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Sexual Precocity in a 16-Month-Old+ ~+ x$ ^) v1 l. @* J
Boy Induced by Indirect Topical
9 L) }; K% `$ Q* e8 YExposure to Testosterone: x: Z; e6 x$ D' y/ U: P2 R# j
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2) p$ f6 i4 g: g. F
and Kenneth R. Rettig, MD1
4 Z" Z7 v6 v% a$ C7 O- g% W0 y% d GClinical Pediatrics% C& _* D0 q* G$ m& w9 p5 E
Volume 46 Number 6* \- T6 W1 y, ~& j7 \
July 2007 540-543' d! N( k+ o6 e
© 2007 Sage Publications
' a* P! R% g0 q4 Q: V10.1177/0009922806296651) q% ]' d8 U3 n6 Y5 }
http://clp.sagepub.com
" l, K$ j( }$ M3 f( i1 _hosted at. D& P+ M5 P/ t3 @ n9 ~3 J
http://online.sagepub.com
4 P( H9 L* Y4 K, T, v; p+ jPrecocious puberty in boys, central or peripheral,, k; M& w! L k! j1 n j
is a significant concern for physicians. Central
8 Y9 s3 @! `% F* E! Zprecocious puberty (CPP), which is mediated
0 I5 R, S3 O8 l- V! K3 f4 ~4 y6 H8 _through the hypothalamic pituitary gonadal axis, has: r" t4 C. z3 _' ^1 e' e8 [
a higher incidence of organic central nervous system
+ F; y8 ?$ H& l4 K! a7 Nlesions in boys.1,2 Virilization in boys, as manifested- K0 z) | [- N! }; K
by enlargement of the penis, development of pubic. M/ c& K$ @, q5 M4 ]1 K; B% r% @
hair, and facial acne without enlargement of testi-
2 p3 }/ S/ N0 t1 Q& u1 acles, suggests peripheral or pseudopuberty.1-3 We4 c* K9 _1 r+ w
report a 16-month-old boy who presented with the
! w4 ]7 N7 }& X+ L2 s5 menlargement of the phallus and pubic hair develop-- p4 g* A* b4 ?2 C8 h1 x
ment without testicular enlargement, which was due
9 @! N) D/ l6 L% o6 |+ Oto the unintentional exposure to androgen gel used by2 y: b/ p8 M" Q0 _- d/ Q. v* u
the father. The family initially concealed this infor-. E' d3 l7 y% `
mation, resulting in an extensive work-up for this0 X3 Z" _; Y: ]* e! Y$ p8 c
child. Given the widespread and easy availability of
- F; O) d# F2 ?: @; \testosterone gel and cream, we believe this is proba-! L# {4 q& V2 Y/ G
bly more common than the rare case report in the& l# [# A( H7 m2 U
literature.4/ c( I; I$ f; `- A" o; z5 Y' G
Patient Report
~- J: x% m2 z* e) NA 16-month-old white child was referred to the
# W) X+ s3 S6 ?2 C5 yendocrine clinic by his pediatrician with the concern
+ o* U4 P! G/ Cof early sexual development. His mother noticed7 K5 ]( [0 G9 G0 u7 Z( x* |
light colored pubic hair development when he was1 X! J# L5 q Q; @! `
From the 1Division of Pediatric Endocrinology, 2University of4 c7 T. s( c y: A
South Alabama Medical Center, Mobile, Alabama.
3 p$ B! l# w+ ?( F6 VAddress correspondence to: Samar K. Bhowmick, MD, FACE,0 A5 R5 a I o* k8 @/ L9 @
Professor of Pediatrics, University of South Alabama, College of" A' e b# d% c1 r& e
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;7 K# z: r2 K, h9 m; N. n) f8 A, G5 B
e-mail: [email protected].
^( K; E1 G0 W8 p5 e7 @about 6 to 7 months old, which progressively became5 v- I: I& D$ N( Y
darker. She was also concerned about the enlarge-
3 w' v8 N8 z2 Wment of his penis and frequent erections. The child
" {- \, _6 F: H7 {was the product of a full-term normal delivery, with
: W* f# b3 u/ A6 D2 za birth weight of 7 lb 14 oz, and birth length of
3 n. L8 c3 \5 o1 K5 \" o! g20 inches. He was breast-fed throughout the first year! C0 z& q9 \1 `# `
of life and was still receiving breast milk along with' o! p3 v* w: j% v# {1 c% [5 Y
solid food. He had no hospitalizations or surgery,
3 g; g6 G; U) C! T3 Q0 T4 \4 @1 ^and his psychosocial and psychomotor development6 ~4 b( S9 I# |. O
was age appropriate.3 K$ E9 h2 e+ g3 y% f& `
The family history was remarkable for the father,
* w- _' X( C9 o4 L+ Jwho was diagnosed with hypothyroidism at age 16,
& C; f. d. y4 t+ _which was treated with thyroxine. The father’s
' ^- n& {1 D+ f8 Wheight was 6 feet, and he went through a somewhat+ C9 {+ P1 w7 ]5 i9 S2 z7 R" O% w
early puberty and had stopped growing by age 14., n3 E! h2 h/ _/ Z1 S# V6 S
The father denied taking any other medication. The
" | q, G" ?( U! x1 nchild’s mother was in good health. Her menarche
" N, r8 V# n- ^, y8 l7 s0 Lwas at 11 years of age, and her height was at 5 feet1 d% N8 a4 Y: y' y+ N
5 inches. There was no other family history of pre-
2 M2 \9 W/ _) R" Q$ Dcocious sexual development in the first-degree rela-' a* K! `- S: F) w w( N5 S# _, N
tives. There were no siblings.
$ g/ c9 Z+ s! M5 |7 [! `$ \Physical Examination; x6 s9 t: s \( s+ t) |
The physical examination revealed a very active,+ z2 h* K& x& ]
playful, and healthy boy. The vital signs documented
& ~! s/ H/ z. F' }$ z0 pa blood pressure of 85/50 mm Hg, his length was `! w0 }1 L, A- ~9 D
90 cm (>97th percentile), and his weight was 14.4 kg
% O. Y C+ l' Y- M I1 k(also >97th percentile). The observed yearly growth
- `* m+ `* G6 J% N {velocity was 30 cm (12 inches). The examination of% @4 T+ K( E$ J7 s
the neck revealed no thyroid enlargement.
6 K1 L$ i M4 p5 m1 }0 MThe genitourinary examination was remarkable for
# D6 `( y. y2 o2 d; a: ~" U8 I: [enlargement of the penis, with a stretched length of1 E$ B7 w1 _2 F
8 cm and a width of 2 cm. The glans penis was very well
; b" {* k" F8 ?developed. The pubic hair was Tanner II, mostly around
* ~/ O1 w( I- \4 }1 [$ A* G. E& N: }5401 H" X( H7 o: k, c6 c! a! s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from4 x0 E- g( R/ p7 \' W
the base of the phallus and was dark and curled. The
0 }% T& `8 e' {0 |) u, x; y+ ctesticular volume was prepubertal at 2 mL each.- g: y6 b# @3 h4 K$ @7 U x) u, M3 h
The skin was moist and smooth and somewhat
5 u9 p, U# r5 u! p5 V: ]oily. No axillary hair was noted. There were no3 V3 Y) D4 u% ?8 e! B8 \+ @" S' @
abnormal skin pigmentations or café-au-lait spots.
( \4 }5 O# f2 q( _2 INeurologic evaluation showed deep tendon reflex 2+( g4 f$ L4 x# h0 U
bilateral and symmetrical. There was no suggestion
' c8 D( M2 @. z) y& Uof papilledema.
6 a0 A% t+ u |4 r( [ e3 M: b# w3 VLaboratory Evaluation
/ T0 C. V7 i# c3 \; y: p$ b1 q) fThe bone age was consistent with 28 months by3 [; V7 n7 V" x0 C
using the standard of Greulich and Pyle at a chrono-
! p- \: g9 D3 G: Alogic age of 16 months (advanced).5 Chromosomal/ ~9 J2 ~" R; _1 i0 m% `) z' K' F
karyotype was 46XY. The thyroid function test3 O" E9 W( |- s ]/ V4 u; }* {
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
9 x: M' w$ p7 {lating hormone level was 1.3 µIU/mL (both normal).1 M& l+ U9 p( @, t6 ` T* D
The concentrations of serum electrolytes, blood" R- a' o% x* x! l
urea nitrogen, creatinine, and calcium all were# s$ m8 t3 T- l _/ c+ X1 f7 D+ c
within normal range for his age. The concentration% |# J8 u. r( V& Q1 O2 b
of serum 17-hydroxyprogesterone was 16 ng/dL
. v9 y. R/ G ]: }(normal, 3 to 90 ng/dL), androstenedione was 20
( a5 S5 Q" j% Ang/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) V+ i/ z+ Q- [8 y# M% Oterone was 38 ng/dL (normal, 50 to 760 ng/dL),* Q6 X2 E. s) E" b! S5 |
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
" }7 \, Q- x. r; X2 h, D' e49ng/dL), 11-desoxycortisol (specific compound S)5 F9 G% S/ b# {5 O7 D$ W9 N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
6 ?+ M7 Y, }( F X# ntisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 C$ }* Y# z% G* g( t% k( r1 D, Ftestosterone was 60 ng/dL (normal <3 to 10 ng/dL),1 x9 O& }- F! N* Z3 J
and β-human chorionic gonadotropin was less than
1 A6 L+ g( L* v# o: p5 mIU/mL (normal <5 mIU/mL). Serum follicular" u2 X/ m9 h% u9 I' ]
stimulating hormone and leuteinizing hormone' b$ \2 V, w/ m1 L, z+ {2 h: D
concentrations were less than 0.05 mIU/mL
' t# Z% K2 n4 a8 V8 t. f(prepubertal).
6 u! x/ G" c& c" ~& T- _6 K! x$ `1 kThe parents were notified about the laboratory" d1 n4 Z" M4 l- c% m
results and were informed that all of the tests were
: n$ e- c# g! A4 Unormal except the testosterone level was high. The. Y; z' W l/ x' L# l% b z; M
follow-up visit was arranged within a few weeks to) M1 h. d T/ g9 B( ]* G
obtain testicular and abdominal sonograms; how-0 n; z- B% H' M
ever, the family did not return for 4 months.
( Z: M$ ]+ E: n. s% m! R: lPhysical examination at this time revealed that the
5 `) K- g! r2 ?; V" Z" Y: achild had grown 2.5 cm in 4 months and had gained
# ~( l$ s% }+ T: `: t( _& H5 O2 kg of weight. Physical examination remained
X _; @, c+ c, |" Zunchanged. Surprisingly, the pubic hair almost com-5 C0 o) s& p# c& r9 U* W5 z
pletely disappeared except for a few vellous hairs at
; y0 n" K7 z8 ]% ?the base of the phallus. Testicular volume was still 26 C7 ~) @2 Z- x& m
mL, and the size of the penis remained unchanged.3 d, [* \' b8 P* n
The mother also said that the boy was no longer hav-
" G' S0 s+ f6 O( W3 `' Ming frequent erections.
4 m9 \3 E: @5 ?9 xBoth parents were again questioned about use of
: F& a6 P ` nany ointment/creams that they may have applied to
% V0 z( o( j8 Y) T, _# zthe child’s skin. This time the father admitted the- [ ]" S& K8 r4 f0 I
Topical Testosterone Exposure / Bhowmick et al 541
' P' h3 W* |" E% C9 b1 R2 Luse of testosterone gel twice daily that he was apply-
! I. G& X: ^ J- H4 T( @, }ing over his own shoulders, chest, and back area for" M% o6 t& }' e7 u
a year. The father also revealed he was embarrassed
, K ^" M, ~& D; d* u- \' bto disclose that he was using a testosterone gel pre-- A! y: I+ G A$ \ y8 D
scribed by his family physician for decreased libido- e1 G. O8 R1 _) n6 ^
secondary to depression.7 W+ j/ l `7 [
The child slept in the same bed with parents.( {- x9 R* B0 r, b4 `/ Z- Y
The father would hug the baby and hold him on his" H- P1 R2 j. ^' `2 g. V" `2 D! Q. L
chest for a considerable period of time, causing sig-
/ F) X9 a$ G( P2 wnificant bare skin contact between baby and father.
/ p9 i# y+ @1 S( fThe father also admitted that after the phone call,$ g6 s# |; a6 O6 \- l9 B8 E. |
when he learned the testosterone level in the baby) U8 x/ T# R, K+ y4 m3 r) h+ W
was high, he then read the product information
5 L9 |* t1 T7 X! Npacket and concluded that it was most likely the rea-" l4 s, ~0 t5 `4 y
son for the child’s virilization. At that time, they, Y% f" S7 b! [* |" R
decided to put the baby in a separate bed, and the3 O' e5 |0 _; n& Q7 o
father was not hugging him with bare skin and had
" y9 r5 K) l! s8 r: g G3 Vbeen using protective clothing. A repeat testosterone4 g% q- S3 p' N* ^" B, L
test was ordered, but the family did not go to the/ q* D- C: Y; _; m3 Q$ w9 e) ]
laboratory to obtain the test.
$ O# j7 `- ?2 U% BDiscussion: Y0 X; f D! H4 c
Precocious puberty in boys is defined as secondary
& Y& e, Y3 F0 V- Wsexual development before 9 years of age.1,4- C3 O; a9 [) _3 v- G+ _
Precocious puberty is termed as central (true) when& c$ | k8 F8 t" }
it is caused by the premature activation of hypo-% ~3 z. o' O- ], B! J/ U8 V0 V
thalamic pituitary gonadal axis. CPP is more com- X. }# A7 W/ ]3 R, q6 I, [
mon in girls than in boys.1,3 Most boys with CPP4 }) m& U1 s5 F7 J- Q
may have a central nervous system lesion that is
- C8 v8 W1 l) j9 W Zresponsible for the early activation of the hypothal-
1 k2 C: L: }6 v' f; aamic pituitary gonadal axis.1-3 Thus, greater empha-
- u8 X h" f' |sis has been given to neuroradiologic imaging in
. R( F" q0 B$ hboys with precocious puberty. In addition to viril-+ V2 V2 R3 ] ]4 K% x2 B% r# j
ization, the clinical hallmark of CPP is the symmet-
$ a% r) b# ?1 O& Arical testicular growth secondary to stimulation by8 D7 Q# f- C- N6 V* L, m. m. i0 [
gonadotropins.1,3( r5 [! L# b, _6 f
Gonadotropin-independent peripheral preco-
6 o; g9 i4 e/ Ncious puberty in boys also results from inappropriate4 C% Z0 F3 ]! o. h+ a. E0 o1 ]/ y: H
androgenic stimulation from either endogenous or
- }& T, n; U, d6 f; aexogenous sources, nonpituitary gonadotropin stim-' g+ R. @ R2 q1 B, }
ulation, and rare activating mutations.3 Virilizing# Z0 N5 J' C3 n
congenital adrenal hyperplasia producing excessive
3 q" E/ U. g% D$ [1 I& X1 q0 Gadrenal androgens is a common cause of precocious0 p# L! B5 u F5 u" l! m, E
puberty in boys.3,4
4 N9 ? x3 _, i4 k1 q9 N4 d, tThe most common form of congenital adrenal
. W7 ~) T! m- Y) p/ f' O; zhyperplasia is the 21-hydroxylase enzyme deficiency.
8 P% Y9 F( Z4 o' ]1 IThe 11-β hydroxylase deficiency may also result in
% G! Q- u5 W, w7 j% e: mexcessive adrenal androgen production, and rarely,6 n) Q5 K& M" u; w# M9 W
an adrenal tumor may also cause adrenal androgen
# G. h( s l, Gexcess.1,3+ c; O7 F2 J5 q- B1 M/ K
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 a$ G% e* y* Y T- ~542 Clinical Pediatrics / Vol. 46, No. 6, July 2007% ?; C% p0 \# C0 o. _
A unique entity of male-limited gonadotropin-
+ u1 z! O# p7 w+ M6 K* Z/ n$ X0 {independent precocious puberty, which is also known
( |& y: E) w( _4 P! tas testotoxicosis, may cause precocious puberty at a8 M: h: X: p$ ]5 k! w
very young age. The physical findings in these boys0 J V- }6 W% b
with this disorder are full pubertal development,/ a% M; t- d0 U" c# N" B: ?
including bilateral testicular growth, similar to boys
" H. x) X3 \+ ?1 V+ ^5 Rwith CPP. The gonadotropin levels in this disorder' v6 v4 Q' L; x
are suppressed to prepubertal levels and do not show
1 L" C0 Y% G( E$ R) apubertal response of gonadotropin after gonadotropin-( ^) e4 e/ r% I9 L$ M ^
releasing hormone stimulation. This is a sex-linked0 v* Z. f* \, u/ J/ ^, J
autosomal dominant disorder that affects only, T3 g& P/ x& ?
males; therefore, other male members of the family
+ M7 `9 V1 V, T7 Z; @may have similar precocious puberty.3
' ?( R; @* Z! j" ?) x. N. nIn our patient, physical examination was incon-5 k( Z( k! z" ~4 Q% k k
sistent with true precocious puberty since his testi-0 } J t2 d9 ?1 ?1 g: ]/ r
cles were prepubertal in size. However, testotoxicosis, u7 H1 E$ Z' \8 o7 r3 L. v# w
was in the differential diagnosis because his father8 L* C' V, ~7 b# |( O: }- B) ~
started puberty somewhat early, and occasionally,! n( G4 C8 ]5 u$ U+ e
testicular enlargement is not that evident in the
/ r6 R! {& ^' b2 l5 D+ a# _beginning of this process.1 In the absence of a neg-
/ g- m7 f% z1 T# {5 lative initial history of androgen exposure, our+ O$ ^6 y, x& W+ W: h4 M" m
biggest concern was virilizing adrenal hyperplasia,
/ @( n- C4 p9 z# N9 F* L1 m2 G5 reither 21-hydroxylase deficiency or 11-β hydroxylase2 ?3 J G5 s6 H- n- W# ^* q& E
deficiency. Those diagnoses were excluded by find-
; X% |2 U/ r0 X! f6 Cing the normal level of adrenal steroids.
, Q: O6 D8 B$ V, N: ` t pThe diagnosis of exogenous androgens was strongly1 e5 Y; L D' t
suspected in a follow-up visit after 4 months because
$ \: e- ~ v! y9 Z6 @the physical examination revealed the complete disap-5 ], C1 X( A: O# |$ |2 k* A7 f E9 [
pearance of pubic hair, normal growth velocity, and9 M9 W8 l Q; V
decreased erections. The father admitted using a testos-; c* P2 C H9 r+ Q" c
terone gel, which he concealed at first visit. He was
( ]0 i0 \( {% uusing it rather frequently, twice a day. The Physicians’$ I/ ?+ B+ ?. D/ g9 D
Desk Reference, or package insert of this product, gel or
. b# k0 b; ~0 f7 n) |. Ecream, cautions about dermal testosterone transfer to8 ]: Q- e) D c X0 u2 C
unprotected females through direct skin exposure.( B1 ~7 y5 B* [$ ?" T
Serum testosterone level was found to be 2 times the
+ f) t7 g6 ]- j/ F" ~baseline value in those females who were exposed to7 y F8 [8 N, j- z6 Z8 D
even 15 minutes of direct skin contact with their male y: {9 _0 y* Z8 j, M
partners.6 However, when a shirt covered the applica-! h' Y) f! b8 S6 g( s
tion site, this testosterone transfer was prevented.
, }# ~7 f- d& C" [Our patient’s testosterone level was 60 ng/mL,7 ^% F- }3 f5 |( p6 K' x1 ^4 o
which was clearly high. Some studies suggest that3 ~' m7 {$ p% ?) o: B1 f* S. e/ R; n
dermal conversion of testosterone to dihydrotestos-
- m+ o& H& R1 `, l f- e& G% Nterone, which is a more potent metabolite, is more' b' c5 x3 C% T1 A, p o- u
active in young children exposed to testosterone- c) A" t4 P8 i, z' D% B' m+ W
exogenously7; however, we did not measure a dihy-
2 f3 S+ ^; ?0 i( I' c5 }8 o, Idrotestosterone level in our patient. In addition to+ x% A0 q0 a9 U- @1 | U- }4 J3 t
virilization, exposure to exogenous testosterone in* e) b4 h' P3 ~, ?
children results in an increase in growth velocity and: R% S, P" p, R3 k) ^" n
advanced bone age, as seen in our patient.* o- P! c7 S' o0 |
The long-term effect of androgen exposure during
; Q% l3 Y/ m3 I* cearly childhood on pubertal development and final
; p1 _+ J N9 ]" ~, Z& e( e) Fadult height are not fully known and always remain6 P- z2 a# w4 T0 W+ Y. R
a concern. Children treated with short-term testos- M' @% {) }( \* Z" T) v. k
terone injection or topical androgen may exhibit some
3 M1 K: X+ [* V) C9 \5 jacceleration of the skeletal maturation; however, after& f# ?2 j+ k2 W8 g, {
cessation of treatment, the rate of bone maturation
$ ^3 l) i; ~' F% I8 Xdecelerates and gradually returns to normal.8,9
' V" I( s! `0 G6 D( U: IThere are conflicting reports and controversy7 x* k! _: K! Y1 C @1 |
over the effect of early androgen exposure on adult
" f/ D) r+ i$ P, k4 v' Ppenile length.10,11 Some reports suggest subnormal+ g: i: T2 N: ]" x. f! w, {
adult penile length, apparently because of downreg-+ ]1 ?6 s1 x+ n3 L; o; B7 P
ulation of androgen receptor number.10,12 However,7 {9 t2 c$ K, ]4 \
Sutherland et al13 did not find a correlation between
1 P4 z }' ?$ B" p5 U" u% ichildhood testosterone exposure and reduced adult
+ I9 y) }& i+ g" ]& i3 D+ Apenile length in clinical studies.
- w' H A7 R, q, y9 uNonetheless, we do not believe our patient is
1 X$ V; _3 M$ H4 }going to experience any of the untoward effects from; e' X1 }( ^' ^
testosterone exposure as mentioned earlier because, t# b$ y5 l. s; T
the exposure was not for a prolonged period of time.
# A& g G" V. Q1 k$ C+ lAlthough the bone age was advanced at the time of
7 h# m/ d0 P; G; q: R; }diagnosis, the child had a normal growth velocity at; ]) [, S9 B1 G. D& t' @; m* S
the follow-up visit. It is hoped that his final adult( E/ |9 @, P0 @
height will not be affected.3 F& P( ` q) \
Although rarely reported, the widespread avail-
% J% ]" g( x- J3 S j; tability of androgen products in our society may
+ U% F2 |. M8 \3 E( g5 J' H! ?4 Oindeed cause more virilization in male or female
2 B, q& y3 x3 e1 M! W; J9 K6 z( qchildren than one would realize. Exposure to andro-
- n0 W# }5 ~1 b( f( `gen products must be considered and specific ques-
8 L9 m! \3 v$ ^ T4 v5 t; Gtioning about the use of a testosterone product or' N7 c( P% j/ m4 e) m7 F
gel should be asked of the family members during
+ B( Y) e! U; T$ Lthe evaluation of any children who present with vir-1 E4 S% p2 \! V% G5 d( F- n* |$ A
ilization or peripheral precocious puberty. The diag-
/ R5 i6 ]: A! H- p5 cnosis can be established by just a few tests and by- r% q2 y% Y% v: S6 B. A* X& e) @
appropriate history. The inability to obtain such a
$ m- ^" R6 E: F9 [: uhistory, or failure to ask the specific questions, may2 _" q( t2 U; ?6 b
result in extensive, unnecessary, and expensive1 L. q$ T6 `. r& j
investigation. The primary care physician should be
0 ^4 L- _3 ~9 baware of this fact, because most of these children
?" j0 S' x5 l- ^8 e/ ymay initially present in their practice. The Physicians’7 U1 p' R/ z+ e% v8 j/ F+ q/ E9 x
Desk Reference and package insert should also put a
/ S$ a# [9 v4 e/ Jwarning about the virilizing effect on a male or
1 f* E0 d* v, T' I. M: H; i0 E, efemale child who might come in contact with some-
* t$ E M, X/ Z7 V4 Yone using any of these products.
" r& z1 q/ L$ s% L' P1 o% \References' Q, T u$ u4 P4 F! k1 q% X
1. Styne DM. The testes: disorder of sexual differentiation& {" w, ^, U8 Q. j& q7 `0 x
and puberty in the male. In: Sperling MA, ed. Pediatric
+ B) x* E% H5 n8 T( h4 ~0 qEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;4 R2 y( ]+ B! W) ^8 O5 }
2002: 565-628.. t6 n, }! h! u) c" D
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious7 }5 D B7 O+ H5 P2 Y6 K
puberty in children with tumours of the suprasellar pineal |
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