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Sexual Precocity in a 16-Month-Old
3 h$ f5 f" f# F; ?* z% q# LBoy Induced by Indirect Topical
) s. a- c% s, fExposure to Testosterone
! d; p9 }4 x4 b* _4 ~Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
0 E* ~! E+ c# z2 Y7 S& band Kenneth R. Rettig, MD1
, @% m/ q7 a3 N- y9 d, vClinical Pediatrics
7 z$ v6 G/ i$ b/ tVolume 46 Number 6. j) p9 n& q' B/ C: y
July 2007 540-543
1 s$ j. _+ {% `% o& q* e* F© 2007 Sage Publications O" W/ F# N& C; ^
10.1177/0009922806296651
- F2 `- h. }& l6 |http://clp.sagepub.com/ }, N' P. O/ N1 n
hosted at
+ Q8 J& Y7 [7 V4 O qhttp://online.sagepub.com" L7 n. T& [4 [
Precocious puberty in boys, central or peripheral,
/ g" `7 n% a5 F R/ bis a significant concern for physicians. Central
9 h4 q; V0 ^: P- ~precocious puberty (CPP), which is mediated, n8 i. v( [5 J4 I/ I
through the hypothalamic pituitary gonadal axis, has
) K! e8 \4 H3 U, A) sa higher incidence of organic central nervous system- O( U" K! F. s% g
lesions in boys.1,2 Virilization in boys, as manifested
# @) X- L0 d, s7 Xby enlargement of the penis, development of pubic
1 g5 {5 E6 a6 S4 ?3 {7 p) }hair, and facial acne without enlargement of testi-4 ^7 P1 S1 z: w5 y6 ?- Z
cles, suggests peripheral or pseudopuberty.1-3 We3 Q# b/ L) ^4 ~; g* T1 _+ `% ]$ p
report a 16-month-old boy who presented with the' t, ^' [- f4 D* d+ M# _2 O
enlargement of the phallus and pubic hair develop-& M; w5 b7 j' w
ment without testicular enlargement, which was due
f% D' k7 W. Y% C' @8 w# Jto the unintentional exposure to androgen gel used by+ V; Q( U) A( s. u( _
the father. The family initially concealed this infor-
3 p( U' E, }; ?* t7 xmation, resulting in an extensive work-up for this
: H7 x e% c" W) ichild. Given the widespread and easy availability of
+ s) S0 K* _2 D$ |) |( a& wtestosterone gel and cream, we believe this is proba-
$ L/ [8 n0 `4 B$ jbly more common than the rare case report in the1 f" o6 \( [+ ]9 z( y: n9 i, m
literature.4
3 E: F- a2 a9 vPatient Report
5 l6 a, }# q, E$ IA 16-month-old white child was referred to the
- Z- q; y3 m3 \+ F* K! zendocrine clinic by his pediatrician with the concern6 p" |7 s% F+ S G9 k
of early sexual development. His mother noticed
' b2 x1 [- V- ~" H5 B# ^+ Olight colored pubic hair development when he was+ l. }( [% H# }2 Q" Q. d ?1 G
From the 1Division of Pediatric Endocrinology, 2University of
7 U1 J) f P. E# D) MSouth Alabama Medical Center, Mobile, Alabama.
, n0 f2 {- u/ l. D7 rAddress correspondence to: Samar K. Bhowmick, MD, FACE,
# M* D! M l, V8 M3 E6 \Professor of Pediatrics, University of South Alabama, College of
* L* @+ o0 C6 b+ T' C a' tMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 i- Z7 M& r* J% m6 G, P
e-mail: [email protected].
/ A; H7 E9 i! p! Qabout 6 to 7 months old, which progressively became
1 H; w, k% j' j: Z; h0 z5 qdarker. She was also concerned about the enlarge-
! h" z5 B$ }3 c. U- O4 O! W* yment of his penis and frequent erections. The child; ?) E0 O M7 ?1 G4 i" ^8 L1 R& {0 @
was the product of a full-term normal delivery, with
# w7 Y& A& @( n7 z i, oa birth weight of 7 lb 14 oz, and birth length of
; j' x2 O& W( \6 T- q0 b20 inches. He was breast-fed throughout the first year7 k! R9 V' {; q/ x# [; t) H5 m3 x7 j
of life and was still receiving breast milk along with. ^- H. d% Y# Y8 l& ^
solid food. He had no hospitalizations or surgery,5 |0 o, k9 c. t, H, d" M& P* g
and his psychosocial and psychomotor development$ U' ^- ]7 G1 H6 Y7 F. ?
was age appropriate.6 Y! e( M+ o" x! l
The family history was remarkable for the father,
R$ A/ J3 X4 Kwho was diagnosed with hypothyroidism at age 16,4 H# g$ r `* C/ A4 @
which was treated with thyroxine. The father’s B+ v( \: l" }. @4 e$ p4 q0 J
height was 6 feet, and he went through a somewhat/ I5 B1 j- W* ^0 J6 X
early puberty and had stopped growing by age 14.. u9 O1 B0 X/ [" O0 d6 F
The father denied taking any other medication. The1 M% t* N5 \6 z4 ?( {
child’s mother was in good health. Her menarche8 x5 }! H2 w) T3 j
was at 11 years of age, and her height was at 5 feet
; r) }0 b4 E( y% b/ T5 inches. There was no other family history of pre-2 V, m0 A1 i/ K2 G
cocious sexual development in the first-degree rela-
% a4 K0 y* I9 stives. There were no siblings.
9 D0 x# K, m9 h7 ?+ m" A. cPhysical Examination
& A7 a; j- x0 ?" t& F& m& QThe physical examination revealed a very active,
! `% p5 { Z7 U* Wplayful, and healthy boy. The vital signs documented
: {" W1 ]' ^6 O" l! wa blood pressure of 85/50 mm Hg, his length was8 p+ Q* l% X4 U* i [. z' F* e3 H
90 cm (>97th percentile), and his weight was 14.4 kg
4 V0 j |) V0 L: c; H! v; p& I(also >97th percentile). The observed yearly growth
8 y$ \- B; g4 D$ p$ _velocity was 30 cm (12 inches). The examination of* G3 ]' _, |0 o' Z- E$ J
the neck revealed no thyroid enlargement.
7 F$ {* X9 m5 Z* J" B& Z+ bThe genitourinary examination was remarkable for/ J L+ c2 f5 |6 f; s. [
enlargement of the penis, with a stretched length of
- H( l# w/ T; [, E: A8 cm and a width of 2 cm. The glans penis was very well X2 C6 y4 ?+ P! P
developed. The pubic hair was Tanner II, mostly around- C- K( t# y+ q
540
1 h y" E0 M1 g& g" S. b5 B3 Z1 Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; Y: ]: B+ q+ f* J- m( ^0 u7 p6 [the base of the phallus and was dark and curled. The
. `$ I5 Z1 o- C B. p% L' n j; a# Btesticular volume was prepubertal at 2 mL each.8 o! w6 ~# g' Q# s' i' Q( @+ G
The skin was moist and smooth and somewhat2 w* x0 l6 W! A1 p# X
oily. No axillary hair was noted. There were no+ x" G5 S+ O" i
abnormal skin pigmentations or café-au-lait spots.
' T, V, x: h5 Q; c8 ?Neurologic evaluation showed deep tendon reflex 2+
& e9 t4 S( X7 J. ]. s, }6 bbilateral and symmetrical. There was no suggestion
; I' E* s. h7 h6 Kof papilledema.# d, m/ D5 V5 _- i5 m- l
Laboratory Evaluation
. J" r! C! y6 L3 oThe bone age was consistent with 28 months by7 U" B% p5 ~* x: L# y5 X/ _5 D: h0 {
using the standard of Greulich and Pyle at a chrono-, j# l5 x/ F) T2 A
logic age of 16 months (advanced).5 Chromosomal6 m9 I* |2 O9 r4 N3 m: ?" ?1 i1 r
karyotype was 46XY. The thyroid function test
# i0 w: n% h1 v' Bshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
3 r2 y! N$ e) |! Elating hormone level was 1.3 µIU/mL (both normal). E+ M2 D# r2 o9 a7 p h$ i
The concentrations of serum electrolytes, blood
: E+ U; W5 \" B/ curea nitrogen, creatinine, and calcium all were
* J7 m: S, L, m, p: w5 ~7 w# t2 twithin normal range for his age. The concentration8 g: D. `: {: c
of serum 17-hydroxyprogesterone was 16 ng/dL+ |1 B* @- V' P' {2 x ]
(normal, 3 to 90 ng/dL), androstenedione was 20
2 W5 B/ z2 C7 {ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-8 M3 ^* w7 Q* W" g1 {% O
terone was 38 ng/dL (normal, 50 to 760 ng/dL),: w8 p9 P# g9 m [$ d: p
desoxycorticosterone was 4.3 ng/dL (normal, 7 to# G; C' Z' i U/ t- x( f# k
49ng/dL), 11-desoxycortisol (specific compound S); ]; P) J3 O# ~9 Z2 _5 w
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-, `+ B! X7 I# l/ F* N% z" G5 F
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 G$ A2 R' H) j- }5 }! b
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 u/ F8 h$ ~& T+ mand β-human chorionic gonadotropin was less than- Z+ ]9 V7 x0 f9 f$ o, u1 e
5 mIU/mL (normal <5 mIU/mL). Serum follicular! f+ t6 ?0 L! A+ m
stimulating hormone and leuteinizing hormone: `0 U/ _2 B+ ~
concentrations were less than 0.05 mIU/mL
2 Q! ~9 G8 w# O* l4 b(prepubertal).
. i2 w$ a- F+ r' u4 }The parents were notified about the laboratory) v* G5 ~, n! I# }
results and were informed that all of the tests were" z' P2 n1 ~) H% {" R# ` A6 _
normal except the testosterone level was high. The
9 m+ P' x3 K& G4 _4 Yfollow-up visit was arranged within a few weeks to$ Z; R9 j5 N+ r l8 g. r0 j
obtain testicular and abdominal sonograms; how-
1 Q9 w% L+ y/ r2 _% {1 gever, the family did not return for 4 months.
& P) D8 b1 h3 s9 vPhysical examination at this time revealed that the; ~' g5 B8 ~6 ~
child had grown 2.5 cm in 4 months and had gained0 j T R; l/ \- K' v: ]4 J
2 kg of weight. Physical examination remained5 a1 k9 z% g2 ~7 b
unchanged. Surprisingly, the pubic hair almost com-5 U4 A& P5 O% I# i
pletely disappeared except for a few vellous hairs at$ i1 A2 X# A6 n* w
the base of the phallus. Testicular volume was still 2, C& N& V7 q1 a
mL, and the size of the penis remained unchanged.7 l6 ]+ u$ V) o( C
The mother also said that the boy was no longer hav-# }4 T6 Z4 C# B+ I8 Q7 P
ing frequent erections.
4 j2 j$ `" l! d% i; u4 _% cBoth parents were again questioned about use of
" P3 U3 Y" o" a" P+ {any ointment/creams that they may have applied to- k1 C b; S, q+ Q6 J
the child’s skin. This time the father admitted the
: i; V2 L5 Q0 X4 A, f# hTopical Testosterone Exposure / Bhowmick et al 541 O: }8 ?" u% _/ i* c1 I
use of testosterone gel twice daily that he was apply-
& e( W/ S, s7 V: ding over his own shoulders, chest, and back area for) z0 S/ _/ H& N! w4 a3 K
a year. The father also revealed he was embarrassed
* `; S |% x0 C' n8 Y* Xto disclose that he was using a testosterone gel pre-4 s+ Q7 b& w. m* ^! k3 g
scribed by his family physician for decreased libido3 L2 p! I) s; u% m; F" A
secondary to depression.
. L: u" Q+ X( L C X. Y, TThe child slept in the same bed with parents.
' H7 _, k5 K5 t; r. H- {3 OThe father would hug the baby and hold him on his
4 o, \3 @, y+ o: j/ N0 z) Rchest for a considerable period of time, causing sig-1 S6 d8 W5 ]: h2 ?% Z7 b
nificant bare skin contact between baby and father.0 D& ^$ y! W5 l4 Z; o4 J
The father also admitted that after the phone call,
# N. u, J; p& Y$ [2 S" x% Fwhen he learned the testosterone level in the baby
5 O: g* `8 U, m' @! ]8 T9 swas high, he then read the product information8 d2 }9 i& c1 u4 R# q
packet and concluded that it was most likely the rea-: l, {" K/ V6 l6 W( P( f
son for the child’s virilization. At that time, they, Z/ V0 L6 W _
decided to put the baby in a separate bed, and the
" _+ s8 `3 U, I/ {$ A# w! Rfather was not hugging him with bare skin and had
/ {( x$ S9 F4 q u8 `* ~been using protective clothing. A repeat testosterone( N' f5 _8 O& l5 f" H
test was ordered, but the family did not go to the: d9 H; W! }( h9 ?; l0 e
laboratory to obtain the test.
# V3 x. x9 P% B% t6 _Discussion4 p* {* y9 m8 u2 r8 L
Precocious puberty in boys is defined as secondary
0 R2 ^- p. [7 |3 T. C1 Qsexual development before 9 years of age.1,4! j+ T/ n q6 \8 P: x2 D
Precocious puberty is termed as central (true) when5 Q6 t5 Q4 c' h3 L- H( s
it is caused by the premature activation of hypo-" `. l) ]. V0 L( n8 E ?' w7 m" E9 s
thalamic pituitary gonadal axis. CPP is more com-, K7 f* U* s! Q& z/ w/ Y4 s
mon in girls than in boys.1,3 Most boys with CPP
- m. p+ r' g; F5 c: w# _may have a central nervous system lesion that is/ {! |: T( @) x% b* f7 c" h
responsible for the early activation of the hypothal-
3 H7 z4 x; w p+ n% Q, O hamic pituitary gonadal axis.1-3 Thus, greater empha-
; U+ i( N! L! Q; |sis has been given to neuroradiologic imaging in/ ]/ t# r4 [+ m' W2 c) p
boys with precocious puberty. In addition to viril-; o8 o# a( ~4 i+ w; _, V3 [
ization, the clinical hallmark of CPP is the symmet-- e; r1 Z% R% k# `7 ^, Y
rical testicular growth secondary to stimulation by
8 _8 W+ T8 H7 Lgonadotropins.1,3
" A) r2 k: `( A4 ]7 BGonadotropin-independent peripheral preco-$ S8 E! H8 E7 ?+ i) a
cious puberty in boys also results from inappropriate
$ D0 I1 B V! M8 Z2 u+ F' candrogenic stimulation from either endogenous or
; x8 f9 D6 x& s) y+ X) }7 h9 [exogenous sources, nonpituitary gonadotropin stim-; v! N5 q' B. h# X
ulation, and rare activating mutations.3 Virilizing
+ t9 O% j) F( T5 M; wcongenital adrenal hyperplasia producing excessive( Y+ g9 s* a( j% G
adrenal androgens is a common cause of precocious+ L7 k) [4 M/ U" }( F; q
puberty in boys.3,4! ^ t3 }) s1 O: [ E. N1 }
The most common form of congenital adrenal8 q% I& W! A4 b6 j& r' f) i
hyperplasia is the 21-hydroxylase enzyme deficiency.
3 F" l& S. d. D/ f! x$ M3 o" HThe 11-β hydroxylase deficiency may also result in
+ K7 ^4 ~7 V1 z0 c2 Q5 |excessive adrenal androgen production, and rarely,! D+ B! s- D. }! M( W7 p4 h; u3 w
an adrenal tumor may also cause adrenal androgen6 p9 O1 V. ~# f
excess.1,30 U9 x4 o% d& |4 u1 ~
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- K9 [- C$ Q' G9 Z7 X1 V
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 ?' C$ g; C: k5 c2 E% t2 }; q/ XA unique entity of male-limited gonadotropin-) l4 Z3 o( l% Z) f ? S3 E
independent precocious puberty, which is also known
# u; I! N/ _% N" Qas testotoxicosis, may cause precocious puberty at a
, d1 ~/ |9 K, W! qvery young age. The physical findings in these boys" ?1 J B6 u: U& E9 B
with this disorder are full pubertal development,4 Z7 I1 o3 k3 W/ T) u9 N: U
including bilateral testicular growth, similar to boys) P6 f5 ?/ A' R' U
with CPP. The gonadotropin levels in this disorder
+ w" k& g& h6 Z; t4 j. I8 z! Zare suppressed to prepubertal levels and do not show5 i9 w3 M! Z' E2 h
pubertal response of gonadotropin after gonadotropin-
) i8 |, v8 X3 @9 Q3 V3 T% breleasing hormone stimulation. This is a sex-linked
" U2 N, _9 a" T l1 dautosomal dominant disorder that affects only
9 l4 i2 Y) m" r2 |0 |males; therefore, other male members of the family$ }. X2 b% z4 ]2 Y! a5 T) }& j
may have similar precocious puberty.3
, Z3 r/ N* e6 x/ v K- MIn our patient, physical examination was incon-4 _) y1 ~3 V# w/ {7 n* V2 Y9 v, j
sistent with true precocious puberty since his testi-1 K2 R! }) H" D9 N* Q0 ~5 f
cles were prepubertal in size. However, testotoxicosis
6 S, J6 h ?$ H6 `! q! u+ l& T' H4 `was in the differential diagnosis because his father6 [/ G8 W& k$ } A# o, p
started puberty somewhat early, and occasionally,) g/ N+ Q6 D6 l& s0 N g8 p
testicular enlargement is not that evident in the
# }! y% r( C: N1 V3 Z! U- q! X; sbeginning of this process.1 In the absence of a neg-
5 \9 M! M: `% P3 oative initial history of androgen exposure, our3 E/ L2 T: q1 m
biggest concern was virilizing adrenal hyperplasia,
2 C, B7 Z/ @1 q0 k0 }either 21-hydroxylase deficiency or 11-β hydroxylase
1 _$ B; u8 P. P n* zdeficiency. Those diagnoses were excluded by find-
; N3 G2 w$ o) Z1 B+ R7 ]) Ling the normal level of adrenal steroids.) ?3 K6 ~+ Q6 x1 q6 G
The diagnosis of exogenous androgens was strongly
, t, l( m+ J8 A! o3 rsuspected in a follow-up visit after 4 months because. u' ^9 H; |! c
the physical examination revealed the complete disap-9 J; i9 r8 O+ ]0 k4 k1 d& L' V! c
pearance of pubic hair, normal growth velocity, and
; w9 [/ s5 L# @decreased erections. The father admitted using a testos-
! s2 w' H. e* E7 aterone gel, which he concealed at first visit. He was) c3 `: N* r& W. ?; t
using it rather frequently, twice a day. The Physicians’& v9 d4 a: j. f! G5 m- A2 x
Desk Reference, or package insert of this product, gel or
9 `: X" D" { `: Pcream, cautions about dermal testosterone transfer to
: J9 M+ r3 b: h& O; lunprotected females through direct skin exposure.# {% i3 z1 R* N- Z" T# C
Serum testosterone level was found to be 2 times the2 O3 G1 i6 K2 ^+ q L% ]: ?
baseline value in those females who were exposed to- ]. R' e% ?8 n8 m3 w
even 15 minutes of direct skin contact with their male0 N1 j7 p1 k5 h2 w" [: E m. {; J
partners.6 However, when a shirt covered the applica-
, \" r' x. I8 {. Ftion site, this testosterone transfer was prevented.8 j% Q J8 }8 m3 ?/ l1 y6 Y
Our patient’s testosterone level was 60 ng/mL,) b* W8 ^7 T) H' g! u
which was clearly high. Some studies suggest that
( j2 S7 g) ?' a/ R' Z" edermal conversion of testosterone to dihydrotestos-, t" m5 }% d! Q) p' h; [: s" r% C$ u
terone, which is a more potent metabolite, is more; h2 G5 G |6 H7 E7 \
active in young children exposed to testosterone1 S$ S l. K% Y' P
exogenously7; however, we did not measure a dihy-( J3 g" ~. Q3 v4 u8 i' F
drotestosterone level in our patient. In addition to7 ?5 h9 V" c& l4 P
virilization, exposure to exogenous testosterone in: G( v4 F" L7 c6 }! E& B
children results in an increase in growth velocity and, n. ?: f2 q6 K, D7 y. M v& @
advanced bone age, as seen in our patient.
& s L/ f2 {" p; T+ QThe long-term effect of androgen exposure during: Z6 ^3 P/ H% o: {
early childhood on pubertal development and final
& a' j5 u- `2 G/ \- Oadult height are not fully known and always remain8 R: n: x8 I1 O+ {$ s! ]' Y/ d; g2 e
a concern. Children treated with short-term testos-6 j' \9 t8 k; D6 @
terone injection or topical androgen may exhibit some
( i! t2 k' ^! @9 a3 k( p3 uacceleration of the skeletal maturation; however, after
0 g% r/ K0 t0 q9 c6 g" rcessation of treatment, the rate of bone maturation
% y7 N* u9 e5 sdecelerates and gradually returns to normal.8,9
3 D* Z7 n, S, Y9 z2 {7 T" B8 x l; cThere are conflicting reports and controversy
. {6 R" {' `; Qover the effect of early androgen exposure on adult
* e& P5 e4 R" G1 S% }( dpenile length.10,11 Some reports suggest subnormal% g( b' \5 ~6 y/ x! K
adult penile length, apparently because of downreg-6 A. k$ j L+ M- M; c1 X5 {- V
ulation of androgen receptor number.10,12 However,
3 W9 k' ~; [% i: r+ A1 }Sutherland et al13 did not find a correlation between
/ L" {% s1 ?- R* o1 @+ t. c- }4 achildhood testosterone exposure and reduced adult6 f9 c- M- m: q1 m. r$ ~
penile length in clinical studies.
+ w2 e8 h1 {4 l5 z" {8 n5 FNonetheless, we do not believe our patient is, h: n$ {" v: b# `
going to experience any of the untoward effects from8 o: u1 W; |" n* X7 E
testosterone exposure as mentioned earlier because: O' n$ | v0 ?+ e; e
the exposure was not for a prolonged period of time.: q$ r* A/ m% D: ]
Although the bone age was advanced at the time of/ {" i5 a( E: d/ X; B
diagnosis, the child had a normal growth velocity at& N. I; \3 o5 j2 b$ i
the follow-up visit. It is hoped that his final adult
0 O( K, x0 b0 q7 D" w8 E0 \& V: xheight will not be affected.. _# Z- C {; d+ e' P& D' z' {. ~
Although rarely reported, the widespread avail-% x$ W# i# t2 M+ j: k$ d! Y
ability of androgen products in our society may/ L; k& P, [+ ~
indeed cause more virilization in male or female
1 w3 |: s4 \7 W7 |& A* Bchildren than one would realize. Exposure to andro-" `- S) v- P6 s+ D7 X
gen products must be considered and specific ques-
% m$ c. D, N( R) }7 H1 y& @tioning about the use of a testosterone product or1 }+ v5 Q& N2 [" k: W1 |" k
gel should be asked of the family members during
* I9 x) V! _+ A5 y" y& i6 rthe evaluation of any children who present with vir-1 |- A0 R3 w% {' c% C
ilization or peripheral precocious puberty. The diag-
* j6 m, s3 ~* g# {1 n" w! ~. lnosis can be established by just a few tests and by/ [& }0 |" F, {: v1 O
appropriate history. The inability to obtain such a
: d/ {1 ^2 T/ l. T% {history, or failure to ask the specific questions, may8 S1 m8 h* T! M( q3 @9 w% Z$ Y3 @
result in extensive, unnecessary, and expensive/ b: e/ U( m. @
investigation. The primary care physician should be
: y- O5 q5 u- |! h( r4 _3 S7 waware of this fact, because most of these children4 B0 _& x9 a- l. v2 S# C8 Q
may initially present in their practice. The Physicians’
' W5 C+ m& Z& ^) f! Q ]Desk Reference and package insert should also put a
. p2 w8 @$ i+ E: x* b: u7 Jwarning about the virilizing effect on a male or/ Z3 ?1 H- c! X4 j$ C9 }" U
female child who might come in contact with some-
& y' J/ j9 X7 |' v, cone using any of these products.
6 o; V2 F; a+ b/ m3 L S0 |References( E) U% E& [ H9 r8 V
1. Styne DM. The testes: disorder of sexual differentiation
7 X Q' g# m! I8 G( t! b, T3 u1 Sand puberty in the male. In: Sperling MA, ed. Pediatric
4 H6 {! e, g# {* `* y3 h% nEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) _: o- G! b! S) g) v$ t. m2002: 565-628.
( W- n0 k2 v1 k. d2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 o" Q' P4 p& _
puberty in children with tumours of the suprasellar pineal |
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