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Sexual Precocity in a 16-Month-Old) ?" k8 R8 ]6 _% k! v* ]9 G1 o
Boy Induced by Indirect Topical
. b* S5 k9 u* [2 ?# @5 B( l/ bExposure to Testosterone% e" x! l" f6 ?* Q8 l6 I# J
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. }; n& O1 ?$ l8 {" a+ A* F% F
and Kenneth R. Rettig, MD1* \+ }" q |% L' z) I
Clinical Pediatrics
% K% X, g' D/ h3 m, \1 m ]- x; @Volume 46 Number 6
6 y) x8 O0 t8 ~! L: Q1 Q4 O6 K' tJuly 2007 540-543* g6 _- A$ [+ d: L# @, @
© 2007 Sage Publications! A! I3 A# _7 V% Z; w6 l+ [
10.1177/0009922806296651
& _- K' t1 W# M7 e/ ~http://clp.sagepub.com# P' h% \* ?* [, w3 j
hosted at1 c6 L- n4 T5 F( ]% ?9 ~
http://online.sagepub.com6 O) c0 o5 ?# G5 Q/ B
Precocious puberty in boys, central or peripheral,; a! J O2 M; j1 @. f
is a significant concern for physicians. Central
6 v9 J+ c3 \; ?: tprecocious puberty (CPP), which is mediated
6 ?* P" q0 O% Athrough the hypothalamic pituitary gonadal axis, has: a; S. L3 A. O
a higher incidence of organic central nervous system* B% J! E; z3 w: H$ O+ h: M# k1 F+ O
lesions in boys.1,2 Virilization in boys, as manifested! c( i; w5 E0 k& a
by enlargement of the penis, development of pubic
r, l9 S, ~* M3 E; ^hair, and facial acne without enlargement of testi-4 p! \6 s8 N" c
cles, suggests peripheral or pseudopuberty.1-3 We
8 i8 H; m W) e& F% breport a 16-month-old boy who presented with the( j2 k" q; f1 {, k5 z: e
enlargement of the phallus and pubic hair develop-' @4 ~4 L/ G+ I1 O0 [
ment without testicular enlargement, which was due
7 k: X: I) S j2 rto the unintentional exposure to androgen gel used by
, m# ]( z7 F) j3 h& a4 L& Tthe father. The family initially concealed this infor-) @. R) r- j) {( P% O& a3 u/ O% m
mation, resulting in an extensive work-up for this y$ ~; n/ d' G' X) c
child. Given the widespread and easy availability of
( h$ z+ n6 Q# ?* D8 M0 rtestosterone gel and cream, we believe this is proba-
5 P4 S* |! A6 M% k# V7 @0 qbly more common than the rare case report in the
, \! q: f. P* B+ ^" G) Dliterature.4
4 }9 Q: N% I+ p3 yPatient Report: J4 t# \# D+ v' S; |
A 16-month-old white child was referred to the
+ R' ^" N# d. | V9 Qendocrine clinic by his pediatrician with the concern
, A% W( A# N0 W- i {of early sexual development. His mother noticed. n- A }7 \& U Z& h' b" ~
light colored pubic hair development when he was
/ t1 T0 `4 i: S/ wFrom the 1Division of Pediatric Endocrinology, 2University of
) c( x/ @* s; o- O. LSouth Alabama Medical Center, Mobile, Alabama.
% A$ h$ {- i) pAddress correspondence to: Samar K. Bhowmick, MD, FACE,
% @$ z+ v$ Z: XProfessor of Pediatrics, University of South Alabama, College of6 a0 v; f; \" k I
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
, A2 q. A. c. w" p7 K# O7 ]7 P- ce-mail: [email protected].$ [" Y1 `" u6 S1 \, p+ M5 R
about 6 to 7 months old, which progressively became
0 t8 d7 y8 m) T \: Sdarker. She was also concerned about the enlarge-5 B% h. e% A8 p% J, M' _
ment of his penis and frequent erections. The child+ M6 P, ~) ~; M" S3 m% F; X/ j
was the product of a full-term normal delivery, with
5 R; B: G$ ^* E3 s* W' s+ d5 Ra birth weight of 7 lb 14 oz, and birth length of: r( G& V" o( _, c. h) k; K9 q
20 inches. He was breast-fed throughout the first year
2 ]) {4 ~- k9 ?( V2 Qof life and was still receiving breast milk along with l6 {2 ?: Z: B
solid food. He had no hospitalizations or surgery," K/ o q- u3 O
and his psychosocial and psychomotor development9 ]: P1 v+ M N ~( V
was age appropriate.
/ R1 T+ X) D8 N3 E) KThe family history was remarkable for the father,/ {& ^0 w3 H! @% g+ v9 q4 U+ U
who was diagnosed with hypothyroidism at age 16,2 g; w( T7 }$ B( t
which was treated with thyroxine. The father’s" a/ Y7 P* C/ q6 F2 s2 Y- j+ g; M
height was 6 feet, and he went through a somewhat
- r2 {+ W2 ~; _early puberty and had stopped growing by age 14.$ k$ b/ m8 z3 S D# c
The father denied taking any other medication. The
3 Z5 }4 f: o0 D1 j4 K S3 gchild’s mother was in good health. Her menarche
3 a# J; s8 q# R: H. lwas at 11 years of age, and her height was at 5 feet
2 n8 V1 n( I a: n5 inches. There was no other family history of pre-! S8 s/ k, `2 J _5 t
cocious sexual development in the first-degree rela-
, }( W* v, M- ~& Q4 |; [) \tives. There were no siblings.
0 g" J. }8 Y1 d5 P& z% p. [Physical Examination
$ S6 B, q; i& A% }* {) I' K4 `The physical examination revealed a very active,9 |( A, }8 v. ^: l3 p# y
playful, and healthy boy. The vital signs documented
0 j; J( A5 k# d' P V* R2 Na blood pressure of 85/50 mm Hg, his length was6 ^7 G% t8 f* O6 ` I2 Q, Y
90 cm (>97th percentile), and his weight was 14.4 kg
8 k, d2 n; m6 S7 I% e v" m8 G(also >97th percentile). The observed yearly growth
, k& l4 r+ n# }9 [5 qvelocity was 30 cm (12 inches). The examination of
' o/ B8 b1 j+ qthe neck revealed no thyroid enlargement.
% Z) s( z7 d4 v, b4 y. I, F' tThe genitourinary examination was remarkable for
' K2 g) g3 ~' H3 x5 e0 ?) renlargement of the penis, with a stretched length of5 S' P- x* f4 g& v8 y% L
8 cm and a width of 2 cm. The glans penis was very well) Y0 u* j5 B/ h& c0 U
developed. The pubic hair was Tanner II, mostly around; B3 b- ^. z9 H
540
; x; H' x6 P. k. A4 U- G9 A, p7 ?at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from G8 S7 |; [% v5 X
the base of the phallus and was dark and curled. The. i( F# ]. K' Q4 T, Q- V* G
testicular volume was prepubertal at 2 mL each.
' n' V- u; U& U# VThe skin was moist and smooth and somewhat! W2 }! S( U9 _
oily. No axillary hair was noted. There were no' l! @6 L8 @& o* j) T# i
abnormal skin pigmentations or café-au-lait spots.
0 q+ j( y0 ]' p5 x c# C; ^Neurologic evaluation showed deep tendon reflex 2+4 X0 r7 d( I6 h; a
bilateral and symmetrical. There was no suggestion
3 m; {+ @' p5 k2 yof papilledema.
; \ `2 f# {& Y9 C& ILaboratory Evaluation5 M1 _& l& s8 L+ N0 r& p2 I* X
The bone age was consistent with 28 months by
+ h5 I- N& h5 E" L7 P1 Husing the standard of Greulich and Pyle at a chrono-( u9 U( C" W& b. }' m' i* I4 A
logic age of 16 months (advanced).5 Chromosomal% O# m3 N/ s0 I x. b
karyotype was 46XY. The thyroid function test! s; l/ ?% Q+ A s) j
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
; J6 s$ [, _8 |: s+ j; Q" I/ i' Tlating hormone level was 1.3 µIU/mL (both normal).
1 {5 I4 C6 l7 ?( s( zThe concentrations of serum electrolytes, blood
6 I- t: T C5 z) H; I0 A# p0 x" curea nitrogen, creatinine, and calcium all were
2 h* [4 V6 N; k! c bwithin normal range for his age. The concentration
9 N& L6 T: y X6 Wof serum 17-hydroxyprogesterone was 16 ng/dL
% b. [# }1 D$ f1 V5 R+ n(normal, 3 to 90 ng/dL), androstenedione was 201 Y0 v% p, |$ a( f, O
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-# ?$ o4 f) i% u4 P( n
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 m" D4 l4 J8 U9 ^, Z+ Mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
: P- \9 S. @9 Z8 T1 O* o49ng/dL), 11-desoxycortisol (specific compound S)
' Z/ z- _* n" ~: x. }- e! ^; g+ @was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 G/ i' k4 N* E6 Q% S- Itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
) \6 O- O2 T' N9 ^2 ctestosterone was 60 ng/dL (normal <3 to 10 ng/dL),2 n. r! o7 g% ]
and β-human chorionic gonadotropin was less than' [+ i* {3 `0 @) D
5 mIU/mL (normal <5 mIU/mL). Serum follicular4 _' u7 _' A& _" b* U4 \. q3 F( ^
stimulating hormone and leuteinizing hormone
" @, ]. a+ o# d R' l9 |concentrations were less than 0.05 mIU/mL1 d- A( ~- W/ K) k, N$ b( H- @# H
(prepubertal).1 j1 E, `- e$ n+ ~
The parents were notified about the laboratory" r; y0 {9 {, w
results and were informed that all of the tests were
( i) r. Q# a- P( G* S- ]! Anormal except the testosterone level was high. The- n5 V9 H/ A6 m1 l% w
follow-up visit was arranged within a few weeks to
8 n2 X$ w# g1 q/ r% ~obtain testicular and abdominal sonograms; how-
8 E* V0 t2 f. o0 U+ f7 i8 eever, the family did not return for 4 months.
# {* l, x4 U. d6 ]0 a1 [5 Z9 ~5 J6 uPhysical examination at this time revealed that the
, n5 N/ Z% X* o$ U q+ k2 ychild had grown 2.5 cm in 4 months and had gained" T( Q6 J4 ~, b$ k! H9 h Y( U+ K
2 kg of weight. Physical examination remained
9 k4 p4 g+ q! Eunchanged. Surprisingly, the pubic hair almost com-; p% X1 h# Q, W- C( d3 r) |3 [
pletely disappeared except for a few vellous hairs at
; b3 S6 u) `' o) {the base of the phallus. Testicular volume was still 27 _! T2 a8 X \3 n ^1 N. `
mL, and the size of the penis remained unchanged.$ ]# R2 L# b" j& o5 r. z J
The mother also said that the boy was no longer hav-
& @5 c3 Z7 U1 a8 {3 ging frequent erections.
2 k* e/ b; m8 L9 y0 ?+ a9 ]4 T* ]Both parents were again questioned about use of4 E3 T. c8 b3 Z- S7 O
any ointment/creams that they may have applied to" ]2 ]" q# G& a( X6 n# n( G
the child’s skin. This time the father admitted the# Q4 v: E- W) L, Z2 A6 X
Topical Testosterone Exposure / Bhowmick et al 541
% ]9 m" ]* t4 ]* ^use of testosterone gel twice daily that he was apply-
j% A/ X) `# t: J) N; fing over his own shoulders, chest, and back area for2 D1 M9 l* z8 y% S3 z# T0 W1 d
a year. The father also revealed he was embarrassed
8 o9 h( O% c. E9 `3 q( n% M" _to disclose that he was using a testosterone gel pre-) ]1 M, O! k3 f& n9 ]! T3 @4 u
scribed by his family physician for decreased libido/ L% a4 K+ {* D% u0 O. l+ f8 r
secondary to depression.
2 N" o& |, n4 b8 Q2 U' _( NThe child slept in the same bed with parents.
. ?7 }7 x' w- j/ e1 H: jThe father would hug the baby and hold him on his1 y! \ s7 z* M6 V0 [/ V4 F
chest for a considerable period of time, causing sig-. n7 R' t0 n6 |' _8 g. ~
nificant bare skin contact between baby and father.
/ {- N9 [8 O. m. F1 `6 bThe father also admitted that after the phone call,
8 A$ j0 E! b8 j& Y j5 w7 @* Swhen he learned the testosterone level in the baby
# b3 Z/ s# u; p( x/ y; Nwas high, he then read the product information
/ G! N( l- `1 B3 u' r. c7 bpacket and concluded that it was most likely the rea-' `+ X3 ]3 ^- w7 X) L" k
son for the child’s virilization. At that time, they. e( h+ S8 K" T7 h- Q: p0 s4 c
decided to put the baby in a separate bed, and the5 {6 b$ I! R# k8 b9 d, p
father was not hugging him with bare skin and had% A& S( \2 L2 ]
been using protective clothing. A repeat testosterone9 [/ a$ ]: O9 ]1 M! X$ y
test was ordered, but the family did not go to the% Y1 i/ e1 C+ f k2 r. @" f8 s3 h- ~
laboratory to obtain the test.5 E# M R3 H. p9 l$ S& z
Discussion9 U' y& p, }& _3 H6 n6 `
Precocious puberty in boys is defined as secondary' v+ O& U. y! h
sexual development before 9 years of age.1,4! \+ k! N1 k& }- w$ N
Precocious puberty is termed as central (true) when
/ Q8 e+ C$ Q3 E5 i* D( C( ^it is caused by the premature activation of hypo-
- R; V8 r) C/ H& vthalamic pituitary gonadal axis. CPP is more com-
+ Y6 F( l- A2 }4 P% nmon in girls than in boys.1,3 Most boys with CPP
, U2 ?" X" H0 ^& I0 Y& Vmay have a central nervous system lesion that is' D9 H, _+ q! |: {, f( U
responsible for the early activation of the hypothal-6 W5 f5 {# v T( D" u7 y
amic pituitary gonadal axis.1-3 Thus, greater empha-
+ c, f7 l. b W! i1 _( L$ f. msis has been given to neuroradiologic imaging in$ ^6 r" o0 W. M+ u
boys with precocious puberty. In addition to viril-% Z9 y1 A, w# ]$ O. g% k# X
ization, the clinical hallmark of CPP is the symmet-, k* _% H! d7 I
rical testicular growth secondary to stimulation by
3 v7 B& C) y# f! a* ngonadotropins.1,3
; k% F) q9 K1 F s2 w7 @7 ^. f7 WGonadotropin-independent peripheral preco-" k% E3 D) t4 _- C N7 Z' j4 Z
cious puberty in boys also results from inappropriate
. o" u! z, K/ Eandrogenic stimulation from either endogenous or+ p! g8 r- W: T: v* H- b2 J& H7 `
exogenous sources, nonpituitary gonadotropin stim-
( L! l( E" n1 Gulation, and rare activating mutations.3 Virilizing
' n1 D: C8 ?- i4 h0 p# Dcongenital adrenal hyperplasia producing excessive% P' N. r9 e- ^, u& s1 B- T
adrenal androgens is a common cause of precocious
3 I2 r( ~7 J2 `# n4 @! D$ O2 X( cpuberty in boys.3,4% N1 M+ {. Y0 w6 y6 R* d
The most common form of congenital adrenal
/ V, C9 P3 } T" P2 @ zhyperplasia is the 21-hydroxylase enzyme deficiency.& a+ f! s3 F6 Z# `) {7 F+ K
The 11-β hydroxylase deficiency may also result in# U% Q9 c% S0 e$ D0 \& b4 c1 x. R1 Y9 d
excessive adrenal androgen production, and rarely,* R- O: Z8 {9 T0 a& K
an adrenal tumor may also cause adrenal androgen
, j# o3 C% h: h/ b6 Y" lexcess.1,3
1 t2 o; y& f: v5 U$ m, i6 oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 s6 z% k5 a" ]. n5 `4 t8 }542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
- s) U1 M, d F- t0 E8 }* Z8 NA unique entity of male-limited gonadotropin-3 B: d* Z4 |. R" m, d
independent precocious puberty, which is also known9 U7 i4 K, g$ j( i6 |
as testotoxicosis, may cause precocious puberty at a
+ l: Q, D$ l8 x8 b. s2 Q5 ]) L: x$ E$ mvery young age. The physical findings in these boys7 I$ M# Y! b# o1 a2 ~! @# Z" S* G
with this disorder are full pubertal development,8 Z! z+ J5 n2 J2 k
including bilateral testicular growth, similar to boys
6 c) [! T0 m2 Awith CPP. The gonadotropin levels in this disorder$ t* [7 w( N* `8 S
are suppressed to prepubertal levels and do not show9 s- m& V( V3 S$ T- P- t0 {; y
pubertal response of gonadotropin after gonadotropin-3 ^' Z& k9 L* s, h8 h; n
releasing hormone stimulation. This is a sex-linked) K j( {+ @5 m" `2 ?1 L
autosomal dominant disorder that affects only
+ e7 y1 I, O2 V% U+ Kmales; therefore, other male members of the family
' g# X! `% a8 c0 R8 w r q" mmay have similar precocious puberty.3
. c4 u, k! N8 Q: i. J1 {In our patient, physical examination was incon-3 p' u* i, C3 m# D- |
sistent with true precocious puberty since his testi-
: m: K0 [" v6 ucles were prepubertal in size. However, testotoxicosis
; E9 R: U8 h# v8 N4 kwas in the differential diagnosis because his father
0 [3 K5 T1 Z8 |1 v) rstarted puberty somewhat early, and occasionally,6 _+ z/ x9 V$ k6 i4 w+ I
testicular enlargement is not that evident in the6 P2 d# ?% I; S- w$ q6 m5 ]
beginning of this process.1 In the absence of a neg-8 F& {1 g+ w8 |, w, ^& ?
ative initial history of androgen exposure, our3 r- J$ C! i: u- E2 Q% p
biggest concern was virilizing adrenal hyperplasia,5 L' l/ `( Q0 P5 s
either 21-hydroxylase deficiency or 11-β hydroxylase/ [% x# [8 f* Q
deficiency. Those diagnoses were excluded by find-
8 v; E0 i5 E" A+ X2 F: l- w9 ping the normal level of adrenal steroids.( |3 x8 }8 {! I* i4 R& J) X
The diagnosis of exogenous androgens was strongly/ Q8 z4 ?) X- `2 T; A
suspected in a follow-up visit after 4 months because9 S& w8 Q6 n6 v2 l& L% y
the physical examination revealed the complete disap-
, s# |. o+ @9 dpearance of pubic hair, normal growth velocity, and& X: ]; n* c/ I7 t
decreased erections. The father admitted using a testos-; O; h. _: I3 r
terone gel, which he concealed at first visit. He was) m+ q: R1 \/ X9 z6 W
using it rather frequently, twice a day. The Physicians’
' y, }( n, y0 p9 u0 D/ U: wDesk Reference, or package insert of this product, gel or
' J5 S% A s# Z" M: ?* u0 Zcream, cautions about dermal testosterone transfer to6 f+ r# Y& }- b; O
unprotected females through direct skin exposure.
1 m( {7 T# [9 F1 J5 DSerum testosterone level was found to be 2 times the
3 ]8 h9 U: F. c: m4 R, m; Mbaseline value in those females who were exposed to/ n. z( D: N( l1 S2 G% a
even 15 minutes of direct skin contact with their male E* U* k; m6 j: R# |
partners.6 However, when a shirt covered the applica-+ {& A- s: {4 |0 N- A9 e
tion site, this testosterone transfer was prevented.3 n, C6 K0 r$ X$ N; S, w2 l
Our patient’s testosterone level was 60 ng/mL,
2 T M+ p* e& y2 T( nwhich was clearly high. Some studies suggest that
6 j8 M# e+ j! l4 [1 m% }dermal conversion of testosterone to dihydrotestos-3 p+ k5 G# L+ }4 ]) `% ^0 B
terone, which is a more potent metabolite, is more3 M7 d6 M) F }4 G; M, s+ B2 i
active in young children exposed to testosterone, O& I7 p( _* [, j# m) e7 R
exogenously7; however, we did not measure a dihy-: C& {7 S k$ a$ V$ u
drotestosterone level in our patient. In addition to9 q2 A3 }6 T c) F: t/ A
virilization, exposure to exogenous testosterone in: R- P5 A. a* w i0 g2 l; `9 E% d
children results in an increase in growth velocity and& b( P! H- M/ r( w5 `" [
advanced bone age, as seen in our patient.
& ~6 E% I" O# o5 V( i& T& mThe long-term effect of androgen exposure during: S; F9 Q5 ]; n$ s
early childhood on pubertal development and final
\# H4 N/ N4 F+ B) R5 xadult height are not fully known and always remain
. k1 P# f# ^9 g6 a$ g0 t! N* Ta concern. Children treated with short-term testos-
( l9 i p8 G/ s+ [+ w. jterone injection or topical androgen may exhibit some9 V+ V" T$ M( _9 o L
acceleration of the skeletal maturation; however, after
3 U8 T" A( g) zcessation of treatment, the rate of bone maturation8 `: P9 U' f; e/ O& p
decelerates and gradually returns to normal.8,9
* ?' Z; K( Z0 J# k1 bThere are conflicting reports and controversy h" i+ X8 u. u1 a6 h6 \
over the effect of early androgen exposure on adult
5 t& b3 Q) S' ?0 q& T% f% M; \( Npenile length.10,11 Some reports suggest subnormal, k, m! b" t# |1 U6 P! u: D
adult penile length, apparently because of downreg-
* R( L/ F2 h9 u# {$ } c3 `ulation of androgen receptor number.10,12 However,
, O5 x+ S2 ?$ R% l: wSutherland et al13 did not find a correlation between6 O* O) n3 i) Y. M: p
childhood testosterone exposure and reduced adult" C; m Y! Y& h* S9 t" s
penile length in clinical studies.2 S. k0 L2 r/ S& S
Nonetheless, we do not believe our patient is' H, n" x* _6 H3 [" \5 {
going to experience any of the untoward effects from
/ G( i' i! Q: h7 ^7 t- O! M9 H2 vtestosterone exposure as mentioned earlier because
% r x4 {2 C2 A5 ~) ^the exposure was not for a prolonged period of time./ }; j1 R E- r/ }; q1 [7 y: e5 Q
Although the bone age was advanced at the time of
) ^4 m, T1 a' f0 G0 Fdiagnosis, the child had a normal growth velocity at6 C, ]) I0 O1 y n e/ w
the follow-up visit. It is hoped that his final adult- [* z0 ]) f) |) x- _ p
height will not be affected.
5 F3 ~% |- N- A% h3 ?' [Although rarely reported, the widespread avail-
P8 u1 S+ K4 T9 jability of androgen products in our society may: a2 `* y- f( r h; \, C) h" X
indeed cause more virilization in male or female( T; M" \" s. t' |. ^7 j; {; ?
children than one would realize. Exposure to andro-
& \2 d7 n5 H9 n$ Cgen products must be considered and specific ques-
# E; [4 V3 _! g5 u* itioning about the use of a testosterone product or
: J8 a% ^9 e3 L7 n9 W/ r, zgel should be asked of the family members during0 w, ?6 T0 r/ w
the evaluation of any children who present with vir-
. Z' g% T! A- z( q' i i) m5 w5 zilization or peripheral precocious puberty. The diag-" Z3 a. K8 m" s+ C
nosis can be established by just a few tests and by5 b5 O }$ [; ~! Z
appropriate history. The inability to obtain such a
& C% K- ?: M. k4 L$ _history, or failure to ask the specific questions, may
. B9 v9 c0 i" _3 l7 R) rresult in extensive, unnecessary, and expensive
0 [# j6 s! b" t& G7 O8 [investigation. The primary care physician should be
0 G. {- I; V) _; j$ N V/ z; S Y* zaware of this fact, because most of these children1 T6 y( ^3 p. O7 K/ ?% h
may initially present in their practice. The Physicians’
+ ^' \$ }( D) [& h) i) f! H* HDesk Reference and package insert should also put a# k% {* k- l! h! K4 S7 b& c m' F
warning about the virilizing effect on a male or
; G1 ^+ ]* c5 Y wfemale child who might come in contact with some-
6 H; l8 H2 N% m( E# Aone using any of these products.
. Z0 |: p* G* p, P) j$ A; y( sReferences
$ a* T1 g( Y: V( E1. Styne DM. The testes: disorder of sexual differentiation
: ?6 `4 R* q4 Hand puberty in the male. In: Sperling MA, ed. Pediatric" ^" o1 ~! |- v' s& B9 B( v$ h
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
6 @( ~9 O5 w/ X4 d& m2 p& t2002: 565-628.
7 M. X( l- z8 n2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
, U- @1 k" Q8 ` ^9 upuberty in children with tumours of the suprasellar pineal |
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