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Sexual Precocity in a 16-Month-Old/ F6 }8 S4 g; v2 o% q3 u
Boy Induced by Indirect Topical- h" \, V( j& h) i
Exposure to Testosterone5 F) L/ G3 c. ]) S3 n! v9 D5 f
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
& p' _! V: J3 Z0 r; K% pand Kenneth R. Rettig, MD1
( t3 q6 B1 t' ~9 z uClinical Pediatrics% q# C( q( i$ M6 l; l
Volume 46 Number 65 K+ c8 M/ ?* I* I1 W" C8 m- w
July 2007 540-543& n2 n& X R$ R& x
© 2007 Sage Publications
+ Z9 ~! j9 p. \ H% `10.1177/0009922806296651
6 t+ v) C: X' {0 ^, N5 r" D* z+ chttp://clp.sagepub.com' S# F. G3 Q0 t0 x2 n8 Y
hosted at
: h: d: k1 g, Chttp://online.sagepub.com
3 I! _" i2 k% o* kPrecocious puberty in boys, central or peripheral,) [- w# V# Q8 N8 A1 x
is a significant concern for physicians. Central
" }0 C6 T' J% O7 x4 L! Q2 u6 }precocious puberty (CPP), which is mediated
* T9 g Y) k m+ L" E, r' hthrough the hypothalamic pituitary gonadal axis, has
6 e* i2 L$ r& X, O$ ha higher incidence of organic central nervous system
( Q& u" Z. q6 K5 zlesions in boys.1,2 Virilization in boys, as manifested- U3 w! D6 t ~; z1 f. R
by enlargement of the penis, development of pubic
+ g+ p3 y; k( ?* y& X: }5 ^hair, and facial acne without enlargement of testi-( D, {& N( r [
cles, suggests peripheral or pseudopuberty.1-3 We! s. r T0 u- d& d, z
report a 16-month-old boy who presented with the: v7 K( Q* h! Y1 C7 `* Q' R# Q; h
enlargement of the phallus and pubic hair develop- y! L- [- K0 S" x
ment without testicular enlargement, which was due
* T$ P8 e2 O3 L+ Sto the unintentional exposure to androgen gel used by
- S! n2 Y3 L4 L. A3 l5 f& Othe father. The family initially concealed this infor-
! a T4 z4 ]. I/ U1 L, Cmation, resulting in an extensive work-up for this9 ~; [$ ]3 S' U
child. Given the widespread and easy availability of
% }6 P; i: @' r& Ztestosterone gel and cream, we believe this is proba-
+ P# I/ V: Z2 c3 V; }6 z6 H. jbly more common than the rare case report in the0 @, V7 A4 m0 N2 @- x9 I8 E
literature.4$ [- D+ ~& Q( E" a0 ~
Patient Report8 K+ c1 Z6 l/ y. E
A 16-month-old white child was referred to the# R8 B3 b# Q8 }: N0 }! E8 w1 A
endocrine clinic by his pediatrician with the concern
`5 q( n2 y' }8 [/ m$ f- N- Pof early sexual development. His mother noticed7 j, k/ R1 p1 N* ]6 r
light colored pubic hair development when he was
! {% t7 n, V2 R9 D2 X$ JFrom the 1Division of Pediatric Endocrinology, 2University of* K [2 D/ |) `7 ~& O
South Alabama Medical Center, Mobile, Alabama.+ v6 u+ ^: T% R8 `8 p
Address correspondence to: Samar K. Bhowmick, MD, FACE,
7 g* w' k- H! f w+ CProfessor of Pediatrics, University of South Alabama, College of2 J$ z$ L+ {- z# ~# { D% G* x
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;( r! ^0 h$ e! j7 i0 @: f. L' U
e-mail: [email protected].
$ `* L( P- b# @' sabout 6 to 7 months old, which progressively became
0 v- O. J, p1 p9 r+ Hdarker. She was also concerned about the enlarge-7 h* F& B1 O+ E/ x2 u9 {7 N- W
ment of his penis and frequent erections. The child R; j, v$ Y) x+ { x" ^
was the product of a full-term normal delivery, with
: b2 n `- ^: H! l* H' ya birth weight of 7 lb 14 oz, and birth length of& X/ l) S" o$ ^
20 inches. He was breast-fed throughout the first year/ A9 a2 E+ Q) X+ c% r
of life and was still receiving breast milk along with! i. a$ K/ f/ R3 Y" C z, Q$ Z
solid food. He had no hospitalizations or surgery,
& C( u; J7 A7 P7 Z& q5 a8 |8 U1 Aand his psychosocial and psychomotor development" R2 q& L5 l8 O1 J, G, {
was age appropriate.
0 R% P+ P* k% @3 g' ?3 K, O, eThe family history was remarkable for the father,
$ m1 C; C4 W2 b, @) a0 x+ I# pwho was diagnosed with hypothyroidism at age 16,$ s" m% s% {5 W
which was treated with thyroxine. The father’s
$ n; c: [8 C7 e. B* Gheight was 6 feet, and he went through a somewhat: q( b& u7 H8 r5 a5 e* \: h
early puberty and had stopped growing by age 14.
/ H7 [4 }% {0 g$ q. uThe father denied taking any other medication. The& U/ E6 L' v( @$ l% k
child’s mother was in good health. Her menarche; z4 y' L4 k1 H& w- `4 c
was at 11 years of age, and her height was at 5 feet$ k2 a2 k. B* I! o& o" J
5 inches. There was no other family history of pre-
" _; `' n! w# W& ]) a4 Bcocious sexual development in the first-degree rela-8 H9 ]+ x; [) c, X
tives. There were no siblings.
. p, H }' G! E, tPhysical Examination% ^" T7 [4 x0 i& j6 D
The physical examination revealed a very active,7 i$ H- {9 X5 ]/ F# `
playful, and healthy boy. The vital signs documented
% V$ D: ?( @( u1 p: {a blood pressure of 85/50 mm Hg, his length was _2 Y' M1 j$ l, _. r" ~. l
90 cm (>97th percentile), and his weight was 14.4 kg
7 T T- n v1 F8 b) e3 p9 F' }: u" A(also >97th percentile). The observed yearly growth
$ h6 I( B! k. Z- g2 m: W' ^' Uvelocity was 30 cm (12 inches). The examination of9 w* H$ U+ v4 c6 u* j
the neck revealed no thyroid enlargement.
. C$ Q6 N$ f7 d/ j9 i, QThe genitourinary examination was remarkable for2 t% @8 w& F! Q3 [: Y1 P
enlargement of the penis, with a stretched length of! M/ d( e# p$ j4 l* l2 {
8 cm and a width of 2 cm. The glans penis was very well
9 G/ S" T# U1 s, u& b& p! sdeveloped. The pubic hair was Tanner II, mostly around
X! o; p- r. a' e5 U& ~2 a5409 W4 Q3 S- \1 X* q3 M5 ^4 t+ t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ N/ A5 Y6 K% v$ T" r& I# Dthe base of the phallus and was dark and curled. The
9 M. B, V( f1 D( itesticular volume was prepubertal at 2 mL each.
% ]; q7 A- F5 U# p2 O9 ~The skin was moist and smooth and somewhat2 v' s( q5 G/ h: b8 C1 Y- F
oily. No axillary hair was noted. There were no) w, P; D& Y9 ^+ o' D5 N" n( F+ U
abnormal skin pigmentations or café-au-lait spots.
$ {7 g6 p y4 T- pNeurologic evaluation showed deep tendon reflex 2+
% T, P) i1 H) C6 p, k5 K, `- {bilateral and symmetrical. There was no suggestion
L! z. H8 c0 N: U7 X: lof papilledema.
# Q: K' w1 t- B" H$ i9 YLaboratory Evaluation* u: O+ {1 ?/ t3 |: g& A8 S D
The bone age was consistent with 28 months by
. v) Q' i3 F1 S2 U8 [1 Cusing the standard of Greulich and Pyle at a chrono-6 {4 w: P E/ Z9 k
logic age of 16 months (advanced).5 Chromosomal
! }6 _( \3 i% {$ }* L' |$ ]karyotype was 46XY. The thyroid function test
, R$ W3 {1 ~- U& N+ w% pshowed a free T4 of 1.69 ng/dL, and thyroid stimu-: y6 A% k" y0 L4 A4 w6 B
lating hormone level was 1.3 µIU/mL (both normal).8 A, o" j1 ?/ ?8 T D. e0 k
The concentrations of serum electrolytes, blood
( T _% U/ L, l4 W& v% u/ z- Uurea nitrogen, creatinine, and calcium all were
$ F3 e8 l/ y! d4 Mwithin normal range for his age. The concentration! L3 O5 d8 Y9 d$ A/ Y! Y7 l
of serum 17-hydroxyprogesterone was 16 ng/dL+ z' M' q, E/ u
(normal, 3 to 90 ng/dL), androstenedione was 20/ u! ]5 v" t5 M% V/ v$ N
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% z8 _7 v3 `/ I' @' M _terone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 y( \7 W! Y; Y6 `desoxycorticosterone was 4.3 ng/dL (normal, 7 to
' }$ |+ M5 {% N49ng/dL), 11-desoxycortisol (specific compound S)+ U, I3 p9 X* a w0 c9 o0 g
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
- J2 k0 n: s) ~tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' X; I( e2 W6 X4 l3 L
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),) a5 D% `& P5 n& S7 o8 J1 G5 |
and β-human chorionic gonadotropin was less than
/ _% z% A- H9 T$ S2 x6 W5 mIU/mL (normal <5 mIU/mL). Serum follicular, `! Y1 j, ~" z, K
stimulating hormone and leuteinizing hormone
5 n4 `: q2 g- ?5 i0 M6 w3 [4 z% [concentrations were less than 0.05 mIU/mL( T. @# y; x" [
(prepubertal).
. C: A2 s" U+ ]2 x8 w) ^3 j- PThe parents were notified about the laboratory
- [1 o/ J( s! h. Y7 U; P+ |results and were informed that all of the tests were, w b8 v; V5 b* n+ ?" F; I
normal except the testosterone level was high. The" z7 ^2 j; D0 N5 f; {
follow-up visit was arranged within a few weeks to: L i( [ b1 A& p x
obtain testicular and abdominal sonograms; how-
3 ?& G3 Y6 L3 J2 D8 Y9 kever, the family did not return for 4 months.
( ~1 @* c8 t1 TPhysical examination at this time revealed that the
3 y$ b8 f) x8 A+ Fchild had grown 2.5 cm in 4 months and had gained
( F& h4 o; f2 y/ S m; w( l0 E) K2 kg of weight. Physical examination remained
# s/ _9 C2 k# C5 k+ uunchanged. Surprisingly, the pubic hair almost com-- K. M q, X. _7 f5 b. G
pletely disappeared except for a few vellous hairs at
) {0 u, U7 x0 S# }, dthe base of the phallus. Testicular volume was still 2; a; a0 K) g$ K: c
mL, and the size of the penis remained unchanged.
$ ~6 Y2 `4 I9 j3 d# h6 xThe mother also said that the boy was no longer hav-
& g( A$ F I7 `ing frequent erections.9 Q! z8 K# @4 ]. L8 }; ?
Both parents were again questioned about use of6 n1 S$ h: L$ ~
any ointment/creams that they may have applied to# B) ~5 s V G( }0 r4 w0 q
the child’s skin. This time the father admitted the
0 _% ~( P( \# qTopical Testosterone Exposure / Bhowmick et al 541$ R$ L4 k$ u, S0 m. W u9 d
use of testosterone gel twice daily that he was apply-) W% D w% j" H! G6 j
ing over his own shoulders, chest, and back area for
- I# f7 @% f2 F/ l2 wa year. The father also revealed he was embarrassed
# f4 `$ G' P( T& `to disclose that he was using a testosterone gel pre-$ T/ V. }( f7 |7 u
scribed by his family physician for decreased libido
6 G% c2 J4 U7 P# v$ msecondary to depression.
& S9 M" ^0 I! O# H. A& @, SThe child slept in the same bed with parents.3 t0 W+ P( W+ o
The father would hug the baby and hold him on his
2 V/ b& U" _6 R7 l8 ^* |! Uchest for a considerable period of time, causing sig-
8 @. U$ n: T2 P# q+ l1 k; inificant bare skin contact between baby and father./ I* ^/ ]. X7 E# h
The father also admitted that after the phone call,
0 c& T' k. @ L1 P( v! J4 T( V, mwhen he learned the testosterone level in the baby, t: P& K! X9 z: ?0 x7 ]
was high, he then read the product information
# u/ [1 h; y9 Cpacket and concluded that it was most likely the rea-! w2 Q. X: F5 W) |( K
son for the child’s virilization. At that time, they
5 m9 w! [, J" ]7 t9 ~decided to put the baby in a separate bed, and the6 q8 j' \9 ?7 W: M
father was not hugging him with bare skin and had
% J* D* g1 B9 R. w1 ^( ^* dbeen using protective clothing. A repeat testosterone2 c4 g' L4 o! i5 F+ s' D1 @
test was ordered, but the family did not go to the% L# E+ T0 m7 s! X+ X( H8 r1 \
laboratory to obtain the test.
8 p1 E) n R& C5 @& p* w5 d* i4 nDiscussion4 W2 \$ u; ?. X" t1 A
Precocious puberty in boys is defined as secondary
9 R* l: m$ ?; Ysexual development before 9 years of age.1,4
# k% @9 t* s3 N* h* \Precocious puberty is termed as central (true) when
1 O. h1 p. H- P. Y, G2 {; Q0 e* Cit is caused by the premature activation of hypo-& Z5 I6 N+ m6 H
thalamic pituitary gonadal axis. CPP is more com-
3 v3 u2 l. K3 L5 s6 p# E4 X4 a; b9 {mon in girls than in boys.1,3 Most boys with CPP
/ Y {4 Y2 c$ I5 [7 n: A2 lmay have a central nervous system lesion that is
. r) {1 n; H( u: y+ Xresponsible for the early activation of the hypothal-
9 J# v7 C0 `% r* ` gamic pituitary gonadal axis.1-3 Thus, greater empha-
7 Z$ f' i- [% Y Osis has been given to neuroradiologic imaging in, A% L& O6 X+ h" b% b
boys with precocious puberty. In addition to viril-$ e. R3 {6 J+ W) h* ^( k
ization, the clinical hallmark of CPP is the symmet-
4 O, H3 {0 A$ P6 srical testicular growth secondary to stimulation by
, w$ x: X0 J- N/ ggonadotropins.1,37 i+ e6 p+ V* p; M) ^
Gonadotropin-independent peripheral preco-
- u* J T$ [8 H: @$ C6 y" Xcious puberty in boys also results from inappropriate+ Q! S) e$ E1 ^' _4 n. Y
androgenic stimulation from either endogenous or
& J ?8 t( T" |. _' Y- x3 D+ Cexogenous sources, nonpituitary gonadotropin stim-
$ n& ^9 H- G% P0 Xulation, and rare activating mutations.3 Virilizing
+ [% A' J' t" F3 r& X. bcongenital adrenal hyperplasia producing excessive
9 Q8 Q: \1 C- |1 [' y- q( [adrenal androgens is a common cause of precocious
; B& }7 [: Z0 ?4 j3 s' w+ L1 }2 cpuberty in boys.3,4! ]' ^% U& \* o9 _0 ~4 g- n: x
The most common form of congenital adrenal
# Y2 U( E) j( P2 N3 W$ shyperplasia is the 21-hydroxylase enzyme deficiency.
/ N6 @% C3 H5 b2 ~% xThe 11-β hydroxylase deficiency may also result in. J0 D( k# D Y0 R
excessive adrenal androgen production, and rarely,8 ?, Z, B. l. g: r: s: ?
an adrenal tumor may also cause adrenal androgen
' h: P) D; ~" r* Qexcess.1,3
' T4 `& ?, ?9 o% ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 F& U+ {% L4 q* N- k1 ~1 C
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
p/ _+ W# o! C* IA unique entity of male-limited gonadotropin-
6 f5 x' z. C/ P' x2 {; d' V" Jindependent precocious puberty, which is also known h' l% _) Q# w# e
as testotoxicosis, may cause precocious puberty at a
% E9 ^7 `; l" y2 pvery young age. The physical findings in these boys8 a2 V% v8 c4 u# |: J
with this disorder are full pubertal development,
; @, p. d% X* ?4 K f3 q& wincluding bilateral testicular growth, similar to boys
/ Q& q( q1 U; v @$ D: H) p0 Dwith CPP. The gonadotropin levels in this disorder
) d: b" H) C7 i' O1 V( B* s. yare suppressed to prepubertal levels and do not show
0 x7 }+ j, V* y9 }9 V1 k; fpubertal response of gonadotropin after gonadotropin-
; [6 N# N$ |$ k9 zreleasing hormone stimulation. This is a sex-linked
2 W7 w$ g/ M) ^3 wautosomal dominant disorder that affects only. e6 P% l" C9 [
males; therefore, other male members of the family0 D' q& i, a2 R; k& k f; i2 v/ X& ?5 O
may have similar precocious puberty.3
2 ]+ M" d# u$ _6 `( vIn our patient, physical examination was incon-# \5 Q: G" j2 B) h( n" @8 I" {% J
sistent with true precocious puberty since his testi-
# |, k E: K6 Zcles were prepubertal in size. However, testotoxicosis$ Z J: c) Z' L( e# p
was in the differential diagnosis because his father% h4 U2 V0 |5 }. X: r/ u$ ~# K
started puberty somewhat early, and occasionally,
) T. q4 A/ k, v' a8 [0 ctesticular enlargement is not that evident in the0 G5 F& T. {. }
beginning of this process.1 In the absence of a neg-; v, N7 T" i8 l+ X# m" i: g; l X
ative initial history of androgen exposure, our
$ u% [8 v4 \$ M6 S) I2 bbiggest concern was virilizing adrenal hyperplasia,
* T) i- t( m! F0 w" L/ reither 21-hydroxylase deficiency or 11-β hydroxylase9 n D; V! l3 g6 O" V% m
deficiency. Those diagnoses were excluded by find-, {! r7 i/ j' {& g0 a) K
ing the normal level of adrenal steroids.
+ _# i2 q' g% I% }( R% ?The diagnosis of exogenous androgens was strongly8 _) X7 [5 E4 U) Z4 z7 G
suspected in a follow-up visit after 4 months because4 E: p& N2 u5 L6 o
the physical examination revealed the complete disap-
/ e& x7 y6 l) G i6 gpearance of pubic hair, normal growth velocity, and3 `( h. j$ s, {3 K) y
decreased erections. The father admitted using a testos-: [, [# A+ F! [$ B6 A' N. [+ F
terone gel, which he concealed at first visit. He was
' E0 R0 j- Q2 k7 o. M1 K9 t# o" ~using it rather frequently, twice a day. The Physicians’7 J+ Q1 y) h- Q* J7 s
Desk Reference, or package insert of this product, gel or. @8 Z, f7 Q i3 T9 f! c
cream, cautions about dermal testosterone transfer to% c6 @* o$ E6 ]
unprotected females through direct skin exposure.
, {0 f! W1 R0 U) N, C- PSerum testosterone level was found to be 2 times the
% K7 E: M& ~$ w8 x/ hbaseline value in those females who were exposed to
3 l& s" z# V5 h! O0 Eeven 15 minutes of direct skin contact with their male( k0 I$ _3 b$ e' f
partners.6 However, when a shirt covered the applica-
, F" ~+ N: k# Q$ U1 E( A O1 otion site, this testosterone transfer was prevented.
! M5 X; ?8 j9 V$ r2 MOur patient’s testosterone level was 60 ng/mL,
( u/ j) | `) `3 |$ A; \which was clearly high. Some studies suggest that% _+ H, z' Z+ ]' \6 _5 V
dermal conversion of testosterone to dihydrotestos-; a% n* ?8 ~* b+ O5 [$ r6 `
terone, which is a more potent metabolite, is more
/ {- i8 G3 m v6 eactive in young children exposed to testosterone3 b% K' D5 ?" U6 z6 M
exogenously7; however, we did not measure a dihy-& k( c( p3 B# t$ @2 U
drotestosterone level in our patient. In addition to
9 u# a1 u% {8 p( o: Pvirilization, exposure to exogenous testosterone in
/ Q" i8 ?# U5 m. |" jchildren results in an increase in growth velocity and" w$ Q2 c: j- p/ i3 x# y$ H+ |/ A
advanced bone age, as seen in our patient.
7 o; G6 I0 f( E( A# xThe long-term effect of androgen exposure during
: `* W- V7 b1 q3 I% u7 u( ]early childhood on pubertal development and final
! s; u3 E. N' |+ L" ?8 Zadult height are not fully known and always remain
. o4 H. q6 z* b) m+ g' la concern. Children treated with short-term testos-
) z* q% b e" t1 K6 {/ Tterone injection or topical androgen may exhibit some+ ?) m6 |0 w& O1 {0 j2 _7 ` o
acceleration of the skeletal maturation; however, after
L. @/ F5 X9 C: `; L8 h5 F* mcessation of treatment, the rate of bone maturation
' C6 |. D% t2 \6 M. udecelerates and gradually returns to normal.8,9; a' b+ b% a! ]" v6 f# I( Z% |
There are conflicting reports and controversy
: {; t# V2 k9 }- E+ N/ z( jover the effect of early androgen exposure on adult2 a% H- t# v, E( |7 ?+ Y% d, J
penile length.10,11 Some reports suggest subnormal1 ?: [5 U, v$ S
adult penile length, apparently because of downreg-: r, @4 Z b) I1 R# g6 e# x( u
ulation of androgen receptor number.10,12 However,
$ `0 e8 t" t3 Q: X6 L z3 kSutherland et al13 did not find a correlation between5 Z7 }- G# x. ?
childhood testosterone exposure and reduced adult
7 i& g# j# f6 W" r3 q2 l9 Ypenile length in clinical studies.
1 e7 |; } | u: T# }0 D' gNonetheless, we do not believe our patient is
" V; E- n, ]1 }3 P) ^8 w agoing to experience any of the untoward effects from$ J' u9 J/ }: c' b/ ^+ E4 [
testosterone exposure as mentioned earlier because- U9 G8 p& `9 F) J& b+ t& G% J: n
the exposure was not for a prolonged period of time.
1 e& o1 S9 q! A/ h+ QAlthough the bone age was advanced at the time of
* k" [% ?. a, ^$ j; \0 V; Xdiagnosis, the child had a normal growth velocity at [4 {' G; i. t7 D9 {7 c( n
the follow-up visit. It is hoped that his final adult
4 O9 R* O; Q1 Jheight will not be affected.# Q8 f4 B4 L5 ?9 V# m" M r7 J# u
Although rarely reported, the widespread avail-
6 U/ |. ?( a$ H" ~ability of androgen products in our society may9 d5 r( [4 o( \; r2 m B
indeed cause more virilization in male or female
" N2 X+ ?5 y$ `7 ^children than one would realize. Exposure to andro-5 j6 [" _8 V( g# U+ m* E0 P
gen products must be considered and specific ques-
* }9 Z4 D" `& d3 Z; p- gtioning about the use of a testosterone product or& ^5 {0 t) A6 @) K1 p& O2 f! K& ?
gel should be asked of the family members during! l0 k1 x5 _# p! O4 F3 e
the evaluation of any children who present with vir-
7 C. v% {, M6 ?9 A. t; t4 K" W0 @ilization or peripheral precocious puberty. The diag-; U5 P' I- @( {, ~( [
nosis can be established by just a few tests and by
1 K5 I% R$ `7 f/ O* uappropriate history. The inability to obtain such a
6 g6 r9 K" b' }% Dhistory, or failure to ask the specific questions, may
- U9 E0 h8 e6 u" w$ Gresult in extensive, unnecessary, and expensive
* R( {3 j5 \ O9 i* b5 vinvestigation. The primary care physician should be0 z: d4 O' b' e, \ ]! S/ ~* \
aware of this fact, because most of these children
& ]$ D. F) c# K J! x# i1 e4 Imay initially present in their practice. The Physicians’
6 M4 p9 n4 V# j* k( ?; J) `Desk Reference and package insert should also put a: G! H3 g# s/ s3 \, p$ V' b4 I9 ~
warning about the virilizing effect on a male or
( ^- u9 B3 C7 i* B8 Tfemale child who might come in contact with some-6 c5 [4 a3 R7 ^7 ^
one using any of these products.& n3 v/ ~) f& m$ s
References& T2 _" l6 e% ~# F
1. Styne DM. The testes: disorder of sexual differentiation$ D! U# |% y' p- H* b
and puberty in the male. In: Sperling MA, ed. Pediatric0 M b! E" w2 u7 s
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;; G" R6 D' v8 U, h4 O
2002: 565-628.$ K# Q' W4 E, T! R3 r+ n" `* D
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious8 ?: y* M( y: @$ Q8 x. J
puberty in children with tumours of the suprasellar pineal |
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