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Sexual Precocity in a 16-Month-Old
6 @& r* k2 y7 m% A, R& u* yBoy Induced by Indirect Topical1 {$ o* v1 c2 m2 r. j
Exposure to Testosterone: P+ g! R0 V. V7 M% O" b+ B: Q4 t
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2* ^$ r8 s/ F8 I0 m$ z$ d
and Kenneth R. Rettig, MD1- H" ~& [3 E& S5 Y8 F& w) y; c
Clinical Pediatrics- D/ U; p9 Q( n* k
Volume 46 Number 6' o9 `) L5 Q: w4 ?- y; k, I+ K: J
July 2007 540-543
* x) b5 C+ I2 b9 t© 2007 Sage Publications
9 l# Q3 g9 i5 ?, ?7 t10.1177/0009922806296651; b' H3 U& t) V; a: n) u
http://clp.sagepub.com
4 K) Q5 R, L$ p% _/ w' }hosted at
3 N1 ^& [$ y6 n! r1 [2 T7 }* w8 }8 nhttp://online.sagepub.com
+ o/ P" }# t% m1 M/ \7 \" }Precocious puberty in boys, central or peripheral,) `+ y4 j9 L& H4 G
is a significant concern for physicians. Central3 f+ C* I7 f/ G: d: F1 J
precocious puberty (CPP), which is mediated
d* `1 b5 j/ \$ ~" h' Fthrough the hypothalamic pituitary gonadal axis, has
s- R6 S* w- s% [" Ga higher incidence of organic central nervous system
/ v7 f& G" j2 n' Llesions in boys.1,2 Virilization in boys, as manifested
! s8 k$ v a& O4 C) Xby enlargement of the penis, development of pubic
' |8 X. y: _4 n+ {6 Rhair, and facial acne without enlargement of testi-
! h% k- ^9 ?- r9 Z0 K( @& M& |cles, suggests peripheral or pseudopuberty.1-3 We
" m! `( P3 Q* |9 ~! t7 kreport a 16-month-old boy who presented with the
- Z) S8 A4 B7 e" }5 c4 Zenlargement of the phallus and pubic hair develop-9 X% d! V( M; t: D
ment without testicular enlargement, which was due8 m% u4 ]+ }; I
to the unintentional exposure to androgen gel used by
( ]( I9 T' j7 F, i" Qthe father. The family initially concealed this infor-3 X. d$ a9 Y: C2 q- d/ J
mation, resulting in an extensive work-up for this
g- U- y9 L6 }0 k6 Hchild. Given the widespread and easy availability of- `# K5 Q1 _) ? H& ^
testosterone gel and cream, we believe this is proba-
+ }+ s$ J# @4 g# p3 t- h S) t: h+ Kbly more common than the rare case report in the
5 O' E/ |4 `% A, l# e$ Iliterature.4; F1 H- p/ e+ w, s( @7 B# Q# Z& g: t
Patient Report
6 c4 r* m3 i6 [" z' @A 16-month-old white child was referred to the2 u8 w4 F3 @4 K( R8 R
endocrine clinic by his pediatrician with the concern; Y* C: x2 B7 I$ w4 W- v
of early sexual development. His mother noticed5 Z# P* [ q" @2 r! c
light colored pubic hair development when he was
$ a9 v, @8 i4 a) g9 ~$ ?From the 1Division of Pediatric Endocrinology, 2University of
! M( _4 v) q4 I0 B$ @South Alabama Medical Center, Mobile, Alabama.
Y+ i, v2 ]5 ]0 Z. {- G& @3 |Address correspondence to: Samar K. Bhowmick, MD, FACE,
O+ P d- A3 E6 |Professor of Pediatrics, University of South Alabama, College of2 S" W% u" W6 c- F
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;6 D9 `' C9 K2 I/ S$ |
e-mail: [email protected]. Y( D) l! v0 Z) X1 S3 x0 a7 }( Z7 w
about 6 to 7 months old, which progressively became' B# K* x; m3 W6 e" e/ r
darker. She was also concerned about the enlarge-
/ q# o+ J( V( a6 Wment of his penis and frequent erections. The child
( I$ h6 m! W, Z% Rwas the product of a full-term normal delivery, with
& X% e5 D, e) r! @% ?a birth weight of 7 lb 14 oz, and birth length of9 Q( J9 Y8 ~4 G* t& w( j" Y
20 inches. He was breast-fed throughout the first year
J4 f" P, `2 c- u& k- T- Oof life and was still receiving breast milk along with
: Y$ ^/ t6 w8 J3 ~3 Z; Usolid food. He had no hospitalizations or surgery,2 c, h9 {5 k' A7 e" u
and his psychosocial and psychomotor development
1 {7 j: h2 w1 s5 G1 Pwas age appropriate.
+ j% Z3 j9 q3 X ]+ rThe family history was remarkable for the father,
5 [4 l" g- T% T7 x1 M& Twho was diagnosed with hypothyroidism at age 16,4 N K1 l) Q1 C4 \" [! j @
which was treated with thyroxine. The father’s
, N* j: ~* X- a) T0 ?- vheight was 6 feet, and he went through a somewhat/ `% |* ~( G0 H& [ `4 N# m' R
early puberty and had stopped growing by age 14.
0 h. j) A K3 C( wThe father denied taking any other medication. The Y% r$ W/ b. X& i
child’s mother was in good health. Her menarche
' l3 X& }: u! Lwas at 11 years of age, and her height was at 5 feet
5 W3 |- y N2 v5 inches. There was no other family history of pre-
( Q, @. `5 x/ W, r+ u# C* ucocious sexual development in the first-degree rela-2 H d* t) z/ B6 `
tives. There were no siblings.
6 {- q: L/ O' \$ Y7 [ j2 KPhysical Examination
6 k# d5 F2 U6 X- nThe physical examination revealed a very active,
Q# o" N, e& Vplayful, and healthy boy. The vital signs documented
# D& G' }7 g8 i+ q2 ma blood pressure of 85/50 mm Hg, his length was3 X; _- e6 T+ l8 X$ J3 w* n1 `9 M
90 cm (>97th percentile), and his weight was 14.4 kg. o- M. b: o. R9 F( n
(also >97th percentile). The observed yearly growth
- K4 \3 N# h* W& ]- M B4 w) U: \( }velocity was 30 cm (12 inches). The examination of
: r& @5 g w% }1 n+ Y& q# Hthe neck revealed no thyroid enlargement.
8 Z" s7 m& T, rThe genitourinary examination was remarkable for0 Y) | X! b7 `, Q, N$ o
enlargement of the penis, with a stretched length of
; Z; j% o& m, j9 i: d5 j, ^8 X* y8 cm and a width of 2 cm. The glans penis was very well
& s$ S5 K: o* k9 r# S* o" R5 mdeveloped. The pubic hair was Tanner II, mostly around" x( C& Q2 }) t4 V* q" |( o% X8 u
540
: j% e2 |% o" N: aat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from6 x; ~! y) l! t1 U7 K, Q+ }+ S
the base of the phallus and was dark and curled. The
l3 b% F; d$ N K$ D( Vtesticular volume was prepubertal at 2 mL each.
+ t* Z( m; R5 ~$ ]8 D9 `The skin was moist and smooth and somewhat+ _5 V: E# m- { u# {2 I6 [
oily. No axillary hair was noted. There were no
- M. a9 r3 r7 p. @* k1 m. Aabnormal skin pigmentations or café-au-lait spots.$ i0 x! S7 a/ O' r# j- i
Neurologic evaluation showed deep tendon reflex 2+3 t, {9 Y8 {* Q
bilateral and symmetrical. There was no suggestion# l9 c$ G3 s% \* g
of papilledema.
) y4 G- B' m$ \Laboratory Evaluation
& D7 k) F: r- J6 |The bone age was consistent with 28 months by; Y2 B1 O0 b3 R2 ~
using the standard of Greulich and Pyle at a chrono-
2 l1 g" T6 f5 x9 D& ?7 Q) \, `( {1 Llogic age of 16 months (advanced).5 Chromosomal* J5 B8 l. _- Q8 ?
karyotype was 46XY. The thyroid function test
+ Y( Z# S$ b% v* Cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-" U( U5 O7 L& f6 [
lating hormone level was 1.3 µIU/mL (both normal).: c2 A1 H; K5 u; v7 d
The concentrations of serum electrolytes, blood+ u) ^8 O, ^2 ?* g- [
urea nitrogen, creatinine, and calcium all were
6 S9 r5 C( J5 c+ Mwithin normal range for his age. The concentration) J0 [! k# L. ]* r+ v8 e$ {+ a
of serum 17-hydroxyprogesterone was 16 ng/dL! A. K. V1 X! S
(normal, 3 to 90 ng/dL), androstenedione was 20
$ P2 ^' O5 A5 h* ]) ~: [ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-6 L5 ?6 E0 I$ X* t
terone was 38 ng/dL (normal, 50 to 760 ng/dL),- e4 l1 c4 _, C( V: [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to4 X0 u7 {8 I9 `6 `
49ng/dL), 11-desoxycortisol (specific compound S) ~/ F$ c/ V+ [$ X" ^
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-) M& ^) \8 X1 h5 t5 e7 t
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total2 w% q4 k$ X, p0 s9 \, P
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 o3 p' S4 ^4 O" |( c+ Aand β-human chorionic gonadotropin was less than2 J! t, ]! u* ]: Y* O
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 o- A3 S/ X# @; v6 d; V
stimulating hormone and leuteinizing hormone" z2 U& z( ]& x- j2 `
concentrations were less than 0.05 mIU/mL
+ B: t3 m# i7 e9 `# k8 Z" E6 `7 T- d(prepubertal).0 y7 ]: \. N8 S8 h) Q. B
The parents were notified about the laboratory
& P% D, Y# l; y" W* @results and were informed that all of the tests were3 R4 {! W* d+ |. I, k
normal except the testosterone level was high. The
5 w9 o; d1 s! w0 i8 m7 N* s& g/ L8 Q' `follow-up visit was arranged within a few weeks to0 b; ?+ o, z& e
obtain testicular and abdominal sonograms; how-
. B+ {; Z) u7 B$ P3 b7 V/ d9 eever, the family did not return for 4 months.
+ h, \/ J) l* l: k/ A5 }Physical examination at this time revealed that the- G1 d4 X# B) e8 B& W# c' w
child had grown 2.5 cm in 4 months and had gained2 H+ h- w' c$ }' z! q
2 kg of weight. Physical examination remained
7 l# [/ [( a( c* j }4 e0 Gunchanged. Surprisingly, the pubic hair almost com-
F G' f# F4 wpletely disappeared except for a few vellous hairs at
4 @, u( n# D: B- X' w1 R5 c/ \. A! ithe base of the phallus. Testicular volume was still 2
6 `7 U6 i5 @" X- BmL, and the size of the penis remained unchanged.8 ]5 Q6 _) `. A! @
The mother also said that the boy was no longer hav-/ g! E2 M) ]/ C" R( ~1 D
ing frequent erections.# s) H$ ~& T2 `3 W0 [& [2 g
Both parents were again questioned about use of9 m: o. A8 C2 Q+ N9 i8 U% p8 b
any ointment/creams that they may have applied to
+ c% J* f9 r. q& Uthe child’s skin. This time the father admitted the
) S. g( c: ^2 t- Z1 k. ]2 |4 U* HTopical Testosterone Exposure / Bhowmick et al 5414 j, H" X6 W, M. `/ z+ p
use of testosterone gel twice daily that he was apply-
J5 B; a1 t4 Z0 D" z2 R# Fing over his own shoulders, chest, and back area for
0 v/ I& y6 D/ S4 C) B, Na year. The father also revealed he was embarrassed
6 A# F8 @; I0 r, @7 tto disclose that he was using a testosterone gel pre-
: @+ P' V$ t. D! Gscribed by his family physician for decreased libido& V( E( u2 c! {
secondary to depression.
: l3 h: a; i& AThe child slept in the same bed with parents.
9 g7 _ m" }/ B7 L6 W3 EThe father would hug the baby and hold him on his
3 e: i* p g% C7 u4 t4 Jchest for a considerable period of time, causing sig-
! l4 I; z6 j* r5 ]0 ^nificant bare skin contact between baby and father.
6 a$ W+ P& ?* ]) ~9 _: TThe father also admitted that after the phone call,
4 M' r( k7 U/ p0 l2 Y+ |when he learned the testosterone level in the baby
X) V8 f& h* @( i3 qwas high, he then read the product information# |- }) y S, s3 G' u' T: A
packet and concluded that it was most likely the rea-/ d! T2 H1 v6 _: ?7 |
son for the child’s virilization. At that time, they
& W- ~* n3 @6 c; E' T" `* G7 ddecided to put the baby in a separate bed, and the
6 D/ Y" P/ T6 Vfather was not hugging him with bare skin and had7 O) p; w Q6 [* v: n! q: T, y
been using protective clothing. A repeat testosterone% R, {3 @ ^5 G
test was ordered, but the family did not go to the. G; d" h9 i% v3 U
laboratory to obtain the test.; a2 S. d& M, Z R. T) v7 A
Discussion6 L1 Z, z0 d% V, Z! J: |: c
Precocious puberty in boys is defined as secondary
5 M: M8 m! ?+ e) }( Hsexual development before 9 years of age.1,4
5 I5 I3 h/ r2 O- jPrecocious puberty is termed as central (true) when
7 `- ?% e0 U0 u+ m d, J4 lit is caused by the premature activation of hypo-
" c2 T" |$ L! j. r$ r6 F! ^' d/ rthalamic pituitary gonadal axis. CPP is more com-6 M/ N( ~, h, B9 {$ K2 ~
mon in girls than in boys.1,3 Most boys with CPP
( X6 ^# s$ P) L$ K7 i O8 q! ^may have a central nervous system lesion that is
* n4 v& H0 l; `/ Yresponsible for the early activation of the hypothal-
$ a* W; w3 u4 ~0 ramic pituitary gonadal axis.1-3 Thus, greater empha-
/ m! v' `) F! K/ u+ ~sis has been given to neuroradiologic imaging in! p0 _8 k+ Z; V s
boys with precocious puberty. In addition to viril-3 y9 G, V6 j5 ~; ~
ization, the clinical hallmark of CPP is the symmet-7 F, Q1 ^ O- D
rical testicular growth secondary to stimulation by( p/ g' P4 ]; Z, g* Z; O6 f
gonadotropins.1,3) h n' P" k) Y# a
Gonadotropin-independent peripheral preco-# f+ x! N& \- O& i1 @
cious puberty in boys also results from inappropriate
! u2 E* J: s* \5 z' ?- v+ ^) nandrogenic stimulation from either endogenous or
4 f; l4 D4 ~$ F2 `- texogenous sources, nonpituitary gonadotropin stim- k) S8 R1 J7 Q5 S; e) p
ulation, and rare activating mutations.3 Virilizing
9 G. J2 B! \- d6 X5 j! T% k$ Y2 ^congenital adrenal hyperplasia producing excessive$ l& N$ N+ w! ~- ~6 k6 o
adrenal androgens is a common cause of precocious
3 N) e N r# _! P( Wpuberty in boys.3,41 U5 [2 Z+ W9 y4 \5 e
The most common form of congenital adrenal0 Z; ] p1 o% J2 P: V- h# K
hyperplasia is the 21-hydroxylase enzyme deficiency.; C E1 d$ M% z% @' ^. W1 u
The 11-β hydroxylase deficiency may also result in- k5 F8 r+ H5 d1 C& w7 l! Q; d
excessive adrenal androgen production, and rarely,2 p7 W' s% t& u) F; q7 l
an adrenal tumor may also cause adrenal androgen
4 m5 w/ `/ e1 fexcess.1,3
7 b! b( M. n& h- Q$ Fat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; y+ i8 b p8 w% z/ t# N3 T
542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 u T' O4 [ F" l) A" e% E! z; X
A unique entity of male-limited gonadotropin-
% |+ t2 S* v1 Q Cindependent precocious puberty, which is also known
2 L* s6 }8 V0 E2 Yas testotoxicosis, may cause precocious puberty at a
* V9 A! M/ B' C5 d1 I! Bvery young age. The physical findings in these boys
" O7 b. i' k! t9 Fwith this disorder are full pubertal development,
9 s* ^& @" L8 [1 k$ Fincluding bilateral testicular growth, similar to boys% V7 `7 o, l n/ p7 C
with CPP. The gonadotropin levels in this disorder
% S O7 b! K7 ]) rare suppressed to prepubertal levels and do not show _: R, `- n: x4 z! ?
pubertal response of gonadotropin after gonadotropin-8 l" Z2 ~2 p. Q
releasing hormone stimulation. This is a sex-linked
! P8 L' G% H: R* `# h3 w3 d' Pautosomal dominant disorder that affects only8 L3 a' q+ z5 W8 i* e+ f [0 f7 k
males; therefore, other male members of the family
7 D5 W3 V) a; Z7 ]# |6 r+ b1 _may have similar precocious puberty.38 p) D0 W6 q" a9 t! i9 L) |* x
In our patient, physical examination was incon-, n$ X* p8 `* R7 h
sistent with true precocious puberty since his testi-
3 d/ P* n( a7 }3 O( \2 h. [: A- K: mcles were prepubertal in size. However, testotoxicosis
0 W S& d+ N% J, s6 k, |9 Dwas in the differential diagnosis because his father' n, r4 g, m4 A6 S$ E3 Y
started puberty somewhat early, and occasionally,
/ j& B- E+ n3 w2 E; l: y( Otesticular enlargement is not that evident in the
9 Q# h) s/ L+ A+ N) |beginning of this process.1 In the absence of a neg-
. F) _: y' O& U: J; U) O5 L9 ?: lative initial history of androgen exposure, our
4 Y4 \& w6 d* \3 t1 ^biggest concern was virilizing adrenal hyperplasia,
, K* S/ w6 a/ jeither 21-hydroxylase deficiency or 11-β hydroxylase
% h4 N' R% \: h8 \' d# g5 _deficiency. Those diagnoses were excluded by find-
! [: i6 B4 r4 ~7 W& L6 [ing the normal level of adrenal steroids.7 f- L9 J) p8 j g/ K+ m
The diagnosis of exogenous androgens was strongly; `- s. y" h. E/ U* \5 T, z
suspected in a follow-up visit after 4 months because' m# ~1 v8 e1 X9 d2 A
the physical examination revealed the complete disap-+ q+ _' r5 [/ v1 F+ M+ l! H; T
pearance of pubic hair, normal growth velocity, and$ a5 h( j8 u* T0 N6 j
decreased erections. The father admitted using a testos-
) k5 W# }' x- f2 J' Dterone gel, which he concealed at first visit. He was, @; w, S( T/ [3 Y
using it rather frequently, twice a day. The Physicians’
( O6 h% M/ R) ?Desk Reference, or package insert of this product, gel or Y9 D) a, L! b6 u0 K( K: g0 q
cream, cautions about dermal testosterone transfer to8 P" f0 c; D6 u
unprotected females through direct skin exposure.' b5 v" a' D) o: p
Serum testosterone level was found to be 2 times the
: ~! _5 H9 m" y" ?baseline value in those females who were exposed to9 l/ |% o/ W g# r# o
even 15 minutes of direct skin contact with their male1 E" X0 i5 g- m4 p7 A n
partners.6 However, when a shirt covered the applica-
- q/ [6 K" A) {) l8 k2 ?( u4 F+ Etion site, this testosterone transfer was prevented.
4 ^% H2 R) I- y* R5 G- o( c, ?Our patient’s testosterone level was 60 ng/mL,7 z+ E5 G3 Z9 D, p" G, t7 w
which was clearly high. Some studies suggest that( l M0 H$ o4 \5 r; }
dermal conversion of testosterone to dihydrotestos-4 E8 G7 P" c" C/ J8 D
terone, which is a more potent metabolite, is more
# e7 r; W# l: |9 i1 Q bactive in young children exposed to testosterone
9 n7 ^3 M7 G9 S6 Z: H# J: \6 W8 C" pexogenously7; however, we did not measure a dihy-
! V7 W$ X7 D. `7 \5 ]5 G" r% D/ |drotestosterone level in our patient. In addition to2 D) _$ Y* V w. P' {% G2 A
virilization, exposure to exogenous testosterone in( ]. X/ R3 H9 ^8 F/ i
children results in an increase in growth velocity and1 [3 r5 P. Q) C
advanced bone age, as seen in our patient.
! r: O4 \' W8 ^) U. @3 _+ NThe long-term effect of androgen exposure during
6 D# I& h" } \$ Z8 gearly childhood on pubertal development and final7 `9 X& D; y$ G
adult height are not fully known and always remain2 F# [ _9 `) x, l( T, T6 K, D
a concern. Children treated with short-term testos-! X- q z$ `0 F# h9 [' s6 V3 Q
terone injection or topical androgen may exhibit some
5 [+ d$ S+ t* z% h: Uacceleration of the skeletal maturation; however, after/ n1 |; l7 Y7 v" a$ o$ a) g& N
cessation of treatment, the rate of bone maturation( \3 @" [) D! }) u4 Q5 Y; v6 F
decelerates and gradually returns to normal.8,92 L ^. N# c4 ]3 o/ F8 P" q
There are conflicting reports and controversy
! H' T# s7 g5 Xover the effect of early androgen exposure on adult! [3 ?7 B+ p$ j( ]$ c) F
penile length.10,11 Some reports suggest subnormal9 v$ e7 N5 y. x2 S
adult penile length, apparently because of downreg-
; t/ M5 S9 C; Z, s- _ulation of androgen receptor number.10,12 However,
$ M9 _. Y% T. W( P9 }7 }. L; xSutherland et al13 did not find a correlation between
8 a- U, E# M9 S8 x1 Q" w$ G; V$ Kchildhood testosterone exposure and reduced adult. U; B' g( `1 }' U7 U3 y3 A- T
penile length in clinical studies.
3 `8 K. H+ R* @0 E( I7 ANonetheless, we do not believe our patient is
1 O7 T' W! z1 Cgoing to experience any of the untoward effects from
2 ^+ B" Z4 F, T, f, O, j. U+ Utestosterone exposure as mentioned earlier because! P* \) j) l0 ?" g
the exposure was not for a prolonged period of time.7 o( K# l- i/ p5 S
Although the bone age was advanced at the time of, x4 e# Q( M- A4 r, n* Z+ k1 g+ i
diagnosis, the child had a normal growth velocity at
6 i$ ~# [ |& g( Cthe follow-up visit. It is hoped that his final adult4 B% O* o s) a$ t
height will not be affected.
4 `; O) N" M" X8 _6 r9 BAlthough rarely reported, the widespread avail-
8 V. W/ y0 x, b1 vability of androgen products in our society may5 g9 U; d4 b# G7 m2 g7 |5 z
indeed cause more virilization in male or female
; J$ D; J/ @$ v9 t$ i- r+ u+ U: Achildren than one would realize. Exposure to andro-
- t' Y8 ]- a0 w$ e' O7 j/ ~7 bgen products must be considered and specific ques-
+ D1 v2 r" Z4 G7 q! R& btioning about the use of a testosterone product or# x/ @$ [& B$ i$ ~7 t4 N
gel should be asked of the family members during
/ p+ v. Y7 }* b$ Q5 }the evaluation of any children who present with vir-6 t; A$ q7 i# g. g2 E3 x8 f
ilization or peripheral precocious puberty. The diag- ]. {/ l' I T9 a* C' T4 y7 h3 S
nosis can be established by just a few tests and by" z" u9 M$ B( v# c% V" K2 a# ]
appropriate history. The inability to obtain such a9 r7 `- v, m7 f+ N7 @* ~
history, or failure to ask the specific questions, may
$ P0 Q, u$ u; D9 oresult in extensive, unnecessary, and expensive* h1 t% S& @ T) V
investigation. The primary care physician should be5 w7 ?: x. i5 k" A+ m7 q
aware of this fact, because most of these children2 w: B) ]: M+ A. ]
may initially present in their practice. The Physicians’
6 x( e1 f$ V$ p; xDesk Reference and package insert should also put a
% W2 U n$ F% W" ewarning about the virilizing effect on a male or
) v4 Y0 A/ u( z" X# Cfemale child who might come in contact with some-
L! t& i- |. s+ _: o9 ]+ |/ None using any of these products. x4 v8 K3 l% F. M8 u8 }% d
References
) Z! z. ?3 a0 K" ^( D1 L2 [" b; v1. Styne DM. The testes: disorder of sexual differentiation' S; L. ~9 W! B7 |" D I
and puberty in the male. In: Sperling MA, ed. Pediatric5 Q9 P0 ^. E5 v/ L
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;2 G$ _3 }2 J6 N+ j0 H+ c# I
2002: 565-628.& W& X* N& l; _, x$ N }
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 G5 P& D% \ `. Lpuberty in children with tumours of the suprasellar pineal |
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