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Sexual Precocity in a 16-Month-Old; v- D* ?" z) i' x
Boy Induced by Indirect Topical
8 `# _- W" s. ]Exposure to Testosterone
) o! N; e& j% a4 }3 ySamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,26 }# d) l9 g# n7 n/ q
and Kenneth R. Rettig, MD1( Y* o3 V: b' d* H
Clinical Pediatrics+ ?6 K, {9 m) N. \* o4 J2 c" D
Volume 46 Number 6
2 D( ?7 d1 J+ \& i# [July 2007 540-543/ v' |! |# z3 a6 W7 s$ p( ^
© 2007 Sage Publications
- h/ I, D( G8 X10.1177/00099228062966519 ]! l; ~( v2 D6 f
http://clp.sagepub.com
' k- s" G8 d. uhosted at
/ ?( ^" o G6 a8 B/ z( }http://online.sagepub.com3 T. b6 f) L% [4 N) C$ d+ \
Precocious puberty in boys, central or peripheral,
. I3 E& r6 ]& j! n! ^is a significant concern for physicians. Central
" `' M) H/ s' P. U" {precocious puberty (CPP), which is mediated
$ `" N% r) @" w5 X. nthrough the hypothalamic pituitary gonadal axis, has
- A% c% I3 ]; M' S& fa higher incidence of organic central nervous system* ?! O w d6 D: _, F U9 ^' Z
lesions in boys.1,2 Virilization in boys, as manifested
5 P$ U# w1 ^# i' ?- Nby enlargement of the penis, development of pubic
' s9 J, V, J! l, t b+ ]" ghair, and facial acne without enlargement of testi-# ?) R. H' E" d1 _
cles, suggests peripheral or pseudopuberty.1-3 We0 G: C" r- y' D; A0 N
report a 16-month-old boy who presented with the& ]2 c+ h& ]5 d- U
enlargement of the phallus and pubic hair develop-" ~, P' }/ R7 t
ment without testicular enlargement, which was due/ r+ Y. h2 s1 D7 t# z5 y# U2 k
to the unintentional exposure to androgen gel used by, N! I5 {6 s# @) U Q! I- d
the father. The family initially concealed this infor-
9 f8 p) d6 m" T3 g4 z6 U$ w2 U1 L% j0 fmation, resulting in an extensive work-up for this1 V2 E0 \9 H5 p% c9 K" x$ S( G
child. Given the widespread and easy availability of7 \- h' J/ K0 V
testosterone gel and cream, we believe this is proba-* u* ]/ A* J# e1 K
bly more common than the rare case report in the
8 T7 v+ J9 J. h; o9 F( }7 S) Lliterature.4
+ [: _. X+ ~& j& T9 t B: |Patient Report% B, w( {4 A* ]- }8 s/ n
A 16-month-old white child was referred to the
2 F4 s: U5 L2 I7 z: uendocrine clinic by his pediatrician with the concern
6 w5 x) `! ?; z0 Bof early sexual development. His mother noticed
* w! m( t& C; S, A5 C( V/ Slight colored pubic hair development when he was
3 z6 c% @; i N% [From the 1Division of Pediatric Endocrinology, 2University of
) m4 e, K' h2 ~/ o/ a- ESouth Alabama Medical Center, Mobile, Alabama.
/ j M7 S1 m& ?+ O& T. P% o/ OAddress correspondence to: Samar K. Bhowmick, MD, FACE,. J2 B. h# _1 r
Professor of Pediatrics, University of South Alabama, College of+ l; Z' g6 M! j- Y. q! ~" i& I% l
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
- }- Y) }+ ^: @, X. c0 Ge-mail: [email protected].; i4 Q. c7 C9 [$ O% b" j
about 6 to 7 months old, which progressively became& V1 n5 |8 A- [% N# i' H9 H3 |
darker. She was also concerned about the enlarge-& W$ S( } G0 _: q
ment of his penis and frequent erections. The child1 K, _& H5 ?; h+ J. y
was the product of a full-term normal delivery, with' l% B. c- N3 ]5 b* V& W% G, `. G
a birth weight of 7 lb 14 oz, and birth length of8 A" M- _' c# F' A. d
20 inches. He was breast-fed throughout the first year
% V/ F! |: }( {of life and was still receiving breast milk along with
l* c w; [; ^' \ vsolid food. He had no hospitalizations or surgery," B; E- N! }2 U8 R
and his psychosocial and psychomotor development6 @$ U3 |+ y1 n' E
was age appropriate.2 v5 ]5 O0 X3 `- f: Q9 T& q3 }# x
The family history was remarkable for the father,
! s# `: i' }/ {7 twho was diagnosed with hypothyroidism at age 16,
& N1 S( [* o3 h# e' l- c/ E) Twhich was treated with thyroxine. The father’s
5 h0 U& ?3 t6 D: B/ Sheight was 6 feet, and he went through a somewhat3 \8 S4 H/ k. N5 m/ A' g- O
early puberty and had stopped growing by age 14.
* l. ?% q) M2 f$ q% KThe father denied taking any other medication. The
0 f$ @4 T+ l+ L, ^child’s mother was in good health. Her menarche- v; o$ @$ ?. F
was at 11 years of age, and her height was at 5 feet/ ]( q. j* j% L! R* s' \! k
5 inches. There was no other family history of pre-
2 G5 t4 h5 `( ?) Scocious sexual development in the first-degree rela-
- N6 |1 {, \8 rtives. There were no siblings.2 I' ` I+ z) O& U% _& @. n) B
Physical Examination9 j3 r+ d+ ^/ Y
The physical examination revealed a very active,% S8 g% W, a6 U" s; E) C1 ?
playful, and healthy boy. The vital signs documented
; r8 ]% t2 y9 da blood pressure of 85/50 mm Hg, his length was
0 c- ]! D" N9 b8 F( y# G8 ?! H8 \90 cm (>97th percentile), and his weight was 14.4 kg
9 }" Q! z4 B! ]5 R; D, T(also >97th percentile). The observed yearly growth/ L3 ?- }$ N1 K3 F3 e
velocity was 30 cm (12 inches). The examination of1 o7 A2 t# S ~3 h0 l
the neck revealed no thyroid enlargement.: S4 Y' a, y& H( z1 k
The genitourinary examination was remarkable for
$ N9 ?/ K: S( B& q; Eenlargement of the penis, with a stretched length of
& q6 H# N$ u7 H! [8 a8 cm and a width of 2 cm. The glans penis was very well
/ W7 }1 M: h8 R9 B8 n: Jdeveloped. The pubic hair was Tanner II, mostly around! m' T! e% w! [( {0 Q, ?4 B4 C
5408 P* R k: Y0 o9 J0 u& p
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 ~- T8 I7 u+ s
the base of the phallus and was dark and curled. The+ s3 f& k. P! z, f% k! q% U
testicular volume was prepubertal at 2 mL each.4 o4 @7 l9 k% x
The skin was moist and smooth and somewhat0 T1 {! i1 W' m/ `. W5 b1 x& |
oily. No axillary hair was noted. There were no6 u, o' m" Y% w5 X* V- n
abnormal skin pigmentations or café-au-lait spots.
% L' ~1 c" S0 C1 d. R3 {2 rNeurologic evaluation showed deep tendon reflex 2+
1 @: Q: O/ T( Z3 w% U, Tbilateral and symmetrical. There was no suggestion' u9 ~9 q8 c8 H) Q, c7 j& A
of papilledema.9 m; M: |7 s# X4 _
Laboratory Evaluation
0 e [, j6 L1 J0 F: u+ AThe bone age was consistent with 28 months by
' B- x; K9 Q/ e/ W# N ^8 P/ Gusing the standard of Greulich and Pyle at a chrono-3 m( f" j! C2 P* \1 c* ~
logic age of 16 months (advanced).5 Chromosomal" j) Z6 C! z7 I2 |3 W
karyotype was 46XY. The thyroid function test
0 w$ D) n3 t: B# I" n. Vshowed a free T4 of 1.69 ng/dL, and thyroid stimu-% F+ w/ |" y5 \7 B! M
lating hormone level was 1.3 µIU/mL (both normal).! `) L' V& g& m1 M. q' c; D
The concentrations of serum electrolytes, blood# ]# S0 W2 v9 ^+ w- _2 m3 e
urea nitrogen, creatinine, and calcium all were
, p8 S" O; @ f' ~8 O: p( E) m rwithin normal range for his age. The concentration. l) `; w/ G8 } v( `6 S
of serum 17-hydroxyprogesterone was 16 ng/dL
, a6 I9 F. I1 j* i" ^6 q1 W(normal, 3 to 90 ng/dL), androstenedione was 20/ S( }, y; q1 ^3 ^
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-( y( b: f9 W; J& m5 v, f, X9 \/ Y
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
% J+ ^7 m i' ~! Odesoxycorticosterone was 4.3 ng/dL (normal, 7 to
4 T3 {7 k! i5 W1 i% @) P49ng/dL), 11-desoxycortisol (specific compound S)
, f' }; e5 I7 r6 W5 D# N% F1 Lwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 W( T+ |! m3 }/ h# H. F& U
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
- b6 ]4 r2 u1 R/ Wtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ Y% ]. M7 G5 ~; ?7 R' s3 t
and β-human chorionic gonadotropin was less than8 i" [+ M7 D' j9 k9 V
5 mIU/mL (normal <5 mIU/mL). Serum follicular% K, Z% C1 C0 m$ M; M# P5 F4 L) U
stimulating hormone and leuteinizing hormone
5 U' H# d; g0 D. R( q& Bconcentrations were less than 0.05 mIU/mL% ^3 j7 D% H( S* f
(prepubertal).
, @# q; N' y1 I, A6 y: HThe parents were notified about the laboratory
J; s+ b! y. K: N0 Zresults and were informed that all of the tests were0 a; a7 n$ |/ b% @! a/ F
normal except the testosterone level was high. The5 `7 c5 \9 y2 m
follow-up visit was arranged within a few weeks to
3 D5 k, B! K) C1 f# mobtain testicular and abdominal sonograms; how-
# l N$ P! w1 z& r9 W) W* Q, |ever, the family did not return for 4 months.6 _: i1 f9 d( u9 k. ?/ T$ K+ g- R
Physical examination at this time revealed that the
, N3 z {& G1 h: d8 bchild had grown 2.5 cm in 4 months and had gained
& d6 d @6 F$ ^8 c2 kg of weight. Physical examination remained
& ]# A$ d: L& x5 W+ n" x8 Gunchanged. Surprisingly, the pubic hair almost com-
- L2 n. u! D' \: @7 L$ xpletely disappeared except for a few vellous hairs at
4 ]" z. r( G. L/ }& Jthe base of the phallus. Testicular volume was still 2
' ~0 E C- \% k8 NmL, and the size of the penis remained unchanged.
2 X/ H. b+ e/ u0 \1 g6 mThe mother also said that the boy was no longer hav-
3 N- ^, |9 ^, x$ ]7 X) n, k/ Ning frequent erections.
0 h5 o: h& K" C: ~6 Z( `, W5 JBoth parents were again questioned about use of
& G* q/ J* `: Lany ointment/creams that they may have applied to3 r* e6 |: X0 t8 T1 c D6 U8 \( _
the child’s skin. This time the father admitted the; {& H! f& B. J& \" _" K) f/ c
Topical Testosterone Exposure / Bhowmick et al 5418 g" w. \$ R. Y! T j
use of testosterone gel twice daily that he was apply-
, |0 U3 s1 b8 c" K ping over his own shoulders, chest, and back area for3 f+ q( k+ J# U6 V9 ^8 M
a year. The father also revealed he was embarrassed
! E$ x, s. f" z- {! ]to disclose that he was using a testosterone gel pre-$ Z4 d8 I' r% C( T( R& Q$ F5 W
scribed by his family physician for decreased libido
9 s3 e& z. _+ S$ _secondary to depression.: @' P n0 `. J/ `
The child slept in the same bed with parents.
/ r9 t- _3 L+ D8 s* sThe father would hug the baby and hold him on his% o1 Q' k2 M6 C) k
chest for a considerable period of time, causing sig-' U6 a1 [- g. Z! M( T* A, k
nificant bare skin contact between baby and father.
; h$ s; I0 e! j/ }* [. KThe father also admitted that after the phone call,+ p' ` m* a8 w* @; @0 e
when he learned the testosterone level in the baby# D* N* z# E, Y' \$ l, |
was high, he then read the product information& H6 n V! p) I! X
packet and concluded that it was most likely the rea-
" X! s: ?$ N2 \ l' t9 ~son for the child’s virilization. At that time, they8 I, B! K2 D" F' U
decided to put the baby in a separate bed, and the* J8 `8 Z3 o- r5 f0 B4 _3 h
father was not hugging him with bare skin and had3 F% M5 Z: l. z2 o2 h/ w7 u7 [
been using protective clothing. A repeat testosterone* d" k6 N6 E1 W5 B' I( V
test was ordered, but the family did not go to the* v& E$ y" o7 v, X. C! t3 @
laboratory to obtain the test.
0 `2 |* m: Z7 Y4 B% |( \Discussion1 m5 X0 `# ?7 z$ r; t4 h; W
Precocious puberty in boys is defined as secondary) {+ O+ g8 M8 ]1 n1 [
sexual development before 9 years of age.1,4$ T1 f8 U3 K ^7 _5 t& [" @
Precocious puberty is termed as central (true) when
+ n+ H: c( d6 E2 }) h+ x' ~2 ?it is caused by the premature activation of hypo-
/ m. j3 |* R p3 ?9 N' k9 Fthalamic pituitary gonadal axis. CPP is more com-' v* Y' j/ R" ~7 f; a- ~2 l
mon in girls than in boys.1,3 Most boys with CPP
0 }' W8 |' e; }/ D' H8 Omay have a central nervous system lesion that is
1 Q% x2 D$ @) J& Tresponsible for the early activation of the hypothal-
/ |0 ]$ Z! \0 X" s) _, o' y* Tamic pituitary gonadal axis.1-3 Thus, greater empha-
% Z' \& H) B% [* ^4 G0 k/ X q" C& ]sis has been given to neuroradiologic imaging in
e; y; e" {- e. y5 `& d1 Qboys with precocious puberty. In addition to viril-
# s; E5 N; l9 _" fization, the clinical hallmark of CPP is the symmet-$ P! m3 a5 i7 }! J8 E' {) @
rical testicular growth secondary to stimulation by
% V4 l, M+ `/ T8 q. g& L9 Xgonadotropins.1,3! U+ n( i4 ~ Z+ Z4 w; e' A+ `8 l( ^$ m
Gonadotropin-independent peripheral preco-
' x9 W }' I' V" Q0 o* I' }cious puberty in boys also results from inappropriate- E0 M7 @3 v, M( ?& \ E' q
androgenic stimulation from either endogenous or
/ s' G1 [" E$ s) z. X9 M; } Oexogenous sources, nonpituitary gonadotropin stim- X& [/ P/ c1 X+ \+ B
ulation, and rare activating mutations.3 Virilizing
, \/ H3 q- H# k+ a3 U3 hcongenital adrenal hyperplasia producing excessive
3 J7 m, K1 e5 b2 k( s5 B# x4 [2 gadrenal androgens is a common cause of precocious
7 F# R |- E3 c% s3 _puberty in boys.3,4. \$ n6 X( Q! Q/ O4 ~7 I! P
The most common form of congenital adrenal' \: L0 t. O0 H7 \+ b, w
hyperplasia is the 21-hydroxylase enzyme deficiency.
) F$ y8 G; R' MThe 11-β hydroxylase deficiency may also result in
1 a9 m9 a6 V, l$ ^excessive adrenal androgen production, and rarely,# B/ \, |+ P `# Q0 U( Z: h! o
an adrenal tumor may also cause adrenal androgen
! E- J/ g6 K1 \, V/ T& Mexcess.1,36 i7 F- [. T7 g
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 V5 }* H. L1 B4 z542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
/ r( ~+ ~2 L, E. ?A unique entity of male-limited gonadotropin-
% d+ K L9 e( ?# i: V# lindependent precocious puberty, which is also known
/ b2 o8 B8 v( e1 F9 kas testotoxicosis, may cause precocious puberty at a
. _& h4 t+ P. |# |& o/ W5 tvery young age. The physical findings in these boys6 J3 ^$ U1 \* O* P$ s
with this disorder are full pubertal development,8 a9 H& C( N# K1 @$ G( H) x
including bilateral testicular growth, similar to boys( R; P1 i$ }" X _3 L9 b+ A% [9 ?
with CPP. The gonadotropin levels in this disorder
, G% A! G# f9 K. aare suppressed to prepubertal levels and do not show; e, T, g$ f+ H* K9 U9 ? H
pubertal response of gonadotropin after gonadotropin-) n- ~4 K4 s9 K+ V$ T3 v5 M4 [
releasing hormone stimulation. This is a sex-linked
& l3 d P: q: f, c* K6 @autosomal dominant disorder that affects only
/ e1 @& d) ~6 G$ r0 L' S" y5 ?males; therefore, other male members of the family
7 Z% t8 i3 N. O; A* }. Umay have similar precocious puberty.3
: j" X! \1 }1 ~( M3 N5 ZIn our patient, physical examination was incon-
( J8 y; K4 ~" Z* W7 ysistent with true precocious puberty since his testi-
; ?( Z) x9 @2 Ccles were prepubertal in size. However, testotoxicosis
2 u0 l0 n) v% {4 s+ }) `was in the differential diagnosis because his father& P; _: l' D7 _. G" }8 c
started puberty somewhat early, and occasionally,) i! P. Y8 Y7 b/ l% ^ T0 o
testicular enlargement is not that evident in the
8 X& B. F% f; \beginning of this process.1 In the absence of a neg-
9 J$ C) k' C/ |' cative initial history of androgen exposure, our
( N' {5 t; p( V3 @0 O# N0 Abiggest concern was virilizing adrenal hyperplasia,7 L3 c% G, v& x# w" ?8 D' U
either 21-hydroxylase deficiency or 11-β hydroxylase0 S' M& h% ^. _$ T; e/ W4 U5 w3 X
deficiency. Those diagnoses were excluded by find-
" `% R i/ O- Cing the normal level of adrenal steroids.' e' i1 @& ^ B9 [' R+ f
The diagnosis of exogenous androgens was strongly" B Q4 w3 T2 b( R$ q- L& ~
suspected in a follow-up visit after 4 months because
' A' K5 l0 k0 h+ e% r, K- a! n+ lthe physical examination revealed the complete disap-! S% a# G4 J: {) @2 f P
pearance of pubic hair, normal growth velocity, and
1 g5 a& Y( Q( {# L+ S r) E$ E fdecreased erections. The father admitted using a testos-
O3 F" A+ ~& x7 `* J4 Cterone gel, which he concealed at first visit. He was! N! l. ^7 b/ z
using it rather frequently, twice a day. The Physicians’
& b1 ]" z5 {% i7 {- c* EDesk Reference, or package insert of this product, gel or; U K1 I9 z) g9 S/ T# b& }7 i, w
cream, cautions about dermal testosterone transfer to0 _* K0 e {% A. {$ ]: g
unprotected females through direct skin exposure.2 I+ X0 y: M4 J) _9 D) U
Serum testosterone level was found to be 2 times the/ _3 E; r9 S9 h m5 i
baseline value in those females who were exposed to
6 d* } r6 n& p5 s/ {1 V" deven 15 minutes of direct skin contact with their male; _( w y% I9 d U3 M/ V- E& o# ~
partners.6 However, when a shirt covered the applica-
) s" Z: f3 F/ q p! x* h( y$ Gtion site, this testosterone transfer was prevented.
3 I3 D& B" Z* m' F3 }% }Our patient’s testosterone level was 60 ng/mL,
5 I% n+ F9 \7 m/ mwhich was clearly high. Some studies suggest that
& b* D9 L+ x; j3 n0 g V0 s) bdermal conversion of testosterone to dihydrotestos-
% v" X7 c- k8 Hterone, which is a more potent metabolite, is more ^" N* C I1 m! e& u* F: {
active in young children exposed to testosterone' E' X% n- M4 s9 N. B/ D, Q
exogenously7; however, we did not measure a dihy-
+ P& L2 Q, k9 E; s! Q6 n: ndrotestosterone level in our patient. In addition to
& N# o1 W: M( t- h2 m1 ^! hvirilization, exposure to exogenous testosterone in" t1 l* c6 }# Z
children results in an increase in growth velocity and! p5 {4 }$ j$ G/ i0 b; J
advanced bone age, as seen in our patient.
& j- d- n# V; w4 B3 aThe long-term effect of androgen exposure during/ Y8 A+ {( J% b, B. ]* T( q
early childhood on pubertal development and final
/ B9 \, t3 q( G9 r$ G. {# w" radult height are not fully known and always remain- L% `' t1 `- Q5 b9 Z l1 B
a concern. Children treated with short-term testos-
) T) l8 e3 m6 O& ]& Uterone injection or topical androgen may exhibit some1 P1 h E4 H/ a0 ]" T! }
acceleration of the skeletal maturation; however, after
+ [* ]" V/ m- w) ycessation of treatment, the rate of bone maturation5 C( Z$ ]7 M2 p3 z6 V- _
decelerates and gradually returns to normal.8,9: n9 u8 o4 B8 P3 A
There are conflicting reports and controversy
/ _& U" L0 ?0 i; U0 H) Bover the effect of early androgen exposure on adult
% F5 g* V2 \! \! B/ Ipenile length.10,11 Some reports suggest subnormal
. f3 h s+ B& [adult penile length, apparently because of downreg-7 D; [" Q) L3 x* h9 h4 V7 r- u
ulation of androgen receptor number.10,12 However,* [# }4 a, R6 Q/ K f
Sutherland et al13 did not find a correlation between: f% G4 \0 z, k1 X* ~) K; ~
childhood testosterone exposure and reduced adult0 k" A: X5 M6 H. R" Y
penile length in clinical studies.4 h w. k8 ~) u, D, E! R
Nonetheless, we do not believe our patient is
9 v) L" A8 A7 \1 s% B% [$ |going to experience any of the untoward effects from
}" v# K$ `9 y( Ttestosterone exposure as mentioned earlier because
: L) s" y% w7 w, L8 \% Nthe exposure was not for a prolonged period of time.; K9 u; Y0 F9 N
Although the bone age was advanced at the time of* U& E7 g, J2 m* p1 n7 F
diagnosis, the child had a normal growth velocity at
( p# A2 A- o# F8 k0 Rthe follow-up visit. It is hoped that his final adult
" L5 U6 ]( }0 o% U3 _7 [height will not be affected.! g& q5 }! S7 }( @3 E. ?* u
Although rarely reported, the widespread avail-7 _3 _+ ]2 d/ E. ^- m: t1 o
ability of androgen products in our society may3 x. f, _/ O% ~8 y( `. k; L t; V I
indeed cause more virilization in male or female
, n4 T3 U8 m, @% }children than one would realize. Exposure to andro-
1 K7 [+ Z: o" e& Q8 Igen products must be considered and specific ques-; K$ j* ~3 x1 I8 r, R- m s" h, q
tioning about the use of a testosterone product or
' _+ @, L: m/ U2 M C* _# Agel should be asked of the family members during/ ?5 V: `- X2 G w9 |1 w3 M" }
the evaluation of any children who present with vir-) y4 G: B& F5 I4 T
ilization or peripheral precocious puberty. The diag-! o8 Y6 W2 O0 V$ G: i
nosis can be established by just a few tests and by; Y- m F$ X8 v @0 ?" m
appropriate history. The inability to obtain such a
7 v @4 ?, C& k' x0 C! n0 c9 hhistory, or failure to ask the specific questions, may" e8 P+ P5 m! [& k7 _
result in extensive, unnecessary, and expensive' c L$ U% ^ V" x5 W. Y% S1 A' I& r
investigation. The primary care physician should be7 u) h8 c/ E+ q+ f- S
aware of this fact, because most of these children
) \5 s9 a7 n' S! Nmay initially present in their practice. The Physicians’1 i( S. R p: ], h" v0 m
Desk Reference and package insert should also put a) y8 K; }6 V4 M- N4 \9 Y
warning about the virilizing effect on a male or! [+ a2 |' c+ N. i7 g5 r5 H
female child who might come in contact with some-
$ g' i8 p% P3 H; r$ Q, J) Hone using any of these products.
7 m( y+ M- D6 G# n1 g3 I7 l, lReferences
5 C: A: o5 S0 C1. Styne DM. The testes: disorder of sexual differentiation
( u! }; j5 G" B# @4 F$ \and puberty in the male. In: Sperling MA, ed. Pediatric
5 j) O9 T, O7 k$ s" KEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 M) q* C& ^; U. d3 {2002: 565-628.; e* j0 ^6 R* G( |+ s2 U) G u
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious9 e) `! i$ P8 @0 ~/ Z
puberty in children with tumours of the suprasellar pineal |
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