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Sexual Precocity in a 16-Month-Old9 _+ k* r" @( ?& ^) t1 |* E1 s
Boy Induced by Indirect Topical
. Y, n* I, {0 w7 wExposure to Testosterone7 H8 `/ g' M! b# {$ R6 ]
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
) Y0 v5 |0 }4 R% ~and Kenneth R. Rettig, MD1
2 e$ p2 e' g9 MClinical Pediatrics% s% K1 e3 E) ~7 P% I
Volume 46 Number 6
" ^ Z! I. `' X( K2 U- xJuly 2007 540-543% R& j4 n4 c0 `, O% _0 D: ?
© 2007 Sage Publications
G: o2 ]9 T! f5 s- K% j) J/ w10.1177/0009922806296651* E6 [5 n9 p6 [* v8 X4 d5 ~5 l
http://clp.sagepub.com
2 V% r2 ]( X7 w' W6 Bhosted at
; K( X# F K2 uhttp://online.sagepub.com
: F [3 s$ t$ M' T! H. g5 D# DPrecocious puberty in boys, central or peripheral,3 R' _1 k2 L" O! { h
is a significant concern for physicians. Central7 v: d0 H4 v, W' C* }( f2 m0 l
precocious puberty (CPP), which is mediated) a9 [! e8 T4 }, f! ^$ L
through the hypothalamic pituitary gonadal axis, has
2 i9 R1 x# |% z+ @a higher incidence of organic central nervous system
0 p$ I6 ?# s4 y4 k$ C+ Ylesions in boys.1,2 Virilization in boys, as manifested( m7 l4 ^- u8 g T" G2 I
by enlargement of the penis, development of pubic
: A5 [& f& j3 M/ A( ahair, and facial acne without enlargement of testi-
. V; r+ `6 F) R4 U+ ?4 I3 Zcles, suggests peripheral or pseudopuberty.1-3 We/ i) I0 W; s- F" u8 p
report a 16-month-old boy who presented with the
2 R! ?: f/ F# v% w$ jenlargement of the phallus and pubic hair develop-
, j" r5 K2 B6 S) O" ?8 kment without testicular enlargement, which was due S8 \% l7 F3 |5 [
to the unintentional exposure to androgen gel used by3 k, x6 V4 \8 E4 r
the father. The family initially concealed this infor-
7 I9 E; M2 o' n8 Emation, resulting in an extensive work-up for this
' z6 T9 N \0 p( [5 x" `child. Given the widespread and easy availability of) I1 D' \7 \) l3 N: z+ X
testosterone gel and cream, we believe this is proba-
+ z! P8 c2 v# D: Cbly more common than the rare case report in the
+ A3 {, f. D5 e4 f* u5 ~8 Xliterature.44 z/ a% l7 [. m v1 ^! o' q
Patient Report" Z2 N, W' I) \) N* l* } \$ F
A 16-month-old white child was referred to the
: `+ L0 {& ?8 L: q$ Fendocrine clinic by his pediatrician with the concern( @+ ]0 v) H: A% `3 l: A
of early sexual development. His mother noticed
" E, @& X p9 ]- D( K) _light colored pubic hair development when he was. [! M, r3 Z, i' S
From the 1Division of Pediatric Endocrinology, 2University of2 t# ~5 U/ ^0 _. Y4 n
South Alabama Medical Center, Mobile, Alabama.7 z. C; g r" [( l
Address correspondence to: Samar K. Bhowmick, MD, FACE,- r; J) l& l3 c9 \
Professor of Pediatrics, University of South Alabama, College of
% Q& g! ]$ l' o8 r: {5 \5 hMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# e" Y% R& B" f \% T
e-mail: [email protected].
( a1 c& R: n8 }4 ?$ D7 eabout 6 to 7 months old, which progressively became
, L+ B+ x. J7 q! W4 udarker. She was also concerned about the enlarge-! `! s! B* H- U, z
ment of his penis and frequent erections. The child
7 v# N( q7 w" V, w1 [1 K# uwas the product of a full-term normal delivery, with
; [1 j. v. E( W+ |1 `' V( o6 qa birth weight of 7 lb 14 oz, and birth length of
) u$ I& A; v8 }. e20 inches. He was breast-fed throughout the first year
. W. z* ]" ]+ x! M/ q% t% Jof life and was still receiving breast milk along with
6 A+ O, A \& I5 y s' q, osolid food. He had no hospitalizations or surgery,
$ Y! |' n& t, V( Wand his psychosocial and psychomotor development! h; |7 R$ F: J) p! ?; _3 }
was age appropriate.
4 n/ |! H$ h0 v& }" P }$ u2 BThe family history was remarkable for the father,/ H- a" }5 n6 |( I% w# C
who was diagnosed with hypothyroidism at age 16,
; c$ M4 j5 m) y, O- B' awhich was treated with thyroxine. The father’s
0 j0 @$ G" z$ _6 {$ ~height was 6 feet, and he went through a somewhat
) M t5 y7 b. _* P) Iearly puberty and had stopped growing by age 14.& B; E+ A* p; ~% e
The father denied taking any other medication. The
5 \! ]' A# k+ Q; f3 @' gchild’s mother was in good health. Her menarche
) s4 i+ T) E3 I+ X/ U X$ b8 kwas at 11 years of age, and her height was at 5 feet+ }) q' @+ o$ e) b
5 inches. There was no other family history of pre-
1 b1 N" R0 ]. o: ~% L4 ]+ Scocious sexual development in the first-degree rela-
, j4 } A( A7 f7 ytives. There were no siblings.
) O# p& q% R, UPhysical Examination# b& m' m8 e2 i0 O0 M' V. N" F. Y
The physical examination revealed a very active,
; b2 Q# i+ o0 ?0 G! p0 N3 @/ G" }playful, and healthy boy. The vital signs documented- n G4 A. L' F
a blood pressure of 85/50 mm Hg, his length was
0 \- w! {& U5 ~. g# q90 cm (>97th percentile), and his weight was 14.4 kg
% y* Z. z! A% y- Y9 G(also >97th percentile). The observed yearly growth* i" I' M! I2 x+ ?9 e6 w! @
velocity was 30 cm (12 inches). The examination of
6 T/ k4 a2 U) P( Nthe neck revealed no thyroid enlargement. `" u. ?, @; z# x/ G1 V
The genitourinary examination was remarkable for; T0 L, R; H' d6 n
enlargement of the penis, with a stretched length of
7 }9 L( Q3 o- d: t0 s: D. ]( Q% k8 cm and a width of 2 cm. The glans penis was very well& p/ c+ }% l$ o, d$ M. j* F5 y
developed. The pubic hair was Tanner II, mostly around
- ^. h( l, G0 d+ _, Q540
f* n% P: j' B vat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( |5 p, l. b% [# Athe base of the phallus and was dark and curled. The1 U( _4 e% N% I( w
testicular volume was prepubertal at 2 mL each. E, H- H# T! |. J! G$ L, n( ~
The skin was moist and smooth and somewhat
# I( }- K u. ^. @' voily. No axillary hair was noted. There were no
0 X4 w& E! T* C$ X' a+ {abnormal skin pigmentations or café-au-lait spots.
`! B& t6 g; O4 f; R/ a( {Neurologic evaluation showed deep tendon reflex 2+
) S7 B! b$ T0 r& C! }bilateral and symmetrical. There was no suggestion- J) ^( t+ [& b. ^/ \8 Z& {" n. ^
of papilledema.
: z- K* G4 j- o. N/ | N: oLaboratory Evaluation
6 R4 @6 ]. I1 r- t0 C* sThe bone age was consistent with 28 months by
+ n4 X( R) I* g& h( \using the standard of Greulich and Pyle at a chrono-
9 o; Q8 V- S: v& E) llogic age of 16 months (advanced).5 Chromosomal- j5 n0 E7 }' }. f2 `' \$ L
karyotype was 46XY. The thyroid function test
/ I: k, L" x& {* Tshowed a free T4 of 1.69 ng/dL, and thyroid stimu-, T0 h- b) Q( W. w
lating hormone level was 1.3 µIU/mL (both normal).& N. ^( E, G& M c; [9 i
The concentrations of serum electrolytes, blood, ]5 y$ a; c" X$ ~% a+ ^, A7 ?
urea nitrogen, creatinine, and calcium all were. m* U H) ^ l E( v2 L
within normal range for his age. The concentration. M$ G! K: ?$ M; R' z
of serum 17-hydroxyprogesterone was 16 ng/dL! J% I( N9 O" y
(normal, 3 to 90 ng/dL), androstenedione was 20
3 [# H7 J3 M$ O9 x, `+ e* Zng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-7 M P2 H* m7 |3 F2 Q% s+ g2 z
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
7 I- ?+ Z" }% F# |# C4 l- ^desoxycorticosterone was 4.3 ng/dL (normal, 7 to$ _! i+ f/ K7 S& a3 l
49ng/dL), 11-desoxycortisol (specific compound S)
e; C \0 y3 X: O9 rwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-4 K8 [; y: F8 K# G+ d; g
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
: v7 @5 Y9 y& r0 ptestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
- \$ j- M6 `* d5 s+ mand β-human chorionic gonadotropin was less than4 J# I! D6 n$ l D8 U3 }, I
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# g4 @/ z1 y2 z$ H. B- [stimulating hormone and leuteinizing hormone
9 K5 G. p* X3 k+ @; z& {concentrations were less than 0.05 mIU/mL
- `/ W! o" J" P7 m! D- R: H* D7 \(prepubertal).
& I; d3 m% z, D3 `8 J7 d" l+ SThe parents were notified about the laboratory4 M: t/ C" B3 M' P) S! m7 v0 f
results and were informed that all of the tests were
+ x7 `* g% E* j0 pnormal except the testosterone level was high. The
+ Y$ `( ^9 T4 X1 ?$ j$ N' Qfollow-up visit was arranged within a few weeks to4 V, k" j+ z. K7 d, Z( V6 d1 c
obtain testicular and abdominal sonograms; how-
. T2 N( h; V- J8 h: kever, the family did not return for 4 months.+ t: D, O5 i9 i) f# w4 g
Physical examination at this time revealed that the7 J9 r& k; N5 o; a
child had grown 2.5 cm in 4 months and had gained0 R0 K: K2 C3 d u1 L4 H
2 kg of weight. Physical examination remained7 Y( t0 z4 j( C9 h" S- X
unchanged. Surprisingly, the pubic hair almost com-
; `8 }6 A, A# S( u G7 P7 Cpletely disappeared except for a few vellous hairs at2 G- W* d7 ]9 W3 q, B2 o' h
the base of the phallus. Testicular volume was still 2% K3 I* v. b$ f& R# \7 x* C
mL, and the size of the penis remained unchanged.8 A0 B5 ` n/ Z) u% K
The mother also said that the boy was no longer hav-4 ~% x0 l( _1 e, R! F: R
ing frequent erections.5 g8 i; J4 p$ M
Both parents were again questioned about use of
8 F! N6 M Q; x. |any ointment/creams that they may have applied to9 f% L7 o# [# U0 x9 p# |
the child’s skin. This time the father admitted the
3 Q& t3 y6 |" ATopical Testosterone Exposure / Bhowmick et al 541
- G, h- J# @5 J) |+ b" q1 Muse of testosterone gel twice daily that he was apply-* C2 m( e- l' T
ing over his own shoulders, chest, and back area for
# o" B w- |8 K6 Ma year. The father also revealed he was embarrassed
/ T- ?( J) I5 f. |: Q H ]6 Mto disclose that he was using a testosterone gel pre-8 c: l3 p) I" \- D+ v* E
scribed by his family physician for decreased libido
9 l5 }! M7 H6 ^# D/ N. asecondary to depression.
/ F2 }( ` Q0 c5 O1 r+ KThe child slept in the same bed with parents.
$ [7 ?% {' @1 ^ s1 M5 E% s- q" QThe father would hug the baby and hold him on his
: s) v( o; Y( E. S) g1 p echest for a considerable period of time, causing sig-+ k l! O( I1 v" c3 Z d
nificant bare skin contact between baby and father.
; C! P* ^6 F: V6 CThe father also admitted that after the phone call,
7 A: T1 |* j& Q3 g! R4 H$ _when he learned the testosterone level in the baby
. v4 W/ Y' ^1 l3 s8 t. Xwas high, he then read the product information
& @9 W: m% y! B* Apacket and concluded that it was most likely the rea-) K* r8 D8 U# a1 o! ?, w8 | x
son for the child’s virilization. At that time, they
1 N$ M9 K, N8 Qdecided to put the baby in a separate bed, and the
3 D0 ^& a2 E$ w3 V8 n5 Zfather was not hugging him with bare skin and had6 n$ A: _- Q/ C6 N
been using protective clothing. A repeat testosterone/ k1 }$ j% l/ R) C: C2 L# V+ u5 k* X5 j
test was ordered, but the family did not go to the( ^/ F3 c& A& C3 f& i9 }, K
laboratory to obtain the test.
7 x# P$ F; D* u% V9 C/ }' _% xDiscussion8 ~' c! |$ u$ W8 |
Precocious puberty in boys is defined as secondary( h) c. D6 ?" o% s, T. ], X
sexual development before 9 years of age.1,49 V2 S# T+ Z+ P8 ^. a
Precocious puberty is termed as central (true) when, a! M& H* L( C1 o8 `: q1 L
it is caused by the premature activation of hypo-$ l0 ^" j* J+ L5 |* }& m
thalamic pituitary gonadal axis. CPP is more com-
/ A, a I8 b$ x9 d: E0 vmon in girls than in boys.1,3 Most boys with CPP' }0 a2 a5 E2 w" O. S: w6 l0 E
may have a central nervous system lesion that is8 X- V% B. A: t5 F
responsible for the early activation of the hypothal-. y7 t! g; F, D# y$ O; h g
amic pituitary gonadal axis.1-3 Thus, greater empha-
) p% a4 N7 E% Hsis has been given to neuroradiologic imaging in
6 D/ `# ~0 F# a- j1 c9 O2 y& G( ?2 Fboys with precocious puberty. In addition to viril-
5 s# R4 u( f! y4 x" B8 W* T9 M$ Rization, the clinical hallmark of CPP is the symmet-* @8 [: v* q) k* Y
rical testicular growth secondary to stimulation by! I9 M5 v4 f, b1 L6 i( s+ y
gonadotropins.1,3
7 G9 |! O; ? T, [* a8 U2 l* uGonadotropin-independent peripheral preco-
( R9 O8 l2 X! Q; |cious puberty in boys also results from inappropriate8 s, y; J! u* P( C! y) A# g
androgenic stimulation from either endogenous or. y4 Y- L7 \2 t8 }
exogenous sources, nonpituitary gonadotropin stim-
+ I0 J- B7 S% `6 p4 c1 uulation, and rare activating mutations.3 Virilizing8 D6 G2 _; M7 n4 L! J. D0 k2 @
congenital adrenal hyperplasia producing excessive
7 O$ T' ?$ [5 q5 R; E9 }/ x( Qadrenal androgens is a common cause of precocious6 j: a2 _1 t" E4 ^
puberty in boys.3,4/ H8 d$ i/ m8 V+ a
The most common form of congenital adrenal
" D3 n6 O5 E. p! L' d# Xhyperplasia is the 21-hydroxylase enzyme deficiency.# |9 q8 u* W6 Q0 E8 M" ^" Q/ m
The 11-β hydroxylase deficiency may also result in
4 l4 J) a& k- J& R: e7 X/ \excessive adrenal androgen production, and rarely," X" N* t8 _5 c6 N/ f
an adrenal tumor may also cause adrenal androgen6 s4 C4 j, ^! |2 O5 n
excess.1,3
- [# G9 E) n" I- K9 Z( Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" x/ N0 }" S/ c# t8 h6 U0 i4 ^542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 A& o+ z" Z" I& k8 ^A unique entity of male-limited gonadotropin-! ?& W( F6 A; t# r" b
independent precocious puberty, which is also known, d6 B; {4 o; k/ t" r; n
as testotoxicosis, may cause precocious puberty at a
3 G' Q" D% i: R' T3 G$ overy young age. The physical findings in these boys
( b9 f. Q5 {! uwith this disorder are full pubertal development,, \' h0 i6 F& S
including bilateral testicular growth, similar to boys
% V" Y* E2 |& Y4 t1 ~ O1 Xwith CPP. The gonadotropin levels in this disorder- k2 r# ?/ T- O, U( X
are suppressed to prepubertal levels and do not show
7 P5 X1 E; N+ a1 k; Q; Mpubertal response of gonadotropin after gonadotropin-$ f1 E) y2 n8 b9 f/ u7 D
releasing hormone stimulation. This is a sex-linked( }' r1 J0 w8 N- n
autosomal dominant disorder that affects only
( {) Y. S1 b5 W) Cmales; therefore, other male members of the family4 J: K s5 K0 { z* ]! A7 l( j. F# y
may have similar precocious puberty.3 F& f: ^4 r: t' I# {: p5 }" h# s
In our patient, physical examination was incon-7 ? m% {8 h- r/ U. p! n* s
sistent with true precocious puberty since his testi-
' S4 e; p9 a( S X9 v$ T$ t) Jcles were prepubertal in size. However, testotoxicosis6 r L# F; [* G8 U
was in the differential diagnosis because his father
4 R1 S. V6 A% {, kstarted puberty somewhat early, and occasionally,
2 H( R& X8 I( B! W/ ytesticular enlargement is not that evident in the
9 z( w. {3 P4 m$ H, e$ Y) Xbeginning of this process.1 In the absence of a neg-
0 s9 S$ C3 w P8 Uative initial history of androgen exposure, our
% A* c* F7 @. S- S4 @! rbiggest concern was virilizing adrenal hyperplasia,
3 c3 y. {' c6 M! C9 \9 meither 21-hydroxylase deficiency or 11-β hydroxylase
a( a6 c' Q/ ?! n0 [$ K: }1 xdeficiency. Those diagnoses were excluded by find-
C5 t# @* [' b l* H/ ving the normal level of adrenal steroids.
3 P8 ^" i1 Q) m: @3 FThe diagnosis of exogenous androgens was strongly! g5 T2 i8 m+ @. |0 W6 d
suspected in a follow-up visit after 4 months because- d8 l, ]+ s7 Z9 ~, d, s" n
the physical examination revealed the complete disap-8 F, d, H0 K, t4 @0 N
pearance of pubic hair, normal growth velocity, and7 X, e; G+ a7 t! M
decreased erections. The father admitted using a testos-( {8 C6 v# l/ G% M" C- Y
terone gel, which he concealed at first visit. He was5 C/ \: j Z& k1 `* P" } N& q6 j
using it rather frequently, twice a day. The Physicians’
* u1 N) P- z' O' C% D eDesk Reference, or package insert of this product, gel or" Q0 T* i/ r2 F v* v% m
cream, cautions about dermal testosterone transfer to
4 u! h2 }: r% z/ y( n+ Y. r; h& ?+ cunprotected females through direct skin exposure.
5 E; h) G2 W3 g* `Serum testosterone level was found to be 2 times the
' `9 s# V" m9 X4 Q) a3 Jbaseline value in those females who were exposed to
0 O; s9 ^8 a4 d" G$ X+ geven 15 minutes of direct skin contact with their male
# z7 a: l6 M' k! ?partners.6 However, when a shirt covered the applica-
. K( F3 d2 G; j7 i! ~tion site, this testosterone transfer was prevented.; {2 H M9 `: o, v6 Z* A1 y
Our patient’s testosterone level was 60 ng/mL,
0 u' N) u# M7 w9 x+ ^which was clearly high. Some studies suggest that
& V* o! C& d7 L* w* [" h, @dermal conversion of testosterone to dihydrotestos-
/ J! O' Y) D7 J, i. }terone, which is a more potent metabolite, is more
% y0 H; ?& ?/ }/ U1 ~ _( |active in young children exposed to testosterone+ {; n* x9 |0 q0 [; q; e2 b) v
exogenously7; however, we did not measure a dihy-* |) ~, s: W& w i
drotestosterone level in our patient. In addition to; z: }5 ~: Q( Q% N
virilization, exposure to exogenous testosterone in
( m+ Z* h0 S) I( v( [children results in an increase in growth velocity and
7 S! m8 R! c9 ^3 l0 i( m8 k2 }1 yadvanced bone age, as seen in our patient.) K6 X# J6 H4 x: g8 D
The long-term effect of androgen exposure during9 _0 _9 S D2 B, H: X
early childhood on pubertal development and final% j$ L: t; n$ M; t% n
adult height are not fully known and always remain
" i, g1 z$ B' R: \a concern. Children treated with short-term testos-
' I( [" \( y7 O0 \$ `9 Fterone injection or topical androgen may exhibit some
0 P/ f% o3 C. b# w% y* a5 D Iacceleration of the skeletal maturation; however, after
; |. x8 @# C! V6 w2 w' ]cessation of treatment, the rate of bone maturation+ ?: K0 p5 k5 U/ R/ W
decelerates and gradually returns to normal.8,9* g1 z3 Y5 t! l7 [
There are conflicting reports and controversy
0 V4 G; @- I0 z) `over the effect of early androgen exposure on adult6 w$ V/ G: s4 _) f
penile length.10,11 Some reports suggest subnormal7 k3 x+ n' O, F
adult penile length, apparently because of downreg-
* P8 q. S" s P% U& K5 O2 Yulation of androgen receptor number.10,12 However,
, t7 D8 E5 _9 d9 s* |5 ASutherland et al13 did not find a correlation between
5 _" ?' F! y2 Xchildhood testosterone exposure and reduced adult$ T x2 I0 z- E$ J
penile length in clinical studies.0 ] X$ h( M2 k6 ^' v
Nonetheless, we do not believe our patient is
: F0 x) H3 |- v5 c+ i9 O/ H! N6 pgoing to experience any of the untoward effects from. a/ J7 w* B' s$ G) Q3 l
testosterone exposure as mentioned earlier because
# L) F* ~0 g5 [0 y7 ]/ n+ wthe exposure was not for a prolonged period of time.( R9 b/ N& w4 n! P8 o# L5 R
Although the bone age was advanced at the time of7 p/ U8 ^* Y* Z5 _( k
diagnosis, the child had a normal growth velocity at
' h$ F0 m6 e. e& Tthe follow-up visit. It is hoped that his final adult
, U- I* b2 _0 C% M' j3 y% [- Hheight will not be affected.4 I2 w7 A# I! f2 V
Although rarely reported, the widespread avail-
7 g w1 W$ C& [ability of androgen products in our society may3 S$ U3 i- ]8 e7 c% I5 E$ v
indeed cause more virilization in male or female
' H4 R2 O- I8 U( ]' Dchildren than one would realize. Exposure to andro-
" U+ ]/ f4 x% H' ]7 V; dgen products must be considered and specific ques-
/ R/ e- G# {, t/ g5 |! U2 _tioning about the use of a testosterone product or
/ n7 \1 E* k y9 d1 Tgel should be asked of the family members during7 a# Y. q" Q. v6 ]% D$ ]
the evaluation of any children who present with vir-
- Q* I. N6 a6 @9 {( L8 kilization or peripheral precocious puberty. The diag-
8 G5 Q. a) L- e+ H4 S& ?nosis can be established by just a few tests and by
8 N, B* x0 E1 e5 }5 i A n0 Fappropriate history. The inability to obtain such a
8 _5 Y7 W& I: L& s2 i$ bhistory, or failure to ask the specific questions, may
P2 b% A' B! F5 |' h. Sresult in extensive, unnecessary, and expensive8 m: B8 s+ b1 I# U! k+ S& ], Y
investigation. The primary care physician should be
1 q$ v. r9 |3 Caware of this fact, because most of these children, c2 K P# f# `* f: ]8 C4 E
may initially present in their practice. The Physicians’
! k6 k( O3 R7 PDesk Reference and package insert should also put a0 p! ?" X% |, I x- G4 A2 u! h! D
warning about the virilizing effect on a male or. @; j8 x4 j4 M6 z' Q' ^) E- Y
female child who might come in contact with some-
2 P% M: I4 d, S# V) t9 x' V, Yone using any of these products.
; \# f2 w6 ^6 [% W; BReferences! N% c+ u* R7 ~/ |* {3 N2 A
1. Styne DM. The testes: disorder of sexual differentiation7 N' l8 Q, t- T5 R
and puberty in the male. In: Sperling MA, ed. Pediatric) A7 n* l/ I) G. ?) z( `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
+ Q4 d$ I; ?5 r6 L7 I6 j5 l5 m2002: 565-628.
- ]1 o$ z/ u# f0 S3 _, d2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
5 ]8 e6 t1 V# `' A- ~puberty in children with tumours of the suprasellar pineal |
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