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Sexual Precocity in a 16-Month-Old
8 J9 c/ u+ N, X' }$ OBoy Induced by Indirect Topical
1 y. K2 |6 F3 ?4 I5 A$ |Exposure to Testosterone8 a+ D- a/ Q3 v1 E7 k3 W( A
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
; M+ F% m$ M. A9 nand Kenneth R. Rettig, MD1$ L; Y) j, U1 l ^( `
Clinical Pediatrics
. Q2 |$ ~2 \9 X0 B8 pVolume 46 Number 65 g; Q. |0 T' u" O7 U
July 2007 540-543( L* o D# L5 v; d
© 2007 Sage Publications1 K5 U! [, K9 U# {* z
10.1177/0009922806296651% z0 j: j$ L& i2 P5 {# Z
http://clp.sagepub.com
R; [' [# a8 t1 {) `1 H' Zhosted at
! h, r: q' X0 E+ V; U xhttp://online.sagepub.com/ G2 H3 l- o5 @* ?
Precocious puberty in boys, central or peripheral,8 K, z" g/ G! Z$ P4 S
is a significant concern for physicians. Central
, ~6 D1 @. s' p8 E) D8 }precocious puberty (CPP), which is mediated: A3 `4 {8 {5 a( H7 f' U+ s
through the hypothalamic pituitary gonadal axis, has
# ~+ l2 I. F0 ]2 ]: R5 Wa higher incidence of organic central nervous system4 {+ l5 g- @, d* J0 I! F
lesions in boys.1,2 Virilization in boys, as manifested
6 Y+ x; F; M9 |+ K- [+ w5 Aby enlargement of the penis, development of pubic. V+ Z. Y4 \" h. D8 A, f8 X
hair, and facial acne without enlargement of testi-
. B: ?5 B* m! o1 b, X4 }0 `- ?cles, suggests peripheral or pseudopuberty.1-3 We
/ v( a. x' u' [report a 16-month-old boy who presented with the
! x; m! X5 ?' |5 n+ `6 `% O `enlargement of the phallus and pubic hair develop-2 ?! r# I( s3 [" Y$ B
ment without testicular enlargement, which was due0 K. k; E6 R- r; o7 n/ S) q
to the unintentional exposure to androgen gel used by p# Z1 ]1 W9 Y) l5 J# P' T
the father. The family initially concealed this infor-
, t2 U' n7 r! l' X! k- b6 hmation, resulting in an extensive work-up for this" N" V0 g+ _: p+ H, N
child. Given the widespread and easy availability of
- j1 l7 \! A+ b* C. jtestosterone gel and cream, we believe this is proba-
7 V4 g, F9 n$ J/ rbly more common than the rare case report in the
, g: n2 t5 {' I* v+ p- |literature.4
% ?# A" p& f& a; n8 |Patient Report- u$ V% t; C5 Q9 W5 R0 t( G" v
A 16-month-old white child was referred to the
2 K9 p& x* @+ Fendocrine clinic by his pediatrician with the concern
$ @0 y9 u$ }, S' v$ M# Uof early sexual development. His mother noticed
" x" m9 m7 N' q* I9 h6 d! }light colored pubic hair development when he was
# J% x$ c* l* U, D q3 Y3 K) tFrom the 1Division of Pediatric Endocrinology, 2University of5 c5 e3 k C% }, p8 J# Y
South Alabama Medical Center, Mobile, Alabama.8 Z6 R) z! s0 D3 O) @' B$ `. y
Address correspondence to: Samar K. Bhowmick, MD, FACE,
: c* M' j3 R, i7 w/ }* v% H- UProfessor of Pediatrics, University of South Alabama, College of' t, [' V: s z* ?
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;" P0 Z9 M! Z5 s8 P
e-mail: [email protected].1 T* H" X' [' U+ k; S9 B
about 6 to 7 months old, which progressively became) D* |2 W7 G# e6 B5 l" ^ z
darker. She was also concerned about the enlarge-
: t6 r$ J* T8 w c/ a- y4 m+ Qment of his penis and frequent erections. The child( G: l4 L% o4 u
was the product of a full-term normal delivery, with# w. D+ J2 u* Q6 y6 N5 ?. i9 P
a birth weight of 7 lb 14 oz, and birth length of5 k+ L8 ^, @( T
20 inches. He was breast-fed throughout the first year
4 }9 P, w+ g ^& }! Uof life and was still receiving breast milk along with: W9 T4 I. C* U+ q# y# ]# y
solid food. He had no hospitalizations or surgery,4 k. `/ H5 Y9 K7 G# m, R6 j
and his psychosocial and psychomotor development4 R* x/ ~& H$ [* x
was age appropriate.4 d) }* A" H' F# @
The family history was remarkable for the father,, y/ v& `! O# I" O
who was diagnosed with hypothyroidism at age 16,
: L, R9 [$ h7 p: b T- B/ ?0 }which was treated with thyroxine. The father’s
; }% g. o8 [' Q3 K$ n1 Lheight was 6 feet, and he went through a somewhat1 }0 r& N* X p8 X% i1 X, P
early puberty and had stopped growing by age 14.5 g# p" }0 K7 W
The father denied taking any other medication. The
. X ~1 w" Q! e T$ _2 [* vchild’s mother was in good health. Her menarche# b4 s1 ^& j! y; e6 Q
was at 11 years of age, and her height was at 5 feet, c$ Q+ G2 `: N3 X
5 inches. There was no other family history of pre-3 O- z, F+ V/ D, W: q5 a& Q
cocious sexual development in the first-degree rela-
& R0 g& a- ~% t' n9 B- Btives. There were no siblings.9 y% e; t+ F" B4 K
Physical Examination
8 |0 S+ i1 d1 p& e3 V. LThe physical examination revealed a very active,3 P, Y! H0 V9 a# e3 `
playful, and healthy boy. The vital signs documented
6 x$ e: O( U. z0 Fa blood pressure of 85/50 mm Hg, his length was
) R' e$ m: Y9 W+ k! G6 Z) z90 cm (>97th percentile), and his weight was 14.4 kg
# }2 C! _# D/ P+ r* e(also >97th percentile). The observed yearly growth' |# e0 K( B. b8 J0 |7 D9 ]! m
velocity was 30 cm (12 inches). The examination of
- |5 U/ \; X- j9 @5 }( k, Jthe neck revealed no thyroid enlargement.
2 Y5 O* b; U- ]+ OThe genitourinary examination was remarkable for
! a! e5 ? X8 T* \$ a$ v6 ]1 menlargement of the penis, with a stretched length of" y8 w7 Z- v, T t
8 cm and a width of 2 cm. The glans penis was very well
. C* ^3 A; F* e6 ~+ Edeveloped. The pubic hair was Tanner II, mostly around
7 h5 Z5 _* g, N% T1 Z( J' I5402 n! U+ T( P) c6 E% u
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
0 V# w% u: O7 |9 fthe base of the phallus and was dark and curled. The& b& ]2 G; J6 a5 o9 @' R
testicular volume was prepubertal at 2 mL each.* n' f4 I+ Y. @9 c( E. A
The skin was moist and smooth and somewhat" c( n4 `+ t" z+ T% j
oily. No axillary hair was noted. There were no
7 [! n, a* H) j0 u, Eabnormal skin pigmentations or café-au-lait spots.
8 h2 J" k/ T# D8 e" K$ D7 B% ^# |Neurologic evaluation showed deep tendon reflex 2+) ~4 |7 w u( a
bilateral and symmetrical. There was no suggestion5 w7 f) y" P. h- P
of papilledema.
6 T- H2 t1 K- A+ ULaboratory Evaluation
; A1 L8 G1 e8 n5 O B/ o- w# OThe bone age was consistent with 28 months by$ Y0 o( b, A2 { R7 F. p8 F) `* U
using the standard of Greulich and Pyle at a chrono-
0 f! R3 I( o6 Plogic age of 16 months (advanced).5 Chromosomal
. s1 o/ E* s' H7 w5 }' U; w5 akaryotype was 46XY. The thyroid function test& R7 S& J% ?, _3 K4 a" c8 I
showed a free T4 of 1.69 ng/dL, and thyroid stimu-' s1 ~4 b6 m) f0 ~
lating hormone level was 1.3 µIU/mL (both normal).
' Z0 [2 B4 i( K& G! X# PThe concentrations of serum electrolytes, blood
d: n+ M- |% P* h( Surea nitrogen, creatinine, and calcium all were
: W6 O3 @6 y/ y9 |" ~within normal range for his age. The concentration
: u% ]+ y2 p# T. Aof serum 17-hydroxyprogesterone was 16 ng/dL
5 f S3 L' M9 C(normal, 3 to 90 ng/dL), androstenedione was 20
/ e7 u' D% ^- [' g5 vng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-) u; O E# G! }& a/ w! B8 l1 H# ]
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ [0 w2 [3 I8 K: ~( J& i6 Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to, W) P& Y7 A Y. R6 t" E
49ng/dL), 11-desoxycortisol (specific compound S)6 `6 s* G- X6 R
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
+ A4 e! P4 g8 O$ Utisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
' e4 g) a6 q, V# o( X: P/ Mtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
, b) [- O9 F' T* s& ~and β-human chorionic gonadotropin was less than% V- p4 S. o+ N: D5 J. x0 p9 _4 Q
5 mIU/mL (normal <5 mIU/mL). Serum follicular/ j1 ^- f& q6 E, E
stimulating hormone and leuteinizing hormone( ^* U" s+ ?, j/ e% Q+ G
concentrations were less than 0.05 mIU/mL r3 F2 B+ U) [, p+ b
(prepubertal).0 q3 z5 I( D2 A1 o4 W
The parents were notified about the laboratory
, B# d8 t5 I+ q; M" {results and were informed that all of the tests were0 w7 d; p+ V3 n, ]& Z/ }
normal except the testosterone level was high. The
1 a# b4 z- w7 j: f+ r$ d2 u7 sfollow-up visit was arranged within a few weeks to8 W' w" m2 |2 b( ]! \1 Y: _
obtain testicular and abdominal sonograms; how-
! k/ W' O. }& _. }( |& mever, the family did not return for 4 months.$ ^3 q! B* L! R. `; A/ c+ b
Physical examination at this time revealed that the3 \, S/ m* c# c/ e
child had grown 2.5 cm in 4 months and had gained
6 {: G. F) J. C8 `# E c2 kg of weight. Physical examination remained
2 E3 p# L- f$ e- m8 Ounchanged. Surprisingly, the pubic hair almost com-
5 a. l1 Z- q% v2 }pletely disappeared except for a few vellous hairs at
5 ?: ?& {8 _1 |; _4 P6 b% y y8 E* ythe base of the phallus. Testicular volume was still 2
( {* b9 U' R X; S4 o/ HmL, and the size of the penis remained unchanged.
, I5 r% T% e( Q1 ^& k) H0 V$ KThe mother also said that the boy was no longer hav-
# T* ]/ ~% v! i- g/ s6 _2 W( fing frequent erections.- ?2 T. O; F& S& E
Both parents were again questioned about use of
& b8 P% Z, @; S' l. @0 e2 Aany ointment/creams that they may have applied to
% l, h/ [, U8 X7 n* t9 S, dthe child’s skin. This time the father admitted the
0 N- Y( w) m4 Q, @Topical Testosterone Exposure / Bhowmick et al 541$ D1 ~5 C+ k& G; E! f
use of testosterone gel twice daily that he was apply-
) a* Q; m- x V$ u! B; ~ing over his own shoulders, chest, and back area for) O- C! R3 ~, s3 ?# ~& H c t7 ^
a year. The father also revealed he was embarrassed {6 B2 x2 U3 w/ i
to disclose that he was using a testosterone gel pre-
4 M& I' ? _: i" P O- @scribed by his family physician for decreased libido
! P8 Z# V2 B$ S3 x# M6 D, jsecondary to depression.
* |5 F. E' d# o2 j, t- n2 xThe child slept in the same bed with parents.
0 @$ `- Z" [, M. L' f6 L4 X' G( cThe father would hug the baby and hold him on his
4 D/ r+ O4 Z. q' Q( jchest for a considerable period of time, causing sig-
, D3 m. u" D; V5 R* Jnificant bare skin contact between baby and father.
' }: o$ ^/ k! \The father also admitted that after the phone call,
0 \8 s6 f- Q3 q/ w4 awhen he learned the testosterone level in the baby
: t1 L1 Z( V; R% c- I, k' Mwas high, he then read the product information7 v- N: t0 K. o7 S
packet and concluded that it was most likely the rea-+ G2 v% ^) T0 I; J+ Q+ R
son for the child’s virilization. At that time, they
( x& P- M9 C+ x" sdecided to put the baby in a separate bed, and the0 J- R0 C' ~; L
father was not hugging him with bare skin and had
4 R+ F: F6 K) Q7 ]1 Rbeen using protective clothing. A repeat testosterone
+ N4 X3 ?3 S7 \test was ordered, but the family did not go to the
; I& n. A% X a' T6 blaboratory to obtain the test.
. o: |8 ~( Y+ c% H, NDiscussion. h! B$ t0 u5 p; h3 [0 f/ h
Precocious puberty in boys is defined as secondary9 o/ w$ K1 N" Z1 j: z
sexual development before 9 years of age.1,4* G# e5 X6 L) m
Precocious puberty is termed as central (true) when7 s$ n/ c i) e# _- Q
it is caused by the premature activation of hypo-& ~1 o( q9 i, E# ?. ]; ~
thalamic pituitary gonadal axis. CPP is more com-
1 J& m) A0 ^/ Y' x) k8 W/ x1 [2 |& a) Tmon in girls than in boys.1,3 Most boys with CPP1 p9 O: r- E* x" m
may have a central nervous system lesion that is
: O0 s. T- W/ b( |& p' X7 ], nresponsible for the early activation of the hypothal-
+ r3 C; C' h# w; j9 N1 Tamic pituitary gonadal axis.1-3 Thus, greater empha-' j: O. I6 ]& ]1 y/ X5 n3 C
sis has been given to neuroradiologic imaging in
# Y: Y/ A* ?6 aboys with precocious puberty. In addition to viril-
% B2 K* p' @& Q! y; eization, the clinical hallmark of CPP is the symmet-3 \6 C" T; D$ L* C( N
rical testicular growth secondary to stimulation by
; X; R( Y" ?" k- f9 ?6 Rgonadotropins.1,3' w' j7 H! G/ h3 R
Gonadotropin-independent peripheral preco-
' c) H; W& E7 @! G% ~cious puberty in boys also results from inappropriate0 o. K( q o( `8 y& k
androgenic stimulation from either endogenous or
! h- B3 b# N3 O, L7 [+ Vexogenous sources, nonpituitary gonadotropin stim-6 I/ s& P# o! ]2 f; [
ulation, and rare activating mutations.3 Virilizing
( `) r1 Y W8 b3 A, ]. l9 ycongenital adrenal hyperplasia producing excessive! A+ ?, n# y" @$ A7 {) j# u1 m% M
adrenal androgens is a common cause of precocious4 [* \7 K( u' a0 H% b
puberty in boys.3,4
# `9 i* M u. }- K3 w* [4 rThe most common form of congenital adrenal e$ C; A m8 Y) K" ?/ C3 t, ~% \
hyperplasia is the 21-hydroxylase enzyme deficiency.6 J: k4 M1 C. \. n( u
The 11-β hydroxylase deficiency may also result in) b% ]9 Y. J$ R$ C' y
excessive adrenal androgen production, and rarely,0 G, M* T9 y/ `( Q
an adrenal tumor may also cause adrenal androgen
7 n$ i, A. m) ~% W C3 T2 C; mexcess.1,32 {: |6 a+ s% C3 M/ N3 a3 W
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" G( r! w; l( V542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
3 u' `, ]0 p5 g: u+ k& Z4 j; m lA unique entity of male-limited gonadotropin-8 j5 Z$ A0 d8 Q( v7 B8 Z7 L6 k! U
independent precocious puberty, which is also known8 X! E2 e2 r3 d) `4 ]2 S
as testotoxicosis, may cause precocious puberty at a# z. \4 n- @3 P- n5 [" D* C* a) O
very young age. The physical findings in these boys
% [8 G8 r. N. V# b* s( p3 f" wwith this disorder are full pubertal development,, i9 k, R1 W% Y3 W0 ?* E1 U, e
including bilateral testicular growth, similar to boys+ N. y. j3 `+ r: m# V8 Z7 ~
with CPP. The gonadotropin levels in this disorder
0 _- m+ }) f5 Uare suppressed to prepubertal levels and do not show' W! k- e8 K7 s7 X& @
pubertal response of gonadotropin after gonadotropin-2 }2 ?/ q' I1 F% c8 k' z. Q% s
releasing hormone stimulation. This is a sex-linked0 T! c4 W; [- d) r
autosomal dominant disorder that affects only
& Y) g. e8 i+ }. Y( Y! n( [males; therefore, other male members of the family
6 @ [7 E7 t/ O8 \: e% ?: e8 umay have similar precocious puberty.3
4 d q5 J! P' ^, P8 b! q7 aIn our patient, physical examination was incon-
0 Y3 z4 u4 w, T0 n/ R! Gsistent with true precocious puberty since his testi-- Y) ~. c2 k4 T: J0 Z8 n; z. S; C- X* K
cles were prepubertal in size. However, testotoxicosis
- f7 |- C0 ?) q @* U D/ awas in the differential diagnosis because his father5 A0 k: e1 N( N4 o# o+ L1 J& e8 |
started puberty somewhat early, and occasionally,: N, Y2 h0 t% I
testicular enlargement is not that evident in the1 ~8 T) o% @/ o) [7 |
beginning of this process.1 In the absence of a neg-+ \4 ^; e& w3 e% b; D: [# [
ative initial history of androgen exposure, our/ A+ P9 K3 c5 g5 M$ m
biggest concern was virilizing adrenal hyperplasia,
/ I* w- }2 F+ F3 j! qeither 21-hydroxylase deficiency or 11-β hydroxylase
0 X8 K( ~4 c4 n) s1 k; ~deficiency. Those diagnoses were excluded by find-$ _: ]# a7 ]" x. N* r, b
ing the normal level of adrenal steroids. j: }+ u4 D+ \, I4 n
The diagnosis of exogenous androgens was strongly5 u8 ]7 ~; L. L
suspected in a follow-up visit after 4 months because5 Q6 T4 n6 t* c8 n- l! F' `1 G
the physical examination revealed the complete disap-- O n [ A4 z6 x9 a
pearance of pubic hair, normal growth velocity, and; o1 U% O# k: j- ~1 U6 k' A# F% ?
decreased erections. The father admitted using a testos-
7 ^( j0 ^4 ^; m3 }terone gel, which he concealed at first visit. He was$ n4 X% f: C( e4 k: _6 j _! b! ^' B
using it rather frequently, twice a day. The Physicians’
' ~% u4 W7 _+ y0 v' BDesk Reference, or package insert of this product, gel or2 O3 t. G- J. G- `/ k) K
cream, cautions about dermal testosterone transfer to$ [0 k5 E3 ~& f
unprotected females through direct skin exposure.
$ |) _9 q) i+ c6 `6 c( n9 i1 rSerum testosterone level was found to be 2 times the
; @1 l5 z, v) Z$ h; nbaseline value in those females who were exposed to
( a) i. L% M4 Y6 E2 reven 15 minutes of direct skin contact with their male
$ A! Q* d& z6 M* o+ g$ {' Dpartners.6 However, when a shirt covered the applica-
) o8 } L, Y! R ption site, this testosterone transfer was prevented.- y. Y$ Y j" c* B+ E/ V
Our patient’s testosterone level was 60 ng/mL,# q$ J) `: q/ A# [
which was clearly high. Some studies suggest that
( R: D$ n, Y$ u/ Y( r% k0 U1 mdermal conversion of testosterone to dihydrotestos-
+ v/ C' b0 k9 J( U4 l$ n: fterone, which is a more potent metabolite, is more
9 k1 n% T# t- y( f% i9 \$ tactive in young children exposed to testosterone7 ~4 N: e% f' b0 e. x2 h2 M
exogenously7; however, we did not measure a dihy-
0 K5 ^) Q t- h2 L _$ Bdrotestosterone level in our patient. In addition to
* I, j( [3 d( o+ K- Zvirilization, exposure to exogenous testosterone in" n& l$ B6 K- e, Y
children results in an increase in growth velocity and
' E7 V) U" q6 q- Zadvanced bone age, as seen in our patient.& o& @* l' g1 w" c; q& E9 i
The long-term effect of androgen exposure during
- B# W3 y, I7 [; [2 c9 ?early childhood on pubertal development and final$ D7 j$ M. T$ |, a. ]
adult height are not fully known and always remain6 N6 _+ g7 n, S9 X+ ?/ O
a concern. Children treated with short-term testos-9 r9 s+ g5 _( k$ ~
terone injection or topical androgen may exhibit some
+ V" y6 B- C. d7 V1 B4 ^acceleration of the skeletal maturation; however, after
' r8 W$ Q, L! h f) Fcessation of treatment, the rate of bone maturation/ W, n$ Y& Y, `
decelerates and gradually returns to normal.8,9
& J! h6 r# p% }6 v6 M1 B: c' a3 fThere are conflicting reports and controversy2 Z' \0 k( @& _
over the effect of early androgen exposure on adult, w; R6 c1 |3 ^3 C J6 U4 @
penile length.10,11 Some reports suggest subnormal" D3 a1 Z2 H9 r+ n9 X
adult penile length, apparently because of downreg-
4 w8 ]2 D# b: B; u, n/ bulation of androgen receptor number.10,12 However,; d* }+ P9 s( ^+ B* m! [) A
Sutherland et al13 did not find a correlation between
2 O+ A7 w8 M, [/ q" {childhood testosterone exposure and reduced adult. l% ?5 I0 i. {) y s- o1 ^6 ?
penile length in clinical studies.
+ X5 J* g3 r, D/ WNonetheless, we do not believe our patient is! D8 L" { e( b
going to experience any of the untoward effects from( p$ M) H7 X2 k$ N3 U
testosterone exposure as mentioned earlier because
" k" o" v- p1 A' B' Dthe exposure was not for a prolonged period of time.
8 R' ^, ~9 q+ A% RAlthough the bone age was advanced at the time of
6 M i- V4 d- X+ x' Mdiagnosis, the child had a normal growth velocity at3 B- p) z# T# R" a, S; o: L4 S( D
the follow-up visit. It is hoped that his final adult$ R3 C2 t; C' [7 }/ t* @
height will not be affected.
( c8 X B6 ]$ SAlthough rarely reported, the widespread avail-
. S1 v& I0 o* n5 W1 z' Cability of androgen products in our society may) U' t5 Z1 t% \9 s- n7 ~
indeed cause more virilization in male or female
% c3 F. `6 m2 S3 j: D, M" fchildren than one would realize. Exposure to andro-) x0 U% z4 j" r) R
gen products must be considered and specific ques-2 D% `/ ]2 J( b* x; _1 n- P2 v
tioning about the use of a testosterone product or
& ?+ w4 E! R3 o* Z# X" z) qgel should be asked of the family members during/ P& Z$ l6 O4 }- S) w9 V. p0 e
the evaluation of any children who present with vir-
6 k) x1 z' y% r7 silization or peripheral precocious puberty. The diag-) ` ^0 q( Z7 W- R5 o
nosis can be established by just a few tests and by: Y' v, z! k4 Z+ w$ k* E$ M
appropriate history. The inability to obtain such a
7 }5 W: a( Y! C; |2 Uhistory, or failure to ask the specific questions, may5 h7 k8 J( ?- A
result in extensive, unnecessary, and expensive
8 C$ `9 B G' x# |. dinvestigation. The primary care physician should be
2 j% O' t" t |' haware of this fact, because most of these children6 Y' k. F4 a8 b+ Q6 F& H- Q: K
may initially present in their practice. The Physicians’1 e" u- F |; b# q
Desk Reference and package insert should also put a2 }5 D1 z7 |; K, K
warning about the virilizing effect on a male or
* M L' f' c; Q- e3 mfemale child who might come in contact with some-: L6 \5 m# a( \3 Y. e% {2 q `
one using any of these products.3 d$ A9 [& V8 w6 {- ?# \* s
References
$ \0 f! }9 A. q( C5 w1. Styne DM. The testes: disorder of sexual differentiation
) Q3 ?4 N: t" b( M0 K+ zand puberty in the male. In: Sperling MA, ed. Pediatric! C- `0 ^' o' L8 L" a# F
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
% J7 ]- D# H- e2002: 565-628.. {% V' e/ `! w; X6 c6 Y
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious6 N, R' g" `, H$ k6 s# E# Z
puberty in children with tumours of the suprasellar pineal |
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