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Sexual Precocity in a 16-Month-Old
l$ }5 E; J7 v6 {# EBoy Induced by Indirect Topical
' }2 `; a0 n4 O( u" k4 t3 DExposure to Testosterone
7 }4 p3 b3 h% z- k3 y: i: iSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
* G7 H' R! x! ?, kand Kenneth R. Rettig, MD1
. c$ ^2 |/ I; r2 K' z6 @Clinical Pediatrics/ V* Y6 E* T8 C$ q& }* l
Volume 46 Number 6
) ?4 S7 ]7 _0 t/ d" zJuly 2007 540-543
/ P* {: E9 N" L' |& D, |' o4 J© 2007 Sage Publications# Y0 P, X3 o5 `6 b
10.1177/0009922806296651
+ Y) S, A3 a- G: t. O7 Rhttp://clp.sagepub.com
4 h# m2 e# ]9 v6 J6 j) ^# y6 Chosted at* W. z* _+ E. j4 X: m/ o4 \
http://online.sagepub.com
- `* I7 Q6 G5 l( Y8 A0 Q; PPrecocious puberty in boys, central or peripheral,
! C0 z' [$ \, ]) E2 {& W) @' Jis a significant concern for physicians. Central
( }0 ~! H1 T2 F# K, tprecocious puberty (CPP), which is mediated
& z( [' t2 B1 ?. ^1 Bthrough the hypothalamic pituitary gonadal axis, has
1 n3 @0 q' s( _% O. pa higher incidence of organic central nervous system
) G4 V( F, u1 N H4 ~: C! W! Flesions in boys.1,2 Virilization in boys, as manifested w" h& Y5 Y: i# R# w, b
by enlargement of the penis, development of pubic
/ w/ q& j6 Q2 |$ ahair, and facial acne without enlargement of testi-
' K) R9 i( W X0 h& v+ s! l3 T) Ccles, suggests peripheral or pseudopuberty.1-3 We3 W, ?% V5 m; k
report a 16-month-old boy who presented with the
4 @* `; B7 Y( fenlargement of the phallus and pubic hair develop-
# A$ `2 r; X- A/ J/ p# C# qment without testicular enlargement, which was due
3 f* [/ I: E2 a( h: N4 K# h1 jto the unintentional exposure to androgen gel used by. @% O, F" p/ e* y5 p! V
the father. The family initially concealed this infor-
/ S; z/ p; ?" }) O) Qmation, resulting in an extensive work-up for this
9 C3 Q4 a" m: T; L2 Z0 `* G. \child. Given the widespread and easy availability of \0 Z& D R& ~( s9 v. _, d
testosterone gel and cream, we believe this is proba-% u( I9 i2 H3 h0 v, R+ R! y
bly more common than the rare case report in the- F9 z5 u4 c9 j$ O5 U6 Z
literature.4
) Y6 c( w6 W: `. I5 }Patient Report6 I4 C/ f, M! `# C) j3 ?( B. S
A 16-month-old white child was referred to the
. D; A7 o7 D7 e2 o# L+ Fendocrine clinic by his pediatrician with the concern
, m! J6 k! ?6 G" S- F9 zof early sexual development. His mother noticed- u" w7 {) X8 r" |
light colored pubic hair development when he was
* a" r8 N. d; N1 TFrom the 1Division of Pediatric Endocrinology, 2University of6 n1 p: ?4 `: M% w& p4 r
South Alabama Medical Center, Mobile, Alabama., S4 G V" L" V& p* l+ l( P
Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 b: h/ B( ` FProfessor of Pediatrics, University of South Alabama, College of
( s' x# u; E0 G3 u6 d/ ~1 \% LMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
x: Y5 |9 f* ~) te-mail: [email protected].
" d! v! C) ~! Y( c* o9 a( `5 y0 F% Kabout 6 to 7 months old, which progressively became
8 M) S. M' g& y9 Ydarker. She was also concerned about the enlarge-
! m+ o9 x/ f4 B! [ment of his penis and frequent erections. The child6 t/ z8 q1 S M1 ?1 o; B- m
was the product of a full-term normal delivery, with
$ C# ^4 t f6 r& va birth weight of 7 lb 14 oz, and birth length of
" J4 z$ k- V/ s7 j9 c1 L) D20 inches. He was breast-fed throughout the first year
& ^" q4 d" ~1 R" Rof life and was still receiving breast milk along with* E4 B7 g, I9 I+ l/ A- P
solid food. He had no hospitalizations or surgery,: o/ o# `7 V) f9 j
and his psychosocial and psychomotor development
! T) Z' h9 q) e/ a' }was age appropriate.
8 S& S0 i4 p' @The family history was remarkable for the father,
# f' L$ z, }: i2 Gwho was diagnosed with hypothyroidism at age 16,
4 u1 {. ]( x. B9 zwhich was treated with thyroxine. The father’s
3 R" W2 v5 u# V+ k" m" Q: kheight was 6 feet, and he went through a somewhat! X0 |* {; [+ P% j
early puberty and had stopped growing by age 14.
! N" D( Z: _6 A3 p$ l9 x% L) lThe father denied taking any other medication. The
/ {, z% P% M+ y& v2 S* [. Y8 Uchild’s mother was in good health. Her menarche' |* h: ?0 C; p7 f8 d8 x
was at 11 years of age, and her height was at 5 feet4 |* q) Q f" Y6 ]( Y7 F7 P6 c8 T
5 inches. There was no other family history of pre-# o- f0 m& V" |- W7 Z6 h, ?( o
cocious sexual development in the first-degree rela-
8 M0 n9 `( D/ f% Z. B5 t2 g4 Vtives. There were no siblings., f+ r3 Y0 E7 F: b: ^0 ?' Q0 N% V
Physical Examination
, ~: K4 D' M5 x+ _0 }4 f2 [: g& ` lThe physical examination revealed a very active,
) X. T" p D4 f" y9 u& {1 B' Hplayful, and healthy boy. The vital signs documented
+ c; O! ]1 L3 }3 F. `- F# w4 ^$ ra blood pressure of 85/50 mm Hg, his length was) @) C9 _ U# |# K, R
90 cm (>97th percentile), and his weight was 14.4 kg0 n0 @8 V: P6 w# r5 C
(also >97th percentile). The observed yearly growth+ Z( {+ g. D7 s) w/ i
velocity was 30 cm (12 inches). The examination of1 T4 U% D" j6 V) y
the neck revealed no thyroid enlargement./ |' v/ m5 S8 D2 @1 O: N
The genitourinary examination was remarkable for
1 ^' s' B+ n$ k% Q6 ^6 Uenlargement of the penis, with a stretched length of
. a% ], C( X! m1 p# ^; m( z8 cm and a width of 2 cm. The glans penis was very well% B# @8 J1 e/ ]
developed. The pubic hair was Tanner II, mostly around* S, b; I# s" F
540
5 `' {; R2 J/ S, r2 v. q& Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from, t4 U. g/ J2 q7 F* {0 P5 s ^
the base of the phallus and was dark and curled. The9 \6 x. Y6 i9 l' X' I7 N( _ J
testicular volume was prepubertal at 2 mL each.
0 \. d6 L0 r& AThe skin was moist and smooth and somewhat
, P& ?7 l& u. c+ hoily. No axillary hair was noted. There were no
: L5 Z; V! m' @9 ~( L! Fabnormal skin pigmentations or café-au-lait spots.3 k) R& K1 q Q: @! N* V
Neurologic evaluation showed deep tendon reflex 2+
, \; z, ~- A) F" m, Dbilateral and symmetrical. There was no suggestion; O# _% f9 T& H' c5 ^ O! Y
of papilledema.
. q% w- ^5 |5 V; k; ~Laboratory Evaluation
+ v* q1 }7 b9 U$ j4 iThe bone age was consistent with 28 months by
$ i0 z- j/ m# S7 w% D9 cusing the standard of Greulich and Pyle at a chrono-( I; W- W6 P3 E! c9 M5 I* F, E, Q
logic age of 16 months (advanced).5 Chromosomal8 G, c# H, V3 e0 N* s! p' m
karyotype was 46XY. The thyroid function test, L; c7 `% h: z9 R0 `& j
showed a free T4 of 1.69 ng/dL, and thyroid stimu-* s% I. p3 O2 J2 H5 r! \% x
lating hormone level was 1.3 µIU/mL (both normal).
( y: |7 U: Z8 d+ f/ Y, i& c( t* ]; eThe concentrations of serum electrolytes, blood
$ _9 {, x0 b" @- @ M% U6 \urea nitrogen, creatinine, and calcium all were- I, a, p) |" y
within normal range for his age. The concentration
: n) J* e$ B0 T7 _of serum 17-hydroxyprogesterone was 16 ng/dL, Y" }$ C: l; L7 @% P' L
(normal, 3 to 90 ng/dL), androstenedione was 207 d# c3 u$ j% t6 T- f" `2 a
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
B% \. J- I$ z$ k& O' E, T2 S7 }terone was 38 ng/dL (normal, 50 to 760 ng/dL),% k6 u! r# v7 g5 [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 a/ G% W2 C+ B: ^6 k8 I49ng/dL), 11-desoxycortisol (specific compound S), W0 s$ u/ r$ \% s9 f1 O
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. E0 N9 S9 j# {. ?+ [
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total& d6 n8 @1 |/ A+ i, p- I/ f
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 \5 I: x$ K1 Y! w% Gand β-human chorionic gonadotropin was less than
8 I7 e: S+ F! N5 mIU/mL (normal <5 mIU/mL). Serum follicular
e5 x" [. k0 J, o6 Gstimulating hormone and leuteinizing hormone6 v: q1 A& b G2 ]; ~" N6 [2 N. b. t
concentrations were less than 0.05 mIU/mL. H9 W% X9 [9 f8 L
(prepubertal).
) [4 Y; x- g& g# [The parents were notified about the laboratory
3 G3 U" k# f9 |" z5 d* t3 R) K3 Vresults and were informed that all of the tests were
/ r! I0 T7 O$ R. \, Fnormal except the testosterone level was high. The/ Y2 p+ P3 k' s) o# |
follow-up visit was arranged within a few weeks to( R- m' o$ ^: Z. \8 _
obtain testicular and abdominal sonograms; how-) \" d! e# e+ u& x& S" \ s7 d
ever, the family did not return for 4 months. K1 u1 |5 O: I, x5 R; d
Physical examination at this time revealed that the8 R# ?; P; I* C. O e# x& ?0 ]# o( Y
child had grown 2.5 cm in 4 months and had gained
7 {( ^1 b% v$ S O2 kg of weight. Physical examination remained' s4 {( {2 Q* o& }9 ` l/ p
unchanged. Surprisingly, the pubic hair almost com-3 {! c1 c- Q# d" i" U
pletely disappeared except for a few vellous hairs at
7 T; f4 k9 e5 G3 }, @5 u6 Tthe base of the phallus. Testicular volume was still 2
% l& }) d7 _8 z: b _mL, and the size of the penis remained unchanged.! m8 `% z* {: `, V7 @
The mother also said that the boy was no longer hav-
9 {8 c" j# j* F3 A; ? A' x& O, u& Iing frequent erections.
7 Q4 @+ f$ u0 KBoth parents were again questioned about use of2 Q" S0 o( X9 X
any ointment/creams that they may have applied to
. N7 m- Q$ N1 s, F) wthe child’s skin. This time the father admitted the
9 r6 G$ g4 N9 Z; e2 R) M& q+ ITopical Testosterone Exposure / Bhowmick et al 541
" ^4 }$ q1 e5 n% b! Z F' F7 O+ X6 Ouse of testosterone gel twice daily that he was apply-$ I; U, W1 a& J
ing over his own shoulders, chest, and back area for$ N- K$ A5 Q' c* q1 n
a year. The father also revealed he was embarrassed w, F0 D, R0 a5 a7 ^/ ?4 }
to disclose that he was using a testosterone gel pre-
4 u0 L* ]! B& p2 U2 Zscribed by his family physician for decreased libido" c0 c) e9 N8 w
secondary to depression.
5 y( x p- w/ W- V: ^% l4 bThe child slept in the same bed with parents.
' P! t: `; t/ [) a, S) K# c8 IThe father would hug the baby and hold him on his6 u+ E/ n. `; T0 N6 S6 l/ H2 h) d- z
chest for a considerable period of time, causing sig-6 i5 P7 { |4 [, L) P, W
nificant bare skin contact between baby and father.
+ r! O: A( g/ x8 z" ~The father also admitted that after the phone call,
) M" V& Y. O) l% N/ Cwhen he learned the testosterone level in the baby
! e& P: [; X7 |# K7 K+ Z$ s+ owas high, he then read the product information* s2 m( O' Q5 q( v$ O
packet and concluded that it was most likely the rea-# O) w% ?) z7 F; ~. w' k8 J) [& z! P
son for the child’s virilization. At that time, they2 G5 d1 n1 A/ `" L" P+ E R% j
decided to put the baby in a separate bed, and the
- x1 w) W7 T- Q% {& D- p Rfather was not hugging him with bare skin and had( J$ g% v7 c8 V/ }$ c
been using protective clothing. A repeat testosterone5 P' E m ?; z0 l- y+ R$ u! Y1 z
test was ordered, but the family did not go to the
! h! m, f' {) claboratory to obtain the test.4 s p( b6 ?% E% w, j
Discussion8 U9 E+ F- ?1 b/ M: p
Precocious puberty in boys is defined as secondary+ N M/ b2 v' u- a* Z
sexual development before 9 years of age.1,4
" p' I# G2 D( e( tPrecocious puberty is termed as central (true) when
1 q G W2 ?% |( K$ Git is caused by the premature activation of hypo-6 `1 k$ i9 Z# @) ^1 H
thalamic pituitary gonadal axis. CPP is more com-; e9 |( {7 }6 l+ ~/ h
mon in girls than in boys.1,3 Most boys with CPP
4 T+ z# w/ R. V. K' qmay have a central nervous system lesion that is W2 W' x3 ^3 p, C. U0 s; Y- M
responsible for the early activation of the hypothal-
: \6 Q9 Y# h0 p1 D/ [; Hamic pituitary gonadal axis.1-3 Thus, greater empha-, `$ z3 O" b7 i+ D8 O8 F2 q
sis has been given to neuroradiologic imaging in1 `3 O2 |4 f3 x9 q+ q
boys with precocious puberty. In addition to viril-* t. X& o5 A- k- d* j
ization, the clinical hallmark of CPP is the symmet-
! J% M& Y: P Z7 Grical testicular growth secondary to stimulation by
# U& V& Q( \9 v# j6 ]1 zgonadotropins.1,3$ c' o5 {6 F- S+ t2 n5 X" T) k
Gonadotropin-independent peripheral preco-" B2 Q" ?9 _; n/ |4 Z' j# |3 |
cious puberty in boys also results from inappropriate
3 W. `9 @3 o3 M/ ]8 Candrogenic stimulation from either endogenous or% o) M; Y. j2 T0 T; p$ a
exogenous sources, nonpituitary gonadotropin stim-! q9 P. Q7 o0 V j- r5 I U" k9 h
ulation, and rare activating mutations.3 Virilizing8 E0 F" k' ^! T' I# J; F
congenital adrenal hyperplasia producing excessive
. M$ n- D4 `8 Tadrenal androgens is a common cause of precocious4 C5 o% u. j, \
puberty in boys.3,44 ? j% A$ ]) V# T+ ?
The most common form of congenital adrenal
4 D4 G! D* m3 s e& c1 x4 Xhyperplasia is the 21-hydroxylase enzyme deficiency.! u* Y! {" n: W' r
The 11-β hydroxylase deficiency may also result in
! P6 q& ~5 L+ T# `+ k0 T0 m2 yexcessive adrenal androgen production, and rarely,
1 J2 {( x5 y8 L8 `) zan adrenal tumor may also cause adrenal androgen1 I3 g* W4 F( b- `; R
excess.1,36 o( M% O+ V. m- n. j* w6 f' ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from3 R; o3 Y9 S m6 y/ x5 ?
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
+ W) }; e$ E, W8 i" q2 ~A unique entity of male-limited gonadotropin-6 v' z1 a8 n' e# p7 n `
independent precocious puberty, which is also known) A" t6 m% U0 Z- ]+ n5 P2 `
as testotoxicosis, may cause precocious puberty at a2 r! I+ R/ G6 |
very young age. The physical findings in these boys/ \+ @0 y' z! A8 _; G1 q# K
with this disorder are full pubertal development,* i& c0 V3 ~- a
including bilateral testicular growth, similar to boys/ T5 ]+ u! H) h' M: \7 R2 A
with CPP. The gonadotropin levels in this disorder- `% A* u+ c, X3 ?, k5 m4 I0 ?
are suppressed to prepubertal levels and do not show& t& P+ H. [& w# M( a( O
pubertal response of gonadotropin after gonadotropin-" E; ~3 {4 k$ u8 ]$ h/ K/ J, d
releasing hormone stimulation. This is a sex-linked
; Y5 L# N# h2 S2 D- r' Gautosomal dominant disorder that affects only
6 c$ e/ w" y7 q, u& |+ O: ?) Qmales; therefore, other male members of the family
( M1 G! V- m' K& t, B2 Nmay have similar precocious puberty.3
N2 a4 ?7 ?& RIn our patient, physical examination was incon-
3 c3 V6 E Q j" m9 ~! Vsistent with true precocious puberty since his testi-, X( A; I/ o! [4 Z0 T% y
cles were prepubertal in size. However, testotoxicosis0 _, V( R- I- U+ P
was in the differential diagnosis because his father
( m3 G# ?" {: u; y6 S. i% Ustarted puberty somewhat early, and occasionally,
+ Y- f& W0 ~& g6 l- r0 atesticular enlargement is not that evident in the N3 V. H4 S2 ^& a) V" ?- M- R
beginning of this process.1 In the absence of a neg-
0 H, U5 x9 w" w! v& N- ~+ Sative initial history of androgen exposure, our
) h/ f2 A9 e! X6 h' L8 U% Jbiggest concern was virilizing adrenal hyperplasia,
7 n$ g0 H/ [# d0 p3 e, e. X( @either 21-hydroxylase deficiency or 11-β hydroxylase( X& z% n: V8 g. ^# \
deficiency. Those diagnoses were excluded by find-
1 N+ s% T; I4 k: Oing the normal level of adrenal steroids.
6 \" M4 K7 H" `& h6 A, XThe diagnosis of exogenous androgens was strongly
- y( \4 x3 [ ~5 {" _suspected in a follow-up visit after 4 months because
- ^ {) Y% P/ o4 B# B8 Gthe physical examination revealed the complete disap-
$ e; _; E+ H, b+ H: \pearance of pubic hair, normal growth velocity, and
. J& g/ Z% [! d8 z$ Rdecreased erections. The father admitted using a testos-
( V2 B2 U# d2 L: b! R: n$ Oterone gel, which he concealed at first visit. He was
7 D# [( A( j( n- N7 d+ Tusing it rather frequently, twice a day. The Physicians’+ L, K- ] y, |9 ^% B
Desk Reference, or package insert of this product, gel or
$ V& V& \4 D0 Pcream, cautions about dermal testosterone transfer to
8 Q3 T# @/ L/ p Ounprotected females through direct skin exposure.
, q& R/ G! l8 \' [+ \7 _* Z% _- ZSerum testosterone level was found to be 2 times the
: b( ^( H7 ^& q dbaseline value in those females who were exposed to
% m) e1 b9 b: S; Meven 15 minutes of direct skin contact with their male( u; P8 o$ |2 s: t
partners.6 However, when a shirt covered the applica- P6 g* f' Q& s8 a( I
tion site, this testosterone transfer was prevented.
6 x, S6 o. {8 \& ~; iOur patient’s testosterone level was 60 ng/mL,- n6 o0 m7 F D( y* v* V: M
which was clearly high. Some studies suggest that
, M1 C/ \( r2 _% Xdermal conversion of testosterone to dihydrotestos-
3 {* l& u4 B4 Q2 A5 hterone, which is a more potent metabolite, is more
8 H* z% [/ V0 [. y% |. Nactive in young children exposed to testosterone
) o- ?/ ` j, E) uexogenously7; however, we did not measure a dihy-, Z G" l+ S& ?' s: k
drotestosterone level in our patient. In addition to
7 H7 N3 s2 v+ l# I* T2 g" Fvirilization, exposure to exogenous testosterone in
4 q) C! s" l6 N. qchildren results in an increase in growth velocity and
( }7 o( o- z9 ?$ Y$ n) y& {advanced bone age, as seen in our patient.+ |( h8 T; ^% F7 a
The long-term effect of androgen exposure during$ P4 m+ {3 H. K
early childhood on pubertal development and final
8 l" @: w' Y: H5 Wadult height are not fully known and always remain* W" k* O, E4 z" N
a concern. Children treated with short-term testos-& i! A8 E# L0 P; Y$ [9 P
terone injection or topical androgen may exhibit some
1 \# l) R; r- i" ^acceleration of the skeletal maturation; however, after# m0 I* E$ c2 Y7 M
cessation of treatment, the rate of bone maturation
# M6 p: j- }% V- wdecelerates and gradually returns to normal.8,9
# ?# k' q3 D& S; s4 `& |There are conflicting reports and controversy
, G- t# Y3 @* L# l. g7 C& Pover the effect of early androgen exposure on adult& C2 h) @& V* c! @
penile length.10,11 Some reports suggest subnormal
# V" G9 d) Y( V% Yadult penile length, apparently because of downreg-
4 p, g8 U9 b1 J+ Aulation of androgen receptor number.10,12 However,- U& }" b3 Y, z
Sutherland et al13 did not find a correlation between; ]+ Q( H; `2 j& [
childhood testosterone exposure and reduced adult
. ~2 B0 y; J9 Ppenile length in clinical studies.
2 M9 M" ? H7 E/ D! o+ j# S' cNonetheless, we do not believe our patient is# h d# i+ L/ P! d9 O
going to experience any of the untoward effects from% I5 h# K2 R9 F) n/ ^' E6 q g
testosterone exposure as mentioned earlier because
* r/ Y4 X5 D0 r. J: f0 nthe exposure was not for a prolonged period of time., P* L+ u2 |0 t5 K! ?1 D. y
Although the bone age was advanced at the time of
6 [: v4 |" w; V/ n) Hdiagnosis, the child had a normal growth velocity at& v- ^4 W" t3 }& |# z# W/ h
the follow-up visit. It is hoped that his final adult- b y- S9 g% A
height will not be affected.% H6 ^2 a4 G3 @% T, c4 p
Although rarely reported, the widespread avail-
+ G1 S9 }( Y7 @5 aability of androgen products in our society may
4 d+ ~1 E! |7 w2 l/ X! rindeed cause more virilization in male or female
_* Q$ |6 E4 Z* h, K# A/ g+ R' Tchildren than one would realize. Exposure to andro-$ l# U4 {5 R' n5 g
gen products must be considered and specific ques-
1 c1 ]% y' I' n# i' w& ftioning about the use of a testosterone product or `1 I* D' x5 x
gel should be asked of the family members during1 Y# ? I6 t4 y4 u: c
the evaluation of any children who present with vir-; d) i5 U* ]- B5 ~$ q
ilization or peripheral precocious puberty. The diag-
$ b% V3 l$ z4 N# ^nosis can be established by just a few tests and by
8 k% B) L, ^" iappropriate history. The inability to obtain such a; Q) y$ i% J3 B
history, or failure to ask the specific questions, may3 ~1 S4 W; q: r- W& d6 B1 h$ C
result in extensive, unnecessary, and expensive
- e+ }: j1 Q& |' y& }8 Z' W8 o" yinvestigation. The primary care physician should be& z+ B$ C& D, g( N3 l! }6 r8 y
aware of this fact, because most of these children( w, l( y1 q) Z/ ]4 H
may initially present in their practice. The Physicians’8 l. v% F1 M; h
Desk Reference and package insert should also put a
$ c" n4 Q- |0 {. y/ X& t: `warning about the virilizing effect on a male or& S+ Y; y; {; b4 `
female child who might come in contact with some-3 u4 J) ~1 y( e
one using any of these products.: m, i% r& R9 M1 y
References
# e% |/ C' }( C3 Q1. Styne DM. The testes: disorder of sexual differentiation% E0 p& j+ `; [
and puberty in the male. In: Sperling MA, ed. Pediatric
7 D" B" G% \3 u8 N! ?Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& c& B7 M$ O0 X+ U
2002: 565-628.$ h. ~ j. {9 G
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious; }( [+ O. S4 h9 Q
puberty in children with tumours of the suprasellar pineal |
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