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Sexual Precocity in a 16-Month-Old" j. h3 s, b: O" F/ b9 s# ?' m
Boy Induced by Indirect Topical
5 M, _3 ~4 E+ W0 ]2 Q( @+ B5 K+ FExposure to Testosterone
/ Y. r1 j2 A& D. j1 B' XSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 A% E* N6 H0 W
and Kenneth R. Rettig, MD13 a! N6 A# Y) h" j3 F8 `
Clinical Pediatrics1 Y, z& n7 v' i+ t
Volume 46 Number 6
2 F( Y! K. X h$ F# z# e* _July 2007 540-543& }9 F o3 X/ f% X. N& X
© 2007 Sage Publications/ ~- U6 Z- O/ c# J- r, H4 I0 ~
10.1177/0009922806296651; H; t& d- K$ q3 z' T! a% T: I: d
http://clp.sagepub.com7 h7 z& v$ H; t% S
hosted at6 N: g* i; \. d6 P. a; E$ M/ m
http://online.sagepub.com+ j/ B5 J# @. Q( [
Precocious puberty in boys, central or peripheral,1 m7 o% O2 v! v& Z7 N) i7 S1 ]4 c6 h
is a significant concern for physicians. Central( }3 J' D" a( I( n2 n) @
precocious puberty (CPP), which is mediated/ I9 J# A7 A& f7 l( X% B) x
through the hypothalamic pituitary gonadal axis, has g! w _0 J: k# _* L( |, g
a higher incidence of organic central nervous system
. [- `/ x& {* U0 zlesions in boys.1,2 Virilization in boys, as manifested
! N- A2 ?/ ?: H Pby enlargement of the penis, development of pubic
1 T2 H9 @8 j: H* M/ ^0 f% v! [5 ahair, and facial acne without enlargement of testi-
* C( V" D7 Z# f8 L0 X9 hcles, suggests peripheral or pseudopuberty.1-3 We
' {8 N I- Y2 i: z+ breport a 16-month-old boy who presented with the
( a( ~) S- Q9 P4 x3 w! G0 senlargement of the phallus and pubic hair develop-6 Y1 ~; P- Q* x! z& X. }
ment without testicular enlargement, which was due5 r. ~0 x J8 M; Y! A; W
to the unintentional exposure to androgen gel used by
( y: o, e( h7 D+ ]; cthe father. The family initially concealed this infor-3 s) U5 x* d* D; u# |5 M, a; {
mation, resulting in an extensive work-up for this
7 n' l4 i& ~3 q; c' {' I N1 `child. Given the widespread and easy availability of- @7 [8 G! ?) H! a! E. V* K Q
testosterone gel and cream, we believe this is proba-
6 L! `& o1 G% i" K1 M( \3 W! z" gbly more common than the rare case report in the/ j. K X5 `" A
literature.4! w# ]$ }8 B1 Y
Patient Report& y9 m2 u: v' [2 h
A 16-month-old white child was referred to the0 v9 K c1 A. ^3 E$ F
endocrine clinic by his pediatrician with the concern
0 x* |$ f% g0 l# l3 x8 Kof early sexual development. His mother noticed
- ]5 k* w& k2 o4 klight colored pubic hair development when he was' n8 @% r$ ] I- d0 B% `# p* R. w
From the 1Division of Pediatric Endocrinology, 2University of
- U3 V7 c7 g W# T; GSouth Alabama Medical Center, Mobile, Alabama.
2 x8 b& [0 m, c: G w7 |Address correspondence to: Samar K. Bhowmick, MD, FACE,& \1 }" v$ P# F7 s7 U+ I
Professor of Pediatrics, University of South Alabama, College of( i! E# z/ X% j' I2 y$ |
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
; H! X- b/ H2 L& J! k. i4 N5 k" we-mail: [email protected].1 o' I4 G o$ V" m
about 6 to 7 months old, which progressively became
. D) W. N& I/ x4 qdarker. She was also concerned about the enlarge-
. |& M( m8 S: j# L( E1 Bment of his penis and frequent erections. The child8 D9 j; j) l; m& u
was the product of a full-term normal delivery, with
4 }" u" R5 [" ^0 w! r/ {/ k xa birth weight of 7 lb 14 oz, and birth length of7 Q9 \! ^! b! S4 h& Z
20 inches. He was breast-fed throughout the first year6 ]0 S* C7 y4 E' `* [
of life and was still receiving breast milk along with3 G" ?" M, a( D, \, D. a* l" \
solid food. He had no hospitalizations or surgery,
+ \# H. D, C6 W6 W: Aand his psychosocial and psychomotor development
# s1 V" J6 g$ ~5 K7 d8 J. uwas age appropriate.
; W, N0 D0 `2 I: ]0 JThe family history was remarkable for the father,0 T7 X. t9 @; g9 m1 Q* Y
who was diagnosed with hypothyroidism at age 16,! L$ C3 m( S' o2 l3 ^3 l9 I# Z
which was treated with thyroxine. The father’s
: M$ N* s+ D; X7 T e+ {: n" wheight was 6 feet, and he went through a somewhat2 T# `7 M- N( F m* |
early puberty and had stopped growing by age 14.
7 {( V5 h/ F8 f! H6 E' g" tThe father denied taking any other medication. The( Z+ w1 V- i- q6 m4 r7 X
child’s mother was in good health. Her menarche
z1 ?$ u8 s0 }3 kwas at 11 years of age, and her height was at 5 feet3 Q0 C# a( i% h
5 inches. There was no other family history of pre-
6 \3 d/ u: s4 s S. bcocious sexual development in the first-degree rela-
5 I D+ }$ y* [+ W, |8 |2 Mtives. There were no siblings.
( F" j% h; h3 z* J5 N, ?& qPhysical Examination: D: @3 l( G! Z$ ^* |
The physical examination revealed a very active,
$ J* c Y2 h( H: `$ @. pplayful, and healthy boy. The vital signs documented! z$ r! p9 G9 ~. [5 }; v
a blood pressure of 85/50 mm Hg, his length was
( I9 ^! `2 w2 {' h& ?& [6 t( ^3 `90 cm (>97th percentile), and his weight was 14.4 kg) U* x M" H: n% r7 D
(also >97th percentile). The observed yearly growth4 _* R! ~6 s0 n! T" u+ O, P- e
velocity was 30 cm (12 inches). The examination of5 l* c5 D) `) A, j9 A8 Z
the neck revealed no thyroid enlargement.) M+ K- E) B6 w ?& k4 G0 o2 i& z
The genitourinary examination was remarkable for
; \/ p: c2 j! v1 |; d% P8 I! c8 b# ]enlargement of the penis, with a stretched length of- p5 _' F* n. `
8 cm and a width of 2 cm. The glans penis was very well
9 `7 c$ w( \4 ] b8 O9 x% ydeveloped. The pubic hair was Tanner II, mostly around- Z ?4 }0 Y0 U0 b% t( U
540
6 y, H, w1 O) G% J" Y" x7 cat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* |% C+ X; I$ q5 s5 @% v2 Z( B" \
the base of the phallus and was dark and curled. The' [% U, F V; c" T4 I/ ?
testicular volume was prepubertal at 2 mL each.; F7 ]* s! N+ {
The skin was moist and smooth and somewhat
1 e9 T E+ }8 q% l, o- b* V$ Goily. No axillary hair was noted. There were no
. D$ t! }+ O$ ]abnormal skin pigmentations or café-au-lait spots.
- M- n; _. g1 z. ?Neurologic evaluation showed deep tendon reflex 2+' }, N/ D; l6 R& ~' N
bilateral and symmetrical. There was no suggestion
" ^! M3 I2 H) ~5 g, ~of papilledema./ H3 R( M6 j1 I
Laboratory Evaluation
7 X* f8 R3 c; b6 XThe bone age was consistent with 28 months by0 f+ v$ ~; T2 u/ r5 Y
using the standard of Greulich and Pyle at a chrono-; b" j" M. G" k7 p5 V
logic age of 16 months (advanced).5 Chromosomal; ]% A$ k' z1 S& |% M" T: x
karyotype was 46XY. The thyroid function test5 B% Y1 [2 G) }; e' P
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
5 |. ]2 k9 J/ o& Wlating hormone level was 1.3 µIU/mL (both normal).. `3 x! z0 t" k0 `: F3 e
The concentrations of serum electrolytes, blood
" E2 M9 C! @, N; i* `; j9 gurea nitrogen, creatinine, and calcium all were
1 V4 ] V6 L) }* a: qwithin normal range for his age. The concentration
B" F5 {9 e& I4 C7 }of serum 17-hydroxyprogesterone was 16 ng/dL3 @6 M' ?5 H( p5 R$ p: h4 Q7 q3 i
(normal, 3 to 90 ng/dL), androstenedione was 20
6 Y6 u/ y0 p) n& W; X0 Ing/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) {' S2 y% Z8 fterone was 38 ng/dL (normal, 50 to 760 ng/dL),; _$ F1 Y2 g4 a) g) N1 v" ^' F# S$ `
desoxycorticosterone was 4.3 ng/dL (normal, 7 to" O! ], s1 z) s$ _
49ng/dL), 11-desoxycortisol (specific compound S)5 J* j+ S: \- Y1 j9 \9 Z c9 y
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: O. |4 I' r1 r0 j% v5 Q3 \- Ktisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 u1 r: n$ |) E! W. b* Ytestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 L' _' O( d2 i1 m2 fand β-human chorionic gonadotropin was less than
& v( n; [& {: a5 mIU/mL (normal <5 mIU/mL). Serum follicular; h! L9 I# ?# p3 F: J( |0 Q- F& {
stimulating hormone and leuteinizing hormone$ I) y' k* K! _* ?- G) @1 L7 M/ @8 c
concentrations were less than 0.05 mIU/mL; l" R$ m" {1 w2 H
(prepubertal).4 W1 y: X+ ]( N& a/ n3 R4 A
The parents were notified about the laboratory, d$ M( c# g- r; R0 t
results and were informed that all of the tests were
6 c) y4 f- _& o' b3 J8 g6 unormal except the testosterone level was high. The! A- h% N3 \8 F* \8 x
follow-up visit was arranged within a few weeks to
' l1 _" c9 a' ?4 g# ^1 J* N7 gobtain testicular and abdominal sonograms; how-$ w# s# A3 h4 v) W
ever, the family did not return for 4 months.
6 Q: D0 L4 E6 @" W8 X4 DPhysical examination at this time revealed that the0 L& m4 s( j, g. {
child had grown 2.5 cm in 4 months and had gained# ^8 b1 j1 ]: T( v
2 kg of weight. Physical examination remained
E/ t8 G6 J9 b. Junchanged. Surprisingly, the pubic hair almost com-
* Y2 U; J: X' L1 B; tpletely disappeared except for a few vellous hairs at
# O6 _. q: Q3 T% `the base of the phallus. Testicular volume was still 2
, I5 [# @; e! b( e' |3 G0 t2 ~mL, and the size of the penis remained unchanged.+ l- F7 B& M# c$ S2 ~
The mother also said that the boy was no longer hav-
8 X U/ _3 x3 \- u* w D+ \; ?0 w" Ging frequent erections.
* Q" L' ]- h: m9 bBoth parents were again questioned about use of
5 M9 }+ ?* J% g2 U" M9 A' ~3 Dany ointment/creams that they may have applied to
. G4 F+ Z. f; f& j1 Dthe child’s skin. This time the father admitted the: C: M) Q7 k& s1 [* q% V
Topical Testosterone Exposure / Bhowmick et al 541 }0 C; b" r4 P9 a& {2 t+ C
use of testosterone gel twice daily that he was apply-
* t F" f: F" v6 ying over his own shoulders, chest, and back area for
' J1 `% K0 I4 k+ A1 ~3 z7 qa year. The father also revealed he was embarrassed& v4 L" y( F& c, q3 n: u
to disclose that he was using a testosterone gel pre-
( N/ r4 d1 k9 Xscribed by his family physician for decreased libido
) x; g, A* E. l$ a I3 S. r4 Nsecondary to depression.
4 L% ~. }, K0 u9 [( w$ y7 fThe child slept in the same bed with parents.
1 @- g- C2 b. M: S8 ^/ O7 G- QThe father would hug the baby and hold him on his
$ C1 Q2 X1 y) L9 m6 P) zchest for a considerable period of time, causing sig-3 g) m! X0 P3 W3 v" B
nificant bare skin contact between baby and father.
" {; B0 R! {; |" {6 N+ SThe father also admitted that after the phone call,
$ t! i( C' q% O( s+ V6 ]3 [when he learned the testosterone level in the baby2 { A4 ]. \3 R8 `$ w2 e+ i
was high, he then read the product information0 M7 I& d e3 Q2 t
packet and concluded that it was most likely the rea-
7 u5 @- @; `+ e3 d. }- l0 ison for the child’s virilization. At that time, they" {+ K6 X4 `' k6 D* V
decided to put the baby in a separate bed, and the
, y; B/ y. J- D: jfather was not hugging him with bare skin and had' v; F r1 a6 p; O) w% ~" {
been using protective clothing. A repeat testosterone
- [+ G; E8 |: v1 ]! K7 v* P3 Etest was ordered, but the family did not go to the
$ l1 `4 U+ x! x4 P- Wlaboratory to obtain the test.
6 c6 C m1 Z6 ^" v1 u9 U- o* mDiscussion( j9 D2 J' `1 j5 o
Precocious puberty in boys is defined as secondary
7 p+ S d4 I: x$ k! m' ?! ~sexual development before 9 years of age.1,4& s# f% M5 C! d7 s$ M, x7 z
Precocious puberty is termed as central (true) when! E( B7 m+ I) g' b4 n }& f
it is caused by the premature activation of hypo-9 D& O( P3 E2 _5 j3 k' t: f
thalamic pituitary gonadal axis. CPP is more com-
* N7 {! a% z6 emon in girls than in boys.1,3 Most boys with CPP
( f: @) f8 i; D1 y; E3 R9 E1 @" v% cmay have a central nervous system lesion that is
- A/ |' O( @8 U; oresponsible for the early activation of the hypothal-
- h' g9 ^6 u. V* |9 Z. R) j- mamic pituitary gonadal axis.1-3 Thus, greater empha-
( \. f/ a' k' |$ osis has been given to neuroradiologic imaging in
: r1 ?3 C: o4 ^' _# _( D Iboys with precocious puberty. In addition to viril-
( J( V: \ U2 n0 u, iization, the clinical hallmark of CPP is the symmet-
) t( }/ {6 K8 Q! A, Qrical testicular growth secondary to stimulation by1 D$ K3 o: t# U) E. D# @. R, b1 U
gonadotropins.1,3
3 q' h4 C- N7 n/ V4 GGonadotropin-independent peripheral preco-7 \& T: H. a: P% X2 D
cious puberty in boys also results from inappropriate0 K- j, k$ f' q" [- d% C
androgenic stimulation from either endogenous or
! f8 G1 N$ ?2 F& Sexogenous sources, nonpituitary gonadotropin stim-) p7 `0 q9 |5 w+ e' b" R) Q3 O
ulation, and rare activating mutations.3 Virilizing
4 r& n/ C; r; tcongenital adrenal hyperplasia producing excessive( q2 C! N* f) V: d3 B
adrenal androgens is a common cause of precocious) V5 h4 E$ m3 c4 u# q; h7 h1 d
puberty in boys.3,4$ S& g* R/ q* K2 J6 C5 @9 m
The most common form of congenital adrenal
( O: Z5 I/ s# _- ehyperplasia is the 21-hydroxylase enzyme deficiency.1 X( L/ K4 ^; A0 L
The 11-β hydroxylase deficiency may also result in
% a& t, j2 ^0 M9 S$ u! `excessive adrenal androgen production, and rarely,2 k! K& Y9 ~* n8 h0 c! m% y! k
an adrenal tumor may also cause adrenal androgen, ~$ H K; Z: f7 {5 C* o( W& u; R
excess.1,3
# H7 H8 f, g9 i6 Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from" M D3 c/ y7 r0 R7 g0 U7 P# ~
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007* m9 M6 O; `5 |) V) `" c
A unique entity of male-limited gonadotropin-
$ \% n4 U3 B/ V6 I& i, J3 hindependent precocious puberty, which is also known
1 i, ?2 U$ [9 Q1 B6 B$ a* E" uas testotoxicosis, may cause precocious puberty at a
! |, a" J3 O0 J. Y" Vvery young age. The physical findings in these boys
/ I* H' N! y) ^) R& kwith this disorder are full pubertal development,
3 M/ H# ?! R: E+ Y" v# C7 gincluding bilateral testicular growth, similar to boys
9 Z' m% C- U! y/ n5 ?* P2 K2 p6 K6 u% Pwith CPP. The gonadotropin levels in this disorder& t- x0 P7 N/ X3 a1 E3 {2 `
are suppressed to prepubertal levels and do not show8 @* W# {9 L: P) R) P: ~
pubertal response of gonadotropin after gonadotropin-
, L1 o/ \8 f1 sreleasing hormone stimulation. This is a sex-linked; }! x, Z; m: K5 Z
autosomal dominant disorder that affects only
, L, h( |9 k1 e2 Tmales; therefore, other male members of the family
# a; V8 \5 x5 M6 H7 s+ y' K5 p$ `( Wmay have similar precocious puberty.3, k8 Q3 s5 u$ U/ G8 Z
In our patient, physical examination was incon-: N( f- ?, k8 i
sistent with true precocious puberty since his testi-
( `6 X9 c/ ~9 i9 A& o* {cles were prepubertal in size. However, testotoxicosis
: W' j, X, A' p+ H/ r$ Iwas in the differential diagnosis because his father
4 A/ Z: |3 k. H. {% Qstarted puberty somewhat early, and occasionally,7 t3 j/ l- B* p5 t7 c+ B* Q
testicular enlargement is not that evident in the
, E7 ] k) Z; r% f4 D( `' ubeginning of this process.1 In the absence of a neg-
6 s, k2 g6 u0 c2 Oative initial history of androgen exposure, our1 d% Y7 K1 [! n% ^
biggest concern was virilizing adrenal hyperplasia,+ ?- D! ^- h. ]- f
either 21-hydroxylase deficiency or 11-β hydroxylase2 l5 o" |: h. r
deficiency. Those diagnoses were excluded by find-8 F- Z+ P v- c$ ?5 ~
ing the normal level of adrenal steroids.5 k' s% g9 Y2 U* P! s: h. ?
The diagnosis of exogenous androgens was strongly
" K, [; y+ |$ ?: R, S3 p- wsuspected in a follow-up visit after 4 months because/ O" R; b$ y& V* x0 M( T
the physical examination revealed the complete disap-
! ~! s2 d r6 s. ~/ I6 Qpearance of pubic hair, normal growth velocity, and
; W7 q- J8 N! {0 U3 z6 ]: ]decreased erections. The father admitted using a testos-; c4 j- j3 r0 g) f. q8 w9 V
terone gel, which he concealed at first visit. He was( R: o' n8 Y& ?
using it rather frequently, twice a day. The Physicians’
3 U% x, ], S0 W3 a8 Q4 E/ FDesk Reference, or package insert of this product, gel or3 U0 L, t/ ]7 P4 ]3 ~3 X
cream, cautions about dermal testosterone transfer to3 u- E% p3 P2 ^8 D
unprotected females through direct skin exposure.
3 K4 ?4 K- U% e7 T5 Q% tSerum testosterone level was found to be 2 times the
# |9 E2 P5 H P, e9 J5 Fbaseline value in those females who were exposed to9 y1 }0 C2 Y Z* }
even 15 minutes of direct skin contact with their male
7 i! ?) B- d5 }+ U. U% r4 Lpartners.6 However, when a shirt covered the applica-5 {5 \' H6 C3 R
tion site, this testosterone transfer was prevented.
- L D/ p. s4 C# g3 h/ I( P2 wOur patient’s testosterone level was 60 ng/mL,
1 w: W4 D$ ~- a# Y. ]which was clearly high. Some studies suggest that
$ l. J; J2 r' r1 H2 X$ Jdermal conversion of testosterone to dihydrotestos-
' W5 {8 D+ V: i' y7 Jterone, which is a more potent metabolite, is more
5 i- W5 _6 H" s; F* tactive in young children exposed to testosterone
3 H: }$ Q" G- }7 P4 s: Eexogenously7; however, we did not measure a dihy-
4 p+ i% t/ X; Z3 m, ^$ @drotestosterone level in our patient. In addition to
6 ~9 Q: H! f8 [" V, Q' U1 O9 m. C1 Mvirilization, exposure to exogenous testosterone in
9 }* y, x7 J5 h/ zchildren results in an increase in growth velocity and
9 D* q" i* [+ O/ Uadvanced bone age, as seen in our patient.9 k5 J4 }/ Y N
The long-term effect of androgen exposure during
' a$ G; k0 n9 P& D2 g! vearly childhood on pubertal development and final
: M: \7 l2 y4 P5 ?* z4 ?adult height are not fully known and always remain
- {) U$ Z, N4 r3 D! ]3 Xa concern. Children treated with short-term testos-) G) t# [% }# i
terone injection or topical androgen may exhibit some/ ~' } i. m, I/ u( I5 o8 v3 h
acceleration of the skeletal maturation; however, after
6 ]# t% q% A/ }( y' [! J7 j/ [' |cessation of treatment, the rate of bone maturation/ D# G6 |# W6 o
decelerates and gradually returns to normal.8,9( O/ |* C. P' _4 t4 P
There are conflicting reports and controversy1 ^. Z- @, k, I# e" l
over the effect of early androgen exposure on adult
) X F9 o. y* Ypenile length.10,11 Some reports suggest subnormal1 P+ {8 A6 s/ M3 `' ~2 X
adult penile length, apparently because of downreg-
% o C9 m8 m- Hulation of androgen receptor number.10,12 However," r7 a# T2 c# Y: s; W$ d- D5 l
Sutherland et al13 did not find a correlation between$ O0 u# h0 k- G5 ]" c
childhood testosterone exposure and reduced adult/ a9 n4 S) |4 ~% U8 [- f1 P' k. K( i
penile length in clinical studies.
0 Q: t* j6 i. r; }4 ^; VNonetheless, we do not believe our patient is" K! u0 f$ r' m
going to experience any of the untoward effects from
2 V" g2 p1 L: ]: [. ?: Q( L& x \testosterone exposure as mentioned earlier because
, `- S6 g9 ]! f' S. }the exposure was not for a prolonged period of time.
$ N( \5 M1 N6 T: Y- D7 K% U# BAlthough the bone age was advanced at the time of
! Q: Q( w$ s8 Z( P, b, [diagnosis, the child had a normal growth velocity at7 {2 ~% ^1 W& }
the follow-up visit. It is hoped that his final adult! Y& ~' B9 d" b; f3 r+ n. b
height will not be affected.
9 h/ E+ N9 J! `' m Z. aAlthough rarely reported, the widespread avail-
0 R M9 B' A( `& [/ {. s. Pability of androgen products in our society may: M& @! ]0 ?4 n( g ^
indeed cause more virilization in male or female* p' ]" z, n. `! H1 s4 j
children than one would realize. Exposure to andro-) T; t" c) k: H2 j, M0 o
gen products must be considered and specific ques-
$ \' D: J; }4 I; w" J9 vtioning about the use of a testosterone product or
" E4 r1 m% }9 w! t u" y( Qgel should be asked of the family members during3 N& \& L# `" i' }
the evaluation of any children who present with vir-
. `9 M7 r" Y0 U% w" N! R# ^ilization or peripheral precocious puberty. The diag-0 F+ T0 T" L0 z9 I
nosis can be established by just a few tests and by, Z1 U7 z+ V$ P/ \+ D
appropriate history. The inability to obtain such a. \0 y* V, H! t/ V3 V" h
history, or failure to ask the specific questions, may
# L/ q0 e0 j% ?% Y9 M) Sresult in extensive, unnecessary, and expensive, N- y2 @$ D$ v5 Y/ }7 v$ Y+ f5 q5 Q
investigation. The primary care physician should be" q& `* F0 k. i/ h# _2 e2 m( g7 r; E
aware of this fact, because most of these children
) a" ^3 I, z- S, O/ Fmay initially present in their practice. The Physicians’
8 q. Q* ~) c7 N# DDesk Reference and package insert should also put a
& V# g, @( a$ B/ x4 Swarning about the virilizing effect on a male or
, D/ c; P0 ?$ V" r9 Y0 Q t/ ^female child who might come in contact with some-' a) n* A3 V/ u( x
one using any of these products.% ~& f' x% P# t( h6 W/ `6 W9 j6 A
References B$ F# R2 i* Q$ h( i* F
1. Styne DM. The testes: disorder of sexual differentiation2 ?/ f0 k$ W0 M& ~( o% [0 H+ {
and puberty in the male. In: Sperling MA, ed. Pediatric
4 i9 a$ n/ O1 p& V, H* s1 q5 [Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;* D& ^/ o8 @; G
2002: 565-628.+ C* Q5 h: _5 D- `. Z& X
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' c4 C$ r8 Y" T( T1 P* rpuberty in children with tumours of the suprasellar pineal |
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