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Sexual Precocity in a 16-Month-Old/ v- X$ ~8 B7 N# [; _; u0 G0 i
Boy Induced by Indirect Topical
8 E# H+ u' j& D. r) H5 kExposure to Testosterone
1 l" H9 `" F$ CSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2 A, D2 m9 c H* Z! n" ~- f
and Kenneth R. Rettig, MD1
+ ]) e: @! k3 p" s6 eClinical Pediatrics
- o# s s& m( U) |' xVolume 46 Number 6; |# b! I' E2 o( G& R! S; Q
July 2007 540-5437 D: Q. y( ]* g+ J- t4 m
© 2007 Sage Publications2 L6 W' Z/ y0 O5 g" Y" {1 O4 ?
10.1177/00099228062966513 p2 G4 ]/ C; L* a
http://clp.sagepub.com" x: q7 _! u7 p' b
hosted at3 R8 G4 _# e4 T, R
http://online.sagepub.com& X- P( D& u) s" ?- E' q
Precocious puberty in boys, central or peripheral,' y; S% H m* i7 D) A% _) i
is a significant concern for physicians. Central$ @! _1 z6 o' U8 B9 `6 P0 E) U
precocious puberty (CPP), which is mediated
: E7 E* @/ b* I6 W/ W' q7 P: D8 qthrough the hypothalamic pituitary gonadal axis, has
' h( d+ w1 `0 v+ r3 N* Ma higher incidence of organic central nervous system8 U, K7 W7 t/ i0 R U
lesions in boys.1,2 Virilization in boys, as manifested6 o3 I" W. d" X
by enlargement of the penis, development of pubic
' F2 y2 m6 F8 T* W/ `9 Jhair, and facial acne without enlargement of testi-
, l1 o4 p8 E1 f S/ H. Zcles, suggests peripheral or pseudopuberty.1-3 We& Y6 T/ K/ @" |+ C5 _4 y3 V% [; p5 a+ R
report a 16-month-old boy who presented with the
0 O9 g9 y1 Z; Uenlargement of the phallus and pubic hair develop-
2 m5 l( D8 A! _$ V0 Cment without testicular enlargement, which was due
M0 _; ?) K; pto the unintentional exposure to androgen gel used by
) v* ~! s2 `6 f" V( H9 e; ^the father. The family initially concealed this infor-
y; a6 t I0 X) y# `1 Umation, resulting in an extensive work-up for this
1 P1 F: v6 a! e% ?3 X* [$ E) u! Bchild. Given the widespread and easy availability of
9 }* o, U N- ^* Vtestosterone gel and cream, we believe this is proba-7 b6 J7 k( i' |- I) f
bly more common than the rare case report in the
9 M3 ]7 n- I+ p! X) T$ I( G4 rliterature.4
' I3 }9 v' e c& s1 pPatient Report
6 Y& c1 a: o# O! Z, b. N$ DA 16-month-old white child was referred to the j0 \& m3 X( e3 Z- p1 b
endocrine clinic by his pediatrician with the concern4 w3 i. S/ c( V1 E6 b) b1 H
of early sexual development. His mother noticed: u5 D7 s* Y1 M
light colored pubic hair development when he was
+ C5 V7 I6 d0 t$ x% J3 L5 kFrom the 1Division of Pediatric Endocrinology, 2University of
- Z. X: H9 M" [/ a& Z' T( M) LSouth Alabama Medical Center, Mobile, Alabama.
# }, \8 N) b1 `) @Address correspondence to: Samar K. Bhowmick, MD, FACE,
6 Z! b! ~) P* E* g3 YProfessor of Pediatrics, University of South Alabama, College of0 w u2 s3 C0 \, [8 a
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;5 K% c$ A6 f$ \9 Y
e-mail: [email protected].
9 K7 O1 S: O0 R- Habout 6 to 7 months old, which progressively became8 w N3 e# P$ v# U) V% ~% N
darker. She was also concerned about the enlarge-
( \7 v3 K6 T0 u3 d2 @: r1 cment of his penis and frequent erections. The child+ W; J& v/ T* O. n
was the product of a full-term normal delivery, with. H% y7 e: y7 W. {: o, u
a birth weight of 7 lb 14 oz, and birth length of, p% m& ] \: [/ h
20 inches. He was breast-fed throughout the first year
, d1 c5 V- i; x4 N. l) G% X4 cof life and was still receiving breast milk along with) g4 x+ Y0 ]% x$ f+ |% F
solid food. He had no hospitalizations or surgery,. y6 P; Z) L" u6 G
and his psychosocial and psychomotor development: C# I2 G1 \5 n7 M7 u, N
was age appropriate.
1 b" s1 c- M1 t* z$ {: }4 ?; gThe family history was remarkable for the father,
5 ^; f. r& C- h G! M+ q$ Z. ^3 A% \who was diagnosed with hypothyroidism at age 16,
2 O% ]# |0 H$ r7 |! A/ E4 Vwhich was treated with thyroxine. The father’s
$ Y' l4 R+ n# N( dheight was 6 feet, and he went through a somewhat2 x5 J8 X8 ~8 m+ g( J
early puberty and had stopped growing by age 14.
' I# C* ?+ [7 g2 |! v) XThe father denied taking any other medication. The
/ M% S b1 g4 j/ a8 P$ ~. jchild’s mother was in good health. Her menarche8 G+ D( M# q9 {- D/ S1 {' t- n3 v( K6 h
was at 11 years of age, and her height was at 5 feet, B3 s* J3 _2 e0 B
5 inches. There was no other family history of pre-" D2 I5 E" f5 A/ @9 J0 B3 Z/ k
cocious sexual development in the first-degree rela-
6 {7 b7 L& f/ Y& ftives. There were no siblings.
) t* t0 {- k, z" ]; x+ oPhysical Examination- t, A7 M$ v( a+ z* ~# F. r
The physical examination revealed a very active,0 ]( w% ?. m) _& V1 F1 W
playful, and healthy boy. The vital signs documented
7 M3 X$ _) V4 W6 u# Oa blood pressure of 85/50 mm Hg, his length was6 t* F6 l2 W& {2 H. M- N
90 cm (>97th percentile), and his weight was 14.4 kg5 @; E- z- C5 O6 h* J' Y2 |
(also >97th percentile). The observed yearly growth
+ N- X E* o3 D, ^velocity was 30 cm (12 inches). The examination of2 m' S, C) k9 p. A
the neck revealed no thyroid enlargement.
) @& H0 s: C$ oThe genitourinary examination was remarkable for
o+ r1 W# J2 u1 nenlargement of the penis, with a stretched length of c2 y; F4 ^+ ~/ s% C
8 cm and a width of 2 cm. The glans penis was very well. q2 C" g# O) Z7 o
developed. The pubic hair was Tanner II, mostly around
M. E4 w2 ]) L0 p& j540! W0 {# l1 F4 n+ e: x! n0 y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 S* v" V: k8 k& a$ Y, ythe base of the phallus and was dark and curled. The
% N( D( \/ {: c* O+ ktesticular volume was prepubertal at 2 mL each.5 h! k( u( A: ]) T; ~9 Y& y" h6 e
The skin was moist and smooth and somewhat
" J; C p& N& s6 @' C' u9 Yoily. No axillary hair was noted. There were no
. D/ E9 b! b( L: s3 b9 U/ xabnormal skin pigmentations or café-au-lait spots.
! ?- d5 X* x- _% U- b; LNeurologic evaluation showed deep tendon reflex 2+
6 |: ?! J% H' ` Ebilateral and symmetrical. There was no suggestion
8 P3 A: t, X; E% W5 Q( `# }4 Tof papilledema.7 r- R6 G8 ?4 ]) n; J# z
Laboratory Evaluation, Y' a3 `9 q% n) k; F+ U. c+ }/ H
The bone age was consistent with 28 months by( K' a# Z; G& J- x
using the standard of Greulich and Pyle at a chrono-8 y* b. ~/ H' N1 O1 R3 H
logic age of 16 months (advanced).5 Chromosomal4 d& I" f9 G c3 G' {
karyotype was 46XY. The thyroid function test) Q, D# W2 T1 J8 q! g) H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-+ @! o5 ?" d6 e( }& s. q+ Y2 k% P
lating hormone level was 1.3 µIU/mL (both normal).
; f7 H4 Z" p9 t( {! ?: w& `The concentrations of serum electrolytes, blood
3 R3 q* p! N# Q1 j& {" [4 xurea nitrogen, creatinine, and calcium all were
N! z2 q! M8 B8 G4 `within normal range for his age. The concentration
9 |/ j0 m0 [4 J2 L8 ^of serum 17-hydroxyprogesterone was 16 ng/dL* j& x( @4 Y/ i% _ Q, @
(normal, 3 to 90 ng/dL), androstenedione was 20
# G! z9 H1 p! z! D$ d+ ?ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
* O% y7 g, d5 G5 f E2 f* K, \& `terone was 38 ng/dL (normal, 50 to 760 ng/dL),6 P! i8 e! E; X/ c
desoxycorticosterone was 4.3 ng/dL (normal, 7 to, W& i" Y7 h; Q
49ng/dL), 11-desoxycortisol (specific compound S)
' j) Z' l- x; \* ]was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-* p3 z F. n9 h/ e6 C" {- i6 |
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
& ?" h! a8 J7 }0 s4 c, htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),2 }+ x# i8 s2 V5 n
and β-human chorionic gonadotropin was less than4 _' z. P: W. @3 l# b: A
5 mIU/mL (normal <5 mIU/mL). Serum follicular
7 z& G7 f# {3 F& M1 P# x/ hstimulating hormone and leuteinizing hormone
8 G8 _$ |+ a* l# }. m$ t6 {! cconcentrations were less than 0.05 mIU/mL' `' H7 A- A; }6 L8 O
(prepubertal).
9 b0 H% R( H2 f' B3 |0 X3 x$ FThe parents were notified about the laboratory( f, [! d8 h% [2 n7 S. L! K
results and were informed that all of the tests were
5 M; A# p9 u$ M& p* l9 I+ n) |, Fnormal except the testosterone level was high. The+ v% f+ n/ t' O% Y
follow-up visit was arranged within a few weeks to: o8 W. i' c7 e3 A4 k6 I
obtain testicular and abdominal sonograms; how-
* o0 t5 ~) P8 B. {ever, the family did not return for 4 months.
, q( _5 [/ ]+ g/ L$ PPhysical examination at this time revealed that the
5 ]6 G& p6 v8 p& ochild had grown 2.5 cm in 4 months and had gained
Z! S3 m+ f8 f% j9 M+ p2 kg of weight. Physical examination remained% @5 U, z ^( ^: _) N
unchanged. Surprisingly, the pubic hair almost com-) M4 f m5 \( T- J
pletely disappeared except for a few vellous hairs at- O* x0 m* E; J" i# `- f
the base of the phallus. Testicular volume was still 2
& G0 s& A( t# ~6 LmL, and the size of the penis remained unchanged.
5 z A0 Q; S8 F \1 g4 `1 f- zThe mother also said that the boy was no longer hav-
+ b7 _( X. q9 _2 b% king frequent erections.* c" ~: F$ n; w. R3 ~: E( ~
Both parents were again questioned about use of5 r+ {) x c! S
any ointment/creams that they may have applied to4 F! Q T8 ~4 ]1 K1 E( e
the child’s skin. This time the father admitted the4 v+ |! X, \5 P& G/ b
Topical Testosterone Exposure / Bhowmick et al 541+ T3 a6 n; ?) v J: h# D
use of testosterone gel twice daily that he was apply-4 @ M7 j7 }5 s6 G* o
ing over his own shoulders, chest, and back area for
, Y* D" O, U+ ]# @a year. The father also revealed he was embarrassed; B1 Q1 H9 |4 E
to disclose that he was using a testosterone gel pre-% v) u( n' r, F* E
scribed by his family physician for decreased libido3 @; ~8 T2 o* d7 a
secondary to depression.
% p1 b' }% @! _5 q8 KThe child slept in the same bed with parents.$ Q, E: Z% I, A. O- b' m
The father would hug the baby and hold him on his
7 h* ~* ]$ q+ j1 {4 s* ?chest for a considerable period of time, causing sig-8 w$ i2 C/ d8 X" a+ J T. _$ g
nificant bare skin contact between baby and father.6 Z; I5 b' d3 X% Y& P5 F6 V
The father also admitted that after the phone call,) [' ~- k& W( N
when he learned the testosterone level in the baby9 x6 C ]5 z6 y2 X
was high, he then read the product information; b$ T, x& V! z) [4 s
packet and concluded that it was most likely the rea- u, L2 z) F9 {/ N1 M, i
son for the child’s virilization. At that time, they
' I2 a* f, l" }5 K3 G$ {decided to put the baby in a separate bed, and the4 S) `# n' Y1 y: `, C. J6 ?& D5 J
father was not hugging him with bare skin and had
/ e+ p' L: z8 X8 v. Gbeen using protective clothing. A repeat testosterone; x2 F, g# a; ?2 h9 q* _# T J& {
test was ordered, but the family did not go to the) E- r. l) l: ?0 f: o
laboratory to obtain the test.) z7 L6 J* l( s9 Y+ ]
Discussion
( H- s7 N' l/ g9 XPrecocious puberty in boys is defined as secondary5 w. B# V& n: L3 J5 C+ ?. @
sexual development before 9 years of age.1,4
D" |8 I6 H+ a1 o$ f$ [* u APrecocious puberty is termed as central (true) when
0 R+ U7 W# x4 a4 D4 iit is caused by the premature activation of hypo-# \5 D8 x9 r+ `+ S+ H8 t
thalamic pituitary gonadal axis. CPP is more com-
; I, J2 {6 Z5 P8 F8 ]7 T, E5 g3 Y7 jmon in girls than in boys.1,3 Most boys with CPP
2 _6 q2 l/ [. W7 s5 s0 Z& cmay have a central nervous system lesion that is# d9 N0 A8 ]+ Z! I- r) {1 \7 ?
responsible for the early activation of the hypothal-
. L2 |. b- @" S6 kamic pituitary gonadal axis.1-3 Thus, greater empha-) x9 o7 j( I( l! c# {2 C" Q$ K
sis has been given to neuroradiologic imaging in [. \/ e( C: `1 D& T1 O
boys with precocious puberty. In addition to viril-
& K1 Q% q1 F- kization, the clinical hallmark of CPP is the symmet-
& S+ K f* p0 ]6 P0 e1 x! srical testicular growth secondary to stimulation by
9 e) l% S2 o* E: X% O; q' Ggonadotropins.1,3. |2 z( r6 Z, v
Gonadotropin-independent peripheral preco-
. c2 {: a9 U& E: d: T3 hcious puberty in boys also results from inappropriate. H7 i, u8 b+ Y
androgenic stimulation from either endogenous or+ a- B: q- J; Y( a" ~
exogenous sources, nonpituitary gonadotropin stim-
- w& J& h+ r* _$ O; Xulation, and rare activating mutations.3 Virilizing
$ ~) ?2 |' b% f* G) Ucongenital adrenal hyperplasia producing excessive
3 q D8 h: ]- v- Y0 yadrenal androgens is a common cause of precocious# S* @, u! B% N. q
puberty in boys.3,4
' O3 w; C1 B% A$ gThe most common form of congenital adrenal2 w# i( t& v# m* t
hyperplasia is the 21-hydroxylase enzyme deficiency.) W0 D" X4 z5 Z9 U! u
The 11-β hydroxylase deficiency may also result in! w. K& q4 g! G |
excessive adrenal androgen production, and rarely,5 w8 m+ T$ @2 |5 D) J; E
an adrenal tumor may also cause adrenal androgen
/ R- j: c( M, X& w6 ~' ^7 k' L3 g; ~excess.1,3
7 P2 i1 {; _$ u" g6 Jat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from F6 S/ D/ N2 Z0 d+ _, v$ N
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
# i3 o' n* ]) _# `1 mA unique entity of male-limited gonadotropin-+ ^! H0 F( n$ w* F
independent precocious puberty, which is also known
1 r! O- i: _. Fas testotoxicosis, may cause precocious puberty at a8 d* j6 K& w9 C7 |' ~- L' \+ b
very young age. The physical findings in these boys
7 T. [1 e6 a6 bwith this disorder are full pubertal development,
! R$ E3 h, M$ H; `, aincluding bilateral testicular growth, similar to boys9 p% b# E) ?+ |
with CPP. The gonadotropin levels in this disorder+ T6 U* t/ ~7 j6 E& {! C+ q; E8 n8 T9 g
are suppressed to prepubertal levels and do not show
[9 ~/ p2 p! f: D6 S. \$ V3 mpubertal response of gonadotropin after gonadotropin-- u o9 a$ c! y& i0 O: P- ~! g9 g
releasing hormone stimulation. This is a sex-linked
# B' v& v/ U3 qautosomal dominant disorder that affects only5 R$ v/ o6 M% c2 G9 N3 f
males; therefore, other male members of the family+ S' {/ ]) M7 w1 o( s2 B4 J+ @
may have similar precocious puberty.35 W/ E- J, n& P5 P% q, X" r
In our patient, physical examination was incon-
* `( @# e; k) V2 J) x1 osistent with true precocious puberty since his testi-
4 L. V/ Z* Q. e( H* ? s) hcles were prepubertal in size. However, testotoxicosis& V/ E) p( j( h$ {6 Y1 r4 \
was in the differential diagnosis because his father
6 p$ ~1 G. h7 ^6 E- c6 i2 istarted puberty somewhat early, and occasionally,
( Y6 k/ S; W: J- l$ S% ztesticular enlargement is not that evident in the/ r5 I' ~' `3 a6 V, t
beginning of this process.1 In the absence of a neg-
9 `$ g" l5 e {% O( q5 C) Lative initial history of androgen exposure, our
5 e8 }, m9 ~0 W- W% }6 t" zbiggest concern was virilizing adrenal hyperplasia,) H1 d j/ O# c f
either 21-hydroxylase deficiency or 11-β hydroxylase
1 A: _/ j7 S' o/ b- rdeficiency. Those diagnoses were excluded by find-
, S9 p q; t* bing the normal level of adrenal steroids.) _1 M. H% z+ q
The diagnosis of exogenous androgens was strongly8 K, b. ~6 K" T m9 M+ D
suspected in a follow-up visit after 4 months because$ q' ^$ `; C2 q a. U
the physical examination revealed the complete disap-
; m' v0 ?& p( W, l) m2 _, ]5 Gpearance of pubic hair, normal growth velocity, and
# v! v* N' P, z P! o2 V! Ldecreased erections. The father admitted using a testos-. L( w# Y6 H; m5 ~% o/ ^4 D0 o2 k1 E
terone gel, which he concealed at first visit. He was/ \: z2 h$ C' Y5 A2 s0 ^
using it rather frequently, twice a day. The Physicians’
: }: N5 B; H7 f' `* LDesk Reference, or package insert of this product, gel or
* u# Z' @- w2 Jcream, cautions about dermal testosterone transfer to
* T% v( _( K+ G! {$ gunprotected females through direct skin exposure.0 Y. y; h7 I/ `' y% k
Serum testosterone level was found to be 2 times the
- {1 t0 [7 x! ubaseline value in those females who were exposed to" m% v9 I# C& h) Y: D3 @+ Y
even 15 minutes of direct skin contact with their male
0 ~0 u4 T) K- `0 |' g. @partners.6 However, when a shirt covered the applica-. e- I( U6 j% v- \7 c
tion site, this testosterone transfer was prevented.9 K; b0 ^5 [+ m- E+ w
Our patient’s testosterone level was 60 ng/mL,
) b: p+ e0 m" S% G8 w% }which was clearly high. Some studies suggest that# K! f& z$ g5 j
dermal conversion of testosterone to dihydrotestos-+ l" y Q1 V# D t, f: s8 |& f
terone, which is a more potent metabolite, is more+ ~. j ?& A: K9 i( F- u& y+ ]
active in young children exposed to testosterone
; a1 B; i3 s0 |7 M2 B6 g2 q0 wexogenously7; however, we did not measure a dihy-8 e4 n7 c. N% C, t
drotestosterone level in our patient. In addition to" K9 B9 {2 y0 z7 D$ ?" ^
virilization, exposure to exogenous testosterone in
1 Z8 ^1 h+ n) E& s/ rchildren results in an increase in growth velocity and
K, ^' B4 u! T' ^! [* s6 Cadvanced bone age, as seen in our patient., \8 ~6 F4 \5 C7 j7 ~" z. A
The long-term effect of androgen exposure during+ G! ~' s4 n( T; {! Z/ h! d
early childhood on pubertal development and final4 v9 O* q& ^; j
adult height are not fully known and always remain
" E" ^& O6 \: T7 r8 Ua concern. Children treated with short-term testos-
5 e3 M7 Z; ^: E$ |/ Iterone injection or topical androgen may exhibit some b. u. n" B& e( a
acceleration of the skeletal maturation; however, after, c( E `/ j9 L2 h: |; i& K+ |* p$ i
cessation of treatment, the rate of bone maturation
/ p# [1 W6 [# } P- xdecelerates and gradually returns to normal.8,9
9 o `+ y" v% W- jThere are conflicting reports and controversy: s* ]( z! A$ h8 K: L' ^: [' c ^
over the effect of early androgen exposure on adult. Q8 {$ l. \. v( e* N( C6 g( s2 E
penile length.10,11 Some reports suggest subnormal% d- I7 ^' l$ n0 j4 o& G
adult penile length, apparently because of downreg-
& M! t$ g& [/ U0 D& ]ulation of androgen receptor number.10,12 However,1 e5 o" _$ Z( f, K4 F, F1 b
Sutherland et al13 did not find a correlation between
0 {; |( g% @: J& s9 y; kchildhood testosterone exposure and reduced adult3 z/ \3 e- h4 {8 ]
penile length in clinical studies.# g1 Z% ^/ @: u" R Y/ o
Nonetheless, we do not believe our patient is
+ k: u$ R7 c! g. g$ Igoing to experience any of the untoward effects from$ u" i$ _* _- Y/ v# s7 l: f& X
testosterone exposure as mentioned earlier because
, R! B* v5 c; lthe exposure was not for a prolonged period of time.
3 _- C7 ]6 w% c! M& [; g, fAlthough the bone age was advanced at the time of1 n' m/ f: l1 O; g3 K0 ?
diagnosis, the child had a normal growth velocity at
# B/ Q: o: @+ f0 u& othe follow-up visit. It is hoped that his final adult
+ i8 N( \3 i% m1 F( i( d" t- h: dheight will not be affected.
) D' Z( q v# U, g* L! Y& sAlthough rarely reported, the widespread avail-8 i' X% r8 y$ B/ n" V
ability of androgen products in our society may! ~, ?7 y% m: [; H5 L: V
indeed cause more virilization in male or female
$ T- H3 Z- ]( z. m7 [. Rchildren than one would realize. Exposure to andro-$ d/ \% R/ J; S+ E0 [5 G9 E
gen products must be considered and specific ques-
, w7 ]: @0 C! ~9 O2 a: K8 @tioning about the use of a testosterone product or
; }; ^: H% E. B" ~! a$ ogel should be asked of the family members during3 Z$ B" m, P9 z
the evaluation of any children who present with vir-
9 y2 N! q! e0 y: e$ r2 }, vilization or peripheral precocious puberty. The diag-
9 b2 |. O: u i5 s& t4 W6 D9 W' fnosis can be established by just a few tests and by
* W* [* q6 \4 {+ P6 pappropriate history. The inability to obtain such a
% u/ {, @/ \& Y+ X6 Ghistory, or failure to ask the specific questions, may* m& L1 N/ E7 f2 b
result in extensive, unnecessary, and expensive
$ Y+ |3 R$ ?, q2 _: |investigation. The primary care physician should be8 ]$ v R4 V' V f
aware of this fact, because most of these children; A* p% o& b6 Q3 s
may initially present in their practice. The Physicians’3 q, K3 D$ f) Q* O2 Q' ^
Desk Reference and package insert should also put a
4 i5 Q8 N% w8 r: Twarning about the virilizing effect on a male or* _0 y& I; o% S1 r
female child who might come in contact with some-
' ^' N! v: x; Q" I% Zone using any of these products., _, Y- @3 d! D M* Z7 T
References
1 Y2 n- J# H" q" W5 d) Q1. Styne DM. The testes: disorder of sexual differentiation$ ]" b2 G: [/ J/ [! q) m
and puberty in the male. In: Sperling MA, ed. Pediatric4 \; I6 l. D: r1 C4 W7 P
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 Q3 h. U' z7 ?- \; }9 P2002: 565-628.
4 ~$ i3 d6 A# M4 h5 A# |2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( `/ V1 t7 Y* m4 \ ]1 K7 jpuberty in children with tumours of the suprasellar pineal |
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