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Sexual Precocity in a 16-Month-Old
3 @, f1 I( E; G' C' p+ `# i. ABoy Induced by Indirect Topical- q) _6 [0 b1 _/ o
Exposure to Testosterone
y$ s$ C$ R8 k/ c2 Z0 }Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
4 \) h2 z/ B+ vand Kenneth R. Rettig, MD1, \# i; d5 u* N# q; v6 S, |
Clinical Pediatrics- \* y. o& q6 n ~
Volume 46 Number 6" d3 E2 T/ X. O9 d3 D* j# ~
July 2007 540-543- \& Y% f! R, u& W" O6 D, W; U
© 2007 Sage Publications" s E6 x9 W% M% D
10.1177/0009922806296651
; V( K! j8 i9 x. jhttp://clp.sagepub.com* n4 J& Q1 Y9 e
hosted at
3 o% W- x" {. Thttp://online.sagepub.com8 |# B: M$ B" q" [2 q3 S s# S
Precocious puberty in boys, central or peripheral,- H' X2 K f, o$ S3 e
is a significant concern for physicians. Central
& G5 E- }" f, P* X: ?precocious puberty (CPP), which is mediated( i, k: _6 m+ a
through the hypothalamic pituitary gonadal axis, has
- K$ |5 d9 l6 R$ b) H$ ga higher incidence of organic central nervous system
- l5 I; t$ M+ Q* S7 K) B, s# ?lesions in boys.1,2 Virilization in boys, as manifested
3 E4 k; y0 p% q; F1 L, ~by enlargement of the penis, development of pubic
0 {8 I& L2 w$ Shair, and facial acne without enlargement of testi-
. V2 |2 u( [( C9 Q; e5 Ucles, suggests peripheral or pseudopuberty.1-3 We, P1 G3 Z, e+ O/ N1 l6 a! ~
report a 16-month-old boy who presented with the# |5 [0 k$ l1 G |: o2 E
enlargement of the phallus and pubic hair develop-/ n) @) g8 f2 T3 A3 y1 w
ment without testicular enlargement, which was due
; V! H! H9 B, Zto the unintentional exposure to androgen gel used by
3 ?% B4 n6 |2 d, Ithe father. The family initially concealed this infor-9 w$ u4 J! }2 p- h9 @' k+ p
mation, resulting in an extensive work-up for this- r4 |8 S* c9 v; O0 X! A
child. Given the widespread and easy availability of
+ L* r; W: R8 H$ ~4 ~testosterone gel and cream, we believe this is proba-
+ L& h# J4 a0 ebly more common than the rare case report in the
/ k0 a3 X4 b3 D( D! |literature.43 w3 T$ a9 b% \% T3 H% Y) }0 N
Patient Report& M1 U4 c& p( ]0 [6 |+ d! q2 F
A 16-month-old white child was referred to the' w% a# Y4 j7 h0 Y
endocrine clinic by his pediatrician with the concern
" ]' P m) {* e8 R( c" S5 ?of early sexual development. His mother noticed
) _( L" |' L* `: F/ i n, Mlight colored pubic hair development when he was
5 [0 D" ^/ z5 T) V6 {! xFrom the 1Division of Pediatric Endocrinology, 2University of
- v( ~( B9 C) j/ YSouth Alabama Medical Center, Mobile, Alabama.
7 }# Y/ N! \+ ^5 D6 W7 mAddress correspondence to: Samar K. Bhowmick, MD, FACE,% k' F# G2 v; ^# q( `& \$ i
Professor of Pediatrics, University of South Alabama, College of2 B9 U8 t( E: C/ h) q) A! d
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
g' \* k% |7 le-mail: [email protected].
( C0 C# K7 _% \1 j# Yabout 6 to 7 months old, which progressively became! ~0 V5 ^( [! V$ B
darker. She was also concerned about the enlarge-, t- e( p4 a/ F; Z
ment of his penis and frequent erections. The child
+ A. d/ m2 A; v Vwas the product of a full-term normal delivery, with- {% e) B5 R* x
a birth weight of 7 lb 14 oz, and birth length of$ T* U4 o" P9 l W7 y% b9 o
20 inches. He was breast-fed throughout the first year) E6 m# [% u2 `" e. F/ `3 c' b
of life and was still receiving breast milk along with. h! ~3 [. Z) F ]. T
solid food. He had no hospitalizations or surgery,, _& J; c% J `+ L6 ~: q3 f" j
and his psychosocial and psychomotor development+ |5 B: u2 @* d/ s$ w
was age appropriate.
, f. k5 c, X* @3 M% wThe family history was remarkable for the father,' P5 H& E( R t2 s1 U9 S6 i3 O
who was diagnosed with hypothyroidism at age 16,
- D y2 [8 m i# L6 k3 [3 Rwhich was treated with thyroxine. The father’s, h* s/ Q# c/ ~1 P9 ^/ g
height was 6 feet, and he went through a somewhat
$ s9 H. N6 A; h! E6 s- U6 Learly puberty and had stopped growing by age 14.
0 Q- _. W2 d0 [$ \The father denied taking any other medication. The
3 @$ X, U# j. O, Pchild’s mother was in good health. Her menarche! d- S6 B" t% F' J4 A, z6 A
was at 11 years of age, and her height was at 5 feet, P* i( P- W0 {8 f2 {
5 inches. There was no other family history of pre-! A* r6 G* b; M3 N) q4 _8 O
cocious sexual development in the first-degree rela-
- b: s. |4 J) I# C8 g6 Ytives. There were no siblings.
E1 ?& e1 ~1 M; y, }# SPhysical Examination0 B* W: Z; S* x/ P- z
The physical examination revealed a very active,
6 N+ w* q h# Z& h# }playful, and healthy boy. The vital signs documented# o/ b7 X$ o( z! O" g5 y
a blood pressure of 85/50 mm Hg, his length was6 \. b5 j$ F- S( J
90 cm (>97th percentile), and his weight was 14.4 kg! R s& i9 T/ U- m) v, } ^
(also >97th percentile). The observed yearly growth
: J7 ]' h" h. @ Z+ I9 _velocity was 30 cm (12 inches). The examination of
6 R9 |2 W# t- I7 q0 p% q: ]the neck revealed no thyroid enlargement.0 r5 |# J D. A# S" c* q5 _
The genitourinary examination was remarkable for0 z; R. }: z) o
enlargement of the penis, with a stretched length of
. e' P1 l4 Q$ W( q% l2 S) c3 ^/ [8 cm and a width of 2 cm. The glans penis was very well
9 R* B. s2 w Edeveloped. The pubic hair was Tanner II, mostly around8 ^/ Z4 k3 i# X
5408 m# N( ]- @' O; d* x2 ^# t
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) B4 D$ t0 v1 `' u, sthe base of the phallus and was dark and curled. The
7 o. J/ n' U$ x5 mtesticular volume was prepubertal at 2 mL each.
, l3 C7 m1 t& L! DThe skin was moist and smooth and somewhat
* K0 t q6 _$ L2 joily. No axillary hair was noted. There were no
: Q7 ]8 q3 r3 @# |abnormal skin pigmentations or café-au-lait spots.% V" o4 t1 D# \; W2 p. N( m# @
Neurologic evaluation showed deep tendon reflex 2+
& |8 D4 q# V6 xbilateral and symmetrical. There was no suggestion
5 `) G8 g4 J, {of papilledema.
2 F3 e1 _% m b6 M% T1 w7 @0 fLaboratory Evaluation
1 r3 r$ ?, M# k9 @& [The bone age was consistent with 28 months by+ @* Y+ V( T9 ~2 q% v' @, s
using the standard of Greulich and Pyle at a chrono-& D) {& ^5 s0 U7 ^4 A! Z7 d/ x
logic age of 16 months (advanced).5 Chromosomal/ x: P G/ I5 `' V5 M6 A' `
karyotype was 46XY. The thyroid function test
5 M, o& H* A6 o1 M* R# R- l0 R8 Mshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
4 ^+ U6 ^% A6 h+ \ C9 t. blating hormone level was 1.3 µIU/mL (both normal).2 C7 h$ g6 Y9 N4 |; f* B& O
The concentrations of serum electrolytes, blood' m E: J: D1 c+ |& e/ o
urea nitrogen, creatinine, and calcium all were
2 V7 k1 L2 J/ m2 z+ u+ Uwithin normal range for his age. The concentration0 h5 `7 \ A5 _. W0 l6 M3 U4 r
of serum 17-hydroxyprogesterone was 16 ng/dL) y W1 |! W7 E; u
(normal, 3 to 90 ng/dL), androstenedione was 20
9 T; w& D) v) p6 o. Eng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
4 q1 S7 f# V A# `0 h2 |" O% o( ^terone was 38 ng/dL (normal, 50 to 760 ng/dL),
8 I8 k) @6 Q4 @/ N+ d# bdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
p# {, y! d8 J( @* y49ng/dL), 11-desoxycortisol (specific compound S)
2 C8 O0 _, T3 n; A% owas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-* d: B+ Y9 f' f0 N. {
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
# J$ ]) @3 \) t+ f: ?: n: g) ttestosterone was 60 ng/dL (normal <3 to 10 ng/dL),# E7 ]" D/ q7 p* r( X
and β-human chorionic gonadotropin was less than
- d" x3 t& J, S: N5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 C3 t& r( f' U2 T# S1 l& N+ Nstimulating hormone and leuteinizing hormone, q; q+ K6 ^7 D
concentrations were less than 0.05 mIU/mL
' n3 p* F a# b/ M( P( d' Q(prepubertal).! g2 T7 Y( V+ n/ C# n0 D. N
The parents were notified about the laboratory
% X, \, r* V" T# Y O' rresults and were informed that all of the tests were+ M. R- r6 ?7 {
normal except the testosterone level was high. The# B6 P5 K8 s/ d/ W6 j
follow-up visit was arranged within a few weeks to
/ f# O* F; F" V- T f! aobtain testicular and abdominal sonograms; how-- u9 b* R. o+ n+ o. g" r$ ]
ever, the family did not return for 4 months.
9 H9 n, q9 z+ V m/ W( v' WPhysical examination at this time revealed that the
L6 X% N( s' z' f7 M8 k5 V0 K5 Schild had grown 2.5 cm in 4 months and had gained( H6 k& U7 a: y- \! S2 H
2 kg of weight. Physical examination remained# p% r) M7 g! i
unchanged. Surprisingly, the pubic hair almost com-
+ s1 ~! c8 Y2 [* ]: j2 ]( Upletely disappeared except for a few vellous hairs at
1 n; z2 R' e4 H. {1 uthe base of the phallus. Testicular volume was still 2
- X; S' Z A& C, ? NmL, and the size of the penis remained unchanged.$ a$ ?# t c, E/ M
The mother also said that the boy was no longer hav-* ?& l6 A! A% b0 Y! d
ing frequent erections.
- g7 R6 n1 T7 h( J3 M5 l% rBoth parents were again questioned about use of+ k4 q. V q8 @$ [9 w. Q% F# F
any ointment/creams that they may have applied to; \1 _2 k6 g2 X' L- s8 }
the child’s skin. This time the father admitted the
) Y, @ r1 h+ X5 wTopical Testosterone Exposure / Bhowmick et al 5416 l/ y. S% q: U: d
use of testosterone gel twice daily that he was apply-
% m& x. b* `' N( h- {& d2 |' j" aing over his own shoulders, chest, and back area for) l' n( {: F! w. Y/ K O
a year. The father also revealed he was embarrassed
- f; E: X9 s" yto disclose that he was using a testosterone gel pre-. Q! u- Y5 ^* g3 M
scribed by his family physician for decreased libido+ S1 J5 |5 Q& o& L% v* j/ P
secondary to depression.
6 i* {9 t$ n3 @5 ^The child slept in the same bed with parents.: }' s7 k; _! M7 O7 q" \6 }
The father would hug the baby and hold him on his
! h+ U: {; |0 w* X6 I, F, Wchest for a considerable period of time, causing sig-9 W+ \0 I/ I) s9 O& p- j* c
nificant bare skin contact between baby and father.3 X: `0 h9 q) z5 l, X5 t
The father also admitted that after the phone call,
5 Y A5 n% O* l# Ywhen he learned the testosterone level in the baby
0 y. X; n3 A8 V% I" @. Qwas high, he then read the product information
/ c5 \6 L) ~% n4 K2 zpacket and concluded that it was most likely the rea-
' J# e8 c0 w4 o2 n( R, L: m) dson for the child’s virilization. At that time, they5 `! l: Q1 }7 i% n
decided to put the baby in a separate bed, and the( t& i) L* [' h: r$ P
father was not hugging him with bare skin and had' S" g- R+ w8 J, B& H7 @) N
been using protective clothing. A repeat testosterone4 Y1 i$ Q' t, }$ |) H# ?
test was ordered, but the family did not go to the
2 @% K9 Z* m* ]+ V$ g' Q0 E) Ulaboratory to obtain the test.( \8 Q9 p6 i: p9 ^% u! {, H
Discussion8 o* J$ Y8 @" ?- Y
Precocious puberty in boys is defined as secondary
- R& i9 L \1 v4 d7 A- q0 v. f6 Hsexual development before 9 years of age.1,4
3 P$ M+ l5 ^1 Z* v6 {9 o! _+ mPrecocious puberty is termed as central (true) when
( `" T* T) m9 P( A ]- d: f3 i. q7 Pit is caused by the premature activation of hypo-5 b% ~( d) f4 G( ?/ V: u/ C
thalamic pituitary gonadal axis. CPP is more com-
, Z" O* C+ Q9 n' `( l6 B" Smon in girls than in boys.1,3 Most boys with CPP; [, E: O# g. l2 d
may have a central nervous system lesion that is
6 j8 b; |# t- H0 i6 `+ t3 Eresponsible for the early activation of the hypothal-* i# q4 ]* o- M5 @: `! W3 V0 x! ^
amic pituitary gonadal axis.1-3 Thus, greater empha-
- V* V4 ~8 X( t$ C( e0 ^3 e2 Zsis has been given to neuroradiologic imaging in
- ^# A0 Z9 B4 M xboys with precocious puberty. In addition to viril-
1 j8 [, E) J. s7 d) n7 H# L* rization, the clinical hallmark of CPP is the symmet-6 [; y. _# u: e4 z( s
rical testicular growth secondary to stimulation by
8 q, B2 x, g1 F/ U' p* u; U5 Egonadotropins.1,3
& C0 P% k' M/ zGonadotropin-independent peripheral preco-
1 |5 E9 J/ E( x* s. z4 Acious puberty in boys also results from inappropriate. D9 C! w; K7 Z% M& @ B
androgenic stimulation from either endogenous or2 ]% x0 ~% {" }, w+ R1 L; z
exogenous sources, nonpituitary gonadotropin stim-2 F8 x+ t$ ]5 s% ~+ x( f
ulation, and rare activating mutations.3 Virilizing
5 c2 I6 P% A, \congenital adrenal hyperplasia producing excessive
' F+ S! h) d$ V+ M7 H6 H0 |" aadrenal androgens is a common cause of precocious
; s' @, B) i! }6 ]3 E+ Hpuberty in boys.3,4
4 J2 X# |% x- Z/ I1 ~The most common form of congenital adrenal& s5 d# f. W _3 X p4 K& h- d0 u
hyperplasia is the 21-hydroxylase enzyme deficiency.
/ ]' v' W* l0 a3 j/ R: g" p$ zThe 11-β hydroxylase deficiency may also result in
6 d$ g: I, h9 [' P$ Hexcessive adrenal androgen production, and rarely,
; X; K% _6 x6 Z6 m- kan adrenal tumor may also cause adrenal androgen
" I; S. @2 ?, x: Z9 p) yexcess.1,35 k" Y* i$ j4 W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% R; C3 m' @# r S& n
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
! d Y5 f. `1 L" y& g8 F( EA unique entity of male-limited gonadotropin-
4 Z9 _3 o% i" [ t1 d7 T6 z$ ]7 _independent precocious puberty, which is also known
3 g' i& _! s4 l T0 r9 Ias testotoxicosis, may cause precocious puberty at a& n9 z5 Q! B P. _8 r* V
very young age. The physical findings in these boys
- i# Y4 h3 a" s9 P _- _with this disorder are full pubertal development,
E& Z: g! A" Tincluding bilateral testicular growth, similar to boys
! L2 g7 T8 F; uwith CPP. The gonadotropin levels in this disorder% \3 w" Q+ W/ W
are suppressed to prepubertal levels and do not show
0 ^" X' Z0 ]9 M! [/ epubertal response of gonadotropin after gonadotropin-
# E0 ~5 G; N H4 [releasing hormone stimulation. This is a sex-linked4 |; d' ^5 R$ u9 H
autosomal dominant disorder that affects only. R1 j ]( j, J4 t
males; therefore, other male members of the family
8 r# d& V3 a# [% jmay have similar precocious puberty.3
$ i, n: u+ z- I! {! q YIn our patient, physical examination was incon-3 l7 G0 Q8 T: G. k- a; f" w
sistent with true precocious puberty since his testi-* z9 v) S3 i+ n7 H# `* }
cles were prepubertal in size. However, testotoxicosis
% z6 G) L) v2 S& t% u, M: C* Qwas in the differential diagnosis because his father) U' D0 X. X/ y% o
started puberty somewhat early, and occasionally,. Z9 b6 @3 h, g) C) a, u- v% T" k( l
testicular enlargement is not that evident in the
* C' B8 E8 J4 x0 U- f/ Y( `beginning of this process.1 In the absence of a neg-
7 b! A. j3 }0 C- B4 ^; Q- n' I! C( i; [ative initial history of androgen exposure, our
) |$ A$ W6 @! o& j3 @0 R) [0 _# _) ?biggest concern was virilizing adrenal hyperplasia,
& y8 Y2 u7 H6 c) M# D% @either 21-hydroxylase deficiency or 11-β hydroxylase
! F1 K$ I, w c9 Zdeficiency. Those diagnoses were excluded by find-
7 x& v. d; Z5 Cing the normal level of adrenal steroids.
i4 | D; i2 JThe diagnosis of exogenous androgens was strongly: j+ v! s% h; Y- M+ m6 g: w, U
suspected in a follow-up visit after 4 months because
; d" |; Y, i5 Q% I* zthe physical examination revealed the complete disap-/ e Q9 O8 m: k, v0 M: O, W5 T
pearance of pubic hair, normal growth velocity, and
0 I% d" R( i& w- ?' N. wdecreased erections. The father admitted using a testos-& J* N1 _9 G: F* r4 ?! L9 G
terone gel, which he concealed at first visit. He was
7 T- k& j& z2 O7 ?using it rather frequently, twice a day. The Physicians’4 u4 Q, ^7 x% V+ J* D4 j# f
Desk Reference, or package insert of this product, gel or7 E2 m6 y% k5 ]7 F b5 j; {
cream, cautions about dermal testosterone transfer to
n+ v7 O8 g$ L' h( ^" Kunprotected females through direct skin exposure.9 G1 i! [. t7 {5 C/ w
Serum testosterone level was found to be 2 times the
- X5 P5 M) s5 T( b4 w, [$ S! }+ qbaseline value in those females who were exposed to, d6 N1 V+ L1 G) Q$ R
even 15 minutes of direct skin contact with their male) y! W# D8 j; V7 d& R: B* k
partners.6 However, when a shirt covered the applica-. @- Z3 [" o9 W- G0 c" Z
tion site, this testosterone transfer was prevented.
8 \5 V- }9 d! \, v4 y0 xOur patient’s testosterone level was 60 ng/mL,
% a8 p- t: G* [; b7 }which was clearly high. Some studies suggest that f5 X5 g( ~8 }# f9 w
dermal conversion of testosterone to dihydrotestos-+ j- I: @" r5 U
terone, which is a more potent metabolite, is more
6 |' U& h/ e0 M- h# ?9 z" ]active in young children exposed to testosterone
: J: t+ _2 C6 ^9 q9 Nexogenously7; however, we did not measure a dihy-. C9 Y; Z& J! m3 M
drotestosterone level in our patient. In addition to4 s( }$ C. G/ N* ?
virilization, exposure to exogenous testosterone in- t j! p1 {. k) J6 M7 l( P
children results in an increase in growth velocity and
' \5 p: h, y3 A# Yadvanced bone age, as seen in our patient.( E' {/ x' Y5 x! x+ ]1 y0 I4 Z
The long-term effect of androgen exposure during
& u( H1 l- m; ?! _" q3 Dearly childhood on pubertal development and final
! j0 S# [% x* [; A3 z1 Wadult height are not fully known and always remain
, r# o" ?' A% x6 La concern. Children treated with short-term testos-! u2 }- v: a8 b$ {: J: ^
terone injection or topical androgen may exhibit some. ^5 S( `) _8 q" Q8 Q
acceleration of the skeletal maturation; however, after
4 j. X8 [0 V% q6 J$ k8 pcessation of treatment, the rate of bone maturation2 F; ~4 b N2 W
decelerates and gradually returns to normal.8,9
( ]3 ^( v; H0 NThere are conflicting reports and controversy' o) |2 h1 Q# W R5 A5 J
over the effect of early androgen exposure on adult% c/ S' a. f6 e1 ]6 R/ { F5 t
penile length.10,11 Some reports suggest subnormal' X. D9 Z. @0 W
adult penile length, apparently because of downreg-
V e7 X8 h& D3 o/ c" Z- G7 B( Fulation of androgen receptor number.10,12 However," ?9 ]5 Q7 w- }: R0 ~: Y9 B8 `
Sutherland et al13 did not find a correlation between" v9 F+ o4 F C: t& W
childhood testosterone exposure and reduced adult! ]' M0 s6 |$ A0 s
penile length in clinical studies.* S6 F! z, E2 A5 x! ~
Nonetheless, we do not believe our patient is$ ^4 e6 ?/ i3 t( W
going to experience any of the untoward effects from
+ f. M' A/ U; v& Mtestosterone exposure as mentioned earlier because- m6 x2 |, ^( e+ i. i) ]6 {
the exposure was not for a prolonged period of time.) G8 s0 ?; ]/ l
Although the bone age was advanced at the time of/ w- d0 P* q% D4 G! U
diagnosis, the child had a normal growth velocity at' t7 u$ F; y, D" Z$ I( p
the follow-up visit. It is hoped that his final adult
: O6 E3 R/ \: y1 fheight will not be affected.
: ?5 M8 V5 F* a! V6 \Although rarely reported, the widespread avail-
* K2 O; K9 k! O7 R4 B, p h* Vability of androgen products in our society may/ M7 Q) y4 [0 N: q7 j
indeed cause more virilization in male or female
6 x$ U5 g, w' t+ ]/ n. V# w! Cchildren than one would realize. Exposure to andro-) Q# _/ a* Z: M: T
gen products must be considered and specific ques-6 g, ?) G; A' E
tioning about the use of a testosterone product or0 ~8 a4 I3 F5 R1 o) ]+ M( x
gel should be asked of the family members during6 H; [/ e5 ]; M9 f4 { @6 ]7 \2 W# S6 ~
the evaluation of any children who present with vir-
- s' g3 m# H) X ]1 gilization or peripheral precocious puberty. The diag-- P6 e- @' @% Q! R; n+ O
nosis can be established by just a few tests and by& X5 g) x. W: t! U7 H# E) G
appropriate history. The inability to obtain such a
; f# ?% \9 r9 M3 Y: ?2 ~2 Ohistory, or failure to ask the specific questions, may
' h" _( ~$ v h5 O7 [2 r$ mresult in extensive, unnecessary, and expensive6 J8 Z1 b+ D) q& I5 B: d5 T
investigation. The primary care physician should be, Y, r4 R! _0 D# o: i
aware of this fact, because most of these children
" g7 G1 E7 Z$ _% M* u' y* Amay initially present in their practice. The Physicians’
1 {2 w% @6 C' z6 y: LDesk Reference and package insert should also put a
9 c7 j% x, O. G3 M. H2 Vwarning about the virilizing effect on a male or
. j- t) I/ @; B% m/ \9 sfemale child who might come in contact with some-
/ [3 d3 z# E& aone using any of these products.9 z# x3 |+ n* u, b* ^8 z' |1 v
References
7 w; E8 P7 a3 s( z5 t. s9 t) b1 f1. Styne DM. The testes: disorder of sexual differentiation
, f* P5 R* I3 R0 D0 N0 pand puberty in the male. In: Sperling MA, ed. Pediatric& B" e$ h$ k% G% m
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
& |/ z) f) H' d& r* y/ n2002: 565-628.
# L8 Q# z& O6 I k Z2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious! b9 w' {3 N) `* n' ]) t8 T9 F
puberty in children with tumours of the suprasellar pineal |
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