- 註冊時間
- 2023-5-6
- 精華
- 在線時間
- 小時
- 米币
-
- 最後登錄
- 1970-1-1
|
發表於 2025-1-4 03:25:35
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old
2 U& L1 W% ?/ yBoy Induced by Indirect Topical$ ~+ Q; i% z$ m5 J) S9 @: V1 Z
Exposure to Testosterone# G$ {4 u' _) B+ W3 i# m
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2' p2 r& l. ?5 L5 N
and Kenneth R. Rettig, MD1& F* G% W- M( t. o4 n! c4 i' i9 B
Clinical Pediatrics( T' o) P& E3 d3 C' _7 Q9 X0 h* N
Volume 46 Number 6
8 m d( I! `- `: ~, x. d; \July 2007 540-543" s3 ~+ T! V$ X7 n
© 2007 Sage Publications
' _# D9 @% M+ H9 [10.1177/0009922806296651. m1 K6 C3 o# M7 M
http://clp.sagepub.com
' g6 \, u) q2 p( U1 W6 r# ^hosted at( \, b% A1 J7 X7 `/ _5 c
http://online.sagepub.com% g. b t' M- H( K Q- t: [
Precocious puberty in boys, central or peripheral,( F& u2 ?8 t4 Z
is a significant concern for physicians. Central
3 i% d! `8 J$ f" z, W8 K& B' S. eprecocious puberty (CPP), which is mediated
$ U: W- `! B+ y5 ethrough the hypothalamic pituitary gonadal axis, has1 r. [- u" A" I8 n& w" B
a higher incidence of organic central nervous system
/ Y9 p8 p7 ^, v1 S, jlesions in boys.1,2 Virilization in boys, as manifested) R0 r! J9 |* ~, _
by enlargement of the penis, development of pubic
. |" o7 C4 c& xhair, and facial acne without enlargement of testi-* p8 Q3 f: i; z$ e" u9 Q
cles, suggests peripheral or pseudopuberty.1-3 We
. V( V; g8 o) ^; Z" T' b/ greport a 16-month-old boy who presented with the( l8 y) S% h+ P2 E
enlargement of the phallus and pubic hair develop-9 I: x$ D; b8 T# V# [7 h
ment without testicular enlargement, which was due4 _' `! w5 L9 v8 d
to the unintentional exposure to androgen gel used by
& w8 U# [/ V, a3 ~) m! @9 Uthe father. The family initially concealed this infor-. z' @% j) {2 A0 H
mation, resulting in an extensive work-up for this$ y4 N. t+ I$ g) n
child. Given the widespread and easy availability of# L/ _- h H) A2 o. ?6 N% {
testosterone gel and cream, we believe this is proba-
' X. Z( V0 j' m8 y# ^% vbly more common than the rare case report in the
8 g! t# E& R" l# Oliterature.4# G3 g9 Z9 ^. V2 E7 [. C
Patient Report2 h$ \+ y: ?) a, z% ~
A 16-month-old white child was referred to the: q/ M1 l6 q' m4 o! [" p# a6 e
endocrine clinic by his pediatrician with the concern$ y g1 u3 E- V" x$ w0 a/ ?( z/ }
of early sexual development. His mother noticed
+ i7 ~* x5 F& Alight colored pubic hair development when he was
. E6 C m4 _9 X0 L& u" T! M& I1 {From the 1Division of Pediatric Endocrinology, 2University of
' Z5 j6 B' d3 H/ t( \% RSouth Alabama Medical Center, Mobile, Alabama.
" ^& I* C6 v3 P: R" AAddress correspondence to: Samar K. Bhowmick, MD, FACE,
5 j4 O: F; `0 {9 L# i2 dProfessor of Pediatrics, University of South Alabama, College of. b) W( s, Q- H2 T% B! A8 w P& \9 _
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;2 ~. j' ^. g3 z$ ^
e-mail: [email protected]. E& X* k/ `, u- X2 h
about 6 to 7 months old, which progressively became
* [. B; ^ C0 l. mdarker. She was also concerned about the enlarge-
2 K! ] |4 I5 U0 E7 {ment of his penis and frequent erections. The child, U5 D1 n6 x( N( w! D6 P
was the product of a full-term normal delivery, with
: s1 I, B, m) j4 `6 i% ^* F+ ]a birth weight of 7 lb 14 oz, and birth length of& E! R+ @) a2 [5 K& A$ @2 _
20 inches. He was breast-fed throughout the first year, m3 A+ u' `. ~% i+ J1 `+ ]
of life and was still receiving breast milk along with
9 g) R; j: L e+ x7 B3 I9 l; Rsolid food. He had no hospitalizations or surgery,+ Z [6 d* X& J0 D
and his psychosocial and psychomotor development
/ I7 Z7 p: H2 p, A" G1 g2 iwas age appropriate.
7 W+ N' S& Y8 j( o! CThe family history was remarkable for the father,
0 f1 s$ H1 Z# x# t0 Ywho was diagnosed with hypothyroidism at age 16,5 h" }6 B' {0 T+ D8 v
which was treated with thyroxine. The father’s
& l& m3 N' A+ W2 W- T0 G2 Jheight was 6 feet, and he went through a somewhat0 R* Y$ F& j) u
early puberty and had stopped growing by age 14.' ?: x, V4 F y* g
The father denied taking any other medication. The1 U+ `" t) d1 D& n- ?5 F) I/ M2 p
child’s mother was in good health. Her menarche5 o3 g, A0 D% ^2 W& v: E
was at 11 years of age, and her height was at 5 feet
/ q( t" U0 M6 G. W( z5 inches. There was no other family history of pre-
5 d/ F+ i$ A, ]1 d: V6 dcocious sexual development in the first-degree rela-, _( n! J( \* Q, @" w0 l/ e
tives. There were no siblings.
- y; V4 A7 c9 M5 \: n: |+ jPhysical Examination
' g; ^5 i3 i' }1 Z/ m( aThe physical examination revealed a very active,
: y1 V/ C* n& _! J k8 K$ N) Qplayful, and healthy boy. The vital signs documented
; P- @3 E- Q0 m: F; K- pa blood pressure of 85/50 mm Hg, his length was( J5 U5 |; M j3 q4 m7 U, F! D/ `" R
90 cm (>97th percentile), and his weight was 14.4 kg
# s# G+ h' U$ \* ~: i6 G(also >97th percentile). The observed yearly growth
% {- c8 y1 @4 E* Dvelocity was 30 cm (12 inches). The examination of* e. e: K, O- ~2 s% J; J
the neck revealed no thyroid enlargement.
' A7 N: L3 `9 ]9 v) H: EThe genitourinary examination was remarkable for
1 Z$ j+ u- y" f6 H6 T% A. l& fenlargement of the penis, with a stretched length of
; ]# u9 J" h ]+ D: c! I8 cm and a width of 2 cm. The glans penis was very well
* }& C% M- F U* c5 K0 B/ ^& ^developed. The pubic hair was Tanner II, mostly around
: i4 l3 Q; w: {9 C7 e540
6 s9 e7 B. `* g: g" b, Qat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 Q7 C8 }, Z- g+ C5 [7 ~the base of the phallus and was dark and curled. The- ~2 E: V/ Z" g, G; U
testicular volume was prepubertal at 2 mL each.
, |7 A& t9 }8 y cThe skin was moist and smooth and somewhat
+ E$ b7 F9 H; z, O0 b V- ooily. No axillary hair was noted. There were no9 d2 x: Y, c% }% l* g
abnormal skin pigmentations or café-au-lait spots.
0 i0 t% p( T( P8 g0 S7 Q! rNeurologic evaluation showed deep tendon reflex 2+' V9 e! d# d; {, D$ [. q" Q
bilateral and symmetrical. There was no suggestion
; D( N7 r/ n& B- O8 k! G3 Q% S6 Lof papilledema.
, w$ [5 f ]& ]; z; k7 D5 k4 TLaboratory Evaluation
, H6 F% Q b$ eThe bone age was consistent with 28 months by
; f) X1 } v! K& J% m8 Dusing the standard of Greulich and Pyle at a chrono-) U. g& f4 x( l1 J. H0 Y
logic age of 16 months (advanced).5 Chromosomal
4 f$ q7 J# O1 v5 }* z; Akaryotype was 46XY. The thyroid function test
2 ]. o& ~ p# |; @. V" u$ _showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% B6 \: p( h/ I; blating hormone level was 1.3 µIU/mL (both normal).
- d) u' X0 B M+ Q2 `The concentrations of serum electrolytes, blood
+ T- n. V9 k7 F5 Yurea nitrogen, creatinine, and calcium all were( F* I4 O u2 e/ [) G$ F; [/ P
within normal range for his age. The concentration9 N* v8 ?8 y3 m$ D/ ~5 m
of serum 17-hydroxyprogesterone was 16 ng/dL
. P& N P+ r+ N0 d- _5 m(normal, 3 to 90 ng/dL), androstenedione was 206 q, J- A) e9 P W+ O; y0 w4 e& {
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-' n! Z. @* L% P
terone was 38 ng/dL (normal, 50 to 760 ng/dL),2 J8 d; `& G Z1 N8 d
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
$ {0 ]; s- d) H- e( B4 U# k49ng/dL), 11-desoxycortisol (specific compound S)4 O3 l9 _ {2 K% v& {
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-( ~% ?3 p5 b' R. ?$ _
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 P& W3 N( K! T& w: R5 h* Y
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),3 K9 |! X" F% O+ {5 b4 V
and β-human chorionic gonadotropin was less than6 S/ ?8 i# ]' \( t
5 mIU/mL (normal <5 mIU/mL). Serum follicular
0 D3 D$ a2 @, ]7 D6 ?- f% `+ Hstimulating hormone and leuteinizing hormone. ~" I. g" x5 Y1 U& q7 z& t
concentrations were less than 0.05 mIU/mL
: {1 S' i7 u9 [5 F- q0 ^(prepubertal).
0 W' R0 }+ i) DThe parents were notified about the laboratory5 t' I: W5 r, W& E! c( i
results and were informed that all of the tests were5 F! h9 y; ?+ p1 W0 l
normal except the testosterone level was high. The/ C. _& P2 O" @( j" Q# q
follow-up visit was arranged within a few weeks to
9 ^ f) M4 c) q$ [% \obtain testicular and abdominal sonograms; how-
4 d5 t4 C5 u/ U3 M' T, z) pever, the family did not return for 4 months.. @3 h/ ]3 H+ z1 c" Y6 F
Physical examination at this time revealed that the
7 ~5 \9 _9 H0 ichild had grown 2.5 cm in 4 months and had gained
) \6 }) N' U# S5 t$ ?5 ~2 kg of weight. Physical examination remained+ ~% D+ G5 Q% u! n0 d
unchanged. Surprisingly, the pubic hair almost com-4 @0 C. T; E6 [9 c; X. S
pletely disappeared except for a few vellous hairs at
. j: f1 s( Q: g9 {0 M- l6 Q6 X) x2 |the base of the phallus. Testicular volume was still 2
* C- r& n8 W% dmL, and the size of the penis remained unchanged.
& T8 N. a8 U- b4 bThe mother also said that the boy was no longer hav-
7 X$ M/ ~7 V" `' j$ B; J. s6 |ing frequent erections.
: v! G6 i* I! KBoth parents were again questioned about use of
) f2 X, [6 R, Q# s) F$ S) K0 Wany ointment/creams that they may have applied to: {9 j; ] o5 Z' ]" M. J
the child’s skin. This time the father admitted the& n, V7 R& M7 h( g4 n
Topical Testosterone Exposure / Bhowmick et al 541
8 g. L0 S( x% A5 \8 @. C7 [0 Quse of testosterone gel twice daily that he was apply-
) {1 D9 p6 R- t- w; b1 }ing over his own shoulders, chest, and back area for
5 H% a! U: a s& [a year. The father also revealed he was embarrassed& A' }: T+ g& i+ }5 U
to disclose that he was using a testosterone gel pre-) ~) D4 A! m, T- ~; _: w
scribed by his family physician for decreased libido
8 w; O1 Q3 ]$ `8 l# f( S( qsecondary to depression.* ~- e* X8 Q- q" y/ Q
The child slept in the same bed with parents.
9 C. w5 f5 I# W9 w- \The father would hug the baby and hold him on his4 E% P/ `" x) r+ g' Q- K% o$ r. y
chest for a considerable period of time, causing sig-
$ c8 P$ D5 c7 F9 Z* ]4 Inificant bare skin contact between baby and father.
3 u. d3 h2 q+ sThe father also admitted that after the phone call, t0 ?. _+ @% v& x, X5 F l# H
when he learned the testosterone level in the baby3 B' A$ u, r, J6 W/ B1 R2 ~' r* U+ u
was high, he then read the product information' b0 F6 }6 P+ Z: u9 @
packet and concluded that it was most likely the rea-
' v0 E- m. u2 ~4 R! u0 Y! ?son for the child’s virilization. At that time, they
( Q$ e% z3 S. M7 n$ x! X d4 j/ [decided to put the baby in a separate bed, and the2 M5 i, x" J" q/ p& E
father was not hugging him with bare skin and had, @3 W. R: n, s* l: U
been using protective clothing. A repeat testosterone+ \7 m& q/ x+ w# I% G8 l" w
test was ordered, but the family did not go to the/ Z# z8 N8 d! f2 W, S# I$ ~+ O
laboratory to obtain the test., c0 Q2 p1 v' y5 \ @- k7 L/ R
Discussion+ u0 ]0 C1 R; R& s" W
Precocious puberty in boys is defined as secondary! C% n$ o6 P9 c! w- O6 ?
sexual development before 9 years of age.1,4
- S8 y4 x7 Y' W* x% z; qPrecocious puberty is termed as central (true) when
" _" ]3 P% @: Vit is caused by the premature activation of hypo-2 l; G1 w+ W* F8 l$ Y
thalamic pituitary gonadal axis. CPP is more com-5 ]- O& q D2 M: d
mon in girls than in boys.1,3 Most boys with CPP
% [: l9 M$ Y* L6 u6 o. O$ e0 v: Umay have a central nervous system lesion that is
5 Z& _& H& G# W! h3 K' W" jresponsible for the early activation of the hypothal-. f) \8 y3 L9 e1 X1 Z3 B& g) a
amic pituitary gonadal axis.1-3 Thus, greater empha-9 ^; g* f" b" N0 T' A9 O; }
sis has been given to neuroradiologic imaging in/ _9 P" p& G0 y R$ E
boys with precocious puberty. In addition to viril-
$ I/ K; [8 A3 n" Qization, the clinical hallmark of CPP is the symmet-
2 K& f6 i% q% E! Q& Q* hrical testicular growth secondary to stimulation by0 ~ o5 X, f6 `& p* ^4 j+ G
gonadotropins.1,3$ O1 w8 f; p* q' A, \# |# s* y( M% X
Gonadotropin-independent peripheral preco-- k* i; p5 c- o4 I
cious puberty in boys also results from inappropriate4 K0 O; `& `3 @6 r; o1 ?: ?5 Y
androgenic stimulation from either endogenous or$ f, N% Y: P% u- N8 f
exogenous sources, nonpituitary gonadotropin stim-6 @* }4 b! Z* W3 ]- M+ M
ulation, and rare activating mutations.3 Virilizing
# I* p9 m8 s. `0 jcongenital adrenal hyperplasia producing excessive
, s2 j9 m1 ^6 Y3 u* N/ z- Kadrenal androgens is a common cause of precocious
& c. R/ t' b' J% ?' ~! apuberty in boys.3,40 h: C5 r* u" C, @
The most common form of congenital adrenal0 z5 S2 n, o, V7 N# w% _' ?
hyperplasia is the 21-hydroxylase enzyme deficiency.. H0 n+ c6 c3 C: @) D* J
The 11-β hydroxylase deficiency may also result in! Y( n! q% m" G. \
excessive adrenal androgen production, and rarely,
$ ^& y' Q/ ^5 M1 pan adrenal tumor may also cause adrenal androgen6 w* b; y, H) u, s
excess.1,3
$ ]- }1 g9 z+ I: w& ?! h4 F/ pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 S' U Q( W4 C5 q; D542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ }0 ?0 ^6 k; N" T T; o9 @1 pA unique entity of male-limited gonadotropin-
+ x) ^. O3 A' F& {independent precocious puberty, which is also known, C+ }9 p8 W" q$ k, R! h
as testotoxicosis, may cause precocious puberty at a; F/ q8 a+ l1 F- B- U4 h. b4 g
very young age. The physical findings in these boys
& P, L0 A* [& h; U. `* T! z' Pwith this disorder are full pubertal development,6 j+ _2 T% ]5 W
including bilateral testicular growth, similar to boys
: u: u# X6 F' c5 L) I) Q2 V! Y \with CPP. The gonadotropin levels in this disorder. Z% `4 g. F4 x. O& I
are suppressed to prepubertal levels and do not show
7 `" I! _* }. _. v( H$ I2 h' x# Ipubertal response of gonadotropin after gonadotropin-# P& P% L% Z4 W2 y9 K/ X* t
releasing hormone stimulation. This is a sex-linked: ^: B# F. t* }# b5 s% C4 t
autosomal dominant disorder that affects only
& K; E5 U4 E! O9 v: Omales; therefore, other male members of the family
# v; J/ U" W" x0 ]6 gmay have similar precocious puberty.3" H3 s" t- V |) J
In our patient, physical examination was incon- t7 K* Y9 Q+ t7 r A
sistent with true precocious puberty since his testi-/ S/ F: B1 S" X. x
cles were prepubertal in size. However, testotoxicosis
! f% J- j0 ]; Uwas in the differential diagnosis because his father1 L$ t& T8 |3 O& F8 H* v
started puberty somewhat early, and occasionally,
! d. Z3 a, F1 p. Ztesticular enlargement is not that evident in the
9 Y3 t9 e$ C0 U: b. ~ G3 Nbeginning of this process.1 In the absence of a neg-
P! F6 k8 R4 K; jative initial history of androgen exposure, our
. M' V9 d7 m9 Z; m% |) |$ }biggest concern was virilizing adrenal hyperplasia,
/ }3 _9 B! o. b7 U4 O% {$ l1 Keither 21-hydroxylase deficiency or 11-β hydroxylase
* s- z" E* T: k( }deficiency. Those diagnoses were excluded by find-9 ]$ I f) A( W$ [. F3 |
ing the normal level of adrenal steroids.; P8 U) Y& J& ^1 C. u
The diagnosis of exogenous androgens was strongly
. G' H5 i$ \' |; S% X- Y+ lsuspected in a follow-up visit after 4 months because
" |6 Q8 s9 p, L/ Nthe physical examination revealed the complete disap-
6 b o' F$ r9 @+ Z' V+ F0 k7 _3 ypearance of pubic hair, normal growth velocity, and# t' K8 [( o' r/ Y+ L9 g5 ^! Y
decreased erections. The father admitted using a testos-
" v7 Q4 |( J4 z5 W; {" Fterone gel, which he concealed at first visit. He was
) [# n; R& _( d7 Y/ t2 g1 Wusing it rather frequently, twice a day. The Physicians’/ X0 r3 U2 _, ^2 ? V
Desk Reference, or package insert of this product, gel or
& q6 S2 P) f7 N* x! d2 Ycream, cautions about dermal testosterone transfer to
5 v% s. K$ n8 L) G* yunprotected females through direct skin exposure.
" V6 |- `4 P: f9 i! _. K+ {Serum testosterone level was found to be 2 times the
2 P& W" ^ _$ f- D3 R: Cbaseline value in those females who were exposed to
# Z/ h$ @ c, s1 n5 veven 15 minutes of direct skin contact with their male$ c" F C" O& u! v- n. Z
partners.6 However, when a shirt covered the applica-, D% W w, v9 v# ~9 Z+ h4 E7 j
tion site, this testosterone transfer was prevented.
: [/ x/ H D8 L1 Y; J" S8 XOur patient’s testosterone level was 60 ng/mL,
! Y) ]# p$ v, ^which was clearly high. Some studies suggest that
. j7 H2 ~) H w( J( vdermal conversion of testosterone to dihydrotestos-% }$ g' E5 x+ g# |
terone, which is a more potent metabolite, is more1 F+ p" Y3 A5 Y9 L- x
active in young children exposed to testosterone
: l% z2 e f! U( F1 Fexogenously7; however, we did not measure a dihy-$ N7 y {$ Y; Z1 P
drotestosterone level in our patient. In addition to. f/ P+ N: a8 `: h, ]7 |% S" k5 c
virilization, exposure to exogenous testosterone in$ d; K& m1 N2 H9 w5 d
children results in an increase in growth velocity and
/ r. F( {# z6 v; W0 ^8 w4 S$ H% jadvanced bone age, as seen in our patient.
/ t {9 ~$ a8 |% kThe long-term effect of androgen exposure during
! @. P* d4 C3 x9 M4 dearly childhood on pubertal development and final1 }: J$ [- g+ v; F
adult height are not fully known and always remain
/ F8 Z) \# e8 D8 ma concern. Children treated with short-term testos-- H4 Z8 p3 Q' R# _
terone injection or topical androgen may exhibit some; \ e& W% I/ w7 i' G
acceleration of the skeletal maturation; however, after( f3 Z3 c. w9 g) W
cessation of treatment, the rate of bone maturation. W8 b: ]( S; Z7 q# V# I" P
decelerates and gradually returns to normal.8,9
$ E, K5 E3 X. R+ WThere are conflicting reports and controversy: ~5 h+ J2 `9 y! M6 S: ?* }
over the effect of early androgen exposure on adult
6 }( @* p j- c+ {penile length.10,11 Some reports suggest subnormal( N; R) H& R" P! z- O- C2 r
adult penile length, apparently because of downreg-1 a, H. E" g8 ]0 z: U
ulation of androgen receptor number.10,12 However,( U) R2 b+ N f) ^; j( z7 S1 n
Sutherland et al13 did not find a correlation between, ?$ Q1 l2 T R6 Z
childhood testosterone exposure and reduced adult
1 T( m8 b1 }( g. K- a! r5 apenile length in clinical studies.0 c( b) s( e% ^
Nonetheless, we do not believe our patient is
( E, H: C: L6 f- ^# j; X( l2 V: zgoing to experience any of the untoward effects from( {! ]2 g) M+ @: o4 D. @
testosterone exposure as mentioned earlier because: T# r+ O$ E2 s7 O
the exposure was not for a prolonged period of time.9 f9 H& Q* v) f* p/ T2 J0 ~6 F
Although the bone age was advanced at the time of
! d* u/ z& h' pdiagnosis, the child had a normal growth velocity at( G4 Y' {6 t/ P* g
the follow-up visit. It is hoped that his final adult1 V0 b0 `* J( o
height will not be affected.
7 ]) Q, Y" Y% U8 @. }" [/ GAlthough rarely reported, the widespread avail-
; }9 M: r0 B6 ~( L- x" Dability of androgen products in our society may
5 _, D& r" N: z" qindeed cause more virilization in male or female
2 n4 I: B, r1 m" x$ w y( ]; o8 Bchildren than one would realize. Exposure to andro-
9 t, T$ q* W( Z |, Pgen products must be considered and specific ques-: @7 N" w8 ?% q) c% J$ R/ X `
tioning about the use of a testosterone product or
6 o) m" C% \/ u/ u. f& kgel should be asked of the family members during9 J1 v, ]. N* ` u# o
the evaluation of any children who present with vir-7 i" j0 h1 Y1 o+ E) T9 ^
ilization or peripheral precocious puberty. The diag-6 f7 {0 Q3 q2 q- ]' z! E
nosis can be established by just a few tests and by" c3 B1 C. P+ c, N& T- F& o
appropriate history. The inability to obtain such a
7 _8 s, i' B& c5 Q5 B& [+ yhistory, or failure to ask the specific questions, may
! t& p% }( B( u4 S5 J% kresult in extensive, unnecessary, and expensive7 a) u) x Z2 j7 r
investigation. The primary care physician should be
1 D. Y; d" ~8 r! ~! C) n2 Aaware of this fact, because most of these children
% \; Q7 n8 ]6 C; j/ vmay initially present in their practice. The Physicians’: G) O, s! C- F Z
Desk Reference and package insert should also put a
. l- i+ }9 U7 M( D9 Z6 Kwarning about the virilizing effect on a male or
- ~+ Z& N$ V, m9 C8 \+ Q" D+ ~& ^female child who might come in contact with some-
7 L0 |9 ~& |2 @9 C# S2 u9 }one using any of these products.
; S, I% x) P7 k6 N* AReferences, K P9 U( k( m! o, l
1. Styne DM. The testes: disorder of sexual differentiation. F) C/ a6 ?% {! s) i2 \/ \
and puberty in the male. In: Sperling MA, ed. Pediatric, ^; Y+ v q3 ]6 d7 t- w& i% n
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
+ a3 e. F! Z* _# ]/ Y2002: 565-628.: P+ n8 r9 }4 M4 t
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
- }. m2 l; d( t; bpuberty in children with tumours of the suprasellar pineal |
|