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Sexual Precocity in a 16-Month-Old3 x0 h& n! H- B" l
Boy Induced by Indirect Topical
) T$ x8 i* B/ ^2 E3 v8 p* p1 ZExposure to Testosterone5 R/ j K; l; |
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
1 `6 b/ N. U; f" e$ d3 Wand Kenneth R. Rettig, MD1
" V, Z$ d0 O, w- M0 AClinical Pediatrics
6 r& B2 b& Y( o+ c' BVolume 46 Number 6. n, @/ a) ~' N1 T5 `2 h, G: ^
July 2007 540-543' u# T' X( n# ^- v0 {. Y0 y
© 2007 Sage Publications
7 ]- f/ ?: c& j7 s& R10.1177/0009922806296651
) z# \6 Y$ r& l6 A9 Nhttp://clp.sagepub.com5 \0 J: @5 ]1 P t
hosted at7 B/ o( ~1 f e! n3 j# B$ X( v& o& K
http://online.sagepub.com
& b* A7 ]# ~6 }5 L. JPrecocious puberty in boys, central or peripheral,* K! n* H$ ~1 E! {' F0 t
is a significant concern for physicians. Central$ Z; ~ s4 K. D5 R: G. i1 D6 {
precocious puberty (CPP), which is mediated
2 u! d6 \8 h5 T8 Q, W" {+ Dthrough the hypothalamic pituitary gonadal axis, has% K4 E7 Y5 |4 O1 s4 d, N
a higher incidence of organic central nervous system: g1 l: w& a$ w3 D) D
lesions in boys.1,2 Virilization in boys, as manifested1 H% G) O4 P1 @: _3 ], z1 R
by enlargement of the penis, development of pubic
# K! P! r) ~+ L8 ~! v* r, d( rhair, and facial acne without enlargement of testi-, [* P- t; B# X9 @
cles, suggests peripheral or pseudopuberty.1-3 We p' y- o7 e# H" J; x% `" _
report a 16-month-old boy who presented with the
6 O$ M6 \, q/ A/ ~/ k1 t* ? n8 G' o6 Menlargement of the phallus and pubic hair develop- Y! ]" U) O, E' l( G- s C
ment without testicular enlargement, which was due9 y$ }: S0 h9 r. n, X0 a
to the unintentional exposure to androgen gel used by4 W5 c' h( h% }
the father. The family initially concealed this infor-
+ _$ n% T4 X4 @, U% cmation, resulting in an extensive work-up for this% u& o* O6 {# w" E9 ]: v) P- n3 h
child. Given the widespread and easy availability of
7 r# n9 J4 l# ? O* i2 wtestosterone gel and cream, we believe this is proba-- V/ r" O: M8 _
bly more common than the rare case report in the! M3 o- e4 y7 ~7 I. M! l" K8 E5 l6 [
literature.4$ s( t+ Q: b! y) B; M/ d/ k. L+ I
Patient Report
' C2 O" ?# U7 X+ Y6 c7 Y8 {& tA 16-month-old white child was referred to the
5 S- U. O6 A8 o% P& Nendocrine clinic by his pediatrician with the concern9 \$ w# {4 `; V$ i$ X i
of early sexual development. His mother noticed5 c% I( ]; K+ s) Z! Y
light colored pubic hair development when he was
4 h( C6 G/ c2 F. K$ v2 wFrom the 1Division of Pediatric Endocrinology, 2University of8 Q$ r8 [! k! D. |
South Alabama Medical Center, Mobile, Alabama.
J7 `3 ]0 j+ B2 J$ wAddress correspondence to: Samar K. Bhowmick, MD, FACE,# o' B# v+ c3 Z8 Y' }+ h
Professor of Pediatrics, University of South Alabama, College of
+ p- N2 K0 K* GMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
6 y: Z0 i. ]8 {+ Ge-mail: [email protected].2 z4 \8 A% T" s4 Y" U; X0 r! U
about 6 to 7 months old, which progressively became
1 {$ t& |5 n# Hdarker. She was also concerned about the enlarge-
1 H+ M& f: f6 oment of his penis and frequent erections. The child2 `0 g. V2 c1 J; L
was the product of a full-term normal delivery, with
7 ~" T8 M2 M3 Y; q* U" [' _a birth weight of 7 lb 14 oz, and birth length of& W3 ?( P4 E# j3 n
20 inches. He was breast-fed throughout the first year
* O; K! _7 ]. [1 u7 o' U5 qof life and was still receiving breast milk along with
1 _( n$ ] {& z# a2 w* ?/ wsolid food. He had no hospitalizations or surgery,3 z) p' z5 @5 N- T
and his psychosocial and psychomotor development
. d& C2 U; ^& I1 Gwas age appropriate.
+ K; |; p" @1 q. bThe family history was remarkable for the father,: ^5 K3 U% ~( e! v: v: U
who was diagnosed with hypothyroidism at age 16,
9 {, U. N% @8 J( C; g# i; Nwhich was treated with thyroxine. The father’s
( f* A j& u% i5 o6 x' xheight was 6 feet, and he went through a somewhat
/ l, M7 a/ a0 f. aearly puberty and had stopped growing by age 14.6 U/ I4 T! V) }
The father denied taking any other medication. The
P4 K+ u- Z$ G' u7 jchild’s mother was in good health. Her menarche3 n$ g8 Z, ?) ?6 E2 I) Z4 E
was at 11 years of age, and her height was at 5 feet- F* f. p7 z8 T4 `2 ?' h, R; Y' k
5 inches. There was no other family history of pre-
. Z3 y' B/ T9 M( ococious sexual development in the first-degree rela-; s' U Z+ V. M. X6 v7 {" {& B
tives. There were no siblings.
5 R! t2 a7 z7 G. `7 G0 y F$ Q! vPhysical Examination3 g4 x) u& p2 `. c: n7 i) i5 D
The physical examination revealed a very active,5 ? F, E6 h+ f2 J
playful, and healthy boy. The vital signs documented' Z, E3 ]1 j: w+ h0 |0 R
a blood pressure of 85/50 mm Hg, his length was
. ?( N9 w2 m. v4 J: P90 cm (>97th percentile), and his weight was 14.4 kg2 n+ n* A, I$ s9 K- u
(also >97th percentile). The observed yearly growth. h! G" c; j" i( W, p$ s
velocity was 30 cm (12 inches). The examination of- x7 s6 l0 L8 X
the neck revealed no thyroid enlargement.
. Q9 B3 m' k- D3 `# wThe genitourinary examination was remarkable for
) N% S! H& R9 Venlargement of the penis, with a stretched length of' @; o8 Q1 r5 p* n' s6 l
8 cm and a width of 2 cm. The glans penis was very well, @; y4 E! |8 Y; v
developed. The pubic hair was Tanner II, mostly around
$ D: d9 ^# ~1 s) c5 \540& z: W B! n. D* K. D
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from% m* T) C1 [+ G+ j
the base of the phallus and was dark and curled. The) m* i0 {) Z; ^* O
testicular volume was prepubertal at 2 mL each.
/ C/ }# f- z$ z) wThe skin was moist and smooth and somewhat
- n/ e, _ T9 V& Q; Aoily. No axillary hair was noted. There were no) S9 t, d: X( ~& ^; y8 s& H% @
abnormal skin pigmentations or café-au-lait spots.
6 Q! P1 s I% H0 n+ ~5 BNeurologic evaluation showed deep tendon reflex 2+
( E, Q: P$ [- c1 i/ o. h% m1 K Ubilateral and symmetrical. There was no suggestion
2 O2 H/ d2 V5 \6 k; g/ Nof papilledema.. N; }, Y! o/ _* K7 R
Laboratory Evaluation% W/ {$ t# b( l% L8 k" `
The bone age was consistent with 28 months by, s; ~9 @1 e5 ?, Z% t
using the standard of Greulich and Pyle at a chrono-
% ?$ k G8 ]& O! clogic age of 16 months (advanced).5 Chromosomal
: \, R8 N: }# P0 ~9 C, A" x) G/ ~karyotype was 46XY. The thyroid function test4 A" b, ?2 I, X! L3 J% i4 V; I
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
: z- I3 t5 O- M9 qlating hormone level was 1.3 µIU/mL (both normal).' [7 Z& A6 x9 Q. |& ^' [3 I) S) v) g
The concentrations of serum electrolytes, blood8 A# \* X7 r( l" p. t
urea nitrogen, creatinine, and calcium all were
: X/ Z) A/ ^0 G( t4 cwithin normal range for his age. The concentration, }& S9 d, b% K7 e" I6 P
of serum 17-hydroxyprogesterone was 16 ng/dL- H/ n2 N8 B9 _' Q! H d* w
(normal, 3 to 90 ng/dL), androstenedione was 20
: F" |. \7 N' P7 U. ung/dL (normal, 18 to 80 ng/dL), dehydroepiandros-$ X; m( s( q7 W. ?. V* Z) u8 R1 C; p
terone was 38 ng/dL (normal, 50 to 760 ng/dL),$ o+ L8 @- ?' W/ z! g. [, L
desoxycorticosterone was 4.3 ng/dL (normal, 7 to* j4 @& v6 {" ~
49ng/dL), 11-desoxycortisol (specific compound S)- @; t1 j$ A% s% L8 y
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
3 r- N% }. Q& X w' Itisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
! M @- W' ?* htestosterone was 60 ng/dL (normal <3 to 10 ng/dL)," _1 `8 u1 E8 G
and β-human chorionic gonadotropin was less than2 M5 Q5 |9 u& [
5 mIU/mL (normal <5 mIU/mL). Serum follicular
! O! X2 C, c6 dstimulating hormone and leuteinizing hormone
) C0 k: M; `9 |+ L& R/ X* e5 D* kconcentrations were less than 0.05 mIU/mL
) h/ h0 d9 v, d& y/ @) ~4 J(prepubertal)./ ~* g% v7 a9 R. v
The parents were notified about the laboratory2 a& e# |, Q* T( c: h1 @
results and were informed that all of the tests were
! r1 y) |% Y+ u& a9 {4 Mnormal except the testosterone level was high. The
) h( v% d Y2 F$ v/ i7 ~follow-up visit was arranged within a few weeks to
) t3 r ?3 d/ C# m6 ?: d/ G- Zobtain testicular and abdominal sonograms; how-+ K9 b' I; o- j) P; ]$ j
ever, the family did not return for 4 months.4 }3 w: b* V; q, |* f9 o( s
Physical examination at this time revealed that the0 ~& B e. H/ K" N
child had grown 2.5 cm in 4 months and had gained
" J0 W5 q9 [9 j6 w* O& c+ b/ U5 j/ R0 @2 kg of weight. Physical examination remained
8 |. f% Y7 _" K: junchanged. Surprisingly, the pubic hair almost com-
; B! I M3 m: F) `pletely disappeared except for a few vellous hairs at
1 ]" E/ X0 q4 B* U% Ythe base of the phallus. Testicular volume was still 2- E* K5 W( d8 a" Y# T) U
mL, and the size of the penis remained unchanged.7 U' R4 r2 D# @$ x7 \
The mother also said that the boy was no longer hav-
: o6 M! K0 E+ |$ P) G$ Zing frequent erections.
0 c) b. N: Z0 e0 ?" j& xBoth parents were again questioned about use of1 C6 c/ H* f4 k/ p4 X" N9 w
any ointment/creams that they may have applied to
( Y. e7 r% M) D9 Uthe child’s skin. This time the father admitted the
% T. Y3 q8 K, K. nTopical Testosterone Exposure / Bhowmick et al 541* P! J# @: Q0 R! J& O2 k' k
use of testosterone gel twice daily that he was apply-4 m& ?7 F1 ]: l* a- q2 [- |
ing over his own shoulders, chest, and back area for
( C! J; ]4 h/ s5 b* _a year. The father also revealed he was embarrassed
; F6 |! y% K! F; F/ o: ^8 cto disclose that he was using a testosterone gel pre-
3 r4 B0 |6 Q1 `1 S. @- cscribed by his family physician for decreased libido
" B' t% G. F4 A* ysecondary to depression.
" h ?2 X9 E0 PThe child slept in the same bed with parents.
( ~! o$ l! i9 q ^The father would hug the baby and hold him on his7 }9 g5 z( q, I5 a
chest for a considerable period of time, causing sig-
% S3 B/ m( U' v C& gnificant bare skin contact between baby and father.
+ x. X8 W+ B* NThe father also admitted that after the phone call,/ V$ ^3 I6 Q8 E
when he learned the testosterone level in the baby1 K" {% K7 Q: h, M" H$ c
was high, he then read the product information
: F, T6 G9 X1 }; m: h# a0 w" xpacket and concluded that it was most likely the rea-
- l% ^8 _* d6 B, O8 y3 t5 tson for the child’s virilization. At that time, they
8 J4 K* o+ y" X2 Y+ u jdecided to put the baby in a separate bed, and the: B1 [: k2 A; T9 R# Q
father was not hugging him with bare skin and had7 t# u5 b! w8 D* s6 X( l' l$ g d
been using protective clothing. A repeat testosterone1 ^( x7 G7 s$ h9 A
test was ordered, but the family did not go to the
% k8 }' O1 A' Vlaboratory to obtain the test.
w D% U; q0 U# W. Z7 F8 XDiscussion
2 o; h- O% \0 e3 I6 }Precocious puberty in boys is defined as secondary# @2 ~) w) F! t | G! o
sexual development before 9 years of age.1,4
6 V3 S0 }% E9 ^' Y- q6 gPrecocious puberty is termed as central (true) when; h: Y0 O# P t6 I y
it is caused by the premature activation of hypo-8 g6 u0 m0 w7 Z; q
thalamic pituitary gonadal axis. CPP is more com-6 I( U* X1 |* L/ A' J: [8 S# [
mon in girls than in boys.1,3 Most boys with CPP
9 m3 K8 b9 i5 P! Y1 W% D, r) b0 j: `may have a central nervous system lesion that is+ v3 q) |. m5 p3 V" h
responsible for the early activation of the hypothal-5 T' Q# S! C, a+ ^' H# A# D4 x X
amic pituitary gonadal axis.1-3 Thus, greater empha-' F3 x& i+ T" A# I* t, T- t3 z1 w
sis has been given to neuroradiologic imaging in. b+ F( ~% `8 M
boys with precocious puberty. In addition to viril-( F: H/ r2 H" O" [2 Z
ization, the clinical hallmark of CPP is the symmet-9 {7 b9 n( T) R7 ]0 f
rical testicular growth secondary to stimulation by( c) d8 E7 H' U
gonadotropins.1,3" J# D6 Q% J8 l$ n+ }: P. [
Gonadotropin-independent peripheral preco-" y; l' b b! A+ u6 K
cious puberty in boys also results from inappropriate
7 ]% G& x) G" c/ i. A! Iandrogenic stimulation from either endogenous or
6 n9 a, C' P1 e. @( y2 O0 p6 y5 hexogenous sources, nonpituitary gonadotropin stim-
9 |8 r# ]9 {4 n" l5 _: `. qulation, and rare activating mutations.3 Virilizing
. E, ?; {1 \1 h- d( @congenital adrenal hyperplasia producing excessive
" R8 B! c5 S( ]$ P( V( o1 |" eadrenal androgens is a common cause of precocious
1 i# R7 |, N2 O8 apuberty in boys.3,4
6 {% M5 w8 c9 M4 b: K5 AThe most common form of congenital adrenal
2 T1 L6 h3 e9 ^3 phyperplasia is the 21-hydroxylase enzyme deficiency. ^) k3 `. \/ L1 a( K# e* E
The 11-β hydroxylase deficiency may also result in4 ^) {7 c$ ?- s! S; v. e
excessive adrenal androgen production, and rarely,
7 I1 s, ?( y" U! e& Ian adrenal tumor may also cause adrenal androgen, F. {. g9 S u
excess.1,3
/ R; P: }3 u1 g6 `; Nat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from5 h- w; B& H, l! a/ n! s
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007 J4 E, g* b( t. m B2 Q: y
A unique entity of male-limited gonadotropin-
+ }' ]9 e2 K/ K$ D: o' ^& r8 nindependent precocious puberty, which is also known
, t6 b+ U% E0 a* U6 _1 oas testotoxicosis, may cause precocious puberty at a6 R3 K5 D q% u- W
very young age. The physical findings in these boys5 a0 S6 Y2 Z9 D. {# ~
with this disorder are full pubertal development,
$ \1 @/ D3 \; o- e! O; xincluding bilateral testicular growth, similar to boys( V" A" r$ ~* r
with CPP. The gonadotropin levels in this disorder1 F1 `7 I8 d9 I0 d5 N" H
are suppressed to prepubertal levels and do not show
/ ^0 g6 G% Z- r! I$ o; l u, y# ?pubertal response of gonadotropin after gonadotropin-9 S! n) z# e+ ?, f" S
releasing hormone stimulation. This is a sex-linked
( b# K C# T: l. Zautosomal dominant disorder that affects only
# u# N+ O$ T: y+ y* Xmales; therefore, other male members of the family8 d# y, C: [3 Z" E
may have similar precocious puberty.3
: b0 ]4 h# z& I( z9 kIn our patient, physical examination was incon-
. u8 _) A! b9 ]6 E4 c: Z7 |sistent with true precocious puberty since his testi-) W/ J c( b C% C& W
cles were prepubertal in size. However, testotoxicosis
+ {( m: M7 s3 v9 T9 Fwas in the differential diagnosis because his father
' \! Y$ e8 u0 f0 l% {% k7 E/ Lstarted puberty somewhat early, and occasionally,( w2 Z7 y, \) ^, w* D0 Y
testicular enlargement is not that evident in the7 m! k# |% O7 k8 i# x1 |% [
beginning of this process.1 In the absence of a neg-
3 _& y2 n% ]( q$ M. wative initial history of androgen exposure, our
1 k) u2 v8 n F6 Ibiggest concern was virilizing adrenal hyperplasia,4 ^! [' f' \/ a* J
either 21-hydroxylase deficiency or 11-β hydroxylase
2 M. I. t1 j3 t- j- w" ideficiency. Those diagnoses were excluded by find-
+ l6 V2 a! q. X2 B( U3 k6 G; |2 @ing the normal level of adrenal steroids.$ B' t0 T' Z. q2 F, Y$ T
The diagnosis of exogenous androgens was strongly
) T3 ~5 x* w: V' [ Q" @8 }suspected in a follow-up visit after 4 months because7 p8 l, I n, n( _2 z2 H
the physical examination revealed the complete disap-
4 i) u& A+ }" k6 ^$ m% s* }pearance of pubic hair, normal growth velocity, and
7 u/ V7 L" [# ^- qdecreased erections. The father admitted using a testos-
, W3 T# m: { U$ e! |+ K& @' J/ qterone gel, which he concealed at first visit. He was: g1 Z$ c) }, F% B Y) W
using it rather frequently, twice a day. The Physicians’
# a7 p# f# D* ~* j3 f: WDesk Reference, or package insert of this product, gel or
2 b! D) P& d8 z% f/ rcream, cautions about dermal testosterone transfer to# L" d6 ?8 A6 l1 c) d
unprotected females through direct skin exposure.8 \! T* r* `8 @! E* V4 k
Serum testosterone level was found to be 2 times the, N# y3 I5 R5 ~) I5 |
baseline value in those females who were exposed to4 H$ ?$ K$ t" p0 _3 ]9 y
even 15 minutes of direct skin contact with their male: a1 D8 V- ]$ ~( S
partners.6 However, when a shirt covered the applica-
3 W. Y+ m& M9 d" Q7 gtion site, this testosterone transfer was prevented.
# n- |) x0 b1 D8 P# MOur patient’s testosterone level was 60 ng/mL,
4 d- w8 f5 }/ o/ d$ Owhich was clearly high. Some studies suggest that. u( ]& c1 P' [3 i% ]. R! n% T! v
dermal conversion of testosterone to dihydrotestos-; l1 p# u1 _4 {1 \, `* _! N
terone, which is a more potent metabolite, is more
8 N7 i. P! B' o( o$ {! j- R* G. iactive in young children exposed to testosterone: Y8 S$ x# t+ Z g. g$ k
exogenously7; however, we did not measure a dihy-
/ \; Z+ ]7 {# g+ I9 q1 ldrotestosterone level in our patient. In addition to
' J6 j. N/ O, F1 G4 \virilization, exposure to exogenous testosterone in
" r, A' e& ]. }7 q) |children results in an increase in growth velocity and
5 G- `8 H8 U8 C! @advanced bone age, as seen in our patient.
) A1 b; `9 ?8 q& U( N5 U7 |The long-term effect of androgen exposure during
) }1 |* c0 d/ o3 Q% cearly childhood on pubertal development and final
' a* |2 l9 g4 h4 xadult height are not fully known and always remain
+ k, [% W7 z- G$ ]a concern. Children treated with short-term testos-
1 J5 @7 \) q1 _1 m/ K8 a Z, @6 kterone injection or topical androgen may exhibit some1 H) y5 h! o! J3 j" M
acceleration of the skeletal maturation; however, after
4 ]; u! o3 d& [6 v: v M7 ^: Hcessation of treatment, the rate of bone maturation
+ D( ^' P! ?- }( X' wdecelerates and gradually returns to normal.8,99 _- x! G: K' x5 a& {7 [7 z
There are conflicting reports and controversy
5 z3 g" e n' V' u6 Rover the effect of early androgen exposure on adult
# R" D( {9 s' k4 bpenile length.10,11 Some reports suggest subnormal
' P# }9 ?! |; x+ `8 radult penile length, apparently because of downreg-# m6 Q4 p+ D4 T% y2 @7 z! H1 p
ulation of androgen receptor number.10,12 However,/ [* `% T* E5 r8 s, G3 N3 Y; X
Sutherland et al13 did not find a correlation between4 Y0 ~8 L$ E( k. \7 Q! r8 ]
childhood testosterone exposure and reduced adult
) U; l, Y8 ?1 v$ mpenile length in clinical studies.$ A; T$ r; j. c% @
Nonetheless, we do not believe our patient is
" o3 A8 V; I: egoing to experience any of the untoward effects from' i, Q' V, u: ~3 x& {3 C8 d! u
testosterone exposure as mentioned earlier because
+ k Z x* E4 u$ d# @$ ^( Y* Pthe exposure was not for a prolonged period of time.
; v/ j6 U! w9 l- v( X$ R, E# hAlthough the bone age was advanced at the time of
- H4 _! T8 o1 S5 N$ Gdiagnosis, the child had a normal growth velocity at
1 u2 ?* q _0 z! ythe follow-up visit. It is hoped that his final adult
$ D& o/ ]2 J) n( G9 E( N+ Rheight will not be affected.
1 g& x% N8 P) K7 x7 s+ U+ RAlthough rarely reported, the widespread avail-
. _' H8 d: v% w1 Uability of androgen products in our society may
" Z8 m. Q: X. Rindeed cause more virilization in male or female6 x; [$ D) x% i& g; [: e
children than one would realize. Exposure to andro-: ]$ z- G, q% E" k( G
gen products must be considered and specific ques-
* d0 ]; w+ b l6 [- f4 m# p* K% Ptioning about the use of a testosterone product or, d0 w) n: v( K7 u2 K
gel should be asked of the family members during
2 H/ L8 p0 {% \- h; T2 o& X2 \5 ythe evaluation of any children who present with vir-
7 @8 ~( Y6 v/ `0 ailization or peripheral precocious puberty. The diag-3 @ Y. r% B- z5 D5 w7 @2 Z
nosis can be established by just a few tests and by
8 W$ L9 c5 f' i- D% ]appropriate history. The inability to obtain such a$ ~6 Y5 i6 x' l; \# g4 ]
history, or failure to ask the specific questions, may! j! m' I) S {; Y9 C' o
result in extensive, unnecessary, and expensive
' l$ U* o0 a4 {- |- xinvestigation. The primary care physician should be3 b. l) _$ @- ~1 g v+ Y
aware of this fact, because most of these children
" D! S/ v( U# B3 m0 {may initially present in their practice. The Physicians’
9 i1 X8 @0 c, ^& W* S7 tDesk Reference and package insert should also put a; f+ R @5 {9 U; P% F
warning about the virilizing effect on a male or
' {; c" b2 M) c# M) ^6 Y! Bfemale child who might come in contact with some-
3 E4 Q# l! p3 ?# Gone using any of these products., f B& Z) d* `, _9 t
References; D u j7 f! |5 M
1. Styne DM. The testes: disorder of sexual differentiation
* g, `7 P# a. }) iand puberty in the male. In: Sperling MA, ed. Pediatric
6 i. n) Z4 d9 q1 w0 rEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
\, ]& c7 U5 v9 i2002: 565-628.
B; c1 H: z% f( l4 A2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
/ Y7 D3 N& U: e) jpuberty in children with tumours of the suprasellar pineal |
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