pre-6 i4 j: z# R2 z9 Q+ J
scribed by his family physician for decreased libido3 j6 |1 j' A; h N7 ?: c
secondary to depression.) t7 g( F) a2 d6 ]$ t4 D$ K0 Z' b& }
The child slept in the same bed with parents.
) s4 i! s2 |: O0 Q' n. p2 u- W$ jThe father would hug the baby and hold him on his
: {$ ~4 _# E2 E! o/ \6 `8 _- g5 x( y) rchest for a considerable period of time, causing sig-
# B4 W2 k" i1 P- G9 f' C5 hnificant bare skin contact between baby and father.- c5 t8 Q7 E E0 t( j* ^! K
The father also admitted that after the phone call,, d" a; O m5 `/ s& o" j" l2 x7 X' y
when he learned the testosterone level in the baby9 g I M5 I" _) _) f8 \5 {
was high, he then read the product information
) y+ ^. y# N& E5 y/ ipacket and concluded that it was most likely the rea-9 I6 {! v/ Y7 o9 h1 \
son for the child’s virilization. At that time, they
0 V: ^. ?& i7 T# B8 ^3 M8 w8 ^' kdecided to put the baby in a separate bed, and the0 I6 ]3 `3 U! D# `5 \
father was not hugging him with bare skin and had2 P. Q9 d7 j3 ]
been using protective clothing. A repeat testosterone4 P7 ~& \' j# G# ^
test was ordered, but the family did not go to the
; i i, n$ z* flaboratory to obtain the test.
4 I+ [& }* g1 W/ HDiscussion6 K- K4 e1 B7 M. c) y# R( F5 C0 k
Precocious puberty in boys is defined as secondary4 I$ k' ^ @/ d+ J( ?
sexual development before 9 years of age.1,4
1 q9 P5 C( b' f- GPrecocious puberty is termed as central (true) when
H* s9 U+ \) y9 G7 @& O9 A2 z& @it is caused by the premature activation of hypo-
4 K& _4 i5 s$ a0 t+ Z; lthalamic pituitary gonadal axis. CPP is more com-) b! W% e0 N# ?
mon in girls than in boys.1,3 Most boys with CPP P( _: Z( i! r6 s, q, Z4 |: S
may have a central nervous system lesion that is& S( ~" @. |' @4 e! R* ~/ [ C4 ]
responsible for the early activation of the hypothal-
5 W* A+ R/ Q# U6 {amic pituitary gonadal axis.1-3 Thus, greater empha-( m+ Y9 U1 m, f; t( W
sis has been given to neuroradiologic imaging in
& E% P! G9 U) B, B6 |6 ]$ Rboys with precocious puberty. In addition to viril-9 Q+ f% l* W; P. D# A0 T( q
ization, the clinical hallmark of CPP is the symmet-
" ^" B; V% C# p$ I6 ?rical testicular growth secondary to stimulation by* K9 l T/ i8 Q3 O' P& b! B/ {, Y
gonadotropins.1,3
" j, m) \8 [0 V; p& ^; u2 GGonadotropin-independent peripheral preco-9 @' @% d% A8 z3 C. K+ |$ c8 a
cious puberty in boys also results from inappropriate
9 l" F1 X0 l9 v- Wandrogenic stimulation from either endogenous or: K8 X+ C5 {7 x. p$ I9 e- i# T
exogenous sources, nonpituitary gonadotropin stim-3 Y7 R q2 t+ |0 l, e8 h
ulation, and rare activating mutations.3 Virilizing" F5 q y8 V& }
congenital adrenal hyperplasia producing excessive
8 u6 o, O" u. }adrenal androgens is a common cause of precocious) H$ `3 X: p6 X: l* C6 W, ]7 e
puberty in boys.3,43 h7 |: `- `/ Y3 X4 ? ~1 G, J3 ]
The most common form of congenital adrenal- F! \( V7 d x9 w. Z/ _% u' R
hyperplasia is the 21-hydroxylase enzyme deficiency.
8 m, K5 C* E4 p' e# ~2 |3 ^9 RThe 11-β hydroxylase deficiency may also result in: q: _' O- z# y, H+ ?% y- O
excessive adrenal androgen production, and rarely,/ w) P/ G: O8 J% d5 b
an adrenal tumor may also cause adrenal androgen
) x5 g! N/ ^6 |, k( Dexcess.1,3
0 K* {" m5 w ]$ m/ Cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 U5 b" [- J- L5 s
542 Clinical Pediatrics / Vol. 46, No. 6, July 20070 t- ~0 \' F( C x" _ w) J5 v
A unique entity of male-limited gonadotropin-
2 _2 n: w' ], W; x9 D7 y W4 Findependent precocious puberty, which is also known z- o: L5 p% J% a& K
as testotoxicosis, may cause precocious puberty at a. l; S1 f. m- m4 L5 A9 T
very young age. The physical findings in these boys* ~0 y/ |! i, Y
with this disorder are full pubertal development, k# T0 U% I- m
including bilateral testicular growth, similar to boys) a0 r2 h0 K2 I& Z: d/ f4 D
with CPP. The gonadotropin levels in this disorder
7 J/ p" X1 p5 Jare suppressed to prepubertal levels and do not show0 T$ e8 \+ i* m- Q7 Z. a
pubertal response of gonadotropin after gonadotropin-# h: b8 T: ?' i5 D8 j" t, q% y3 E6 s1 S
releasing hormone stimulation. This is a sex-linked
- O" b5 j! h: m- Y# C f' ]autosomal dominant disorder that affects only9 Q( }1 D" X) B u- ~* C/ ^6 \' I
males; therefore, other male members of the family* d- q& P2 v$ j+ f+ ?* q( c4 ^
may have similar precocious puberty.3$ G$ x' d; K# h0 u
In our patient, physical examination was incon- [; x+ G* _+ ~1 U
sistent with true precocious puberty since his testi-
5 _# Z5 p5 j$ {5 K( _+ K7 F. i H5 {cles were prepubertal in size. However, testotoxicosis+ U& b4 @/ X; D5 U, w
was in the differential diagnosis because his father
. l) |+ S; ?0 ^1 \3 Tstarted puberty somewhat early, and occasionally,
Z; ~1 G( z( r5 Q6 e! d8 etesticular enlargement is not that evident in the& ~5 { x6 W& z P6 ~+ a; R
beginning of this process.1 In the absence of a neg-" u/ P" y+ c$ \8 `7 k
ative initial history of androgen exposure, our
( M+ U h. k$ l$ p0 B! |/ V: Nbiggest concern was virilizing adrenal hyperplasia,& r" j* F9 B: j" n, o) N
either 21-hydroxylase deficiency or 11-β hydroxylase& J9 F- M+ a: J2 K& O1 |
deficiency. Those diagnoses were excluded by find-
% w9 l% t: ^! a5 S: Ying the normal level of adrenal steroids.* T F- W5 h7 j$ U7 w- Y
The diagnosis of exogenous androgens was strongly! Y1 Q4 Q) X$ g6 Y N/ e
suspected in a follow-up visit after 4 months because Z& m4 H# i7 s& \. t1 S
the physical examination revealed the complete disap-
' G5 j' O2 M/ Y, z# d/ `pearance of pubic hair, normal growth velocity, and w! g) c* n1 X g
decreased erections. The father admitted using a testos-# Y$ `3 \* v/ R7 F, u; ?. o
terone gel, which he concealed at first visit. He was
. V. v, O I. L" musing it rather frequently, twice a day. The Physicians’5 B/ q/ k5 a, `7 d4 E) h" w; i1 R
Desk Reference, or package insert of this product, gel or0 Z( `: L# _+ a2 E; W3 E! N7 Z
cream, cautions about dermal testosterone transfer to7 P* W: S( |3 R) j- ]7 r/ T5 W+ w
unprotected females through direct skin exposure.
& W3 n! }6 b: ^3 qSerum testosterone level was found to be 2 times the6 J9 k3 Q: D% k; K/ S, R
baseline value in those females who were exposed to" y- d `; \, ~6 j+ {2 z1 t( k
even 15 minutes of direct skin contact with their male I" } t& z. ^6 L
partners.6 However, when a shirt covered the applica-; O* o7 P! ]& f
tion site, this testosterone transfer was prevented.
# g H/ ~9 k$ a$ UOur patient’s testosterone level was 60 ng/mL,
5 E- |+ ]0 o8 |. x9 R/ pwhich was clearly high. Some studies suggest that3 ]7 e3 Q: T' ]( J& `- Z" E- g
dermal conversion of testosterone to dihydrotestos-
! p8 f9 w3 J/ {0 Z6 z! P% a1 R( aterone, which is a more potent metabolite, is more4 j- ^ D$ v" n9 b0 I6 a: t
active in young children exposed to testosterone; c2 ]2 {$ T4 t0 K/ k
exogenously7; however, we did not measure a dihy-- P* C, C" G3 a; {
drotestosterone level in our patient. In addition to
9 d+ h; R# _3 @+ o' T* ^/ Wvirilization, exposure to exogenous testosterone in2 \' _2 r# p# u; a( B7 _6 r' P1 A( {
children results in an increase in growth velocity and
, B% w# [2 h7 x' V( j4 fadvanced bone age, as seen in our patient., C/ k" a7 d) T
The long-term effect of androgen exposure during
4 k$ g' ^$ Q5 F0 s eearly childhood on pubertal development and final1 v7 L F+ m3 h! p, S$ e# K
adult height are not fully known and always remain. U; t+ W: W+ U8 ]/ }
a concern. Children treated with short-term testos-# E0 z: e' Y4 C& Y
terone injection or topical androgen may exhibit some# k4 y: m: d9 }9 s- Q
acceleration of the skeletal maturation; however, after6 y% H* q5 q& }3 `8 @" {0 E
cessation of treatment, the rate of bone maturation
' m: M7 R+ l1 E h' U3 Idecelerates and gradually returns to normal.8,9: ~* s4 ?3 h; I
There are conflicting reports and controversy3 C2 z$ @) f& k ^- ]
over the effect of early androgen exposure on adult
) y4 g4 l2 o( w) X9 q: V1 j; xpenile length.10,11 Some reports suggest subnormal
3 m( I, e! Z, kadult penile length, apparently because of downreg-
! S1 G/ J. Q8 c) l' {1 nulation of androgen receptor number.10,12 However,
- F4 y7 \- `# ]Sutherland et al13 did not find a correlation between1 Z5 j# m! X1 Q- ?2 }
childhood testosterone exposure and reduced adult
" L% Y: a& p- a; Qpenile length in clinical studies.# w8 C) R+ B7 e) A+ v
Nonetheless, we do not believe our patient is
" }: J* d. H1 u4 `going to experience any of the untoward effects from" i2 l1 j# c7 M
testosterone exposure as mentioned earlier because
% _4 |# Y# c# s+ `* J$ xthe exposure was not for a prolonged period of time.; E$ @8 C: a9 w* j8 o
Although the bone age was advanced at the time of
! t- [8 p, A3 z+ rdiagnosis, the child had a normal growth velocity at7 t2 s% p. O; M- W n/ A1 ^
the follow-up visit. It is hoped that his final adult
2 C) u& c k1 J" V) ?" ~( F4 o! Aheight will not be affected.
4 s6 b- I1 b( m% I& j* M" RAlthough rarely reported, the widespread avail-
, F8 N; i7 y, ~ }% b) i! ~" @0 Q6 u3 qability of androgen products in our society may
3 ?; |5 r& @, {& r( I$ E9 m5 jindeed cause more virilization in male or female
! H5 k1 s5 `3 ~children than one would realize. Exposure to andro-
' M( O4 Y ]$ X! Ygen products must be considered and specific ques-5 H z; W1 v: ?% ]; t7 W
tioning about the use of a testosterone product or
; z3 T' |1 _: }+ W: z$ H( E6 Igel should be asked of the family members during5 o' Q! O& y) U& |0 F+ K c9 D9 X
the evaluation of any children who present with vir-9 i m7 W5 r D6 k- K$ ?+ ]
ilization or peripheral precocious puberty. The diag-7 Y) e0 B- t7 a& H
nosis can be established by just a few tests and by: E: s& s. e* J' V$ h# V+ p
appropriate history. The inability to obtain such a
# |2 h+ v* ^, ]. s5 [3 {' Qhistory, or failure to ask the specific questions, may' Z" f9 s! ~- s; z- a, s) R. F
result in extensive, unnecessary, and expensive( x* U: `: Z+ h) F$ l, b
investigation. The primary care physician should be
9 _: i$ c2 L* _' T. C+ P9 n- [aware of this fact, because most of these children
! v5 p& N r' P5 ~. s9 b$ b1 Amay initially present in their practice. The Physicians’
c: s. U% ~% M: E0 K9 J8 @Desk Reference and package insert should also put a/ B5 x7 \( p5 q, { Q8 ^2 U
warning about the virilizing effect on a male or! [# l$ G4 l Y0 Q- h
female child who might come in contact with some-
% r7 e7 Y% ]4 A( c( qone using any of these products./ s' f8 d& P/ T- B
References3 N8 R6 z# K9 F; K0 s
1. Styne DM. The testes: disorder of sexual differentiation
; f7 E; d* [0 Wand puberty in the male. In: Sperling MA, ed. Pediatric
$ e, z/ E6 a) q% M8 h+ [ \4 B1 ^Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
0 j& |9 ~3 m* y+ v* `8 b+ C( I& `2002: 565-628.
; ]7 J5 [( J+ b& L9 P0 B" e r2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
0 o1 P# Y6 J" u) M6 Kpuberty in children with tumours of the suprasellar pineal |
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