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Sexual Precocity in a 16-Month-Old( n8 c" Y2 C+ i, N( E% C
Boy Induced by Indirect Topical
( g' c, W2 v) m2 P' @2 t2 V' TExposure to Testosterone' ^0 b) p5 ^( u: ~9 z. e- m* L
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 B2 Y6 n; }# |8 R1 A1 @( }and Kenneth R. Rettig, MD1
- `' Q, e- H2 }3 J0 V+ f6 mClinical Pediatrics
; _7 \- f; U* OVolume 46 Number 61 o; Q- O; H6 T/ I: b3 }6 M: |
July 2007 540-543
) p d" @4 R5 K, f7 m, D© 2007 Sage Publications
% A) a7 h6 U7 C3 |: d( y10.1177/0009922806296651
5 X2 P1 @' n/ m$ j, ?" \0 [. a! ~http://clp.sagepub.com
7 K5 r* f4 Y- S) i% f7 L* T0 Zhosted at
- q* q: f& `1 e& C$ Hhttp://online.sagepub.com
( a. y8 V5 `3 Z- T+ y5 dPrecocious puberty in boys, central or peripheral,5 e5 K6 r( Y8 P. @& b$ y* Z
is a significant concern for physicians. Central
2 O8 h. \0 E' T. H+ p" W$ ^6 bprecocious puberty (CPP), which is mediated
* o8 A, l) B% z* D. ]/ M9 ~through the hypothalamic pituitary gonadal axis, has; `: P4 {5 J. b% d
a higher incidence of organic central nervous system: ]. _5 V; l o
lesions in boys.1,2 Virilization in boys, as manifested
7 f2 m2 P+ D. B: i, t3 Lby enlargement of the penis, development of pubic. O7 y, u5 E; @
hair, and facial acne without enlargement of testi-7 Z" M. p' K9 g) |
cles, suggests peripheral or pseudopuberty.1-3 We+ B; ]. F- z5 \ o! |
report a 16-month-old boy who presented with the
$ W# z& S, [ [+ x6 P- Nenlargement of the phallus and pubic hair develop-/ T. k6 _7 u# L5 ]- a7 J: R" }( v
ment without testicular enlargement, which was due+ {1 K y$ M( a, T, p+ Y6 J* G
to the unintentional exposure to androgen gel used by, k0 m! n) x6 u& l {6 }
the father. The family initially concealed this infor-: C, Q/ ~7 i' \' w& L! k0 O- Y' i9 x
mation, resulting in an extensive work-up for this
9 e% ]5 l# Y: l; J; f$ A' T$ B$ cchild. Given the widespread and easy availability of
* W+ o0 r- [' w0 }testosterone gel and cream, we believe this is proba-
6 ]+ g0 U) S/ K+ Sbly more common than the rare case report in the8 a! J4 W3 G p @
literature.4
- I0 j. U9 E. ~4 A+ L0 u$ a g$ `3 GPatient Report8 f$ Y2 P) b: I
A 16-month-old white child was referred to the
1 l6 Z1 }3 [, }8 J) Q( wendocrine clinic by his pediatrician with the concern
4 x" G, D7 [8 Sof early sexual development. His mother noticed9 J4 l% c- Y4 q% P2 ?
light colored pubic hair development when he was; j6 {- ?' a- ?; B# Q
From the 1Division of Pediatric Endocrinology, 2University of
- E% z9 h" r6 W% L% e5 G5 C% PSouth Alabama Medical Center, Mobile, Alabama., R0 K* u+ D3 H
Address correspondence to: Samar K. Bhowmick, MD, FACE,, G3 p: v$ v7 L% b2 Z' A# k- ^9 t
Professor of Pediatrics, University of South Alabama, College of
- p2 n d# r6 V i3 PMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;1 @; G. S. I+ a: a9 l! i5 U: a: ]$ N
e-mail: [email protected].
6 N4 B5 x& U& j" Vabout 6 to 7 months old, which progressively became( ]8 m% t& \+ ]3 D/ e8 J
darker. She was also concerned about the enlarge-# d7 U' Y# f- g: Q# ^; P3 n
ment of his penis and frequent erections. The child4 N* U" ]0 @" ]8 t5 P- ]- u
was the product of a full-term normal delivery, with/ S( \2 `8 p1 p. k' k% O$ z$ m
a birth weight of 7 lb 14 oz, and birth length of: N- b! @) a4 }
20 inches. He was breast-fed throughout the first year
( R8 H, W; `* E7 H. g/ q% kof life and was still receiving breast milk along with
5 n, R( }! A+ L# o( Asolid food. He had no hospitalizations or surgery,
/ U% g O7 y ?! {: j$ W, hand his psychosocial and psychomotor development3 t c; W- n. Z) a0 P
was age appropriate.
' }9 `& t, Q# v: v( ?& T5 vThe family history was remarkable for the father,
. Z% q' n. c4 f# b7 j4 \who was diagnosed with hypothyroidism at age 16,/ a) M9 Z2 I( u g5 g& J! f
which was treated with thyroxine. The father’s- J" V5 }, O% }/ x7 Y5 C& c. v
height was 6 feet, and he went through a somewhat
4 G9 R' s+ u* G/ k4 ^" @9 Kearly puberty and had stopped growing by age 14.& T8 i+ r& C1 c0 x* f
The father denied taking any other medication. The# g2 b3 P% S4 n, C7 b3 r
child’s mother was in good health. Her menarche( F# E* e% B3 g6 V+ W0 E
was at 11 years of age, and her height was at 5 feet
3 J" G7 P/ z8 J! \6 f7 w5 inches. There was no other family history of pre-
' i2 K% `/ r4 N; Pcocious sexual development in the first-degree rela-$ H+ ~; Z e* g
tives. There were no siblings." l: j8 `' J! ~, l
Physical Examination
2 b0 }" W: G9 o) O# KThe physical examination revealed a very active,3 y- q" h( U- S! R/ f# Y
playful, and healthy boy. The vital signs documented* B+ m, s, Q% E2 Z1 M0 J5 b
a blood pressure of 85/50 mm Hg, his length was
, V- V8 D; l" ?/ l90 cm (>97th percentile), and his weight was 14.4 kg
) L4 t: g) ~3 r( z(also >97th percentile). The observed yearly growth
8 I4 B) Y) y8 s$ ovelocity was 30 cm (12 inches). The examination of' D! N+ u2 L- ?$ j7 z& R# \0 }& C
the neck revealed no thyroid enlargement.
0 E3 { e* m4 `* uThe genitourinary examination was remarkable for
* L# a X* [' {3 |enlargement of the penis, with a stretched length of
0 W8 x8 I' }- s8 cm and a width of 2 cm. The glans penis was very well
) M6 d! E3 P" k" e1 [developed. The pubic hair was Tanner II, mostly around0 t. {! ]2 @- ^& z; ^
540# e( Y2 f( \$ I/ ^4 _' r/ A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% h& ?5 e- ? B& ]the base of the phallus and was dark and curled. The
8 w2 r0 L* }5 Rtesticular volume was prepubertal at 2 mL each.4 A- b+ z( D7 U X4 ~ Y K5 \
The skin was moist and smooth and somewhat
5 B; c; J1 Q& n( F1 ^oily. No axillary hair was noted. There were no
7 ?7 D; D: a0 v# Z6 I2 L1 vabnormal skin pigmentations or café-au-lait spots.
6 A9 h0 W: I0 q3 D G9 v) i" `Neurologic evaluation showed deep tendon reflex 2+
3 b6 H9 k" ]( d! I4 Kbilateral and symmetrical. There was no suggestion1 i/ Q g0 }& f
of papilledema.
* p5 G$ X% L6 h- eLaboratory Evaluation" y5 a2 E% S9 f G$ i1 }; H5 H+ M
The bone age was consistent with 28 months by
g# f% {2 W3 {$ S0 ?using the standard of Greulich and Pyle at a chrono-7 V! X0 p k2 l( Z- }
logic age of 16 months (advanced).5 Chromosomal
, W7 z8 D- {. o" `. fkaryotype was 46XY. The thyroid function test
* v( ^6 J* S+ e% d& D: P4 I6 @" u! P/ qshowed a free T4 of 1.69 ng/dL, and thyroid stimu-5 t: n& z2 g% M+ Y- c
lating hormone level was 1.3 µIU/mL (both normal).
" X; `6 Y' s+ ]- X% |The concentrations of serum electrolytes, blood" E) b, S6 M+ S6 i% C
urea nitrogen, creatinine, and calcium all were
0 x) B2 x3 v1 q2 Zwithin normal range for his age. The concentration
& o M7 q, W0 p$ [( O4 Pof serum 17-hydroxyprogesterone was 16 ng/dL" ]: L; s4 o- k5 G7 a
(normal, 3 to 90 ng/dL), androstenedione was 200 a( j3 B# k+ C% |5 O! D
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-9 o$ w; o7 W8 e
terone was 38 ng/dL (normal, 50 to 760 ng/dL),) i6 \* {( H6 A8 ^5 P& \
desoxycorticosterone was 4.3 ng/dL (normal, 7 to+ T- P. f8 X: d) h0 ~8 g
49ng/dL), 11-desoxycortisol (specific compound S)1 `' h: v( g; T H& I
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
7 b! b( c( D% I1 d) X" Stisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total" ~6 Q$ K/ j/ r4 W! r$ Q
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
7 S) ^" L# X/ i1 _and β-human chorionic gonadotropin was less than
, n2 i7 [: ?+ x/ @5 mIU/mL (normal <5 mIU/mL). Serum follicular1 z1 ?" l* Y1 F4 U1 _
stimulating hormone and leuteinizing hormone4 Q9 ~8 ]% A% q6 j& u. ~
concentrations were less than 0.05 mIU/mL
; T4 y: t- O$ p* b7 m9 [(prepubertal).4 h4 }% j* o" u8 P/ H: w" z
The parents were notified about the laboratory% `3 P& G* _) S; R; a
results and were informed that all of the tests were
$ D5 h7 B& p2 S9 t9 @4 Pnormal except the testosterone level was high. The: K( l- n$ {, q* Z) e
follow-up visit was arranged within a few weeks to
. N' Z5 u1 a9 W7 Yobtain testicular and abdominal sonograms; how-' k% X$ l2 {! O/ O( a- s
ever, the family did not return for 4 months.! | [. J: }% `9 \1 u
Physical examination at this time revealed that the
1 {' d+ X6 E1 M9 D7 E A- M. bchild had grown 2.5 cm in 4 months and had gained% f+ Y( p8 W7 {% t/ P
2 kg of weight. Physical examination remained2 k; a, H4 x* ?7 m U) k/ O {
unchanged. Surprisingly, the pubic hair almost com-
) J: f w) R7 i) ?pletely disappeared except for a few vellous hairs at9 b" `& T X' y
the base of the phallus. Testicular volume was still 2" ?4 P& H0 l0 v K2 K
mL, and the size of the penis remained unchanged.
4 b" a5 U; A+ I6 E# kThe mother also said that the boy was no longer hav-
5 J) ?6 h) t$ ?( }6 _2 n1 x b7 Ding frequent erections.
: V# V; Y x$ J! [Both parents were again questioned about use of- ?( |- Z6 r6 s) v
any ointment/creams that they may have applied to- {& U+ K+ J) _ D9 n& d3 ]- W
the child’s skin. This time the father admitted the
6 f: A+ Z0 f4 H5 A* u8 h3 R" |' GTopical Testosterone Exposure / Bhowmick et al 541: u; f, `# Y4 e9 t$ P- a+ y" q
use of testosterone gel twice daily that he was apply-; o9 J8 F* V+ _( x( \/ B' U# ~
ing over his own shoulders, chest, and back area for
( E+ r- ^ Z4 ~& s/ ]: K. ua year. The father also revealed he was embarrassed
" x* i `) @0 A) \/ fto disclose that he was using a testosterone gel pre-
& J. ^% U, V: D: Xscribed by his family physician for decreased libido
/ d$ f' w8 c# m- S' ~% B5 [! ]secondary to depression.
9 ~2 \3 h5 L* ]! m& AThe child slept in the same bed with parents.
7 F; W m; @( k! NThe father would hug the baby and hold him on his
/ Z- A: U( b$ U+ ?, Ychest for a considerable period of time, causing sig-
! v1 V( q* m& p9 X/ bnificant bare skin contact between baby and father.0 N! l/ l* u0 U! L# ~' J/ x6 U
The father also admitted that after the phone call,/ x/ M' p$ B) u1 E. i! P8 k
when he learned the testosterone level in the baby
) V# W1 o# j% d ]+ r5 j+ K' Q- Hwas high, he then read the product information/ o/ b* X- {3 ~ j8 G! f
packet and concluded that it was most likely the rea-
7 @7 l! S% A! T. o. j7 P6 M0 Qson for the child’s virilization. At that time, they& _/ n- K6 r8 h
decided to put the baby in a separate bed, and the- m. U0 c# o" D; ]8 `2 s
father was not hugging him with bare skin and had1 Q' P, r( C G+ [( q
been using protective clothing. A repeat testosterone" P+ ~8 r1 u; d) I
test was ordered, but the family did not go to the
, v. K$ Q: D8 Z. dlaboratory to obtain the test.8 o+ R* A. V2 [! M
Discussion9 W% J% ?9 P! |0 q- o
Precocious puberty in boys is defined as secondary9 U# b) h( Z# {# B! H
sexual development before 9 years of age.1,44 {- S& K! Z; j/ a
Precocious puberty is termed as central (true) when
2 _4 |( E; ?2 \6 b7 {( U: ]) Xit is caused by the premature activation of hypo-
2 l0 w' \2 P) o5 Bthalamic pituitary gonadal axis. CPP is more com-% O0 Q6 A; D- h0 v# z' A
mon in girls than in boys.1,3 Most boys with CPP( s+ ]5 O% I% p/ Q, R
may have a central nervous system lesion that is
! g1 u+ v, `5 J5 j1 I, Y$ g) }+ Mresponsible for the early activation of the hypothal-
( N& P: s b# u$ V/ Bamic pituitary gonadal axis.1-3 Thus, greater empha-+ n8 d2 ?# x7 n) v1 e
sis has been given to neuroradiologic imaging in) j2 o/ Y. d& D {9 {1 ?' j
boys with precocious puberty. In addition to viril- [- D! D: k7 R$ E* s* r* H
ization, the clinical hallmark of CPP is the symmet-
6 w; P# `- y! Zrical testicular growth secondary to stimulation by
8 z M9 }7 f( ~- j1 _& `- Hgonadotropins.1,3
6 I" z% S, D; |3 ~( B" p7 g YGonadotropin-independent peripheral preco-+ y; l& M& m7 z
cious puberty in boys also results from inappropriate2 J; q; z j+ c# _# o7 Q
androgenic stimulation from either endogenous or
0 _& X/ D. a* V- kexogenous sources, nonpituitary gonadotropin stim-, R9 r2 M- S" ?4 ^* N3 u- k; }
ulation, and rare activating mutations.3 Virilizing( L: u7 G& ]( p; h1 ?
congenital adrenal hyperplasia producing excessive
J/ ^3 x9 o, @& ?4 Zadrenal androgens is a common cause of precocious- F1 t0 j4 Z4 D% D; y) q8 m
puberty in boys.3,4
* h8 C: X& l4 LThe most common form of congenital adrenal1 p3 f& J/ p' D7 M9 N2 C
hyperplasia is the 21-hydroxylase enzyme deficiency.
' B, F& v" K- m5 c; ?6 [! pThe 11-β hydroxylase deficiency may also result in
3 |6 ]/ D2 g& m/ x; ]" g3 qexcessive adrenal androgen production, and rarely,
1 f2 F0 \: q( a4 o6 _an adrenal tumor may also cause adrenal androgen
" o9 {9 G, u# E5 ]9 gexcess.1,3
( S7 a* v. n! q- X* O$ kat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' H) F. w7 x% j( c542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
* V/ N( ]8 ]( e4 pA unique entity of male-limited gonadotropin-
/ y a; ^/ i3 w; a4 cindependent precocious puberty, which is also known$ W9 f) I) z# _- L3 A3 p
as testotoxicosis, may cause precocious puberty at a
; O$ F0 \- s5 vvery young age. The physical findings in these boys
/ U; [ I) y% P1 B9 Twith this disorder are full pubertal development,- q& H/ ^3 _, g$ k& E0 f3 D8 D( K
including bilateral testicular growth, similar to boys+ \8 j7 W5 d+ s; A
with CPP. The gonadotropin levels in this disorder
. s5 e, D5 A6 Yare suppressed to prepubertal levels and do not show
; l2 |& k! ~, A1 u; dpubertal response of gonadotropin after gonadotropin-
1 ~( J- L/ P# P( ?releasing hormone stimulation. This is a sex-linked
4 p2 v* v# S: ]+ w5 Oautosomal dominant disorder that affects only
9 A4 x, v( y# V& W/ Omales; therefore, other male members of the family M/ R9 P, g7 p, @ f1 j
may have similar precocious puberty.3
8 P8 c* \) P8 D6 _ L, cIn our patient, physical examination was incon-6 l$ y0 [0 J4 ^; K- J- W& G
sistent with true precocious puberty since his testi-6 j, O; \' [$ s# N- A
cles were prepubertal in size. However, testotoxicosis# S% \" s7 t" ^$ m. s
was in the differential diagnosis because his father
* v5 Z+ B8 ~! x) q: W! lstarted puberty somewhat early, and occasionally,& P3 U# j1 i0 z- i' ?
testicular enlargement is not that evident in the
( ?: M3 G' I7 l9 Lbeginning of this process.1 In the absence of a neg-& u& I& Q% R, @9 q7 F$ S+ O
ative initial history of androgen exposure, our; P+ i! s2 a# W/ V$ S {
biggest concern was virilizing adrenal hyperplasia,8 U; g- h d p
either 21-hydroxylase deficiency or 11-β hydroxylase
7 e; N7 A. Z: L2 h Gdeficiency. Those diagnoses were excluded by find-# s1 z2 C2 V5 ?" l5 i
ing the normal level of adrenal steroids.' C% ]& P# F8 b' b/ t
The diagnosis of exogenous androgens was strongly' D- p0 G, `. D- u4 t# i/ k5 |
suspected in a follow-up visit after 4 months because
( n' p: `! L. zthe physical examination revealed the complete disap-
, d6 u( [7 d9 \9 c6 H6 Jpearance of pubic hair, normal growth velocity, and1 W6 w) z% @* a! K4 A7 ~2 U
decreased erections. The father admitted using a testos-
6 c3 @3 k* U+ ?* k7 O( w, f' [terone gel, which he concealed at first visit. He was
3 y) \0 g! b6 C! d* }/ Tusing it rather frequently, twice a day. The Physicians’
7 f, X9 X1 g! h% H6 v- PDesk Reference, or package insert of this product, gel or+ `- r# F) E" }$ t1 b5 B( x- o
cream, cautions about dermal testosterone transfer to# h) ]- `, n& S7 t- n- }% D& B' J
unprotected females through direct skin exposure.
2 }* ~, k, l) I- x% YSerum testosterone level was found to be 2 times the
9 ^- ~. N) d+ D7 gbaseline value in those females who were exposed to+ \1 A* s+ ^; {9 `
even 15 minutes of direct skin contact with their male
/ w0 `/ Z: E! }$ }! Tpartners.6 However, when a shirt covered the applica-
w; R, x+ j6 i! q5 X/ _. etion site, this testosterone transfer was prevented.
% Z8 B9 b6 O, A+ Q; l3 _4 fOur patient’s testosterone level was 60 ng/mL,+ k/ y; j& \9 Z8 {, u$ p7 L
which was clearly high. Some studies suggest that
" c( e! T3 I# X5 z# u" I8 _! pdermal conversion of testosterone to dihydrotestos-( O% L: C6 Q4 K4 d R! A0 k4 k
terone, which is a more potent metabolite, is more
% e) O& A+ w6 r5 W2 Cactive in young children exposed to testosterone
o7 W5 E1 M4 r3 m8 C8 iexogenously7; however, we did not measure a dihy-. ~% f- _! O6 D& ~: i' c
drotestosterone level in our patient. In addition to) q" y- s4 ?% D8 N
virilization, exposure to exogenous testosterone in
# y" h4 \- j& ?# mchildren results in an increase in growth velocity and! X: W1 X# [/ V' h* J" }1 r! x
advanced bone age, as seen in our patient.: Y7 L" S9 Y9 E
The long-term effect of androgen exposure during
& l' u& D B9 L b* e2 z0 ^/ s$ oearly childhood on pubertal development and final3 ?7 ^0 F% ]. M! k7 k1 Z9 R, D
adult height are not fully known and always remain; A* r: W# |! Z: ~- b7 J2 r
a concern. Children treated with short-term testos-
. u* n+ Z _ z3 ^/ }+ B& @" f' o9 pterone injection or topical androgen may exhibit some
6 X5 N3 o& i6 b% v: {2 z& {acceleration of the skeletal maturation; however, after: A8 G# \ g( {/ T0 ]
cessation of treatment, the rate of bone maturation9 T. w1 u- h1 O* p% @2 A- e# [1 Y$ z+ x
decelerates and gradually returns to normal.8,9/ r- C' M! n( Z
There are conflicting reports and controversy4 M/ o/ l7 K: t
over the effect of early androgen exposure on adult- F; A' v7 ?: {, f$ M% m r
penile length.10,11 Some reports suggest subnormal0 y4 j! H+ R' R0 s
adult penile length, apparently because of downreg-$ Y- |* b0 `! N- _ K
ulation of androgen receptor number.10,12 However,0 O& N& n; q9 R2 H5 j4 J
Sutherland et al13 did not find a correlation between
# L" z+ S) b7 C5 h# ychildhood testosterone exposure and reduced adult
: x# ^1 P+ {7 ]% O* d- h {penile length in clinical studies.
1 j8 m7 n' X' x a& P M& w) p( cNonetheless, we do not believe our patient is" V, w* S/ _, W; l' |. }
going to experience any of the untoward effects from
6 j) _% U# q( d8 s% c3 {4 ttestosterone exposure as mentioned earlier because
3 y9 P/ l+ _* q; L+ z1 x/ r9 Jthe exposure was not for a prolonged period of time.
% K, q& v0 M' mAlthough the bone age was advanced at the time of0 G8 Z- ^! x5 s6 R9 ~# H
diagnosis, the child had a normal growth velocity at
5 H1 R% P; x4 Ithe follow-up visit. It is hoped that his final adult8 a: o; W, d, S7 q8 o/ C9 L
height will not be affected.
8 R6 z2 p4 {$ Y/ v1 sAlthough rarely reported, the widespread avail-/ N5 t7 z/ Y8 G1 x! N
ability of androgen products in our society may
3 S/ J! t; c! @# D- o+ Uindeed cause more virilization in male or female
) w3 b- R7 }9 D6 Achildren than one would realize. Exposure to andro-" P% \: w o* S+ f) \# G [
gen products must be considered and specific ques-
% i; @' M! e1 Ationing about the use of a testosterone product or: F6 v/ @: j# G: M; B6 l
gel should be asked of the family members during
& m6 i) z2 Z- |& h" Cthe evaluation of any children who present with vir-: m, @- f6 u! }4 b9 B+ l$ c
ilization or peripheral precocious puberty. The diag-
# | A4 O& t! [7 G$ Dnosis can be established by just a few tests and by3 }# L7 n) V) e4 b+ e6 R4 k, S
appropriate history. The inability to obtain such a" F9 |1 z$ Q8 {) d! v! J' B4 P: B
history, or failure to ask the specific questions, may; i) p1 M3 k5 u0 `/ B$ F
result in extensive, unnecessary, and expensive# G" W0 }2 `! v8 Z3 m2 H
investigation. The primary care physician should be
. v1 H0 R7 Q, u [7 m- v7 @5 `6 paware of this fact, because most of these children
: a) P! g6 W- ~: Xmay initially present in their practice. The Physicians’
; s) _8 C$ W: ADesk Reference and package insert should also put a
2 @: y/ C- E$ I& u( G$ x" [warning about the virilizing effect on a male or# r' X6 @ ?/ V! D7 D+ m$ Y
female child who might come in contact with some-. ?: @. a( I5 k' a: F% _
one using any of these products.1 p( P! ]% i8 W( a
References
$ \/ k6 S& U! S0 R! R, h1. Styne DM. The testes: disorder of sexual differentiation! [3 L" c. i' Q/ X4 i3 [; a& v, |' A
and puberty in the male. In: Sperling MA, ed. Pediatric. Y3 K3 r1 |* u! z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;3 m5 @) r! J9 ^, S& ~
2002: 565-628.
* W8 a# Y. ~/ a5 T2 A9 [% S2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious# a' J% O5 J+ }% p
puberty in children with tumours of the suprasellar pineal |
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