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Sexual Precocity in a 16-Month-Old( `" L8 J' j/ T, N' A$ b1 u
Boy Induced by Indirect Topical, `# `5 D/ ?- F" i+ g
Exposure to Testosterone8 h! \* t3 z/ t9 G/ |" n
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
( A+ ?" d8 D, s1 F0 x8 s6 X1 G& Kand Kenneth R. Rettig, MD19 P4 v4 g% [6 f& I
Clinical Pediatrics6 {3 f, {( ]$ A! { B
Volume 46 Number 6
6 L |* ~0 ]. `( P$ k2 gJuly 2007 540-543, I9 [$ z4 ^6 b- D% ]9 B( S
© 2007 Sage Publications& R! H% G5 s5 @' |% c; w
10.1177/0009922806296651& K4 l1 o3 m4 Y9 l* e/ F% W2 d
http://clp.sagepub.com
# q4 o+ ]/ p' s& Y7 E, Khosted at6 ?9 ~" o+ V. z* B8 L) P% h) K( p
http://online.sagepub.com4 z. T- b2 w: p0 x2 d7 ?# C1 s6 c
Precocious puberty in boys, central or peripheral,' Y8 C# y2 s& {, e
is a significant concern for physicians. Central
! s) I( i, K& o5 o- I s3 J$ a' @$ Qprecocious puberty (CPP), which is mediated* h- _3 }; p* c% k* |' `* L
through the hypothalamic pituitary gonadal axis, has9 p3 l& |( j' o3 j6 ^
a higher incidence of organic central nervous system
& G4 ^5 K' X! C3 M" ?$ Z4 tlesions in boys.1,2 Virilization in boys, as manifested
2 O7 K; ?1 [5 R/ V$ A7 pby enlargement of the penis, development of pubic
O" t* a# h- {& [hair, and facial acne without enlargement of testi-, i! O( U+ @" {3 u; B4 V. j
cles, suggests peripheral or pseudopuberty.1-3 We( }# k) F" @+ g' w, Q
report a 16-month-old boy who presented with the4 D3 O, D3 @# t% b! G
enlargement of the phallus and pubic hair develop-* V- s- k9 k A, [# F3 l
ment without testicular enlargement, which was due
: O) V( q* ]5 H% i7 Wto the unintentional exposure to androgen gel used by% A k6 q' V6 v; {4 K/ ?$ Q$ i
the father. The family initially concealed this infor-3 K2 K4 y/ `: h
mation, resulting in an extensive work-up for this
. }0 y6 n6 p9 w2 D% W. schild. Given the widespread and easy availability of
z4 Y; j$ h3 p2 F2 F1 }+ ftestosterone gel and cream, we believe this is proba-. k. ^6 a/ k3 @7 F
bly more common than the rare case report in the1 V. B/ J) @1 ^, t6 j5 R* w- C( C
literature.4+ a3 a; G0 {- U5 E$ g
Patient Report* V% q* [) u5 U. \2 @9 t
A 16-month-old white child was referred to the
V1 r# l4 k& x' }endocrine clinic by his pediatrician with the concern
# ]0 b8 W6 V- ~8 h$ s/ A( gof early sexual development. His mother noticed
$ u0 ^# f" X/ R" z; Clight colored pubic hair development when he was2 T, A w9 T" }. a7 j. B
From the 1Division of Pediatric Endocrinology, 2University of
0 t8 L' R8 J* U1 o5 ]South Alabama Medical Center, Mobile, Alabama.
7 g$ N! f' j" b9 C$ ]. TAddress correspondence to: Samar K. Bhowmick, MD, FACE,& P' `+ Z+ E6 D- ]4 C& T
Professor of Pediatrics, University of South Alabama, College of
, a3 |. Y* R- f/ [4 vMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
3 \. ]: f; [0 ^- X; a/ Qe-mail: [email protected].% H1 y* h4 T! M; _( s; B: N9 `$ A
about 6 to 7 months old, which progressively became
' Y% ~' @7 c1 L. Xdarker. She was also concerned about the enlarge-" h8 [/ v1 k$ L9 ]" y- {
ment of his penis and frequent erections. The child
& U1 m& z0 M4 Z& n- |; Wwas the product of a full-term normal delivery, with
$ E! Z7 L# w# F! y! Xa birth weight of 7 lb 14 oz, and birth length of: [8 L- E0 O# n7 o9 s# A- ?
20 inches. He was breast-fed throughout the first year
; }6 O+ I, b2 ^1 f) a0 z! ?* | Yof life and was still receiving breast milk along with+ V. U$ u2 A# |/ [: @" j/ [5 k
solid food. He had no hospitalizations or surgery,% s# J. E' T8 |& T7 E
and his psychosocial and psychomotor development2 g6 ^2 x5 X! y- R8 U, z, h
was age appropriate.
4 N1 n. \$ M! @. jThe family history was remarkable for the father,8 M2 ], c7 [; B; m6 F
who was diagnosed with hypothyroidism at age 16,0 e* K1 [( q- s* ~0 Z
which was treated with thyroxine. The father’s# L( N. s- Y" C
height was 6 feet, and he went through a somewhat8 Y1 Y: ^- n" ~- L1 v
early puberty and had stopped growing by age 14.
; `! [$ N" R0 {" L: b, tThe father denied taking any other medication. The
& A6 x9 G$ ~: r4 W4 Q" pchild’s mother was in good health. Her menarche5 E5 q6 f v9 L' v9 \
was at 11 years of age, and her height was at 5 feet5 s6 @7 x, `1 o# `7 j
5 inches. There was no other family history of pre-
5 ^( c0 W' q3 Q" @1 a5 ]cocious sexual development in the first-degree rela-
" m; ]5 {; G9 a6 v" `tives. There were no siblings.
8 }7 w9 b" e% \8 j u8 Y+ SPhysical Examination
9 k& B: {: w7 M. ^9 aThe physical examination revealed a very active,
* m- }; p% Q8 A# ?$ |: b) J4 uplayful, and healthy boy. The vital signs documented
' U8 h6 a( U# L- F' ?a blood pressure of 85/50 mm Hg, his length was; t8 }7 t: m5 A0 r
90 cm (>97th percentile), and his weight was 14.4 kg
# N9 R& [5 U/ ~2 y8 T0 B: ^(also >97th percentile). The observed yearly growth, V" M, q" E7 Y- i2 o8 [0 h s
velocity was 30 cm (12 inches). The examination of4 K% S N# t0 w* L0 s
the neck revealed no thyroid enlargement.
% U% e7 a# m' q# X, xThe genitourinary examination was remarkable for0 S" P( \$ W `4 g
enlargement of the penis, with a stretched length of
1 @! b1 w0 |/ ?2 s% O; f6 D; A8 cm and a width of 2 cm. The glans penis was very well* w' j* }' j4 g# N+ k7 [5 M
developed. The pubic hair was Tanner II, mostly around
' d0 A: b! |; w6 y( v/ O z! @540( C) g9 r5 x5 U6 G
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
. t( G4 ]; ] {5 a6 athe base of the phallus and was dark and curled. The
0 L& Y$ j6 B6 x6 y8 }" itesticular volume was prepubertal at 2 mL each.
3 y% L" g3 f! bThe skin was moist and smooth and somewhat% Q: Q2 x, P( v5 ]( J$ P; y
oily. No axillary hair was noted. There were no
' u, F+ j- l7 Y2 p5 yabnormal skin pigmentations or café-au-lait spots.
- `; @ M4 @+ J" I+ xNeurologic evaluation showed deep tendon reflex 2+
, A& \6 }) T, Q7 r% M! O* gbilateral and symmetrical. There was no suggestion
: S# T/ p/ k d7 b. b+ m: Jof papilledema.
; U& I" x T4 G3 ^! MLaboratory Evaluation
1 d9 |7 q, F5 X) G( {% LThe bone age was consistent with 28 months by+ ^# _' _0 [% I! u% o9 h* z \
using the standard of Greulich and Pyle at a chrono-
, {2 v2 V8 E+ z# Clogic age of 16 months (advanced).5 Chromosomal% Y' |* B% P# Y* v
karyotype was 46XY. The thyroid function test8 N* H( M; j. H/ f
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
; N! z1 M H" K. v% h+ ylating hormone level was 1.3 µIU/mL (both normal).0 Y K7 z" G- v5 ?8 W3 R! J5 f( \
The concentrations of serum electrolytes, blood' J! X9 z b4 i: z" H5 `4 }2 S
urea nitrogen, creatinine, and calcium all were
7 V: @7 B- {/ D' k& ^within normal range for his age. The concentration
, p' x0 \$ P$ j2 g% t2 m; Tof serum 17-hydroxyprogesterone was 16 ng/dL# z! s, N7 n8 P/ F( U& p
(normal, 3 to 90 ng/dL), androstenedione was 20
8 S( s7 @1 u2 T8 j- t. f$ ^ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: t8 c h( B& Y! E
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
9 U7 e4 }; t0 m0 Q- udesoxycorticosterone was 4.3 ng/dL (normal, 7 to3 {! ?% U3 P5 e
49ng/dL), 11-desoxycortisol (specific compound S)0 c3 n+ f6 h: u; [/ p! v3 [
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
$ @ J( v8 e$ Utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
7 r& O( U a) e% v! f6 B8 g. s5 etestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 V# f$ F. z1 t, }' xand β-human chorionic gonadotropin was less than
9 ?/ @" q2 L" B! h5 mIU/mL (normal <5 mIU/mL). Serum follicular! w1 g, @. u$ q ?7 T% J# j
stimulating hormone and leuteinizing hormone4 N3 A& s$ L+ R9 r+ b- @' ^7 H* A
concentrations were less than 0.05 mIU/mL
! G# v* B3 T2 {! d* q! F9 c$ \2 G(prepubertal).
7 R5 R. G* a0 L% |The parents were notified about the laboratory
& G- I9 x: w$ A- Uresults and were informed that all of the tests were& u4 x. b. i7 u/ F v- B7 U/ T
normal except the testosterone level was high. The6 J7 F/ v' o/ g
follow-up visit was arranged within a few weeks to; O' e4 e3 `3 l. l3 p; f. _7 u
obtain testicular and abdominal sonograms; how-
4 ]) Z" W" L' c$ J) g; k9 rever, the family did not return for 4 months.: V/ C: d+ z/ _9 Q# `% Q
Physical examination at this time revealed that the
+ S$ G; L/ U8 V z2 w6 Q) j0 Q7 {child had grown 2.5 cm in 4 months and had gained
$ H" [, _- H& ^8 O: ^) y2 kg of weight. Physical examination remained
# m7 y# c7 |1 @8 [$ c- ?unchanged. Surprisingly, the pubic hair almost com-* O* P# `1 H5 A+ {
pletely disappeared except for a few vellous hairs at' o5 A( \% P3 s$ N, ~6 A4 Y5 T; j
the base of the phallus. Testicular volume was still 29 P" M/ C6 r# R! f+ M/ l
mL, and the size of the penis remained unchanged.
6 n+ N3 G, [5 H" g2 f$ y; s& cThe mother also said that the boy was no longer hav-7 k: A d0 Z# m9 F
ing frequent erections.
7 X p5 r- v5 r9 EBoth parents were again questioned about use of
* P. Y2 J4 D5 K9 O! vany ointment/creams that they may have applied to9 R. t5 c- k) T9 Y
the child’s skin. This time the father admitted the/ m* h; {& A/ }# K4 `+ Z. B: f- H, S
Topical Testosterone Exposure / Bhowmick et al 541
: O# ]0 E- m+ ?7 Huse of testosterone gel twice daily that he was apply-0 n0 C7 u, @% j( X" i
ing over his own shoulders, chest, and back area for
) l. x6 X, R; Z6 {# }7 ka year. The father also revealed he was embarrassed
6 ^- B3 {" }% G8 Cto disclose that he was using a testosterone gel pre-( b5 J, }/ w/ c7 ?
scribed by his family physician for decreased libido. `$ ?6 i% m( T/ B
secondary to depression.! i8 i& A; O/ c. D# I
The child slept in the same bed with parents. ^9 C, y1 W& g% U4 R$ Q4 O
The father would hug the baby and hold him on his+ y+ `6 C! B) y. u
chest for a considerable period of time, causing sig-) r5 j" Y+ B/ H0 [8 i
nificant bare skin contact between baby and father.
5 M, s- u0 w, S% i4 mThe father also admitted that after the phone call,6 f2 i6 F3 `* z( T
when he learned the testosterone level in the baby6 a& D2 _# R: _1 L
was high, he then read the product information& d; e/ _6 P5 ]. h
packet and concluded that it was most likely the rea-
4 y( `4 F6 x: W+ ^$ u3 W1 S. yson for the child’s virilization. At that time, they
+ E& S( j& q& Edecided to put the baby in a separate bed, and the
& }% t. ^3 a* Ofather was not hugging him with bare skin and had0 ^' }- X. c6 R+ M: x# a" R
been using protective clothing. A repeat testosterone# x6 P3 Z* F% g( s. { ]5 _( h
test was ordered, but the family did not go to the3 \8 q. l, D1 O& r, P5 t
laboratory to obtain the test.% l. o7 O$ O P* F) t2 z
Discussion5 D( z8 d: N. X) d. I
Precocious puberty in boys is defined as secondary; {! s( I, c3 G& p5 k5 A& O" |
sexual development before 9 years of age.1,4
9 b+ M+ |! M' @( h5 R! ^4 y. x4 XPrecocious puberty is termed as central (true) when$ v' t6 Y0 h, t: G! U# s
it is caused by the premature activation of hypo-
9 v( ^+ j' G9 m* Tthalamic pituitary gonadal axis. CPP is more com-1 a0 T4 c, f- i/ m
mon in girls than in boys.1,3 Most boys with CPP
& n5 E5 X' L' A, mmay have a central nervous system lesion that is* H. r) M5 g* B4 ?. W& ]
responsible for the early activation of the hypothal-( U- c4 ^/ f% g" {
amic pituitary gonadal axis.1-3 Thus, greater empha-
/ u( l/ X6 q: s/ f" m/ Msis has been given to neuroradiologic imaging in
9 |- Q7 n9 x8 R+ ?# C: g) Oboys with precocious puberty. In addition to viril-
; z) b r- D) } iization, the clinical hallmark of CPP is the symmet-
& s2 i" v- u& Z+ v6 ?9 \rical testicular growth secondary to stimulation by7 w( i5 R9 @$ g) e: n
gonadotropins.1,3
1 X) a) K- m5 E, W7 LGonadotropin-independent peripheral preco-: Q. n% v# V2 k: x3 s4 T/ u5 m8 ~
cious puberty in boys also results from inappropriate. h% i- I8 `' B$ K" h2 ~- _5 I3 Z9 L7 [
androgenic stimulation from either endogenous or% K8 w( v5 e2 t" V
exogenous sources, nonpituitary gonadotropin stim-
! M1 w4 V$ {- k4 ^ulation, and rare activating mutations.3 Virilizing* N* \3 Z& S, z, [
congenital adrenal hyperplasia producing excessive( q! u& B2 Y" g$ Z% j1 Y
adrenal androgens is a common cause of precocious' L8 v- d: j7 R: ^6 s
puberty in boys.3,4
. q* P$ i( l& g1 L) T5 OThe most common form of congenital adrenal; t: M' R1 N: [: }! R5 M; j0 H2 I
hyperplasia is the 21-hydroxylase enzyme deficiency.& [5 Y( b% ~4 |$ C
The 11-β hydroxylase deficiency may also result in
& v4 F N3 ]5 w$ O; @excessive adrenal androgen production, and rarely,
7 M! }; n/ V4 P! Q" E5 Yan adrenal tumor may also cause adrenal androgen7 n7 S6 i c' M4 ?+ U5 ^
excess.1,3
9 e' G# _ I2 ~6 y2 y6 n6 \/ rat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from9 j, a3 z4 i6 K' P
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
0 z! P/ x) X) e; m5 O6 xA unique entity of male-limited gonadotropin-) Y$ `0 u6 o& a! t
independent precocious puberty, which is also known
, \! z8 T& T0 yas testotoxicosis, may cause precocious puberty at a9 v# }$ p. r. r( Q8 b
very young age. The physical findings in these boys
: Y3 F( ?4 d6 C" a: y5 d. o, dwith this disorder are full pubertal development,/ \$ i1 l. _( u4 E- _* l
including bilateral testicular growth, similar to boys. E, w2 B( m, d
with CPP. The gonadotropin levels in this disorder
" G& [( B# R2 Uare suppressed to prepubertal levels and do not show: r2 ^& v5 ?' }' i' D
pubertal response of gonadotropin after gonadotropin-
3 A% W3 D( a, M7 Z8 X$ _releasing hormone stimulation. This is a sex-linked. o1 w s% ?, v) C
autosomal dominant disorder that affects only
. |$ W$ U8 a; r# _5 A% y, imales; therefore, other male members of the family
% d* p& H- ~0 h6 m m. tmay have similar precocious puberty.3/ p( a" o% {* D/ ~( J
In our patient, physical examination was incon-' ~3 K* E* i4 _2 E L9 S( h! W9 A
sistent with true precocious puberty since his testi-, B( W$ I' b7 @9 u1 x& y9 v/ G
cles were prepubertal in size. However, testotoxicosis. J1 i% E: ]% ~1 f) Y1 L
was in the differential diagnosis because his father2 |/ k+ S3 I; G9 w" O
started puberty somewhat early, and occasionally,
0 u) ?! E0 [% m% S$ N. H; Ltesticular enlargement is not that evident in the8 G% S: K, |9 z6 Y
beginning of this process.1 In the absence of a neg-
! L: ]* C" \$ l3 tative initial history of androgen exposure, our4 U' F- O/ K7 e# y
biggest concern was virilizing adrenal hyperplasia,
5 l7 _) @0 q$ Q; T- v: Deither 21-hydroxylase deficiency or 11-β hydroxylase
$ S6 T+ |/ k. J* f- ^. fdeficiency. Those diagnoses were excluded by find-
7 c2 _9 ?$ @$ R5 c) xing the normal level of adrenal steroids.
1 W7 M C/ p( \% O* }1 A& `The diagnosis of exogenous androgens was strongly0 D; [' Y P5 R1 h7 E! V
suspected in a follow-up visit after 4 months because( J% A" G% L: g9 S
the physical examination revealed the complete disap-4 f5 s% d0 {5 C- b
pearance of pubic hair, normal growth velocity, and8 D$ s$ P5 B0 Y
decreased erections. The father admitted using a testos-( A' Y2 N, H4 I! o+ p
terone gel, which he concealed at first visit. He was
1 k" p( i$ c! B8 @4 ousing it rather frequently, twice a day. The Physicians’' m: V3 a. U2 q& \4 \, D, G
Desk Reference, or package insert of this product, gel or+ y3 N; A$ U; B2 H% C
cream, cautions about dermal testosterone transfer to" ^8 r5 h, b: a4 R
unprotected females through direct skin exposure.' C8 S) V" U( n# O8 O! u8 M9 e: D
Serum testosterone level was found to be 2 times the: @/ I" R2 k, s m
baseline value in those females who were exposed to" C& ?" P/ s' x3 y4 K3 M; T+ y
even 15 minutes of direct skin contact with their male' ?$ i0 t4 R' r" {! u5 Q
partners.6 However, when a shirt covered the applica-
/ k* y# ]2 ?$ t% E9 p; U, @tion site, this testosterone transfer was prevented." P% {% O7 X) y! H' K
Our patient’s testosterone level was 60 ng/mL,
1 T4 Y, O1 C) \* O$ r$ Rwhich was clearly high. Some studies suggest that
8 ]9 p* Z) W: Jdermal conversion of testosterone to dihydrotestos-
6 M2 V, X' g& ^terone, which is a more potent metabolite, is more
) k" A3 j. l; P6 _, g1 i& Yactive in young children exposed to testosterone
# [! e+ Y% v C+ M( C+ n7 \; yexogenously7; however, we did not measure a dihy-
) X' _3 I" T0 R, {# D; k9 D8 { F8 edrotestosterone level in our patient. In addition to
2 e+ r; M0 y6 u$ t: P# y$ ^2 Dvirilization, exposure to exogenous testosterone in
7 n! w; d/ J0 ~- C+ ?2 z) Schildren results in an increase in growth velocity and1 ^" k& J L' I1 ] r" f+ t
advanced bone age, as seen in our patient.
- W$ P2 e1 ~/ r1 E& D; l( R tThe long-term effect of androgen exposure during
, p3 _2 _" L# }early childhood on pubertal development and final
& y+ `. l6 A" Qadult height are not fully known and always remain: A; c! P) t- y! w1 x+ @( m
a concern. Children treated with short-term testos-
) ]$ d% e9 M0 E( t* ?0 Kterone injection or topical androgen may exhibit some- n5 A/ r9 l0 z4 S
acceleration of the skeletal maturation; however, after& M/ `$ B0 }, Y+ ~" r
cessation of treatment, the rate of bone maturation
5 S# Y1 y# l' idecelerates and gradually returns to normal.8,9
6 O$ M; T9 a7 S; L" P. F! VThere are conflicting reports and controversy0 b& Y; X1 p: {: E& }( A
over the effect of early androgen exposure on adult
) t3 t# ^/ g& C) d) ~3 rpenile length.10,11 Some reports suggest subnormal2 [6 d9 }* H( p8 L: r# v. l
adult penile length, apparently because of downreg-
- n9 [! c, H0 `. x3 b& x9 b2 \ulation of androgen receptor number.10,12 However,- Y& R) P7 X" y0 H
Sutherland et al13 did not find a correlation between
! T$ ~5 w' d T: a& Zchildhood testosterone exposure and reduced adult
: R, f- B& a: Upenile length in clinical studies.8 v# Q# r+ I( h2 f" j; X
Nonetheless, we do not believe our patient is" U `2 i$ B: ~4 f
going to experience any of the untoward effects from9 w$ k8 q" D. ]( ~& Y
testosterone exposure as mentioned earlier because. Y6 _* t. Q* N9 b2 D0 |$ u: M% ?
the exposure was not for a prolonged period of time., l K1 v% d/ R( z0 ~
Although the bone age was advanced at the time of
# H. Q7 O6 f) w9 N& o' F& _diagnosis, the child had a normal growth velocity at3 R3 S+ h6 N& @9 r
the follow-up visit. It is hoped that his final adult) ` F2 e* D7 w' {* \2 d
height will not be affected.3 ^+ ?: _4 x, }8 @; u
Although rarely reported, the widespread avail-( `/ f" m" v* k& V/ u0 I$ z& c; u
ability of androgen products in our society may
" s4 n, T2 Y3 i4 \indeed cause more virilization in male or female" O1 R, k9 @) }6 [2 I# F9 Y
children than one would realize. Exposure to andro-
7 C! v/ d" x7 M: J( T; Kgen products must be considered and specific ques-9 I, t$ K+ v2 P) K- s2 m9 p
tioning about the use of a testosterone product or. V2 M* ]! d; {( Z% W; b& D
gel should be asked of the family members during" @ b: V' H$ l1 s' B$ q- A- H
the evaluation of any children who present with vir-
1 i$ ~7 j& a% r' ~: x/ @/ L, v4 [ilization or peripheral precocious puberty. The diag-) U; @" c' P, ?& O
nosis can be established by just a few tests and by- x" m# P; b, @# c9 F$ |$ R' I
appropriate history. The inability to obtain such a' K0 y, p9 o. g; K* W8 u
history, or failure to ask the specific questions, may6 z4 p8 ^, f9 U8 Q& \
result in extensive, unnecessary, and expensive
( ^, J5 K( L4 G/ M* O; g; pinvestigation. The primary care physician should be
# D! {" q3 k; n6 S u+ Vaware of this fact, because most of these children
6 T+ \$ v! J% h- i7 U7 Ymay initially present in their practice. The Physicians’
8 q4 J( |# T4 h( p# ^Desk Reference and package insert should also put a
; G! L8 ?, \' _- gwarning about the virilizing effect on a male or; L6 E1 m& J* E1 l+ m
female child who might come in contact with some-! @6 s: a# b5 U
one using any of these products.# J- O- z) b& r6 `
References
% m a3 S0 S$ q' T1 I, f1. Styne DM. The testes: disorder of sexual differentiation& M* e5 A' z) ~, S
and puberty in the male. In: Sperling MA, ed. Pediatric' V, Q; J, C& R/ [; a$ X; L0 `
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;% C% |% ^7 t, h) s$ {- a7 L3 R
2002: 565-628.! X* I. j/ f, h* z7 Q% A, K9 k9 l
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. e/ o9 b8 Z/ z8 y6 N* \. R. y
puberty in children with tumours of the suprasellar pineal |
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