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Sexual Precocity in a 16-Month-Old- w+ C( u, E) G: Q; S2 F
Boy Induced by Indirect Topical( i5 i5 q9 R- o8 z
Exposure to Testosterone
2 f- u' J( b( G8 n( J8 T( uSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) x; X! G7 I7 Q. K
and Kenneth R. Rettig, MD1
! N; O. V1 i$ \+ {5 @& _+ w1 \! I4 \Clinical Pediatrics. p+ {+ ]3 f3 n: `
Volume 46 Number 6) Q( ]2 y, o9 f* V
July 2007 540-543$ f# E. C# I8 @, |0 l) |0 Y
© 2007 Sage Publications" Q8 y. f/ V' z) Y1 E) F0 `
10.1177/0009922806296651
# Z; B0 H) a+ t7 Rhttp://clp.sagepub.com
1 P, U; }: |2 l* q. w/ n0 Qhosted at
$ ?2 }' [/ G% J3 Q0 a% _http://online.sagepub.com4 k* }0 I2 v, n9 W$ X/ w7 l
Precocious puberty in boys, central or peripheral,
# ~; f' M1 O5 z$ W5 I2 [) Dis a significant concern for physicians. Central
( l- x* L7 n+ Uprecocious puberty (CPP), which is mediated% o! j. t9 m" n2 O9 a
through the hypothalamic pituitary gonadal axis, has
3 f m+ v! K) {, ?" w" I$ aa higher incidence of organic central nervous system
' X8 \ y! x- Z$ k7 U h7 ?# k klesions in boys.1,2 Virilization in boys, as manifested
$ d( m$ ?, z" { |+ fby enlargement of the penis, development of pubic
+ P! x9 L, F. C7 ^. I5 ~- khair, and facial acne without enlargement of testi-
; ?: b% E9 Q# G; M* r; @cles, suggests peripheral or pseudopuberty.1-3 We9 s: }* {+ n) v9 @- I% }
report a 16-month-old boy who presented with the
; _# p7 n% r; q. S1 W& [enlargement of the phallus and pubic hair develop-
; z9 g; t; X2 a$ w- w& O+ }2 `% Oment without testicular enlargement, which was due
6 c6 d3 Y* n' Tto the unintentional exposure to androgen gel used by2 A7 h4 s' W) c* t
the father. The family initially concealed this infor-: f" I9 m& z9 Z6 o* `
mation, resulting in an extensive work-up for this' l9 L! p6 @2 S* ]) \! M: i
child. Given the widespread and easy availability of( A( N( `# w2 T0 v# s r# i. C
testosterone gel and cream, we believe this is proba-
$ s+ q4 K3 D7 B9 i( ?' Zbly more common than the rare case report in the# ]( Q4 z6 q/ B9 m/ A" `+ l
literature.49 K" }1 [) [1 {) J
Patient Report+ u5 k+ U- {/ R3 h4 P1 e& ?
A 16-month-old white child was referred to the1 S! i- H9 Q7 ]+ E
endocrine clinic by his pediatrician with the concern5 t$ g4 k& a+ U2 G# E/ O+ i2 i0 C- ?
of early sexual development. His mother noticed3 n2 ~& S- ~6 z# s: f
light colored pubic hair development when he was
* m1 ]6 o1 v- P! H4 fFrom the 1Division of Pediatric Endocrinology, 2University of
8 I, J/ a5 b3 U2 v, ]% Y; }0 pSouth Alabama Medical Center, Mobile, Alabama.
) ^5 T4 i6 C1 g6 RAddress correspondence to: Samar K. Bhowmick, MD, FACE,
4 ]& W5 T: u; J9 }8 g" N* ]Professor of Pediatrics, University of South Alabama, College of: n- \/ [& d; x: x/ N8 V- ?
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
; w3 \) Y. e5 g% `5 y4 ^e-mail: [email protected]." `* J) w1 A$ F0 v3 ~
about 6 to 7 months old, which progressively became
) [) D! T: q8 u$ o% Ydarker. She was also concerned about the enlarge-, \) N& H# e1 F6 N8 n
ment of his penis and frequent erections. The child; b) I, p+ y z9 m! ~
was the product of a full-term normal delivery, with* t2 S# E* _; u
a birth weight of 7 lb 14 oz, and birth length of
6 c: i1 s Y3 Y: e$ m8 {20 inches. He was breast-fed throughout the first year
9 Z! }- h4 v+ E- G* F' x" sof life and was still receiving breast milk along with
; |$ F/ F( K; i8 p! r: [! n& Ysolid food. He had no hospitalizations or surgery,+ k: x6 b. O- F3 N2 I# B) R
and his psychosocial and psychomotor development
1 n% l. W1 r% B6 i0 lwas age appropriate.
6 \2 u Z K" k* C) VThe family history was remarkable for the father,
9 I2 H* {; J. K B/ \who was diagnosed with hypothyroidism at age 16,
# s- `; D( f! [' U! N# v- iwhich was treated with thyroxine. The father’s2 P- ?6 S: n+ I6 Z
height was 6 feet, and he went through a somewhat
) ^9 u! N/ U7 Y( H, O, l d$ uearly puberty and had stopped growing by age 14." ]& i# a$ D. r+ ], f: Y
The father denied taking any other medication. The9 }8 v9 ^+ l& R3 D( w
child’s mother was in good health. Her menarche
9 `' z2 T: K* owas at 11 years of age, and her height was at 5 feet
" M, E% P+ T; X0 b5 inches. There was no other family history of pre-$ o. I+ y$ R7 X+ m! t
cocious sexual development in the first-degree rela-3 @0 E. t; A- b4 @; B4 F& H2 A
tives. There were no siblings.
8 b* Y) [5 r2 T5 jPhysical Examination% h9 u% b) s, _$ N+ {0 u
The physical examination revealed a very active,
) C* ]$ ]! P" L) B) `, `3 `- [playful, and healthy boy. The vital signs documented+ w |+ ]8 _# a) N6 h. K
a blood pressure of 85/50 mm Hg, his length was
* j3 Q y' @% O90 cm (>97th percentile), and his weight was 14.4 kg, H0 H1 f7 S# ^$ e8 r
(also >97th percentile). The observed yearly growth: s# ]( q/ \9 @
velocity was 30 cm (12 inches). The examination of
) Z7 ]/ {3 i$ c4 d1 c, uthe neck revealed no thyroid enlargement." z4 Q6 N5 s0 o9 ]* T, p0 V
The genitourinary examination was remarkable for( V% W. V9 A" v* U
enlargement of the penis, with a stretched length of
, R+ }% w! J# f- Z; |2 z0 z. q8 cm and a width of 2 cm. The glans penis was very well7 a. B- `6 f. ^: ~5 C; @
developed. The pubic hair was Tanner II, mostly around3 T( _8 o! V. f( C- ^3 c0 W
540 {3 ~) I% d& G. Q& K- l5 J, f
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 ~4 ?* }6 P* K( q
the base of the phallus and was dark and curled. The) i2 D& P2 ^! x/ f+ ?+ C* O. x p K; @
testicular volume was prepubertal at 2 mL each.4 T! Z1 G3 o- M; m. p- V; R
The skin was moist and smooth and somewhat
0 O- w9 i* ^+ ]! koily. No axillary hair was noted. There were no
4 Y$ @- F5 c* w/ d3 Uabnormal skin pigmentations or café-au-lait spots.8 i2 M1 d. |" n$ ?, @
Neurologic evaluation showed deep tendon reflex 2+
) w9 C+ j* R; s9 j) R+ H3 n* Y7 Sbilateral and symmetrical. There was no suggestion
/ U( S9 e! H/ ~$ U# M3 ]of papilledema.
/ c( X2 e; K& U8 {0 SLaboratory Evaluation
3 E7 U/ _1 Q# @The bone age was consistent with 28 months by+ X: Y1 K/ l3 m' ?' u7 g
using the standard of Greulich and Pyle at a chrono-3 J$ |8 E' P/ D) k1 B) w5 f
logic age of 16 months (advanced).5 Chromosomal
, e% [+ x; k. r* D7 ]# akaryotype was 46XY. The thyroid function test
# v2 U9 _ v7 B6 I5 Fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-7 m& C7 B# j; W9 u- J _. {+ l
lating hormone level was 1.3 µIU/mL (both normal).
, p! D* W" h% d* lThe concentrations of serum electrolytes, blood
7 C$ [1 i& i9 w. I2 Qurea nitrogen, creatinine, and calcium all were
4 N) ^* P( W8 ?, i) |( j+ o# Xwithin normal range for his age. The concentration# s" I/ s5 R* w8 z5 R
of serum 17-hydroxyprogesterone was 16 ng/dL
_2 m( X- t" J0 U4 Y(normal, 3 to 90 ng/dL), androstenedione was 20
. z* n( _) X7 w- y5 I0 c$ ]. I# Nng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 P- n& k2 G2 P _- }
terone was 38 ng/dL (normal, 50 to 760 ng/dL),; K' n! r2 c1 c! q, P' e( W
desoxycorticosterone was 4.3 ng/dL (normal, 7 to3 t: Q$ R, R' O2 |0 G
49ng/dL), 11-desoxycortisol (specific compound S)
+ {5 C" A8 y- A% e0 i& ?was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
6 b4 k: r$ F/ t& qtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total( @; O9 |/ M! [* k
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),5 I8 D$ x6 @! v# O& \# {# }( O
and β-human chorionic gonadotropin was less than g9 Z7 X* @/ }, }9 J
5 mIU/mL (normal <5 mIU/mL). Serum follicular: K+ x& U U, |/ d1 T/ m
stimulating hormone and leuteinizing hormone2 f W# ]0 N% }2 }" j4 `; P
concentrations were less than 0.05 mIU/mL
& n1 Z+ D. ?) f8 n1 ?(prepubertal)./ F& A* [$ `1 F1 E
The parents were notified about the laboratory
- s9 G4 a( Z1 j, d7 l3 l0 }8 F' z6 u. qresults and were informed that all of the tests were! z) M6 F) T3 s7 [1 ]
normal except the testosterone level was high. The/ T5 [: E$ M" K* u0 C# e! F+ v
follow-up visit was arranged within a few weeks to' k0 e" P- c( Q- U3 J$ a6 t
obtain testicular and abdominal sonograms; how-
& g V- G2 n$ I2 z0 `" Oever, the family did not return for 4 months.
}6 p' \- t! E0 q9 oPhysical examination at this time revealed that the
/ \# e" H; |5 X% o: ]$ hchild had grown 2.5 cm in 4 months and had gained% T+ s% M9 U5 N% n, o
2 kg of weight. Physical examination remained) V: O' S4 [, N% x4 e, ?
unchanged. Surprisingly, the pubic hair almost com-
4 |* Y0 D f" a @' \8 U$ wpletely disappeared except for a few vellous hairs at- m3 E1 m/ z! @( i1 }! E; u' ^! `
the base of the phallus. Testicular volume was still 2* p; } u7 J/ G- T" t
mL, and the size of the penis remained unchanged.* t% w/ d$ x- K, c
The mother also said that the boy was no longer hav-8 B3 L+ {6 \( g
ing frequent erections.; n; z: N$ p$ D' @0 f1 p
Both parents were again questioned about use of$ J7 c% i! [5 j: Y" ?0 z
any ointment/creams that they may have applied to, l. \0 R3 ^% H4 L2 P' H6 T q
the child’s skin. This time the father admitted the8 ]9 P ^! C! S
Topical Testosterone Exposure / Bhowmick et al 541
* n6 r+ ?2 U) s) Uuse of testosterone gel twice daily that he was apply-
& p7 G3 }1 U, ?1 Uing over his own shoulders, chest, and back area for
. G2 C- C: a2 }9 ^3 qa year. The father also revealed he was embarrassed
8 u; Z0 g0 M9 Y8 _4 kto disclose that he was using a testosterone gel pre-
8 i( f; ~; P. c" K* N9 Z2 m( [5 t/ Escribed by his family physician for decreased libido
4 M: V0 c: Z2 `3 M, O" D' \secondary to depression.
" w Z; r) B9 F( r3 SThe child slept in the same bed with parents.4 @& x: N. h8 G
The father would hug the baby and hold him on his; _4 V7 y; }4 `9 U9 l/ I' T' F
chest for a considerable period of time, causing sig-" k3 c2 W" b. X& i) K" c5 z
nificant bare skin contact between baby and father.- x; [8 i X, m. S0 [; D" z, T
The father also admitted that after the phone call,
' @4 P! y3 d. c: qwhen he learned the testosterone level in the baby
/ u. S' t @1 {# [was high, he then read the product information
/ O \( E6 `0 A# v6 G; [6 T: rpacket and concluded that it was most likely the rea-/ N2 S+ c7 }4 J+ ~( U
son for the child’s virilization. At that time, they
) a) k' ~8 ?& Udecided to put the baby in a separate bed, and the4 {$ J+ V" I8 b8 H
father was not hugging him with bare skin and had' G. Y6 g* i t7 ^. n
been using protective clothing. A repeat testosterone) ^# H& ~: T9 j
test was ordered, but the family did not go to the
9 P# c: f& M1 x; Ulaboratory to obtain the test.+ P/ O( c4 @& B9 f
Discussion
) {3 t6 m$ B4 P4 l9 H7 X2 gPrecocious puberty in boys is defined as secondary
3 u* r" X( H5 [; h1 z4 Tsexual development before 9 years of age.1,4, K. \# \; @, f
Precocious puberty is termed as central (true) when i. S, w: ~+ @' f5 p: r' }, U
it is caused by the premature activation of hypo-
. g2 {8 q: m8 u* K/ ~% vthalamic pituitary gonadal axis. CPP is more com-
5 {3 X, j+ [8 q _) Xmon in girls than in boys.1,3 Most boys with CPP$ `) q. U4 C8 b% e$ Q
may have a central nervous system lesion that is4 |% Y& J! [) w" [* a3 f6 z$ h) X
responsible for the early activation of the hypothal-
5 c5 Q4 _: `1 G* N% `+ }+ Yamic pituitary gonadal axis.1-3 Thus, greater empha-7 z' T8 x/ |6 o7 k- }+ T. D2 w
sis has been given to neuroradiologic imaging in( r) m# B& R7 A' O$ D) {# U
boys with precocious puberty. In addition to viril-/ h6 z! r- U. Z! q1 x
ization, the clinical hallmark of CPP is the symmet-" N7 `- `( r, y8 C* N' ?
rical testicular growth secondary to stimulation by# O8 r7 {5 s+ L. x2 z p: u) I
gonadotropins.1,3
$ D$ @. k9 F5 I8 pGonadotropin-independent peripheral preco-. P' N, l# \' I* a( [8 \/ h
cious puberty in boys also results from inappropriate% `/ h8 i5 C3 M- ]' ?; ?3 j
androgenic stimulation from either endogenous or
) i! j" U/ r1 T. Hexogenous sources, nonpituitary gonadotropin stim-
1 p6 A3 ?, R9 Gulation, and rare activating mutations.3 Virilizing/ W6 |* m9 R2 A- F
congenital adrenal hyperplasia producing excessive
- T9 H0 w6 \9 [) Padrenal androgens is a common cause of precocious. c9 c1 A" Y) \1 K. \. s
puberty in boys.3,4
" F2 Y* n# V1 k" S5 _$ {0 TThe most common form of congenital adrenal
% e1 o* g8 C, zhyperplasia is the 21-hydroxylase enzyme deficiency.
. r R6 Q# K0 I/ p9 t$ `The 11-β hydroxylase deficiency may also result in
! g3 f0 @, P3 u8 wexcessive adrenal androgen production, and rarely,7 f) P* w( [ j+ {& Z
an adrenal tumor may also cause adrenal androgen
6 C' p6 ~7 M; f" R5 a, pexcess.1,3
9 ^, h; f6 C+ h, ]8 [at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 A$ i% \8 g3 W, [+ _
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 j& K* N2 h8 {2 n+ FA unique entity of male-limited gonadotropin-
. h" s4 X( P# }; R- h" ~independent precocious puberty, which is also known! [3 p, T2 j/ l! }7 e" T8 O
as testotoxicosis, may cause precocious puberty at a
! u! V# L' f- z% Y3 L) o- H4 Every young age. The physical findings in these boys* U- l0 o6 j- @* V& z
with this disorder are full pubertal development,
m# r* V+ O, e# M7 y+ G8 f) aincluding bilateral testicular growth, similar to boys. X2 V# S/ o2 G1 O
with CPP. The gonadotropin levels in this disorder
7 e* ]+ H0 U9 W3 g2 C, @are suppressed to prepubertal levels and do not show, t6 O# _+ P2 C: G
pubertal response of gonadotropin after gonadotropin-$ @7 _! v6 L4 w
releasing hormone stimulation. This is a sex-linked
: X5 c! _' I0 z8 p+ W: D- P- pautosomal dominant disorder that affects only
* [# z4 e' z y+ Smales; therefore, other male members of the family
6 c/ ^" P3 ?$ s/ R+ k' \9 b' Cmay have similar precocious puberty.3
0 @/ `" V; y6 VIn our patient, physical examination was incon-
}, a- y p3 dsistent with true precocious puberty since his testi-1 e8 O* m; ?4 b, U( I9 Q6 g
cles were prepubertal in size. However, testotoxicosis
* ?" N6 P* R9 r) |4 @$ ]- Lwas in the differential diagnosis because his father
$ ]$ E) g3 `0 B8 m' r0 nstarted puberty somewhat early, and occasionally,
5 \9 L$ ^, {( _+ e3 Otesticular enlargement is not that evident in the
, a* _! o- \6 D8 Ebeginning of this process.1 In the absence of a neg-
5 \$ L, J9 _0 R8 F6 B N* O7 f1 m: Vative initial history of androgen exposure, our+ i6 ^+ w& M7 h* H
biggest concern was virilizing adrenal hyperplasia,
) Y' `) z% q' Q! X. aeither 21-hydroxylase deficiency or 11-β hydroxylase% c& [ G' N% ~& J
deficiency. Those diagnoses were excluded by find-
5 f% W# l; `8 l, w K* T; P6 Zing the normal level of adrenal steroids.
( D% m* a! ?+ H( |The diagnosis of exogenous androgens was strongly
3 R* F8 ?5 n3 P1 zsuspected in a follow-up visit after 4 months because0 O. R# o$ N* A/ H1 {
the physical examination revealed the complete disap-. Q! u* F+ X' x: v! ?2 k9 X/ N
pearance of pubic hair, normal growth velocity, and% V# d- }8 y3 Z" q L' A4 I
decreased erections. The father admitted using a testos- v/ H: p* G* }* Z1 S' l* M
terone gel, which he concealed at first visit. He was
, S! P( M' P0 W5 f& A; |3 Z$ zusing it rather frequently, twice a day. The Physicians’
. E$ ?4 j2 O7 w6 MDesk Reference, or package insert of this product, gel or
2 I' ~7 }% ~( l! G$ D. Ocream, cautions about dermal testosterone transfer to
+ e4 d! I* W3 o7 runprotected females through direct skin exposure.
# ~& w" S) W1 R9 N5 G8 hSerum testosterone level was found to be 2 times the
, [* h3 A* Y- G7 h- Y! U+ {baseline value in those females who were exposed to' f1 \# O4 m; W# ]7 z- L5 r
even 15 minutes of direct skin contact with their male& U4 W* J8 ?. N5 j D: l9 h2 F! E
partners.6 However, when a shirt covered the applica-
3 X6 f8 |( ?- ^! k6 V5 x9 ltion site, this testosterone transfer was prevented.
' }6 h8 J0 }- c9 v# f0 s% DOur patient’s testosterone level was 60 ng/mL,' Y5 W3 H& X" e8 }
which was clearly high. Some studies suggest that0 }# X' Q. [1 s: X6 Y
dermal conversion of testosterone to dihydrotestos-
4 o$ x) T+ ?# I' L2 U- p2 O. w% Wterone, which is a more potent metabolite, is more
4 A: T- H2 E8 q! g4 f. m% \active in young children exposed to testosterone& }' U. m! S) J
exogenously7; however, we did not measure a dihy-
) U# i7 c& f ~7 O" Wdrotestosterone level in our patient. In addition to
' W$ |; o1 L& G5 Fvirilization, exposure to exogenous testosterone in
) |" y, `% n$ Jchildren results in an increase in growth velocity and: V0 f% q u" v
advanced bone age, as seen in our patient.
* { ~2 U3 P8 QThe long-term effect of androgen exposure during2 w0 c" d) l" k$ ^5 e; U) E
early childhood on pubertal development and final
9 V. c H: y6 D6 r5 Iadult height are not fully known and always remain
. L$ ~: l# H$ q; R# a, aa concern. Children treated with short-term testos-' Q$ J9 U5 z' ?& A. g8 s! C
terone injection or topical androgen may exhibit some1 [8 i6 G, j" a( w9 F8 X- H
acceleration of the skeletal maturation; however, after
3 J! y- I! t6 `# f$ q0 P0 \# tcessation of treatment, the rate of bone maturation! h" N" s5 O- c( P( F9 u
decelerates and gradually returns to normal.8,9
1 D; N. l, C8 v6 ~% ~! XThere are conflicting reports and controversy
" U9 ^2 r( H4 h: F% Cover the effect of early androgen exposure on adult
% h, u7 U4 c7 S6 Gpenile length.10,11 Some reports suggest subnormal& U# m& N+ R) \) Z5 ^
adult penile length, apparently because of downreg-( S- g' j B3 C8 T8 {
ulation of androgen receptor number.10,12 However,
; j9 _% R7 X' V8 K/ YSutherland et al13 did not find a correlation between
" |" c) t w8 N: H( S6 i# r: e2 s8 Tchildhood testosterone exposure and reduced adult- s$ y" o* h6 L0 L1 I; o2 B# Z
penile length in clinical studies.
5 h2 }4 _$ o; pNonetheless, we do not believe our patient is' t7 @1 T/ N! w+ W% S; ?! \
going to experience any of the untoward effects from
" N! B0 \+ C/ `8 t0 d, q. Itestosterone exposure as mentioned earlier because
" s5 E) U" H, W4 Qthe exposure was not for a prolonged period of time.6 L3 S" }' M" N* T
Although the bone age was advanced at the time of0 u E& k/ |" ?% Q
diagnosis, the child had a normal growth velocity at
" M( R& ^" v, [) W! zthe follow-up visit. It is hoped that his final adult c; `* m3 S$ n# b
height will not be affected.0 y( {" {2 A- ^( w5 ~: P" V1 ?
Although rarely reported, the widespread avail-1 c. M5 F' p0 ^ H1 }6 b
ability of androgen products in our society may
5 A. r; z# Q% U2 }( |0 Vindeed cause more virilization in male or female2 m! t# h/ F% K5 |
children than one would realize. Exposure to andro-' Q% ?( k" B& v# s8 \( v# y1 D
gen products must be considered and specific ques-, E* D0 j; O/ Q
tioning about the use of a testosterone product or
) H7 K7 M* C0 r l- |! i" [gel should be asked of the family members during
7 [5 r) X' b4 L: x) J; a+ L Xthe evaluation of any children who present with vir-
4 x3 ^* _) I5 }) i$ V5 qilization or peripheral precocious puberty. The diag-; Y- h+ U" r8 n3 m5 y: q& [0 j. u8 K
nosis can be established by just a few tests and by6 T0 f- K( b! y! `5 d Q
appropriate history. The inability to obtain such a" u' F, r7 q1 q$ k
history, or failure to ask the specific questions, may1 H: t" U' w5 h. q7 o& Z6 M) C
result in extensive, unnecessary, and expensive
0 Z5 m1 ^& a R4 t1 e$ ^5 Ninvestigation. The primary care physician should be4 f) @9 ?! G: X5 s4 b6 ^
aware of this fact, because most of these children; l1 g* {, [' [6 M. j6 E+ ^9 I
may initially present in their practice. The Physicians’3 D4 ]) H* Y- a% q
Desk Reference and package insert should also put a
+ b) i* F8 v* I! Owarning about the virilizing effect on a male or
* t6 Y+ M# N. z& d# m8 R4 Mfemale child who might come in contact with some-( h& K7 y: j$ X. _! a, F( D" S4 P
one using any of these products.6 o$ Z }0 R* T9 u
References! H- m, a. `1 a& ], ^, V
1. Styne DM. The testes: disorder of sexual differentiation" L# E+ g! ` | H/ ~
and puberty in the male. In: Sperling MA, ed. Pediatric v2 z; {, y9 T3 w
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 q+ \2 e" [0 t2 |, i2 l2002: 565-628.
& ]. N0 ?, ?% d" c% O0 x2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
& h3 p; k' ~/ m5 E( h: Cpuberty in children with tumours of the suprasellar pineal |
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