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Sexual Precocity in a 16-Month-Old
3 e7 j% {# I3 n1 B2 E' \) \* jBoy Induced by Indirect Topical
6 Q# X! r% ]3 Z" p: M( l6 oExposure to Testosterone/ h9 o$ `& H& O. ]- ]
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* |' Q3 e. P$ m. `and Kenneth R. Rettig, MD1
" R6 n9 T$ c# ?+ x m/ F' J2 xClinical Pediatrics8 E0 G# a, o. \, q( @# q5 j
Volume 46 Number 6$ g6 ?8 J4 z) X* B3 k
July 2007 540-543
6 R5 [# e3 [, j z/ f/ T3 m, `2 s© 2007 Sage Publications- J5 E% V6 q! z% n
10.1177/0009922806296651" C7 z) J* m2 p% B: G9 X
http://clp.sagepub.com
$ w! I" d5 P% A0 T$ Y( l3 w4 n# Shosted at! m0 V& P7 p! j6 r
http://online.sagepub.com: c/ n+ Y' g' P! @' x3 ]# m7 `
Precocious puberty in boys, central or peripheral,
# \- }! d. B" j4 ~; {is a significant concern for physicians. Central
2 U D. M. ?2 z3 E% wprecocious puberty (CPP), which is mediated% S5 D1 o; m3 b9 E6 ~) ~) }# l: D
through the hypothalamic pituitary gonadal axis, has8 \6 [: u0 m' i/ h
a higher incidence of organic central nervous system
. c( w- C' B1 N# S+ e: ~3 rlesions in boys.1,2 Virilization in boys, as manifested
+ m* f) u0 E9 z! Aby enlargement of the penis, development of pubic
0 c X, x/ z4 d6 @hair, and facial acne without enlargement of testi-
/ ^, a: A+ @ v0 _1 F6 i* xcles, suggests peripheral or pseudopuberty.1-3 We
; @* Z' p( r) ?- t4 H# Z' a d. b4 breport a 16-month-old boy who presented with the
" Y- v' V+ F! Venlargement of the phallus and pubic hair develop-
S5 m* ]# w1 {: [0 Jment without testicular enlargement, which was due
! t% u/ q* y: X6 O/ q a3 Cto the unintentional exposure to androgen gel used by* }" X, S# T) r
the father. The family initially concealed this infor-/ ^% ]6 H& _+ I, b. g9 J0 `
mation, resulting in an extensive work-up for this
4 a" m0 e' t- `7 A) i) Achild. Given the widespread and easy availability of
) i! y1 f% N' J: btestosterone gel and cream, we believe this is proba-
: j( v G( n% ~ z2 `; Gbly more common than the rare case report in the9 v/ v% b2 n, F
literature.4
6 P0 T) h5 ~1 F$ D- Y! ?% |Patient Report
9 B$ o6 {6 e! ?5 uA 16-month-old white child was referred to the- m- a' a, r! I) _) J: r9 S& J
endocrine clinic by his pediatrician with the concern2 _- g& e8 `. u% q4 ^$ v
of early sexual development. His mother noticed7 w# Q; n# _: u
light colored pubic hair development when he was$ Y/ [7 V, F( n. K
From the 1Division of Pediatric Endocrinology, 2University of
. Z. l N% Q/ B1 rSouth Alabama Medical Center, Mobile, Alabama.! ~: A$ o8 f W4 O3 i
Address correspondence to: Samar K. Bhowmick, MD, FACE,
) y* M! q! i' q1 _/ hProfessor of Pediatrics, University of South Alabama, College of. Y$ t r5 y3 p8 ~2 K$ Z, {
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- F* N' h- X# l% N, o- P$ [* \
e-mail: [email protected].
& L! D- `% O" W8 y' @) fabout 6 to 7 months old, which progressively became
6 q+ Z9 y/ {# C0 r7 ~darker. She was also concerned about the enlarge-& [, o$ N8 I1 Z" B6 K: D* j" s: B
ment of his penis and frequent erections. The child- H/ T8 r% _- s0 j# y. g4 J
was the product of a full-term normal delivery, with
* M0 q b+ e9 K! O8 Ca birth weight of 7 lb 14 oz, and birth length of6 k8 l' W! B! x! k0 X, q% p
20 inches. He was breast-fed throughout the first year% S" l( x) g/ g) w% w& k
of life and was still receiving breast milk along with
6 b/ F% K& {: d usolid food. He had no hospitalizations or surgery,/ f5 I# \% }" r' B8 E
and his psychosocial and psychomotor development% n5 q% ]- i: t- Y0 C7 J$ o! w
was age appropriate.
2 Q: _( g% P( \The family history was remarkable for the father,. T7 m2 ^5 |" I( ^
who was diagnosed with hypothyroidism at age 16,
, {! e8 |9 o$ C2 J9 \ Twhich was treated with thyroxine. The father’s
/ I7 |+ M* k, E4 Q3 Kheight was 6 feet, and he went through a somewhat
/ F# m( k9 p/ Z( T% p$ g) B [early puberty and had stopped growing by age 14.
& K9 } l! k" q9 D/ ?4 D; ]- SThe father denied taking any other medication. The
% e; X% d2 |- f- n) [child’s mother was in good health. Her menarche
6 b9 N- y) v1 s6 J. k6 C) _was at 11 years of age, and her height was at 5 feet5 b% n- i7 `; y- a* V: g
5 inches. There was no other family history of pre-
: B D1 [4 }6 c: _" s! Y7 f |cocious sexual development in the first-degree rela-& T1 I) C2 t3 J$ g6 m
tives. There were no siblings., V! W: h# X9 Y% A/ K# B$ \6 A
Physical Examination( h, b0 c6 @1 e4 J2 I
The physical examination revealed a very active,
. n/ ?' a" x! C0 f9 \playful, and healthy boy. The vital signs documented
0 ~) j9 m/ r' e# }5 ha blood pressure of 85/50 mm Hg, his length was) a3 K0 O: I6 O* X$ W+ C
90 cm (>97th percentile), and his weight was 14.4 kg
5 [7 b& m- }$ u" d0 A7 |(also >97th percentile). The observed yearly growth" C h! J* h" u0 ~9 G$ y
velocity was 30 cm (12 inches). The examination of- G1 B1 ]7 a. |2 c; c1 x
the neck revealed no thyroid enlargement.
+ h& Q* m G Y7 S5 zThe genitourinary examination was remarkable for3 t/ c. n* c2 |- O- @4 H
enlargement of the penis, with a stretched length of# _' C9 R4 I" D) l3 r
8 cm and a width of 2 cm. The glans penis was very well3 u- w2 b) b8 S ]0 l! ]* W
developed. The pubic hair was Tanner II, mostly around" S* K3 _/ G( h8 `2 M$ j
540
( x$ }2 d: @) G1 N+ f0 X/ uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' v' a+ |% T; h
the base of the phallus and was dark and curled. The
5 s, r5 a. L& W" C7 p1 \! k, { htesticular volume was prepubertal at 2 mL each. O: r- x b4 {6 Z- q" U
The skin was moist and smooth and somewhat
5 [0 T i# |1 T3 K f3 j) Joily. No axillary hair was noted. There were no4 ^8 S" s" {1 j v" i
abnormal skin pigmentations or café-au-lait spots.
# A! h$ ~, x! e& Z+ d% H% RNeurologic evaluation showed deep tendon reflex 2+
; W) }1 D* a5 L6 _: t) m; qbilateral and symmetrical. There was no suggestion
8 |* X! _% T$ _' ?% U, `9 Lof papilledema.: ~ X4 v* |3 T1 x. p
Laboratory Evaluation) a7 S# i5 w2 n1 i
The bone age was consistent with 28 months by
( q: U. D/ `" Q' Zusing the standard of Greulich and Pyle at a chrono-) ~* Q2 L, Z |9 F
logic age of 16 months (advanced).5 Chromosomal' L4 [, T$ t! l) C# [% j
karyotype was 46XY. The thyroid function test. Z$ x- H) z0 Q9 }% [
showed a free T4 of 1.69 ng/dL, and thyroid stimu-% s) `. v D; Q0 R- q
lating hormone level was 1.3 µIU/mL (both normal).: R3 B& l9 P+ [% o: N
The concentrations of serum electrolytes, blood
t7 r: w4 l. u; u0 O. r, gurea nitrogen, creatinine, and calcium all were3 H8 ~# `0 p. s5 E; H. _4 G9 M5 \/ O
within normal range for his age. The concentration# T9 d* g. ~9 z) r8 a7 E# X
of serum 17-hydroxyprogesterone was 16 ng/dL2 N4 b' q7 S# b! {
(normal, 3 to 90 ng/dL), androstenedione was 20
% x; a' f0 ~9 L/ {# c, {* eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
, N: q8 `& n. M; pterone was 38 ng/dL (normal, 50 to 760 ng/dL),
4 K% Z) O" V- A* e. S8 T7 Ddesoxycorticosterone was 4.3 ng/dL (normal, 7 to
- W7 q5 H3 j' r, d. z. T49ng/dL), 11-desoxycortisol (specific compound S)
& s( K, h0 a: V5 T Vwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
0 v. m1 e5 Z% u1 t; @0 v6 |* Z( gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! p" g/ K2 S- F! j1 G+ c4 F7 h m& Ltestosterone was 60 ng/dL (normal <3 to 10 ng/dL),: k9 A z/ d+ ?6 F. j2 v
and β-human chorionic gonadotropin was less than
( U' }& c8 X5 v/ ?; j5 mIU/mL (normal <5 mIU/mL). Serum follicular/ x" Q, r, g8 K$ f! e) _7 W$ S! p W
stimulating hormone and leuteinizing hormone
0 t, f: Y% D& n2 k0 A9 \- Uconcentrations were less than 0.05 mIU/mL
& L5 u; }( r) v' ~5 l" ](prepubertal).
& H/ B. O+ L+ f* XThe parents were notified about the laboratory
0 n* O2 Z* {+ ^) u9 T/ yresults and were informed that all of the tests were
& }/ y- J" t- t2 E- p+ `6 v* q9 J- Hnormal except the testosterone level was high. The
2 x/ ?" P8 \9 P, Vfollow-up visit was arranged within a few weeks to6 ?4 X9 i- A. A7 l% i0 U
obtain testicular and abdominal sonograms; how-1 Q7 n N7 c/ z! `( A3 m, V
ever, the family did not return for 4 months.9 I3 P! H' A( V* N, k
Physical examination at this time revealed that the _0 w( ]8 R4 P6 V4 _: _. N
child had grown 2.5 cm in 4 months and had gained7 T0 T$ _6 \" ~/ `
2 kg of weight. Physical examination remained
. Z* T. d: I0 d# ?3 M- M* Zunchanged. Surprisingly, the pubic hair almost com-
" b/ o% W8 M9 U0 j$ fpletely disappeared except for a few vellous hairs at6 A2 t* _- D; {/ w' S6 _ g
the base of the phallus. Testicular volume was still 2
/ \4 }, H* i, ^2 {4 mmL, and the size of the penis remained unchanged.
. m" ^0 e* ^" ~* H& RThe mother also said that the boy was no longer hav-6 U* p; ]- u# g$ j, O/ H
ing frequent erections." n9 J+ j9 I0 a0 E
Both parents were again questioned about use of
2 H; ^% z$ ?% G4 F% [6 j# E9 j4 W* xany ointment/creams that they may have applied to- H. H% \- s2 l: {
the child’s skin. This time the father admitted the
5 h( ]+ j) k4 a- C' F( g& d7 z T: W9 wTopical Testosterone Exposure / Bhowmick et al 541' A' |) O9 n+ E k" F
use of testosterone gel twice daily that he was apply-" g0 X$ a; d4 q& L& U1 T
ing over his own shoulders, chest, and back area for
" x5 b; C. o- e7 w' Ha year. The father also revealed he was embarrassed0 r/ g. Q _" K% e/ U8 e* F
to disclose that he was using a testosterone gel pre-8 T5 H8 n/ [& |* N
scribed by his family physician for decreased libido
2 n; X d& S8 Q4 a8 @( Wsecondary to depression.
5 c1 y/ h! _8 X! G. A6 Z7 N" o4 GThe child slept in the same bed with parents.8 L% |$ z. \7 m+ \
The father would hug the baby and hold him on his
& p$ b! f& ]9 Vchest for a considerable period of time, causing sig-" K6 S% W* C4 q* l7 f7 D! h
nificant bare skin contact between baby and father.! I2 a Y# K' {9 e9 m4 e
The father also admitted that after the phone call,
+ d8 c( t7 Q0 x& Owhen he learned the testosterone level in the baby
$ v0 C0 x/ q: t, d2 i7 W7 ]was high, he then read the product information
' Q. r; M+ @# [) Wpacket and concluded that it was most likely the rea-3 K b) A% b) W
son for the child’s virilization. At that time, they8 h+ c0 b4 q5 C
decided to put the baby in a separate bed, and the) t9 V% I9 m. \
father was not hugging him with bare skin and had
* \2 ] W# t+ H( Z0 Dbeen using protective clothing. A repeat testosterone( B$ U4 Y, I; w R, w' e
test was ordered, but the family did not go to the8 U5 k% X* s5 }% y
laboratory to obtain the test.
7 N0 a5 ]4 v. u9 ODiscussion
# l9 d; U, P: r0 ^Precocious puberty in boys is defined as secondary8 B6 f, H$ I8 }; i4 o' t+ n, }
sexual development before 9 years of age.1,4
7 i# S) E/ R7 a! T$ rPrecocious puberty is termed as central (true) when
6 q- C; k! R+ L- x! ~; bit is caused by the premature activation of hypo-4 V1 @: A2 K& @" o, l+ a: |1 Q
thalamic pituitary gonadal axis. CPP is more com-
' ]* {2 y( w+ z) g) r9 C$ G$ s8 a+ U$ vmon in girls than in boys.1,3 Most boys with CPP/ F& R t T. A$ l$ ?
may have a central nervous system lesion that is5 h" n9 B, J1 Z0 j! f
responsible for the early activation of the hypothal-( U: _2 q4 p1 X3 ]1 v$ H
amic pituitary gonadal axis.1-3 Thus, greater empha-
; ^ W. i) K/ O0 p0 @/ I B$ D/ H8 Lsis has been given to neuroradiologic imaging in) S) C; r/ W. L; {6 n
boys with precocious puberty. In addition to viril-
; ~. X/ z! n/ l/ uization, the clinical hallmark of CPP is the symmet-, { M3 N( G+ M& ^# R, Y' p6 r3 E
rical testicular growth secondary to stimulation by
. O0 P! X1 f; ~gonadotropins.1,3; a2 [# N$ G2 L5 y7 H* K9 M
Gonadotropin-independent peripheral preco-
6 ?8 b: y* `4 V: {4 w% wcious puberty in boys also results from inappropriate
$ f) N9 v6 ~* X3 O: i) c, |$ Q% P' jandrogenic stimulation from either endogenous or
& D- C9 Y& p6 S/ K" K# rexogenous sources, nonpituitary gonadotropin stim-
4 r9 X8 `2 X& D0 [7 d# Bulation, and rare activating mutations.3 Virilizing; a1 ?) t- o! c5 a/ B
congenital adrenal hyperplasia producing excessive; k$ h1 u9 J8 @- E
adrenal androgens is a common cause of precocious
; B( M8 c/ h0 Q& q! }7 ` C2 Ypuberty in boys.3,4$ y% O# _% Z; m: ~! o* E
The most common form of congenital adrenal
/ m( R1 X3 a/ o! J# u3 w7 _9 Yhyperplasia is the 21-hydroxylase enzyme deficiency.
' a& ^) T) k& k0 _2 {The 11-β hydroxylase deficiency may also result in
L/ E% d& o3 lexcessive adrenal androgen production, and rarely,# E. }. F* c: }+ w4 w8 S
an adrenal tumor may also cause adrenal androgen
( _6 K i+ e) K* ~. o( L Iexcess.1,3
2 H# w" [ _" {at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from( a, g' t( Z, _% |1 S9 \( s
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, s5 I8 C' B; c
A unique entity of male-limited gonadotropin-
' g7 j7 `$ N5 J( H+ M5 U/ Eindependent precocious puberty, which is also known
3 Y8 J: p' |4 b, o' v% h7 R5 x( @as testotoxicosis, may cause precocious puberty at a
2 m1 W$ N j* P6 xvery young age. The physical findings in these boys& Z7 @, a6 B! _% @) _. u
with this disorder are full pubertal development,
& y. I9 D* q4 u/ L7 {- l+ hincluding bilateral testicular growth, similar to boys$ Q5 g% e' [0 k% ^% w5 e& [7 A" I9 p$ c
with CPP. The gonadotropin levels in this disorder- J6 h6 n+ m7 r$ A+ l
are suppressed to prepubertal levels and do not show7 K- P# F- r! h9 B# G
pubertal response of gonadotropin after gonadotropin-& [% P% B9 a- u. i+ j2 {
releasing hormone stimulation. This is a sex-linked
4 `5 H1 V) p6 P" r4 L lautosomal dominant disorder that affects only' I$ Z* S, W _$ j0 X
males; therefore, other male members of the family
' ~( O& M0 g, F% U9 z; nmay have similar precocious puberty.36 i& e, O$ m* n$ J4 E- z* H2 I
In our patient, physical examination was incon-
. g0 Q' P0 _- f, f. Q: Fsistent with true precocious puberty since his testi-# A$ j7 `: w. R0 E( b1 g, @0 y7 p
cles were prepubertal in size. However, testotoxicosis
' g7 n: W& F7 o5 l0 f/ Xwas in the differential diagnosis because his father
$ c* H/ {1 G# b" \started puberty somewhat early, and occasionally,; D% b. _+ q4 C- D6 ^
testicular enlargement is not that evident in the
3 q+ e# ~8 A/ j# cbeginning of this process.1 In the absence of a neg-
$ B, D& o( ]) R- x" a1 e" F6 lative initial history of androgen exposure, our
: }$ c6 D' j# L# v/ S. Mbiggest concern was virilizing adrenal hyperplasia,2 b& Y4 q B. n( a; {! p, h" c6 f
either 21-hydroxylase deficiency or 11-β hydroxylase
7 X* w4 T8 U2 }1 Cdeficiency. Those diagnoses were excluded by find-
. b$ J1 c# F x K. s: Qing the normal level of adrenal steroids.
5 M, b7 ~ N+ h. e9 y8 t! Q' {1 N5 NThe diagnosis of exogenous androgens was strongly# M! J7 }; R+ [! x; O& Q
suspected in a follow-up visit after 4 months because
6 [0 Q3 n; X1 E8 ^! Gthe physical examination revealed the complete disap-
+ {0 W: m: o4 z8 }- Q, Ypearance of pubic hair, normal growth velocity, and
$ s! J+ B; q( K C: T' ?decreased erections. The father admitted using a testos-
9 M! E/ N* f% aterone gel, which he concealed at first visit. He was& p. f; \4 a. O" D2 R
using it rather frequently, twice a day. The Physicians’2 J- w1 @/ H5 V j4 ]2 G+ f/ ~
Desk Reference, or package insert of this product, gel or$ K6 F0 F" Q+ J3 o( _
cream, cautions about dermal testosterone transfer to
/ ]" P( i$ s* N- W. M7 `unprotected females through direct skin exposure.
2 Q0 R- {- p1 m' l& ~) D9 r: I- P! aSerum testosterone level was found to be 2 times the
; T# B& i: H, G4 Vbaseline value in those females who were exposed to' w+ [9 a/ w+ ~& |" q
even 15 minutes of direct skin contact with their male
e7 Y$ @* f3 s1 ?' N+ Ipartners.6 However, when a shirt covered the applica-
W$ m, e8 w; Qtion site, this testosterone transfer was prevented.
: a+ S2 w/ S; l: L* H' o; zOur patient’s testosterone level was 60 ng/mL,
* E! L( b# p% n0 t: O* {" Zwhich was clearly high. Some studies suggest that4 t5 x8 m8 E- l7 q6 R
dermal conversion of testosterone to dihydrotestos-
5 q5 R2 ~: k3 f$ x* j% G7 rterone, which is a more potent metabolite, is more
, g0 m2 K0 w6 r( @0 _3 W0 Sactive in young children exposed to testosterone- O, z/ E2 z$ u; i& h7 H& e* p
exogenously7; however, we did not measure a dihy-2 Q% J% M+ Z: r$ d3 S7 z7 j
drotestosterone level in our patient. In addition to
- _* B7 x8 G. W' m& Avirilization, exposure to exogenous testosterone in
' M+ _, B' K% {3 U+ wchildren results in an increase in growth velocity and# h. Y9 k3 q. s: e, u$ R& L8 ?' p
advanced bone age, as seen in our patient.' m2 J- t0 A/ N. k8 a" G8 d, `. Q: H' c
The long-term effect of androgen exposure during+ p4 H; a1 x; _% w- R& H3 g K
early childhood on pubertal development and final7 w1 s: W8 r6 D/ ^
adult height are not fully known and always remain3 W+ e l* [% g5 W2 q) f
a concern. Children treated with short-term testos-: I; v( T1 z: ^* S. k
terone injection or topical androgen may exhibit some1 |" R: J+ F; ^! k& m( s2 g3 ~2 p& K" Q4 P
acceleration of the skeletal maturation; however, after
! R6 t5 N2 `$ j/ hcessation of treatment, the rate of bone maturation
, C5 P: v2 C6 R+ vdecelerates and gradually returns to normal.8,99 I) s& N1 w# M9 y, c' I
There are conflicting reports and controversy
) I5 }9 T! g9 _+ Mover the effect of early androgen exposure on adult
5 }; E* `) a6 ]" Upenile length.10,11 Some reports suggest subnormal
0 i% a1 J7 ^) h% t6 J0 dadult penile length, apparently because of downreg-
7 Z- J b) O8 @ulation of androgen receptor number.10,12 However,
/ G0 c" }9 ~5 `5 x6 W6 O: b. J S% gSutherland et al13 did not find a correlation between% [+ @) \! w3 U" B
childhood testosterone exposure and reduced adult
d7 w! A; z6 n; \, dpenile length in clinical studies.4 a1 }2 e6 r) T1 B1 E" y
Nonetheless, we do not believe our patient is
0 u7 s1 }. _* u! rgoing to experience any of the untoward effects from! [$ m. I0 i c7 B4 Z7 h' c7 F
testosterone exposure as mentioned earlier because
9 g( ^' P1 H: Q7 h# R0 c) Jthe exposure was not for a prolonged period of time.
G( O( ?- _3 H; M: VAlthough the bone age was advanced at the time of: D* o6 {1 v' c1 `# q% r" M( G
diagnosis, the child had a normal growth velocity at" T5 j+ I/ J+ }7 Q+ } N" w
the follow-up visit. It is hoped that his final adult/ f# X( q0 x1 q; X& s
height will not be affected.* H2 W: k$ W) q' Z0 f
Although rarely reported, the widespread avail-% y1 {' @9 a# t' l8 i3 }3 D
ability of androgen products in our society may
* E7 A o5 }) y" K% t/ O7 Nindeed cause more virilization in male or female
/ k( \% q# d" m9 B8 G5 P; Nchildren than one would realize. Exposure to andro-
; {1 h B7 I5 q. Mgen products must be considered and specific ques-; G+ O: @1 D- M; i f3 J
tioning about the use of a testosterone product or
* d+ n# }6 u6 P. d( V' Ygel should be asked of the family members during
: I9 X! j* f' k' B- Othe evaluation of any children who present with vir-0 b; J- y5 T0 C4 C/ I) N
ilization or peripheral precocious puberty. The diag-1 V' d2 k7 q4 D8 h
nosis can be established by just a few tests and by
3 g0 |, w: d% F' i9 q7 Happropriate history. The inability to obtain such a
4 y5 R( R+ X* Yhistory, or failure to ask the specific questions, may
) ~; L5 r* b* M) O& |! Q& }+ K! Gresult in extensive, unnecessary, and expensive1 y4 M# w2 y4 } J+ _
investigation. The primary care physician should be% i" h: M' c% c! Q7 g
aware of this fact, because most of these children. q1 V# C1 E( N
may initially present in their practice. The Physicians’- o- S3 t! G( z- P
Desk Reference and package insert should also put a1 U4 A& q/ N. n7 ?
warning about the virilizing effect on a male or
, g; x; D' N6 I( Gfemale child who might come in contact with some-3 D( ]/ x9 K! a+ R) N
one using any of these products.* s$ v" I# L6 P
References: l$ x1 \; ]: B" |3 D( \
1. Styne DM. The testes: disorder of sexual differentiation8 E7 N+ H6 b- a
and puberty in the male. In: Sperling MA, ed. Pediatric
1 V2 m1 K" Y% i" `" yEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 }, ^; ~6 o9 w4 B
2002: 565-628., X7 t$ G: g/ _8 ~2 P' j
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
6 @. s' a0 q+ J5 D2 xpuberty in children with tumours of the suprasellar pineal |
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