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Sexual Precocity in a 16-Month-Old0 n% j2 v9 p/ W8 Q" N# O
Boy Induced by Indirect Topical
9 d! Q+ @: u8 V8 H4 zExposure to Testosterone# E8 D1 N% I) A' v2 Z
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2% U, b# ^9 Z- W" z
and Kenneth R. Rettig, MD1' |3 v$ r' x. G8 N- _/ g- X
Clinical Pediatrics
5 i, u, s4 V' B, F3 m2 G/ FVolume 46 Number 6% t1 r& h% g; W/ ^( I
July 2007 540-543+ E5 e8 a: [% D8 V
© 2007 Sage Publications
0 l8 B A3 E, I0 n10.1177/0009922806296651
: K# f C, e) k: E8 C* ~http://clp.sagepub.com4 _& q" w3 ?- ^: d$ U+ q, y
hosted at$ c) m: [; [5 ~$ _: M# Q3 v; Z
http://online.sagepub.com
+ H, _/ G: C) P- \' [& fPrecocious puberty in boys, central or peripheral,6 }4 z C `7 o2 J: }3 U5 ?. F
is a significant concern for physicians. Central
" W4 G- S5 ~, r1 V& lprecocious puberty (CPP), which is mediated
* C& M4 w' o+ i+ U- Mthrough the hypothalamic pituitary gonadal axis, has
7 Z6 s+ C& b# K) K/ Xa higher incidence of organic central nervous system
[4 [0 N8 V% i6 i8 W2 v5 alesions in boys.1,2 Virilization in boys, as manifested
/ V8 l ] k/ r4 aby enlargement of the penis, development of pubic
! s" k- w. o. W- [$ ?hair, and facial acne without enlargement of testi-
& ^2 `. X( U4 N) z( R! Ccles, suggests peripheral or pseudopuberty.1-3 We1 W' V1 F3 A S5 o& X) m8 X+ \
report a 16-month-old boy who presented with the
* }2 a- ^- L ]& {enlargement of the phallus and pubic hair develop-8 j$ f% M0 m5 s9 ?. [- {' }+ B4 i
ment without testicular enlargement, which was due
. R) W& A: x) Wto the unintentional exposure to androgen gel used by
# p n& a1 f) V, ~1 @& ^5 J; fthe father. The family initially concealed this infor-
" y- f0 ^/ d8 e( W3 N- kmation, resulting in an extensive work-up for this
6 y' Y, v9 ^; [9 G) wchild. Given the widespread and easy availability of
+ ^- y; H" R1 P7 }, n7 |* I5 ntestosterone gel and cream, we believe this is proba-, c& Q6 L/ i- Q
bly more common than the rare case report in the
" ~# r# L) S E5 v( x% R+ Aliterature.4
N% l: b% _ PPatient Report
+ Q# m1 R. W- {1 }! J2 RA 16-month-old white child was referred to the1 I! w6 E/ ~3 v$ v0 r* n
endocrine clinic by his pediatrician with the concern2 k3 X* x7 B5 K! j& a
of early sexual development. His mother noticed/ F5 O- [3 I) |1 [+ Q1 _; z, a
light colored pubic hair development when he was, M" l! `0 x& B/ V
From the 1Division of Pediatric Endocrinology, 2University of
& S6 \$ N5 Q- j2 {# b7 ZSouth Alabama Medical Center, Mobile, Alabama.: _* S! |# d" [0 {1 C9 q" B
Address correspondence to: Samar K. Bhowmick, MD, FACE," @" j- X0 C- D Q
Professor of Pediatrics, University of South Alabama, College of6 j& Q) U) H- \- m" }7 p5 q3 G! x
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 ~ x% c' ^2 v- Ue-mail: [email protected].
4 f. l4 k4 t6 G3 Habout 6 to 7 months old, which progressively became& z. ~* Q/ c: K: V" O
darker. She was also concerned about the enlarge-9 H% d$ w+ B/ |4 B5 ^
ment of his penis and frequent erections. The child. }, D2 }' t6 s# y; M$ E3 r3 b1 E
was the product of a full-term normal delivery, with* Q) M2 \, u1 u: _' i( ^! b: }: L8 _0 p
a birth weight of 7 lb 14 oz, and birth length of; V3 C& Z6 ]+ @3 M: i6 V% E6 ~$ g
20 inches. He was breast-fed throughout the first year, H: w, ~, m! P- s) ?' u7 c
of life and was still receiving breast milk along with4 B3 `6 ~3 ]) G9 S
solid food. He had no hospitalizations or surgery,. y) e' H- r8 f
and his psychosocial and psychomotor development! T0 h. D2 H# w- e, G
was age appropriate.. L2 u1 t8 K8 }. K! h, J$ M
The family history was remarkable for the father,- V4 l7 V" j9 D2 j( ?
who was diagnosed with hypothyroidism at age 16,% b3 E `- t0 ^2 ]) e9 m
which was treated with thyroxine. The father’s
- g% _1 x; n8 A9 _9 H# L* vheight was 6 feet, and he went through a somewhat
: D; I' W+ i4 E8 w# Q; Hearly puberty and had stopped growing by age 14.8 n4 u3 `! ~) X8 S2 n- p
The father denied taking any other medication. The
3 D& {5 l) h9 i! hchild’s mother was in good health. Her menarche. }4 I b% }& W' Q4 [% E' R) I' M
was at 11 years of age, and her height was at 5 feet/ A5 u: Q" z8 F: C2 I3 |
5 inches. There was no other family history of pre-
0 j4 t' R9 m! [cocious sexual development in the first-degree rela-
\' k4 R! w( f5 o$ f& ?tives. There were no siblings.
3 R `. Y9 K5 i, L$ t7 E7 g- k vPhysical Examination, N; f9 @. {3 J$ Y8 w# j3 p
The physical examination revealed a very active,2 \3 w1 c+ A( _/ v3 J
playful, and healthy boy. The vital signs documented( K: d7 n1 V8 O9 X
a blood pressure of 85/50 mm Hg, his length was! p4 P* P9 J3 V5 s. B1 B
90 cm (>97th percentile), and his weight was 14.4 kg
6 z/ g- V8 N" ]/ o, i2 H(also >97th percentile). The observed yearly growth* O9 G1 K8 C, U' R
velocity was 30 cm (12 inches). The examination of8 s5 r2 @2 p7 h' a% U
the neck revealed no thyroid enlargement.# g3 w. f" H' T% N
The genitourinary examination was remarkable for! S1 R( k- E& f; w) T
enlargement of the penis, with a stretched length of
6 n1 @5 }8 P7 k6 s" d8 cm and a width of 2 cm. The glans penis was very well6 J' J, ]" ?7 ^$ D, Z
developed. The pubic hair was Tanner II, mostly around
2 X$ |" v) {; }5401 H E* ~3 u, z( d J& h" F
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' Q S! S# Q: h ^) O) a) p
the base of the phallus and was dark and curled. The! Z; h T7 S8 i
testicular volume was prepubertal at 2 mL each.: q7 U. [& D3 _8 f
The skin was moist and smooth and somewhat, c8 s% F `0 l% ^3 d
oily. No axillary hair was noted. There were no
n+ }5 z& ^* u: H3 d2 Iabnormal skin pigmentations or café-au-lait spots.
3 G m8 A/ \- r8 p! [Neurologic evaluation showed deep tendon reflex 2+/ A, F* J* d4 \" J" H# \7 ~4 i
bilateral and symmetrical. There was no suggestion
( i, k' D5 }, a, tof papilledema.5 P$ w( Z6 E# h- h: e
Laboratory Evaluation# E. p8 G7 P! U( P$ _9 M" v, }& N
The bone age was consistent with 28 months by1 E( V) q& @% C# v% c4 M& x7 ?
using the standard of Greulich and Pyle at a chrono-
9 ]. U: |2 f/ c8 p2 F3 llogic age of 16 months (advanced).5 Chromosomal7 o0 {/ P" m, D: e6 w' N
karyotype was 46XY. The thyroid function test
9 C1 l* _' k8 _: I2 O/ Pshowed a free T4 of 1.69 ng/dL, and thyroid stimu-! X2 C4 K% T" p1 A
lating hormone level was 1.3 µIU/mL (both normal).
* X% p6 [- ~2 x' c# T# Y* tThe concentrations of serum electrolytes, blood
# m$ x' K3 e! v3 ?; ~, Burea nitrogen, creatinine, and calcium all were
. Z+ _+ d' [* Q4 J iwithin normal range for his age. The concentration: J! s9 \% h P- d) r$ R$ [# M% ]
of serum 17-hydroxyprogesterone was 16 ng/dL7 [1 M$ X) s7 | g4 ]& X
(normal, 3 to 90 ng/dL), androstenedione was 20( i( [- j, X7 n- a/ }" l8 t
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
8 F( e0 u7 m( s5 n# r+ kterone was 38 ng/dL (normal, 50 to 760 ng/dL),3 ~) b/ W |( J1 f/ ?+ I: k
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
Y& V |$ H/ x, v49ng/dL), 11-desoxycortisol (specific compound S); I* B) b; x/ r9 r& j
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
6 I8 I7 ]$ {3 e/ \' m. l7 G) gtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total5 O+ _, {! a. N: S6 p
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),) b1 d% i* z7 R7 }
and β-human chorionic gonadotropin was less than1 R3 j/ I) h+ J5 a% \& ?2 W
5 mIU/mL (normal <5 mIU/mL). Serum follicular
8 I; j) L7 C: estimulating hormone and leuteinizing hormone
1 A% w1 X/ `$ d* C' g( |concentrations were less than 0.05 mIU/mL
- x# h% q0 t* z( e/ R(prepubertal).
e) y4 m3 D9 R, d3 nThe parents were notified about the laboratory
$ `1 b- m/ Z q: n4 F3 G1 z6 zresults and were informed that all of the tests were
- }$ p( F- t4 X- E4 \& F2 Ynormal except the testosterone level was high. The
' J; h( q6 _" Bfollow-up visit was arranged within a few weeks to
. A" s0 J5 B: e. y" gobtain testicular and abdominal sonograms; how-. t; H% \, B& v+ t' _
ever, the family did not return for 4 months./ P/ _6 Y7 X' S8 q9 B
Physical examination at this time revealed that the
% l; q% U8 p9 o8 V) {child had grown 2.5 cm in 4 months and had gained" o3 z, [" c: y' p, |7 m, k
2 kg of weight. Physical examination remained
# D9 V/ d3 E/ q; p6 t* Q: Q( Z0 _unchanged. Surprisingly, the pubic hair almost com-
% o1 S: R. G) W, E+ L$ upletely disappeared except for a few vellous hairs at
5 K' Q* U- B" M7 J gthe base of the phallus. Testicular volume was still 2; N2 Q) g% B+ r( E: W+ h
mL, and the size of the penis remained unchanged.% u1 \3 x: i3 Y& Q6 W( W/ E
The mother also said that the boy was no longer hav-
* k6 d) e7 { Y: Sing frequent erections.; ]: g6 }5 r2 o+ {+ [8 L5 x$ a
Both parents were again questioned about use of) }2 Q/ `9 j. p% Z
any ointment/creams that they may have applied to
& M/ f$ V" o# u. `1 ~) {3 Tthe child’s skin. This time the father admitted the* ?4 ^7 B( w7 O1 [2 S4 `6 t
Topical Testosterone Exposure / Bhowmick et al 5411 V6 O6 ~0 Y4 P0 J0 k' l5 `
use of testosterone gel twice daily that he was apply-
% N: @8 ?5 h( F. }8 S5 Ning over his own shoulders, chest, and back area for
: k1 y" B/ P8 @: xa year. The father also revealed he was embarrassed
) D' @8 f8 y4 f9 Z3 Uto disclose that he was using a testosterone gel pre-
. b1 q4 j% U7 _5 a: P/ h+ w6 }scribed by his family physician for decreased libido
b% t4 K j1 o) g" e& J5 isecondary to depression.
& Z- W$ i, E' H) Y# }7 @The child slept in the same bed with parents.1 r% x7 q* f- E1 z* e3 C
The father would hug the baby and hold him on his
! x7 N3 z% J$ S' p& tchest for a considerable period of time, causing sig-
' A8 s3 D$ V$ Pnificant bare skin contact between baby and father.
3 x8 o) z6 F) Q: H! G' H [/ xThe father also admitted that after the phone call,
$ ~' a$ x8 x f+ hwhen he learned the testosterone level in the baby/ O, I( _2 u9 l7 ]0 K2 M
was high, he then read the product information0 F% J, `8 l4 c" V$ X
packet and concluded that it was most likely the rea-6 U @2 n2 ~. g( V2 o8 N
son for the child’s virilization. At that time, they
+ R, d. j2 B. @. O6 G4 A" Xdecided to put the baby in a separate bed, and the
5 l1 I/ U* @1 } q- ?father was not hugging him with bare skin and had5 ?" r2 [; M7 \
been using protective clothing. A repeat testosterone
! |# [/ r3 P( M& W; ]& t) `test was ordered, but the family did not go to the
* Z6 D/ v" V9 i# n& Claboratory to obtain the test.
' A2 F. q" g7 r1 j/ k) EDiscussion
4 H9 \6 u& s. c; ]Precocious puberty in boys is defined as secondary
8 k ]7 X4 p5 |% E& `! l3 V0 K: s5 jsexual development before 9 years of age.1,4) }) c- u$ `' c% q6 s
Precocious puberty is termed as central (true) when
Q4 W& q0 Y4 M) g) J& t, ]! kit is caused by the premature activation of hypo-1 F3 w) s8 P, M
thalamic pituitary gonadal axis. CPP is more com-
' Y1 O Q" K6 J( C0 b5 l! umon in girls than in boys.1,3 Most boys with CPP
1 W) |! |0 W5 L; ~3 q% j5 N( xmay have a central nervous system lesion that is; f/ Y3 Q+ e8 \: {$ Z* z/ F
responsible for the early activation of the hypothal-+ D# W. R# \; r; l' H
amic pituitary gonadal axis.1-3 Thus, greater empha-6 I3 h, J: u8 Z5 W; A" s
sis has been given to neuroradiologic imaging in
7 H+ f3 R9 o6 Q* O rboys with precocious puberty. In addition to viril-
" \3 n# z3 H$ l, R' ?4 r2 {" _1 iization, the clinical hallmark of CPP is the symmet-
* S0 \2 ~" ~$ q* ^rical testicular growth secondary to stimulation by
1 f) E; I0 Z/ n. \' R" Y( hgonadotropins.1,3
6 C# P; Z) o; `/ s( m) SGonadotropin-independent peripheral preco-
7 F# j6 ] p/ A$ g# R' M; icious puberty in boys also results from inappropriate
q0 h& u% `1 S/ m; mandrogenic stimulation from either endogenous or
, K) ?" g" n9 @1 [" Z- t9 M% `exogenous sources, nonpituitary gonadotropin stim-( |1 S+ e6 a/ c* C+ w5 f
ulation, and rare activating mutations.3 Virilizing# O: r& k R8 ] f
congenital adrenal hyperplasia producing excessive
8 h0 f& n l. \* L" U wadrenal androgens is a common cause of precocious
- v- V0 X$ n# o& b) u4 J3 R# apuberty in boys.3,4
1 ^: U) x: L6 YThe most common form of congenital adrenal
3 s* Q' M$ |+ Q% J; Bhyperplasia is the 21-hydroxylase enzyme deficiency.2 j6 X @* Z, x* L! R3 J
The 11-β hydroxylase deficiency may also result in! l9 {2 g# A3 w7 H- z
excessive adrenal androgen production, and rarely,
8 a% R" i5 K6 A0 I1 x6 Zan adrenal tumor may also cause adrenal androgen
/ n* J: R2 q3 l; Y9 G9 `excess.1,3) ]# f" K/ r' p- m$ ^$ ]4 E
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
4 P+ K1 x2 h% w* ^542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 J% E% ]' x) ~: T' aA unique entity of male-limited gonadotropin-$ x s+ G2 O U
independent precocious puberty, which is also known- \' B5 @0 r; l. h: _
as testotoxicosis, may cause precocious puberty at a9 p* [& n0 \) [
very young age. The physical findings in these boys
. k; _1 V. A( r" O0 i7 h: W+ R' F7 ~with this disorder are full pubertal development,
2 d: A8 A$ `4 @% l9 _6 cincluding bilateral testicular growth, similar to boys( F U# f7 y9 o$ r3 C* h
with CPP. The gonadotropin levels in this disorder
; A2 a1 e* ~5 X$ `5 V+ care suppressed to prepubertal levels and do not show
; F% R! n V% j- _pubertal response of gonadotropin after gonadotropin-
2 t8 \0 }& ^2 e2 [5 \* n& _7 t% j# Creleasing hormone stimulation. This is a sex-linked( j4 G9 _- E6 O) Y: f
autosomal dominant disorder that affects only
" u' k! O N1 @4 k2 {males; therefore, other male members of the family5 _% D: E+ s7 M7 X, G% o
may have similar precocious puberty.3
, u: R' a8 K# D+ c- b" ]8 y5 k0 eIn our patient, physical examination was incon-
, @9 u4 D; Z+ _2 z) Xsistent with true precocious puberty since his testi-
* `+ p) D( R; v4 wcles were prepubertal in size. However, testotoxicosis) ]0 }" @# ^: ?" n0 o8 g9 ]
was in the differential diagnosis because his father
' O. V% b1 W! k- R+ p1 dstarted puberty somewhat early, and occasionally,% s/ ]4 Z7 e$ |/ M! M0 q3 M' f$ X: y
testicular enlargement is not that evident in the
: `1 F* m) |( V$ m n# Ibeginning of this process.1 In the absence of a neg-4 i" f: }& m* E# C6 B5 d
ative initial history of androgen exposure, our
( v9 t2 q% S+ a, p4 Z" G- g# Q3 hbiggest concern was virilizing adrenal hyperplasia,0 z$ S) H# Z, L# W7 ~: R
either 21-hydroxylase deficiency or 11-β hydroxylase
* |9 F6 p- [5 rdeficiency. Those diagnoses were excluded by find-
; |! s4 c( e9 G2 m; a$ h# Wing the normal level of adrenal steroids.( C8 S1 j( i* _4 k& {% [* J
The diagnosis of exogenous androgens was strongly
: F6 v& }/ {( {+ d% Tsuspected in a follow-up visit after 4 months because
/ F {& ]( H' C. @0 y* G+ Tthe physical examination revealed the complete disap-
% Y' y$ b4 M* p' spearance of pubic hair, normal growth velocity, and
' C3 J1 G# V6 ~* w ndecreased erections. The father admitted using a testos-
6 \, R1 C% j8 e. z. A4 U/ Iterone gel, which he concealed at first visit. He was
; z* S& h9 X3 x, P" S+ i$ kusing it rather frequently, twice a day. The Physicians’
$ q9 B7 q- Q$ p2 `: b w+ G5 F: A. qDesk Reference, or package insert of this product, gel or0 T; z& }+ [8 `5 n
cream, cautions about dermal testosterone transfer to
! V% I" c( H( N @! Hunprotected females through direct skin exposure.8 f1 N0 w: k2 x* I/ C7 l1 p
Serum testosterone level was found to be 2 times the: Y5 i4 W4 F8 a& `2 \0 [
baseline value in those females who were exposed to
+ E9 F- h& @' _) Ueven 15 minutes of direct skin contact with their male; y5 M" }4 q. n( D- y1 x3 ~
partners.6 However, when a shirt covered the applica-
* R: n7 }, K3 S: {5 ntion site, this testosterone transfer was prevented.
; n" q) R/ m# IOur patient’s testosterone level was 60 ng/mL,( o, P8 O0 O5 l+ p
which was clearly high. Some studies suggest that
+ b& ~& J" J7 G" Kdermal conversion of testosterone to dihydrotestos-1 h- J* B5 [. }# z6 }6 I
terone, which is a more potent metabolite, is more' n) j7 D" ^: v/ Z
active in young children exposed to testosterone& ^9 c( A( s2 C8 T
exogenously7; however, we did not measure a dihy-
. [8 N$ F# }7 A# r5 q( B: r) Qdrotestosterone level in our patient. In addition to
9 x1 p- r |( [ _- d4 G4 M7 f+ avirilization, exposure to exogenous testosterone in% p# L' x5 P, ~
children results in an increase in growth velocity and
. E! S. G; P& T: C# ?advanced bone age, as seen in our patient.
+ l6 A' K- Z" s1 WThe long-term effect of androgen exposure during
7 G2 |; k" V- u: r! vearly childhood on pubertal development and final
- V l* Z: D9 p, {% [adult height are not fully known and always remain! `) a$ ]! I0 T1 P( P! J
a concern. Children treated with short-term testos-. H8 o" i) {5 M& `) _* C
terone injection or topical androgen may exhibit some9 w, E' S0 w" c1 W5 F3 H
acceleration of the skeletal maturation; however, after: P# Y( K/ y \, {
cessation of treatment, the rate of bone maturation
n' B! X3 S* C; Adecelerates and gradually returns to normal.8,9
" ?9 F1 P: N4 e! B) z8 o3 w bThere are conflicting reports and controversy5 u6 \1 D. G7 ?, ~6 r! [% E. `
over the effect of early androgen exposure on adult1 n4 ~6 [0 j: X$ E" T8 l) u7 a4 U4 C
penile length.10,11 Some reports suggest subnormal
* {+ v. I* [5 T% M0 _; _; yadult penile length, apparently because of downreg-% K. n* `( `; T# y+ R, A' I9 L
ulation of androgen receptor number.10,12 However,
4 C3 C% o* W+ C8 @Sutherland et al13 did not find a correlation between
) _! d9 |3 y) Y! g- r% achildhood testosterone exposure and reduced adult
$ _0 n5 v, _. ~5 [, @% kpenile length in clinical studies.
6 x# P1 E+ Y sNonetheless, we do not believe our patient is k6 b" U, b3 I+ C, J2 O5 R' x
going to experience any of the untoward effects from% e. R, M6 S! [3 a, o
testosterone exposure as mentioned earlier because" `( P6 S, g, M/ O
the exposure was not for a prolonged period of time.2 L ]* r8 {4 C& Y" j( R
Although the bone age was advanced at the time of
; g1 N2 _: B; Y8 Sdiagnosis, the child had a normal growth velocity at
) {$ O$ O$ D8 x3 u/ u( Sthe follow-up visit. It is hoped that his final adult
" n6 W2 [0 u0 E7 [" H& T( oheight will not be affected.8 e$ [- ?) W! B/ e+ P/ J
Although rarely reported, the widespread avail-" f; z6 E! O2 L5 I+ L
ability of androgen products in our society may0 e$ R' l: e7 X, U
indeed cause more virilization in male or female
& S/ Z: B- c1 d. i0 K) \3 Echildren than one would realize. Exposure to andro-+ c7 S1 R( \% W, K* ^, m
gen products must be considered and specific ques-, Z3 Z- f$ \5 A+ k; V& i
tioning about the use of a testosterone product or
+ {* _; x( W1 f" X1 T1 ~5 C# V" Tgel should be asked of the family members during
2 P8 H, G; M: k0 {. Mthe evaluation of any children who present with vir-
. L4 J2 A: P/ O/ Z( tilization or peripheral precocious puberty. The diag-
- m: R1 q- d6 g$ Y: Y) [1 e; R) i" }nosis can be established by just a few tests and by. u! E4 b. S2 Q! w
appropriate history. The inability to obtain such a
5 y* c1 U+ o2 j; a+ ghistory, or failure to ask the specific questions, may) ^) F2 k6 `' ~0 v
result in extensive, unnecessary, and expensive" l& H+ N& D; {: s* ^: S6 a2 \
investigation. The primary care physician should be
( X$ V2 k {5 Faware of this fact, because most of these children
$ X$ c' V: P, t. s7 {( Nmay initially present in their practice. The Physicians’- d( ?: {8 K5 c1 u
Desk Reference and package insert should also put a
1 Z( C/ {2 X* ?, k' Zwarning about the virilizing effect on a male or3 q$ \7 W" ^. A( \$ o8 E5 [+ E/ n
female child who might come in contact with some-+ g* y7 W6 n9 G5 Y
one using any of these products.
, a0 W" G8 l3 _1 @References
$ T4 Y# K4 N$ m6 L- n6 h; X1. Styne DM. The testes: disorder of sexual differentiation
- Z1 K- [( r! x& K! j+ v4 Dand puberty in the male. In: Sperling MA, ed. Pediatric
o0 q, \7 u8 sEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;1 m. X; Z( b( I* J
2002: 565-628.# l' z3 o e! w6 G: V, E
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious z+ u" {& x T+ o4 e1 ^ Y4 o2 U
puberty in children with tumours of the suprasellar pineal |
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