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Sexual Precocity in a 16-Month-Old* u0 l# A/ T7 K& G _* A
Boy Induced by Indirect Topical0 I! I l6 f" s
Exposure to Testosterone5 ]/ Z" C7 m: X u5 c6 `. K
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
) q7 p& _" K: A& J% \7 oand Kenneth R. Rettig, MD1$ C& ~9 q! v3 V9 I* S0 m
Clinical Pediatrics
2 h) _8 Q) u) o, n$ z* k+ WVolume 46 Number 6. Z6 j, J! X$ n3 P
July 2007 540-543: s3 w' v R6 v7 T
© 2007 Sage Publications& L) O a2 t. a1 P/ k
10.1177/00099228062966510 z# N6 D+ e% f) C+ O" `
http://clp.sagepub.com7 X1 f' e# Q/ X( A* @* l" W
hosted at+ E7 i. U$ l) ?& j4 c
http://online.sagepub.com
5 b q. I( ^; p+ {$ JPrecocious puberty in boys, central or peripheral,
' S& P4 a( `# h/ b v$ cis a significant concern for physicians. Central
u$ E! [' Y+ G7 U( W2 x. x0 |" _precocious puberty (CPP), which is mediated2 k' o& U }; `5 m. D8 t5 K7 s" i
through the hypothalamic pituitary gonadal axis, has* l8 |0 W) K4 V0 n' T/ z; g
a higher incidence of organic central nervous system
- }, _$ r, D4 U; G7 Plesions in boys.1,2 Virilization in boys, as manifested% M0 I$ L% @# f7 q0 m; Z; D* h
by enlargement of the penis, development of pubic9 T: q! b5 n0 T
hair, and facial acne without enlargement of testi-8 S# c- `! @' C- U% w
cles, suggests peripheral or pseudopuberty.1-3 We
, ~2 K* M& X' E3 ureport a 16-month-old boy who presented with the/ L1 j% b0 }; T0 C7 H
enlargement of the phallus and pubic hair develop-
* X, O5 R' ^$ \% c, J1 Sment without testicular enlargement, which was due
. T( b( G1 N; ~) T, g6 w/ ?: }! Ito the unintentional exposure to androgen gel used by
8 w h! U( J& @. sthe father. The family initially concealed this infor-/ ]$ I8 t" G+ g: X
mation, resulting in an extensive work-up for this
$ A" \' x5 ?; H# qchild. Given the widespread and easy availability of
' J. E. N$ Z1 U7 M ^/ H* wtestosterone gel and cream, we believe this is proba-7 R( S, Q) [: E# P2 i$ G0 ^
bly more common than the rare case report in the
+ C/ W Z$ a Pliterature.4
d2 R, T o. D: a, a8 APatient Report
3 D4 v; J: \& \% o OA 16-month-old white child was referred to the
6 Z# D0 j$ e- Q' [endocrine clinic by his pediatrician with the concern) N, p" e* r/ y5 B. c' n" ?8 {4 s
of early sexual development. His mother noticed" r7 ?3 Q" }; m9 j4 m' A2 ]
light colored pubic hair development when he was
2 ^. d* k* A2 x$ B0 F6 DFrom the 1Division of Pediatric Endocrinology, 2University of
8 e) i4 |' d6 B) dSouth Alabama Medical Center, Mobile, Alabama.
) D! e! u1 [; }0 v5 d' X& ~1 P! ?& @Address correspondence to: Samar K. Bhowmick, MD, FACE,
5 J5 N* b8 F. x0 I' Y9 ~3 AProfessor of Pediatrics, University of South Alabama, College of
7 e0 _- X0 M/ p$ VMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
% K- V4 b U7 r# s# b. ~9 ?$ @e-mail: [email protected].: l! ?( d0 J, T& P
about 6 to 7 months old, which progressively became2 z, \: Z6 p, h; _! T: @
darker. She was also concerned about the enlarge-# B& y: ~- T, M: e$ g
ment of his penis and frequent erections. The child
- @% @5 n' M6 r# m' gwas the product of a full-term normal delivery, with7 _6 |3 r) F* f2 n5 K, L& Y
a birth weight of 7 lb 14 oz, and birth length of
" S) ]: v2 n v ^6 g. W0 u+ U$ |20 inches. He was breast-fed throughout the first year7 |' o4 g2 B/ k" g6 ?3 }9 l* _
of life and was still receiving breast milk along with6 I) _* w9 D4 _4 s& N% |
solid food. He had no hospitalizations or surgery,
6 D; X% |- }, G: {5 F8 Q0 `+ Y4 mand his psychosocial and psychomotor development
4 G* L( x5 L p) u, g3 Xwas age appropriate.8 I% z2 v0 k$ j: n! L' ]
The family history was remarkable for the father,
2 S+ N. I0 L! P1 u- d" Iwho was diagnosed with hypothyroidism at age 16,$ T% P6 u u W: E# V, y6 C
which was treated with thyroxine. The father’s0 Q, q* H& g: N/ z9 a
height was 6 feet, and he went through a somewhat
' O2 M# T$ n7 m2 o# pearly puberty and had stopped growing by age 14.
' I" }. f" {, `# e) A5 EThe father denied taking any other medication. The
4 u+ u3 K7 E$ b# P/ K+ @8 u# gchild’s mother was in good health. Her menarche
# V/ m5 p1 G0 S, M, Dwas at 11 years of age, and her height was at 5 feet
3 C/ y/ _' P# K0 E! n0 e' f9 A5 inches. There was no other family history of pre-3 C) c/ l7 G: w. A
cocious sexual development in the first-degree rela-
8 g+ U9 [ _0 G3 l) r/ E: atives. There were no siblings.. a7 }! d6 @( {# s/ y" V/ ~0 p/ l
Physical Examination
7 k, y2 }/ o z5 U+ U$ JThe physical examination revealed a very active,
2 Y7 l+ n( X8 E1 hplayful, and healthy boy. The vital signs documented
7 y* V# {, j& ~* x: A1 @a blood pressure of 85/50 mm Hg, his length was
% G% ^0 i6 w; Y; _% m- W2 `; I7 j90 cm (>97th percentile), and his weight was 14.4 kg( u& O- o: [0 H& h3 a1 G
(also >97th percentile). The observed yearly growth! o) {2 w; ~5 L: ?& n
velocity was 30 cm (12 inches). The examination of9 n- I" d; |. E" _# u9 x1 ]) I
the neck revealed no thyroid enlargement.0 p/ j( [* r1 d1 s* B9 I* e
The genitourinary examination was remarkable for' s& j& L) v' P& }
enlargement of the penis, with a stretched length of% L8 ^8 I! P& _/ z) b- f
8 cm and a width of 2 cm. The glans penis was very well
9 [% F* o4 d* |/ ]: [5 O: ndeveloped. The pubic hair was Tanner II, mostly around" a2 C/ n- I4 {9 n
540$ N& H2 m3 ~% k4 b# m7 G$ {9 b" Q ^
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from$ {0 a, f- T+ m
the base of the phallus and was dark and curled. The; y/ {9 J, f+ A+ K0 N5 g- Z D6 L
testicular volume was prepubertal at 2 mL each.' A2 V5 H* z# j L( M
The skin was moist and smooth and somewhat
) l# p+ A* _5 m' `7 c( r3 eoily. No axillary hair was noted. There were no" \- L2 j' l \+ B. N
abnormal skin pigmentations or café-au-lait spots./ O, p) v- K- a& d6 p) } u
Neurologic evaluation showed deep tendon reflex 2++ \; O; U, Z$ ? Z$ z
bilateral and symmetrical. There was no suggestion3 s7 l4 j9 H" }5 F* o" C
of papilledema.
: w7 e9 p5 B$ M P! sLaboratory Evaluation h5 L |9 {1 M% l# J
The bone age was consistent with 28 months by/ g. v! M5 f4 @4 M! I4 c
using the standard of Greulich and Pyle at a chrono-0 q v. Q8 n, Z+ \
logic age of 16 months (advanced).5 Chromosomal5 |$ Y0 m4 Q- X* I0 V; R
karyotype was 46XY. The thyroid function test' R7 w) y, ^' n/ b3 [
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
: b3 s" N3 A2 [/ m: K1 Nlating hormone level was 1.3 µIU/mL (both normal).& f0 D2 j& q+ l1 f4 O0 h+ A
The concentrations of serum electrolytes, blood/ j' }) e+ Q' S! Q( O
urea nitrogen, creatinine, and calcium all were# e4 p3 d& C$ K8 z2 Y; D5 F
within normal range for his age. The concentration" w& B2 L+ v+ O' C1 O
of serum 17-hydroxyprogesterone was 16 ng/dL7 o+ s. `4 M, | g
(normal, 3 to 90 ng/dL), androstenedione was 20) [ t, k. r0 f
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
- c( m. f; D, e5 R O }# E) jterone was 38 ng/dL (normal, 50 to 760 ng/dL),
% X. R8 M! p. ^" x6 B/ Adesoxycorticosterone was 4.3 ng/dL (normal, 7 to1 B7 _5 c8 Q0 s" U& [
49ng/dL), 11-desoxycortisol (specific compound S)2 J" J' |; k6 @9 J4 Y8 l
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor- r5 |9 M# z a6 a4 U$ K
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total' _# T& n/ u9 \7 F1 F; l
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& I# S D5 [+ }. E# F* c' `
and β-human chorionic gonadotropin was less than
) p- N* a+ A( V& y5 mIU/mL (normal <5 mIU/mL). Serum follicular+ U H0 S$ @2 i j" ~/ ^, N
stimulating hormone and leuteinizing hormone9 e4 Y. m& e6 R6 J
concentrations were less than 0.05 mIU/mL
* x/ K2 @6 g5 G7 [(prepubertal).
/ g6 B1 t- m# {! {/ AThe parents were notified about the laboratory4 ~7 {' f/ `# V0 r, Y4 g& m$ _' m
results and were informed that all of the tests were4 E- Q( u; {/ J9 _4 U+ L# F' j
normal except the testosterone level was high. The
* g+ _) \6 B1 G: s Ffollow-up visit was arranged within a few weeks to
E. B" U3 _ L) L! N" xobtain testicular and abdominal sonograms; how-& ~, G( G0 }# t3 p" S
ever, the family did not return for 4 months.
5 y, I- I# M( s2 [Physical examination at this time revealed that the& F& |" G: n# _0 B/ ~6 N* e
child had grown 2.5 cm in 4 months and had gained
+ g& A) ^1 e% s. I; Y1 v) R2 kg of weight. Physical examination remained0 D( \6 }! h9 b6 [
unchanged. Surprisingly, the pubic hair almost com-
. X3 w1 _; @+ `" X% z8 xpletely disappeared except for a few vellous hairs at4 W4 y2 l$ u' B2 w
the base of the phallus. Testicular volume was still 2+ L$ n7 m, U3 p; j( S* C6 E
mL, and the size of the penis remained unchanged.
W5 w# A) b: n6 e/ Z r$ h7 J3 @The mother also said that the boy was no longer hav-3 E- B; r, X& H+ ]* ~
ing frequent erections.4 z! v) s( P a
Both parents were again questioned about use of, F3 z0 @# s7 E9 k
any ointment/creams that they may have applied to. Z5 q! f: C5 `- T, @: ?4 O4 y) i& g
the child’s skin. This time the father admitted the( P2 C- F+ D; n& X. U+ x5 G
Topical Testosterone Exposure / Bhowmick et al 541& S8 i. p5 K4 B9 D: y/ o
use of testosterone gel twice daily that he was apply-
, C- M- n/ N4 c) g' a" q/ eing over his own shoulders, chest, and back area for
! I- {8 R; x. sa year. The father also revealed he was embarrassed! Q4 u9 B! v& m1 {! j9 \
to disclose that he was using a testosterone gel pre-. Z$ c8 V5 k7 l2 l' x$ b
scribed by his family physician for decreased libido2 K/ v% ^! p0 `, ?7 A' y/ h8 ~) \
secondary to depression.
" X" X8 M/ a" W' U7 M0 H/ d6 nThe child slept in the same bed with parents.
. h) U+ X3 s$ M, V5 yThe father would hug the baby and hold him on his
3 M! s- q( b R. f) U# Y+ Schest for a considerable period of time, causing sig-5 V6 n& z9 U* J8 b
nificant bare skin contact between baby and father.8 M M5 w& c: z3 i9 u: u
The father also admitted that after the phone call,, v. ~3 O E- z8 h; y' V' J
when he learned the testosterone level in the baby/ h" \9 h; i1 A. v3 q( l
was high, he then read the product information5 F1 j1 H8 r8 | j0 w- Q
packet and concluded that it was most likely the rea-6 {! r5 [+ u% l
son for the child’s virilization. At that time, they2 d* f% N" }: D7 ]8 y
decided to put the baby in a separate bed, and the! b/ j0 {1 w, ^4 Z9 i% h
father was not hugging him with bare skin and had, p; h+ z1 r9 [ s7 L
been using protective clothing. A repeat testosterone
m* r/ c+ b! C3 z/ C& c' Stest was ordered, but the family did not go to the
: S2 A6 }- @7 z4 g5 M* flaboratory to obtain the test.1 Q- I. c. d& Z$ i7 s
Discussion9 }8 F8 M. S0 K; e; J
Precocious puberty in boys is defined as secondary
4 r7 N. U* V' a& S- @sexual development before 9 years of age.1,4' o, l- W. B- l: H
Precocious puberty is termed as central (true) when" o7 v% ^1 f( g& s( b, q- M
it is caused by the premature activation of hypo-
# H( O$ b4 a# P, M/ @thalamic pituitary gonadal axis. CPP is more com-" u$ K, D3 a" b" w2 N
mon in girls than in boys.1,3 Most boys with CPP
8 Y* V( \) n3 @# I9 [5 Dmay have a central nervous system lesion that is( K8 E) m8 A+ h* [9 V
responsible for the early activation of the hypothal-
6 V8 k% { G3 y) Lamic pituitary gonadal axis.1-3 Thus, greater empha-
9 e- n0 A# n4 Csis has been given to neuroradiologic imaging in' j" M# Y$ m+ {. M% W: ^0 X7 N5 E
boys with precocious puberty. In addition to viril-8 q5 w" e7 P: `/ n. c. v
ization, the clinical hallmark of CPP is the symmet-
/ j" g8 G: {0 ^# urical testicular growth secondary to stimulation by
0 U6 d. j* d% h% U, Z$ z; ?( xgonadotropins.1,3
$ ?$ f- \, G1 R( \$ d9 n- F: UGonadotropin-independent peripheral preco-
8 T/ z0 e! O; [6 Ycious puberty in boys also results from inappropriate
' u: [4 ^8 X' ^androgenic stimulation from either endogenous or' v8 c% M1 S6 r
exogenous sources, nonpituitary gonadotropin stim-3 l; ?- P4 W# b+ l
ulation, and rare activating mutations.3 Virilizing
: w# Z8 W8 `: o0 O# _6 F fcongenital adrenal hyperplasia producing excessive
3 H* H8 o. {4 C- j) madrenal androgens is a common cause of precocious- W- U2 e+ G7 K9 X
puberty in boys.3,45 f4 i, |( d- f8 ?$ B
The most common form of congenital adrenal' M# d5 u% K6 F/ p
hyperplasia is the 21-hydroxylase enzyme deficiency.6 r' \ D+ m! s% W# }
The 11-β hydroxylase deficiency may also result in
/ F& y3 j5 V8 X& O$ g9 G" \excessive adrenal androgen production, and rarely,& D: i/ I+ l$ `4 l) W
an adrenal tumor may also cause adrenal androgen; H' \, @4 X) \. t" p$ ~
excess.1,32 @# K& b# K$ D1 c! h$ {. u
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
; ?. L: @$ ^. X i- Y542 Clinical Pediatrics / Vol. 46, No. 6, July 2007" _$ _6 |" ^$ n( i
A unique entity of male-limited gonadotropin-
2 Y2 ]' B, L: F9 y0 @3 A) h2 bindependent precocious puberty, which is also known
: o) @" ~" s: x; qas testotoxicosis, may cause precocious puberty at a
# \1 V9 V4 f6 K6 x) C Q4 y, Mvery young age. The physical findings in these boys
" Z& _! P! V- m! ~7 T: ]/ J3 {. {with this disorder are full pubertal development,
: G* ~* t( r C6 ? uincluding bilateral testicular growth, similar to boys
' I; x+ T9 W1 ^# Zwith CPP. The gonadotropin levels in this disorder* U g3 y, d$ S
are suppressed to prepubertal levels and do not show) K2 e" h0 P' Q. g/ N
pubertal response of gonadotropin after gonadotropin-
' D8 k# W6 ]. `7 j, T0 Q9 ^releasing hormone stimulation. This is a sex-linked7 L7 h+ Z' B/ l0 Z% |$ U
autosomal dominant disorder that affects only
. c' |( O6 n$ E& P! n9 F. w! Z5 fmales; therefore, other male members of the family
& U" C2 l2 X+ n4 X- F2 |! B, O/ x) [may have similar precocious puberty.3 z1 Y) {! B- g. w& S" N/ Y( {! P
In our patient, physical examination was incon-. Q9 ]2 I9 k8 z! o
sistent with true precocious puberty since his testi-
! x @% ?4 b2 M3 | P! icles were prepubertal in size. However, testotoxicosis2 }0 t; x6 [6 z9 G& e! {9 b
was in the differential diagnosis because his father- W& g9 ?0 z6 j0 p, T2 q* C
started puberty somewhat early, and occasionally,
' E) m1 ]3 W; L3 o( Jtesticular enlargement is not that evident in the
$ w- o0 b; q, l: @1 C: l& nbeginning of this process.1 In the absence of a neg-3 l' P9 G# l2 W( s, B7 J
ative initial history of androgen exposure, our
6 r9 s: @0 c7 v) mbiggest concern was virilizing adrenal hyperplasia, \/ f$ Z' i' z* m$ U' r
either 21-hydroxylase deficiency or 11-β hydroxylase# h! E) K0 r5 a% B
deficiency. Those diagnoses were excluded by find-
, ?2 l2 S2 s! D9 h7 V9 d$ Jing the normal level of adrenal steroids., q2 t; d! {( I- @# X7 t8 K
The diagnosis of exogenous androgens was strongly
9 r. H; h# }* k8 @( u3 hsuspected in a follow-up visit after 4 months because, m8 X y1 }" N3 y) l
the physical examination revealed the complete disap-. X2 k6 y4 n5 j6 @% y! z
pearance of pubic hair, normal growth velocity, and+ Z# ^0 @5 I ~/ W+ P# a- _
decreased erections. The father admitted using a testos-- X8 c9 B y: j; B8 i
terone gel, which he concealed at first visit. He was
0 `; n: M9 A+ O9 Q3 H7 d5 susing it rather frequently, twice a day. The Physicians’7 e/ x3 D% {' I) b8 p
Desk Reference, or package insert of this product, gel or1 k% A9 y' X4 b* }
cream, cautions about dermal testosterone transfer to
# M2 `, t4 w* z8 w5 a4 M, bunprotected females through direct skin exposure.
4 u+ K. a# m5 t5 J5 [Serum testosterone level was found to be 2 times the
! ^& C e6 P/ l! o5 a1 ~baseline value in those females who were exposed to
0 i% E$ ]( _5 p8 z+ v' Xeven 15 minutes of direct skin contact with their male
+ p% q' i$ O; i' D; n0 H$ Vpartners.6 However, when a shirt covered the applica-, r: Z. m* M1 t- y* S
tion site, this testosterone transfer was prevented.0 {- ~! {! p0 `: [* b1 x
Our patient’s testosterone level was 60 ng/mL,
; A$ i0 q- y9 r- Y! T0 y3 _6 twhich was clearly high. Some studies suggest that$ O; w6 Q9 M& n ]" j, V# k. i8 i
dermal conversion of testosterone to dihydrotestos-
0 t/ ?3 G/ U5 Q% n% d5 N: R: lterone, which is a more potent metabolite, is more
9 r$ u; f/ G4 b/ ~6 @! s4 N, gactive in young children exposed to testosterone& G# H* ?3 G w. S7 n7 ]
exogenously7; however, we did not measure a dihy-: P. l( }& T4 i7 j* R
drotestosterone level in our patient. In addition to! E# _$ p4 x8 E% @- H4 S) {8 L
virilization, exposure to exogenous testosterone in
9 d8 Y) }! T- K, t0 achildren results in an increase in growth velocity and
- O7 V. H" R, i( Oadvanced bone age, as seen in our patient.: q& b3 l8 ?9 d2 P
The long-term effect of androgen exposure during+ ?% Y( E1 c, I; ?- O- L# P7 v2 m
early childhood on pubertal development and final
. u% c7 H/ A- C2 F' jadult height are not fully known and always remain
/ p& L3 d, W% i" n; K# ^5 F) fa concern. Children treated with short-term testos-/ ~" h! x* S/ |* v
terone injection or topical androgen may exhibit some
6 b5 D: q; s7 Eacceleration of the skeletal maturation; however, after
3 c3 J0 ?) z3 n! Ncessation of treatment, the rate of bone maturation5 D) m9 c4 }5 `1 w. ^. `9 |
decelerates and gradually returns to normal.8,9' p) A2 ?7 i/ I
There are conflicting reports and controversy
, s4 U1 |& N/ H( m) Rover the effect of early androgen exposure on adult# [* y* n* _. L# \. b7 r
penile length.10,11 Some reports suggest subnormal1 K; p8 }4 p- A
adult penile length, apparently because of downreg-3 o- ^$ ^3 b) J$ T8 G ^" B
ulation of androgen receptor number.10,12 However,2 J9 d/ W& S. D- C( p
Sutherland et al13 did not find a correlation between
4 M) S) k! ?& C. dchildhood testosterone exposure and reduced adult- A$ X" |9 U @% ^$ ~
penile length in clinical studies.6 k1 M1 _8 K5 R
Nonetheless, we do not believe our patient is% K' J3 Q7 p+ g4 b) K. C- k
going to experience any of the untoward effects from
5 y; B0 z6 A' z$ n8 T. ]4 P% A3 X/ Mtestosterone exposure as mentioned earlier because# Z) z4 C" M4 q4 c
the exposure was not for a prolonged period of time.3 y! \) M J' W# d
Although the bone age was advanced at the time of+ q4 I! a4 }+ H& @& A. t t
diagnosis, the child had a normal growth velocity at7 P5 M4 N. u x9 U6 \4 `2 z6 ~- Y$ i
the follow-up visit. It is hoped that his final adult8 J% c- r* g+ |* ]1 v* v5 \. b
height will not be affected.- v; f( a" B, q' L
Although rarely reported, the widespread avail-( W+ z# H0 S9 @
ability of androgen products in our society may
8 y7 s, R+ h" i2 w! Qindeed cause more virilization in male or female
! J& C* r+ l- y- pchildren than one would realize. Exposure to andro-
+ W* ]! a K( {$ Q$ y- agen products must be considered and specific ques-
; Y8 h; i, ~/ d/ V& o7 M% U. Ltioning about the use of a testosterone product or
* ^9 k% x) n% `7 X8 lgel should be asked of the family members during
+ e7 r5 r1 ^# zthe evaluation of any children who present with vir-
. B0 d( @2 X9 g+ oilization or peripheral precocious puberty. The diag-9 [8 R3 U5 V- y
nosis can be established by just a few tests and by1 V( f' U- i" c5 ~/ ^9 P" }1 _
appropriate history. The inability to obtain such a
% V: I% a* R! S" o$ Khistory, or failure to ask the specific questions, may
) M7 Y# `8 ~ b! h) `) K& Yresult in extensive, unnecessary, and expensive
% K8 n7 B- M* h6 A) Q. x/ B$ [6 Iinvestigation. The primary care physician should be3 P! v$ o3 S" S8 {4 h% @
aware of this fact, because most of these children6 L7 ] b0 G; O
may initially present in their practice. The Physicians’; F) U* V* g# Z8 O; ~" ?
Desk Reference and package insert should also put a
9 ~& E0 k' j# |: i3 ]+ ]: Uwarning about the virilizing effect on a male or
( c, k: J1 w: {female child who might come in contact with some-
) g2 R# J2 g1 N7 I& P0 Cone using any of these products.
# f6 ^; \5 m! AReferences
* `' e/ D! @6 e/ Z1. Styne DM. The testes: disorder of sexual differentiation
! q. z* u8 ?. V6 x ^and puberty in the male. In: Sperling MA, ed. Pediatric
4 j6 b/ W- O; A6 u7 X7 IEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;: A0 Y9 X( v n, l" \4 H. a
2002: 565-628.- s7 k" s0 ]( S' ]& l8 z0 K. H9 V/ z
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 K, _2 O; X5 z( h! A- E
puberty in children with tumours of the suprasellar pineal |
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