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Sexual Precocity in a 16-Month-Old
6 Y, @4 D$ B9 |" x4 a% i8 sBoy Induced by Indirect Topical+ o$ v* ?5 @2 @$ k4 _
Exposure to Testosterone
I, T* g* v' L, @6 c0 A7 RSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2& }1 z" l! M0 C( x
and Kenneth R. Rettig, MD15 E. c3 A( z3 ~. l; [! [8 R
Clinical Pediatrics
5 Y/ e& ^# F5 c. V C- v0 OVolume 46 Number 6
) J+ [& E; a1 G! ^2 F; }July 2007 540-543# s) D0 N9 {* W9 c5 c
© 2007 Sage Publications) G) z r! X$ p. `. z( e; l3 L
10.1177/0009922806296651
! y' T4 d4 R, K3 zhttp://clp.sagepub.com$ ?/ K$ u. L+ S* x1 V2 U
hosted at% F8 S! o' E; w) g' ^
http://online.sagepub.com& t1 E9 t( y$ }: m- B0 T n: K" D
Precocious puberty in boys, central or peripheral,) k* R- L3 |9 L5 R$ K
is a significant concern for physicians. Central
3 q) O- j8 P& f2 N6 n; S) m5 b9 @precocious puberty (CPP), which is mediated
: m1 }6 r# {- M; t& z2 r% Uthrough the hypothalamic pituitary gonadal axis, has" M8 H' ~- _; A0 t% f; W
a higher incidence of organic central nervous system
" F; D$ {' |: C; {$ p# z9 B+ G. E* Llesions in boys.1,2 Virilization in boys, as manifested
8 c" |4 v1 e7 V! l( E0 wby enlargement of the penis, development of pubic
- F1 A: M% o" V9 ?9 w. @% \hair, and facial acne without enlargement of testi-: }) J, `8 h1 K& z$ Y
cles, suggests peripheral or pseudopuberty.1-3 We- C; h/ C( f: ?$ t9 a& U& C
report a 16-month-old boy who presented with the
0 K. I+ |- [4 ~enlargement of the phallus and pubic hair develop-
# r; p0 |/ X5 u9 Z$ J+ K& oment without testicular enlargement, which was due3 @8 q+ Q7 O' g8 z" n6 y6 U
to the unintentional exposure to androgen gel used by
: L3 l# \0 A* J2 Wthe father. The family initially concealed this infor-
- f7 s! N0 y7 w2 @mation, resulting in an extensive work-up for this! z6 h( R& X: |
child. Given the widespread and easy availability of
% P# M: {* H" o0 u& g5 dtestosterone gel and cream, we believe this is proba-
! e, q+ F1 |; |2 ?! A: nbly more common than the rare case report in the5 _& x9 r5 ~4 ^! b" g; z
literature.4! j% b; ]1 m0 l' ~1 k! b& r1 c- V" z
Patient Report5 F2 j' w3 B% b* b3 @
A 16-month-old white child was referred to the7 n. M/ [6 ?# `! Z+ |
endocrine clinic by his pediatrician with the concern+ j% Z+ U) H& H: m
of early sexual development. His mother noticed3 X/ ?" Q: h9 D- A0 }
light colored pubic hair development when he was
f$ `3 j- Z% A1 O* fFrom the 1Division of Pediatric Endocrinology, 2University of
T7 K% w( H/ s0 ]* E1 m' uSouth Alabama Medical Center, Mobile, Alabama." p7 o, ?: k! _3 R [) A9 I( u
Address correspondence to: Samar K. Bhowmick, MD, FACE,; D. M4 ~% a3 r
Professor of Pediatrics, University of South Alabama, College of
2 `& d/ H1 G6 rMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
A) O0 j+ `' I/ i, |2 B3 qe-mail: [email protected].
, J+ B0 `# O! pabout 6 to 7 months old, which progressively became4 R5 u/ z; `; K# h' A) A7 E# L
darker. She was also concerned about the enlarge-! `# N# f+ `% F; ]2 [7 o. @8 M
ment of his penis and frequent erections. The child
1 Y% g: I9 `9 @1 C3 a/ Rwas the product of a full-term normal delivery, with
# _8 n- l: N' V- Y. h( |% D* ja birth weight of 7 lb 14 oz, and birth length of6 x* d" `+ M3 [& b/ E6 U* `
20 inches. He was breast-fed throughout the first year* b) k3 S* |0 T% S) r; n! j
of life and was still receiving breast milk along with
4 R1 I( `# L/ q. {4 ssolid food. He had no hospitalizations or surgery,
: J [0 F$ m! O) z- e2 B4 band his psychosocial and psychomotor development
9 I& Z) F2 S; j8 h6 ?1 c5 |& Xwas age appropriate.
( n; P& U9 \, M" D9 Q3 U6 @The family history was remarkable for the father,% B+ y Z$ \2 f2 c( w# B0 ~5 L
who was diagnosed with hypothyroidism at age 16," C0 U5 t# d+ e8 B
which was treated with thyroxine. The father’s
R3 K( M; A0 o% f/ Sheight was 6 feet, and he went through a somewhat M/ [7 d4 d) I$ P6 s; j
early puberty and had stopped growing by age 14.0 R+ Q1 d: n- A/ L9 [5 {3 g
The father denied taking any other medication. The
$ m2 l [4 j2 \5 ichild’s mother was in good health. Her menarche3 W. I# ?4 d0 _+ V
was at 11 years of age, and her height was at 5 feet% i0 G1 C0 j/ i) a
5 inches. There was no other family history of pre-, Q8 Y; n' h+ H9 R+ t9 W
cocious sexual development in the first-degree rela-4 }( h# |) f& r2 m* ?. f6 m
tives. There were no siblings.) m$ H, C" q x; ]6 @3 t' p2 K
Physical Examination
; {9 e" y9 L2 s3 T5 xThe physical examination revealed a very active,9 l6 P% h; F1 {5 o3 U- x, o
playful, and healthy boy. The vital signs documented
: g3 l. x a6 Y5 N9 Z% |: h% ja blood pressure of 85/50 mm Hg, his length was. e1 I) V. I( R v4 S2 p
90 cm (>97th percentile), and his weight was 14.4 kg& p0 j* i \' f/ u5 K6 O
(also >97th percentile). The observed yearly growth
+ L- _) r6 j' ^- Z( yvelocity was 30 cm (12 inches). The examination of/ G+ g+ C2 w1 K( C
the neck revealed no thyroid enlargement.
' g4 R7 R5 O6 dThe genitourinary examination was remarkable for
% S7 K7 D8 L; O& Henlargement of the penis, with a stretched length of
9 c1 ? ?+ E# Z+ ], Q5 j Y, E; x, T8 cm and a width of 2 cm. The glans penis was very well: F3 \- }% Q: ?, B/ \( I$ }
developed. The pubic hair was Tanner II, mostly around
) W# y: Q9 M5 V. A Y7 i8 ~540
) x2 D. _, B. Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" S" _7 v5 w E' [, ]the base of the phallus and was dark and curled. The
) U* a# Z) C. A9 Z+ O2 R9 U; Jtesticular volume was prepubertal at 2 mL each.
9 C0 ~8 P7 A- ]- g2 ~! Y4 mThe skin was moist and smooth and somewhat
* S" z, R; ^; Roily. No axillary hair was noted. There were no! G6 Z% @5 T! c4 t
abnormal skin pigmentations or café-au-lait spots.% T+ L7 z1 b5 \. D" c8 b
Neurologic evaluation showed deep tendon reflex 2+2 u* a/ `9 P/ Z/ }& A1 a
bilateral and symmetrical. There was no suggestion
( p6 [9 ^! N4 X% Z* b2 R$ Hof papilledema." T7 f7 q/ z/ f4 f t
Laboratory Evaluation
) M9 @3 |! f% U1 fThe bone age was consistent with 28 months by% X8 m: r( i2 f$ H& V1 y4 J
using the standard of Greulich and Pyle at a chrono-
. l6 j4 g: a; Y9 `logic age of 16 months (advanced).5 Chromosomal- e6 @ \. @- l6 E% _2 }0 O
karyotype was 46XY. The thyroid function test
4 {6 L3 t6 O' h8 E5 M% Ishowed a free T4 of 1.69 ng/dL, and thyroid stimu-
/ Q+ j% e8 m! Y6 [! elating hormone level was 1.3 µIU/mL (both normal).; q/ k1 w4 _% t# @: ?
The concentrations of serum electrolytes, blood1 Q7 y/ B6 ]% h- C& x$ K. Z' c1 M
urea nitrogen, creatinine, and calcium all were! `$ S4 M$ `9 A/ Q' |
within normal range for his age. The concentration
2 j/ z5 e7 u+ z( x( y1 x3 Dof serum 17-hydroxyprogesterone was 16 ng/dL
+ m. J# c! p" W1 G* F% j/ ?(normal, 3 to 90 ng/dL), androstenedione was 209 v$ X, i7 E2 _, p+ j( z3 N9 H
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
3 R8 ?$ _% p4 Z0 Cterone was 38 ng/dL (normal, 50 to 760 ng/dL)," t! J8 Z* Q* u R
desoxycorticosterone was 4.3 ng/dL (normal, 7 to H( m8 }/ I0 a& b( K- F
49ng/dL), 11-desoxycortisol (specific compound S)
" X; a7 v5 s0 Zwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
2 ^8 P; v) @7 c# btisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total4 o1 @8 j4 J' T9 |
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 @" T; v3 s D2 Dand β-human chorionic gonadotropin was less than
% ~; F/ \: m1 n7 h3 ]3 z1 n% @5 mIU/mL (normal <5 mIU/mL). Serum follicular9 E J' m4 m; ^: }# R4 B
stimulating hormone and leuteinizing hormone' w7 r( c, E4 I# Q5 t |3 k6 M
concentrations were less than 0.05 mIU/mL
2 ~2 N6 b# @& p! `' F(prepubertal).( s8 _6 [1 U3 t
The parents were notified about the laboratory2 j3 Q* B7 V/ A& M! s% E
results and were informed that all of the tests were ~6 z! w% ~1 ]
normal except the testosterone level was high. The( g* z- o1 T, W" w$ O
follow-up visit was arranged within a few weeks to
/ j- E9 S( C+ zobtain testicular and abdominal sonograms; how-
1 `3 M# Z- L& }4 P9 Y+ E+ h3 Mever, the family did not return for 4 months.
0 W$ N( h) c) K2 KPhysical examination at this time revealed that the
- w$ L( s& ]5 M# q! ychild had grown 2.5 cm in 4 months and had gained
/ z' o; N/ S3 ~: |, q. y, s2 kg of weight. Physical examination remained
7 e+ ~; T, g2 ~; z, _unchanged. Surprisingly, the pubic hair almost com-; u% |4 x0 [$ G/ ]7 ~& B
pletely disappeared except for a few vellous hairs at
2 Y/ B- l/ c% athe base of the phallus. Testicular volume was still 2$ F w3 P) _# D0 a% k
mL, and the size of the penis remained unchanged.
- q3 B8 X0 X3 `8 K+ AThe mother also said that the boy was no longer hav-& U. i' E0 k' A& f' Y
ing frequent erections./ z V2 Z$ T- F1 Y8 a# x1 ?# g4 L: X! K
Both parents were again questioned about use of5 z8 I/ i' B' ?
any ointment/creams that they may have applied to
* h+ n. f1 H0 s0 sthe child’s skin. This time the father admitted the
/ h' ^$ M( b7 j7 p1 X0 D* W( KTopical Testosterone Exposure / Bhowmick et al 541
2 u, ]& {- z7 U" H" Cuse of testosterone gel twice daily that he was apply-
: V4 t9 C% F0 r6 ?2 Zing over his own shoulders, chest, and back area for q- ]* H# H( T3 H
a year. The father also revealed he was embarrassed) M6 _9 u0 \% Z$ U5 D: K$ u! a
to disclose that he was using a testosterone gel pre-- P) B& O5 x. L
scribed by his family physician for decreased libido3 u% ^/ [# P2 s/ t
secondary to depression.7 d. K" t* Q" Q" {
The child slept in the same bed with parents.
( v% D; D- a- O) ?5 j9 K, \The father would hug the baby and hold him on his" c* L4 m1 ?% f6 a/ |" U
chest for a considerable period of time, causing sig-5 j# p6 i9 s* @# v8 W. X
nificant bare skin contact between baby and father.
3 R2 m# v: Q9 [# r8 h7 M: ?# _The father also admitted that after the phone call,
; Y+ J8 d% D% T4 ^% Lwhen he learned the testosterone level in the baby
) a' a, x2 A+ z: f7 q# ^" J& e6 G% `was high, he then read the product information
& B! a J8 \ T4 H$ Z( n- F7 opacket and concluded that it was most likely the rea-
+ {( F9 x& ^) n) S9 @" Q1 Rson for the child’s virilization. At that time, they4 `! x( o! q! I4 ?/ ]
decided to put the baby in a separate bed, and the
4 @$ N T! Q9 K) z2 _father was not hugging him with bare skin and had0 g) @6 h1 Y" k2 G
been using protective clothing. A repeat testosterone
* h s4 `+ `+ p$ Q. C: mtest was ordered, but the family did not go to the
; @7 ~! y) j, H9 B2 B, Flaboratory to obtain the test.
0 Y; b# m2 R! [% F% u6 sDiscussion3 h, C' A: k4 B/ \4 D& n4 W/ |1 h4 T+ o
Precocious puberty in boys is defined as secondary
8 l; q+ X' P+ m$ A+ d% H% Isexual development before 9 years of age.1,4
" S; ?( M) O& R6 T% IPrecocious puberty is termed as central (true) when
( A' h" O- V0 K; K: t# c% Sit is caused by the premature activation of hypo-" k) @0 a/ X c' q3 i1 n! A
thalamic pituitary gonadal axis. CPP is more com-
. H4 }- K* D4 D. C- w* h6 Z% pmon in girls than in boys.1,3 Most boys with CPP
8 l4 w) `; {5 ~8 k. }may have a central nervous system lesion that is3 G5 o/ @1 V& T3 D! V( z( |
responsible for the early activation of the hypothal-
; \2 G) d" X9 M3 i0 Mamic pituitary gonadal axis.1-3 Thus, greater empha-4 E( y, C9 t e0 h1 }) P
sis has been given to neuroradiologic imaging in* x+ \! I* \, K* U) l2 Q
boys with precocious puberty. In addition to viril-% L: L, x& k* |: J$ l, O" a- [
ization, the clinical hallmark of CPP is the symmet-2 m* |9 F( f$ ]! z+ ?4 [, N; i- z
rical testicular growth secondary to stimulation by- z' p8 ~. h3 d
gonadotropins.1,3, m0 ]! r3 l5 [) d h, [6 b
Gonadotropin-independent peripheral preco-7 D- j$ B! T/ x+ p
cious puberty in boys also results from inappropriate/ l7 u( _( ?) L9 q n
androgenic stimulation from either endogenous or) D) X9 \8 i8 o! H5 S/ N
exogenous sources, nonpituitary gonadotropin stim-
$ Q! T1 x! ]4 l3 o* Xulation, and rare activating mutations.3 Virilizing! Y2 W* d% Y6 c ~' W5 g
congenital adrenal hyperplasia producing excessive
8 X# N4 ]- j# o' R0 _& {/ |+ Fadrenal androgens is a common cause of precocious
" c" w* o( v$ {7 M' M; k; Ypuberty in boys.3,47 q5 \. u: T1 X! ~- \
The most common form of congenital adrenal" A7 ?; Q" L* V1 R
hyperplasia is the 21-hydroxylase enzyme deficiency.
- f- I4 t, b% \& L. C* G1 EThe 11-β hydroxylase deficiency may also result in
" o9 H9 w4 x! G; p* jexcessive adrenal androgen production, and rarely,3 H+ f% X" ?; h6 U' c4 k6 ^7 X7 P: J
an adrenal tumor may also cause adrenal androgen9 Z0 y0 v' L% S9 F
excess.1,3
% e. b% [% d1 `6 g2 W) W( Oat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- L% ?. X+ _# Z3 S5 E: I9 K Y
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
M7 t5 k" e! e: AA unique entity of male-limited gonadotropin-7 D2 n& c6 z/ o7 M2 w
independent precocious puberty, which is also known
# S, B w- N- Ias testotoxicosis, may cause precocious puberty at a
1 a' o- J% l& m. p4 b; R+ I. zvery young age. The physical findings in these boys: W% T- \9 O3 h$ H
with this disorder are full pubertal development,0 R9 T6 r9 l0 x" _7 L% g2 |
including bilateral testicular growth, similar to boys7 S ?2 `/ ^; |7 G1 K" j
with CPP. The gonadotropin levels in this disorder
% w" J6 ^7 w: Hare suppressed to prepubertal levels and do not show, H, a X& d8 C+ K
pubertal response of gonadotropin after gonadotropin-2 r1 e) C- {: }; a. s8 H
releasing hormone stimulation. This is a sex-linked
- A# m( j# k, p+ O! Vautosomal dominant disorder that affects only
( ~' {& ]; m5 Z7 I/ Y2 m& N. omales; therefore, other male members of the family
6 b' ~! @8 o+ [: _* \may have similar precocious puberty.38 |0 s O9 `0 d" ]( x
In our patient, physical examination was incon-& n" u) G( _( _2 w. s
sistent with true precocious puberty since his testi-! U1 N u, Q0 I) e' h
cles were prepubertal in size. However, testotoxicosis! F3 p& P& H8 }; h, ]! W) t8 V) c7 t O
was in the differential diagnosis because his father
, O( m. i) s' k# l8 Z2 g( Tstarted puberty somewhat early, and occasionally,
0 E5 a7 D1 F; Itesticular enlargement is not that evident in the; @5 J$ |' Y% ]4 i5 V" J1 Y. k
beginning of this process.1 In the absence of a neg-" I$ k/ r5 @) N9 t
ative initial history of androgen exposure, our
! {4 D9 d6 e, Obiggest concern was virilizing adrenal hyperplasia,
& O4 v8 n+ t% M- Veither 21-hydroxylase deficiency or 11-β hydroxylase# {4 _! h. Q+ a6 F8 R+ M' q
deficiency. Those diagnoses were excluded by find-% p* Y# k9 }' {: X2 j8 k- j
ing the normal level of adrenal steroids.
! Y" i' o4 L t8 u8 R6 H$ ^$ H2 qThe diagnosis of exogenous androgens was strongly
* t& A6 O9 D5 isuspected in a follow-up visit after 4 months because
7 x; c1 x3 N+ Q/ V" [- n! v0 qthe physical examination revealed the complete disap-% H# l2 r/ K( {
pearance of pubic hair, normal growth velocity, and
: o$ A+ e2 p: M/ gdecreased erections. The father admitted using a testos-, K' T2 p- n* L( [6 }
terone gel, which he concealed at first visit. He was7 Y- |% D2 q) z% ]/ f
using it rather frequently, twice a day. The Physicians’
* v/ A. [, s8 \% QDesk Reference, or package insert of this product, gel or
6 G- @, ]% h- u% S3 hcream, cautions about dermal testosterone transfer to
& B9 N r( k8 V1 i# lunprotected females through direct skin exposure.
' C8 u1 j) S u" s: U& lSerum testosterone level was found to be 2 times the5 n z" [4 B0 Z7 h9 f
baseline value in those females who were exposed to8 q, A9 N4 Z! X+ E/ @
even 15 minutes of direct skin contact with their male3 o* }& y$ S, `6 c! h6 @: Y
partners.6 However, when a shirt covered the applica-
, z3 R3 k4 e6 h$ ztion site, this testosterone transfer was prevented.8 r; V }3 h4 ?. Q( @& ~3 m$ J3 \
Our patient’s testosterone level was 60 ng/mL,
3 i& F, z) r+ @0 F5 W2 v! ywhich was clearly high. Some studies suggest that- x* P" M. E7 T9 A. }6 y
dermal conversion of testosterone to dihydrotestos-
' a# \) h+ ~ W0 o. i; d5 cterone, which is a more potent metabolite, is more$ Z, S9 O7 d0 F A) \
active in young children exposed to testosterone7 y, X; n0 l& j7 `3 W- X
exogenously7; however, we did not measure a dihy-
W- E t5 @3 O( ^9 ?drotestosterone level in our patient. In addition to) V# q2 R8 ^3 N0 r& G% @" t" p
virilization, exposure to exogenous testosterone in
/ \, `1 V6 j1 Xchildren results in an increase in growth velocity and! P" z* q$ d& T$ X: v% W. u
advanced bone age, as seen in our patient.2 ^8 | q, @4 g* i$ j4 ]8 f
The long-term effect of androgen exposure during- I0 M& |" j# D2 C
early childhood on pubertal development and final4 p( D9 A$ H% J# s/ V
adult height are not fully known and always remain
& Y& E. s3 { e: ea concern. Children treated with short-term testos-1 [# Z' m: I6 ?, j7 ]( q- e s
terone injection or topical androgen may exhibit some) T6 F" A$ L c# h9 o- H3 g6 I4 j
acceleration of the skeletal maturation; however, after
. X* U% r5 e! M/ f* E/ Kcessation of treatment, the rate of bone maturation
8 P, o1 M- H- T) f% ], _decelerates and gradually returns to normal.8,96 C/ W$ O+ E% E, L! M
There are conflicting reports and controversy
^4 E7 W+ A, J; r0 S* `% @over the effect of early androgen exposure on adult X1 A9 H; r0 u" T8 c; ] A7 f
penile length.10,11 Some reports suggest subnormal5 o/ i4 F0 s& s
adult penile length, apparently because of downreg-
; n$ k5 F6 T3 ?. s- @: xulation of androgen receptor number.10,12 However,7 v' ~ G+ C8 }$ I- R7 w
Sutherland et al13 did not find a correlation between$ ], {- Y! |7 U2 F. C# z, f
childhood testosterone exposure and reduced adult
3 v* G! a, N- s2 ? r8 Z0 y: apenile length in clinical studies.
) s. H% Q5 j, o# \, _Nonetheless, we do not believe our patient is& `8 Q" r3 z4 ~: p: Q8 v
going to experience any of the untoward effects from
( v" ]) ~( u+ ^) @testosterone exposure as mentioned earlier because
/ o( u' b; c( b" W$ W2 B' I3 ithe exposure was not for a prolonged period of time.
* x. a$ W) F6 P7 {+ t5 f. y, @/ jAlthough the bone age was advanced at the time of6 g: z) v& U8 E7 ~6 F5 f4 d' |
diagnosis, the child had a normal growth velocity at
1 }5 R5 m# Y- _4 \1 hthe follow-up visit. It is hoped that his final adult
- D( v4 _' b6 c8 b1 Gheight will not be affected.
% |% a3 W% R% j, ?+ V8 HAlthough rarely reported, the widespread avail-7 K/ A6 |, l( T3 N1 F
ability of androgen products in our society may- b1 ^3 F2 v, S s4 ]
indeed cause more virilization in male or female6 _* s6 B( Y2 [. o6 M0 N' z+ h
children than one would realize. Exposure to andro-
" J' G1 P D' C, Cgen products must be considered and specific ques-
0 b1 D* z. [- t& b! f3 }6 |+ S$ f6 |tioning about the use of a testosterone product or, A( H" O! |7 d) y: `8 h3 S8 F
gel should be asked of the family members during
5 h2 K& G5 D2 H2 i7 ?3 dthe evaluation of any children who present with vir- j4 }1 j, T7 I9 r0 {1 Y# r! l
ilization or peripheral precocious puberty. The diag-
# o& t0 ?9 b6 a, ]9 znosis can be established by just a few tests and by. G j% y( _# c1 i9 ?
appropriate history. The inability to obtain such a, U0 X/ U g8 R3 a7 m, x0 b0 k3 ]5 e
history, or failure to ask the specific questions, may
% I7 m! l! Y% Y! _ rresult in extensive, unnecessary, and expensive
- m2 i. T7 g8 T% Y, R0 jinvestigation. The primary care physician should be: G, x2 [& p( c. N" A3 ^
aware of this fact, because most of these children
: s$ K5 T; q5 ?" Rmay initially present in their practice. The Physicians’
2 h' H9 w, g3 V' h, ?4 sDesk Reference and package insert should also put a
% z& ^4 e" e% q8 `( ?$ Swarning about the virilizing effect on a male or# j8 O& g I+ e; A3 {- z, D8 r
female child who might come in contact with some-
' L2 j. }) S& n k8 Cone using any of these products.& f2 o9 b. h; _. l, R
References
" M! a+ j# G+ M* V$ _$ F$ F1. Styne DM. The testes: disorder of sexual differentiation
! g, \* m- K1 l& W5 _and puberty in the male. In: Sperling MA, ed. Pediatric: }0 M5 H: g5 T# Y& N4 t' F
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ a" B: ?2 h+ z, j- n0 C% S
2002: 565-628." p+ t U4 y2 w M7 b S! c/ K. B' M
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& S( h- I/ `! c6 apuberty in children with tumours of the suprasellar pineal |
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