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Sexual Precocity in a 16-Month-Old0 U+ b; x) j; m$ a3 D: q
Boy Induced by Indirect Topical
! n' ]/ a& ]; f# R' O. WExposure to Testosterone
- ?1 \ F2 `4 o) LSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
5 \9 S2 Z1 s5 |# C9 p: t& [0 Oand Kenneth R. Rettig, MD1. d8 J% a# h+ D F- a
Clinical Pediatrics
6 l, Q4 M3 F* q% y0 A3 H, AVolume 46 Number 6
0 L! v0 x, h$ U2 }* L" Z( FJuly 2007 540-543
2 G+ V( |, H& c7 b, u- _" `; q© 2007 Sage Publications
( i0 i9 b2 n3 x2 R10.1177/00099228062966510 H% D( H& B$ W# @0 C. R
http://clp.sagepub.com
2 z. @ T/ G1 {4 ~hosted at
8 K& x; j# q, `! {) M# Yhttp://online.sagepub.com, H5 v4 g- ?- n {4 L
Precocious puberty in boys, central or peripheral,
& t/ B- C& r) f3 T! |* Cis a significant concern for physicians. Central
8 \. d* {; D* u0 s1 l+ M7 j- |* uprecocious puberty (CPP), which is mediated4 H& I7 }9 [: N( a+ j
through the hypothalamic pituitary gonadal axis, has
: B8 V( w6 Z4 ca higher incidence of organic central nervous system3 v( r' P+ S" J0 z X' V4 a2 v
lesions in boys.1,2 Virilization in boys, as manifested3 T3 [3 v9 Q8 U# C4 b9 H
by enlargement of the penis, development of pubic
' T# z/ d* Q- p6 E, q# d, _% Qhair, and facial acne without enlargement of testi-
5 Q. D, R" c% W7 Ycles, suggests peripheral or pseudopuberty.1-3 We3 W9 p0 L/ ^* D* {" ]( v
report a 16-month-old boy who presented with the
5 {$ m ?! z+ B& p* \enlargement of the phallus and pubic hair develop-
$ H" q3 p/ }) E: J/ d+ O: |ment without testicular enlargement, which was due
8 | C: P% u; G3 Yto the unintentional exposure to androgen gel used by0 c7 J9 n7 h; K. X1 O
the father. The family initially concealed this infor-9 u% M: p7 R( D. n( ~& ]* h
mation, resulting in an extensive work-up for this( `5 l6 c( f. h# e7 |# O
child. Given the widespread and easy availability of+ r! U- F+ y( I+ h$ R
testosterone gel and cream, we believe this is proba-/ c* F; o" o0 G6 d2 D
bly more common than the rare case report in the
& R2 [3 |) j+ b* |# Mliterature.4, D, {& s& p; c0 y p. ~# l
Patient Report
0 {# F& I0 \0 X1 g8 t% {A 16-month-old white child was referred to the* x8 o/ Q2 K- _* `2 o
endocrine clinic by his pediatrician with the concern
/ ~% C/ I! n& z0 L% Qof early sexual development. His mother noticed
) P% g2 d8 {: M- Xlight colored pubic hair development when he was
: S2 M6 M0 A4 }: |- GFrom the 1Division of Pediatric Endocrinology, 2University of
) b D3 G9 ~& L) `3 ESouth Alabama Medical Center, Mobile, Alabama./ K3 Z9 u! C! v$ n& V
Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 F G" C/ Z" T) fProfessor of Pediatrics, University of South Alabama, College of$ d- c+ B1 e3 @# y6 p) B7 G0 F
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" n& c/ @, n" i8 v, U7 me-mail: [email protected].
: C! S: {3 S8 ~) v5 D: ?% Babout 6 to 7 months old, which progressively became; q- G1 |: W* f- [
darker. She was also concerned about the enlarge-1 H. _. \7 N+ w. M+ w5 `
ment of his penis and frequent erections. The child
; N2 i# }. ~, U6 @+ o; w. Wwas the product of a full-term normal delivery, with- t, r! k3 W* B: S2 y8 H% w
a birth weight of 7 lb 14 oz, and birth length of
5 @5 ]5 B n6 [+ L, Z4 U20 inches. He was breast-fed throughout the first year( E1 S/ W7 o9 g: T' q% C
of life and was still receiving breast milk along with
2 d% D. S. \( \- Q x9 G& O% w; Msolid food. He had no hospitalizations or surgery,
- y! \( v4 J( z4 Q% ?0 Uand his psychosocial and psychomotor development
6 m# j7 ~; D! |0 ^& lwas age appropriate.2 x( s* r) K* w
The family history was remarkable for the father,. F _ ^4 s' }% {0 q5 b: Z
who was diagnosed with hypothyroidism at age 16,
; i8 c& E6 D C9 Hwhich was treated with thyroxine. The father’s/ p( Y" w- }( L" u8 _
height was 6 feet, and he went through a somewhat9 O( `/ t+ [7 {
early puberty and had stopped growing by age 14.
4 ?/ x6 i1 r# }4 c: u8 bThe father denied taking any other medication. The, @ p; H: S/ M6 A
child’s mother was in good health. Her menarche4 A7 |. \/ J+ G: f6 }7 ?3 f
was at 11 years of age, and her height was at 5 feet
# P2 @/ s6 G0 v- p( t& S( w% ?5 inches. There was no other family history of pre-1 U6 U5 L% r. o1 U
cocious sexual development in the first-degree rela-
0 F* F7 Y8 p9 v/ y% l9 Wtives. There were no siblings.
. v5 G3 g) }5 A# n. f: @9 _Physical Examination
- ~ P) Z9 l P7 W1 T$ U' ^The physical examination revealed a very active,3 O6 \! C* _4 y* v% f
playful, and healthy boy. The vital signs documented( t, R, e1 l$ A, f
a blood pressure of 85/50 mm Hg, his length was! y0 ] K! L0 I$ c# F
90 cm (>97th percentile), and his weight was 14.4 kg3 X' {' K7 F/ P0 B2 j) T/ k
(also >97th percentile). The observed yearly growth4 V5 c7 U# P3 z# m/ q8 }
velocity was 30 cm (12 inches). The examination of4 f! p7 {9 ^# e5 r6 \1 |* J
the neck revealed no thyroid enlargement.
% n! _5 Z! q0 q, X9 pThe genitourinary examination was remarkable for3 V0 |1 _. m) @( L' \: X
enlargement of the penis, with a stretched length of Q0 U3 F( s0 R' I' e% f
8 cm and a width of 2 cm. The glans penis was very well
5 u; z% s/ R o6 K/ x1 h5 pdeveloped. The pubic hair was Tanner II, mostly around( `4 K' J# } D v8 e3 {# e
5409 N& w" f: `4 E r) Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ o$ n" L& ~/ u: d0 D! l Mthe base of the phallus and was dark and curled. The
0 [( T, S9 p; d; m; `* ttesticular volume was prepubertal at 2 mL each.! V" W0 C5 Z# R6 x3 h. {$ ]
The skin was moist and smooth and somewhat! R, i7 w, t* C$ a
oily. No axillary hair was noted. There were no
/ R- }% n% @! \/ Zabnormal skin pigmentations or café-au-lait spots.
8 A* e5 t9 ^ {9 f: ~. ONeurologic evaluation showed deep tendon reflex 2+; h: ~. F" W4 D& w
bilateral and symmetrical. There was no suggestion% O, k' W' K1 l' C* m
of papilledema.
% |3 l6 u- V2 C) eLaboratory Evaluation5 [( Q9 Q; O. m J4 n, ]* p
The bone age was consistent with 28 months by2 X- F) k, T. C. I
using the standard of Greulich and Pyle at a chrono-1 j& P/ W. d V' a+ T
logic age of 16 months (advanced).5 Chromosomal
- L% f0 f. j% | Wkaryotype was 46XY. The thyroid function test
+ S. T% j" a2 y# H# x4 }+ E9 zshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
Y% z5 \3 X! w& b0 _lating hormone level was 1.3 µIU/mL (both normal).
1 b' v; E% }+ c4 V1 D* rThe concentrations of serum electrolytes, blood
2 ~' m" S6 W" F9 L2 lurea nitrogen, creatinine, and calcium all were
0 K7 @3 ]2 [/ w$ U) }! Uwithin normal range for his age. The concentration
& W( E! c7 E3 A- fof serum 17-hydroxyprogesterone was 16 ng/dL( h- r, L2 c4 i' ~
(normal, 3 to 90 ng/dL), androstenedione was 20, @- ~1 C, B1 a6 Y% e
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ \! P7 k2 k: H+ C" f& Vterone was 38 ng/dL (normal, 50 to 760 ng/dL),
6 d: S( ]6 p0 Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to& P( [! U* L* H
49ng/dL), 11-desoxycortisol (specific compound S)" r8 t* Y* E0 C* {. x
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
' m+ x) l1 N. ztisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% Z: Y T: t: q' A6 m& K: ?7 Y+ itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),4 \0 ^- o3 Y9 i0 {
and β-human chorionic gonadotropin was less than+ i2 h# s2 t2 |" K, [5 y8 |! V# _8 d
5 mIU/mL (normal <5 mIU/mL). Serum follicular3 b1 X2 x+ U8 V3 p+ R, f' A
stimulating hormone and leuteinizing hormone
8 d# d" q0 e0 j+ h9 C$ M$ J9 }5 Kconcentrations were less than 0.05 mIU/mL! c4 b8 o( P! G8 `) M; q
(prepubertal).5 u6 k. l+ m- t* X
The parents were notified about the laboratory( y+ @* h- K' i- [3 C
results and were informed that all of the tests were
! m9 J1 g: x! ^: e- jnormal except the testosterone level was high. The
" M& L. j+ T+ x& _1 T; e+ r( Lfollow-up visit was arranged within a few weeks to M F+ a. f7 q3 ]% v9 c) k
obtain testicular and abdominal sonograms; how-" i7 x* ~+ N8 g( Q: W
ever, the family did not return for 4 months.( h; t& B, t+ @: u
Physical examination at this time revealed that the
# B9 v$ X4 O5 i1 {child had grown 2.5 cm in 4 months and had gained' z q7 C3 a" x8 i: {
2 kg of weight. Physical examination remained
! u: \$ b. s2 W3 E2 s* k: ?* \unchanged. Surprisingly, the pubic hair almost com-
4 o9 v4 C' ?3 ^' Xpletely disappeared except for a few vellous hairs at
# G9 h$ w1 z3 D: U& {+ c0 \the base of the phallus. Testicular volume was still 2
4 M# T$ O9 [9 jmL, and the size of the penis remained unchanged.
1 d- O W! n0 V% `' IThe mother also said that the boy was no longer hav-
+ F5 v# r G: ^8 C0 W# @! J* c: ?ing frequent erections.6 H* n; P2 `+ W# w
Both parents were again questioned about use of
" c& c0 }$ z9 |& M4 r! F: ~any ointment/creams that they may have applied to: H# l/ t" {+ n- L9 {' D1 o
the child’s skin. This time the father admitted the; P( i1 z W( p4 j1 h
Topical Testosterone Exposure / Bhowmick et al 541
6 _) B8 k( G, c6 Nuse of testosterone gel twice daily that he was apply-" H1 ~8 x* C. ]* z3 o, { b9 P
ing over his own shoulders, chest, and back area for. X: w0 L8 k1 O- z; _
a year. The father also revealed he was embarrassed
. r. x$ t Z: V+ e0 N {3 ?( f+ [9 Oto disclose that he was using a testosterone gel pre-6 ?' A, C; _( C) M9 P8 m
scribed by his family physician for decreased libido; @+ e& C: W- Y4 l; y
secondary to depression.# M& W2 O$ u a
The child slept in the same bed with parents.
4 Y% ^, B- [8 a1 m! \ b1 _9 J5 zThe father would hug the baby and hold him on his
2 p' S2 l' _! B5 ~) a: m3 kchest for a considerable period of time, causing sig-
+ d0 V& ?0 V% {0 Z& onificant bare skin contact between baby and father.: g z5 Y, R* g& N' ~* N
The father also admitted that after the phone call,
; Q5 v9 n# w* Y+ o+ M# A/ c3 awhen he learned the testosterone level in the baby
0 N- `) \' M9 a1 ^& v: wwas high, he then read the product information n/ l$ B0 @" c: a; B) r
packet and concluded that it was most likely the rea-
! ~5 x% J. u% E0 V- ~5 d' ~son for the child’s virilization. At that time, they, z% [; u: c P& ~5 z
decided to put the baby in a separate bed, and the
' }4 U* n a5 ifather was not hugging him with bare skin and had" ?: ?$ j# k( I- W1 b: n
been using protective clothing. A repeat testosterone y- R0 }3 ~, }, e/ g7 v
test was ordered, but the family did not go to the2 x+ z+ }" w$ S) k" p
laboratory to obtain the test.0 Y% L" T8 W% J k3 F
Discussion2 Y2 ]! B$ n7 B; G
Precocious puberty in boys is defined as secondary1 K5 u/ `1 L9 \3 l' c
sexual development before 9 years of age.1,4
1 |4 o' i3 P/ F1 X) FPrecocious puberty is termed as central (true) when$ R/ n1 Q, v) y2 {2 _: A6 R
it is caused by the premature activation of hypo-& R8 B: b' a5 x1 U m; U* s& ~3 k
thalamic pituitary gonadal axis. CPP is more com-
( u* a0 e# Y6 k% k; q: B$ }mon in girls than in boys.1,3 Most boys with CPP- z/ d/ P* b- e! X7 u
may have a central nervous system lesion that is/ B. R; c9 W/ L! x5 v5 N: F
responsible for the early activation of the hypothal-
) }/ o4 T) [, W7 z# y K9 vamic pituitary gonadal axis.1-3 Thus, greater empha-
8 R3 x: K0 [; ?+ U% K8 O" dsis has been given to neuroradiologic imaging in- p' @. _: K5 B {
boys with precocious puberty. In addition to viril-3 j4 k" u! a# R, t
ization, the clinical hallmark of CPP is the symmet-' h! f. Z% M; ]) s$ Q, f l' g
rical testicular growth secondary to stimulation by
- w7 ^, E" p0 F1 H! h Wgonadotropins.1,3
, v7 y, [; Y$ v" ?: i; v3 KGonadotropin-independent peripheral preco-
2 [7 T8 }; j: D, z$ Q: S! kcious puberty in boys also results from inappropriate' L/ N3 Z- Q# w: O$ ^
androgenic stimulation from either endogenous or
& @$ L! p4 b7 C! jexogenous sources, nonpituitary gonadotropin stim-
* u9 {+ l3 Y) G- i8 c' Wulation, and rare activating mutations.3 Virilizing5 g1 l/ J7 v. F |9 L3 a
congenital adrenal hyperplasia producing excessive% N) x) S/ I9 e2 D9 i" U2 Q% ^; h
adrenal androgens is a common cause of precocious$ h3 T$ v: P) \; a8 a8 Z* h
puberty in boys.3,4! L7 B/ X5 K# s, X6 O" p) T+ j
The most common form of congenital adrenal6 M. R! L, ~( \! R! z8 {/ q
hyperplasia is the 21-hydroxylase enzyme deficiency.# t; o$ y( |# w# E- w. u) n
The 11-β hydroxylase deficiency may also result in
5 c+ }, H X$ v$ L8 @0 qexcessive adrenal androgen production, and rarely,) O- Z2 t9 p# k) ~
an adrenal tumor may also cause adrenal androgen
* o8 O0 ^2 J7 J7 |+ t1 q# Jexcess.1,33 n+ s5 M6 ?2 x+ A- _/ f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- k' m. J$ s4 Y/ A: \542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' s7 ]* o' w" e9 d3 r: U! T
A unique entity of male-limited gonadotropin-
) C8 \- `, B1 lindependent precocious puberty, which is also known
) b0 C' m7 @- A2 \3 {as testotoxicosis, may cause precocious puberty at a! A: Q5 o: r) D0 ~( ` z/ g+ H
very young age. The physical findings in these boys
9 E0 B5 i# w4 jwith this disorder are full pubertal development,
% W3 @% s: O* _including bilateral testicular growth, similar to boys% Z6 B4 r9 K+ {, F2 w- M6 o
with CPP. The gonadotropin levels in this disorder, n/ \/ I- h: H4 k- L
are suppressed to prepubertal levels and do not show
+ X Y5 A+ y( B% _9 D, B. ^pubertal response of gonadotropin after gonadotropin-% O. ^5 R% g0 c( t6 B
releasing hormone stimulation. This is a sex-linked# {( l9 l$ `0 g. E! U5 r# n z
autosomal dominant disorder that affects only
2 l0 \! {4 m$ e8 `4 V$ R' Hmales; therefore, other male members of the family u( t. ^0 Z# B9 | \
may have similar precocious puberty.3
" ^) i4 z+ q$ c: @$ p; X! e- mIn our patient, physical examination was incon-( ]4 \2 s2 A. x4 e+ p( k
sistent with true precocious puberty since his testi-
4 Y: ~) N% ]- {- a$ K( {5 i5 ?2 Icles were prepubertal in size. However, testotoxicosis; p* F* }% l7 ^( {4 O1 M* d
was in the differential diagnosis because his father
* \) o* s3 {$ g( Z }) Pstarted puberty somewhat early, and occasionally,
: Z+ l0 \4 K- l' u8 |6 |testicular enlargement is not that evident in the1 G# ~' @- N6 N9 K2 K/ Y* Y" P! P
beginning of this process.1 In the absence of a neg-
: y; \' E+ k' m5 n( A4 C1 dative initial history of androgen exposure, our
4 ^7 w! Q# @5 N' }, P# n, Nbiggest concern was virilizing adrenal hyperplasia,. w9 ?/ r) d5 D7 ~8 B
either 21-hydroxylase deficiency or 11-β hydroxylase' Q! |2 y/ O7 Z' H* Q- N5 X7 S; ^
deficiency. Those diagnoses were excluded by find-: L& {6 D3 @ S& w* N, Y+ C$ t
ing the normal level of adrenal steroids.: k! Q/ B8 N% ]7 H5 o
The diagnosis of exogenous androgens was strongly
/ M0 l4 |) z1 h: U3 G3 p( _2 D1 esuspected in a follow-up visit after 4 months because0 m4 N! P$ y8 @ R
the physical examination revealed the complete disap-
: g% N$ U8 E2 E) F7 E; P7 D6 tpearance of pubic hair, normal growth velocity, and
4 ~. R5 M: Y1 l$ j* a; u" i# L7 f1 kdecreased erections. The father admitted using a testos-' ~& {8 [# L/ i( d8 A
terone gel, which he concealed at first visit. He was
9 _# K8 h( I }8 N. \1 @) Z7 Busing it rather frequently, twice a day. The Physicians’( F3 T+ z7 m% V+ Q: p' H6 R4 e
Desk Reference, or package insert of this product, gel or7 K8 ?3 Q Y" G1 r3 g5 ?( h: l
cream, cautions about dermal testosterone transfer to- N @( Z( q; P7 `$ b- k
unprotected females through direct skin exposure.
/ g) q, r6 i0 sSerum testosterone level was found to be 2 times the
! c5 z+ \. A( d3 {baseline value in those females who were exposed to
) |& l' n# B. D% f. I. geven 15 minutes of direct skin contact with their male6 [* y; i" A2 U; F2 t B( ], b! H
partners.6 However, when a shirt covered the applica-
% O) U# {0 F1 z# mtion site, this testosterone transfer was prevented.
$ X8 I# V! u: ~Our patient’s testosterone level was 60 ng/mL,
^ ?6 p J& P- U" Lwhich was clearly high. Some studies suggest that6 [! H# |( u, P, I/ N' M# ~
dermal conversion of testosterone to dihydrotestos-: W6 J/ f; @" A5 T' g4 F3 {- v& u
terone, which is a more potent metabolite, is more$ |' z% X" W( J; ~, y! G8 n
active in young children exposed to testosterone
* n; d! P* s! i, W7 mexogenously7; however, we did not measure a dihy-9 i$ b6 T! i3 N1 Q6 c, V
drotestosterone level in our patient. In addition to
! O0 {8 u8 W. `+ {virilization, exposure to exogenous testosterone in2 a0 `+ ~$ G/ ~8 t ?
children results in an increase in growth velocity and. o, Y! ~3 A" L$ g
advanced bone age, as seen in our patient., Z0 m o; j" R. k3 }2 M3 O0 l
The long-term effect of androgen exposure during$ w9 B% |9 Z/ J9 Y+ x% a g
early childhood on pubertal development and final
' ?% x. X1 Q0 v1 R1 i% wadult height are not fully known and always remain
' Q- Q- b. U k2 ^2 ra concern. Children treated with short-term testos-
! s, W2 c! F# f- y- xterone injection or topical androgen may exhibit some# ~7 D8 ?, d" V! K7 @: s# m( n
acceleration of the skeletal maturation; however, after c' `; F/ _# Z3 u. j
cessation of treatment, the rate of bone maturation
% Q, R" Q! m5 _- Fdecelerates and gradually returns to normal.8,99 N3 u, p k( y0 l6 v
There are conflicting reports and controversy# w" n# U/ C0 e/ H, v7 _2 k
over the effect of early androgen exposure on adult8 i( B3 `; z9 I
penile length.10,11 Some reports suggest subnormal9 m0 K9 X* q3 a8 e
adult penile length, apparently because of downreg-5 N0 A% F# Y! |5 o: }# t/ }
ulation of androgen receptor number.10,12 However,9 q) @) X; i1 U. H: ^1 \7 O) ]
Sutherland et al13 did not find a correlation between
3 Q( A7 q) Y9 {3 f- Jchildhood testosterone exposure and reduced adult2 I! Z7 t1 A+ V( u
penile length in clinical studies.( n/ Q6 u1 B# W4 ]! A% J z0 X6 S
Nonetheless, we do not believe our patient is
1 I: Y8 `! ~1 e+ k M. ngoing to experience any of the untoward effects from5 t& a1 W3 W& x" l
testosterone exposure as mentioned earlier because! @' b# e5 K/ @& e
the exposure was not for a prolonged period of time.
/ Z. c- s( N ~5 s r9 y1 AAlthough the bone age was advanced at the time of- X m" D( V# Z# r" ]: h# N9 r* h
diagnosis, the child had a normal growth velocity at z, o7 Y* a* k5 e. X( F
the follow-up visit. It is hoped that his final adult% p9 ` `/ ^" K; [ A
height will not be affected.
# T, J$ w3 Z& W) ~# v, ~4 nAlthough rarely reported, the widespread avail-
* u/ M: Q2 K" U( T2 i mability of androgen products in our society may7 K$ P6 p, O. B) y" L4 T- u) k8 u
indeed cause more virilization in male or female; Q$ S, t6 I3 N0 i8 ]
children than one would realize. Exposure to andro-) w5 e( `/ c9 y' [! @: z- a8 ~1 e
gen products must be considered and specific ques-
" q6 Q+ j! T2 itioning about the use of a testosterone product or
% a) X% f% t: C$ G; Qgel should be asked of the family members during
! c1 ^# |( m4 [; _the evaluation of any children who present with vir-
4 G1 R) t- |3 q/ } W; x2 A8 I' bilization or peripheral precocious puberty. The diag-
7 i ~# r J) c) G0 L$ |- r' lnosis can be established by just a few tests and by
4 G, \0 |5 ]6 X2 vappropriate history. The inability to obtain such a- d7 n+ W1 M# @; R/ P4 U O
history, or failure to ask the specific questions, may
0 x/ h, `; L9 k7 `% Z1 p4 yresult in extensive, unnecessary, and expensive! V" \! a6 U) W8 U. S
investigation. The primary care physician should be. v* g( }, g8 Z$ i( [" t2 D! p! m
aware of this fact, because most of these children6 j. j& ^6 R/ i `' U5 W, e) g" u
may initially present in their practice. The Physicians’4 g, H; N9 W0 e& }
Desk Reference and package insert should also put a
+ U& s2 Q$ f$ ]4 }) [5 mwarning about the virilizing effect on a male or. H) ~' Z. H4 m* I# x' r0 r- w
female child who might come in contact with some-& a3 L- [" B; e
one using any of these products.
- ^0 ?; k u, U4 O7 ]References
y) [3 _( U6 r" T! q4 ?1. Styne DM. The testes: disorder of sexual differentiation
; r: o, a2 O7 @7 \9 e, B7 \6 ]and puberty in the male. In: Sperling MA, ed. Pediatric
+ E3 i+ s2 s! R; P; d2 K6 UEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 k* h; h* q; E4 B" ~2002: 565-628.
% L7 s: [% k+ U I- T7 _2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious3 N8 \! j9 p+ `3 o9 c: _3 J( N
puberty in children with tumours of the suprasellar pineal |
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