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Sexual Precocity in a 16-Month-Old
m# b0 y3 F) S" U. U4 rBoy Induced by Indirect Topical) B& ~" J; U& f5 `. U+ |
Exposure to Testosterone
8 s; c; G+ t! V" ~0 hSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
! F& J: g6 I/ z" ?2 b+ dand Kenneth R. Rettig, MD1& J6 S- \# E1 ^1 k& ] ~* P2 ]
Clinical Pediatrics
# q4 B+ b* z+ X LVolume 46 Number 6
& N: b9 {: N7 V5 c4 a5 aJuly 2007 540-543( s8 G, D9 y: H% |/ v( @5 V0 U
© 2007 Sage Publications
0 R, E- J4 V) A, z10.1177/0009922806296651 }6 X) \( Z' d* ~* t' ?
http://clp.sagepub.com
% M/ f3 q: ~* G$ P' V, _hosted at" O5 |& c0 I4 L. j2 w% W
http://online.sagepub.com3 N- Q' i% O: c. L7 f
Precocious puberty in boys, central or peripheral,8 c6 N1 o) V" e7 I$ ~0 s
is a significant concern for physicians. Central/ _5 g3 _! n( f! r& q z! R
precocious puberty (CPP), which is mediated
, S# F/ s6 N/ i* H( v, Sthrough the hypothalamic pituitary gonadal axis, has+ F$ A7 K5 O( {; e3 b: K
a higher incidence of organic central nervous system
7 v2 F" j, D. j' X3 H4 m N5 Rlesions in boys.1,2 Virilization in boys, as manifested; s4 m3 K6 F% z! `! G! s% M
by enlargement of the penis, development of pubic( r5 Z# S! K: x# A* g1 D3 z5 s( J
hair, and facial acne without enlargement of testi-
6 c$ W2 x+ M- i9 n p3 G0 |% lcles, suggests peripheral or pseudopuberty.1-3 We3 ?% Q) D! g. e6 ?. @/ o6 x
report a 16-month-old boy who presented with the
1 o. w/ }! B. _" U! x. Denlargement of the phallus and pubic hair develop- {- h2 }, G* ?5 v! F
ment without testicular enlargement, which was due* }( n K. w1 h) k' X: s# h
to the unintentional exposure to androgen gel used by6 E6 d3 h+ v! r
the father. The family initially concealed this infor-
; q/ \) ?% j# {% v: W0 l% D: nmation, resulting in an extensive work-up for this. b- l" i4 j q. v
child. Given the widespread and easy availability of4 F" R" {9 K; ]+ w5 R* j& L
testosterone gel and cream, we believe this is proba-4 L/ i( Q, S) O! N" ]
bly more common than the rare case report in the% X$ U- u9 o' b
literature.47 d w8 `/ j3 h# s4 C0 i1 P K0 L
Patient Report8 m- Y+ v! e& T: e& u# T! C" g X* W
A 16-month-old white child was referred to the: s+ _1 R# N" K$ p7 I, r+ B
endocrine clinic by his pediatrician with the concern, _/ N5 c9 j( i* y \8 Q
of early sexual development. His mother noticed
0 f5 M" V6 w. j6 ]light colored pubic hair development when he was
7 a& a I6 l& g- z% y% yFrom the 1Division of Pediatric Endocrinology, 2University of7 ~) p" q8 F. Z
South Alabama Medical Center, Mobile, Alabama.
u& Q) ^" i. s# }7 q W" PAddress correspondence to: Samar K. Bhowmick, MD, FACE,
7 y% I" b( k# t5 a3 FProfessor of Pediatrics, University of South Alabama, College of; k( l2 y0 J5 m
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" U& ]0 {5 J. |) B
e-mail: [email protected].- q" D1 O _1 F+ x* C
about 6 to 7 months old, which progressively became2 |; h9 B5 w7 M$ S* m" p
darker. She was also concerned about the enlarge-
0 I$ h6 Y& d) P( I$ c- c9 Q! G( a% @7 xment of his penis and frequent erections. The child
0 r6 x" e' L/ Y$ S9 T2 N! z( hwas the product of a full-term normal delivery, with i5 i: Z% h+ y: ], s& l; X8 z
a birth weight of 7 lb 14 oz, and birth length of* I0 S9 ~) L3 p7 r, _
20 inches. He was breast-fed throughout the first year
% H6 m1 E% w. x; R r' q) u1 O( C: K* Bof life and was still receiving breast milk along with
0 t! Y8 b! M4 |4 X3 V9 |/ Q5 d, g# W+ Ksolid food. He had no hospitalizations or surgery,
5 T( N% e, @% d, H3 C# J& O* {and his psychosocial and psychomotor development9 ^( S9 z# X, @3 t
was age appropriate.* E' r9 \+ Q) t5 c
The family history was remarkable for the father,0 A4 W T7 p7 ]
who was diagnosed with hypothyroidism at age 16,' e* M* R; H* K
which was treated with thyroxine. The father’s8 h# X9 ^6 X; r
height was 6 feet, and he went through a somewhat j: c5 k9 [6 a6 S/ a8 M. W
early puberty and had stopped growing by age 14.! `* I- H3 y6 z
The father denied taking any other medication. The) J7 l( O4 u9 D' R8 h6 c
child’s mother was in good health. Her menarche8 o2 M' v2 b; \/ ?! v2 O2 l
was at 11 years of age, and her height was at 5 feet4 l7 i$ H; O) t2 h6 y& x
5 inches. There was no other family history of pre-
A4 s/ d# I! r' Vcocious sexual development in the first-degree rela-# f; q. k& ?$ w) l, S
tives. There were no siblings.7 ?& @9 s- G, [) h7 t _
Physical Examination
$ k, ?$ k! e* i* c5 H. F5 CThe physical examination revealed a very active,4 m6 z. q! ^) w- c& v) Q
playful, and healthy boy. The vital signs documented
, S" W5 z* R" [+ ga blood pressure of 85/50 mm Hg, his length was
, b# l) u( E$ j/ k90 cm (>97th percentile), and his weight was 14.4 kg
9 {! p" w$ C/ V$ l8 J(also >97th percentile). The observed yearly growth
& l9 M/ ]) ] c( C. L+ Mvelocity was 30 cm (12 inches). The examination of$ {2 }4 f8 v% D8 J* h3 A
the neck revealed no thyroid enlargement., H) e2 v% X8 {/ W$ q
The genitourinary examination was remarkable for
+ d! k0 @, C" y" J3 N* w' yenlargement of the penis, with a stretched length of
9 `" `2 {8 y0 l6 U; Z8 cm and a width of 2 cm. The glans penis was very well r- c1 Q: `4 z- E J: K4 w
developed. The pubic hair was Tanner II, mostly around
m( [$ ]2 v' N/ n" x/ \# V& y540$ u" |: j6 h1 c9 x8 Y7 H1 L
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; r3 t. o, j8 @* C+ Ithe base of the phallus and was dark and curled. The, f/ q3 c. s2 ], A
testicular volume was prepubertal at 2 mL each.8 q h, y X# j
The skin was moist and smooth and somewhat0 m* O+ t3 O8 j7 v. X/ m5 c2 b
oily. No axillary hair was noted. There were no8 i) N/ X a4 \9 b, B! i
abnormal skin pigmentations or café-au-lait spots." c! D& Z( u. l4 t: H# u8 f9 q
Neurologic evaluation showed deep tendon reflex 2+8 p/ |+ C4 z5 \' V+ x d! h
bilateral and symmetrical. There was no suggestion) }2 i! f7 X4 U% x4 p, p
of papilledema.
# R9 f- ^& N. Y0 bLaboratory Evaluation$ A" ^0 ]$ W; t! _3 O3 D
The bone age was consistent with 28 months by
, ^) {7 r5 d/ g( n' H9 ~# Ausing the standard of Greulich and Pyle at a chrono-
8 a8 g- g+ h; h# P# v2 {logic age of 16 months (advanced).5 Chromosomal
. q7 X. I) j# Y" Y- {- r9 Ukaryotype was 46XY. The thyroid function test
2 D3 ~6 X6 ?" q+ B$ _6 fshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
% G; z4 x3 }4 g1 H) llating hormone level was 1.3 µIU/mL (both normal).
3 Z( x3 @$ ~, H( M5 \" Q$ l. G5 FThe concentrations of serum electrolytes, blood
" u8 t) w1 O6 J% o5 k4 i$ \, _urea nitrogen, creatinine, and calcium all were* @* e' m8 o$ W6 A) B5 j
within normal range for his age. The concentration
& K- A8 }8 C7 X9 `' r* D8 mof serum 17-hydroxyprogesterone was 16 ng/dL
5 D5 I: J8 ~, Q/ j8 P( M: J. y% m3 f(normal, 3 to 90 ng/dL), androstenedione was 20
* {$ o8 w; Z0 k8 ?' F2 m- y% H tng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-, [1 u2 ~9 ]5 b0 r3 _
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
# c, P) B) n9 ^# Udesoxycorticosterone was 4.3 ng/dL (normal, 7 to
1 v% y% o/ {( T/ v/ U% v49ng/dL), 11-desoxycortisol (specific compound S)
; J1 z8 N+ C" \$ f- l8 |4 [was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-$ p7 q) u0 I6 k& F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 g8 D( ^: e( \" Qtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
# K9 b( _- m2 ~ Aand β-human chorionic gonadotropin was less than
1 ]! r8 ?3 Z$ V6 o5 mIU/mL (normal <5 mIU/mL). Serum follicular
% A# m9 l6 F. ] M1 c# q0 Rstimulating hormone and leuteinizing hormone, K! y0 ~ W9 T# ?2 g
concentrations were less than 0.05 mIU/mL
3 J% c" Q4 |" a/ B: X(prepubertal).8 o/ H9 H; P* ]2 c9 ~- B+ o! z, w: v
The parents were notified about the laboratory
: k8 T; R2 F" A; Vresults and were informed that all of the tests were
9 G9 a2 `) V8 @0 `normal except the testosterone level was high. The
% l, [# c+ D) o' ~0 l; ~follow-up visit was arranged within a few weeks to1 O& j5 c* }- V4 k$ L% ^) S
obtain testicular and abdominal sonograms; how-( z P( r7 R& e/ w4 [
ever, the family did not return for 4 months.5 p) G/ i- W1 m* |- ]. Y8 O# b! |
Physical examination at this time revealed that the4 L+ s: v* W6 o) C9 L
child had grown 2.5 cm in 4 months and had gained3 I, Y9 D$ t Y
2 kg of weight. Physical examination remained& X7 t" a- z4 W* n. G7 X
unchanged. Surprisingly, the pubic hair almost com-
" U4 g7 R, g& c/ R5 apletely disappeared except for a few vellous hairs at! n" f% G) p; L& m1 F/ B
the base of the phallus. Testicular volume was still 2
, } Z+ w: t6 gmL, and the size of the penis remained unchanged.
' G! b+ K+ v* z6 G7 N* k" dThe mother also said that the boy was no longer hav-
$ q4 \2 s! L3 }5 A+ fing frequent erections.! o5 ?! n' v8 X) x1 S0 F8 Q
Both parents were again questioned about use of
; f/ p3 }: `/ O7 o9 O6 v, sany ointment/creams that they may have applied to
; ?9 Z" z; @# j S @8 r1 ?the child’s skin. This time the father admitted the
, o h% P% n8 pTopical Testosterone Exposure / Bhowmick et al 541) V9 ^8 I0 {- W3 k4 y @
use of testosterone gel twice daily that he was apply-& d$ H% @% Z4 f9 x' ^. M# s
ing over his own shoulders, chest, and back area for
7 |9 M6 z0 i% E- G x* Da year. The father also revealed he was embarrassed8 [) j9 C# h& O7 W# S0 ^ F
to disclose that he was using a testosterone gel pre-
3 g+ E# U1 \5 ascribed by his family physician for decreased libido
5 X z0 } g; n( e/ d! |' W/ h4 B, ?secondary to depression.. e1 n4 e$ H% U) u! g$ G
The child slept in the same bed with parents.; Z9 V. q+ v6 K5 k" m% n" P: w
The father would hug the baby and hold him on his
% x* r# A9 s) s8 L1 X1 echest for a considerable period of time, causing sig-/ A" A$ b# |5 x
nificant bare skin contact between baby and father.+ g4 c6 b) |4 A# f+ v- R
The father also admitted that after the phone call,
5 c: a* |# Q0 o1 v+ Xwhen he learned the testosterone level in the baby+ D ~( T( \: B7 f1 x' T- N
was high, he then read the product information
6 y# _+ P% e5 G. L: k1 \9 Ipacket and concluded that it was most likely the rea-7 ?1 f* ]4 m0 M; x4 l i# Q
son for the child’s virilization. At that time, they: u8 p& [2 Z9 M) k5 `
decided to put the baby in a separate bed, and the
, Q1 _* p; e7 R. t, efather was not hugging him with bare skin and had
E/ I' c1 X; qbeen using protective clothing. A repeat testosterone" E0 c, f6 V" s$ v
test was ordered, but the family did not go to the
) L! G3 K/ W0 A7 ^laboratory to obtain the test.
* w5 R1 }+ e T$ H1 S. M2 uDiscussion
% q) t& f. j, _Precocious puberty in boys is defined as secondary7 u$ }, P" z/ w! Q/ J
sexual development before 9 years of age.1,4( c4 Q% G8 d# g4 z% U1 H: M
Precocious puberty is termed as central (true) when
Y$ A H, C4 t# @it is caused by the premature activation of hypo-
% U$ S. G) L, O8 [) W$ ythalamic pituitary gonadal axis. CPP is more com-, Q/ ]# a: F I2 Y$ g
mon in girls than in boys.1,3 Most boys with CPP
2 H9 g. U1 m- H |" A9 V/ Imay have a central nervous system lesion that is1 V {. i4 E1 i+ @7 L
responsible for the early activation of the hypothal-4 H, Q+ | m9 Y0 C
amic pituitary gonadal axis.1-3 Thus, greater empha-
% C. H- O" T6 B7 Y: G! \0 Tsis has been given to neuroradiologic imaging in! v6 S, |; e! m: X3 `
boys with precocious puberty. In addition to viril-
4 ^' _/ l/ @ p4 k# L! a; Xization, the clinical hallmark of CPP is the symmet-( o* {; M7 Z& M6 l9 G
rical testicular growth secondary to stimulation by
- K# c5 w; _4 x, W4 Tgonadotropins.1,35 X( f' c# X! h! q8 ?4 v
Gonadotropin-independent peripheral preco-; l m" J! h8 K% N I. t) i/ B$ W
cious puberty in boys also results from inappropriate9 w( ]" J- l" }2 |- p/ L* T
androgenic stimulation from either endogenous or, u2 Z( U" E) P# J, _9 }5 X- }0 }
exogenous sources, nonpituitary gonadotropin stim-
' `% |1 k. Q4 x; Oulation, and rare activating mutations.3 Virilizing1 K# J: C" y2 M0 |" f) U$ ~2 G
congenital adrenal hyperplasia producing excessive
3 e3 M& l, E7 [2 p- Sadrenal androgens is a common cause of precocious: F [3 U9 [, ` s
puberty in boys.3,40 v! Y9 W, J2 |! y0 e% h1 i$ B: ~
The most common form of congenital adrenal
% K. \3 q/ q& q/ Y' Phyperplasia is the 21-hydroxylase enzyme deficiency.
$ v7 Z; F1 g) \: QThe 11-β hydroxylase deficiency may also result in
# ^$ J% q0 Q- H" Iexcessive adrenal androgen production, and rarely,) s/ c. c% a% b' x$ ^! H
an adrenal tumor may also cause adrenal androgen g7 y. D9 {* \9 S8 m
excess.1,3
! W& g) M/ n& }8 C$ N0 l! pat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 s5 a& C; ?3 T# v4 y542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
2 |! ]+ B) B( H0 bA unique entity of male-limited gonadotropin-
/ U3 @% N F9 q7 ]' `* iindependent precocious puberty, which is also known/ I* m0 S4 n W2 {8 X+ [; k, h) {
as testotoxicosis, may cause precocious puberty at a. n( W N2 J3 E) z$ T9 }) G* H! w
very young age. The physical findings in these boys1 }/ F. e; |5 B( |1 S7 d; i
with this disorder are full pubertal development,9 ]) N% ^7 H3 N) @7 w# e
including bilateral testicular growth, similar to boys
, Y( r9 Z; o% U, iwith CPP. The gonadotropin levels in this disorder
: R" T% i; G" U. kare suppressed to prepubertal levels and do not show% a6 B7 A3 d# T! l' f
pubertal response of gonadotropin after gonadotropin-
6 {6 ^5 p* W& D% m6 A. preleasing hormone stimulation. This is a sex-linked: }. M! C! @! S( ^
autosomal dominant disorder that affects only+ P6 }1 [5 \" ^! w
males; therefore, other male members of the family) S3 n4 ]; b/ b! t
may have similar precocious puberty.3( f: ?' v: |& y: R& C
In our patient, physical examination was incon-+ h& @4 |- k* W' S: r
sistent with true precocious puberty since his testi-
) K5 w) m' x7 Lcles were prepubertal in size. However, testotoxicosis
6 ` s/ F M; z7 Mwas in the differential diagnosis because his father4 J6 j" ~0 c! L; F4 z2 I
started puberty somewhat early, and occasionally,; J4 e+ ~- j; P8 o3 ^; O3 F- E
testicular enlargement is not that evident in the
; w# m& G9 m" jbeginning of this process.1 In the absence of a neg-4 _2 Y9 s) D; @- z
ative initial history of androgen exposure, our
, r6 Z) v K# c9 B% Vbiggest concern was virilizing adrenal hyperplasia,& h: t: X# }+ G& t! ]9 P% V* g# \
either 21-hydroxylase deficiency or 11-β hydroxylase
& V, S8 q+ \: `* o- @! gdeficiency. Those diagnoses were excluded by find-" E% \$ r+ C. j, e+ \0 t
ing the normal level of adrenal steroids.
( D, H4 @8 k3 e7 L3 b+ tThe diagnosis of exogenous androgens was strongly
7 P4 K4 s& X, \/ t& V H: I3 x+ Ysuspected in a follow-up visit after 4 months because
9 Z/ |2 u0 P1 T, w) Kthe physical examination revealed the complete disap-
# u9 m5 B' A8 _* b+ }pearance of pubic hair, normal growth velocity, and" |+ q/ O* J% U$ M- B
decreased erections. The father admitted using a testos-
$ {9 D4 ~1 e( h4 uterone gel, which he concealed at first visit. He was1 d1 H# U% M: k' B0 n m9 x ]( Q
using it rather frequently, twice a day. The Physicians’
$ y# V0 p# ]( J( l" wDesk Reference, or package insert of this product, gel or* M4 l, d: T1 Q3 z6 g$ m% Z
cream, cautions about dermal testosterone transfer to
1 d" E! F) e6 m' funprotected females through direct skin exposure.
( n8 J6 S. B- d6 }Serum testosterone level was found to be 2 times the" u4 K+ n7 H% N( ? `
baseline value in those females who were exposed to4 Z) [; Z4 m, T ~+ Q
even 15 minutes of direct skin contact with their male
. a7 ? o1 D3 {4 [, jpartners.6 However, when a shirt covered the applica-# |: n! x+ C1 [# H
tion site, this testosterone transfer was prevented.
! {' F% j7 s7 W7 s0 k5 COur patient’s testosterone level was 60 ng/mL," D/ P) Y- K* y9 t9 k$ ^+ ]' [
which was clearly high. Some studies suggest that$ C6 H6 I3 l0 o% K! M) B! u/ |
dermal conversion of testosterone to dihydrotestos-
5 B6 X X4 O9 Dterone, which is a more potent metabolite, is more7 F% y' l9 @6 i& A! N# y& {3 L
active in young children exposed to testosterone+ j( I3 t! y: R8 Z9 S' q' N8 i) F
exogenously7; however, we did not measure a dihy-
! s: }6 G; E3 b" t& f$ |$ bdrotestosterone level in our patient. In addition to" e7 }" h4 m% g" M* [6 `9 {4 Y! _4 m
virilization, exposure to exogenous testosterone in
( E& c3 k# D! K* ?( echildren results in an increase in growth velocity and
, J! p4 [% C% v4 A ~5 sadvanced bone age, as seen in our patient.
0 h$ G' G& Q( A% `1 K2 fThe long-term effect of androgen exposure during
7 s) |1 i% Q. Z A4 d, _ jearly childhood on pubertal development and final
7 v( o3 ^2 n: r+ ladult height are not fully known and always remain
! c# h; ?" ^/ {% g3 f, ga concern. Children treated with short-term testos-
! X1 i/ @5 ?% ]! u+ B* x5 gterone injection or topical androgen may exhibit some
* D9 A0 [; L- p5 R& y0 V) Qacceleration of the skeletal maturation; however, after" @1 x( b' y3 ~0 ^! r" }
cessation of treatment, the rate of bone maturation" t0 `! d" Q( L- _
decelerates and gradually returns to normal.8,9
9 _+ i* `1 c2 O. s5 Z& T; P& A! G1 B- |There are conflicting reports and controversy* p3 e" }. K- k! [
over the effect of early androgen exposure on adult. b( m% M* `: _1 n( ]* \+ n
penile length.10,11 Some reports suggest subnormal
% H' N' e! u. x3 {# D! Ladult penile length, apparently because of downreg-
% P/ Y3 Y7 j/ l/ Nulation of androgen receptor number.10,12 However,6 M+ a! r c8 m; X. x
Sutherland et al13 did not find a correlation between
' P' ?4 u. @ \( Ochildhood testosterone exposure and reduced adult
$ i9 F: Q2 h" J+ t) H9 Ipenile length in clinical studies.- S8 ^1 L' B$ \
Nonetheless, we do not believe our patient is. V! y* o6 R9 |& D9 c; p
going to experience any of the untoward effects from* `+ h. q( ~7 k) _. V8 d
testosterone exposure as mentioned earlier because
- h6 Y1 R, X4 J, v0 U" p uthe exposure was not for a prolonged period of time.( K/ `6 U0 Z) k# F$ t5 Y
Although the bone age was advanced at the time of8 I/ ~7 ? ]+ k! [* Y1 l0 Z
diagnosis, the child had a normal growth velocity at
% a$ o, ?. K% Cthe follow-up visit. It is hoped that his final adult( }6 U# J. B% m; f5 s' i
height will not be affected.( }9 |& O) t q5 b
Although rarely reported, the widespread avail-
1 B) z3 S8 Z3 H, S/ B& mability of androgen products in our society may
. w# Q: G, {' Y' `indeed cause more virilization in male or female2 O, T4 ^0 q: B: S+ z2 B
children than one would realize. Exposure to andro-
' m2 p4 F/ ~6 Z" M; y2 S1 S8 Ngen products must be considered and specific ques-6 W m A2 [7 Y# {
tioning about the use of a testosterone product or% {. |6 T) a# I2 g9 A. J
gel should be asked of the family members during2 R, {6 F5 |5 ?0 u- ?! J1 A
the evaluation of any children who present with vir-% t( d$ Y0 g6 x7 `, [2 Z7 K
ilization or peripheral precocious puberty. The diag-
7 a8 S+ W, v9 O+ s. l& g! Onosis can be established by just a few tests and by
6 D' f! c/ D9 |2 i8 O, J. Oappropriate history. The inability to obtain such a
1 ]% T$ l @8 q' Z) S* F! Shistory, or failure to ask the specific questions, may5 d5 b3 y9 r7 k$ V$ S- N
result in extensive, unnecessary, and expensive
% n2 ]+ r3 i# D$ E( Jinvestigation. The primary care physician should be
; a& ~5 a* n$ s5 oaware of this fact, because most of these children- u7 x& \5 d$ @% F9 d, u5 w
may initially present in their practice. The Physicians’
' m$ S6 j: ]. d3 RDesk Reference and package insert should also put a
8 Y6 L+ S* C0 dwarning about the virilizing effect on a male or
) p* T% h* z7 R; @female child who might come in contact with some-
( ~5 r$ ~' U' z8 @, P8 o& M. Rone using any of these products.
! i3 P* i- N" Y. J) Q8 {7 wReferences+ S& Q% I# I Q
1. Styne DM. The testes: disorder of sexual differentiation7 ~8 a: M6 P/ {" s, \7 G
and puberty in the male. In: Sperling MA, ed. Pediatric
( M6 ` N" a: y; f0 QEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
3 }) c, x7 Y8 u+ p0 Z# K3 Y$ S2002: 565-628.' y3 U5 U0 \. V* ~3 A
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious& H S& G! ~: U3 O" y, C
puberty in children with tumours of the suprasellar pineal |
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