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Sexual Precocity in a 16-Month-Old+ m$ b* V8 x7 l$ T3 |9 W
Boy Induced by Indirect Topical
* K2 x* N! _: L' `Exposure to Testosterone
( o% d; Z2 l; WSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
( n; t9 G+ A% o( |3 dand Kenneth R. Rettig, MD1# p/ I6 A( _1 e0 g1 Y
Clinical Pediatrics, v1 l3 f' F: R/ X g
Volume 46 Number 65 H1 p# o( {$ H+ z
July 2007 540-543
C3 ^. `) O7 V# u1 L: c2 }8 |6 G! o© 2007 Sage Publications4 S2 P: J# _0 [. Q5 T& W7 Q, M' k
10.1177/0009922806296651$ e, `* ~+ X* `* ~; m8 W4 X
http://clp.sagepub.com
4 H) `' i8 u0 H: ehosted at
2 j9 B; a9 t% W$ xhttp://online.sagepub.com: a: n4 H1 B o5 K* h( n+ J
Precocious puberty in boys, central or peripheral,
: |7 Z* y0 u! qis a significant concern for physicians. Central
$ m0 |6 U( b* c% Qprecocious puberty (CPP), which is mediated
|! U, G% K% ythrough the hypothalamic pituitary gonadal axis, has, `0 V1 P2 N7 Q" h' u/ C7 ^. B, s: p
a higher incidence of organic central nervous system
7 {- t8 m: s& h K" i; R% Nlesions in boys.1,2 Virilization in boys, as manifested) Y: t9 l1 T% @" B: d- Z
by enlargement of the penis, development of pubic
( g! p' ]" Q; B, {$ _% A1 g4 Fhair, and facial acne without enlargement of testi-
; n, z. h* F8 e8 k/ P' ^2 t) {cles, suggests peripheral or pseudopuberty.1-3 We5 y4 Z2 I9 k) R4 x6 m6 k r
report a 16-month-old boy who presented with the
; ?1 K. k, c) M) @/ Uenlargement of the phallus and pubic hair develop-
: M, P; l) a6 T7 J! @ment without testicular enlargement, which was due) |% O% }. o% @1 `9 E( q
to the unintentional exposure to androgen gel used by" g: F9 Z; k* T/ ~% K/ t) q/ q* v
the father. The family initially concealed this infor-, h2 s/ V6 E) Z/ r+ X
mation, resulting in an extensive work-up for this/ S7 A# K9 ]: P! o5 S- G- W! q
child. Given the widespread and easy availability of9 A- g" b5 x, m) N5 Q0 z' `
testosterone gel and cream, we believe this is proba-
$ \' m/ D: Q- ]1 a/ jbly more common than the rare case report in the
1 V6 h8 m9 p3 V" f3 dliterature.4' }6 l0 {# o+ w$ V' j
Patient Report
6 h7 Z2 U9 i& a' ?0 ~A 16-month-old white child was referred to the# F/ B' \. `2 z8 G; k! h, l; A
endocrine clinic by his pediatrician with the concern+ J! E1 \. V' P/ I
of early sexual development. His mother noticed
6 H- N2 L/ J* R( f. `light colored pubic hair development when he was8 v5 l9 _+ N+ [- ]) _
From the 1Division of Pediatric Endocrinology, 2University of
+ y* M' e9 z) R- t/ c( D) YSouth Alabama Medical Center, Mobile, Alabama.! u' X w4 y' l$ R
Address correspondence to: Samar K. Bhowmick, MD, FACE,
; b5 e* h8 D, l) r# gProfessor of Pediatrics, University of South Alabama, College of
$ [; K! |: U6 q+ m8 B2 aMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;- i3 r% @* d- c# I% W: @; N
e-mail: [email protected].0 L! k% c$ e+ V0 U" ~+ s
about 6 to 7 months old, which progressively became
5 I/ `7 n8 @4 H1 x3 wdarker. She was also concerned about the enlarge-
0 h! I8 Z* P( O. q* V- R% _7 mment of his penis and frequent erections. The child
8 `1 M) z1 w8 ]4 g! u8 twas the product of a full-term normal delivery, with4 D6 G* Q( q% W) [( m; s
a birth weight of 7 lb 14 oz, and birth length of: X# f8 l& } W+ j, t. J. Q0 x/ F5 B+ I
20 inches. He was breast-fed throughout the first year0 M5 B& K7 q% r# y) [" g6 ^1 C
of life and was still receiving breast milk along with& x2 }* y; [# C0 O' F% l
solid food. He had no hospitalizations or surgery,
2 w/ i1 s! m" q. |, {( R4 @and his psychosocial and psychomotor development
' e# L: I$ J! ewas age appropriate.$ ~- {, j- _1 @( a
The family history was remarkable for the father,
; d4 h' x/ X2 q$ c+ fwho was diagnosed with hypothyroidism at age 16,/ w' Z7 t8 b- P: u! \
which was treated with thyroxine. The father’s) v+ n3 z& i; g* D4 M: p
height was 6 feet, and he went through a somewhat& }- U y1 w* A
early puberty and had stopped growing by age 14.; Y" T; l7 d" h( Y" B/ F/ s7 ?" @
The father denied taking any other medication. The A! e& h* C+ Q! ]
child’s mother was in good health. Her menarche: g$ z" K0 t) P4 `
was at 11 years of age, and her height was at 5 feet
7 S# x; f5 w+ c9 L& f5 inches. There was no other family history of pre-
# c, K Y/ |5 j# P9 Scocious sexual development in the first-degree rela-
3 K4 a0 P+ Q' gtives. There were no siblings.
+ R6 ^5 r- ~9 Y& _; Q+ r- g" KPhysical Examination
7 ?; q6 ]) f! p7 S! K: ~The physical examination revealed a very active,2 D6 }4 d4 k2 V5 |
playful, and healthy boy. The vital signs documented
; S8 A% R3 A' [8 B: h+ ?a blood pressure of 85/50 mm Hg, his length was
' x8 Q2 w. B9 S2 p( Y90 cm (>97th percentile), and his weight was 14.4 kg
9 N0 ~' N4 F" [* E, `( @7 G* d(also >97th percentile). The observed yearly growth) W8 s* t) r& ], [; l- ?
velocity was 30 cm (12 inches). The examination of
0 {2 Z, a4 ^+ A3 I8 @7 P! a lthe neck revealed no thyroid enlargement. q0 e4 ]' h/ k3 b: _
The genitourinary examination was remarkable for( ?6 f# v, f$ S* h! n | Q
enlargement of the penis, with a stretched length of* b8 Y6 W3 ~7 r6 Z1 _! s" b: e
8 cm and a width of 2 cm. The glans penis was very well
( m$ v4 L _2 }3 |. k4 L* x0 Pdeveloped. The pubic hair was Tanner II, mostly around
$ @9 B$ o' |/ f0 x, ?9 R3 h. a. ?540
/ S6 c0 \9 N, s. ~& `( \at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
- o2 t& i: i& U3 q. j% }, a* Jthe base of the phallus and was dark and curled. The; ] F' ~; o1 l# T# y6 o
testicular volume was prepubertal at 2 mL each.
/ T( l" I; @. P, dThe skin was moist and smooth and somewhat
$ z" J% Z4 `. h' E/ j* }oily. No axillary hair was noted. There were no8 W8 }; O3 V7 h' z
abnormal skin pigmentations or café-au-lait spots.
- z8 n7 M. j5 i Z3 DNeurologic evaluation showed deep tendon reflex 2+
, H. @1 F: e! d& U: ^& W8 x* O! \bilateral and symmetrical. There was no suggestion, T2 ^( @, S+ W4 o, T" `! y
of papilledema.# _( |5 E+ {" X& R' s
Laboratory Evaluation3 ~/ ?' K0 \7 R/ i( m
The bone age was consistent with 28 months by8 \. Y0 a! E) S& e/ N1 l6 V
using the standard of Greulich and Pyle at a chrono-
, a" G' x/ x% @! Ilogic age of 16 months (advanced).5 Chromosomal
, E J: E2 @, V9 ~karyotype was 46XY. The thyroid function test
$ s6 q6 ]5 D( E# r0 [" sshowed a free T4 of 1.69 ng/dL, and thyroid stimu-" G( n8 I4 s3 H9 U, L3 X4 p
lating hormone level was 1.3 µIU/mL (both normal).% ^+ G% l3 z+ j. F: T
The concentrations of serum electrolytes, blood
/ U' Z% }5 X0 V1 G ]1 }/ M6 Z. lurea nitrogen, creatinine, and calcium all were
V% o# t8 E8 F: Qwithin normal range for his age. The concentration, E) a* j4 u$ e/ D4 \3 u2 A) k* a8 {6 `
of serum 17-hydroxyprogesterone was 16 ng/dL
; V3 A7 q7 b1 Z# G! ?% o" N& k(normal, 3 to 90 ng/dL), androstenedione was 201 }* }4 q1 N/ k4 a* ]5 f3 O
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
6 X& _4 r7 ]4 P( o8 Kterone was 38 ng/dL (normal, 50 to 760 ng/dL),: T( F) n6 U3 {& ^+ H
desoxycorticosterone was 4.3 ng/dL (normal, 7 to$ m9 R) s% S W; ]8 X2 V
49ng/dL), 11-desoxycortisol (specific compound S)
! U( C Z+ T9 L6 X3 Pwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! a% ]) J8 n# }# s- L. N" ?+ z
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 V w9 Y; s1 o2 U1 h% ]6 \6 ntestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
% d7 Z! p. }$ `7 S; Sand β-human chorionic gonadotropin was less than# i( \1 h* p4 U3 [
5 mIU/mL (normal <5 mIU/mL). Serum follicular
9 y% Z* V4 k2 |, V! Astimulating hormone and leuteinizing hormone4 y4 i+ |; W5 k' {$ I
concentrations were less than 0.05 mIU/mL
/ N7 }, l! A" k G% h2 V(prepubertal).
: Y. o. O& H3 O3 c$ @The parents were notified about the laboratory
1 Z5 F( S$ l7 `- S7 i4 U" \0 | lresults and were informed that all of the tests were2 q. Q" {' x# [( t O2 d( D; F
normal except the testosterone level was high. The/ u+ l% \3 s9 u( b3 }6 \
follow-up visit was arranged within a few weeks to) {+ s! s3 e" z0 x
obtain testicular and abdominal sonograms; how-, I7 M9 A* E! W* M
ever, the family did not return for 4 months. ~0 a5 N9 j9 n4 W% V3 [3 M
Physical examination at this time revealed that the
/ @0 C5 F$ D$ zchild had grown 2.5 cm in 4 months and had gained
7 F# O8 X' x% B2 kg of weight. Physical examination remained
! f! n9 |9 X, `" F5 X. w# qunchanged. Surprisingly, the pubic hair almost com-* g; c8 \0 P* n/ Z
pletely disappeared except for a few vellous hairs at$ I7 b+ U; t9 ^4 o3 \& ]: L5 H
the base of the phallus. Testicular volume was still 2% q$ b \* i, Z6 s' l; G9 g {
mL, and the size of the penis remained unchanged.
- x5 c7 R0 i8 Y2 i1 sThe mother also said that the boy was no longer hav-
6 M9 v2 N. W" |' y* M) V B6 L% |ing frequent erections.1 [2 x5 G: e7 G# |
Both parents were again questioned about use of
* T5 b1 s* i( _0 T' E# b3 r8 Wany ointment/creams that they may have applied to
; O- p% o, |1 j6 }the child’s skin. This time the father admitted the- L) d, @4 N/ e2 @. W
Topical Testosterone Exposure / Bhowmick et al 541
( N% ~- x" B9 V" T3 ause of testosterone gel twice daily that he was apply-
1 ~4 }' P1 m- T" ]ing over his own shoulders, chest, and back area for
, _- U/ ^) t5 Ea year. The father also revealed he was embarrassed
! }: _2 E3 g+ G: A Zto disclose that he was using a testosterone gel pre-' {$ l& y2 W7 W
scribed by his family physician for decreased libido
! f5 r4 P4 P9 ~secondary to depression.0 h C. {: r$ r$ A9 V
The child slept in the same bed with parents./ i {! v2 T4 n! a
The father would hug the baby and hold him on his7 z- G+ g/ C) X
chest for a considerable period of time, causing sig-& ` n- Y4 ^4 w8 l) M
nificant bare skin contact between baby and father.- r m8 K" `. K4 S/ s) W; y
The father also admitted that after the phone call,! {6 V' ^" t: p$ j# p
when he learned the testosterone level in the baby
* l( x- x9 B0 k, dwas high, he then read the product information- i2 D, v: B8 @$ m( q& X" h
packet and concluded that it was most likely the rea-
: Z5 Y. ], S& c( f5 u. Pson for the child’s virilization. At that time, they( D& @( Z& M, I7 P$ e$ [7 |
decided to put the baby in a separate bed, and the% I5 a! U" m( d$ Y% Y2 c7 c
father was not hugging him with bare skin and had' U5 N# t/ k* g: ^' U2 ^% H) H% W
been using protective clothing. A repeat testosterone8 k' H$ _4 B5 u. n
test was ordered, but the family did not go to the
: Z; J0 ^% ?, {- A: C! {7 Nlaboratory to obtain the test.
) q3 s+ m1 d% q$ L9 `Discussion1 q) E' J5 J+ ?- b2 U+ o. w
Precocious puberty in boys is defined as secondary `* i+ R4 S9 H
sexual development before 9 years of age.1,4
8 F* K A$ m: f7 ^" M4 \+ Y, TPrecocious puberty is termed as central (true) when
( v& Q7 e- c/ \& E/ \3 Jit is caused by the premature activation of hypo-5 c2 O# J2 U8 R( z+ @2 O
thalamic pituitary gonadal axis. CPP is more com-! h9 p$ g, w/ B. t& X/ t8 G
mon in girls than in boys.1,3 Most boys with CPP6 }1 M% G4 |1 X+ ?' S3 f* A, x
may have a central nervous system lesion that is
$ o( M1 [0 m6 I8 z" h8 P. O0 X: aresponsible for the early activation of the hypothal-9 L" H8 I& X: L z! ~4 L
amic pituitary gonadal axis.1-3 Thus, greater empha-
1 V( Q8 W4 l! V* R% xsis has been given to neuroradiologic imaging in
& t( x, s9 Z5 Uboys with precocious puberty. In addition to viril-
( T- ~! g4 t. y! Q) F" @8 n% e7 Lization, the clinical hallmark of CPP is the symmet-' \, @: s* J& c% Z# `+ ]0 }
rical testicular growth secondary to stimulation by
. [8 Z3 c* o1 G! w9 qgonadotropins.1,3
1 a( c9 s8 M$ c+ }: i8 FGonadotropin-independent peripheral preco-" J4 l& b5 J- Q8 o! E: |' i
cious puberty in boys also results from inappropriate
- X$ [5 f f$ o/ N/ b: dandrogenic stimulation from either endogenous or
" m$ m% ?5 H. Y2 F& rexogenous sources, nonpituitary gonadotropin stim-
4 J! F' L5 M# s& \. Q# W* y5 ?/ fulation, and rare activating mutations.3 Virilizing; ~1 [) N* |) B2 g! g: s
congenital adrenal hyperplasia producing excessive
! y6 d. F' u7 l: _+ R1 Kadrenal androgens is a common cause of precocious
& L4 b* B3 w2 @puberty in boys.3,4. u3 [4 w" e/ M' w3 n' x0 q6 w* o& {
The most common form of congenital adrenal' W* D" X5 K2 d7 z. x+ }: H) {
hyperplasia is the 21-hydroxylase enzyme deficiency.
& ~5 \9 o; D* v0 f4 t; d) EThe 11-β hydroxylase deficiency may also result in+ y7 ?+ u4 G+ _/ K d
excessive adrenal androgen production, and rarely,
, u& m* K- s* A. |an adrenal tumor may also cause adrenal androgen" x% W7 J, t; A3 I
excess.1,3( [( M+ L& [, H1 q9 Q$ X7 d: X
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from1 ?( p1 P- L$ D* G0 J2 M
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007" T. g5 R* H5 c- @
A unique entity of male-limited gonadotropin-- X: ]$ X2 d) @
independent precocious puberty, which is also known
a/ r3 `4 [: R8 R7 ^% Bas testotoxicosis, may cause precocious puberty at a
0 w8 W% M( K' m; qvery young age. The physical findings in these boys
, W k" ]3 ^4 d" b& T) @with this disorder are full pubertal development,% b1 |7 ^, p: b' S% L4 n
including bilateral testicular growth, similar to boys u3 l/ T- T% O/ \* R) x
with CPP. The gonadotropin levels in this disorder
1 J# X& G* W6 d0 \3 M$ care suppressed to prepubertal levels and do not show) O2 o) m. h2 y6 `: V7 o
pubertal response of gonadotropin after gonadotropin-
8 d) x9 E l: j5 @& l) i6 Ireleasing hormone stimulation. This is a sex-linked' _3 M0 O* h3 I( u. V& _) @
autosomal dominant disorder that affects only
, y5 l- \! M9 q) a8 y/ Tmales; therefore, other male members of the family
' L4 j7 B% w" [2 M" n6 hmay have similar precocious puberty.3# ]! c9 h$ W4 H- q6 ]
In our patient, physical examination was incon-3 h3 A- _' G& T. b
sistent with true precocious puberty since his testi-, i+ V, A6 Z p8 u' g, B
cles were prepubertal in size. However, testotoxicosis
2 F8 k) H, q' a5 @ S! U* ~' Owas in the differential diagnosis because his father
( k0 c' \" l8 e; |, e/ [started puberty somewhat early, and occasionally,6 v, K3 C" ]# g) j
testicular enlargement is not that evident in the% q0 X4 D! z$ P/ I
beginning of this process.1 In the absence of a neg-" I7 r+ U5 e7 D4 Y8 \$ Y
ative initial history of androgen exposure, our
& q; d" h& ^8 U/ g9 g& M! ]9 s, Tbiggest concern was virilizing adrenal hyperplasia,% i* R# z- p' e
either 21-hydroxylase deficiency or 11-β hydroxylase
* R1 E( e( Q# j& Wdeficiency. Those diagnoses were excluded by find-
" I/ z6 G( M2 w: l/ ring the normal level of adrenal steroids.8 ?& S, }+ O& U' C6 i* l3 v
The diagnosis of exogenous androgens was strongly
1 }2 \& |- S- B9 @1 tsuspected in a follow-up visit after 4 months because
: h" C/ B" {0 W- h, \the physical examination revealed the complete disap-
' y# \' s @7 w2 S; d! Y) h# bpearance of pubic hair, normal growth velocity, and# \* j. U/ J1 I1 \
decreased erections. The father admitted using a testos-
o, _- I( C; Vterone gel, which he concealed at first visit. He was% i3 Y" N2 i' g- ]
using it rather frequently, twice a day. The Physicians’- ?( k8 ~, L% Y. g
Desk Reference, or package insert of this product, gel or
) ? ^8 W; x% b+ r% X7 `3 lcream, cautions about dermal testosterone transfer to4 L" K' ]& L' d, }0 w
unprotected females through direct skin exposure.7 m. U* j/ c) [6 {8 {9 U* O- A. e
Serum testosterone level was found to be 2 times the; p7 T5 I0 A& p) U8 T
baseline value in those females who were exposed to, `8 X- p" q' ~! @; ]# f" \9 {# b
even 15 minutes of direct skin contact with their male
/ P: R/ u/ v, |) I T- d) k" P0 vpartners.6 However, when a shirt covered the applica-
, C) w. u ?2 [/ U/ ntion site, this testosterone transfer was prevented.. T* }0 Q0 [5 l+ z' C0 R3 U
Our patient’s testosterone level was 60 ng/mL,# Q' Y8 \) c6 Q- x/ I" {7 N
which was clearly high. Some studies suggest that
2 l# g5 m; q5 Tdermal conversion of testosterone to dihydrotestos-9 d2 D+ W3 X) G2 y8 @
terone, which is a more potent metabolite, is more! P8 N& b# @$ j# t, |8 l7 |
active in young children exposed to testosterone$ `, j2 R3 }1 I
exogenously7; however, we did not measure a dihy-4 t; S% o( p4 U" s5 S3 [" A9 R1 m8 C
drotestosterone level in our patient. In addition to
$ P0 J/ J+ U4 T4 C+ w, E* f, Nvirilization, exposure to exogenous testosterone in& Y* m* B& t5 J2 H" X r
children results in an increase in growth velocity and
. M; E3 C; o1 `' ^advanced bone age, as seen in our patient.) B0 H! h8 E C( M; M: ~' R" @
The long-term effect of androgen exposure during
d8 `; t. s6 ^: H8 J' @% d/ zearly childhood on pubertal development and final: A4 O, k' |- @2 g) q- l2 o
adult height are not fully known and always remain! p# P; Z0 _5 h
a concern. Children treated with short-term testos-4 s+ j# U8 i$ S5 l* F
terone injection or topical androgen may exhibit some
' W, r- n3 o& @1 T8 J- @7 ^; gacceleration of the skeletal maturation; however, after, G8 L6 p' o5 _
cessation of treatment, the rate of bone maturation
8 W9 {6 c8 v* @, I- J+ Z9 Adecelerates and gradually returns to normal.8,9
' S7 x. F4 C4 K2 XThere are conflicting reports and controversy3 h% ?% D. V |) l4 B
over the effect of early androgen exposure on adult
1 D# d/ n% O5 ~9 x+ |( q4 Bpenile length.10,11 Some reports suggest subnormal
- L6 _" h9 B, h" B+ \4 o( y1 ^$ yadult penile length, apparently because of downreg-
6 Q& u3 |$ X2 i# |ulation of androgen receptor number.10,12 However,
& c3 z$ p A# O& d& a6 K* ?4 X/ nSutherland et al13 did not find a correlation between
1 t+ D: Y/ u! X9 o; y- Hchildhood testosterone exposure and reduced adult0 E( s' ~( x6 i- j. E3 E( i8 X
penile length in clinical studies.! H M: B$ b- X6 W3 ^
Nonetheless, we do not believe our patient is
1 v3 l/ b- |# b% i. Q( cgoing to experience any of the untoward effects from9 w+ i$ x `% G; `$ M8 g1 K
testosterone exposure as mentioned earlier because! z- I X% n. h: E
the exposure was not for a prolonged period of time.
' ]9 [, h" s# e, u) YAlthough the bone age was advanced at the time of- r- V3 W% [" G0 o! ?4 ~
diagnosis, the child had a normal growth velocity at: x" M& y; E9 Y5 j2 ^
the follow-up visit. It is hoped that his final adult
# t* A( t$ f5 u# ~+ I; @height will not be affected.7 }3 T U4 x, t' M ^* r T' n
Although rarely reported, the widespread avail-( f l/ Z2 h: F3 l& F4 q+ O
ability of androgen products in our society may
. m2 Y; X6 k! j. p" L5 G" xindeed cause more virilization in male or female# ~* c) m% H* [
children than one would realize. Exposure to andro-" }% |6 ?1 z u# q4 R5 \
gen products must be considered and specific ques-( d. J( A5 b/ T6 M5 v) ]
tioning about the use of a testosterone product or
. K3 O1 }5 T& z) |+ Mgel should be asked of the family members during
2 J' \5 g1 m1 | I% H9 Pthe evaluation of any children who present with vir-; d, `/ ?$ D* O9 n
ilization or peripheral precocious puberty. The diag-
5 S# R. }' h5 R2 K! gnosis can be established by just a few tests and by
# n3 O4 Y; e/ G1 P) Z/ ^- xappropriate history. The inability to obtain such a
( A- X* g, q+ L7 s* _ q! Phistory, or failure to ask the specific questions, may
3 p$ v- x4 Y$ | zresult in extensive, unnecessary, and expensive
/ Q, b! C, p. D7 D# minvestigation. The primary care physician should be
* I) \+ [9 T+ j, caware of this fact, because most of these children2 R$ s& Z8 e; J$ a2 Y1 C
may initially present in their practice. The Physicians’
a: Z1 x1 s+ IDesk Reference and package insert should also put a: M. V+ {+ X( W7 H
warning about the virilizing effect on a male or" P J) c1 v m0 l. c
female child who might come in contact with some-8 \) i: Q* y3 }- w) u% ]! T
one using any of these products. B9 r _! f$ b* _' a! u3 Q
References
* Q6 h: j! x& v, W' |! w4 b, F1. Styne DM. The testes: disorder of sexual differentiation
) X: h5 k. U! p ~and puberty in the male. In: Sperling MA, ed. Pediatric
1 k) {6 d4 T( H7 i+ s4 R8 p7 EEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 A0 z. V/ S- @( t2 \+ x% f6 c( G2002: 565-628.: I1 B* [! C5 g9 u# h
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. y [8 G T9 x
puberty in children with tumours of the suprasellar pineal |
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