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Sexual Precocity in a 16-Month-Old2 J* {4 p/ G4 w+ C* C/ [: Z
Boy Induced by Indirect Topical# \3 V, @' c$ E* D6 t5 S
Exposure to Testosterone
4 z3 o4 w3 L# r$ V: m1 ?, ~% ~Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. |+ v9 j4 j2 i3 X0 v. r/ `
and Kenneth R. Rettig, MD1* Z& w# [3 N1 Z2 r) J, Y, _. n
Clinical Pediatrics, z" r; I, l8 a% Q( O/ S+ B3 \
Volume 46 Number 6, G1 k$ h# s: Q
July 2007 540-543) i3 X5 _! r* P/ U& V1 o9 f2 d7 q, l
© 2007 Sage Publications
7 x1 c8 N7 W0 ]) |10.1177/0009922806296651; F/ @: W' ~/ p( h, K! u
http://clp.sagepub.com x+ M1 J. {; U: W& ] ?/ G
hosted at
& W) g; Z# K0 O* A: Zhttp://online.sagepub.com
9 \ ?3 T6 T5 A" J2 A/ _/ V x" CPrecocious puberty in boys, central or peripheral,1 V2 _& T( J- R; }; o* @
is a significant concern for physicians. Central" }7 g1 G! `5 ~" b
precocious puberty (CPP), which is mediated
' Y9 a/ E$ {6 X& e3 Athrough the hypothalamic pituitary gonadal axis, has* t5 X W( ^4 u+ K* a$ s/ i* ^
a higher incidence of organic central nervous system
4 w `( q. a r a% r. u+ plesions in boys.1,2 Virilization in boys, as manifested
7 \! A9 D- { k* hby enlargement of the penis, development of pubic
% Y6 m1 }* N( S2 k9 M0 ahair, and facial acne without enlargement of testi-8 o" `1 X+ j/ |8 e& X/ a
cles, suggests peripheral or pseudopuberty.1-3 We/ R- Y9 @$ r& g- [
report a 16-month-old boy who presented with the
' `0 C/ V" U& p% Jenlargement of the phallus and pubic hair develop-9 `9 G0 k ` i7 H: f7 S3 N. K
ment without testicular enlargement, which was due% x2 D0 _& {- Z9 |
to the unintentional exposure to androgen gel used by
4 o* b1 h8 i; ~/ I' l! }the father. The family initially concealed this infor-: b2 H. U, s @$ Q9 c1 w
mation, resulting in an extensive work-up for this
( ?0 v$ W+ f: z d* O; qchild. Given the widespread and easy availability of
, b* O! C, r' Ktestosterone gel and cream, we believe this is proba-# q; T2 p" i$ y1 q$ c% m
bly more common than the rare case report in the
) K M3 b `* G+ K' j) fliterature.4
$ [5 e4 t9 Y7 B& k- C3 GPatient Report8 X/ f* l6 v! C C4 b1 e
A 16-month-old white child was referred to the& Z& \+ f9 D, H/ ?$ X: X
endocrine clinic by his pediatrician with the concern
, R% a& W$ Q) b) f( ]) x" [of early sexual development. His mother noticed
' X4 Z) @* c" N$ @# zlight colored pubic hair development when he was
: a) F0 T$ R) L: IFrom the 1Division of Pediatric Endocrinology, 2University of
/ h* x$ ]2 h( X7 S6 ISouth Alabama Medical Center, Mobile, Alabama.
- i7 b/ P" V( l6 O; @; ?& f) kAddress correspondence to: Samar K. Bhowmick, MD, FACE,
( z+ \0 p1 E; M$ Q/ c4 Q) I: I$ sProfessor of Pediatrics, University of South Alabama, College of+ `! N/ b5 \" Z. p. f
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% ^) Y7 A* J! r' Y4 k+ p2 me-mail: [email protected].$ K; B! w4 Q% w$ |
about 6 to 7 months old, which progressively became
) {" E$ v0 j6 s: B' n6 ~$ @7 Pdarker. She was also concerned about the enlarge-
1 D7 K, t( Z" ~/ u- g- yment of his penis and frequent erections. The child3 I% @0 n3 r5 C. h; a1 E! Z" u
was the product of a full-term normal delivery, with! [# r( Z0 q% {9 v5 X
a birth weight of 7 lb 14 oz, and birth length of
4 j) l1 Y5 x6 p2 W20 inches. He was breast-fed throughout the first year
2 ?* j. }4 ]9 b, o& S! E7 Dof life and was still receiving breast milk along with
& K* \+ i# E* p6 G+ @+ i- Wsolid food. He had no hospitalizations or surgery,; w# d7 t) {' ^" }8 P
and his psychosocial and psychomotor development& K$ ?! X( C6 s2 B% Y$ Y9 r
was age appropriate.
p. @( ^1 O, K+ P4 fThe family history was remarkable for the father,; [; b* D9 H% I& z' G' B. l, o
who was diagnosed with hypothyroidism at age 16,. \4 w/ p3 n7 j5 d/ b4 K: ^6 B5 I$ ^
which was treated with thyroxine. The father’s
9 Q" P( p2 N% h: V t6 h. pheight was 6 feet, and he went through a somewhat
' [4 L; [5 R4 }1 v# q/ searly puberty and had stopped growing by age 14.) X. |, x8 \/ _" ?: j
The father denied taking any other medication. The
4 x% ^+ h( j# B. n& j3 Uchild’s mother was in good health. Her menarche
0 A$ Y# A% f' F5 s8 }9 Mwas at 11 years of age, and her height was at 5 feet
8 l/ F3 L! ?3 W( r5 inches. There was no other family history of pre-) I1 p9 ^# ~) K0 `' p
cocious sexual development in the first-degree rela-9 M. a9 I1 C8 n8 ~
tives. There were no siblings.
, W) \. _5 t/ W/ NPhysical Examination; R j' U, F/ [
The physical examination revealed a very active,6 J! W% Y1 u1 S3 J+ R, _
playful, and healthy boy. The vital signs documented6 O A) w, | P! u% E0 m2 r
a blood pressure of 85/50 mm Hg, his length was
( { I m2 n; T$ Y/ [+ w$ O90 cm (>97th percentile), and his weight was 14.4 kg2 z* \7 S5 p: s7 E2 q& ]5 c
(also >97th percentile). The observed yearly growth5 J1 P, R. [4 s8 ?) X: `* D0 m
velocity was 30 cm (12 inches). The examination of
) b2 M( U# n. D" s: c! s0 Kthe neck revealed no thyroid enlargement.: l( x$ b8 n, d6 `
The genitourinary examination was remarkable for
! B6 ~) R, `8 i3 }# J6 uenlargement of the penis, with a stretched length of
/ S0 [* Q: q/ T2 {8 cm and a width of 2 cm. The glans penis was very well
- ?# m/ a) q: r/ Z3 q: Fdeveloped. The pubic hair was Tanner II, mostly around; ~4 F( e; v3 Q* W7 t0 h+ x1 b
540/ i% \* K) C9 n/ U# h, x; _: I& \
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
+ u! ?# z) P# \the base of the phallus and was dark and curled. The
) q: [) A) Z: m( b2 D1 Wtesticular volume was prepubertal at 2 mL each.
/ Z3 c. t/ W o$ c$ }The skin was moist and smooth and somewhat
9 {* {* b4 w6 n9 I. g$ i! voily. No axillary hair was noted. There were no
- N0 G( K9 Q! v( }8 `abnormal skin pigmentations or café-au-lait spots.
4 w+ O9 b/ ^8 o' X- wNeurologic evaluation showed deep tendon reflex 2+
. M# v8 b) ^% ]4 |bilateral and symmetrical. There was no suggestion. @' u% d/ E2 j
of papilledema.! F9 g7 H9 s& o- e/ _
Laboratory Evaluation
& M% w# Z, [, D1 {8 bThe bone age was consistent with 28 months by L6 I- ?" Y+ b% O( \
using the standard of Greulich and Pyle at a chrono-
7 N2 t Q; d+ Z( @logic age of 16 months (advanced).5 Chromosomal) R3 t$ C) E1 }5 F
karyotype was 46XY. The thyroid function test
& ~ F8 D- `$ n4 Z, [$ Ushowed a free T4 of 1.69 ng/dL, and thyroid stimu-
% x: W. A" I7 \/ ilating hormone level was 1.3 µIU/mL (both normal).! Z" c2 L; @. l; f D7 t9 Y3 f: G/ A
The concentrations of serum electrolytes, blood) v: O- i4 K% w
urea nitrogen, creatinine, and calcium all were
& |; p9 K5 J( h8 C( Z+ H% M- m ?within normal range for his age. The concentration: D. }2 i9 l* y
of serum 17-hydroxyprogesterone was 16 ng/dL
3 ]& R0 ~4 p& _+ k; S: E2 z5 X(normal, 3 to 90 ng/dL), androstenedione was 20
" F2 Y' `) e) x5 Wng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-0 @7 b1 Q" H5 L2 t
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; P* k& t& A, @* Q
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ X9 ]7 e h2 M" ^3 y49ng/dL), 11-desoxycortisol (specific compound S); a& I$ c) {# B" |
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
1 o0 a- a" Q" f1 _3 gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
+ w! m7 s4 |! c( Y' o& e* gtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),8 P( y' Z; I, z- f
and β-human chorionic gonadotropin was less than4 d1 S U0 w7 g
5 mIU/mL (normal <5 mIU/mL). Serum follicular" f. B" g* G* X3 w, a, @& A
stimulating hormone and leuteinizing hormone* U3 Y+ L5 c$ m4 y" k5 K$ b$ @! ~
concentrations were less than 0.05 mIU/mL& {" r9 X" _2 l& O
(prepubertal).
- d: u# g& Z, nThe parents were notified about the laboratory+ q' w2 Q' D6 s4 _; n& Z- Y
results and were informed that all of the tests were
& ?1 L8 V* w; l6 F9 onormal except the testosterone level was high. The* _( v! o( h. t1 c. c, Z* [
follow-up visit was arranged within a few weeks to( }# m+ E. Z* N7 D( `9 o
obtain testicular and abdominal sonograms; how-
" y0 P. z% f7 {& ^+ J& i4 o/ k( Z. Uever, the family did not return for 4 months.
y& d, h+ \ Y! |1 w& o mPhysical examination at this time revealed that the
6 c% \% Q* Q' n6 pchild had grown 2.5 cm in 4 months and had gained2 ]7 `4 H& c5 ^
2 kg of weight. Physical examination remained
' Z& T. D$ P* t% s& Junchanged. Surprisingly, the pubic hair almost com-
, v8 [' b1 }& k- t/ vpletely disappeared except for a few vellous hairs at
7 `8 l( u$ B2 V9 cthe base of the phallus. Testicular volume was still 2
" { U/ }7 Q; Y* R8 rmL, and the size of the penis remained unchanged.+ w' D' V9 ^( S/ x V" ^# B+ U
The mother also said that the boy was no longer hav-0 y/ R- z" v7 K6 T' |0 Q, I
ing frequent erections.8 D! @) n* a3 Q) m3 r
Both parents were again questioned about use of% w: X3 @1 f2 T' R1 b( |0 Z* K
any ointment/creams that they may have applied to
5 ^' p1 f9 [2 q3 u- zthe child’s skin. This time the father admitted the
. g* E2 \& z/ D1 S' C7 v- QTopical Testosterone Exposure / Bhowmick et al 541( G) A7 m, v: y
use of testosterone gel twice daily that he was apply-
9 t: Z0 W4 o- x6 D: c, bing over his own shoulders, chest, and back area for1 R' E, f9 G& M& S" I9 G
a year. The father also revealed he was embarrassed- \4 M* P. f; ~' h5 L. f
to disclose that he was using a testosterone gel pre-
* \& |: v9 j5 M; Vscribed by his family physician for decreased libido5 l* Q/ W% i# {, Z
secondary to depression.& d7 Y! a" A0 ^8 L! {6 a
The child slept in the same bed with parents.6 k) n7 Z* t. T1 h( Q c, w
The father would hug the baby and hold him on his. u5 F% v( O! w5 q7 O$ ?* U
chest for a considerable period of time, causing sig-2 T1 b! u/ M) k0 Y" H" b' [! k
nificant bare skin contact between baby and father.
/ t" e( A' [- ~/ B4 d; P) O& `The father also admitted that after the phone call,
5 u; m" I% t8 K5 Qwhen he learned the testosterone level in the baby
" W9 V; B. ~7 [was high, he then read the product information
- p3 C2 V7 w) [$ l7 apacket and concluded that it was most likely the rea-7 j, h' r$ R# q. N5 U, y1 w
son for the child’s virilization. At that time, they) |8 Q }# p4 [5 p2 p a% n; Q" X/ x
decided to put the baby in a separate bed, and the
7 c) ?! e e7 ~3 k* tfather was not hugging him with bare skin and had
3 @: E( |& g7 a! [: p" G( Bbeen using protective clothing. A repeat testosterone
& [4 k( [! K9 H8 |" o' Btest was ordered, but the family did not go to the
' a; h5 }& ?) B+ ?laboratory to obtain the test. I9 B' A2 K5 Z+ @# ]8 Y5 o
Discussion* |$ G6 g9 H' s8 \6 C& G
Precocious puberty in boys is defined as secondary# n4 r) R8 l0 u) J" P- U
sexual development before 9 years of age.1,4" y2 M" H! j) r6 S9 s, b! Y% i
Precocious puberty is termed as central (true) when
6 J o$ N4 U* N% R8 nit is caused by the premature activation of hypo-9 g* a( V" [' v% B
thalamic pituitary gonadal axis. CPP is more com-
* T0 W: n' _) ?, n' o: Nmon in girls than in boys.1,3 Most boys with CPP, m3 R3 f. c& E% ^- P$ h a
may have a central nervous system lesion that is; l0 W, w# r9 n! ^
responsible for the early activation of the hypothal-
, `. A( @8 u9 j$ B7 a2 ramic pituitary gonadal axis.1-3 Thus, greater empha-/ \ j+ D6 L! H0 P. a( ]& F* G
sis has been given to neuroradiologic imaging in
. e/ v1 d: U/ Oboys with precocious puberty. In addition to viril-* ]' K' `0 n _3 ~, d& }; A% u, G
ization, the clinical hallmark of CPP is the symmet-
# P6 F1 r' H/ E" @- |rical testicular growth secondary to stimulation by" l7 i; R; d; N# N5 }2 j" M9 Y
gonadotropins.1,3
$ G; n7 M4 _# d6 e, HGonadotropin-independent peripheral preco-% m) O+ _( Z& v% M
cious puberty in boys also results from inappropriate6 J7 j9 D$ W6 D
androgenic stimulation from either endogenous or: R! W0 h1 J' Q& A7 O: I
exogenous sources, nonpituitary gonadotropin stim-
2 A+ ^% \9 q6 X$ H( ?ulation, and rare activating mutations.3 Virilizing
9 i& }. r3 `$ m& x8 C" Rcongenital adrenal hyperplasia producing excessive, y8 h7 U/ C/ _4 i3 h; B' H7 E
adrenal androgens is a common cause of precocious' b3 D# C' O9 c% g2 I
puberty in boys.3,4
. {( Y% M- e# N7 ^The most common form of congenital adrenal
, R3 W" E9 L( x) A- }7 k5 R( w. @hyperplasia is the 21-hydroxylase enzyme deficiency.
1 T) u7 c6 B: N( k. G: tThe 11-β hydroxylase deficiency may also result in; Q7 g* E8 W0 N( D: r/ o3 \# j
excessive adrenal androgen production, and rarely,3 @) T4 }1 Y1 t5 d2 M1 c. E
an adrenal tumor may also cause adrenal androgen
: f0 F+ J' O" [: K6 Q( z2 ~excess.1,3
) C! X) D. t k+ g: ]9 U0 ~# Lat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ o2 o! H" h6 G3 G$ i( b2 n W/ y2 L7 _
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
9 G# q. R1 a/ |# U: hA unique entity of male-limited gonadotropin-
& n( m7 E1 Z9 C+ ^ aindependent precocious puberty, which is also known6 H4 M* n/ }) H: r
as testotoxicosis, may cause precocious puberty at a. l3 D( ?7 {+ K3 e
very young age. The physical findings in these boys: w, U' ?" q* a7 w( [% z
with this disorder are full pubertal development,& J( S" _" r0 {" X* K" o, q
including bilateral testicular growth, similar to boys. N8 K4 @9 c9 A$ @* p8 f
with CPP. The gonadotropin levels in this disorder
c( H3 J7 l+ Pare suppressed to prepubertal levels and do not show
: g2 U7 ~- r L8 Z' u$ \pubertal response of gonadotropin after gonadotropin-
, @& T# |0 p8 `1 u2 _9 X$ c! oreleasing hormone stimulation. This is a sex-linked' c. Y: L* L( d- A; y8 m
autosomal dominant disorder that affects only2 h4 n# r6 p2 c$ O. b, v& P. ?
males; therefore, other male members of the family
9 B- U- o4 Z8 O( _* c5 Wmay have similar precocious puberty.3
" @2 f) @) _# S U4 GIn our patient, physical examination was incon-
- {2 C+ @# a7 ~' M+ H+ Dsistent with true precocious puberty since his testi-+ X0 r! R' X6 a7 N
cles were prepubertal in size. However, testotoxicosis2 u2 e9 {, Q/ P* q
was in the differential diagnosis because his father6 U9 e5 }& k0 M
started puberty somewhat early, and occasionally,
( R7 O2 F# j. q( ]0 atesticular enlargement is not that evident in the
8 M/ h# x( D* obeginning of this process.1 In the absence of a neg-
) T' y* ?# f- P' hative initial history of androgen exposure, our
' M- ^; R4 A6 I* z+ H7 }biggest concern was virilizing adrenal hyperplasia,
0 X+ v& r# t; }5 H* |. Yeither 21-hydroxylase deficiency or 11-β hydroxylase
1 P+ U1 _- g/ |) \' K7 vdeficiency. Those diagnoses were excluded by find-3 h6 x3 F; L6 O+ P& p9 A. B
ing the normal level of adrenal steroids.! M1 h! v. ?+ z
The diagnosis of exogenous androgens was strongly
6 N# }8 Y/ a3 I& C$ Asuspected in a follow-up visit after 4 months because
) M% n' i& R0 y. t' w8 Qthe physical examination revealed the complete disap-% g2 b' e1 w' p9 G* H
pearance of pubic hair, normal growth velocity, and. E Q! W7 u j/ ^0 N
decreased erections. The father admitted using a testos-8 U& X; j0 b* L. C3 B& l3 p ?
terone gel, which he concealed at first visit. He was
2 H+ R. l/ k5 O1 p' ^using it rather frequently, twice a day. The Physicians’
3 Z8 i! [ q, T$ k' W9 q$ g% h* FDesk Reference, or package insert of this product, gel or
) i( h- A) I, Q9 |cream, cautions about dermal testosterone transfer to% a8 w: ^& _& n' f& N) q3 f: N6 \% l
unprotected females through direct skin exposure.7 S8 B& p! b' s. o f) |
Serum testosterone level was found to be 2 times the3 t. X% U1 ]6 z% l$ W' U
baseline value in those females who were exposed to
5 i* n! s' v, F8 x1 feven 15 minutes of direct skin contact with their male3 P. t! {, e! G" Z# ?0 a. l" E
partners.6 However, when a shirt covered the applica-
7 u" f9 Q" f- [4 Ction site, this testosterone transfer was prevented.7 E2 p0 [% ~' o8 E# m6 _1 A" n9 Y
Our patient’s testosterone level was 60 ng/mL,
; K8 U' z$ j2 N, rwhich was clearly high. Some studies suggest that; p8 `0 B4 X: x0 J8 f) H( ~& u- [4 G
dermal conversion of testosterone to dihydrotestos-
7 U( j0 \- y% o: c4 gterone, which is a more potent metabolite, is more, B L5 ?* }+ b. X) d
active in young children exposed to testosterone/ ]* |( u& g2 @! f# h5 V* A
exogenously7; however, we did not measure a dihy-+ T% o0 g5 l& x: c9 I! Z
drotestosterone level in our patient. In addition to3 C/ c2 f( L9 |8 i t9 r! L
virilization, exposure to exogenous testosterone in3 F. P3 y1 ^. N5 u5 u
children results in an increase in growth velocity and
7 v$ W5 J6 c5 b2 [2 ~5 y$ p" c5 uadvanced bone age, as seen in our patient.: K; c3 a5 {9 d
The long-term effect of androgen exposure during5 V, r7 }+ d8 n" b# v
early childhood on pubertal development and final
; ^% d. o$ b9 sadult height are not fully known and always remain
9 ?; c& j. l! N9 w% d ?a concern. Children treated with short-term testos-* [, k- ^0 x1 o, T5 h6 j
terone injection or topical androgen may exhibit some
9 V8 I! G3 E8 n) zacceleration of the skeletal maturation; however, after
/ |; T6 g5 Z$ T. [, F! `cessation of treatment, the rate of bone maturation
0 Y' H1 f# ?) _decelerates and gradually returns to normal.8,9
1 R- O) v, } @1 U: z3 OThere are conflicting reports and controversy6 F: l5 Q7 Y( \4 `9 y
over the effect of early androgen exposure on adult; s7 Z# N, [& ?/ Z K$ i! Z) g; p
penile length.10,11 Some reports suggest subnormal
& A9 _! o6 h# f4 jadult penile length, apparently because of downreg-
$ p, ?3 O" u; Q M6 S7 Dulation of androgen receptor number.10,12 However,
: w' f, I, j [$ ~Sutherland et al13 did not find a correlation between9 i+ ~5 S3 {- Q! n8 @+ c% p
childhood testosterone exposure and reduced adult
8 A$ J: |' O& }3 O% l4 J& [penile length in clinical studies.) k, T! t, O! E' Q) @5 l2 ^
Nonetheless, we do not believe our patient is' P2 X- w3 {% y4 S$ B
going to experience any of the untoward effects from& z; K0 z# ]0 ?# {/ i+ y: b4 {
testosterone exposure as mentioned earlier because4 h7 \* K; m9 Z4 ]" |1 G
the exposure was not for a prolonged period of time.
# a+ {- N; c$ U8 m* |- zAlthough the bone age was advanced at the time of8 o! H- D$ i2 z3 o
diagnosis, the child had a normal growth velocity at
& L f' \$ r" sthe follow-up visit. It is hoped that his final adult
, a6 \4 `( T& ~3 K1 G# t. I9 w6 yheight will not be affected.
0 c R2 ?, e/ V$ E$ }$ h0 RAlthough rarely reported, the widespread avail-
5 p% G$ F2 y; A+ t5 M8 uability of androgen products in our society may
5 k1 ^4 X' d5 w3 ]7 kindeed cause more virilization in male or female7 p8 }4 v# z& F) p% g. \
children than one would realize. Exposure to andro-) t) _* s/ G" M! h+ t( N4 H
gen products must be considered and specific ques- u2 ^1 u* p( x9 A8 }
tioning about the use of a testosterone product or- u. a' M' s6 A0 k% _
gel should be asked of the family members during
5 g9 R& h) C1 o) X9 Fthe evaluation of any children who present with vir-
9 }' p( J$ e7 Gilization or peripheral precocious puberty. The diag-
( g% s2 A* C) \nosis can be established by just a few tests and by
+ b i9 o. n" }) J+ Q& s6 q. c `appropriate history. The inability to obtain such a3 u, n# j% h" l7 q' {4 e( Q. g
history, or failure to ask the specific questions, may# h- Q* c, S: R
result in extensive, unnecessary, and expensive* S$ p" y% g* v6 F% \
investigation. The primary care physician should be
6 K/ x7 w! z: q {0 I7 Aaware of this fact, because most of these children
0 m" P6 W) t. K: A6 E! _8 Q( amay initially present in their practice. The Physicians’+ z% O3 p _) G/ F6 }
Desk Reference and package insert should also put a
% C1 t' U- \; Owarning about the virilizing effect on a male or
`* u$ N2 [# b {7 z& hfemale child who might come in contact with some-
( g2 A! S8 j# u8 C) K/ S4 Yone using any of these products.1 ?0 @% ~6 A. S- }4 d9 p; s4 N5 `
References+ i8 W2 h8 Q1 }% O5 X& ^, Q+ x$ r
1. Styne DM. The testes: disorder of sexual differentiation
9 F, X8 F2 J4 K3 D8 r+ Yand puberty in the male. In: Sperling MA, ed. Pediatric8 I' M% L" @3 d3 g3 S
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 \% s, j5 u" g
2002: 565-628.
( g3 P0 \ m/ F, u2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
. v; D7 t B/ S) ?1 g( S3 u+ zpuberty in children with tumours of the suprasellar pineal |
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