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Sexual Precocity in a 16-Month-Old' K& q: Y7 B% \6 S
Boy Induced by Indirect Topical' A* Y+ G& p, h' l' J
Exposure to Testosterone
: ~) b3 F E5 v/ LSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* x- `+ S C+ D2 R: }7 y. f/ m
and Kenneth R. Rettig, MD1) _& e9 @( B9 L
Clinical Pediatrics
6 h2 U5 o' f4 N& N5 ^& r) z& BVolume 46 Number 6
q J) M9 C2 I, [' R8 V. H' JJuly 2007 540-543; [% {' O% \4 r, ?' {# |
© 2007 Sage Publications
2 E0 |4 I* _- N) j H/ `10.1177/0009922806296651- i2 e% c* P/ u2 r/ D% o8 d( j# S3 B
http://clp.sagepub.com
* {; u( V5 T; Ehosted at
7 p8 m1 X" S! B# t) h& ^http://online.sagepub.com
% i7 f6 c/ k: O- [3 x6 {5 _Precocious puberty in boys, central or peripheral,
* p. ?9 p! Z. a5 }is a significant concern for physicians. Central
$ W9 E& o8 X5 \ {" x/ o, Q# z8 {precocious puberty (CPP), which is mediated
' m5 Y0 D: i* \6 p& u, s( `through the hypothalamic pituitary gonadal axis, has
/ U% S* Y1 y+ |- S$ ^a higher incidence of organic central nervous system
' c& B( l& H9 H$ Z& h, wlesions in boys.1,2 Virilization in boys, as manifested
! t( {3 o/ @4 m4 e4 {9 |by enlargement of the penis, development of pubic
% t5 `5 a4 Z2 v+ h4 r) Ihair, and facial acne without enlargement of testi-
# \) ^' [, q. M" [) vcles, suggests peripheral or pseudopuberty.1-3 We
1 i0 B( K/ P- \( sreport a 16-month-old boy who presented with the1 l& h8 R" t( x8 c
enlargement of the phallus and pubic hair develop-" c+ e! J" f( u5 Y) O" N7 u6 N
ment without testicular enlargement, which was due- h! g* j1 R" t
to the unintentional exposure to androgen gel used by
, j) I2 j2 r; {9 {the father. The family initially concealed this infor-
' f& h$ d' Y' V. k$ |# {; Zmation, resulting in an extensive work-up for this
/ q: D7 x) w1 fchild. Given the widespread and easy availability of, t+ n8 W4 X* A9 {$ B
testosterone gel and cream, we believe this is proba-* ^4 |8 n% k) }: G/ ~+ I
bly more common than the rare case report in the
( I8 t0 \4 H5 F- Y2 ^literature.4
, `# D/ n& W7 L' U9 c6 Y) N6 rPatient Report, s# N6 }- `+ Y. t# Z: v& V( M
A 16-month-old white child was referred to the
) r' I9 \2 c) y& `endocrine clinic by his pediatrician with the concern
$ v' W2 z& J7 ^$ F3 B/ {+ q& Yof early sexual development. His mother noticed
) b1 _+ I. h' b6 clight colored pubic hair development when he was7 O" B* W0 D: O3 u* [* Z3 m
From the 1Division of Pediatric Endocrinology, 2University of: W9 S7 N" n0 x3 } C+ f# n, [
South Alabama Medical Center, Mobile, Alabama.& Z" K5 q- _ x3 s0 y: E
Address correspondence to: Samar K. Bhowmick, MD, FACE,, b, ~. A" q8 B- V4 P& q( @# K: ]
Professor of Pediatrics, University of South Alabama, College of
& y) F" ~( o4 @6 z: w' aMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 e F( `; N( S6 W! m* m) }$ b1 C: Be-mail: [email protected].3 @/ }& h$ V3 Z9 b, y0 [! g
about 6 to 7 months old, which progressively became
' U) v+ s* m7 H) S, ^! g2 Adarker. She was also concerned about the enlarge-9 i& G2 j* R& R. _ [9 { W
ment of his penis and frequent erections. The child
% e7 h6 P& A) {" K4 T. F5 `' {was the product of a full-term normal delivery, with( C+ ?) M/ X) H& _* x% f
a birth weight of 7 lb 14 oz, and birth length of2 b! _8 i5 z- W+ C& C' L
20 inches. He was breast-fed throughout the first year
% ?( w9 h4 S) v/ n6 bof life and was still receiving breast milk along with2 ]$ k8 A' V/ F" r! j8 ^
solid food. He had no hospitalizations or surgery,* h/ ?3 i6 v1 Z/ N2 l
and his psychosocial and psychomotor development
' T2 r3 x m& E% c& G9 Swas age appropriate.
2 b5 p! ]' ~# r9 g5 \( {The family history was remarkable for the father,4 b, t6 s( @9 D, |- Z
who was diagnosed with hypothyroidism at age 16,7 j6 f+ {9 d$ u7 }1 m9 {: ?9 _
which was treated with thyroxine. The father’s+ Y- }- J: S; g3 I, m( t+ o
height was 6 feet, and he went through a somewhat; }, A# E% ~5 J7 C( }0 _! g6 I5 H
early puberty and had stopped growing by age 14.
w4 y7 |; K! K: p5 v; n! Q$ o9 PThe father denied taking any other medication. The
2 J9 b. l2 K, t* H2 V9 v' dchild’s mother was in good health. Her menarche
0 R1 _0 H; N: T) P: _was at 11 years of age, and her height was at 5 feet
H! o1 F9 B; k1 f3 S# B5 inches. There was no other family history of pre-4 z9 z# J' {( k' x. e; B$ Q
cocious sexual development in the first-degree rela-
0 V* p; }, ]3 n) ]tives. There were no siblings.
! g* X# y1 q: A+ [7 fPhysical Examination- b, I, M+ {0 C
The physical examination revealed a very active,
' C8 ?/ x) Z+ {" ]. K0 Pplayful, and healthy boy. The vital signs documented
9 n+ f7 x/ G; \& y$ J9 K ya blood pressure of 85/50 mm Hg, his length was R7 {& C. }7 h# Y# r4 m
90 cm (>97th percentile), and his weight was 14.4 kg
" p3 n3 z( F; K2 c& P G(also >97th percentile). The observed yearly growth
4 X R+ u2 H% Avelocity was 30 cm (12 inches). The examination of) j' K/ o4 @1 h5 {' C. [" I
the neck revealed no thyroid enlargement.6 D; o/ u" E N( X& e
The genitourinary examination was remarkable for2 Y! |& ~3 Y6 h9 M; |& k, X" v
enlargement of the penis, with a stretched length of
: k v, G: G- p& ]$ ^( ?4 B- X8 cm and a width of 2 cm. The glans penis was very well
0 _" r) P% K6 J# C4 ?" I: vdeveloped. The pubic hair was Tanner II, mostly around
* c* ]* j; y- g0 A. g! `540' X; N& F7 |- F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from7 y) i" W3 Z! F
the base of the phallus and was dark and curled. The
! m7 a6 Q2 C1 stesticular volume was prepubertal at 2 mL each.9 ]$ J0 H, S9 `/ ~5 }
The skin was moist and smooth and somewhat
) A) J, L3 T- ?) f5 poily. No axillary hair was noted. There were no( F4 u# [; o, Q% c" f0 v
abnormal skin pigmentations or café-au-lait spots.
& I8 W3 Y2 D! sNeurologic evaluation showed deep tendon reflex 2+9 | |( @3 [) ?# L
bilateral and symmetrical. There was no suggestion6 H# `4 Z* \% J+ t4 r
of papilledema.8 G) Q7 H: g' t( I
Laboratory Evaluation0 i0 e7 w8 U) A- K
The bone age was consistent with 28 months by0 U5 z5 j# s8 J; d! { q1 A2 l
using the standard of Greulich and Pyle at a chrono-
! n1 K, L. T: ^+ T1 Tlogic age of 16 months (advanced).5 Chromosomal
& O" Q9 D/ m5 tkaryotype was 46XY. The thyroid function test/ k8 \: [2 f' [' r; b1 W/ L
showed a free T4 of 1.69 ng/dL, and thyroid stimu-8 i8 u4 S4 _# C$ g5 C
lating hormone level was 1.3 µIU/mL (both normal).
# ?! a! B& m" R$ tThe concentrations of serum electrolytes, blood
) F5 b8 T" m; xurea nitrogen, creatinine, and calcium all were
0 z8 u5 w$ h" H1 Awithin normal range for his age. The concentration1 o0 ^; o8 _! _1 L- y; g* {
of serum 17-hydroxyprogesterone was 16 ng/dL; G5 ?* A2 Q4 u9 T
(normal, 3 to 90 ng/dL), androstenedione was 20/ C" I" G/ T3 ?9 O( F8 X! J
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-( J# }4 l. u M* n6 S0 y& F! D
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
( M; R: K! a& v7 C; kdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 e7 t s6 ~; I, S( v49ng/dL), 11-desoxycortisol (specific compound S)( a& x' B1 }4 [
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: {5 u! s& b: B" Y4 q: K7 P- N
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total9 h/ p- O8 @$ W
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) J- Q5 i2 j' V. V. {and β-human chorionic gonadotropin was less than9 c% j8 a- I5 B M
5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 F5 r, W: L u' v4 wstimulating hormone and leuteinizing hormone: k' j/ T' T$ W* R5 H
concentrations were less than 0.05 mIU/mL' c9 C3 E# F# Z7 N1 h |+ z
(prepubertal).. w% E! x7 C `8 x. ^
The parents were notified about the laboratory
1 F+ ~- a' @& M* W9 kresults and were informed that all of the tests were* K2 V. R' W! K; x+ M/ T" G; h* b; ~
normal except the testosterone level was high. The$ g2 M; O, h( T& c! Q, @
follow-up visit was arranged within a few weeks to' M* B3 c( L3 F" ]
obtain testicular and abdominal sonograms; how-4 V# a( y& h) U" ^, U* q6 }+ U( C
ever, the family did not return for 4 months.
" W6 ?, e' q3 @3 e* L- uPhysical examination at this time revealed that the
! R) m t# u4 L9 \$ R4 G7 a' {: mchild had grown 2.5 cm in 4 months and had gained
( p0 }- j+ X# t0 [8 S2 kg of weight. Physical examination remained0 k |1 i" E5 T8 T, t
unchanged. Surprisingly, the pubic hair almost com-
5 ]0 n3 [0 X/ s7 {- v9 S/ wpletely disappeared except for a few vellous hairs at' S: @! I7 K1 J: {- D
the base of the phallus. Testicular volume was still 2
# ~% t: q; e( OmL, and the size of the penis remained unchanged.
( e$ z8 S6 t8 R; F4 `5 w+ TThe mother also said that the boy was no longer hav-7 U1 ]% {7 t0 }" N5 C
ing frequent erections.
0 h4 N% \8 t. M! zBoth parents were again questioned about use of
9 \ @% n/ B7 c& Sany ointment/creams that they may have applied to/ ]- Z% E, F: K' l
the child’s skin. This time the father admitted the
1 N6 C& X `6 z+ aTopical Testosterone Exposure / Bhowmick et al 541
8 {, ?8 O, e/ Y# u! B+ l' Guse of testosterone gel twice daily that he was apply-$ a; J" K+ \: m, s% A6 l5 s
ing over his own shoulders, chest, and back area for
' }$ i6 g" i( t. ]5 I# H5 c3 `a year. The father also revealed he was embarrassed( M, i% n N* N2 ]( h8 p& S
to disclose that he was using a testosterone gel pre-
0 b( _7 B: M' X( J# t2 n% Yscribed by his family physician for decreased libido
' ?& H. ~! ? _5 A( Zsecondary to depression.& y$ {' @5 Y8 ^. P
The child slept in the same bed with parents., u, ^) o7 q- M: t" Y* }9 J
The father would hug the baby and hold him on his
1 R" w6 S/ [2 c7 ~& B* m; s) z8 Kchest for a considerable period of time, causing sig-
& H$ i9 `3 e. E9 o6 bnificant bare skin contact between baby and father.
6 U; O$ e2 S# T8 ]# C; p! Y& A- JThe father also admitted that after the phone call,
& y" e: u% y b2 J) dwhen he learned the testosterone level in the baby3 R% h" ?* ^8 A5 ]& S% O
was high, he then read the product information/ X* }8 p! F$ R1 k, m1 M
packet and concluded that it was most likely the rea-
1 h1 Z( z. y# M& _% [' H" Ason for the child’s virilization. At that time, they. u! h" ~1 Y; O \& {( l3 j0 o
decided to put the baby in a separate bed, and the+ n5 i; E- ^1 c* Y
father was not hugging him with bare skin and had
; ~+ t; z$ G0 D0 ^/ K& nbeen using protective clothing. A repeat testosterone+ B# v. H% C9 a2 W/ `
test was ordered, but the family did not go to the/ s' ?8 {4 w* i0 L4 Q. t
laboratory to obtain the test.
, B. r, k& O# ~) @3 x+ pDiscussion
. j" J! W2 |( z- q% L7 b& j$ NPrecocious puberty in boys is defined as secondary
; ~, G- p! I8 p9 P0 G) l0 xsexual development before 9 years of age.1,4
) ?) R* M ^0 W5 g+ iPrecocious puberty is termed as central (true) when
~, f/ s% M+ hit is caused by the premature activation of hypo-
. `/ K" ^1 [/ I6 q8 Zthalamic pituitary gonadal axis. CPP is more com-
# s8 I+ Y; V' B! | Zmon in girls than in boys.1,3 Most boys with CPP' ^& S8 m d& i- s
may have a central nervous system lesion that is9 w/ D5 G. C/ U" u7 K+ ^
responsible for the early activation of the hypothal-
* `7 Q- }/ O& y8 l3 Q" Samic pituitary gonadal axis.1-3 Thus, greater empha-) P5 f/ i% R7 R# f) i8 @4 a+ U1 c
sis has been given to neuroradiologic imaging in' f- u* Y! Q Y& }6 u, W
boys with precocious puberty. In addition to viril-( i9 Z0 S! |$ ?' S8 q
ization, the clinical hallmark of CPP is the symmet-
& q( }* |! g1 @rical testicular growth secondary to stimulation by1 Z8 R. ^( p2 ]% C9 ^% c1 M
gonadotropins.1,3; \, }% E3 R- P6 l, [; @ K
Gonadotropin-independent peripheral preco-9 X0 g' ]& \. Y
cious puberty in boys also results from inappropriate M, R6 Z" N( w. A; U. W( m
androgenic stimulation from either endogenous or( Q, l& M+ @0 g7 Y* l6 q" \
exogenous sources, nonpituitary gonadotropin stim-3 T0 m n, y! H$ P$ m6 E
ulation, and rare activating mutations.3 Virilizing
2 Y7 N1 ], n1 T" u# Ucongenital adrenal hyperplasia producing excessive
8 y; ^, H0 `# W& Z% radrenal androgens is a common cause of precocious- ^8 C, f6 h* I k& p' O
puberty in boys.3,4
7 \$ Q. {6 J( C/ Z. p: jThe most common form of congenital adrenal* s' |$ p4 g7 F* {9 M
hyperplasia is the 21-hydroxylase enzyme deficiency.
5 `% T4 i. a# w4 F0 a0 {3 FThe 11-β hydroxylase deficiency may also result in+ V E4 E; U1 v
excessive adrenal androgen production, and rarely,; A" D4 _7 a6 W& m- d
an adrenal tumor may also cause adrenal androgen1 w; U }7 ^6 b* S
excess.1,37 ]. T" {. h# M, f/ v" u \& X$ X ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! U. \. {* V" Z* ]2 w1 g2 R& H5 O542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
8 H" z/ G6 K# j2 g/ V2 j) i5 a* [A unique entity of male-limited gonadotropin-3 [1 Q9 F2 Y$ O8 f3 [! f6 o
independent precocious puberty, which is also known
- }$ E t1 s5 n9 zas testotoxicosis, may cause precocious puberty at a, Q- s/ \/ X' S: T5 u% k0 ?
very young age. The physical findings in these boys) H: ~# A, R$ r; a$ k5 C! m
with this disorder are full pubertal development,9 @, n1 }7 t( U! J- N
including bilateral testicular growth, similar to boys
/ H. G; X' ~- swith CPP. The gonadotropin levels in this disorder" e0 O) _3 d- ?) k6 H$ S: M
are suppressed to prepubertal levels and do not show# @3 \. Z* u4 \# R) O) W
pubertal response of gonadotropin after gonadotropin-
. f, c. r2 g! d% e7 |8 U' K' \releasing hormone stimulation. This is a sex-linked0 @; {4 t, Y+ ~' i+ G; d7 y" F% n
autosomal dominant disorder that affects only3 Y& p7 O$ ]3 x- `4 n8 P7 k
males; therefore, other male members of the family" L G0 Z* ]& }8 i+ N( | d& R
may have similar precocious puberty.32 L( h3 w/ G" [8 |
In our patient, physical examination was incon-3 E. W5 b6 [8 k# `4 g& T0 c6 V+ F
sistent with true precocious puberty since his testi-
5 d9 q/ X8 W" R3 S% Z- R4 ccles were prepubertal in size. However, testotoxicosis' B* q9 k8 O, |$ Y' _
was in the differential diagnosis because his father
4 [4 }2 h7 V, Y- e2 Zstarted puberty somewhat early, and occasionally,
4 @* Y8 }, e( G. E& O3 Z1 D, S' dtesticular enlargement is not that evident in the2 S. a- }8 T$ Y* L3 {. u
beginning of this process.1 In the absence of a neg-* m( E( k! l" ]0 C @4 c2 m4 d
ative initial history of androgen exposure, our
( a$ d4 O. o f! o2 B2 Tbiggest concern was virilizing adrenal hyperplasia,0 F7 w7 s$ F) t2 K9 R! U$ G3 X
either 21-hydroxylase deficiency or 11-β hydroxylase; I3 }" {( a* u4 D/ }4 t
deficiency. Those diagnoses were excluded by find-' R& d! z: G4 a
ing the normal level of adrenal steroids.7 q; Y G6 A5 O
The diagnosis of exogenous androgens was strongly- ?7 J9 B+ x, t- H8 T2 m# p
suspected in a follow-up visit after 4 months because
z0 @" M6 M% V2 ethe physical examination revealed the complete disap-
' O& D9 g- Q. H+ T' Jpearance of pubic hair, normal growth velocity, and
+ l5 M+ Z% _, }6 r F0 Xdecreased erections. The father admitted using a testos-5 i: @! T% g g0 v7 a$ W' l- n
terone gel, which he concealed at first visit. He was
; J6 r' I' K/ kusing it rather frequently, twice a day. The Physicians’; U0 [5 F' h( [! P+ c
Desk Reference, or package insert of this product, gel or# w. h6 v3 |/ O# j$ z
cream, cautions about dermal testosterone transfer to4 k2 }5 x$ z3 L7 L: ]
unprotected females through direct skin exposure.
( S# L4 s" t6 T& o1 u& mSerum testosterone level was found to be 2 times the% b% W% i! K# J# S. d; G
baseline value in those females who were exposed to$ U9 ]# G' M% y1 l- c9 }: S, r
even 15 minutes of direct skin contact with their male' k2 c) H9 [- d; [) p) S0 r
partners.6 However, when a shirt covered the applica-% T* g$ w- H A5 l1 Z+ z9 S& _
tion site, this testosterone transfer was prevented.
1 K9 g1 n8 U, z5 |, P& n! x) JOur patient’s testosterone level was 60 ng/mL,
! k% W9 ^# d2 M$ |; W2 Owhich was clearly high. Some studies suggest that) b% H0 @1 M1 e. l
dermal conversion of testosterone to dihydrotestos-
6 o$ F* J p; Lterone, which is a more potent metabolite, is more6 j4 f) G9 K% t
active in young children exposed to testosterone
3 X5 C* n& z6 i$ D- B" u- e6 Vexogenously7; however, we did not measure a dihy-1 C# @2 ]3 P7 i: O
drotestosterone level in our patient. In addition to
' D% q7 _" L- |virilization, exposure to exogenous testosterone in
1 f$ d# d u9 O- S5 a4 b$ h2 `children results in an increase in growth velocity and, X" X- o" _ K% s- ]5 p
advanced bone age, as seen in our patient.
! S) U$ C/ J/ U) o" e& B8 f1 mThe long-term effect of androgen exposure during
/ E$ r0 p3 D2 v2 Mearly childhood on pubertal development and final
" L- F- A: P/ C% s6 [8 `: uadult height are not fully known and always remain; w5 u4 ?8 ^2 Q: x
a concern. Children treated with short-term testos-+ I1 H* R- ~8 z+ f3 Z/ V
terone injection or topical androgen may exhibit some* w _" H; a9 |+ h
acceleration of the skeletal maturation; however, after
4 h4 \8 c0 Y) H) \% p& s4 bcessation of treatment, the rate of bone maturation
6 y# m: K% r6 ]2 R' }5 `# u! \' j+ bdecelerates and gradually returns to normal.8,95 c, O [2 b! s& X
There are conflicting reports and controversy9 @$ p. _- J$ t+ k* p2 {; D' C
over the effect of early androgen exposure on adult
* V, d0 g. P- P3 K- }penile length.10,11 Some reports suggest subnormal
; _5 H1 N$ Y3 P3 B- H0 Nadult penile length, apparently because of downreg-
7 D. d) W) H* Z" E( w# V% Fulation of androgen receptor number.10,12 However,8 y$ \! F; T5 U1 c+ {) |/ }
Sutherland et al13 did not find a correlation between
8 F9 V! j1 v' R: n1 i1 N) D9 E- Gchildhood testosterone exposure and reduced adult
, B: K* d, J% F9 U/ H% r o* l, V |penile length in clinical studies.
# b$ N! v9 r' q7 u7 g5 u3 cNonetheless, we do not believe our patient is B# C3 H8 c3 b* w3 F0 y- G
going to experience any of the untoward effects from
5 H6 S% M. B2 Itestosterone exposure as mentioned earlier because2 @7 u& C( m# D: `/ Y# A
the exposure was not for a prolonged period of time.. Q8 ?+ e. c' f* E/ v
Although the bone age was advanced at the time of
# q0 W; O% D8 E0 }/ S- ]diagnosis, the child had a normal growth velocity at# R" p( Z) k9 H3 e& V1 i9 ~$ m
the follow-up visit. It is hoped that his final adult" x, _: ]+ o: g+ W, D9 \
height will not be affected.
- l* }( x; P" P$ bAlthough rarely reported, the widespread avail-
' N, x# {: _# X; mability of androgen products in our society may0 f" O+ l0 |% t# Q1 Y+ s% Q
indeed cause more virilization in male or female
( l3 g7 }$ o [+ f6 J- o9 U1 nchildren than one would realize. Exposure to andro-
6 \3 w. j3 v" `! ?0 ], pgen products must be considered and specific ques-' A5 h5 P3 B3 a/ B6 p3 O/ Y
tioning about the use of a testosterone product or
: ^6 n9 a* B, @8 I* `6 Ggel should be asked of the family members during
2 |: D1 d9 G4 q9 Ithe evaluation of any children who present with vir-
- a7 A: p N1 a: p, Yilization or peripheral precocious puberty. The diag-
) r9 t& b. g! @% z; q. t0 z# A8 jnosis can be established by just a few tests and by
H0 z6 R! C% U' j$ l0 Qappropriate history. The inability to obtain such a' K& v; B. R; O0 K* Q# J
history, or failure to ask the specific questions, may ^( |4 r) L" x
result in extensive, unnecessary, and expensive
9 \+ A/ h* L- jinvestigation. The primary care physician should be
8 X/ t+ C% [8 f6 Y3 o3 T2 X) _6 _/ K- qaware of this fact, because most of these children* i1 T6 }8 d/ V: c; O# o4 `6 U
may initially present in their practice. The Physicians’
. K$ @6 N6 g) T+ hDesk Reference and package insert should also put a/ C, Y. \) n! V. ~9 L% W7 I+ q
warning about the virilizing effect on a male or
% p' y* Y. I( o; I3 qfemale child who might come in contact with some-6 u4 x1 ^, }, \. }( N" n/ g6 C
one using any of these products.
4 f1 G2 B/ k bReferences
, i) _5 `7 u- g* O1. Styne DM. The testes: disorder of sexual differentiation3 w8 D( ? N! Y( n2 \( k
and puberty in the male. In: Sperling MA, ed. Pediatric
1 j+ G' m' m1 x3 u$ BEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
Q) Q j- q0 ?8 A7 `. D2002: 565-628.
' P. O# ^6 Q- m! I8 ?- M+ u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ {' P; x8 V. Y Z( Opuberty in children with tumours of the suprasellar pineal |
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