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Sexual Precocity in a 16-Month-Old$ |8 h2 d, z J
Boy Induced by Indirect Topical
2 n/ B* T* Z3 a3 U0 b* ^, N+ ~Exposure to Testosterone
2 x3 W2 i3 C; q. YSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
8 W w" f" B) M- o7 t& Jand Kenneth R. Rettig, MD15 Z3 Q+ a7 k8 ~7 x) R! P1 y" P( F& r' A
Clinical Pediatrics* m6 ~9 X# @7 S/ d! a/ y
Volume 46 Number 6
4 d) n; L# W$ ZJuly 2007 540-543/ u( @: S3 Y o3 I1 l
© 2007 Sage Publications( S+ y: P# A- Q
10.1177/0009922806296651
7 Y8 Y' g1 j" q4 g' ^# _http://clp.sagepub.com) A& j6 K, B5 R- C5 \9 A
hosted at5 X* l& R5 n: t6 @1 h
http://online.sagepub.com: |; a+ z9 A2 L% \
Precocious puberty in boys, central or peripheral,
0 c) @+ Y0 ^; h/ S# X% Ais a significant concern for physicians. Central+ f; m8 Z/ u: P6 K0 ^: m5 X5 {
precocious puberty (CPP), which is mediated
- f& N5 B! o ithrough the hypothalamic pituitary gonadal axis, has5 K( k2 v4 G* ?5 m
a higher incidence of organic central nervous system
( D {1 r9 M' V- l9 tlesions in boys.1,2 Virilization in boys, as manifested
, G7 N/ Q1 I$ H+ Q1 F) Aby enlargement of the penis, development of pubic
2 J" x* i, b4 |$ Z" \hair, and facial acne without enlargement of testi-- R, [" i3 V1 `: ?% e4 K8 y
cles, suggests peripheral or pseudopuberty.1-3 We
6 z3 d5 O A; areport a 16-month-old boy who presented with the1 N! s2 M/ i0 w0 d3 ?5 ?
enlargement of the phallus and pubic hair develop-
8 }1 S. z: t, g9 c9 X( `" t3 A$ |ment without testicular enlargement, which was due
# t+ \; p+ o% u# M" J8 {2 S- i+ Uto the unintentional exposure to androgen gel used by) P( Y( ]; j! d/ C/ W( H
the father. The family initially concealed this infor-
+ D( Y3 Z& L( b" f- y! x( ^# Kmation, resulting in an extensive work-up for this
! C A$ R6 C7 m* ~. x8 hchild. Given the widespread and easy availability of
4 l) P( S6 c4 wtestosterone gel and cream, we believe this is proba-; Q' e( }, P. i
bly more common than the rare case report in the+ x; y7 J! S8 a0 F$ V) ^
literature.4, X5 O6 }- B2 s9 O; \% I3 k
Patient Report
" b% b5 J0 v0 x8 t1 F) TA 16-month-old white child was referred to the7 k& }& J' H3 h( j9 W
endocrine clinic by his pediatrician with the concern$ V; m) Q) J) [- b
of early sexual development. His mother noticed
, n- J! ?; a9 a' e. \; k$ O+ Alight colored pubic hair development when he was
$ i$ H1 U! V. C% l& J; M8 |From the 1Division of Pediatric Endocrinology, 2University of7 @. h/ v! e( n; r0 \- X
South Alabama Medical Center, Mobile, Alabama.) J$ n" M. g* _% ^) d
Address correspondence to: Samar K. Bhowmick, MD, FACE,& R, Y+ h% d2 c9 X6 U/ Z5 S2 a. B2 I
Professor of Pediatrics, University of South Alabama, College of
8 o$ w( Y. |0 G! X; n) S( G4 IMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;* M* _2 B; u; }* y2 N. x8 m
e-mail: [email protected].
1 { X! g# h. S$ L( `about 6 to 7 months old, which progressively became) o2 i" Q0 }7 z4 u2 T+ A/ |. q
darker. She was also concerned about the enlarge-5 `1 p2 f" j6 E/ H; j
ment of his penis and frequent erections. The child
8 Y" E$ j1 ^& f4 s" _7 _, K; {! cwas the product of a full-term normal delivery, with
! U+ C# p8 W) z va birth weight of 7 lb 14 oz, and birth length of( e6 M8 M5 _7 f# b
20 inches. He was breast-fed throughout the first year9 `, J9 F6 [9 T
of life and was still receiving breast milk along with; u* `: E, e* E9 `. c+ b; t0 I
solid food. He had no hospitalizations or surgery,
1 l" `, ^3 }2 J9 nand his psychosocial and psychomotor development
7 S* ?) a0 a0 w( iwas age appropriate.
% c- \- v' M( l: HThe family history was remarkable for the father,
) U' B; V/ b* W+ X& Pwho was diagnosed with hypothyroidism at age 16,
; ~; {9 d% k' Y: Wwhich was treated with thyroxine. The father’s
6 K6 C+ X) P4 @. ]height was 6 feet, and he went through a somewhat
- f8 r. \ Q4 ^1 yearly puberty and had stopped growing by age 14.
" _# R. d% d, `The father denied taking any other medication. The
4 Q- z: F% a) j* E5 L* K8 D: F% achild’s mother was in good health. Her menarche
" U9 Y9 o! M8 l a ]% Z5 Ywas at 11 years of age, and her height was at 5 feet
6 T" F4 K* ^0 z! _' n5 inches. There was no other family history of pre-! Y7 d' \7 I, ]0 Q5 G' \. H
cocious sexual development in the first-degree rela-$ t+ r% E( o- h7 c4 P
tives. There were no siblings.
2 N2 L0 I0 V' @5 UPhysical Examination- L( v9 t% {# \
The physical examination revealed a very active,
6 I& Q! K3 M9 x0 x+ A' o4 {0 x. ~playful, and healthy boy. The vital signs documented
, ?4 Y5 `1 ^9 |5 Qa blood pressure of 85/50 mm Hg, his length was/ r* ?3 p9 X* H! B9 U8 Q5 _
90 cm (>97th percentile), and his weight was 14.4 kg) A% l$ i, I- Y7 m% m* r
(also >97th percentile). The observed yearly growth3 b' E; w+ s# X/ d5 X8 `
velocity was 30 cm (12 inches). The examination of
$ ~3 h0 u% Z% E' _5 D8 J, y9 Fthe neck revealed no thyroid enlargement." K( Q1 F8 R# ]/ [9 O2 S( k
The genitourinary examination was remarkable for/ C8 D m9 y) }
enlargement of the penis, with a stretched length of
( E7 P; O. H* R3 _$ L$ Q8 cm and a width of 2 cm. The glans penis was very well
E! J) Z5 @; a4 G; K' G( Cdeveloped. The pubic hair was Tanner II, mostly around n9 B }0 f7 S6 P; F0 ^5 T
540
. z3 c/ P7 v6 mat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 ~/ i9 |# v0 E& @+ r% \& V: i. hthe base of the phallus and was dark and curled. The
; P2 }# D5 Y4 W( Stesticular volume was prepubertal at 2 mL each.
' ]1 o& w% p0 } P4 TThe skin was moist and smooth and somewhat
) z+ Z. o- ], b" E4 _8 [6 w7 Hoily. No axillary hair was noted. There were no
# @, ]) k! ?2 ]abnormal skin pigmentations or café-au-lait spots.* O% S5 ]6 C9 F8 ~. F# k
Neurologic evaluation showed deep tendon reflex 2+8 j! I( a. A% h$ i8 g
bilateral and symmetrical. There was no suggestion. l. O! `3 |8 w9 C* _
of papilledema.- j5 u: p$ m0 r; E# N
Laboratory Evaluation( {3 d$ Y$ u u4 p$ F0 S
The bone age was consistent with 28 months by
7 V! |. _! ?' qusing the standard of Greulich and Pyle at a chrono-
3 |9 N q+ u# J+ u2 w1 F) N @logic age of 16 months (advanced).5 Chromosomal
4 l" {, \& ?, \4 e. Skaryotype was 46XY. The thyroid function test
7 a H8 I- E; h. ~; z2 W# Cshowed a free T4 of 1.69 ng/dL, and thyroid stimu-1 S2 w3 [3 I1 K% i: b
lating hormone level was 1.3 µIU/mL (both normal).) @6 k: b+ `4 R1 T5 F+ d3 v
The concentrations of serum electrolytes, blood$ y( B/ Q; N7 y4 r
urea nitrogen, creatinine, and calcium all were! M% W: i8 z* C8 }$ W9 W, V
within normal range for his age. The concentration
7 p0 v( ]7 R/ l" ]! N1 f; k, ^+ Vof serum 17-hydroxyprogesterone was 16 ng/dL
5 `0 O9 K" |8 r2 b' Z" P(normal, 3 to 90 ng/dL), androstenedione was 209 w) _& O# r; q0 _; C
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 ?, j2 m8 i% j+ k5 ^
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
- _3 G0 m) P% F* I+ p3 l2 @( ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to6 {( i, A& t' M" `1 Z w
49ng/dL), 11-desoxycortisol (specific compound S); A$ o7 v0 J" G$ o* Z
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: z' {' L4 a3 W/ f/ F8 E" W) i/ Y6 ptisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
5 W4 f' m) d3 M1 r- G$ _% T% ftestosterone was 60 ng/dL (normal <3 to 10 ng/dL),9 Z3 }- \! j- m% g/ i; H0 `
and β-human chorionic gonadotropin was less than9 P. w* V" P/ S2 v6 }1 ^
5 mIU/mL (normal <5 mIU/mL). Serum follicular8 q! g* u! l% S0 E
stimulating hormone and leuteinizing hormone9 k" [) u2 o& H2 q
concentrations were less than 0.05 mIU/mL
5 b7 ]$ e1 R& {0 A, b! O6 q! A(prepubertal).; ~4 i. x% H% a* u8 Z7 l
The parents were notified about the laboratory
, d, V- b7 }' R2 I: Lresults and were informed that all of the tests were
: O' h$ w" l! T' v( Ynormal except the testosterone level was high. The
* _1 [; c! A6 A+ h* j% Hfollow-up visit was arranged within a few weeks to: Q6 A+ R0 X3 K9 m3 |
obtain testicular and abdominal sonograms; how-. l- l5 ^' B1 D
ever, the family did not return for 4 months.
1 S; s& ]& _7 B! CPhysical examination at this time revealed that the
9 T0 A( F( I; @# Q4 Hchild had grown 2.5 cm in 4 months and had gained2 ~" m+ K$ g; L5 z6 w; |
2 kg of weight. Physical examination remained
& t1 J0 C' j# j% E- V8 Punchanged. Surprisingly, the pubic hair almost com-
) C* J/ l5 `- @7 ^pletely disappeared except for a few vellous hairs at M# d5 Q" W( K
the base of the phallus. Testicular volume was still 2
( s( T; }: x- ~9 c, xmL, and the size of the penis remained unchanged.
/ [% z3 q8 V# z/ v* E, kThe mother also said that the boy was no longer hav-4 o8 W+ ?7 e4 _% K' |/ {
ing frequent erections.7 c+ ^6 @9 E: ?: b
Both parents were again questioned about use of% m+ ~0 D1 @$ P$ ]
any ointment/creams that they may have applied to
# V% s- Q) Q4 A6 Nthe child’s skin. This time the father admitted the
. q, B5 W: G$ A/ L& [Topical Testosterone Exposure / Bhowmick et al 541' I% b. m Z' D% Y6 W
use of testosterone gel twice daily that he was apply-
+ K! D. Y* @1 R; G4 b0 Z$ J+ Qing over his own shoulders, chest, and back area for# _. m9 e+ T! B: Z# v
a year. The father also revealed he was embarrassed
% t, J5 t# Q2 n9 B; mto disclose that he was using a testosterone gel pre-2 ]+ O: y: a' X5 o4 j
scribed by his family physician for decreased libido
( P* F# f; ]8 c; A9 J' A3 zsecondary to depression.% F# `9 F$ n* B8 a
The child slept in the same bed with parents.* ~% D8 B0 p; F) j
The father would hug the baby and hold him on his' N- V+ i8 @' k, v# s, z9 G6 [ H" i: j
chest for a considerable period of time, causing sig-" n% i' [4 m! Y r |8 ^; ]# Q) u
nificant bare skin contact between baby and father./ x- I! x* G( H$ `
The father also admitted that after the phone call,
" _5 S& b9 k% J% d- x1 Ywhen he learned the testosterone level in the baby$ ~; ] T+ N+ W1 a/ m
was high, he then read the product information
3 E9 O) Z/ F; ]$ z% B+ s, W& hpacket and concluded that it was most likely the rea-8 y1 m+ v3 K9 P! O' l( X
son for the child’s virilization. At that time, they1 J; k7 B6 g, _* l) J8 [1 e- U" V
decided to put the baby in a separate bed, and the' u/ z$ H9 b' b' G/ E8 e
father was not hugging him with bare skin and had
0 f. `" |( z2 w i5 V. k2 zbeen using protective clothing. A repeat testosterone. N. ]1 g1 n1 y$ e% Z* z# H
test was ordered, but the family did not go to the
5 q2 z V$ T8 C! D, V+ Q* W2 dlaboratory to obtain the test.
: W. u! K7 \1 ^. D. R) a- l5 c4 yDiscussion
: [( p/ u3 r) x% d( kPrecocious puberty in boys is defined as secondary
0 |: W) x/ |% ~sexual development before 9 years of age.1,4
+ n' p) T* @4 z$ l2 B: @' Z+ sPrecocious puberty is termed as central (true) when; Q& X3 }, c) N) g% m0 \
it is caused by the premature activation of hypo-
' L- a! @1 l( M6 cthalamic pituitary gonadal axis. CPP is more com-& |( e) h8 f( [
mon in girls than in boys.1,3 Most boys with CPP* A3 U4 P2 N" W C# ^4 ]! h2 y$ H
may have a central nervous system lesion that is
2 q+ I+ O4 ^3 b% N& X! Wresponsible for the early activation of the hypothal-
* t3 D1 T+ u' b/ q1 [amic pituitary gonadal axis.1-3 Thus, greater empha-
+ P( i4 U3 Y+ I0 `; J1 v5 e* o* Isis has been given to neuroradiologic imaging in
5 G8 a c7 H/ ~boys with precocious puberty. In addition to viril-% `2 Q2 o* P6 C; g$ l% |. a: R
ization, the clinical hallmark of CPP is the symmet-; J. f: J; P u% v: h5 y
rical testicular growth secondary to stimulation by
; i- i1 R, y$ R* z+ s& a9 \* a: sgonadotropins.1,3
( M4 L( u2 ^; S$ z/ m* hGonadotropin-independent peripheral preco-
- |2 G5 |* G; P( lcious puberty in boys also results from inappropriate
p+ P1 \- e* Bandrogenic stimulation from either endogenous or& F8 Q2 `1 }0 o" a3 H
exogenous sources, nonpituitary gonadotropin stim-: G6 M! j o' P$ P# F7 U
ulation, and rare activating mutations.3 Virilizing
1 Y, A: c" @ r1 ]- t1 wcongenital adrenal hyperplasia producing excessive
2 t b4 Z8 r* M& h% M E5 kadrenal androgens is a common cause of precocious2 D% \: x, p' ~
puberty in boys.3,4 H, e# u. R3 E
The most common form of congenital adrenal
7 t, V1 E5 f" _( H0 [8 {# Qhyperplasia is the 21-hydroxylase enzyme deficiency.
: e5 M0 H2 d, m A4 D8 d4 B7 ^ g! }The 11-β hydroxylase deficiency may also result in* M6 L* ^+ q# T- Y# m* b
excessive adrenal androgen production, and rarely,7 E3 N. [' M* q( Z) W: G1 n
an adrenal tumor may also cause adrenal androgen
5 K; D( N1 e z9 ^0 W7 @/ Zexcess.1,3
$ i5 K _8 R4 w* Tat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
1 c r0 v5 O5 f. p' ?; l542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ q- x4 S! ^% F" \0 S7 tA unique entity of male-limited gonadotropin-9 N* K9 M( J% k$ q7 E7 X
independent precocious puberty, which is also known
! a" c2 h0 y, E C2 v1 E9 h6 [as testotoxicosis, may cause precocious puberty at a: i5 F3 \( d5 M( e% T1 e" a, h6 Q
very young age. The physical findings in these boys- @( s# s( ^1 H( u) f0 G ~' r8 r" ~
with this disorder are full pubertal development,# e/ D) `2 C& O" t
including bilateral testicular growth, similar to boys
8 a' _# [4 \ v/ lwith CPP. The gonadotropin levels in this disorder1 s) d& e; w0 R6 s0 p$ x) d& W
are suppressed to prepubertal levels and do not show9 @7 U9 Y% m1 h
pubertal response of gonadotropin after gonadotropin-0 f: { F2 h+ S' p4 l9 V
releasing hormone stimulation. This is a sex-linked
7 ^8 N! b3 i2 P/ U' W) qautosomal dominant disorder that affects only" J, |7 i C' p3 j- e& U
males; therefore, other male members of the family
0 ^0 E9 f# p, Y! bmay have similar precocious puberty.3
/ H; s& O( a/ G2 aIn our patient, physical examination was incon-3 N, i% w5 p( B+ c
sistent with true precocious puberty since his testi-/ r! m9 q0 W- [
cles were prepubertal in size. However, testotoxicosis
( S, J5 M! @2 Q) y7 ?% M7 swas in the differential diagnosis because his father7 @2 ~; R0 u8 D! B4 I
started puberty somewhat early, and occasionally,
% d# T. l/ A. ^" @- Etesticular enlargement is not that evident in the
9 R4 K) R% J$ ^) wbeginning of this process.1 In the absence of a neg-( ^/ Z2 @2 e) p% P3 [0 Y% N
ative initial history of androgen exposure, our
) b; k( B, i7 d' N4 vbiggest concern was virilizing adrenal hyperplasia,0 N' Z6 w# M* x
either 21-hydroxylase deficiency or 11-β hydroxylase4 ~9 Q& h5 ]! d4 H
deficiency. Those diagnoses were excluded by find-! V' K7 D2 @5 p* k
ing the normal level of adrenal steroids.' D9 c2 s* H" S
The diagnosis of exogenous androgens was strongly
1 w/ q: k! h0 [: hsuspected in a follow-up visit after 4 months because, v& ? w0 X( \' k8 m. p( O8 \
the physical examination revealed the complete disap-7 q; W! i2 N$ a
pearance of pubic hair, normal growth velocity, and
6 @1 `' B, H7 k7 a- c& l/ t% y) ~decreased erections. The father admitted using a testos-
; C: i y- j$ m$ I3 \6 u" lterone gel, which he concealed at first visit. He was
0 J5 `1 p8 k( [$ B2 W0 t( Eusing it rather frequently, twice a day. The Physicians’
& }# I) N/ o) q; gDesk Reference, or package insert of this product, gel or8 R. @, Q' X* k4 H# @# |, Y0 E
cream, cautions about dermal testosterone transfer to" T- P5 F; s4 B8 M$ H: j
unprotected females through direct skin exposure.6 l) U9 C( v6 J' K+ K0 k* ?- l
Serum testosterone level was found to be 2 times the
2 B4 N4 Z! [+ G9 [, {0 r/ dbaseline value in those females who were exposed to
( O) z C8 ~+ G/ teven 15 minutes of direct skin contact with their male
4 s- S5 F- b3 u6 b* t1 M! |9 vpartners.6 However, when a shirt covered the applica- @- R! Q. K" e' E$ W
tion site, this testosterone transfer was prevented.! l! j* V* M% M$ P h
Our patient’s testosterone level was 60 ng/mL,
9 w( T g8 [: j( J; n Ywhich was clearly high. Some studies suggest that
! H6 O# u6 a$ u) Ydermal conversion of testosterone to dihydrotestos- R0 h. M5 \# i3 y) l
terone, which is a more potent metabolite, is more
4 H4 f$ G3 [. d2 B' i- P# O7 i6 pactive in young children exposed to testosterone
1 l5 a$ |5 D: d' R3 aexogenously7; however, we did not measure a dihy-
/ z: @; \ q3 i( adrotestosterone level in our patient. In addition to
* x' ^) K2 ^2 s7 r3 b/ Fvirilization, exposure to exogenous testosterone in
& y+ V' U4 m9 l! L9 q; m# Achildren results in an increase in growth velocity and
! U# O, Y) d6 l1 nadvanced bone age, as seen in our patient.
% y& @& m. C" M# _: a* V7 lThe long-term effect of androgen exposure during4 z7 O& ]! j/ K$ o" l
early childhood on pubertal development and final; o( A4 [* _, Q1 _" o0 r1 C; a
adult height are not fully known and always remain
) R3 Z8 w4 T( L p' G' J3 Wa concern. Children treated with short-term testos-
0 h/ Y M, j+ Pterone injection or topical androgen may exhibit some4 |+ l0 u8 t9 v/ ~: F
acceleration of the skeletal maturation; however, after$ k: m2 |/ j) Q7 k9 v7 _
cessation of treatment, the rate of bone maturation. f, Y4 B, c% N; Z' q3 [
decelerates and gradually returns to normal.8,9
* E- c" c) c' p# i) NThere are conflicting reports and controversy
" a1 h/ t7 P' Zover the effect of early androgen exposure on adult
4 X/ r# \2 T# ~& B7 Qpenile length.10,11 Some reports suggest subnormal9 ?# J1 b; j, Y5 [) c6 K9 e
adult penile length, apparently because of downreg-) [8 |' v' U* v& r
ulation of androgen receptor number.10,12 However,9 ^9 [8 q' l* C; m) B
Sutherland et al13 did not find a correlation between
4 c& A$ p8 a1 x2 echildhood testosterone exposure and reduced adult0 l6 m6 x! I3 N
penile length in clinical studies.
3 Q; W3 y3 e, g$ yNonetheless, we do not believe our patient is
3 W' R8 A( u6 e3 [! F6 u7 |/ Bgoing to experience any of the untoward effects from
+ P0 e& b _5 |' l- M( wtestosterone exposure as mentioned earlier because
, I# w- T6 |0 |( Jthe exposure was not for a prolonged period of time.
. j: `& v7 O, V* y/ M* a+ LAlthough the bone age was advanced at the time of
* \' w F# U. _; [$ Q' v# w* e2 Fdiagnosis, the child had a normal growth velocity at3 m+ b Q. o+ d' h
the follow-up visit. It is hoped that his final adult
3 O! C- ^1 `6 Lheight will not be affected.! ]7 B; v% R! V5 i6 @& x! p
Although rarely reported, the widespread avail-, M9 h5 E1 n6 G9 k- n. x
ability of androgen products in our society may
t5 F6 ~* R Q: N6 ?indeed cause more virilization in male or female
, q+ b5 r8 }$ q5 ^1 E, vchildren than one would realize. Exposure to andro-
* Y4 S& @4 ?. T! s/ g% M$ Ngen products must be considered and specific ques-, L. p0 a$ ^! N5 B! M
tioning about the use of a testosterone product or% G% I3 W3 a4 o3 F0 h8 D6 V
gel should be asked of the family members during
5 |" O; O! @9 c; v2 rthe evaluation of any children who present with vir-) l; s( \$ B" I; {0 a, @4 b
ilization or peripheral precocious puberty. The diag-. y$ g1 J4 A/ w" ^ n
nosis can be established by just a few tests and by' ]1 @! C- M4 T0 V7 L0 i' i: n
appropriate history. The inability to obtain such a
, }# b& I) A- |9 Z& Y* T3 m8 `( ^history, or failure to ask the specific questions, may
; \; |: k7 I2 t: T- Lresult in extensive, unnecessary, and expensive. A) P, d( t/ h4 p+ I
investigation. The primary care physician should be
; N0 ?$ k7 _$ t+ ]2 A( |aware of this fact, because most of these children8 B* M" L- B$ v' ^
may initially present in their practice. The Physicians’2 m4 D& v% c5 @% ?0 Z! Z; b3 J
Desk Reference and package insert should also put a3 S4 l2 w, E. a
warning about the virilizing effect on a male or
1 z* N- J( ?5 n& Zfemale child who might come in contact with some-
% s9 m4 [, R5 _0 h7 Jone using any of these products.
7 m) y$ _$ f9 `* s9 IReferences6 Y4 H1 |* n8 ?
1. Styne DM. The testes: disorder of sexual differentiation
0 O1 o& c( n7 u! x5 Rand puberty in the male. In: Sperling MA, ed. Pediatric ]: q# N/ l% J" {2 n+ q) r
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ ~* A, q+ t5 O, r& a1 ]7 c# Y# d
2002: 565-628.
: p# c3 ~6 E9 p* ]2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious0 I! S5 [5 Y" ?& ?
puberty in children with tumours of the suprasellar pineal |
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