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Sexual Precocity in a 16-Month-Old
2 o. u" R+ H3 u. S# P; kBoy Induced by Indirect Topical
( ?% m5 e# S( \7 k" c" S5 @Exposure to Testosterone
" L& v/ M1 b) I' o& e' P, jSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2! }7 Z3 x' j1 X! F7 ^% T' _
and Kenneth R. Rettig, MD1
$ D3 {9 L( C# u g# M8 q6 aClinical Pediatrics
7 ?0 J& T* w6 }1 D$ VVolume 46 Number 6. w! N' [/ b/ U/ q% ^. Y
July 2007 540-543
4 Y/ }+ \! t& N© 2007 Sage Publications4 i. Z6 ~. Q& \& O$ u1 y3 G
10.1177/0009922806296651% H5 y$ J5 p: s+ e
http://clp.sagepub.com
& u+ E' w% T4 u% Qhosted at3 w$ T3 y- F; v5 d4 u( A
http://online.sagepub.com- S. g1 c# Q2 E( }
Precocious puberty in boys, central or peripheral,
- s7 t1 B, R9 i9 H! iis a significant concern for physicians. Central
% Z% G7 B. e% g1 I! V; L0 Lprecocious puberty (CPP), which is mediated
( G6 s# C2 M. athrough the hypothalamic pituitary gonadal axis, has
0 |- {/ b' U' D+ D9 M# b$ P1 da higher incidence of organic central nervous system
- i7 {) u- ~: n* V7 Ulesions in boys.1,2 Virilization in boys, as manifested
9 q( ~% }" s! B" p( C$ D* _1 Uby enlargement of the penis, development of pubic
3 u8 t* q/ b Ohair, and facial acne without enlargement of testi-: h T) C6 T( z7 W& P/ \
cles, suggests peripheral or pseudopuberty.1-3 We1 }2 _" w" @) R9 g$ G
report a 16-month-old boy who presented with the
8 U3 V' H6 o [, n7 \! cenlargement of the phallus and pubic hair develop-1 t1 A0 D7 [3 r7 _) M
ment without testicular enlargement, which was due% m- F7 ]2 j# \/ q. |; Z* u& T ^3 Y- o
to the unintentional exposure to androgen gel used by2 K/ C+ ^+ k1 U$ y$ \
the father. The family initially concealed this infor-# V% \- r2 P1 r& o) S) W
mation, resulting in an extensive work-up for this
1 L. ^9 O+ ^8 M8 r/ H0 achild. Given the widespread and easy availability of, j/ _1 t, y7 e X. ^
testosterone gel and cream, we believe this is proba-
$ |# n! O0 R J( f4 C+ U! x8 Kbly more common than the rare case report in the
6 t9 m Q/ B, k6 C, K; J9 T. Cliterature.4& a7 j4 w% p+ @; T, b
Patient Report
& o9 o( g' L% s3 d4 Z. qA 16-month-old white child was referred to the& ^1 O4 N" f) k5 V- G$ ?) A2 B3 @
endocrine clinic by his pediatrician with the concern; O: X# F+ V/ r& P1 m+ Z! R* Q4 Q
of early sexual development. His mother noticed
1 k# z5 _1 q' j$ N D9 Clight colored pubic hair development when he was, @5 y& ]) V" [# X! k, ~2 M' b
From the 1Division of Pediatric Endocrinology, 2University of$ e6 ~7 F# w& Z' O8 M I1 i
South Alabama Medical Center, Mobile, Alabama.6 x2 _9 u0 b/ u1 y3 v: @
Address correspondence to: Samar K. Bhowmick, MD, FACE, T! n- E' `9 d
Professor of Pediatrics, University of South Alabama, College of, d: r5 U/ I, C8 z# Z
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
0 E6 P1 g' y8 C1 I& _2 Le-mail: [email protected].
: P- M: J( [4 K* b+ b: f3 T( v; }about 6 to 7 months old, which progressively became
+ q2 I. [5 A3 |0 ]9 Odarker. She was also concerned about the enlarge-: R1 p+ m' \" K: D( @
ment of his penis and frequent erections. The child
: q3 M7 H1 R" X+ {6 w+ W+ s1 S; O1 cwas the product of a full-term normal delivery, with
_: M9 l9 r. p8 o$ m0 x9 sa birth weight of 7 lb 14 oz, and birth length of
' A2 s1 X% \; v4 T20 inches. He was breast-fed throughout the first year" I* T$ [" X- b! H v2 T
of life and was still receiving breast milk along with
( y) X1 R4 B# l1 ]: h8 Fsolid food. He had no hospitalizations or surgery,
7 Y* z: q# }3 I3 |- I9 w* B; Nand his psychosocial and psychomotor development
4 [) z: ~( h+ P( s& {% E# O* Iwas age appropriate.2 i. _: `- h) M$ C
The family history was remarkable for the father,7 G r0 K( E' r j1 Z! v
who was diagnosed with hypothyroidism at age 16," S3 e( S; ] f
which was treated with thyroxine. The father’s/ I5 K/ ]8 C$ X! ~. [
height was 6 feet, and he went through a somewhat
9 h2 X* c) Q! ]& aearly puberty and had stopped growing by age 14.
5 p9 \+ S. `" f! U3 GThe father denied taking any other medication. The
% A1 f5 z0 p( c# C2 c- r% ^child’s mother was in good health. Her menarche/ \* X6 o; W7 ]. U
was at 11 years of age, and her height was at 5 feet3 Y( b0 @; ]3 U2 [5 |
5 inches. There was no other family history of pre-
m0 R' z( l* ]7 j/ P/ ucocious sexual development in the first-degree rela-# e! g2 {% C! ?' l+ L* x
tives. There were no siblings.' Z5 D1 N% N2 v# q
Physical Examination0 T! k; s9 [0 m) W9 l3 G
The physical examination revealed a very active,% j3 T0 q$ |* d) Z& }+ X! c$ H
playful, and healthy boy. The vital signs documented) H+ O8 t( P4 s1 g
a blood pressure of 85/50 mm Hg, his length was
7 S/ _; |4 W* l* v90 cm (>97th percentile), and his weight was 14.4 kg
: V: j; Q) v5 `% |, [ K8 k3 p(also >97th percentile). The observed yearly growth
, t) s1 z( a) e; B7 @velocity was 30 cm (12 inches). The examination of, ]: x3 v' n* K) c1 r
the neck revealed no thyroid enlargement.+ e. g. Z6 P1 ?6 z3 r$ a7 L' }
The genitourinary examination was remarkable for8 G3 Z7 w+ S/ ^; j7 [: B
enlargement of the penis, with a stretched length of" R7 y% `# t* m9 h( D: ^
8 cm and a width of 2 cm. The glans penis was very well
7 L# W7 W7 H4 _$ s: z' ldeveloped. The pubic hair was Tanner II, mostly around
8 B" Q2 W4 o, k* H8 @540. K$ Q) {5 r3 F, m9 s# W* o! m
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, Z; Z0 P4 N4 o9 }* M, C
the base of the phallus and was dark and curled. The
" N/ n% d! P$ k+ ~7 u5 u$ ]testicular volume was prepubertal at 2 mL each.) l" K4 g- y% V0 J6 W2 F
The skin was moist and smooth and somewhat
; m6 D: e: y# z o# I; J9 ioily. No axillary hair was noted. There were no5 y: u5 u1 _3 Q' R1 }
abnormal skin pigmentations or café-au-lait spots.7 C! ~9 y2 k5 A, g
Neurologic evaluation showed deep tendon reflex 2+$ T; a+ Q+ v! q* R( Q- `7 K d, ~, F
bilateral and symmetrical. There was no suggestion( M9 o7 @4 N m* e& S
of papilledema.6 n2 f1 y1 p5 G8 L1 f
Laboratory Evaluation& n0 u# s: r1 ~# W
The bone age was consistent with 28 months by, w2 f: w/ `) l1 M, ~( M
using the standard of Greulich and Pyle at a chrono-
, d$ \$ ]5 n8 L6 r7 p! ?! ?logic age of 16 months (advanced).5 Chromosomal6 H; X' L6 `, t' @7 O) X0 D
karyotype was 46XY. The thyroid function test3 J5 _' |; S* P; G& {
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
) a; a4 W/ c. b0 [5 slating hormone level was 1.3 µIU/mL (both normal).. A% M3 n$ p5 e, p& w
The concentrations of serum electrolytes, blood1 {" ~* B$ @& Z7 L$ M
urea nitrogen, creatinine, and calcium all were$ f) d; P. l& `) M1 }' H) s7 _
within normal range for his age. The concentration/ Q4 a% M, v4 i9 T3 z; E& E
of serum 17-hydroxyprogesterone was 16 ng/dL
" I7 Q- i p6 B(normal, 3 to 90 ng/dL), androstenedione was 20; G& C+ M. I' h5 z( E8 {8 ]0 i
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
. k. n4 H7 a2 ^0 B7 L% Qterone was 38 ng/dL (normal, 50 to 760 ng/dL),
1 \6 ^+ Y, O. T n# l) ?6 u& adesoxycorticosterone was 4.3 ng/dL (normal, 7 to' [/ u" V- q! V. G8 v
49ng/dL), 11-desoxycortisol (specific compound S)
; ?2 d5 r5 f. p6 u; P, Z# Jwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! F7 r5 [$ R% A) `; ~- b
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total( o: {+ F1 P, t+ R
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
R, {4 q% G3 I1 i Y2 Pand β-human chorionic gonadotropin was less than W' G; S, Q- ~* M e$ N
5 mIU/mL (normal <5 mIU/mL). Serum follicular7 J0 G$ Z# w9 e) h1 s0 O
stimulating hormone and leuteinizing hormone
, Q0 r7 E0 N% J7 k$ ^( X$ vconcentrations were less than 0.05 mIU/mL
$ K* K. O- i8 V+ k: V$ Q$ L% T(prepubertal).& ?/ U; `4 D9 v2 W* V/ x! e
The parents were notified about the laboratory1 c5 v+ o; @5 l. {3 N
results and were informed that all of the tests were
, f' R, V- ?3 w0 i Fnormal except the testosterone level was high. The
: B0 L5 O; [7 N3 j' Ofollow-up visit was arranged within a few weeks to4 y% r I" N4 ]9 s: Z$ Z5 I
obtain testicular and abdominal sonograms; how-
) a8 U7 [8 M( m/ E, Kever, the family did not return for 4 months.
3 S, _% k, ]$ V1 O) sPhysical examination at this time revealed that the
" S/ N& `9 ?. p, G+ [' u6 H5 F% dchild had grown 2.5 cm in 4 months and had gained& ?0 _: f; S5 V- x5 [8 E- G
2 kg of weight. Physical examination remained/ r. H' o6 |/ j1 g
unchanged. Surprisingly, the pubic hair almost com-2 D6 j( v' F; C% A1 A2 `
pletely disappeared except for a few vellous hairs at
/ G- _& B2 ]4 T7 I& ~the base of the phallus. Testicular volume was still 2
- A/ z& }; L$ K2 VmL, and the size of the penis remained unchanged.
& O, i% \* }2 s AThe mother also said that the boy was no longer hav-
1 @/ {- }$ y) ?9 `& M; Iing frequent erections.
8 z! d+ j$ y9 q! ~2 i0 \Both parents were again questioned about use of
) P9 w2 l: S5 Y# K" Sany ointment/creams that they may have applied to4 K W& N% S( U0 n( ]
the child’s skin. This time the father admitted the
3 r8 Y! X% \# `3 u" k3 u M6 a0 l0 gTopical Testosterone Exposure / Bhowmick et al 541
- U0 o, G! I5 w7 z! Huse of testosterone gel twice daily that he was apply-
5 }5 d% n' F; Z) U4 jing over his own shoulders, chest, and back area for( ^% s9 e$ n; Q4 X
a year. The father also revealed he was embarrassed
) a- j9 P7 [( I4 ^/ E5 P$ ?( k5 }to disclose that he was using a testosterone gel pre-' u) y. f& x. P2 H# ~
scribed by his family physician for decreased libido; Z8 t& H9 h4 c* Y! ^0 h
secondary to depression.9 V0 g: j. q2 F& C1 I3 S4 m
The child slept in the same bed with parents.
0 o# w* Q+ l! s; m5 e P CThe father would hug the baby and hold him on his
; B+ p5 w& a) wchest for a considerable period of time, causing sig-
* C1 s" ~5 q1 s# N* D! n @nificant bare skin contact between baby and father.' E9 V9 f- a z, F4 [ d. }
The father also admitted that after the phone call,- n4 b; G. h! L- m: S- s! V8 \
when he learned the testosterone level in the baby
6 v( [2 O" n* n4 D! ?/ Xwas high, he then read the product information
* ^# P) c+ } Y1 dpacket and concluded that it was most likely the rea-
1 M9 t/ `& k5 l) X. }; q7 nson for the child’s virilization. At that time, they, k' s- w- ~# I( x) j5 ^# B
decided to put the baby in a separate bed, and the3 W3 c8 W2 r2 x% P' \
father was not hugging him with bare skin and had& Y, J( ?% L3 }2 M2 U
been using protective clothing. A repeat testosterone, T4 S# S' J, b7 @0 s
test was ordered, but the family did not go to the
* y0 P: b0 L0 z# F( m0 I: Xlaboratory to obtain the test.. ~: Z2 `; x \
Discussion7 g! U, S2 V( V) \8 {; U
Precocious puberty in boys is defined as secondary
: f% T) q+ U, L- {/ J9 M7 msexual development before 9 years of age.1,4
0 ]! n9 u: S# w5 J% Q+ u: j' \Precocious puberty is termed as central (true) when6 [* H% q8 `+ e1 x3 E8 H1 e8 \7 X% n v
it is caused by the premature activation of hypo-
$ J" a6 M9 E; o x) k1 L+ T8 F3 Sthalamic pituitary gonadal axis. CPP is more com-
8 K1 G ?3 o% w1 T+ Rmon in girls than in boys.1,3 Most boys with CPP: A* x! F4 W0 N
may have a central nervous system lesion that is' m/ b _+ c$ c* c* M# q
responsible for the early activation of the hypothal-
* f) ^, I4 T1 d1 N. Tamic pituitary gonadal axis.1-3 Thus, greater empha-% Y* G# G) f0 V6 q: a6 |9 x
sis has been given to neuroradiologic imaging in
! d$ |+ F! E+ `& q7 R0 V% Dboys with precocious puberty. In addition to viril-( x, c5 t5 U- j8 M# W* e" U
ization, the clinical hallmark of CPP is the symmet-
( q- U" k4 |9 q$ d; R l: mrical testicular growth secondary to stimulation by
9 H; e! Q% W' ]& r9 k+ Zgonadotropins.1,3
/ M. I: ?3 c" H# XGonadotropin-independent peripheral preco-" o) I3 H. ` d4 n; R
cious puberty in boys also results from inappropriate; ^: G% u1 t/ ?- M$ ^
androgenic stimulation from either endogenous or) b, g6 x3 ], J. i
exogenous sources, nonpituitary gonadotropin stim-
0 i" ~: f8 @* |9 y- |- b/ O' X$ fulation, and rare activating mutations.3 Virilizing
( u4 P; S4 a9 K8 G1 o2 J2 wcongenital adrenal hyperplasia producing excessive
y0 C9 C4 t( s+ X' `adrenal androgens is a common cause of precocious
, R& Q7 g" s! j8 p- j: xpuberty in boys.3,4
& ^& A. U) l8 _The most common form of congenital adrenal' v$ P) t5 ~# N' a4 e! @( [# l
hyperplasia is the 21-hydroxylase enzyme deficiency.3 z5 @2 M! d2 e# [, w
The 11-β hydroxylase deficiency may also result in6 `9 x J6 }( r0 i! K
excessive adrenal androgen production, and rarely,3 H; T3 ?+ { b' b
an adrenal tumor may also cause adrenal androgen
3 e7 k" B% ^( D6 Aexcess.1,3
! Q7 D3 u' W; h9 [/ Kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& _, c, p3 p1 C9 Y542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
& Q s, w% @4 k4 R5 ?3 uA unique entity of male-limited gonadotropin-) @. L8 p8 o$ M |) L' Z
independent precocious puberty, which is also known
# l* J( h. T; M7 Zas testotoxicosis, may cause precocious puberty at a
% F. s5 C, W8 Z/ v" E9 a! x1 Q$ o s0 [very young age. The physical findings in these boys
3 \. H& {7 @9 k/ R6 _& u- mwith this disorder are full pubertal development,0 b8 f; j; W9 E1 M2 I
including bilateral testicular growth, similar to boys
1 N$ u1 J- f% N* h% ~, ]# bwith CPP. The gonadotropin levels in this disorder
) D. |! `6 k' fare suppressed to prepubertal levels and do not show; W3 e; g j" e: I* g. O
pubertal response of gonadotropin after gonadotropin-9 ?+ v. h- u O+ k6 S3 @
releasing hormone stimulation. This is a sex-linked! ^3 C4 J3 ^- h5 E5 _( a: l
autosomal dominant disorder that affects only3 C' V( C8 Q, f6 I- V" P! B7 Y
males; therefore, other male members of the family
6 ?; h& g6 H: J( T' ^may have similar precocious puberty.3) d6 Q3 F6 s+ J2 d: R2 y
In our patient, physical examination was incon-
* {, d* D2 |6 h5 ^/ b+ Ksistent with true precocious puberty since his testi-
" u! A2 d" {/ Y8 `1 F; n6 ^cles were prepubertal in size. However, testotoxicosis
& U2 C0 g+ `: K4 R7 m6 [7 bwas in the differential diagnosis because his father8 G5 l% J# s# I: [* d2 ?
started puberty somewhat early, and occasionally,# X3 e8 R! A. i0 i. F& x4 `8 N
testicular enlargement is not that evident in the
+ J% f' F' J1 {4 m+ [- rbeginning of this process.1 In the absence of a neg- v) ]# H9 s8 n$ Y
ative initial history of androgen exposure, our
8 t9 L, V0 z! cbiggest concern was virilizing adrenal hyperplasia,
7 G5 {" ], f P2 [3 Ieither 21-hydroxylase deficiency or 11-β hydroxylase
/ {9 B- w7 c* j; r+ edeficiency. Those diagnoses were excluded by find-
- W/ r* s m+ d0 ]$ g: d, v v1 Y7 l' Ging the normal level of adrenal steroids., \; B+ ?; _! W4 h( m4 F' w, L; W
The diagnosis of exogenous androgens was strongly' G! b( _0 F3 [. G; {; w* R
suspected in a follow-up visit after 4 months because; [" e2 Y& P5 }9 l& \$ T
the physical examination revealed the complete disap-* j( K7 [0 r J; {
pearance of pubic hair, normal growth velocity, and8 O. q% K7 m1 \
decreased erections. The father admitted using a testos-8 @' o4 L# d- K# D
terone gel, which he concealed at first visit. He was' P b% f3 x1 Q* r) f
using it rather frequently, twice a day. The Physicians’
6 T7 T; J, j! E5 [" i: o0 FDesk Reference, or package insert of this product, gel or- r. s: `2 o3 |' f
cream, cautions about dermal testosterone transfer to4 s* ^8 [7 a! \, }3 m
unprotected females through direct skin exposure.- n( I+ L9 z. \: z
Serum testosterone level was found to be 2 times the% W8 m1 I/ E* s6 R" b6 t
baseline value in those females who were exposed to) M l0 Z' F) m, X& @
even 15 minutes of direct skin contact with their male3 i. F* f% `3 K
partners.6 However, when a shirt covered the applica-# w; \/ J" N/ o' M" Y+ Z
tion site, this testosterone transfer was prevented.5 |3 n/ x4 u& D+ a8 N6 y/ u6 h+ U
Our patient’s testosterone level was 60 ng/mL,
2 M0 a! L* ?5 m) l( \# @which was clearly high. Some studies suggest that" z6 q* ]9 J# s) Y8 q0 U
dermal conversion of testosterone to dihydrotestos-1 Z+ J, L: R) \
terone, which is a more potent metabolite, is more# |$ D5 b) H( p/ V$ U S0 V
active in young children exposed to testosterone0 A& `3 s+ n; o. Y C+ b* g
exogenously7; however, we did not measure a dihy-/ K) `1 n2 ]8 q) y% X8 b
drotestosterone level in our patient. In addition to7 `4 B2 T ~5 N. |) c. L5 f0 e) A
virilization, exposure to exogenous testosterone in
1 ]- ~( C4 v8 s! n0 v: xchildren results in an increase in growth velocity and' _* T* g3 K7 Z( u, N
advanced bone age, as seen in our patient.
! ?& v" q' B4 `! Q' o! I. vThe long-term effect of androgen exposure during
0 Y6 U3 O: E* r+ |& I5 u0 t. Searly childhood on pubertal development and final1 h$ y# i" `; ? N/ n
adult height are not fully known and always remain2 m% p; `6 N: H& [! [4 y: t5 ?
a concern. Children treated with short-term testos-2 k4 _& W' E2 y6 f" Q
terone injection or topical androgen may exhibit some
4 g- H0 t3 ]& d) H3 s4 J0 Cacceleration of the skeletal maturation; however, after
# k1 k: }9 e o- l: xcessation of treatment, the rate of bone maturation% x- B! J% r! c$ @7 e) j# r5 Z
decelerates and gradually returns to normal.8,9
9 H7 G$ B5 D4 H% T5 tThere are conflicting reports and controversy
' m8 Q" @3 x c' S B" m) Cover the effect of early androgen exposure on adult7 b: e! ^+ \' D9 b t9 \3 j' h
penile length.10,11 Some reports suggest subnormal9 z: c. [4 J& m8 t
adult penile length, apparently because of downreg-( c' I6 d& \: y. \
ulation of androgen receptor number.10,12 However,6 W5 d+ V9 k, B$ b
Sutherland et al13 did not find a correlation between
M8 J% a6 \& v4 S8 Vchildhood testosterone exposure and reduced adult
, i2 H' G- `: n7 zpenile length in clinical studies.5 p5 f. Q' U2 J
Nonetheless, we do not believe our patient is
- H+ ?' O) `* Kgoing to experience any of the untoward effects from
7 v! ~1 O8 A l8 T& `# Ntestosterone exposure as mentioned earlier because9 [- l8 S9 b: T! I3 f
the exposure was not for a prolonged period of time.% d+ ?2 v+ K9 G4 y( t4 V7 ]
Although the bone age was advanced at the time of
1 t( O3 ~: ]( e9 R3 i. Pdiagnosis, the child had a normal growth velocity at/ r+ M$ D9 o# l0 f
the follow-up visit. It is hoped that his final adult
' F0 a/ j& u/ B0 A: j, p" yheight will not be affected.2 y' g0 H/ E7 j9 ?2 z
Although rarely reported, the widespread avail-. m6 `; y: W7 k: R
ability of androgen products in our society may
) k+ b; w2 H# o8 _2 x3 Windeed cause more virilization in male or female
+ ]7 w& b/ g9 k8 d! @children than one would realize. Exposure to andro-
8 G8 ~9 L/ X, \ @% _! xgen products must be considered and specific ques-
* M4 G+ |$ o2 i' J( Rtioning about the use of a testosterone product or8 o* O+ [) N/ S8 @6 v1 t
gel should be asked of the family members during* Y* @6 v: m3 S( y1 _3 s9 ]9 x
the evaluation of any children who present with vir-
( A( [8 G% t9 _. M! ^& E- Rilization or peripheral precocious puberty. The diag-0 j" `- Q3 q8 J1 ]
nosis can be established by just a few tests and by' @0 @" Q/ T, P( g, ?4 M
appropriate history. The inability to obtain such a
$ {9 ~ b% X3 }' dhistory, or failure to ask the specific questions, may# p+ X+ l! P D+ f
result in extensive, unnecessary, and expensive* A# e9 }6 c% ?# F( Z
investigation. The primary care physician should be
) r5 y& R! S8 f& r0 A8 ~, K: jaware of this fact, because most of these children
8 C' C! l4 ` b# M' vmay initially present in their practice. The Physicians’3 e. K, a9 U/ P4 f
Desk Reference and package insert should also put a
. S- {3 d @" R# A- n4 y2 i3 Swarning about the virilizing effect on a male or9 W! D e+ k% y. o4 M9 [$ ?8 I2 ~% h
female child who might come in contact with some-: o" q$ g- E- s J
one using any of these products.
8 v6 t" X3 l/ Y7 r) x% m: f) E$ R3 vReferences
+ j8 _& b- G# Z1. Styne DM. The testes: disorder of sexual differentiation
( _2 d7 L! a, `$ k! xand puberty in the male. In: Sperling MA, ed. Pediatric
2 h0 @ |* n, O' q& _0 i7 L- i K; KEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 A- D$ t' z' X3 \
2002: 565-628.
/ C( q4 l6 f% J6 K4 Z2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
$ O0 O( G: o, e( e/ X( J4 Lpuberty in children with tumours of the suprasellar pineal |
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