- 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 03:27:02
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old
( F$ Y* Q0 Y" z; IBoy Induced by Indirect Topical2 p$ V) Z3 l& p9 u# s+ |2 k8 v- }
Exposure to Testosterone
* Y. Q% `% a0 \2 Q+ |/ b; ASamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,23 y# A5 z1 `7 e/ D* H; S
and Kenneth R. Rettig, MD1/ b' s+ X, z# s
Clinical Pediatrics9 e% d8 z9 v+ D% a& k2 u/ G( \# }4 i
Volume 46 Number 6
* \. G E: ^7 x+ tJuly 2007 540-5437 p4 T/ j" |1 X* g5 O& F
© 2007 Sage Publications" ^% |& c6 `( K) B8 b- E
10.1177/0009922806296651% i: C$ j5 B+ D$ O: B
http://clp.sagepub.com1 p. K8 L" u. P; v8 o) |
hosted at
' r! P# d/ V. p8 Yhttp://online.sagepub.com& v/ x$ l6 n1 t, [
Precocious puberty in boys, central or peripheral,: m* D# D: ^' u8 d: V! W9 g; ^9 Z
is a significant concern for physicians. Central% g' U4 p7 f( `5 j' k
precocious puberty (CPP), which is mediated: i9 M1 w, ?; U+ S0 y
through the hypothalamic pituitary gonadal axis, has
- N( S- g9 T H4 P: w+ B1 X) Ea higher incidence of organic central nervous system" \7 w2 U0 m* U7 z3 Q
lesions in boys.1,2 Virilization in boys, as manifested
; N2 V$ G" Y& Z7 Xby enlargement of the penis, development of pubic
% m; A' ^7 r- @9 Hhair, and facial acne without enlargement of testi-
, p ~* r- r( z" y) D- }0 Icles, suggests peripheral or pseudopuberty.1-3 We: I# I$ r6 `7 ~: c4 _* u
report a 16-month-old boy who presented with the Y$ W8 o; X" A0 a0 `5 h
enlargement of the phallus and pubic hair develop-% u3 A. n* f# @4 ^; r! P4 r
ment without testicular enlargement, which was due. N( ^: D J5 l: I5 r) U
to the unintentional exposure to androgen gel used by9 n/ G& w( S5 v& m
the father. The family initially concealed this infor-
. l. c" B" M) _* q( `mation, resulting in an extensive work-up for this
" [- I* C c1 n3 A/ [" p tchild. Given the widespread and easy availability of* C# o; p) j) B/ e3 t' G; i
testosterone gel and cream, we believe this is proba-
) Y9 Y& H+ Z* W1 {bly more common than the rare case report in the7 Y# g0 v2 u1 X1 h; ]* G' Q
literature.45 }: `' X3 \, ^* @; L l
Patient Report
- z# j# j8 D6 \/ p$ RA 16-month-old white child was referred to the+ @) R6 v/ M/ l7 H$ v+ f$ V
endocrine clinic by his pediatrician with the concern" [2 P) ]- c( W) M1 h" H- a$ m
of early sexual development. His mother noticed9 D: |4 h( j; H# k ?3 G
light colored pubic hair development when he was
& L! e: T1 S% g* l. S+ ~( _From the 1Division of Pediatric Endocrinology, 2University of
6 p1 R# ~+ E @6 [1 |South Alabama Medical Center, Mobile, Alabama.
$ h# [) J/ `+ `: D7 a/ u2 CAddress correspondence to: Samar K. Bhowmick, MD, FACE,+ r) b. n% w+ g6 \8 o1 D
Professor of Pediatrics, University of South Alabama, College of8 X+ l0 w) m& _9 f8 v6 s- V
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
1 z% o5 y4 F! ]! m( Pe-mail: [email protected].- M* u1 F" b! M$ b% `- E
about 6 to 7 months old, which progressively became
! Q# u. F& s7 tdarker. She was also concerned about the enlarge-. z2 Y+ _7 s5 p0 L& `6 @% K* f/ [" x
ment of his penis and frequent erections. The child
: v1 {. K ]' t Gwas the product of a full-term normal delivery, with# I% `5 Z9 n* I" z5 U( [
a birth weight of 7 lb 14 oz, and birth length of
' E* k6 d! Y5 r9 S f8 p X I20 inches. He was breast-fed throughout the first year2 Y* s# X( M, {& G: K T) c
of life and was still receiving breast milk along with
! {1 _/ N% ? I( g; Jsolid food. He had no hospitalizations or surgery,
, K8 f- W! C) @$ \! g0 c# O9 O0 p; z, vand his psychosocial and psychomotor development; J* s% T* w' O& P; ^1 ^+ n
was age appropriate.# p' F! D. [2 w
The family history was remarkable for the father,
+ |; L8 F/ W, W4 p! n7 Cwho was diagnosed with hypothyroidism at age 16,, p3 ^6 I) P1 f- i* p: J, ^
which was treated with thyroxine. The father’s
; v4 t* ?. N m5 Pheight was 6 feet, and he went through a somewhat! z7 N g4 M e, n# q; B2 L
early puberty and had stopped growing by age 14.
" ?8 R. p$ |; p4 c1 \ F v- CThe father denied taking any other medication. The& _: w: J2 F6 @ s4 h1 c
child’s mother was in good health. Her menarche
2 [$ z/ j- X2 x/ ]- S% I* Z/ r8 s( Twas at 11 years of age, and her height was at 5 feet$ j2 I% G# v* N
5 inches. There was no other family history of pre-3 z) D$ h0 I- N; [$ [
cocious sexual development in the first-degree rela-
& S$ y" v/ g: W L3 g5 T* ltives. There were no siblings.
0 }- U8 [$ L7 o1 DPhysical Examination
' H) h6 e6 U6 z& U R! A) V+ qThe physical examination revealed a very active,
! d/ ^7 \7 ]! }% dplayful, and healthy boy. The vital signs documented8 b z1 U o( g
a blood pressure of 85/50 mm Hg, his length was. l# g0 k2 z1 Y6 y g
90 cm (>97th percentile), and his weight was 14.4 kg' o& ]& h: P9 l# W) O1 h# u
(also >97th percentile). The observed yearly growth
" O6 j5 A+ N6 N* O( J! P7 dvelocity was 30 cm (12 inches). The examination of& \' B$ q/ w! A' D
the neck revealed no thyroid enlargement.5 k; p# {+ J( a- G z
The genitourinary examination was remarkable for7 w/ \# b, e8 [* R
enlargement of the penis, with a stretched length of: i& M- Z2 W4 I$ J4 ]4 _
8 cm and a width of 2 cm. The glans penis was very well3 f% H# M4 V8 ~- `
developed. The pubic hair was Tanner II, mostly around( A3 ?$ B1 o/ }0 n4 Z1 z7 n
540% n: g, A; H x+ f3 S6 N7 Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
& r+ l7 P) a# Y* nthe base of the phallus and was dark and curled. The. Z8 P' U- {0 W+ m. J0 F8 L9 t
testicular volume was prepubertal at 2 mL each.
" \4 ^6 d; O. n! eThe skin was moist and smooth and somewhat3 m. R; i) i; E2 s$ Y, @
oily. No axillary hair was noted. There were no
- i" ]; d' d9 Z$ B; h3 H6 R. uabnormal skin pigmentations or café-au-lait spots.
6 L; ?3 \: k5 `Neurologic evaluation showed deep tendon reflex 2+
$ U3 x+ P _/ u) L9 `( wbilateral and symmetrical. There was no suggestion
; f X* E' l3 {of papilledema.; ^' _9 A" h7 R" ^/ I
Laboratory Evaluation& x4 j; C. \" b% c
The bone age was consistent with 28 months by
0 c" J x9 ]7 _" J# z ]+ {using the standard of Greulich and Pyle at a chrono-
/ W0 z8 ^6 {8 P7 Z+ y& U# ulogic age of 16 months (advanced).5 Chromosomal$ b! g1 q9 v* y. J: A
karyotype was 46XY. The thyroid function test* x0 V& o% M0 x1 ]" I2 [2 n
showed a free T4 of 1.69 ng/dL, and thyroid stimu-: B! X4 g) I. R% R
lating hormone level was 1.3 µIU/mL (both normal).
, Z$ d5 C: I3 x4 T1 gThe concentrations of serum electrolytes, blood) t! D' A" i* Q5 N9 k+ t" Q- x7 p
urea nitrogen, creatinine, and calcium all were2 Q5 m7 h2 d1 |) @' @/ r, |9 I
within normal range for his age. The concentration
, K( o4 u7 y: K X* zof serum 17-hydroxyprogesterone was 16 ng/dL# \9 ~# m* P9 x
(normal, 3 to 90 ng/dL), androstenedione was 201 V, ~" a% c: E' s% G0 C8 z% p
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
9 E0 H& d. ~" p7 Q; S. }terone was 38 ng/dL (normal, 50 to 760 ng/dL),
2 X$ {( F$ F, Cdesoxycorticosterone was 4.3 ng/dL (normal, 7 to+ ]7 U$ m, `, D; ~2 G4 N
49ng/dL), 11-desoxycortisol (specific compound S)& ]8 M2 q' Z. ?6 g
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
/ A1 ?8 u# _3 v, Z: q/ W( Ctisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total# T4 K# j7 c0 a. j6 e
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),' ]8 g/ ^) i4 d ~6 k6 F' Q# m
and β-human chorionic gonadotropin was less than, e+ \7 M- O$ D. `
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 r! p4 f- ] r) i0 ]stimulating hormone and leuteinizing hormone: w7 [) U" _/ L$ x1 M% e
concentrations were less than 0.05 mIU/mL
, `$ D- O$ D& X6 ?! K1 H" S0 f* z(prepubertal).
" h9 H: K+ r$ T$ t8 {3 o& Z: WThe parents were notified about the laboratory
5 u$ r" r1 R( wresults and were informed that all of the tests were# I6 l! g }$ Z& f
normal except the testosterone level was high. The+ J1 M# N+ }0 a1 a0 `% A
follow-up visit was arranged within a few weeks to: t/ p" B7 h" O, s. E1 h+ h: M% z
obtain testicular and abdominal sonograms; how-
& _8 {- z# a9 Zever, the family did not return for 4 months.. q/ |* `, O. N2 t9 x- J/ [
Physical examination at this time revealed that the
3 e, ]+ G9 h9 }child had grown 2.5 cm in 4 months and had gained* Y& g# U6 B8 v) W2 b8 ?
2 kg of weight. Physical examination remained
' @7 t& K% q$ Q7 H0 eunchanged. Surprisingly, the pubic hair almost com-, k' }* y/ Q p- Y4 U
pletely disappeared except for a few vellous hairs at) \5 m1 F. D2 O% k5 ~
the base of the phallus. Testicular volume was still 2& p C6 V, D0 W/ J1 X4 S/ l* m& x
mL, and the size of the penis remained unchanged.! N! P: B3 t, |# J
The mother also said that the boy was no longer hav-
. u7 I+ Z! O$ @" x- V. cing frequent erections.2 m" N; r) l9 Q3 B% q0 J
Both parents were again questioned about use of3 K1 D. Q* D% ]6 N% S5 d, F
any ointment/creams that they may have applied to
m; X3 J6 L$ `the child’s skin. This time the father admitted the
: ~2 f: w: l* I ~. ETopical Testosterone Exposure / Bhowmick et al 5412 s0 k1 A! c' |, X
use of testosterone gel twice daily that he was apply-
( q6 W/ L. }. b1 I+ `4 Z! N/ C5 y; Ping over his own shoulders, chest, and back area for
4 `( j* Q' t' u5 |" n' l1 ja year. The father also revealed he was embarrassed. ?- s5 @( Z5 _+ F2 L, z! {" X
to disclose that he was using a testosterone gel pre-
* p& q! ?. z5 T( |* M( `scribed by his family physician for decreased libido3 k/ L1 B! N. @1 @+ b
secondary to depression.% z& }' [' C' o7 h
The child slept in the same bed with parents.9 o, O: T- ?3 U! }
The father would hug the baby and hold him on his6 L' r' I4 q/ }# [' P
chest for a considerable period of time, causing sig-' R Z& ~$ o$ u& S
nificant bare skin contact between baby and father.
+ h# D5 y, \" n; S$ Z8 }) `2 kThe father also admitted that after the phone call,4 P/ z) [' ^8 ?% j5 B" k# X
when he learned the testosterone level in the baby7 X3 \" S8 I! |! G% l
was high, he then read the product information
) I) b0 L2 G3 x* {0 x6 gpacket and concluded that it was most likely the rea-; _9 P0 A, g: X2 Q% K5 _
son for the child’s virilization. At that time, they
. H3 S. }; G; R, k) T" f4 g$ M: udecided to put the baby in a separate bed, and the4 b$ d! f6 ]3 ^7 w4 |
father was not hugging him with bare skin and had
, E- q ~. _* q6 o# k1 i$ mbeen using protective clothing. A repeat testosterone
, b6 b# L. y! D% M J) j+ {, X! t9 Jtest was ordered, but the family did not go to the
: s2 N- }& a V9 hlaboratory to obtain the test.; o3 B! g3 ]" L Z7 u* Z
Discussion: E4 T; z/ r" f" K/ w( X& A- A3 k
Precocious puberty in boys is defined as secondary' [3 Y% |, r) z$ n B0 k
sexual development before 9 years of age.1,4
# d- M3 D( \- Y1 `5 kPrecocious puberty is termed as central (true) when
& u: @3 e9 O% [7 X3 kit is caused by the premature activation of hypo-
/ C4 S' P. B; f5 K1 K2 r/ B3 V ]thalamic pituitary gonadal axis. CPP is more com-' d/ c. `! D- X7 s% v3 c
mon in girls than in boys.1,3 Most boys with CPP4 l! L& A1 r/ |/ N3 h2 p( U
may have a central nervous system lesion that is2 o6 c0 ]: ?% N9 q7 B/ C
responsible for the early activation of the hypothal-9 o/ q- y8 i% Z i
amic pituitary gonadal axis.1-3 Thus, greater empha-- ~4 R2 R4 Y& V. k8 u3 f$ ?. Y/ d
sis has been given to neuroradiologic imaging in
/ w: e, W, w, z4 I" P. Aboys with precocious puberty. In addition to viril-( ^" z& a4 c8 A" A% M
ization, the clinical hallmark of CPP is the symmet- I3 O1 W& e) A$ ~/ r* E& A+ Y
rical testicular growth secondary to stimulation by
) }, w7 {. n2 `" ?" w7 r" o0 ^+ o# ugonadotropins.1,3
' f- M }! |, D0 Z4 n! f2 W, rGonadotropin-independent peripheral preco-* k- Z& h: H3 B5 t2 H8 E# }
cious puberty in boys also results from inappropriate5 q, A6 {9 J* R/ ~, E
androgenic stimulation from either endogenous or' l+ N3 { H$ N0 \6 d
exogenous sources, nonpituitary gonadotropin stim-
9 e( Q6 K/ f! iulation, and rare activating mutations.3 Virilizing& v8 |+ g. A# H5 r# n
congenital adrenal hyperplasia producing excessive
( Q e3 o7 K- B, A, J0 `1 yadrenal androgens is a common cause of precocious/ ]0 F3 T! E0 o
puberty in boys.3,4
5 y4 o* q$ N1 RThe most common form of congenital adrenal
- P) O2 b- S2 _ G! thyperplasia is the 21-hydroxylase enzyme deficiency.3 D( \6 c7 |0 Z% L2 g& |/ l" A# E. m
The 11-β hydroxylase deficiency may also result in* d) v, {( F. {# [9 M6 j. E
excessive adrenal androgen production, and rarely,
: Q/ ^: h2 O$ l. T" |6 l( a; Aan adrenal tumor may also cause adrenal androgen6 @: _- s, K: X/ U3 o1 |
excess.1,3( {- w: o2 t) x! t5 Q' J$ m% d% ^5 i
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from. O- Z1 W; o( f, P5 x
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
1 S2 N* q U, SA unique entity of male-limited gonadotropin-: D. A# K7 H+ T' w- a
independent precocious puberty, which is also known
O8 m: ^# k9 B* \- ~! O, [0 Bas testotoxicosis, may cause precocious puberty at a
* K+ b0 d; Q5 z2 [: Qvery young age. The physical findings in these boys
% v1 y* x8 B4 X+ M( q* Uwith this disorder are full pubertal development,
( o! M% A( y! |5 k0 mincluding bilateral testicular growth, similar to boys# M& p2 K9 x( L. t1 d8 N% @
with CPP. The gonadotropin levels in this disorder; ~/ ^4 ]9 y1 |- K1 E" }
are suppressed to prepubertal levels and do not show
- m# {- s% D- N% J5 J/ cpubertal response of gonadotropin after gonadotropin-
) V9 a+ |1 H5 h9 wreleasing hormone stimulation. This is a sex-linked6 C4 \4 t6 ^. U
autosomal dominant disorder that affects only
4 z, w: t: p! M5 Dmales; therefore, other male members of the family/ p0 c% p: T" |, n% }% a8 o/ U
may have similar precocious puberty.3+ W3 V+ Y; |8 C$ L) q
In our patient, physical examination was incon- H! `0 x" [6 j1 w! B O1 ?
sistent with true precocious puberty since his testi-
" h' T8 u1 w3 K8 Q" |# a e+ |. Bcles were prepubertal in size. However, testotoxicosis( [. q6 j4 i. ]$ B$ V
was in the differential diagnosis because his father
+ }& P. p! p4 Y u2 Ystarted puberty somewhat early, and occasionally,7 }) y1 t! a4 X1 {
testicular enlargement is not that evident in the
% A" u: I9 s- t/ g4 v% Wbeginning of this process.1 In the absence of a neg-5 s8 _& k; P+ i) A
ative initial history of androgen exposure, our
2 p5 Y# P. Q5 H% `biggest concern was virilizing adrenal hyperplasia,, w+ j6 F- ^5 j0 R8 W% Q5 }
either 21-hydroxylase deficiency or 11-β hydroxylase* x$ u% A3 j; w* O# U$ Q l
deficiency. Those diagnoses were excluded by find-( K4 c7 q4 v+ }1 n
ing the normal level of adrenal steroids.
: o+ q% [, |8 b9 O2 x9 WThe diagnosis of exogenous androgens was strongly
3 @6 h8 g5 e& P# @8 Q# F& |suspected in a follow-up visit after 4 months because4 ?- {7 Q* { O V5 S7 Q
the physical examination revealed the complete disap-! n) _) W" H+ ?' y7 x
pearance of pubic hair, normal growth velocity, and
# Z7 `) a& h" D0 b" Q" xdecreased erections. The father admitted using a testos-
6 E( |0 [' n2 i; i+ {# r& K) B% i9 Iterone gel, which he concealed at first visit. He was
: C6 u5 |2 a5 j0 m5 ?% I6 V- H* Vusing it rather frequently, twice a day. The Physicians’
/ k. x/ z9 i; i) K' m# |' L5 GDesk Reference, or package insert of this product, gel or
, D: _& Z9 G, S! A3 ?5 vcream, cautions about dermal testosterone transfer to7 t3 U: V# i; R6 f: S) k
unprotected females through direct skin exposure.& o$ l" H, x. [" J$ n% O1 k
Serum testosterone level was found to be 2 times the" @" s: b! D' A" y4 a* u+ ^ H+ d: c
baseline value in those females who were exposed to
! Y* ], \' [4 p# E" f! Eeven 15 minutes of direct skin contact with their male2 f7 J/ U/ D1 R9 w2 I
partners.6 However, when a shirt covered the applica-
- F% P% [: }& H$ s, h+ Y* u% Qtion site, this testosterone transfer was prevented., Z7 k c# W) g
Our patient’s testosterone level was 60 ng/mL, w; w3 u8 ?3 w) p+ Q, M
which was clearly high. Some studies suggest that
+ L* a" `' h D/ udermal conversion of testosterone to dihydrotestos-
( s' w% T; a* t1 i2 Nterone, which is a more potent metabolite, is more
+ q) C; d) |. J* kactive in young children exposed to testosterone
9 A6 S% L5 s7 }3 ]8 iexogenously7; however, we did not measure a dihy-
4 g' k7 ?3 E- v' cdrotestosterone level in our patient. In addition to
$ ^ Q% H/ I- d% b# a0 uvirilization, exposure to exogenous testosterone in, ~5 L2 t9 _' n- G3 y9 h
children results in an increase in growth velocity and
9 N4 r* ^) u p( m9 Q* H7 Cadvanced bone age, as seen in our patient.. c7 w7 ]5 F8 `( `2 \. L
The long-term effect of androgen exposure during
$ e- O, f" D0 H# i7 b9 kearly childhood on pubertal development and final
3 b( L. v+ }: [0 [; [0 Xadult height are not fully known and always remain- m! ?2 }7 U( ?. n: H
a concern. Children treated with short-term testos-
3 @0 l y, {. K- J; N' | h8 E4 c3 m. xterone injection or topical androgen may exhibit some# @- V Q2 \$ R% ~) i; R+ D% [. L
acceleration of the skeletal maturation; however, after% r) s7 q. _7 x7 V9 t
cessation of treatment, the rate of bone maturation1 H C$ d! I4 T0 V
decelerates and gradually returns to normal.8,98 e2 f# J. Y6 x U
There are conflicting reports and controversy
' c/ E g$ h% v; f sover the effect of early androgen exposure on adult
) p& B- g$ b1 E) r0 Y9 lpenile length.10,11 Some reports suggest subnormal8 @9 n5 J6 l& A A# O$ s. T
adult penile length, apparently because of downreg-! c/ ?# v0 Z3 l: z/ ? O
ulation of androgen receptor number.10,12 However,
2 J6 e5 Z. C) I1 G/ fSutherland et al13 did not find a correlation between. S& M, L ~7 ]' B
childhood testosterone exposure and reduced adult
1 s- C6 l; z8 f0 ]& @1 c6 Rpenile length in clinical studies.
6 B; C! ]) t" p TNonetheless, we do not believe our patient is
4 F% z* \& M7 a) pgoing to experience any of the untoward effects from* t! Q% c+ U2 y n, h: }
testosterone exposure as mentioned earlier because
0 |% E4 Y6 w, wthe exposure was not for a prolonged period of time.# ]( @% F: F& R
Although the bone age was advanced at the time of) ]0 V. t. y$ C2 Z' D7 O- O
diagnosis, the child had a normal growth velocity at; p% ?8 ^& Y5 A5 P. ~: X4 z
the follow-up visit. It is hoped that his final adult& n# E, s1 f g
height will not be affected.
: a' ]! d- b* s4 b6 v8 J, xAlthough rarely reported, the widespread avail-
* Z0 D! a6 ?$ x( Wability of androgen products in our society may
* I* `/ x) v- t. A6 oindeed cause more virilization in male or female% y. k8 c- r' E
children than one would realize. Exposure to andro-6 v6 x' L+ r* r3 r, @% ^
gen products must be considered and specific ques-
0 M; T" F3 v. e2 xtioning about the use of a testosterone product or0 ?+ [* f O3 w) @2 w
gel should be asked of the family members during
/ z+ R( L6 j/ {3 k: F- {the evaluation of any children who present with vir-$ b) o; J/ B% D, ~( O; ]& A5 k! R$ L
ilization or peripheral precocious puberty. The diag-7 w1 X2 G, m( v* Z. D
nosis can be established by just a few tests and by0 ~7 Y( ?$ z k2 o, V v
appropriate history. The inability to obtain such a+ L1 i% _7 t6 u" B
history, or failure to ask the specific questions, may
! c9 W x0 ~0 w1 gresult in extensive, unnecessary, and expensive
/ Y6 W& K# I F, U6 Ginvestigation. The primary care physician should be
0 K0 a; V a k. |0 ], y3 |) caware of this fact, because most of these children
?5 @) G4 Z* K" ~1 {! y$ Nmay initially present in their practice. The Physicians’. J" ]& r$ W W" g4 `8 E
Desk Reference and package insert should also put a
0 d( Z" ^$ M2 T+ f& ]+ I8 c% {warning about the virilizing effect on a male or o: \) m' }5 j- |9 L
female child who might come in contact with some-
" k5 q4 S* a+ M; y$ hone using any of these products.( O5 \* k+ o( e+ K
References
8 {8 F) l o' z' h* E+ R0 M1. Styne DM. The testes: disorder of sexual differentiation
$ B }8 V% w4 L5 Kand puberty in the male. In: Sperling MA, ed. Pediatric: R6 d/ ~# j1 h0 V( J) S# f, x8 B& h
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% T* r5 E5 o( {/ \) s2002: 565-628.
: P& F8 O# n# Q$ _8 n1 u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
7 X$ Q+ f/ }$ Ppuberty in children with tumours of the suprasellar pineal |
|