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Sexual Precocity in a 16-Month-Old
# Z) x1 F# B& s# K% Z4 c7 h- KBoy Induced by Indirect Topical& J8 ~# x# U; Y' ~/ I
Exposure to Testosterone! C" M2 K/ G3 i7 c
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2 [1 X! e. b2 q- o' {* Q1 C
and Kenneth R. Rettig, MD19 V9 | r$ |1 U" {
Clinical Pediatrics! R6 u+ \/ ?5 K+ ?7 ?
Volume 46 Number 6
; p! e4 a0 Z" P1 o" `July 2007 540-543
& |8 U8 r4 {) Y f9 i" V© 2007 Sage Publications- t4 W+ L, [0 @ G
10.1177/0009922806296651# {1 X2 ~( }. y5 S
http://clp.sagepub.com8 h' Z" b$ H, q& S* E$ F
hosted at* R6 b- ]1 C$ G4 u
http://online.sagepub.com& Y6 O. T: y& J0 j
Precocious puberty in boys, central or peripheral,
3 A6 \ ]& b+ y: F+ [is a significant concern for physicians. Central
' Q" B* x4 A) Bprecocious puberty (CPP), which is mediated
% I1 V d/ ~8 S! V5 T+ s# v2 i( A) Uthrough the hypothalamic pituitary gonadal axis, has; |7 d- H/ }' R- g5 w
a higher incidence of organic central nervous system8 n4 K5 G& p" k
lesions in boys.1,2 Virilization in boys, as manifested
( H3 r+ W2 ~+ Hby enlargement of the penis, development of pubic. a& [0 F$ Y3 o5 B% l$ g5 }
hair, and facial acne without enlargement of testi-$ E) D$ v+ V0 x' Y* t1 T4 v5 a
cles, suggests peripheral or pseudopuberty.1-3 We m; {# `8 h- s+ c
report a 16-month-old boy who presented with the% h& @+ R7 r$ ^4 i6 d6 C4 E, p8 k
enlargement of the phallus and pubic hair develop-- }6 g. ^% n( M U" C9 V
ment without testicular enlargement, which was due5 o5 d* R5 O# ~$ i, L# `0 Z0 W
to the unintentional exposure to androgen gel used by
! v0 ]) F- |# Z1 v) _& Y9 }) f- othe father. The family initially concealed this infor-& X9 f) U" V2 p
mation, resulting in an extensive work-up for this5 e2 N! u0 F9 t
child. Given the widespread and easy availability of
6 f, x" j$ Q; v' e4 Rtestosterone gel and cream, we believe this is proba-
4 r- { H, @9 E; A! p8 qbly more common than the rare case report in the: C/ {% h1 F' `, E
literature.4+ p2 s( @9 [. I
Patient Report& O6 m9 s3 ^5 w! F& f$ X4 h4 j" ^
A 16-month-old white child was referred to the
" E/ a8 V- C+ X1 \endocrine clinic by his pediatrician with the concern
6 x/ R0 Y& [9 i0 |" R* r# m9 Mof early sexual development. His mother noticed' m) ~8 E1 T; g
light colored pubic hair development when he was
% o0 o- H+ e3 u: R5 w; S1 z8 FFrom the 1Division of Pediatric Endocrinology, 2University of
0 H* {) r# U2 L JSouth Alabama Medical Center, Mobile, Alabama.( \: I9 F" |8 f3 r
Address correspondence to: Samar K. Bhowmick, MD, FACE,/ `9 A/ F* C( ]
Professor of Pediatrics, University of South Alabama, College of( v0 u" U: Q" @' f3 }
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
: r& M" z( Q8 @+ me-mail: [email protected].
I/ l4 K# \9 L" f) ^9 u, ^about 6 to 7 months old, which progressively became: A9 _* P1 o" w d( O" t
darker. She was also concerned about the enlarge-) x# f# Y- x1 P' |4 n% T" u) p
ment of his penis and frequent erections. The child
0 S1 ]8 N$ d8 O& ~ X3 v0 jwas the product of a full-term normal delivery, with
9 F2 i; p' v2 Q0 Ja birth weight of 7 lb 14 oz, and birth length of
6 {3 S/ Q1 x* m. y' v# l8 ?20 inches. He was breast-fed throughout the first year0 h- K+ F* j' F) {. M, ?# x' T
of life and was still receiving breast milk along with8 Z U( _$ |2 j
solid food. He had no hospitalizations or surgery,# f* A! o# ^3 J# Q- J, |/ C
and his psychosocial and psychomotor development
) k/ H, @( ^, \* m: ~( Mwas age appropriate.
& R5 I9 w! o, I" \' }The family history was remarkable for the father,
& _! j( X* n# @( _4 R" Cwho was diagnosed with hypothyroidism at age 16,( A- j# T' e% u& U5 k: X4 d; w
which was treated with thyroxine. The father’s/ C8 {) l; T4 L( @- j) ~8 p! K
height was 6 feet, and he went through a somewhat
0 d' \) Y* \/ A, jearly puberty and had stopped growing by age 14.
2 M8 ~! P% @' r9 f5 Z4 T4 y9 l% HThe father denied taking any other medication. The
& ]3 J6 ^) Y2 R, dchild’s mother was in good health. Her menarche
' e ~; s( j9 ?( r- owas at 11 years of age, and her height was at 5 feet
9 \" r/ u7 Y0 k1 }% d* q8 \5 inches. There was no other family history of pre-1 c: O, b8 z4 h3 h) R; H
cocious sexual development in the first-degree rela-7 v7 w3 J' D& {* e U/ n2 W
tives. There were no siblings.
( R; S$ V! \( U. Z( @- LPhysical Examination$ M4 J5 V: A- T1 G1 C% s: Y
The physical examination revealed a very active,6 l- b) N# C7 ?) w
playful, and healthy boy. The vital signs documented
/ F1 S: Q! {2 X: oa blood pressure of 85/50 mm Hg, his length was2 W, s3 F, C" ]" a5 y) B# ~6 I& Z
90 cm (>97th percentile), and his weight was 14.4 kg, f9 E6 v7 U' U/ v
(also >97th percentile). The observed yearly growth
3 ?1 C3 C, j+ @2 @, E* k Pvelocity was 30 cm (12 inches). The examination of9 o8 O, D; d. y: h
the neck revealed no thyroid enlargement.
/ {- _8 `! b ]2 JThe genitourinary examination was remarkable for
& |# K1 O8 H4 F, G! @9 {! z- K( s4 o* p. @enlargement of the penis, with a stretched length of
* I$ ^3 l* T5 k* |% m# S' f% r8 d8 cm and a width of 2 cm. The glans penis was very well
7 ? g+ Q3 v1 r$ `) jdeveloped. The pubic hair was Tanner II, mostly around
7 |% V. r- q7 ~8 G/ T5 n540( t: t/ c& H& L7 z( L0 R: c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from; [, |2 S' b3 N$ U
the base of the phallus and was dark and curled. The- @3 B" Y; b0 _" q) M9 e, {
testicular volume was prepubertal at 2 mL each.8 s) h+ ~* ]' |+ c; {
The skin was moist and smooth and somewhat" C9 J+ Q. P' z/ q$ l0 O- ?
oily. No axillary hair was noted. There were no% m; E" g3 x3 V9 V" H
abnormal skin pigmentations or café-au-lait spots.
5 [2 M8 _4 m4 ONeurologic evaluation showed deep tendon reflex 2+
! X8 U) y* J& `1 ibilateral and symmetrical. There was no suggestion; |5 B8 j# t" ?) z. m8 B, V
of papilledema.7 e: M; L C7 r) f w1 I8 _
Laboratory Evaluation4 ~ o* m; l. B3 G
The bone age was consistent with 28 months by
\5 L# K e' ]. wusing the standard of Greulich and Pyle at a chrono-) j; O2 G3 O$ K: g' b
logic age of 16 months (advanced).5 Chromosomal8 w9 D P {( b7 y6 N; q. w
karyotype was 46XY. The thyroid function test
0 r# L3 g6 A3 dshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
. e) o! k7 o1 Y0 Xlating hormone level was 1.3 µIU/mL (both normal).2 m0 B3 p4 l$ W% }, A5 @ g+ O
The concentrations of serum electrolytes, blood
$ p! K$ F) W8 f/ @; ]7 I2 Curea nitrogen, creatinine, and calcium all were* @- C5 _( B1 b: u* r/ A% m4 N
within normal range for his age. The concentration
) n9 k; j* ]! i4 Z4 u4 jof serum 17-hydroxyprogesterone was 16 ng/dL
1 O% H& m9 z' P7 ?" q1 n(normal, 3 to 90 ng/dL), androstenedione was 207 K, l0 |/ F) C8 Q3 M% ~8 w
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-* }8 K. X9 @. \$ k' A; |
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
! L8 ?6 G0 m/ ~+ H5 s3 F, Ddesoxycorticosterone was 4.3 ng/dL (normal, 7 to
! A5 f' m$ k9 A+ u, @+ x1 { t2 ~49ng/dL), 11-desoxycortisol (specific compound S)# h6 V2 u0 U$ c0 u1 |* E
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-: l+ Q* ]# R6 D- v- _
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total1 s Y, F0 u) x4 Z) G
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
' f$ }4 L# ]) m9 E! Z( m( Mand β-human chorionic gonadotropin was less than, D8 Q) I$ g; q# s
5 mIU/mL (normal <5 mIU/mL). Serum follicular3 D, l/ F4 u3 Z6 v) P
stimulating hormone and leuteinizing hormone6 A5 B( Z$ A: f% _
concentrations were less than 0.05 mIU/mL8 x' ^/ B1 F% e/ a- C
(prepubertal)./ a& Z; _* s8 W/ \+ M
The parents were notified about the laboratory5 K1 E8 c: F- x6 \# o0 g
results and were informed that all of the tests were' l+ D; r2 L% ?
normal except the testosterone level was high. The
P# C4 j1 {3 T/ o! ^8 p+ `follow-up visit was arranged within a few weeks to7 F$ \/ F: u& J* k: O7 s
obtain testicular and abdominal sonograms; how-
^' _2 k. i U3 w; Z* S& Pever, the family did not return for 4 months.
! ]* w5 o( c* TPhysical examination at this time revealed that the/ k; {( a' L7 c
child had grown 2.5 cm in 4 months and had gained% x4 r6 s, I, ~5 _4 x- J! |
2 kg of weight. Physical examination remained I" P3 y& {+ M/ i; y8 ^% e1 M
unchanged. Surprisingly, the pubic hair almost com-
8 f) {9 {3 U/ ^2 upletely disappeared except for a few vellous hairs at
: Z( w3 ~& B; r! l! O3 nthe base of the phallus. Testicular volume was still 2- t8 I( ^/ E) X) c1 | n; {
mL, and the size of the penis remained unchanged.
. G {- w; d# U3 B& m, QThe mother also said that the boy was no longer hav-0 J% M% B! }3 s+ H; M" ?, D& |
ing frequent erections.. i* M' E! J8 m t9 A) e! `& W" z
Both parents were again questioned about use of
' l: k/ K$ ]; Y* T$ N& _any ointment/creams that they may have applied to
/ z0 g2 w( a' pthe child’s skin. This time the father admitted the
& V, P6 H1 d) r! HTopical Testosterone Exposure / Bhowmick et al 541
2 P: G- z+ c Z; Q' i2 {3 ruse of testosterone gel twice daily that he was apply-
% U8 V) g( l4 G5 T# y& j t" ding over his own shoulders, chest, and back area for3 N3 X6 r+ L7 }! S. v% l
a year. The father also revealed he was embarrassed
6 u3 J8 A/ q. B4 }) |" ]to disclose that he was using a testosterone gel pre-
0 P! h4 u& Q0 u6 w4 X) y9 bscribed by his family physician for decreased libido
& h# `) D+ A& ~6 y- G$ e6 `secondary to depression.
" E: N. [3 F4 c, cThe child slept in the same bed with parents.' O9 A4 @. i# m
The father would hug the baby and hold him on his( [% X) R( a$ O. k: I- r
chest for a considerable period of time, causing sig-( Z w/ ^( y- X8 \3 j% }
nificant bare skin contact between baby and father.7 Z" R5 Q) g) ^
The father also admitted that after the phone call,
$ X( v1 d5 w% _3 p m' F. b, \4 kwhen he learned the testosterone level in the baby
8 @ }% w( R2 I/ s" nwas high, he then read the product information
3 Z, A% \& ~: p" m: a" p+ } vpacket and concluded that it was most likely the rea-4 Z4 `9 ]5 O, A, Q; y
son for the child’s virilization. At that time, they
% `7 R0 w$ h9 t& L k0 vdecided to put the baby in a separate bed, and the" `7 k5 b6 m' R+ H6 _: F
father was not hugging him with bare skin and had
1 e F7 K0 V4 pbeen using protective clothing. A repeat testosterone9 L8 k( D" i1 s% B. g
test was ordered, but the family did not go to the
$ @) x# j$ r* Rlaboratory to obtain the test.8 O5 D5 [0 Q" p7 P
Discussion# V6 C. C2 w/ F) H% e- b( a
Precocious puberty in boys is defined as secondary0 G- ]+ ~/ Y6 K1 C* h# p; i [1 C
sexual development before 9 years of age.1,4
+ n z4 f3 ~! i9 L$ qPrecocious puberty is termed as central (true) when
5 T- e p. j5 k! r2 ]it is caused by the premature activation of hypo-
/ m! i/ C1 h6 P) O# @thalamic pituitary gonadal axis. CPP is more com-
, E" U5 ~: z! W, f- `2 kmon in girls than in boys.1,3 Most boys with CPP+ w2 ^: R: _) j4 w/ y( ]
may have a central nervous system lesion that is* f1 A8 G8 p" h! x+ `) K
responsible for the early activation of the hypothal-
( }, u0 V& |8 J8 j8 Samic pituitary gonadal axis.1-3 Thus, greater empha-% s. L& N0 h! x6 [% ~
sis has been given to neuroradiologic imaging in- ^1 e& ^ _6 i) d
boys with precocious puberty. In addition to viril-
! Q1 ~# m S# A: H, v0 oization, the clinical hallmark of CPP is the symmet-1 W" s: ?; @9 A3 I+ o
rical testicular growth secondary to stimulation by& _1 L' u- l, l8 O& b$ a
gonadotropins.1,3' G( d+ u5 i' E9 P6 i4 M
Gonadotropin-independent peripheral preco-. W- O: W5 i4 x# k8 a
cious puberty in boys also results from inappropriate* U5 G% @1 @% G6 Z4 u8 X' I$ T8 V
androgenic stimulation from either endogenous or( {: f! l( w" v0 G7 r- W
exogenous sources, nonpituitary gonadotropin stim-, Q) b5 ^& T( Q+ V# b2 P! A
ulation, and rare activating mutations.3 Virilizing
) z+ r) R: p: e2 P( V+ \( ]congenital adrenal hyperplasia producing excessive. U4 j6 h. h6 f# y l: Z; B$ ?
adrenal androgens is a common cause of precocious
- T0 U2 B3 X. d }/ N. L) Xpuberty in boys.3,4
! ]. d$ ^3 d* {3 yThe most common form of congenital adrenal
* V# j/ J' x: t6 U0 shyperplasia is the 21-hydroxylase enzyme deficiency.0 Q3 m; R4 r' W' r1 n
The 11-β hydroxylase deficiency may also result in$ {' m# ~8 _3 {- x* }2 \& A
excessive adrenal androgen production, and rarely,
; U' d7 {) g, D( R$ tan adrenal tumor may also cause adrenal androgen3 u5 D- D; h) H. Y
excess.1,3
/ Z( q+ A' ?5 D s2 m) X g( ^at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 _* Q; G$ ~9 V- R V+ Y$ e542 Clinical Pediatrics / Vol. 46, No. 6, July 2007( Z+ q5 @" f3 ^ [+ ]
A unique entity of male-limited gonadotropin-5 d. x4 n6 q9 O7 m% v
independent precocious puberty, which is also known
1 {5 L$ V* u2 O L% O5 o7 das testotoxicosis, may cause precocious puberty at a' x( q- q' }0 T8 b; m+ h: b
very young age. The physical findings in these boys6 k7 S6 o" `7 a9 H8 i" w
with this disorder are full pubertal development,/ w: @: C% }, O5 Z9 v2 z
including bilateral testicular growth, similar to boys
4 A9 C- c$ O9 [- u e) ^5 q; Dwith CPP. The gonadotropin levels in this disorder
2 V8 M8 h3 x7 y; u7 S, \' Q6 Fare suppressed to prepubertal levels and do not show- A X" w: a Z) S5 d* S+ j; a! _+ U5 I+ x
pubertal response of gonadotropin after gonadotropin- x+ _8 O: L* ~, r2 j' u: X
releasing hormone stimulation. This is a sex-linked- A5 P& G% k, s! V
autosomal dominant disorder that affects only; C, \* T, t% a+ g6 t' z
males; therefore, other male members of the family
+ p4 T, r J! J$ F& Umay have similar precocious puberty.3
- Y1 t; C Z, K2 jIn our patient, physical examination was incon-6 {, ~! H, T F' `! G; M
sistent with true precocious puberty since his testi-0 M( O9 C; }. m* a; K
cles were prepubertal in size. However, testotoxicosis* N4 R1 b" I2 E r1 D3 X# p
was in the differential diagnosis because his father
1 O2 Z$ Q' n, p- _/ Y! Vstarted puberty somewhat early, and occasionally,
" [% q3 O6 q1 Y9 E! A2 G0 A0 Ktesticular enlargement is not that evident in the
6 q7 X8 S# }4 kbeginning of this process.1 In the absence of a neg-4 S$ F, o# S# o
ative initial history of androgen exposure, our
1 B* m1 i: e; @9 @% _. r% K1 a. obiggest concern was virilizing adrenal hyperplasia,: X, f2 a" b$ |( D# P3 L6 R- z
either 21-hydroxylase deficiency or 11-β hydroxylase
# G8 M% B' ]& b/ L1 w6 k- ddeficiency. Those diagnoses were excluded by find-
9 C- p6 M8 j$ ?3 ^# Zing the normal level of adrenal steroids.
% a, O7 n0 E7 ?5 l wThe diagnosis of exogenous androgens was strongly
2 f4 u1 {# `7 L- ^# D$ z1 N0 a: Rsuspected in a follow-up visit after 4 months because
/ S% J: V& A! b {the physical examination revealed the complete disap-9 F. K# _. p0 h! L4 X& j
pearance of pubic hair, normal growth velocity, and- i7 ^9 x3 ~8 _
decreased erections. The father admitted using a testos-$ f) @" G/ P: _, [' R) ]3 J
terone gel, which he concealed at first visit. He was
; R9 U5 t, b( U. G# i4 E$ xusing it rather frequently, twice a day. The Physicians’" ^- d" s3 f( p( {6 |
Desk Reference, or package insert of this product, gel or
( b! N( @0 _; Z& I Q% p) B. ccream, cautions about dermal testosterone transfer to* t3 X. y. X! b0 S2 i7 h/ m5 |
unprotected females through direct skin exposure.
# {4 t; x; M3 H7 U3 ^9 xSerum testosterone level was found to be 2 times the
- a3 b* m8 w) W; ]8 \" q; ^) c: U% Hbaseline value in those females who were exposed to# I! I5 |4 E; U
even 15 minutes of direct skin contact with their male
$ K9 ?; _# i9 A. C, a/ Hpartners.6 However, when a shirt covered the applica-
! O* J9 d7 l! Q% M' Ation site, this testosterone transfer was prevented.
; R; d: }" I( y3 H9 e2 i& OOur patient’s testosterone level was 60 ng/mL,
o, @% W2 G1 C2 f5 h; t- }which was clearly high. Some studies suggest that
6 u6 u: o# B! ^( c3 ^# \9 Vdermal conversion of testosterone to dihydrotestos-
7 U; c5 y! f" o6 h1 J) Dterone, which is a more potent metabolite, is more4 P& V# n+ U: k3 O, @ P
active in young children exposed to testosterone6 L( }$ L# b) Z( ]* x
exogenously7; however, we did not measure a dihy-
: |; v& H$ R3 sdrotestosterone level in our patient. In addition to
4 \$ ~( }. Z' n& A) Cvirilization, exposure to exogenous testosterone in8 `: C+ w7 y6 [' r; N6 w4 [5 G
children results in an increase in growth velocity and; _0 P* C0 N# V& R: z$ D9 U) N+ Z
advanced bone age, as seen in our patient.
6 I( u, U5 Y: _2 R1 M7 N& wThe long-term effect of androgen exposure during
, v, R! [: v) o0 r/ q% I [early childhood on pubertal development and final" H2 k# r$ w9 ?* y
adult height are not fully known and always remain' J& e9 I7 N) P
a concern. Children treated with short-term testos-
% I8 w) l. ~ }terone injection or topical androgen may exhibit some
7 t, P+ W; Q2 N* oacceleration of the skeletal maturation; however, after
0 ^7 [' A( y" n5 d# ]4 n+ Vcessation of treatment, the rate of bone maturation! R0 `- U4 `2 r4 J4 A! i
decelerates and gradually returns to normal.8,96 L' j! J2 Y* t
There are conflicting reports and controversy3 J# M9 J1 b5 d& I$ R
over the effect of early androgen exposure on adult! h2 Z' ~8 G% ^ ~1 S% M: h( S
penile length.10,11 Some reports suggest subnormal$ K* e; r) o2 D) D' W
adult penile length, apparently because of downreg-
" ~* ]* K0 ?1 b# {ulation of androgen receptor number.10,12 However,
: U ]/ I( b+ t. rSutherland et al13 did not find a correlation between9 V3 {$ m# ~) |4 B" ~# a+ c, r
childhood testosterone exposure and reduced adult7 ]# _1 _* I4 v) w( X# \& P
penile length in clinical studies.
9 a* k6 O! @6 ?5 kNonetheless, we do not believe our patient is! Y0 _; Y3 |/ f8 C
going to experience any of the untoward effects from
: Q' i s! a6 L* f: p% ftestosterone exposure as mentioned earlier because3 |0 C4 J% H6 i3 [; R# U
the exposure was not for a prolonged period of time.9 z# u& F/ U7 [, Q4 X: {' n
Although the bone age was advanced at the time of
) Y3 e2 {) w- \) @: e% Udiagnosis, the child had a normal growth velocity at
* B7 h* S! Q2 K, Bthe follow-up visit. It is hoped that his final adult
8 {, x3 d! Q7 x* B) @. m6 Uheight will not be affected.; x% {' v b) F9 _' K
Although rarely reported, the widespread avail-
8 j; e" N$ K' O$ N/ B" Aability of androgen products in our society may
# G4 ~; ?% q2 i O# @, g, f* jindeed cause more virilization in male or female! L! H5 J# _$ \! D; |4 ]0 h& c
children than one would realize. Exposure to andro-
8 l; S( b+ v! v4 p- ]4 q jgen products must be considered and specific ques-; Z3 S# @; _6 {2 x
tioning about the use of a testosterone product or+ ?* i7 A( v" l
gel should be asked of the family members during( F; [% c; i+ _3 `& \: t8 f7 n
the evaluation of any children who present with vir-
% a1 n. P% Y" ? i i2 V( A4 [8 kilization or peripheral precocious puberty. The diag-
" d, N/ X- h/ H6 W1 }" snosis can be established by just a few tests and by
+ }* J, b. R8 J7 t" k `appropriate history. The inability to obtain such a9 w J2 D1 R# u1 G
history, or failure to ask the specific questions, may
, J2 S+ \" }9 l: ] ^result in extensive, unnecessary, and expensive
7 A0 B1 |: _3 ]- tinvestigation. The primary care physician should be
# {3 z Y# y+ b. k) Yaware of this fact, because most of these children) e+ P6 W3 W8 o* ~$ r5 Z; [
may initially present in their practice. The Physicians’
0 q7 Z( a( b/ gDesk Reference and package insert should also put a
; ?. c; s0 S- Kwarning about the virilizing effect on a male or
7 F1 |/ h$ ], Y4 _' lfemale child who might come in contact with some-
8 ^' V- ]; f0 b }% gone using any of these products.2 {& L0 X" Y2 `+ m9 s* D- _, |; V
References
) j0 j, V3 D, L. F4 o5 l1. Styne DM. The testes: disorder of sexual differentiation
( g* x/ V) J' a4 Eand puberty in the male. In: Sperling MA, ed. Pediatric6 C# V2 a' G& y8 U8 ?
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;5 o8 ?3 {( R; P/ v
2002: 565-628.4 M+ _+ l$ k. H
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
+ j: J& A' P# K. m3 T0 H9 ^puberty in children with tumours of the suprasellar pineal |
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