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Sexual Precocity in a 16-Month-Old
5 L$ `/ I; ~9 @/ b( _Boy Induced by Indirect Topical: X- v L" M7 \: G) \8 V# J0 I( B: n) G
Exposure to Testosterone
+ E5 W3 d9 h- j; z8 x& j; t/ JSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2% G3 ~" V) p. B. n
and Kenneth R. Rettig, MD1
+ A! L& [# m1 G- NClinical Pediatrics6 p; q9 V+ s/ E6 b! I+ r
Volume 46 Number 6
/ o. c% E( e$ MJuly 2007 540-543
# X4 @5 l, }: X& s: E1 S© 2007 Sage Publications
. f7 f3 l5 q* c) ^& _10.1177/0009922806296651
+ y) R: {" e# h' B6 Fhttp://clp.sagepub.com
. _6 d' w) ?/ h6 B- W) U- @hosted at( w+ k7 d9 u* M9 u, r, T4 K
http://online.sagepub.com
6 s. E& T) u: Y: QPrecocious puberty in boys, central or peripheral,
& b" S6 S0 Z2 j. ?4 Kis a significant concern for physicians. Central2 v! {2 c) k+ U9 o, w+ w
precocious puberty (CPP), which is mediated: f+ _5 \; M, }4 _7 J/ C
through the hypothalamic pituitary gonadal axis, has: C2 m7 C( E* c
a higher incidence of organic central nervous system! r- y8 n1 E' ]
lesions in boys.1,2 Virilization in boys, as manifested+ v1 S7 q/ D; z
by enlargement of the penis, development of pubic( [* F8 E7 w* Z4 Z
hair, and facial acne without enlargement of testi-
8 {# ~, I' m& E* \- e) \cles, suggests peripheral or pseudopuberty.1-3 We2 L5 w( e' ?0 |1 P0 P
report a 16-month-old boy who presented with the
# d4 Q" f) l8 H0 ^enlargement of the phallus and pubic hair develop-4 a* ^/ d# H' g3 \* r
ment without testicular enlargement, which was due" W( V) O+ B2 L C1 c U, B% L- J
to the unintentional exposure to androgen gel used by
+ I" o( l/ K& |# I, s. S. Nthe father. The family initially concealed this infor-
4 z7 j6 u/ R/ N3 W: E5 c' B( mmation, resulting in an extensive work-up for this! O B4 s3 F# I& M
child. Given the widespread and easy availability of2 B4 ] L/ H- _# ^$ X6 b
testosterone gel and cream, we believe this is proba-* m' Y; r% `# P, g9 j& N# `7 h
bly more common than the rare case report in the' B! f7 j) o) W. m* F
literature.47 D# B. ?" H9 p
Patient Report
6 u$ m" g) l' D$ d, x3 ]A 16-month-old white child was referred to the0 V3 T) _' \, u, s8 v9 g5 {) L( g
endocrine clinic by his pediatrician with the concern
+ w+ u+ n) n) G( Y" {of early sexual development. His mother noticed X* ]' |# h) _; T% C3 J+ w* }) `# r
light colored pubic hair development when he was
- ~, y# I* m) N8 O9 BFrom the 1Division of Pediatric Endocrinology, 2University of
4 U4 I6 g) J: ~2 Q) ZSouth Alabama Medical Center, Mobile, Alabama.
( H0 ?! \( Z& D, t1 [- N. NAddress correspondence to: Samar K. Bhowmick, MD, FACE,
! I( d7 F w$ u1 I6 JProfessor of Pediatrics, University of South Alabama, College of) K- e' b: i' _+ G3 t
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 o3 W1 x* r+ c7 s$ H ?7 U
e-mail: [email protected].
3 }/ Z3 b/ C. e8 }" Pabout 6 to 7 months old, which progressively became
/ ~6 }. u- O0 ?darker. She was also concerned about the enlarge-5 C+ }+ F# w+ B: K
ment of his penis and frequent erections. The child* X( g& @; S/ N8 Y/ y: f( O- |
was the product of a full-term normal delivery, with
% p0 J/ ~5 \5 v3 y8 H+ U, Fa birth weight of 7 lb 14 oz, and birth length of& Z8 b" I% a5 L& `' y. p8 e
20 inches. He was breast-fed throughout the first year
# B q, _7 j7 d+ Nof life and was still receiving breast milk along with9 B9 z! q6 z8 h& X
solid food. He had no hospitalizations or surgery,8 l/ s' ]! U8 b5 p6 W
and his psychosocial and psychomotor development
9 @4 R" O. p) d1 Cwas age appropriate. O. R" Z0 A- X' l3 A/ J* s
The family history was remarkable for the father,5 s: A' U9 m6 Q2 A: q
who was diagnosed with hypothyroidism at age 16,
6 `% D2 J2 y, r. x$ C7 X" x( Z8 _7 G7 W& ywhich was treated with thyroxine. The father’s
1 Y3 n' `" j6 I- Qheight was 6 feet, and he went through a somewhat4 C. m( O: J. w* U6 Q2 p! A
early puberty and had stopped growing by age 14.
, c/ w: v' ], R& d( P1 w5 O+ YThe father denied taking any other medication. The$ i9 j0 w! ]( Y6 N8 \! r0 C
child’s mother was in good health. Her menarche$ h7 J, d% d% } n
was at 11 years of age, and her height was at 5 feet
. _: j, |7 J/ b" v% \% Q- A5 inches. There was no other family history of pre-# ^/ g4 M, N; W- f$ e$ s7 n$ ?1 k9 k
cocious sexual development in the first-degree rela-4 u! s( |' \$ j
tives. There were no siblings.
4 J: r8 m* c) l/ s6 |4 ]Physical Examination" R3 d! }7 T: [0 m. c1 H0 z$ Q
The physical examination revealed a very active,6 r" O- {& F% g4 O( q
playful, and healthy boy. The vital signs documented5 O2 B1 b3 W4 \
a blood pressure of 85/50 mm Hg, his length was
: x9 [2 Z- O, e9 ~) d# ^# D# F90 cm (>97th percentile), and his weight was 14.4 kg
( [5 ?3 g9 G# C0 F(also >97th percentile). The observed yearly growth
U; c" \& A2 J+ M6 Q, ?velocity was 30 cm (12 inches). The examination of
8 z1 E, ] L+ ~3 D) Lthe neck revealed no thyroid enlargement.
4 ?: h9 U. z4 \$ `The genitourinary examination was remarkable for' g( g4 G6 T9 E" i+ X& ]2 m s0 U" E
enlargement of the penis, with a stretched length of
9 A* ]. ]) o3 D6 U, c! T7 Y8 cm and a width of 2 cm. The glans penis was very well- a& M/ p) u; M: \$ b1 L. j
developed. The pubic hair was Tanner II, mostly around
* a" P8 Z% T! I0 H. j# L* o7 G540
: L5 l. L" S$ E+ v' D; j# S2 [" dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* \) w& Q) _9 @ Lthe base of the phallus and was dark and curled. The
& J; n( L6 k% z' Etesticular volume was prepubertal at 2 mL each.+ _+ i3 u' d( p! K* m% a
The skin was moist and smooth and somewhat& R8 u8 b$ e4 G6 e e6 c5 G
oily. No axillary hair was noted. There were no
/ T* c4 L4 D8 q# l3 cabnormal skin pigmentations or café-au-lait spots.
; I* m/ w g& t; T) Y) ]Neurologic evaluation showed deep tendon reflex 2+
) L O+ l6 T, S9 @- s* x Kbilateral and symmetrical. There was no suggestion% D( K( ^3 f. z& q/ r. r) d
of papilledema.
# L% o+ t/ K' Z1 I0 C0 e+ L9 _5 k8 B \Laboratory Evaluation! j3 Q. ?' F' n
The bone age was consistent with 28 months by7 Z) z' j! I$ |9 D0 s
using the standard of Greulich and Pyle at a chrono-
$ a- \2 ~1 v3 e7 k v. z/ Klogic age of 16 months (advanced).5 Chromosomal
6 G& B0 @2 X' h5 skaryotype was 46XY. The thyroid function test
, m; ~1 S2 w" V% y" Cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
7 k4 s- ]1 t% u+ d \: P1 ^" }lating hormone level was 1.3 µIU/mL (both normal).
3 X, y5 K" K3 Z7 p3 {The concentrations of serum electrolytes, blood
; {5 V" a( x# J+ [urea nitrogen, creatinine, and calcium all were
7 a! E: {, i% q. j. w! i9 Fwithin normal range for his age. The concentration5 g7 U: E, ]7 h* l: B9 m- e0 a
of serum 17-hydroxyprogesterone was 16 ng/dL' ? ]: x+ A: t
(normal, 3 to 90 ng/dL), androstenedione was 203 {7 J2 d2 C; `1 n! H7 n
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
8 W& H9 W* l; i! yterone was 38 ng/dL (normal, 50 to 760 ng/dL),0 i' W3 K- [1 S! ^) J" Y7 a# y
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
( z4 _. ~! M( |49ng/dL), 11-desoxycortisol (specific compound S)
9 [7 A' h6 J5 b3 \* k: nwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-% z0 G* h9 g/ \4 }8 q4 l
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
0 u) f# [% s* J& j- d0 @testosterone was 60 ng/dL (normal <3 to 10 ng/dL),/ x7 d. G6 M0 ~: H0 A1 }3 C6 k
and β-human chorionic gonadotropin was less than
5 Q7 }* H2 I. H9 W0 ?8 k! U5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 o' W, E% F4 b; x8 w2 W) }stimulating hormone and leuteinizing hormone' z! U5 N/ w* t4 @
concentrations were less than 0.05 mIU/mL S' J$ i, b& G7 w
(prepubertal).
( R3 m" w% g2 m# \- [8 }$ [: G! @The parents were notified about the laboratory
& o' A6 ~6 |% o. xresults and were informed that all of the tests were; U; Z$ f* w/ }
normal except the testosterone level was high. The
+ r! c3 e4 q4 D5 v5 B7 {* Q; Jfollow-up visit was arranged within a few weeks to
' y4 |* N4 B2 Y8 ?* Z7 s. yobtain testicular and abdominal sonograms; how-* H" d8 S! G/ i) ?) s
ever, the family did not return for 4 months.
; |7 {" B7 `; Z+ J5 dPhysical examination at this time revealed that the7 n( L, G' Q+ G' B6 r" o+ T
child had grown 2.5 cm in 4 months and had gained. _* P d$ o; _" ~, @# [/ ~
2 kg of weight. Physical examination remained) N* j. V9 `+ X/ m! w+ B
unchanged. Surprisingly, the pubic hair almost com-4 e; y. Y3 f) p ~+ {: ?' o: Y
pletely disappeared except for a few vellous hairs at3 d8 y& p; Z) P! e1 R
the base of the phallus. Testicular volume was still 2 U: ~% n" v1 B& b
mL, and the size of the penis remained unchanged.
* B5 p6 m M2 X9 W8 I' AThe mother also said that the boy was no longer hav-7 v/ n/ @5 P) w: S) O
ing frequent erections.
( S( D% }: ]" \) |7 O- jBoth parents were again questioned about use of
' k( |, {, M( Dany ointment/creams that they may have applied to
( Q6 L! J" V% J# d* V) Jthe child’s skin. This time the father admitted the
4 Y: a7 _# w! b- k% `1 {. k/ BTopical Testosterone Exposure / Bhowmick et al 541/ H% ]" r4 ?9 q1 u
use of testosterone gel twice daily that he was apply-
# N2 a. W( W, o( t8 xing over his own shoulders, chest, and back area for
6 _. v) T& O5 y$ _0 L8 Ba year. The father also revealed he was embarrassed
' h7 b9 M! L; F, j/ a5 ^. Sto disclose that he was using a testosterone gel pre-! N5 T/ {5 v( k
scribed by his family physician for decreased libido
+ E3 C' b4 A) Nsecondary to depression.8 w) [) |8 P& P5 P
The child slept in the same bed with parents.9 J, V! P S! ?3 Q. |" w2 U- b
The father would hug the baby and hold him on his) b% @+ f% |# k+ d/ Z0 r
chest for a considerable period of time, causing sig-
* C7 j! O0 j2 x8 O3 D- H8 }nificant bare skin contact between baby and father.' E0 @1 g9 T5 y( L- r: B
The father also admitted that after the phone call,/ S! u8 G, k$ S# x: y, U1 ]' O4 A
when he learned the testosterone level in the baby B- g% P$ E3 b+ s7 Z
was high, he then read the product information
9 J# b) R( ]- O o r6 xpacket and concluded that it was most likely the rea-
/ W: R0 a2 m2 z1 n7 Hson for the child’s virilization. At that time, they, c0 `6 q8 _+ F( [7 b
decided to put the baby in a separate bed, and the
( U) A/ [& B+ k9 O+ o& q( nfather was not hugging him with bare skin and had6 {/ e6 Q7 G/ H- R+ {! D( i! p6 b- h
been using protective clothing. A repeat testosterone
) j$ o/ h& q" ntest was ordered, but the family did not go to the
- B% S0 ]$ d3 J. Y8 [# |, Ylaboratory to obtain the test.
! G8 q1 g- _$ wDiscussion; R" Q+ r5 B Z& ?5 E& B3 b2 |
Precocious puberty in boys is defined as secondary
; q! b0 a4 L! y5 Hsexual development before 9 years of age.1,4: h2 \+ I$ g+ N9 z
Precocious puberty is termed as central (true) when
% Z* a5 a! q4 |2 A% p/ hit is caused by the premature activation of hypo-0 `7 p& \6 g, J
thalamic pituitary gonadal axis. CPP is more com-
9 Q3 Z5 L: k% _! E+ Q: Mmon in girls than in boys.1,3 Most boys with CPP) y/ i- ]3 E5 S# s% I
may have a central nervous system lesion that is6 U& I# T+ T/ \3 Q$ ]4 m
responsible for the early activation of the hypothal-' U0 U- P$ |/ P- R6 y5 c' b# m7 m2 c
amic pituitary gonadal axis.1-3 Thus, greater empha-0 {' ~! \8 j" ~8 ~# G- ?4 C+ \4 z
sis has been given to neuroradiologic imaging in
2 y' x/ Q6 G& t( aboys with precocious puberty. In addition to viril-4 x' L: x1 N3 s
ization, the clinical hallmark of CPP is the symmet-
, W8 ?% f$ W E7 V* A' y& W Urical testicular growth secondary to stimulation by. g5 Q1 |7 J( R2 }; \& ?5 O6 i, r
gonadotropins.1,33 o9 C# L8 e6 g/ L, G
Gonadotropin-independent peripheral preco-
6 U* e* L6 ?% [cious puberty in boys also results from inappropriate6 s5 \$ i; g1 G( S
androgenic stimulation from either endogenous or
9 g! E5 v* _# a# d( Rexogenous sources, nonpituitary gonadotropin stim-
% i$ w& W0 G+ d @ulation, and rare activating mutations.3 Virilizing# n8 K( y- j) g" d/ N9 o
congenital adrenal hyperplasia producing excessive: P' N' `, Y' m; ^; `
adrenal androgens is a common cause of precocious2 m" V6 a3 l% O0 v: J
puberty in boys.3,4
1 H, S/ @: G; Y& p# F S7 K# c' XThe most common form of congenital adrenal
3 K) N3 r; W- C2 ^9 W+ D' @# Qhyperplasia is the 21-hydroxylase enzyme deficiency.& b3 _5 ~# k. S9 Y
The 11-β hydroxylase deficiency may also result in
* q- B! f/ }- ~2 I( { Mexcessive adrenal androgen production, and rarely,7 y6 Y9 a ~! |: e2 J, h8 P
an adrenal tumor may also cause adrenal androgen
% i6 |3 @4 a$ ]excess.1,39 y; ^: S& h* c
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) j! d0 j5 x# T# Z3 r1 i! F542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
5 U" \+ ~# |. U* L2 zA unique entity of male-limited gonadotropin-( a( @' n5 }) @$ C' J
independent precocious puberty, which is also known; r: G, E$ {* J+ O' D' @$ S
as testotoxicosis, may cause precocious puberty at a$ N: B2 I2 V& z4 y: w5 [8 n/ m
very young age. The physical findings in these boys8 V. ^5 f0 h$ c0 W
with this disorder are full pubertal development,
) g* L! z( F+ lincluding bilateral testicular growth, similar to boys
. b+ ^/ @4 r2 q& b' V9 Kwith CPP. The gonadotropin levels in this disorder
* H# ]2 [+ E! _9 }2 @( Hare suppressed to prepubertal levels and do not show' L2 M7 E. V% ~3 d
pubertal response of gonadotropin after gonadotropin-& K6 a" h4 G% D+ R
releasing hormone stimulation. This is a sex-linked1 d% ]; \- T6 a) z4 O9 }
autosomal dominant disorder that affects only5 U0 E, k& d z5 S3 J
males; therefore, other male members of the family4 N% @4 z0 D6 V: K4 X2 A
may have similar precocious puberty.3' t$ R0 B; g! K' i
In our patient, physical examination was incon-
( @- K' P4 ]& C/ h4 _, ~7 l2 Usistent with true precocious puberty since his testi-
1 w( }4 X: Z, L3 y2 p' c5 Ycles were prepubertal in size. However, testotoxicosis
6 s7 @& V+ `- \/ M# t4 I' S3 Owas in the differential diagnosis because his father! c. B. [. @9 ^
started puberty somewhat early, and occasionally,2 _( B8 y, b4 D
testicular enlargement is not that evident in the! G( n4 c3 P1 \* n1 X' Q
beginning of this process.1 In the absence of a neg-, r, v; k, S* f
ative initial history of androgen exposure, our
8 ^- e, Q M7 a& r) z$ gbiggest concern was virilizing adrenal hyperplasia,
5 N% M' t) y# ~& feither 21-hydroxylase deficiency or 11-β hydroxylase% M5 L# S( a, ?9 _
deficiency. Those diagnoses were excluded by find-8 m) s* V* V3 D. X0 p& z9 I
ing the normal level of adrenal steroids.
9 ?+ Y( \) S( h% m7 F }' M4 GThe diagnosis of exogenous androgens was strongly
1 k- ^3 K; x7 T) E1 O B- A- |2 _+ vsuspected in a follow-up visit after 4 months because
6 U' p; w0 y) K+ Dthe physical examination revealed the complete disap-
. l9 J2 Y+ J k* i9 Y; E7 ^pearance of pubic hair, normal growth velocity, and1 [4 B7 D& s# ?
decreased erections. The father admitted using a testos-7 ?. b2 D1 C0 e2 Q9 v! i
terone gel, which he concealed at first visit. He was% p- c4 R( M8 z, c8 Q
using it rather frequently, twice a day. The Physicians’* G) B* a9 _# M
Desk Reference, or package insert of this product, gel or# i3 s- X" s# j7 P% N( Y
cream, cautions about dermal testosterone transfer to
; G0 q$ x6 X6 ~5 g. o. w5 d: tunprotected females through direct skin exposure.5 D! n* X+ O$ d, ^3 H* m
Serum testosterone level was found to be 2 times the
# Z# Z* t) Q; Vbaseline value in those females who were exposed to
0 F7 L' t4 N$ V5 weven 15 minutes of direct skin contact with their male1 i% M. u- I8 L; Y; G
partners.6 However, when a shirt covered the applica-
6 G n! K* `8 T+ q/ Z3 \+ ution site, this testosterone transfer was prevented./ D8 J4 Q, [0 n5 ?) M, N* z) i* Q0 U
Our patient’s testosterone level was 60 ng/mL,
! Q e( [7 i& [, O" e/ z3 h! e* Kwhich was clearly high. Some studies suggest that
% v& B; b% v, L1 _dermal conversion of testosterone to dihydrotestos-
/ W+ P) r5 e7 v8 P* L4 {/ D$ ?terone, which is a more potent metabolite, is more6 S' W) Y1 R! r" ?
active in young children exposed to testosterone2 z5 w% Y1 y) k) q* ~! ?/ s0 c
exogenously7; however, we did not measure a dihy-
0 X: i/ i3 `' g/ _' F0 `. O6 i, Edrotestosterone level in our patient. In addition to
- e3 Q2 J6 p/ l- u8 ^3 c) pvirilization, exposure to exogenous testosterone in, j" K* L0 d- y- L4 _% d
children results in an increase in growth velocity and
! n. c& I% ~! i% a5 \advanced bone age, as seen in our patient., r8 s. v- h5 W2 z0 }0 j( ]( x
The long-term effect of androgen exposure during
& F# {0 l1 D N2 |) p% `0 D# Jearly childhood on pubertal development and final, z9 k" e' M3 Z8 {9 F/ f" k
adult height are not fully known and always remain& s& p# T, v$ S3 X$ ?5 _, Y* l
a concern. Children treated with short-term testos-
2 Z, A- z, o- {# ^3 Aterone injection or topical androgen may exhibit some
, }& ]- A* f% [. o. @acceleration of the skeletal maturation; however, after
1 C" S! x r; w5 ~( Tcessation of treatment, the rate of bone maturation
7 Z& B4 G6 C: l6 ~decelerates and gradually returns to normal.8,9
' w+ l7 v0 t$ X9 E+ tThere are conflicting reports and controversy
' c1 q8 B' G# F) sover the effect of early androgen exposure on adult
- j6 u" d1 Y* t G% u5 jpenile length.10,11 Some reports suggest subnormal
7 B! U1 N9 \3 i) X7 @adult penile length, apparently because of downreg-; L! V9 ]8 ^1 `
ulation of androgen receptor number.10,12 However,
* @2 c' a8 n! m) a3 |* eSutherland et al13 did not find a correlation between
% F" }" G1 _" w8 k& O; ]( _childhood testosterone exposure and reduced adult8 F" k: B$ s h9 a' b" D* g( V
penile length in clinical studies.
9 f. `* T2 Z$ G0 _- `( ~: H0 P$ WNonetheless, we do not believe our patient is
2 H- l1 M1 R. l# t6 Y( wgoing to experience any of the untoward effects from* I5 L" Q! D! G& _8 v" I
testosterone exposure as mentioned earlier because
6 G2 v( j- R7 v# C$ lthe exposure was not for a prolonged period of time.& d: P9 @: B k$ }2 g: }+ I- t3 F- A* h
Although the bone age was advanced at the time of
- `. e( D% E4 i, R/ Ndiagnosis, the child had a normal growth velocity at
7 }6 N" n% d, p/ Nthe follow-up visit. It is hoped that his final adult0 I' X, v9 A1 e" [+ p
height will not be affected.) V/ t& T! W" H7 ^) m
Although rarely reported, the widespread avail-
. F- {: _% ]( R9 M/ Lability of androgen products in our society may
( U8 {/ t+ J5 g' k$ [indeed cause more virilization in male or female
; G* Z: I+ B% z2 }children than one would realize. Exposure to andro-
# ]( ]5 c) Z# g" k- g& Q3 igen products must be considered and specific ques- i1 i0 P5 f" x, P( @8 w- v! ?
tioning about the use of a testosterone product or
& H' w4 n3 g* ggel should be asked of the family members during5 j+ g0 ]% V5 l
the evaluation of any children who present with vir-' b( c; o1 \4 U/ y/ o7 l! N
ilization or peripheral precocious puberty. The diag-
' C0 G7 j4 z6 h) I) ]8 G( onosis can be established by just a few tests and by
, L$ ?. T$ F! l `, z- Zappropriate history. The inability to obtain such a
# ~) H* }! ~. q; W- Ihistory, or failure to ask the specific questions, may
6 T' m( x: i6 d6 vresult in extensive, unnecessary, and expensive: x# U: S, n( T0 b" ^9 b& _
investigation. The primary care physician should be% u i# b5 P. }" X: y( W% Y
aware of this fact, because most of these children1 l6 G1 b" N2 d' e1 o! v7 i$ R
may initially present in their practice. The Physicians’
) c; C% D" D ]Desk Reference and package insert should also put a
1 M7 U- D5 K! z% x' swarning about the virilizing effect on a male or. A! C! _% ^# n8 U( X6 V+ t
female child who might come in contact with some-
$ h6 c# l& Y1 F2 Y8 C( R9 Cone using any of these products.
) Z) y5 x$ k& Q, N& F+ p# HReferences( T# o0 V& `3 c7 }6 R7 K! z6 z, D8 Q
1. Styne DM. The testes: disorder of sexual differentiation+ r* t# i: h: [$ s7 i
and puberty in the male. In: Sperling MA, ed. Pediatric
& l) R; _" a% S3 u( F- SEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
1 i v8 A8 |, C( Q: d: {2002: 565-628.
' p5 M. S7 D* D/ V$ F1 w2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious- E7 R: f9 x* @/ w
puberty in children with tumours of the suprasellar pineal |
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