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Sexual Precocity in a 16-Month-Old
" ]+ `$ A( }0 x+ C9 GBoy Induced by Indirect Topical
8 E0 V/ W: B# `+ W2 [Exposure to Testosterone
/ x: g2 U1 `3 |/ H- H% s4 S6 zSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2# ]$ N" N, q* ^, R
and Kenneth R. Rettig, MD16 Y" H( x ` c+ k6 r
Clinical Pediatrics
( b$ |3 K$ o- t C2 z8 _Volume 46 Number 6- J5 g `. _3 `& R8 u1 O
July 2007 540-543
9 ]; z1 R" u7 l* ?© 2007 Sage Publications
T# l7 f5 v/ \: Q+ B7 z( I( V& I10.1177/00099228062966518 d+ |* d) W2 Q1 @
http://clp.sagepub.com
) L) b9 a2 U0 G% R( hhosted at
5 \) H) l; V. M' g- J2 D/ @http://online.sagepub.com
1 k4 ?1 ^8 p) ?5 g2 _0 R9 y& ~Precocious puberty in boys, central or peripheral,2 H! w' ?: ?/ c/ D. O
is a significant concern for physicians. Central
7 b9 e/ X) o0 O+ T* ^0 ]" fprecocious puberty (CPP), which is mediated, ~0 J3 }9 h5 r; g! g9 a: K
through the hypothalamic pituitary gonadal axis, has
: J' l- `8 i! ` Y& i1 na higher incidence of organic central nervous system
* d3 `+ T0 {9 x1 B* T5 Alesions in boys.1,2 Virilization in boys, as manifested2 J" r/ _$ Q- d- W, Q
by enlargement of the penis, development of pubic
, {+ J: i4 B2 [hair, and facial acne without enlargement of testi-
) j4 X7 C' ?, `. ?cles, suggests peripheral or pseudopuberty.1-3 We
. B! f. D# E; b; Y9 f! X1 d9 i2 Kreport a 16-month-old boy who presented with the
1 n+ I4 _1 @# u( i( m/ R7 _. {enlargement of the phallus and pubic hair develop-
' O9 I# p% v; m2 w& Q: s oment without testicular enlargement, which was due7 Z9 N) I$ p( o6 J) ^/ ?: @7 N
to the unintentional exposure to androgen gel used by- }( F2 G+ H/ V L7 Z, v$ R
the father. The family initially concealed this infor-9 r# B5 R8 Z% P2 l( l; L! P
mation, resulting in an extensive work-up for this( B( B) n. J: A! D8 h" a+ a
child. Given the widespread and easy availability of
/ O! s) @' N j: t* {testosterone gel and cream, we believe this is proba-4 p" w, `) u+ w9 X$ J0 c
bly more common than the rare case report in the
5 n; t: ~' D% Z hliterature.4
& c4 _8 j! W$ a3 ]* yPatient Report
) _' u3 t0 I5 N8 ~3 ^& U3 jA 16-month-old white child was referred to the
5 }4 _9 H9 M- L& P! b7 U$ k zendocrine clinic by his pediatrician with the concern
" N/ h8 c& I: f; H) Rof early sexual development. His mother noticed4 {0 d2 R2 k/ Z. c6 X+ f7 S
light colored pubic hair development when he was) ~- B: Q" ]3 R
From the 1Division of Pediatric Endocrinology, 2University of# ^2 J2 v( U, a, P1 W
South Alabama Medical Center, Mobile, Alabama.: j2 c* P/ D" x7 e, R7 P* o3 e
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 C# a X) c; C8 k' CProfessor of Pediatrics, University of South Alabama, College of
2 y, ~+ y _ f, QMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
8 K/ y3 k9 B- o& f7 F' a1 qe-mail: [email protected].
0 [+ W) ^2 p0 Q( Oabout 6 to 7 months old, which progressively became
# X6 l+ @0 r1 U" @( tdarker. She was also concerned about the enlarge-/ n) Y. D, F& s* C; F+ W
ment of his penis and frequent erections. The child+ U( c* Q7 B2 s* o% K- I% x
was the product of a full-term normal delivery, with
' L/ T9 I$ n+ xa birth weight of 7 lb 14 oz, and birth length of6 L O: u. [9 A# r- j$ Y
20 inches. He was breast-fed throughout the first year
) Q' }1 ?& I, s; [, b9 Jof life and was still receiving breast milk along with; D2 ]3 g) v3 d6 A
solid food. He had no hospitalizations or surgery,, w+ s# f! [8 W5 D2 G8 }* \
and his psychosocial and psychomotor development9 m; g+ t, e* B3 t I
was age appropriate.
5 u Z* S1 G! c9 [& H- K1 JThe family history was remarkable for the father,
2 p S# }- e1 X, g+ ]who was diagnosed with hypothyroidism at age 16,3 P3 Z0 d( N, e- k; L7 r
which was treated with thyroxine. The father’s
& {3 o5 t/ A8 sheight was 6 feet, and he went through a somewhat
- E C8 @$ v2 ?0 e( Yearly puberty and had stopped growing by age 14.
: t# _8 I6 z& u& b3 `' x% ~3 o; AThe father denied taking any other medication. The) @; N R3 ^7 f( k9 L T
child’s mother was in good health. Her menarche( C) w. r6 T4 `& q- B5 ?3 L
was at 11 years of age, and her height was at 5 feet
1 l% a; Z4 _7 p/ U) F5 inches. There was no other family history of pre-
, Q7 V! b x/ e Y) ccocious sexual development in the first-degree rela-- ?& W7 w* i1 ?
tives. There were no siblings.: H' @* I& z/ @! p8 a, E G: g
Physical Examination+ D; F R) L; v
The physical examination revealed a very active,
! o: b. k3 d9 T3 F1 ^# W" [; yplayful, and healthy boy. The vital signs documented' j5 B. u3 L+ q/ R3 C7 U
a blood pressure of 85/50 mm Hg, his length was
6 l$ o* { b$ p3 T90 cm (>97th percentile), and his weight was 14.4 kg
+ e8 p, L; d( z$ m3 |(also >97th percentile). The observed yearly growth: r( m/ y. l9 K
velocity was 30 cm (12 inches). The examination of! \2 ]5 S8 m5 Q6 X$ c: U- O
the neck revealed no thyroid enlargement.
8 e+ l. j% _' M4 k3 W4 N- \5 D: DThe genitourinary examination was remarkable for
/ e4 J- ]3 d9 D% X7 p+ Qenlargement of the penis, with a stretched length of
" Q; p" c0 U8 b+ U8 cm and a width of 2 cm. The glans penis was very well
. v# U! c, E6 D, Ndeveloped. The pubic hair was Tanner II, mostly around( k- D9 G7 ~7 O
540- l8 r- `, |$ o/ U$ C
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
5 ~8 u X# @: \/ A- R9 l+ ]the base of the phallus and was dark and curled. The
2 f/ H& |- q- [7 ^- p/ q0 x% d& Atesticular volume was prepubertal at 2 mL each.
, K e. {9 _( f1 AThe skin was moist and smooth and somewhat, n/ }; n: [5 N
oily. No axillary hair was noted. There were no" X3 }4 O }% I' e! |9 Z1 ]
abnormal skin pigmentations or café-au-lait spots.7 p1 d' q# @5 ]* n
Neurologic evaluation showed deep tendon reflex 2+
4 L3 F X2 V, ibilateral and symmetrical. There was no suggestion. m1 d# r" k& }) R& G
of papilledema.( C, H8 Y _5 u7 {: X& c0 X
Laboratory Evaluation
; A1 I3 ^* W# y# f/ E0 ?) [6 YThe bone age was consistent with 28 months by; S/ p7 v2 D, m; @! y
using the standard of Greulich and Pyle at a chrono-$ D+ n6 j: D8 ^0 N9 n4 ~
logic age of 16 months (advanced).5 Chromosomal
2 s* Q$ K) ?' ?, [% N6 ykaryotype was 46XY. The thyroid function test; a3 m) r$ P2 Y. j' s& K
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
" z& f0 @6 Q9 b; ?$ C7 {3 dlating hormone level was 1.3 µIU/mL (both normal).2 _9 C7 ~: j0 d
The concentrations of serum electrolytes, blood
/ u& R, t0 q y% H/ {urea nitrogen, creatinine, and calcium all were* `# _7 }( `. D6 q1 i
within normal range for his age. The concentration7 Y0 X( L3 D5 e9 _# t
of serum 17-hydroxyprogesterone was 16 ng/dL
* F. {" r& }! j(normal, 3 to 90 ng/dL), androstenedione was 20
$ m5 @: }- E* rng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
5 q1 K3 }0 `5 Z- w( O: C- ]; Vterone was 38 ng/dL (normal, 50 to 760 ng/dL),! C7 i% B% N* ^6 g+ N
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ @! @1 g7 ]) X7 ?6 x" W$ J49ng/dL), 11-desoxycortisol (specific compound S)
7 t- V" d. m. M% a% Ewas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-6 S) X; r! c) l# Z5 U8 b( d
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
. W/ g; ]' Y: c; b4 y6 ^% Z' Ztestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
4 _$ S r1 {$ q) x- r+ ~1 p8 eand β-human chorionic gonadotropin was less than0 [0 B, v5 K) M+ y7 q7 V3 M
5 mIU/mL (normal <5 mIU/mL). Serum follicular
7 J! a9 P$ {# p, W& j5 g) p. m1 ostimulating hormone and leuteinizing hormone
0 q/ {# e% a% [: rconcentrations were less than 0.05 mIU/mL9 h3 T$ A8 t; a
(prepubertal).
. r2 \" y* T/ wThe parents were notified about the laboratory. I% k t6 n8 h& c3 e4 x& ]. Q9 \ w
results and were informed that all of the tests were
4 `; j+ a* e5 ?$ X1 Unormal except the testosterone level was high. The
" n( G5 J2 {- U/ ?; U( f( I2 @follow-up visit was arranged within a few weeks to: J( |6 T5 K+ Z$ K
obtain testicular and abdominal sonograms; how-
, d* Q% x1 V$ t% _$ i. Q1 n& F8 bever, the family did not return for 4 months. E" Q; b& m* V$ G8 O9 Q& u
Physical examination at this time revealed that the% ], s( }5 J( [) j
child had grown 2.5 cm in 4 months and had gained- i. ^* _% F% L2 s$ G
2 kg of weight. Physical examination remained
2 J8 [4 }$ [- P$ O' Cunchanged. Surprisingly, the pubic hair almost com- l+ w% m |4 { Q& N# e. L
pletely disappeared except for a few vellous hairs at/ O; U( ?+ x# r+ z2 U s
the base of the phallus. Testicular volume was still 29 g b$ E0 w7 |; T: Q n
mL, and the size of the penis remained unchanged.
0 J& y4 T8 V D; D* T; mThe mother also said that the boy was no longer hav-/ v1 O5 h m# _1 I. L
ing frequent erections.
0 @/ v( f- W- qBoth parents were again questioned about use of
, Y7 I( M7 J( R( V& [, o5 r( ?/ eany ointment/creams that they may have applied to' \; k/ Z- C. N1 j! x
the child’s skin. This time the father admitted the9 J6 z! F0 x. t* z& a
Topical Testosterone Exposure / Bhowmick et al 541
. i, x: o5 {0 n! u7 h- G; F/ ]2 u5 yuse of testosterone gel twice daily that he was apply-
, [8 @4 o0 k7 ?/ uing over his own shoulders, chest, and back area for
# e' \- {: ]6 v4 E+ }1 g8 }a year. The father also revealed he was embarrassed
/ y! e f1 _/ |; n+ gto disclose that he was using a testosterone gel pre-
; N8 |" C! `3 o$ O9 jscribed by his family physician for decreased libido7 R3 r# V" }3 }9 ^3 q# p2 o
secondary to depression.
- {4 J, Y# E6 ]9 G8 e* W* r3 \" KThe child slept in the same bed with parents.
/ |. Q( ]% @1 a2 TThe father would hug the baby and hold him on his
' T: m \# y8 ^# gchest for a considerable period of time, causing sig-
) I: b% i* b7 Y* `: znificant bare skin contact between baby and father.! q6 j+ E7 S. I5 u; I# w
The father also admitted that after the phone call,
3 H2 |1 V# e, dwhen he learned the testosterone level in the baby
+ E& Q" H% W# ^. {# L7 nwas high, he then read the product information' b5 r: D t& S# ^; f
packet and concluded that it was most likely the rea-
% k' y7 X9 \! n: S2 V) ]: Dson for the child’s virilization. At that time, they
8 N6 {9 l) \7 l7 X$ Ydecided to put the baby in a separate bed, and the
$ a- x8 C" T; h+ p A' Pfather was not hugging him with bare skin and had
. b1 ]% m8 A* _+ v+ t- i$ V6 S/ pbeen using protective clothing. A repeat testosterone4 w& p. U- _* l+ L
test was ordered, but the family did not go to the; f1 W% |. V4 o2 T; R6 D
laboratory to obtain the test.
+ g2 z3 W/ ]& T: }Discussion! `8 A7 ~2 f' m* ~# ~2 @, k) a
Precocious puberty in boys is defined as secondary( C! y$ V0 {+ o. N
sexual development before 9 years of age.1,48 z4 y& }" J) A) G
Precocious puberty is termed as central (true) when7 _) z6 R w e
it is caused by the premature activation of hypo-
4 Q; p7 h! u: ]2 T5 O# |7 @6 athalamic pituitary gonadal axis. CPP is more com-
3 D5 _! r9 ?2 B! ?$ Tmon in girls than in boys.1,3 Most boys with CPP5 a. t) N* [& o1 g
may have a central nervous system lesion that is) P% }! v. G) d" X# D+ U0 l5 [1 Z
responsible for the early activation of the hypothal-! n O3 }3 j% n1 Y" Y
amic pituitary gonadal axis.1-3 Thus, greater empha-. H0 V8 l9 P( X! U$ L0 _
sis has been given to neuroradiologic imaging in Q4 B9 a& P! g3 C6 E! A6 I
boys with precocious puberty. In addition to viril-
; c& ~4 |+ L, j2 e9 V: Q$ Uization, the clinical hallmark of CPP is the symmet-
& M5 S, W% M8 Q2 b" N% Krical testicular growth secondary to stimulation by# R2 J% Z5 P$ J8 M# S
gonadotropins.1,3, U& B) ^/ E/ [' j" w
Gonadotropin-independent peripheral preco-0 }$ q2 o4 Z. F! |! g
cious puberty in boys also results from inappropriate3 s+ {. m7 {7 b1 c, R8 j% V# {
androgenic stimulation from either endogenous or. @' K/ I0 d$ n, {
exogenous sources, nonpituitary gonadotropin stim-% O O5 n3 Q1 x# o. c3 B( C& Y
ulation, and rare activating mutations.3 Virilizing, G/ G Y+ w3 E. W& F
congenital adrenal hyperplasia producing excessive) J; s: d1 T0 u) M& I
adrenal androgens is a common cause of precocious6 f& s6 B- O5 |6 ]- H$ u
puberty in boys.3,4
* F' U( t" T6 v) o9 [The most common form of congenital adrenal
# Q( m0 J- U% Z8 u- h* a! H3 rhyperplasia is the 21-hydroxylase enzyme deficiency.
3 q/ ~7 ^) G3 k- h6 OThe 11-β hydroxylase deficiency may also result in% M: Q1 v4 J% t. D7 B; D3 z9 z) O9 F
excessive adrenal androgen production, and rarely,/ b0 d5 u% O( S2 F2 p* T* ]0 s
an adrenal tumor may also cause adrenal androgen; `4 E' V/ t7 p" s
excess.1,3
* y* _+ W1 c4 v% m& v9 c& rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 ^! |1 }, O; a) A5 a! w3 U% W
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
% E; T0 o1 y8 g0 q5 NA unique entity of male-limited gonadotropin-
5 c4 n! @2 i# findependent precocious puberty, which is also known; C* ~( l" N+ j6 C1 c( ?
as testotoxicosis, may cause precocious puberty at a
2 i4 ], `' d A, W$ Kvery young age. The physical findings in these boys
- B8 f6 D5 X# A: S, ~: Awith this disorder are full pubertal development,
- H5 k0 E! D* E9 Nincluding bilateral testicular growth, similar to boys
% v2 a5 ]: U c+ n0 ]) Owith CPP. The gonadotropin levels in this disorder3 w/ i' o7 e6 o4 I# W% l/ V
are suppressed to prepubertal levels and do not show! E3 F8 C: J# m4 i7 O y, @! W3 g
pubertal response of gonadotropin after gonadotropin-
! ]+ b7 _& A2 treleasing hormone stimulation. This is a sex-linked
1 V* {3 M) t8 M. Q9 [autosomal dominant disorder that affects only& @3 \/ T+ w. n7 }3 I' ?# X
males; therefore, other male members of the family0 h; w) Y2 o$ L J. \
may have similar precocious puberty.37 r# c% B2 L9 m2 w4 K
In our patient, physical examination was incon-
+ F3 [ ~. N) T* o2 k8 q7 G" usistent with true precocious puberty since his testi-
: C" [4 Y: G! m4 N2 D( Ccles were prepubertal in size. However, testotoxicosis* s: }+ N0 C5 r
was in the differential diagnosis because his father0 R+ R+ j9 P3 i1 q
started puberty somewhat early, and occasionally,& {* T/ R+ C, L- V6 m8 _: D( u
testicular enlargement is not that evident in the% s; Y. h$ Z. v5 P3 e! B
beginning of this process.1 In the absence of a neg-. A0 f3 p" X* x8 u+ B1 t5 i& D3 i
ative initial history of androgen exposure, our8 m, c, z, o0 _; Y" h. z
biggest concern was virilizing adrenal hyperplasia,
5 Q, S7 k4 F( I3 z7 u+ Deither 21-hydroxylase deficiency or 11-β hydroxylase7 V2 I0 Z; k4 P3 u) b
deficiency. Those diagnoses were excluded by find-1 P, n$ g5 o; n
ing the normal level of adrenal steroids.
- h- M2 z- u4 n v. N' IThe diagnosis of exogenous androgens was strongly
# e/ a4 n, @, {7 {/ |suspected in a follow-up visit after 4 months because: K, y2 S* m. L+ d
the physical examination revealed the complete disap-' T( P' \) u: h- j2 s0 m2 g
pearance of pubic hair, normal growth velocity, and' g6 m7 A2 J' E$ g
decreased erections. The father admitted using a testos-, F* [% C o- o; P
terone gel, which he concealed at first visit. He was
6 U! f0 q. m {2 M4 n; l) D2 M- r, Yusing it rather frequently, twice a day. The Physicians’/ a6 a( i: ^! \$ ^8 S
Desk Reference, or package insert of this product, gel or
, L( P. Y3 V) u% U: jcream, cautions about dermal testosterone transfer to
7 l7 _5 T, `7 M0 O: l+ w2 Zunprotected females through direct skin exposure.: A0 O: \* o3 H+ ?( g5 Q
Serum testosterone level was found to be 2 times the C% M% N$ A) c; r) v, ]4 [' R7 r
baseline value in those females who were exposed to& {2 t% l% d9 B
even 15 minutes of direct skin contact with their male
; w- ~/ U2 |# v7 x& B, ?partners.6 However, when a shirt covered the applica-
+ C: N6 @3 O; b1 p9 W. d7 qtion site, this testosterone transfer was prevented.( h2 u$ p' @1 J
Our patient’s testosterone level was 60 ng/mL,
) V, R* Z4 B. ^: C4 pwhich was clearly high. Some studies suggest that
$ Z" W/ A" c7 x9 \7 Bdermal conversion of testosterone to dihydrotestos-
. G8 z+ i* K/ y) y# O* d" Sterone, which is a more potent metabolite, is more8 k: \3 i, R2 s, q) k( B
active in young children exposed to testosterone
5 l6 n' T8 A7 K9 rexogenously7; however, we did not measure a dihy-
) [% B' O3 p! u; T Q/ i- H# adrotestosterone level in our patient. In addition to
) J+ z5 F/ `' t' Bvirilization, exposure to exogenous testosterone in
( |& s0 J% l6 H' j% ?3 X8 rchildren results in an increase in growth velocity and
- X" l* d0 c$ ?0 p8 x; T- dadvanced bone age, as seen in our patient. N0 l3 y+ P4 }% v8 J
The long-term effect of androgen exposure during
$ _8 F. H5 H" F: j! Learly childhood on pubertal development and final
: Q5 K: g) [0 Z- p1 W8 D# l; Uadult height are not fully known and always remain$ ]" t1 v b( X! v8 t E( U: \
a concern. Children treated with short-term testos-
5 P! ]% }4 |* e3 k% Y0 M, Wterone injection or topical androgen may exhibit some
- e* W/ n1 R8 U# Jacceleration of the skeletal maturation; however, after
8 K( B$ K6 P, \7 zcessation of treatment, the rate of bone maturation. p* p9 y$ m! G! x" I {. u9 m
decelerates and gradually returns to normal.8,9
* J% {+ S0 G; k; k/ g {" g7 S. r: G$ KThere are conflicting reports and controversy
4 \& q& B; [, s& j( _4 Nover the effect of early androgen exposure on adult
' A9 i0 j4 f0 ]5 dpenile length.10,11 Some reports suggest subnormal
2 m* T, j# ]- P x) x: iadult penile length, apparently because of downreg-* h0 `1 W/ [* l0 l0 h
ulation of androgen receptor number.10,12 However,
0 e( p% F! d# n# k% _Sutherland et al13 did not find a correlation between
5 m$ N9 d- Y$ M) V, gchildhood testosterone exposure and reduced adult+ R6 m; c) T3 k: M+ B, \2 `. I. E
penile length in clinical studies.
# \( P0 {2 N4 |) I. J! N. ~" \. jNonetheless, we do not believe our patient is
3 @. G0 J7 a4 G0 K* lgoing to experience any of the untoward effects from$ z7 F8 A8 S% G- r2 ]- l. v
testosterone exposure as mentioned earlier because; J& v: D1 |* U2 R" v; w
the exposure was not for a prolonged period of time.
7 n. V0 w/ p$ V X# MAlthough the bone age was advanced at the time of6 ^) N+ f% b# P' r8 l
diagnosis, the child had a normal growth velocity at
% D4 ^; z6 b+ A/ O0 Tthe follow-up visit. It is hoped that his final adult
A6 P& B+ I8 t# _0 j3 `9 Mheight will not be affected.
7 X1 y4 g) w+ `Although rarely reported, the widespread avail-: z3 s, v' }* |/ h7 w
ability of androgen products in our society may
; [7 A8 p6 u0 c5 X9 G6 ^ Vindeed cause more virilization in male or female
" D" g, w+ F. s% Echildren than one would realize. Exposure to andro-. q5 A( W; i* t/ j$ n
gen products must be considered and specific ques-
/ x( M2 M/ {: a6 Ntioning about the use of a testosterone product or
" `! W7 B' O: }$ [& v pgel should be asked of the family members during
9 g4 ?' k+ [" Q; ?0 `1 B' E1 a) Wthe evaluation of any children who present with vir-0 S7 W. X/ @2 e* A0 [" P6 @
ilization or peripheral precocious puberty. The diag-' C! c p a3 c6 k$ c: W& _' d
nosis can be established by just a few tests and by
, _4 w5 F/ X. u1 S \; bappropriate history. The inability to obtain such a
' M. ^2 G c/ Vhistory, or failure to ask the specific questions, may2 [* ?7 P6 E1 I# T8 z
result in extensive, unnecessary, and expensive
5 c; U; _9 U3 i) b! ?investigation. The primary care physician should be, j9 r( H* y* k6 Y, B% r/ w
aware of this fact, because most of these children! Q1 p' r0 a5 v; o: b; d; V
may initially present in their practice. The Physicians’$ w6 f% c* X6 V4 e
Desk Reference and package insert should also put a% s0 V0 b1 f7 O
warning about the virilizing effect on a male or
: ~- E' p j) qfemale child who might come in contact with some-
, W8 Z7 u$ G& i9 a' J8 L# ^one using any of these products.
, L& ~$ g `" S4 dReferences2 p, M1 d9 C: t5 ?/ Y8 L8 _
1. Styne DM. The testes: disorder of sexual differentiation
. R4 \2 _* D6 ]0 C3 j2 zand puberty in the male. In: Sperling MA, ed. Pediatric5 J$ u8 w. c9 I
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
. O/ |. D; a0 g- x) U# |, \2002: 565-628.6 L% C' v* j! E
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
8 C8 Y7 u/ l9 ?" Y; H1 X. Epuberty in children with tumours of the suprasellar pineal |
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