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Sexual Precocity in a 16-Month-Old
& }8 b9 F" e: L% U6 f) M# B, S1 ABoy Induced by Indirect Topical4 E# g4 E n$ J1 |# F. _
Exposure to Testosterone
" z2 x' V/ W' I1 @8 Q" jSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2: E$ s9 n. g1 _' [& ^
and Kenneth R. Rettig, MD1. x& e4 y3 t2 K1 B( _& `
Clinical Pediatrics6 @& N- K. M2 R4 O7 A( H
Volume 46 Number 6# k/ |- m' m% K$ c2 D: C0 \, s! R
July 2007 540-543
- E& u+ A! v/ D2 {4 d, D© 2007 Sage Publications* j7 V& r/ P- u. B4 c4 `
10.1177/0009922806296651
% W( ?# }; m& q" _ fhttp://clp.sagepub.com6 f" u9 \/ G/ h; v; ~5 Y$ h
hosted at
! R) _* g; |9 h4 \4 v1 Ahttp://online.sagepub.com
/ @& ]) Q+ J2 } ?5 B. nPrecocious puberty in boys, central or peripheral,1 E) M( }) C. M6 K7 ?
is a significant concern for physicians. Central$ l: U: g8 f6 k) s, C8 |
precocious puberty (CPP), which is mediated9 y! u" \- i& e7 L
through the hypothalamic pituitary gonadal axis, has6 p* M! f6 m" C& T) U
a higher incidence of organic central nervous system
6 w. r) \. I: W: ^# o) jlesions in boys.1,2 Virilization in boys, as manifested2 O% n% W3 x. W+ K
by enlargement of the penis, development of pubic' g' G, f, |/ i: q; g
hair, and facial acne without enlargement of testi-
+ u7 y- R: i9 z" X& C7 xcles, suggests peripheral or pseudopuberty.1-3 We7 m" k- K, ]9 r4 j9 E- Y! x4 D
report a 16-month-old boy who presented with the
: h' x5 C3 G0 \, [enlargement of the phallus and pubic hair develop-+ H' T! G" J7 P$ X: k m
ment without testicular enlargement, which was due
8 c: r: M( L* x; y9 s6 x8 Z' r" x4 sto the unintentional exposure to androgen gel used by% @5 t- c+ K1 f x+ u7 O
the father. The family initially concealed this infor-( q: L/ [4 m: G8 Z! ^1 j3 }
mation, resulting in an extensive work-up for this
! N8 L! X: V# E8 A9 p, R; T- k4 ]child. Given the widespread and easy availability of/ a" q( M- q% _! [0 V
testosterone gel and cream, we believe this is proba-( {/ N; t% A/ ?$ f* {( C
bly more common than the rare case report in the
7 C7 j0 l* L" l$ ]( ^* t5 a9 R+ I7 zliterature.4
1 _2 T: l; k. p5 I* P8 B; V+ ZPatient Report
- l! }, X# _8 I, S$ \A 16-month-old white child was referred to the
/ [, w9 u+ r B! ^endocrine clinic by his pediatrician with the concern$ l9 E% F: U/ L. g0 F1 e" V- l
of early sexual development. His mother noticed
X/ F' a( Z1 {( slight colored pubic hair development when he was: U, ~$ M P1 s/ A2 V" e5 |
From the 1Division of Pediatric Endocrinology, 2University of
) C, I( D; w* ] B* Z; ZSouth Alabama Medical Center, Mobile, Alabama.
0 A( y- u5 [1 a9 bAddress correspondence to: Samar K. Bhowmick, MD, FACE,$ a S; @1 S6 [) ?# \* |
Professor of Pediatrics, University of South Alabama, College of
( q6 b6 x; `2 i( Q8 A- ?* P8 [. ZMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
9 q4 G+ z _! j- h" ?e-mail: [email protected].. I/ {, _2 ~0 @
about 6 to 7 months old, which progressively became7 |! k$ @' y: T p
darker. She was also concerned about the enlarge-
" z( R$ \4 l6 @: ]: Bment of his penis and frequent erections. The child
* n+ N* C9 i( I$ g: ^0 N8 f+ t" twas the product of a full-term normal delivery, with
3 b. P: @2 n3 G) la birth weight of 7 lb 14 oz, and birth length of8 v: c2 e. j& z, d2 f9 B; F# g
20 inches. He was breast-fed throughout the first year
6 B( F; W8 o- k/ {; a, K+ Xof life and was still receiving breast milk along with2 g- }9 w2 F7 q. N
solid food. He had no hospitalizations or surgery,
& U/ {; q( \1 w, S9 n" P" _and his psychosocial and psychomotor development! u' U& ?$ P6 L$ c9 _
was age appropriate.
0 P; O3 r) E$ wThe family history was remarkable for the father,3 H. T: b. B# J% _$ y- U0 Z
who was diagnosed with hypothyroidism at age 16,1 U4 Q6 O; a) C, s* M" x @
which was treated with thyroxine. The father’s
T, d# k* U* [% ~height was 6 feet, and he went through a somewhat: c( }% w1 W& j! Y
early puberty and had stopped growing by age 14.
( v( p m( g3 O, P) e; gThe father denied taking any other medication. The! W! y. u& P5 m# e0 H' ~5 v
child’s mother was in good health. Her menarche
# N" @$ j/ S! [# Cwas at 11 years of age, and her height was at 5 feet0 ^% @2 W! H" M/ w2 h
5 inches. There was no other family history of pre-
) L+ O/ e; k) K1 o- [8 tcocious sexual development in the first-degree rela-$ F0 v X9 k n9 S" t: p
tives. There were no siblings.) }8 n6 s7 ]2 k f/ w
Physical Examination* [) ?" i& }3 ]9 J+ Z
The physical examination revealed a very active,
2 {& a& a2 L7 ` K0 _- cplayful, and healthy boy. The vital signs documented9 q, @! x, F7 u {5 |. n
a blood pressure of 85/50 mm Hg, his length was" |" `1 S8 ~8 }, P
90 cm (>97th percentile), and his weight was 14.4 kg
) `+ L: q. X2 D' j3 V( w% d/ A0 \0 q(also >97th percentile). The observed yearly growth2 k! Y: I" ^. H# p, ]* H
velocity was 30 cm (12 inches). The examination of+ l* i' T. B# K8 Z9 p* Y* n( ~
the neck revealed no thyroid enlargement.
$ F; c; Z. M* N5 |1 d" }6 hThe genitourinary examination was remarkable for: s& I+ G5 b- @1 a4 u$ Q
enlargement of the penis, with a stretched length of3 x1 K0 ]& T# a# s
8 cm and a width of 2 cm. The glans penis was very well- P3 W( i- B; R- z! x# ?" [* M
developed. The pubic hair was Tanner II, mostly around- i- r- \6 v/ N0 o' [9 C3 G
540) [+ T! v" X6 ]6 P/ Y
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% S( l1 @0 c5 a5 _the base of the phallus and was dark and curled. The
9 }9 m, s; y9 Y/ q6 K1 Atesticular volume was prepubertal at 2 mL each.
: }1 N6 H/ @' {$ ~9 B: ^; WThe skin was moist and smooth and somewhat# n# |- M& V; O. R& I% Z5 o% J
oily. No axillary hair was noted. There were no4 H1 r' `' d9 B4 Q3 ~
abnormal skin pigmentations or café-au-lait spots.
% u6 D |, k9 _5 q$ z9 E; X$ s) VNeurologic evaluation showed deep tendon reflex 2+( H, B- s+ e7 u: b% [1 d$ O' C4 o
bilateral and symmetrical. There was no suggestion
$ N% v; q" o# Uof papilledema.9 n5 f; |% G* d% e4 F# U2 R
Laboratory Evaluation
! Z" A$ T8 C" yThe bone age was consistent with 28 months by" H$ F# r, |9 ?$ U3 P. x
using the standard of Greulich and Pyle at a chrono-3 s+ D; g+ C# [
logic age of 16 months (advanced).5 Chromosomal
" \. ^2 B J/ Q% s. dkaryotype was 46XY. The thyroid function test" A8 ^9 `" N8 _! u2 H/ a, O5 I
showed a free T4 of 1.69 ng/dL, and thyroid stimu-0 U, S$ A: ?+ k' S1 v
lating hormone level was 1.3 µIU/mL (both normal).6 X+ Z$ o, P! J9 y
The concentrations of serum electrolytes, blood
. }4 B( a- N0 W" v9 Zurea nitrogen, creatinine, and calcium all were1 Z/ c0 T$ p8 u s" d
within normal range for his age. The concentration0 \8 ^/ q' x4 v
of serum 17-hydroxyprogesterone was 16 ng/dL( R4 H& {" o. V) M, T
(normal, 3 to 90 ng/dL), androstenedione was 20! x$ X `6 C- j: z& F
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-1 ?/ P" O0 d+ H0 a/ o; e
terone was 38 ng/dL (normal, 50 to 760 ng/dL),/ J" W4 ^" \: b+ k% f
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 m, ~7 B3 s0 B/ L: \% m49ng/dL), 11-desoxycortisol (specific compound S)1 Y3 V- _* k: Y/ @
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-5 ~4 l7 ^1 O# j R0 b M( ^. ^
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
. `# f( c0 M9 b7 ?1 M7 P. F+ \testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, Z# y, j9 P9 {* N2 zand β-human chorionic gonadotropin was less than
4 w [9 t+ V* o8 [$ C7 b5 mIU/mL (normal <5 mIU/mL). Serum follicular
, b7 R2 H# G; J; B/ G) c5 kstimulating hormone and leuteinizing hormone
Z: a* U! Q7 Bconcentrations were less than 0.05 mIU/mL9 A( v# O" g+ ]/ g
(prepubertal)." f( S. A( `6 Y6 J& N6 d: Y; L
The parents were notified about the laboratory
, u' Z b8 Q/ K2 Q* ]' iresults and were informed that all of the tests were
; Q. y& B' i* F$ l- p8 {# J* Bnormal except the testosterone level was high. The2 _; p" Q/ o2 D
follow-up visit was arranged within a few weeks to
/ Y: l0 b% Y( Vobtain testicular and abdominal sonograms; how-
* F. I( Z; ?; ]9 Cever, the family did not return for 4 months.1 S8 p; \' _6 U
Physical examination at this time revealed that the
# l4 {4 A( ~1 {child had grown 2.5 cm in 4 months and had gained9 `1 F% H$ G3 ~. K8 N3 I
2 kg of weight. Physical examination remained
( U9 C4 o1 ?) K) M3 C! ounchanged. Surprisingly, the pubic hair almost com-4 G0 E% }5 w+ c0 @
pletely disappeared except for a few vellous hairs at
! `+ N& O6 h. R" ^ G0 v9 Z, othe base of the phallus. Testicular volume was still 2
1 O2 x- D' {1 ^8 }! PmL, and the size of the penis remained unchanged.; j' G. H3 {; }. L! {
The mother also said that the boy was no longer hav-
( ?9 c0 q5 O2 ^ing frequent erections.
3 r9 |! w# z, UBoth parents were again questioned about use of
) x. o4 P9 A6 D: s9 I7 @any ointment/creams that they may have applied to5 o$ Q6 I& J. I0 k {' @
the child’s skin. This time the father admitted the4 v$ b0 Z7 L1 X% \) p7 F
Topical Testosterone Exposure / Bhowmick et al 5419 v+ C7 o8 p" Z$ _" R3 H9 w
use of testosterone gel twice daily that he was apply-
+ L5 V6 ]8 X v* ping over his own shoulders, chest, and back area for
# f8 w! b+ E5 u5 Q" Ca year. The father also revealed he was embarrassed$ o; ]8 ?; p* H3 }% @) U& P
to disclose that he was using a testosterone gel pre-
% h) K- c! \! e. a) m) oscribed by his family physician for decreased libido
: P6 H$ j( N$ ]: y9 Gsecondary to depression.) [$ s9 G% c; Q& R
The child slept in the same bed with parents.8 h' a' m# U% g% Q- W3 r
The father would hug the baby and hold him on his
q0 B, ?7 U) u+ j4 Q& M( {chest for a considerable period of time, causing sig-' U. [1 X2 K+ D9 |- \/ e0 W
nificant bare skin contact between baby and father.7 b1 ]# ~% A/ w7 I, \9 ?2 s
The father also admitted that after the phone call,
) y5 ^( Q- T: T3 pwhen he learned the testosterone level in the baby
- x$ t6 z5 u# a, [was high, he then read the product information* l# o+ b5 b" K; M; E" d$ g+ N% _
packet and concluded that it was most likely the rea-! @" `8 m. R/ e% z" P
son for the child’s virilization. At that time, they3 w, R: w# U( ]( U: D# E7 M& U) U
decided to put the baby in a separate bed, and the4 e& u5 T! k4 w7 i! j2 ^, ^9 w/ X
father was not hugging him with bare skin and had( E$ n2 p1 Z2 |
been using protective clothing. A repeat testosterone5 _- E' ]4 [1 L; B
test was ordered, but the family did not go to the
$ L4 ], l5 u; X: ?laboratory to obtain the test.4 f- F2 E, n, f3 `, N2 T
Discussion
. i n* s, W3 o8 g5 sPrecocious puberty in boys is defined as secondary
- M, f* t; Q& _" C6 }% D5 `3 Hsexual development before 9 years of age.1,4
7 ~- D! s4 A" [& G# DPrecocious puberty is termed as central (true) when
: p$ ~: k+ K% z$ ~% w/ Z3 O* Fit is caused by the premature activation of hypo-4 r. z4 Q) z. i0 v. e7 A
thalamic pituitary gonadal axis. CPP is more com-
4 v o. U: i- n5 Omon in girls than in boys.1,3 Most boys with CPP
$ O" g+ j! c3 Q& {may have a central nervous system lesion that is
8 G( ^! h5 y/ A- ]/ Eresponsible for the early activation of the hypothal-
6 _7 m# ]; O! |amic pituitary gonadal axis.1-3 Thus, greater empha-
4 e2 _2 S0 s% s8 h: _sis has been given to neuroradiologic imaging in
8 w3 b$ k6 Z, N& Lboys with precocious puberty. In addition to viril-
, F' d/ H( l6 ]+ x6 k# K( S: \7 C6 Cization, the clinical hallmark of CPP is the symmet-) h7 _' X+ r( B- m! h, Q
rical testicular growth secondary to stimulation by
; X3 a' W6 r3 N4 c6 O/ X+ Ngonadotropins.1,3; e* O, g, `* ?7 @, h0 v- w! o: P+ n
Gonadotropin-independent peripheral preco-
9 r1 \9 u# L B, mcious puberty in boys also results from inappropriate; \% `6 @( ^8 {, U5 S# D' t, B$ B% p) f
androgenic stimulation from either endogenous or% H6 D0 ]7 a: U' S+ G1 _5 H1 k
exogenous sources, nonpituitary gonadotropin stim-
4 j8 u# u" V9 Z$ W( vulation, and rare activating mutations.3 Virilizing
. J6 p! |0 l& |7 I8 N/ n' V5 ^( jcongenital adrenal hyperplasia producing excessive" o! C. f; X7 S" X3 b$ q
adrenal androgens is a common cause of precocious4 {5 u; Y9 S5 x% L6 G5 d* r' b
puberty in boys.3,49 n, U3 [1 b9 @9 J! R [
The most common form of congenital adrenal. x9 G" U0 f( J+ T
hyperplasia is the 21-hydroxylase enzyme deficiency.
! p) D9 H, |! w* ? V5 F; iThe 11-β hydroxylase deficiency may also result in
- E$ h8 v4 C5 s1 y: }excessive adrenal androgen production, and rarely,
" H7 V `& a. Z- H# j7 Yan adrenal tumor may also cause adrenal androgen
( [8 F& U& r* S' l$ E$ h0 Dexcess.1,3 L1 `" {8 P/ w; p9 ^/ w1 V
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
2 G9 D' M: i! e542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 R# { I# F/ U1 N3 m1 `" |* K+ b& zA unique entity of male-limited gonadotropin-
6 Y g* f3 M: W% b7 o! B* ?" Z; F/ Pindependent precocious puberty, which is also known4 X9 E9 m3 h% p1 ^
as testotoxicosis, may cause precocious puberty at a9 |+ s' X6 L& y* X
very young age. The physical findings in these boys( q4 z7 y! H. J
with this disorder are full pubertal development,3 D6 D7 U8 O4 m6 p- V' J ~* J
including bilateral testicular growth, similar to boys
) ~; I( B% I; F1 W2 Dwith CPP. The gonadotropin levels in this disorder4 U+ h) \/ h+ y
are suppressed to prepubertal levels and do not show
1 }6 v3 i5 [! ^/ I5 c% `" Tpubertal response of gonadotropin after gonadotropin-, S: E( g1 M/ M( H5 e: N) V) l
releasing hormone stimulation. This is a sex-linked
' X. y- ^4 x! W) Q9 ?) N- Rautosomal dominant disorder that affects only6 G+ v4 T: }- u; f( J
males; therefore, other male members of the family
6 S) O# w$ x7 n& j- Wmay have similar precocious puberty.3
`8 S& ~! [. | ], QIn our patient, physical examination was incon-
/ m1 ]9 V8 g. E9 `' g7 `6 ^sistent with true precocious puberty since his testi-
. [' k- B0 n, ^. l: @cles were prepubertal in size. However, testotoxicosis
1 Y+ O+ v( j6 M0 K2 qwas in the differential diagnosis because his father* ~9 H* h' G' K/ i" K
started puberty somewhat early, and occasionally,
0 G7 g: N; f! O8 stesticular enlargement is not that evident in the1 W1 M$ E# I& h5 [$ \
beginning of this process.1 In the absence of a neg-
/ H$ I1 `$ T H" T/ z/ Y \$ native initial history of androgen exposure, our4 f" e1 V' Z$ i# [. B7 S: J
biggest concern was virilizing adrenal hyperplasia,
3 X6 l' ?. n. X; T9 beither 21-hydroxylase deficiency or 11-β hydroxylase
7 H1 w5 S# a* X) d: u$ `: Hdeficiency. Those diagnoses were excluded by find-* D( J' D. S9 r/ _6 a" p' K; B, M
ing the normal level of adrenal steroids.
. D8 l: u$ i: g m* w3 b4 nThe diagnosis of exogenous androgens was strongly/ Z& E# }* Y/ S. v8 {
suspected in a follow-up visit after 4 months because
- i3 @) \5 z3 Y/ [/ e1 E# r5 nthe physical examination revealed the complete disap-
! [; n( Q$ _- }" a) l! Ipearance of pubic hair, normal growth velocity, and$ L9 R# v/ |0 u+ c8 `* {: Q
decreased erections. The father admitted using a testos-, R: E0 o: U; T+ s" m) V: h
terone gel, which he concealed at first visit. He was
' a* `' B; Z3 P; d$ ^using it rather frequently, twice a day. The Physicians’
; E) e" d7 p; h7 m6 ODesk Reference, or package insert of this product, gel or
- h. I. d J! m' Vcream, cautions about dermal testosterone transfer to
" }2 V9 D2 X9 F# w1 xunprotected females through direct skin exposure.
7 ?; e! ^+ \- T8 pSerum testosterone level was found to be 2 times the
3 Z1 w" m3 s* q4 O L2 m/ Ebaseline value in those females who were exposed to
! |: o7 B2 O& c) D' Meven 15 minutes of direct skin contact with their male3 I. E; B5 K, j0 n
partners.6 However, when a shirt covered the applica-# n6 y: l1 e- b# V
tion site, this testosterone transfer was prevented.
% c2 P$ l7 p. y* `$ ~. `Our patient’s testosterone level was 60 ng/mL,
2 p2 o ~' {0 Twhich was clearly high. Some studies suggest that
* d, C) A- _$ Udermal conversion of testosterone to dihydrotestos- q9 z6 {1 x4 q. `7 ]5 f
terone, which is a more potent metabolite, is more9 v- O- O; r5 p3 B4 q( o
active in young children exposed to testosterone. X1 a' A5 o# ?9 I' l
exogenously7; however, we did not measure a dihy-
$ A9 D. w1 X9 ^; y- f0 ]# X3 `drotestosterone level in our patient. In addition to2 t# @, F: y6 T, u# B
virilization, exposure to exogenous testosterone in
% {; ]( J9 u, w' m0 R# bchildren results in an increase in growth velocity and
2 C s3 T5 i4 iadvanced bone age, as seen in our patient.
3 J! M# o) M) f" F' w4 L9 u eThe long-term effect of androgen exposure during
8 G0 p9 r Z% Wearly childhood on pubertal development and final
! r5 F, n) B) O0 k2 ?adult height are not fully known and always remain
5 m, w' t! I. C* @- Q0 |5 u E+ Qa concern. Children treated with short-term testos-1 J$ w( _6 Z/ R( U S5 ~: o$ D( Q
terone injection or topical androgen may exhibit some) w2 _3 e, P ~ ~2 X$ E/ R- J
acceleration of the skeletal maturation; however, after
! Z$ L8 y7 w& I# ?cessation of treatment, the rate of bone maturation
6 M" m* b4 J+ ^# _+ s3 h4 ldecelerates and gradually returns to normal.8,9
3 b0 R* v+ k# e4 Q% BThere are conflicting reports and controversy3 m# }# p& k8 B! Q' p
over the effect of early androgen exposure on adult
0 |# N0 C8 Q4 U" L) K8 g5 d4 vpenile length.10,11 Some reports suggest subnormal3 R& e, q' v3 ^5 D E' v
adult penile length, apparently because of downreg-! V- g6 E% [( t2 L( D. d
ulation of androgen receptor number.10,12 However,# B$ D- k& a: r9 x5 i2 z, A- K" R" R
Sutherland et al13 did not find a correlation between/ T) n# y1 B2 y/ {* b
childhood testosterone exposure and reduced adult
' {2 }* }0 C+ ?" \7 g; openile length in clinical studies.( F7 Z5 B" f* x/ m4 C
Nonetheless, we do not believe our patient is! k# J1 H% q; E$ O& C
going to experience any of the untoward effects from3 R' G) t- p8 f8 ]5 ]+ T$ W+ f
testosterone exposure as mentioned earlier because( n* Q5 J) \+ f7 }
the exposure was not for a prolonged period of time.
! Y. q3 l l$ m8 z7 ~0 [Although the bone age was advanced at the time of9 o- H' R8 P8 l2 L4 V& T
diagnosis, the child had a normal growth velocity at
- m3 K* G; r, i6 l2 P7 A3 I; L* othe follow-up visit. It is hoped that his final adult
1 ]& X. E/ _5 q4 d% Sheight will not be affected.; k S: Q$ {2 C) @: `& @
Although rarely reported, the widespread avail-
2 [6 ^- x. L1 B- Cability of androgen products in our society may
/ Z; |# T7 y. ^5 Uindeed cause more virilization in male or female! u( f& `! {' a% Y- i
children than one would realize. Exposure to andro-
2 p! | w: E$ j# ?gen products must be considered and specific ques-% P6 ^5 l+ `* r! B
tioning about the use of a testosterone product or- v. n8 j4 P- J2 r* ~7 T
gel should be asked of the family members during
u# q; O! s# R. y: d. z+ F; _the evaluation of any children who present with vir-0 d m7 J# W$ V! h
ilization or peripheral precocious puberty. The diag-8 J5 @ t, U$ i. g
nosis can be established by just a few tests and by6 U) E' H% u, _. S3 ]$ Z& G
appropriate history. The inability to obtain such a
A3 D9 }7 q( E1 y. Chistory, or failure to ask the specific questions, may: }, v4 X0 k4 |% H, }1 I
result in extensive, unnecessary, and expensive
2 W5 ^5 x6 F, W$ L5 u% kinvestigation. The primary care physician should be
, P+ Y$ z4 I' Y$ v/ h8 t! H) Caware of this fact, because most of these children7 k7 v8 K3 G1 c7 E
may initially present in their practice. The Physicians’# ?5 a8 C! r$ \0 s$ R7 L/ }
Desk Reference and package insert should also put a1 p* A P' s+ g) k+ J
warning about the virilizing effect on a male or ~$ l& K$ K( X, U+ L
female child who might come in contact with some-
- R6 T( N# r+ u) H" J, U0 rone using any of these products.
# F M- O* N m3 H! cReferences
8 `* c* l9 ]4 `( @% Q+ \1 c8 h1. Styne DM. The testes: disorder of sexual differentiation
7 H* ^- Z O+ {5 \and puberty in the male. In: Sperling MA, ed. Pediatric: i# I' y; {9 Y$ m
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
) m1 ^7 s$ U6 m9 Q9 p3 G2002: 565-628.
, ] R u' T' @- i q, w% w/ y. a( ]2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
4 `5 U2 |0 E5 }puberty in children with tumours of the suprasellar pineal |
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