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Sexual Precocity in a 16-Month-Old( e1 C3 L" }$ W0 ?' j7 U7 [, P
Boy Induced by Indirect Topical$ X7 E9 Q9 X0 \2 F' Z1 F x. Z
Exposure to Testosterone
2 O3 w) |( {5 E1 u. ASamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
( T" J% z4 F6 ?2 O4 O* w+ band Kenneth R. Rettig, MD1
! |3 i; _& u8 S/ `4 K. R& M+ kClinical Pediatrics
! b1 i: ]+ ?% u& U* g* G# NVolume 46 Number 66 J6 G8 n6 [! \% K& I$ B
July 2007 540-543# H# n/ i' b% J! P+ x4 v6 m
© 2007 Sage Publications
: w5 K2 z( k9 B3 V" r10.1177/0009922806296651
* p, I1 z( r3 Q8 ]; L. S# \http://clp.sagepub.com ^( ~% ?3 A& W; v k
hosted at
% ?: R5 T+ F+ g& A. \6 k! P4 Whttp://online.sagepub.com
- P; R9 X" x! Q4 _Precocious puberty in boys, central or peripheral,
' N$ F; ]& e: e @is a significant concern for physicians. Central
. {) A: \2 m1 S; @% y' A9 `. qprecocious puberty (CPP), which is mediated
# ?$ L$ ^& T! X" Uthrough the hypothalamic pituitary gonadal axis, has; ?# h5 @3 U; `: n) y2 f2 F4 D* e+ d
a higher incidence of organic central nervous system
) a' a; p) |$ e, d; h9 Q! H0 O$ Nlesions in boys.1,2 Virilization in boys, as manifested ]8 B1 [2 R' [4 z: L) v! Y1 ?
by enlargement of the penis, development of pubic1 J/ e9 A; h+ I$ v: B k& \) _
hair, and facial acne without enlargement of testi-: w: q$ k; B3 z( z7 N+ y
cles, suggests peripheral or pseudopuberty.1-3 We
" P0 M* g! b) X7 Q. yreport a 16-month-old boy who presented with the1 h! C7 e0 B" O1 H( U' M: h
enlargement of the phallus and pubic hair develop-
0 d+ o3 C* O: K( P; X% [4 ]ment without testicular enlargement, which was due
: I" B4 `% B# R% ^6 z! u- i* sto the unintentional exposure to androgen gel used by
# f6 \+ I6 ?5 y7 {0 J: u6 Pthe father. The family initially concealed this infor-
: R! r* X7 d X' b7 a1 Rmation, resulting in an extensive work-up for this' O7 |0 f2 G$ E) e0 X! U
child. Given the widespread and easy availability of, I7 S/ X. K$ J
testosterone gel and cream, we believe this is proba-
5 e% _: Q" _, T2 d6 d9 O! ~bly more common than the rare case report in the3 a, }0 j V5 U3 G, _5 V
literature.4
2 K1 i( x% \, pPatient Report
' X0 D# J3 s& B& B* r7 f: ]; ]A 16-month-old white child was referred to the
i) t- d; p5 v+ |endocrine clinic by his pediatrician with the concern( \2 @! E5 r4 d) q, P
of early sexual development. His mother noticed
1 ^- x* c0 O6 I3 }8 ?0 {6 J: Ylight colored pubic hair development when he was7 T5 y% r. A& D3 [4 f
From the 1Division of Pediatric Endocrinology, 2University of& G& J* s# k* x- j
South Alabama Medical Center, Mobile, Alabama.
8 F9 f* f5 o, F8 \: fAddress correspondence to: Samar K. Bhowmick, MD, FACE,8 a% i( L4 l2 ]- {
Professor of Pediatrics, University of South Alabama, College of
; a& j" @4 R# _1 E: ?Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
4 `6 r% P: X9 S1 X5 i$ Ge-mail: [email protected].
3 B- J, T3 W+ i3 r/ k, V6 Fabout 6 to 7 months old, which progressively became
8 w, p+ N2 A2 N1 m% k! W1 rdarker. She was also concerned about the enlarge-, |8 P* r. _1 A% k+ \! t5 {, h
ment of his penis and frequent erections. The child: m4 L' P, t9 c8 Z; p, M
was the product of a full-term normal delivery, with0 G5 Z: H* D; g7 T! L
a birth weight of 7 lb 14 oz, and birth length of
3 T: ~* |( G, a0 n20 inches. He was breast-fed throughout the first year
" ~( K4 a% b" V0 t/ {of life and was still receiving breast milk along with
0 ?( B, V( n9 R. W- V9 T0 w; i' Vsolid food. He had no hospitalizations or surgery,9 L" E) D# J. V
and his psychosocial and psychomotor development( J3 s! r; l% k/ u. X, r9 b
was age appropriate.
$ j4 S/ {5 f! B9 C1 b4 ZThe family history was remarkable for the father,
4 E0 i; R9 C- f* D2 L1 Dwho was diagnosed with hypothyroidism at age 16,9 _& Y* O% L+ q5 H' f* d0 ` G2 V
which was treated with thyroxine. The father’s
2 V3 }+ T9 U8 uheight was 6 feet, and he went through a somewhat
' T* [1 E) c8 gearly puberty and had stopped growing by age 14.; U$ V% W$ F8 i. r% g
The father denied taking any other medication. The3 o* X I% K7 |* h) G6 e' x
child’s mother was in good health. Her menarche5 [" w, a6 R( e6 V
was at 11 years of age, and her height was at 5 feet! F; T. t1 N& ^2 |! P( P7 k
5 inches. There was no other family history of pre-
4 Y1 N- G& V( e4 P Qcocious sexual development in the first-degree rela-; P; }2 @) ^6 ]; {
tives. There were no siblings.( F* x- }- K5 a( G4 b+ ^
Physical Examination
+ W$ F$ g' W1 a+ C) N4 ]7 [The physical examination revealed a very active,) D" H3 Q& j0 n4 B
playful, and healthy boy. The vital signs documented
5 E( M- z" a3 U8 a4 n6 ^6 r4 T! qa blood pressure of 85/50 mm Hg, his length was1 A, t4 K$ d5 Q
90 cm (>97th percentile), and his weight was 14.4 kg' }6 }& L- [9 S. t
(also >97th percentile). The observed yearly growth
/ R. G7 z- y" D# Ivelocity was 30 cm (12 inches). The examination of% @6 h$ K: k9 f2 m5 m R: L B' t
the neck revealed no thyroid enlargement.7 `7 N5 {2 l$ c6 `0 U* j
The genitourinary examination was remarkable for5 |+ y, H7 K* e, L
enlargement of the penis, with a stretched length of! r/ \; a: H. o1 j9 d
8 cm and a width of 2 cm. The glans penis was very well
5 _! _; Y; d! ^7 n* F% adeveloped. The pubic hair was Tanner II, mostly around z2 j$ g7 {% S8 A0 m8 i' q
540$ o: ~3 d* N5 ]' j; I
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 {6 ~0 E6 X) L3 m8 W- `the base of the phallus and was dark and curled. The1 i0 \+ h- L: o" `
testicular volume was prepubertal at 2 mL each.0 Z r+ Q# z6 _ c# e* n0 X1 J* T
The skin was moist and smooth and somewhat2 x0 K7 E4 [/ e. \
oily. No axillary hair was noted. There were no3 F+ E: e; P7 F0 G" h, m
abnormal skin pigmentations or café-au-lait spots.' E: G8 k* I2 L" m* f: H- \- X) k5 }
Neurologic evaluation showed deep tendon reflex 2+
7 {0 x7 n W% W3 bbilateral and symmetrical. There was no suggestion
8 d x" [+ W+ q: N# z9 [of papilledema.
% b! E# Y/ Q* ~" ALaboratory Evaluation
6 L7 h& F6 h& y) n* S$ j# \7 TThe bone age was consistent with 28 months by2 R$ z' d& l' q1 s+ U) T
using the standard of Greulich and Pyle at a chrono-
) r6 o. a2 D) J6 k1 ?- Y7 vlogic age of 16 months (advanced).5 Chromosomal
, _. l1 K# o) E+ dkaryotype was 46XY. The thyroid function test
5 B, g7 y5 ]6 w) ?$ g3 N3 rshowed a free T4 of 1.69 ng/dL, and thyroid stimu-* r, K# ~; `: q0 i1 k/ M
lating hormone level was 1.3 µIU/mL (both normal).
8 k1 K R8 O i$ \The concentrations of serum electrolytes, blood9 _6 y; L( i1 m: Q+ o) A8 }$ D4 D
urea nitrogen, creatinine, and calcium all were4 }/ ]9 Y3 {. S* ^
within normal range for his age. The concentration8 s; ], C; T( n9 i4 {
of serum 17-hydroxyprogesterone was 16 ng/dL
: K4 \$ S) g8 [(normal, 3 to 90 ng/dL), androstenedione was 208 Q: w/ N2 U( N; i5 z3 z3 V
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" u0 I! [3 r V2 e% K; uterone was 38 ng/dL (normal, 50 to 760 ng/dL),% t% x+ J4 i; i! j, b' U# X1 X0 H
desoxycorticosterone was 4.3 ng/dL (normal, 7 to3 ]* K2 P; j3 ]3 ^
49ng/dL), 11-desoxycortisol (specific compound S)' @8 s% Y+ ?" s' U
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
, J1 k) O/ @/ r# E% w) n% P$ Ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total; G/ k. x) o9 A6 j% B
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& b. |3 |2 Y$ k) n. i" Q2 W
and β-human chorionic gonadotropin was less than
9 ^# ]3 j6 g9 S' \# x( T5 mIU/mL (normal <5 mIU/mL). Serum follicular0 A3 ^9 t" [% X2 ?
stimulating hormone and leuteinizing hormone: }0 {) e- d% G
concentrations were less than 0.05 mIU/mL
6 h8 o0 \0 z" s( I4 d(prepubertal).
) |1 Q% a$ y# Q2 Z7 wThe parents were notified about the laboratory# \; k' [' J* `# `9 J
results and were informed that all of the tests were! d1 o% I* f6 ^: G
normal except the testosterone level was high. The
. c" `0 {/ U; C: S( ^ Zfollow-up visit was arranged within a few weeks to5 P6 d$ M/ ]( x$ a9 K
obtain testicular and abdominal sonograms; how-% w; d, p: [/ v) m! _; i
ever, the family did not return for 4 months.
9 H% h2 e' X( @' ~- yPhysical examination at this time revealed that the3 L. g/ j2 x- Z6 [
child had grown 2.5 cm in 4 months and had gained8 y9 f( j" y2 m7 Q
2 kg of weight. Physical examination remained, X" u, `8 j5 u" g
unchanged. Surprisingly, the pubic hair almost com-
4 D$ U' _- |/ Q, Z; G6 spletely disappeared except for a few vellous hairs at
5 a4 I9 v W9 h9 v$ S! Mthe base of the phallus. Testicular volume was still 24 X" \& |6 n9 q% I% a) ?
mL, and the size of the penis remained unchanged.* e1 {# b% x/ s9 c ` |4 q
The mother also said that the boy was no longer hav-! q& S4 j0 I/ z& o/ o4 R: }: G
ing frequent erections.
) r; ~: k/ D, w+ ]9 `* L, S8 nBoth parents were again questioned about use of1 o6 B, E' O1 h5 {4 V y& p) C O2 A
any ointment/creams that they may have applied to6 G$ p# e+ d' P3 d
the child’s skin. This time the father admitted the
; K. U* U+ \5 d% `Topical Testosterone Exposure / Bhowmick et al 541
3 U: h! S1 W7 huse of testosterone gel twice daily that he was apply-0 N/ T6 W4 r* l: j3 r# L
ing over his own shoulders, chest, and back area for! ^4 x9 _7 J2 U2 _
a year. The father also revealed he was embarrassed
- g8 P$ R- O& K9 v) Nto disclose that he was using a testosterone gel pre-/ V: O) m# g/ u
scribed by his family physician for decreased libido0 T6 `: z$ ~ V' c- R' Q0 z
secondary to depression.
W' V+ W9 ~ h. t. X0 V EThe child slept in the same bed with parents.# H* p+ f3 H3 y* }8 z
The father would hug the baby and hold him on his# U, m" \3 J, `% U* {
chest for a considerable period of time, causing sig-- e2 B( E7 J: U! w+ i) D3 \# S) Y
nificant bare skin contact between baby and father.
1 b* ]5 A8 [8 G) P/ a+ C7 QThe father also admitted that after the phone call,
1 L }% J: n; a: l& o8 Kwhen he learned the testosterone level in the baby
4 i: u' b, b- |0 x2 E7 B! Mwas high, he then read the product information3 H' r8 E8 X( c0 N. l9 f/ W) u
packet and concluded that it was most likely the rea-
' ^3 r, Z+ H4 U+ j4 ]& x; Wson for the child’s virilization. At that time, they9 g5 I" {- i; u9 \6 C1 S
decided to put the baby in a separate bed, and the
' p2 q0 O" y* }5 Ffather was not hugging him with bare skin and had
3 N* {5 R% A- Z8 l, ?/ r+ x( {been using protective clothing. A repeat testosterone! t8 v+ g& @7 E: V( |2 C& Y
test was ordered, but the family did not go to the+ ?2 l4 c/ e6 {* |. P, {
laboratory to obtain the test.
; w9 p8 Q3 F& @( m% Z; GDiscussion2 H* q; S+ K$ X% U
Precocious puberty in boys is defined as secondary% m, Y7 ~0 d: n5 Z4 ~2 [
sexual development before 9 years of age.1,4
. c% j0 I5 ^2 UPrecocious puberty is termed as central (true) when
( L& g9 k! w' A8 Qit is caused by the premature activation of hypo-8 \4 ?9 s$ r7 R
thalamic pituitary gonadal axis. CPP is more com-5 N2 Z/ {! K6 }0 |
mon in girls than in boys.1,3 Most boys with CPP6 u5 G% t) s l) x9 @9 L
may have a central nervous system lesion that is
& X2 N$ C" v+ Q# W: |responsible for the early activation of the hypothal-- I' P- E" B! V- z( u
amic pituitary gonadal axis.1-3 Thus, greater empha-+ z3 _; x! |8 J7 ^9 X
sis has been given to neuroradiologic imaging in% y3 _1 a& b4 A& H
boys with precocious puberty. In addition to viril-9 T) X/ @: m. S* x; H5 S
ization, the clinical hallmark of CPP is the symmet-
, |4 W$ g; L: J; H" @- Y1 Jrical testicular growth secondary to stimulation by5 O8 `! w' i3 ]) W
gonadotropins.1,3/ _5 p/ l7 ?6 \. B6 Y
Gonadotropin-independent peripheral preco-
; q) }# @* n0 u, L' y& q$ `7 xcious puberty in boys also results from inappropriate
( J) N( ?6 P; y3 k7 pandrogenic stimulation from either endogenous or. e4 i1 r/ t) a4 ?
exogenous sources, nonpituitary gonadotropin stim-# s$ O7 I' V& e) V: m: n0 o+ V
ulation, and rare activating mutations.3 Virilizing1 w: Q8 L7 c: q
congenital adrenal hyperplasia producing excessive
+ z; E/ t1 X( A! h; H+ ~# a Xadrenal androgens is a common cause of precocious* Y. Q2 I& T5 J4 E2 g$ F
puberty in boys.3,44 t, `8 S* b8 y" ~( l
The most common form of congenital adrenal
2 T, O) m6 b7 F# m" E! S2 e2 Lhyperplasia is the 21-hydroxylase enzyme deficiency.
' D5 K, T( T9 Y. W& _% m% XThe 11-β hydroxylase deficiency may also result in1 M2 f- F5 H# \6 @
excessive adrenal androgen production, and rarely,
2 D+ R4 z/ m) [. [# [: ?. t+ ran adrenal tumor may also cause adrenal androgen6 b7 S. L- J) j
excess.1,3
/ m3 v/ ?7 s0 q% y* b( eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from0 }" K- o5 s5 _$ N% h S+ g# ]
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* s; a# T2 ], \
A unique entity of male-limited gonadotropin-% \+ p7 s g2 t' }2 \4 N! p/ C
independent precocious puberty, which is also known$ P4 M' S1 b$ ^7 \6 }" c: F
as testotoxicosis, may cause precocious puberty at a3 u- Q- t7 X' ~4 c0 j/ H: N/ V, Z
very young age. The physical findings in these boys
6 Y, H% t2 }5 c9 H" J1 uwith this disorder are full pubertal development,+ o/ h; y8 Z( Q# C: Z) m
including bilateral testicular growth, similar to boys
9 T- l6 j; Q, \with CPP. The gonadotropin levels in this disorder% x4 r: {8 Z: P8 X5 p
are suppressed to prepubertal levels and do not show
( \9 p, h5 O5 p- j, a& q x. u0 Upubertal response of gonadotropin after gonadotropin-
/ E) y) ^( N: ?1 t$ L4 y6 zreleasing hormone stimulation. This is a sex-linked
& z( Z4 _1 e! }& Wautosomal dominant disorder that affects only: _# X2 ?5 \- b& n+ F0 H
males; therefore, other male members of the family
0 [0 T) l/ j7 N* g% N2 I, dmay have similar precocious puberty.3
Y9 Y7 f! ~# s$ v+ v" ]In our patient, physical examination was incon-
) Y+ o5 G. @" n8 _$ `, }sistent with true precocious puberty since his testi-
6 ]9 b; u8 V' e! d* E0 scles were prepubertal in size. However, testotoxicosis
7 a& v; D+ C% p% Z Vwas in the differential diagnosis because his father
8 t; d+ e1 ?! o Estarted puberty somewhat early, and occasionally,* R4 ?6 |% s6 ?' h# E/ t
testicular enlargement is not that evident in the
8 E1 V6 W9 ^; v ?0 U% W, _beginning of this process.1 In the absence of a neg-2 m0 S5 n$ O& F* H, H
ative initial history of androgen exposure, our+ [- @, q- |" X8 E2 @7 Z# S
biggest concern was virilizing adrenal hyperplasia,
, k, D0 I2 J6 leither 21-hydroxylase deficiency or 11-β hydroxylase* _. j/ a1 e! i4 i; Q; T2 r! |
deficiency. Those diagnoses were excluded by find-* _, H0 r }; v0 f' X0 q' b; a/ U
ing the normal level of adrenal steroids.
! q( D1 q! D9 T1 X, I1 [+ BThe diagnosis of exogenous androgens was strongly8 n6 T B( G% I2 q! z
suspected in a follow-up visit after 4 months because
; J$ l6 p8 l* a/ U9 O1 D" w7 Sthe physical examination revealed the complete disap-
( |$ A& b3 _7 [0 s( W. J upearance of pubic hair, normal growth velocity, and
. i0 p7 E: q9 L7 C4 t' qdecreased erections. The father admitted using a testos-
1 H7 d7 ?' Q+ {( ~# B8 ^terone gel, which he concealed at first visit. He was
2 v" M. M& O+ i5 ?using it rather frequently, twice a day. The Physicians’3 Q" ]5 h( y7 j4 Z
Desk Reference, or package insert of this product, gel or
& N5 u5 i- e" m1 W: mcream, cautions about dermal testosterone transfer to
, [+ Y) g7 u- f1 S& tunprotected females through direct skin exposure.& j: D8 B `4 K4 t; J' A
Serum testosterone level was found to be 2 times the
5 U( S, T( Y+ r% F o! M; o& qbaseline value in those females who were exposed to
5 G5 c9 A3 G+ L; j* ieven 15 minutes of direct skin contact with their male7 J) E" u8 ^9 v: h: x
partners.6 However, when a shirt covered the applica-
: b* e1 z2 [$ t* B$ G) k) i( }tion site, this testosterone transfer was prevented.; R1 O, B7 z9 V$ _& P7 |" n" \( M, b) _
Our patient’s testosterone level was 60 ng/mL,
& S, ]9 E; p5 A/ |% dwhich was clearly high. Some studies suggest that
9 i n1 W1 j: U/ y; }; ?7 Ldermal conversion of testosterone to dihydrotestos-/ N8 I3 i* v8 G: c5 W! w
terone, which is a more potent metabolite, is more
) ^" n, A: T! aactive in young children exposed to testosterone+ o( E6 R8 O2 ~4 P4 O, C
exogenously7; however, we did not measure a dihy-# E5 Y9 q P" E! `' I1 }" G K
drotestosterone level in our patient. In addition to
/ A6 h6 s4 J8 G2 S/ o+ R) F4 Jvirilization, exposure to exogenous testosterone in
1 c6 x) L* }* Dchildren results in an increase in growth velocity and
% t( c. e) \/ U$ e8 eadvanced bone age, as seen in our patient.6 p# @! Z$ ?2 F9 a1 }3 k, d0 m
The long-term effect of androgen exposure during4 n; h/ N5 l' }+ C9 I+ V7 u% a
early childhood on pubertal development and final/ A, P3 r5 G0 o- B0 \: E
adult height are not fully known and always remain
( o5 Z0 m' l; z S+ aa concern. Children treated with short-term testos-" l9 M6 J |) ?9 M, k. q# \
terone injection or topical androgen may exhibit some
; R% C# g P- F4 N- w! a7 xacceleration of the skeletal maturation; however, after: [6 T3 V* d! ^' N
cessation of treatment, the rate of bone maturation
% c! m" f' \! Ldecelerates and gradually returns to normal.8,9. ^0 Q, ~, P$ P1 C- K" W
There are conflicting reports and controversy
1 \9 ]0 {) t( b1 x( F$ `* v# Yover the effect of early androgen exposure on adult
: H. `& x$ Q* f" j mpenile length.10,11 Some reports suggest subnormal
* m* _2 o/ {& u* p' f2 A6 J7 Tadult penile length, apparently because of downreg-+ B: A$ v2 v1 u* G3 d
ulation of androgen receptor number.10,12 However,
" _$ r- j1 f5 V7 E* |+ J# |Sutherland et al13 did not find a correlation between
5 h% O, ?( j) H6 B. g3 xchildhood testosterone exposure and reduced adult
5 d$ P* D c. M+ X0 D+ A9 Xpenile length in clinical studies.7 j. k& v7 |+ C( b
Nonetheless, we do not believe our patient is& c: |1 j/ T, `' }5 ?+ L
going to experience any of the untoward effects from
3 q' _' S8 o8 `testosterone exposure as mentioned earlier because
" G/ }" k" q, K5 S7 P+ Rthe exposure was not for a prolonged period of time.3 `; D) ?+ f d9 T
Although the bone age was advanced at the time of
/ y0 C5 @, y+ gdiagnosis, the child had a normal growth velocity at6 b# `! Z1 f5 E* y8 {% t+ V
the follow-up visit. It is hoped that his final adult. `- q! i7 X# @% S! L5 }
height will not be affected.7 S9 \. S0 a6 |- \. g: z
Although rarely reported, the widespread avail-' ^/ V) u9 W) ~7 F. V3 } J5 {
ability of androgen products in our society may# p [( O) g7 M! t
indeed cause more virilization in male or female, ?! Y+ L+ `5 c
children than one would realize. Exposure to andro-& c' W% L* F& y+ b' J( _
gen products must be considered and specific ques-
: u1 p5 j( T: ?/ N6 E1 A7 Qtioning about the use of a testosterone product or
) K8 s3 I' I9 A; U9 c Ngel should be asked of the family members during
8 l3 J y9 R8 s& l+ M9 A7 mthe evaluation of any children who present with vir-
3 h# }- c- \- v. silization or peripheral precocious puberty. The diag-
+ B, V6 T# o% {1 V3 Anosis can be established by just a few tests and by4 R% V- z; K6 I$ z5 z4 `
appropriate history. The inability to obtain such a6 r8 K \/ n. W
history, or failure to ask the specific questions, may! @$ R# ?# `5 ?. i( \1 x+ f
result in extensive, unnecessary, and expensive! m% I" C* ]' J2 l* W0 S+ L- x, }
investigation. The primary care physician should be
' x! l6 y- z) R- vaware of this fact, because most of these children
9 o% J7 F' \; W) ~+ g7 A5 Qmay initially present in their practice. The Physicians’
9 g; A1 H! a5 r# W" v; x+ Z3 KDesk Reference and package insert should also put a% ~' S$ ~2 { Y, H
warning about the virilizing effect on a male or" [- l: m3 q: O: |
female child who might come in contact with some-5 R; D" T9 i" P( V* L$ o
one using any of these products.
* s6 N, W' X* Z# M) c5 gReferences
4 z1 @% F' H f3 x1. Styne DM. The testes: disorder of sexual differentiation$ M- }! V' n) L# D) K
and puberty in the male. In: Sperling MA, ed. Pediatric* l" T$ V) G$ W7 W
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
: _$ e$ s% r G$ z" i/ M! X" m2002: 565-628.
7 I0 u, m/ w% [2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. v, [, C6 Z/ r; x
puberty in children with tumours of the suprasellar pineal |
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