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Sexual Precocity in a 16-Month-Old
# z' a8 j, W! [$ V. M* g3 KBoy Induced by Indirect Topical
" |$ k+ @8 v4 a m( F$ V Q6 _- tExposure to Testosterone
- f% n. w4 b7 S5 c7 ESamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2' ~$ p! z, S w& B9 i, y: s) Q/ `
and Kenneth R. Rettig, MD1
0 t0 [" |* P7 O* HClinical Pediatrics
' M$ L& ~) L* N7 `Volume 46 Number 6
5 a$ ?3 N0 D" L; m+ p% p9 AJuly 2007 540-5439 y0 d7 m) |7 g2 T: K
© 2007 Sage Publications
/ _" t. v0 f! i. n- n10.1177/0009922806296651
. t' _8 U: ^$ V+ A; d6 U8 A) j9 \6 Ohttp://clp.sagepub.com& u: B N5 l3 |$ d2 D
hosted at
: r3 Y* n( G# s& T* zhttp://online.sagepub.com6 h# m0 c3 l/ ^& h
Precocious puberty in boys, central or peripheral,9 C* w9 x# p+ h, B! V0 ?- _
is a significant concern for physicians. Central/ Y0 v6 _6 ]8 Z- u( W! H. X, f
precocious puberty (CPP), which is mediated) L' I. ^/ C7 _ J! t
through the hypothalamic pituitary gonadal axis, has% {& E9 {( g) x' ~1 O. e) a! \3 {
a higher incidence of organic central nervous system( K1 K4 \/ C+ _1 |8 {
lesions in boys.1,2 Virilization in boys, as manifested
, t4 h) ?' @& |5 O- @' Iby enlargement of the penis, development of pubic
" h- M; P# _7 f ~& Uhair, and facial acne without enlargement of testi-$ y7 Z. x" \% P1 c4 G4 J! s
cles, suggests peripheral or pseudopuberty.1-3 We+ `! a" y3 u( X; V: b8 S
report a 16-month-old boy who presented with the
$ Q. D4 e/ i3 u0 H( x. B" b8 cenlargement of the phallus and pubic hair develop-
4 }2 Q, ~* [2 K2 ?7 I5 Zment without testicular enlargement, which was due+ Y+ j6 g. U1 |0 J
to the unintentional exposure to androgen gel used by0 Y& [) j$ G( O4 J
the father. The family initially concealed this infor-; d) L& I# A* X' v5 _
mation, resulting in an extensive work-up for this' Y+ l8 Y1 e. ]. T6 Y
child. Given the widespread and easy availability of$ ]2 P* p$ a" z
testosterone gel and cream, we believe this is proba-
3 H8 i* n0 F% x$ ~) Xbly more common than the rare case report in the
: U7 Z- i- A# L+ `literature.4
3 I5 H' H$ H+ l* n: R. }" A: R/ EPatient Report' T. `: Z/ h# p. Z5 _7 U7 y
A 16-month-old white child was referred to the
5 Y+ Z( @0 R. ^- s! i) x% Y; Rendocrine clinic by his pediatrician with the concern* e. D; ~- ]: F( l
of early sexual development. His mother noticed6 F# Q% K! c5 T7 v i( P! ^
light colored pubic hair development when he was
% M5 l4 F( L$ y; `From the 1Division of Pediatric Endocrinology, 2University of
# h2 q, G" e8 A, ]( HSouth Alabama Medical Center, Mobile, Alabama./ J8 x. s- k! `, M; g8 r
Address correspondence to: Samar K. Bhowmick, MD, FACE,- d i7 j( l2 p5 X8 i9 U0 }
Professor of Pediatrics, University of South Alabama, College of
8 S, g3 B8 I* f; JMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
& ?$ X( R+ i$ e9 I1 L+ Je-mail: [email protected].$ d, m; i, d# E1 e2 n7 `
about 6 to 7 months old, which progressively became8 Z0 Q0 B' G( \; j8 R
darker. She was also concerned about the enlarge-$ z* u" a( s: a5 [3 [* w9 e
ment of his penis and frequent erections. The child3 q$ Y+ W- B4 I, X9 ~. z
was the product of a full-term normal delivery, with8 P+ N4 T p( e1 \- y* u( E
a birth weight of 7 lb 14 oz, and birth length of$ n: i; j: ]( K# |
20 inches. He was breast-fed throughout the first year! Z2 o1 q- H! R
of life and was still receiving breast milk along with
$ l+ }' K/ f) M' }/ d, L4 ^" \1 esolid food. He had no hospitalizations or surgery,1 z3 e. Z! J8 t7 c! h
and his psychosocial and psychomotor development
1 ]. j' Q7 t7 n: U! Vwas age appropriate.
) V4 q! A- {( H- k& n1 V6 r7 SThe family history was remarkable for the father,, t( z- h9 m& L" y
who was diagnosed with hypothyroidism at age 16,, i4 f- }5 B6 o
which was treated with thyroxine. The father’s% o& l, n6 @3 B
height was 6 feet, and he went through a somewhat, B, J' {- P& W/ ]3 Q
early puberty and had stopped growing by age 14.
7 F \% k* D" x3 I3 [The father denied taking any other medication. The( ^ i( D% b. Z# ?% \3 N
child’s mother was in good health. Her menarche4 t: s& G9 O- G4 f( b S* f5 d
was at 11 years of age, and her height was at 5 feet
, o' i0 m: l0 X3 V5 inches. There was no other family history of pre-
; @- ]& M1 T! q0 ` h2 A& K! v& Ncocious sexual development in the first-degree rela-
. v C }1 |5 c4 K5 ptives. There were no siblings.% e& r! E' x5 K N
Physical Examination5 `. r. X; g+ d8 f, ^
The physical examination revealed a very active,5 _- _7 b0 ]9 A$ l3 s$ O1 L* A
playful, and healthy boy. The vital signs documented8 j, n! S) Q7 I$ Y
a blood pressure of 85/50 mm Hg, his length was
7 }8 R! @6 n C. N$ g+ q90 cm (>97th percentile), and his weight was 14.4 kg! T3 p- b% o$ R5 x8 e" F3 ]
(also >97th percentile). The observed yearly growth
$ L: `% P5 L9 D* E' c. cvelocity was 30 cm (12 inches). The examination of6 [+ j/ H' o1 ^( j- s' [$ g& P
the neck revealed no thyroid enlargement.0 V% @( R# F; E. g( U* F. u/ C
The genitourinary examination was remarkable for& S0 j9 u/ Z3 N! n( J( r+ b/ F
enlargement of the penis, with a stretched length of/ i) ^( [9 U+ U; g
8 cm and a width of 2 cm. The glans penis was very well& c" e" k2 ]" U1 P
developed. The pubic hair was Tanner II, mostly around
. i$ g- z: U' z' _- u4 T, r540
4 b7 z/ |+ R. Eat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' R, S5 M k, b: gthe base of the phallus and was dark and curled. The
' E) O0 B0 L5 r3 O) G# }testicular volume was prepubertal at 2 mL each.
! B8 s0 C) Y1 l4 oThe skin was moist and smooth and somewhat
( N! b3 v g* @, R1 E- ~! L" o1 A1 zoily. No axillary hair was noted. There were no/ v$ Y, q* x9 f' g+ z# t3 B
abnormal skin pigmentations or café-au-lait spots.. Q( k! G9 ~, `9 Y
Neurologic evaluation showed deep tendon reflex 2+
. H* p) m3 e0 r1 Ebilateral and symmetrical. There was no suggestion& C( G; e9 w& }* `. n7 P
of papilledema.- c( s9 s. R- H! J2 R
Laboratory Evaluation
0 \5 N5 K1 ?; p. `' I/ V' QThe bone age was consistent with 28 months by
& {- r [! {9 \. ?9 u' Tusing the standard of Greulich and Pyle at a chrono-: h4 B+ _* d, U; a0 U* p
logic age of 16 months (advanced).5 Chromosomal
0 G6 m8 `$ r: F& M# Bkaryotype was 46XY. The thyroid function test
( m' o2 o& \& b" o5 Gshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
! z" x1 o1 @, r" qlating hormone level was 1.3 µIU/mL (both normal).
0 M1 Q# L6 N6 x& \The concentrations of serum electrolytes, blood' J% V% ]2 T* o- W
urea nitrogen, creatinine, and calcium all were+ D/ h2 @/ N, Y7 A! u" {9 c
within normal range for his age. The concentration; V- J$ ^+ a$ z2 K1 A* e/ w
of serum 17-hydroxyprogesterone was 16 ng/dL% B/ l4 r t# K- X8 J( Q' T) a
(normal, 3 to 90 ng/dL), androstenedione was 20. E' F# U3 ^7 Q- N
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-2 @* u2 u' T, w8 t5 L/ S& y5 \
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
/ u U$ c: }' T: Sdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
0 y; J3 ^& h+ P M( g49ng/dL), 11-desoxycortisol (specific compound S)
F( ~) Z) u- Z: ~. T' xwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
: S7 ~+ g3 C# n1 ?/ H2 n3 dtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total. q2 j4 j# I2 d: P! L* O+ d
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
; d0 m# W. Q1 R1 F' P& uand β-human chorionic gonadotropin was less than5 R9 q2 y- y1 X; ]
5 mIU/mL (normal <5 mIU/mL). Serum follicular
5 Z- O% z3 c3 T6 O; p1 v8 dstimulating hormone and leuteinizing hormone
/ j5 _* Q# p) H; j. pconcentrations were less than 0.05 mIU/mL( Q2 ]) u* G9 H' I( }* h4 x
(prepubertal).
6 p5 r) Q$ D ?, r, j+ yThe parents were notified about the laboratory
5 g/ \, C# L& l. }results and were informed that all of the tests were* W1 n/ u. v G+ _' C
normal except the testosterone level was high. The
K m% S0 Z" p* Qfollow-up visit was arranged within a few weeks to& v' [' ^3 Q3 v7 _2 q- n
obtain testicular and abdominal sonograms; how-, J7 ?. o+ m' `% Q
ever, the family did not return for 4 months.
. p* J& f' [/ d: [9 cPhysical examination at this time revealed that the$ m) V( F) v2 y" W7 U# ~
child had grown 2.5 cm in 4 months and had gained
, }4 _2 O1 V: d$ Q1 n6 t+ N2 kg of weight. Physical examination remained- A: L" C/ G, n' [* y% r
unchanged. Surprisingly, the pubic hair almost com-
. B. ~+ v& C- F) h( c4 Q6 k" qpletely disappeared except for a few vellous hairs at
4 L9 M2 p+ G+ Y* l' \9 Lthe base of the phallus. Testicular volume was still 2/ u, q$ z- g. M9 }) s$ v2 e
mL, and the size of the penis remained unchanged.
' D. c5 c i# e/ K2 g# \9 QThe mother also said that the boy was no longer hav-
& @+ c( d- D" t+ n" ~8 xing frequent erections.
3 N. r& p& q- k5 n& TBoth parents were again questioned about use of
( x" m3 L9 r! V) Jany ointment/creams that they may have applied to
" R- M2 r2 j3 c# r9 E! @' D: ethe child’s skin. This time the father admitted the6 [1 z6 E! Z1 s7 w0 y2 i
Topical Testosterone Exposure / Bhowmick et al 541
& v( ?2 z/ [ B4 W# d" x4 Tuse of testosterone gel twice daily that he was apply- G" o, W: }. m. I2 C T
ing over his own shoulders, chest, and back area for
) n) D- @( {3 u: v; J* T$ Ca year. The father also revealed he was embarrassed& E6 t/ t1 [( x
to disclose that he was using a testosterone gel pre-: F, R+ ^& I. l
scribed by his family physician for decreased libido
& m. E3 r8 c. y! bsecondary to depression.
. Q, y+ [& ], ]3 ^The child slept in the same bed with parents.' i p( _- \% a7 P7 E" T
The father would hug the baby and hold him on his. [( Z2 P. V1 L& Y8 ?5 z! @
chest for a considerable period of time, causing sig-
6 ? l* g* W& F P% ]; |1 k6 _: h8 Rnificant bare skin contact between baby and father.
7 B9 ?! S" k& B n& D0 S2 K5 O- [) B% zThe father also admitted that after the phone call,
' g5 a9 C. e, v3 k) Y; owhen he learned the testosterone level in the baby- D/ D5 c9 F" K1 c
was high, he then read the product information
0 b9 L8 S; y! j% ]8 K7 T3 \packet and concluded that it was most likely the rea-) p" _3 |$ e$ B$ u# E5 a
son for the child’s virilization. At that time, they
% Q0 S3 q/ ]) Kdecided to put the baby in a separate bed, and the3 ^( g: P+ |# Y
father was not hugging him with bare skin and had! `; {1 N* F( o/ ]8 v0 Z0 Q q7 Q
been using protective clothing. A repeat testosterone) m3 W/ V* ~& J* ^( ]0 K0 U
test was ordered, but the family did not go to the e- [; M. [. h/ F5 i5 O" V
laboratory to obtain the test.) v! O" V9 x4 z. f& C9 g
Discussion0 ?$ |/ `, B. ~- W! f3 q1 m
Precocious puberty in boys is defined as secondary
2 O' e& V q5 w: S" V2 k3 osexual development before 9 years of age.1,46 j5 D: r! S H/ I2 C& I" a2 K
Precocious puberty is termed as central (true) when
3 m0 G! Y+ I2 y' V& c3 {" t& ]it is caused by the premature activation of hypo-
/ o' b+ F8 q; `2 N9 ~; i8 V- d6 Mthalamic pituitary gonadal axis. CPP is more com-0 g; b! K5 L4 t" K& ^4 {$ B" V
mon in girls than in boys.1,3 Most boys with CPP* W$ E, X/ F" b3 S
may have a central nervous system lesion that is* v7 p! J `5 a
responsible for the early activation of the hypothal-" C0 I; W! c5 Y& ?1 m; j2 z) S
amic pituitary gonadal axis.1-3 Thus, greater empha-
8 W! u8 Q* c/ h3 X- X8 h2 e$ D2 qsis has been given to neuroradiologic imaging in
- o/ @) N% [3 k. B$ q7 a6 k, `boys with precocious puberty. In addition to viril-2 K: m' b! o( k; h0 ]& m" L; n/ Z
ization, the clinical hallmark of CPP is the symmet-$ ]7 w) [! a' i- d6 K$ b A( n8 L- ^
rical testicular growth secondary to stimulation by0 ~7 J' N/ {- V* Q- C
gonadotropins.1,38 ^6 A( A# i4 D; ~$ z/ {6 c! o
Gonadotropin-independent peripheral preco-
# J) d6 M5 Y% m- H1 Bcious puberty in boys also results from inappropriate+ E5 ?- h* n. x6 G" A
androgenic stimulation from either endogenous or
" `# `8 c, T2 ^exogenous sources, nonpituitary gonadotropin stim-
. C% b# c* s+ `$ i, A. y! J+ Z% aulation, and rare activating mutations.3 Virilizing5 B. c- o' G) e' |
congenital adrenal hyperplasia producing excessive* A6 G+ X! l: A) @
adrenal androgens is a common cause of precocious" w( Z4 x+ D; r: w" _( E$ P
puberty in boys.3,49 k1 P( U. Z- o& Q& Y; q$ s6 l
The most common form of congenital adrenal
" F* t! v8 ]& `/ Q7 Q8 u k. E, N( yhyperplasia is the 21-hydroxylase enzyme deficiency.0 b( [3 y6 Z1 d" X) `8 |* E) d
The 11-β hydroxylase deficiency may also result in
: X- f: t5 h- S. E9 F7 a! Yexcessive adrenal androgen production, and rarely,1 t& h8 S- V3 [% }# V8 J
an adrenal tumor may also cause adrenal androgen
s. @9 y1 z& w1 [: O U& v9 E; aexcess.1,3
2 e7 G0 \" k9 O# Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
$ \! n3 G8 T4 N! t! x1 m542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
$ I- d' w1 Q: a$ q( HA unique entity of male-limited gonadotropin-* E3 t. m% S4 B
independent precocious puberty, which is also known1 v% l2 I( Z5 f) x7 P' C
as testotoxicosis, may cause precocious puberty at a/ e5 d4 o2 u9 r# C& o" C' h1 q
very young age. The physical findings in these boys/ z0 k1 X2 W6 S! S
with this disorder are full pubertal development,/ G( k' Y+ {5 D9 N0 b
including bilateral testicular growth, similar to boys9 F6 |0 C9 n: W* a) d' l, L
with CPP. The gonadotropin levels in this disorder
- v3 t! Q6 E+ K; t- lare suppressed to prepubertal levels and do not show0 Q( U" T, M; `3 Q
pubertal response of gonadotropin after gonadotropin-
8 F9 K$ X+ B) l: Z+ @& |releasing hormone stimulation. This is a sex-linked) ?. L3 R7 l" M
autosomal dominant disorder that affects only
l( G$ S j1 b5 ]2 E& X4 Ymales; therefore, other male members of the family
" j: I, o; T u1 pmay have similar precocious puberty.31 d1 E, m# m1 f- X% K4 [; G
In our patient, physical examination was incon-
" d0 u: x s+ T0 R' q. osistent with true precocious puberty since his testi-
9 K* b( U, |; V3 P! P- ~cles were prepubertal in size. However, testotoxicosis
H2 }8 ]6 e6 Wwas in the differential diagnosis because his father- s1 G' _: |* N6 n4 e" J
started puberty somewhat early, and occasionally,
3 I3 n* ~# g9 i5 ^1 qtesticular enlargement is not that evident in the8 S% |" M U8 [; t- X4 r ?# q
beginning of this process.1 In the absence of a neg-
' F& ? ?& k) ^$ a& pative initial history of androgen exposure, our, f3 m; v, R& R; S0 C6 V: Z
biggest concern was virilizing adrenal hyperplasia,
) M% w; D9 p; W$ l, yeither 21-hydroxylase deficiency or 11-β hydroxylase8 @* O3 j+ s4 x3 R7 Q/ b
deficiency. Those diagnoses were excluded by find-
5 O R6 ?- w* Q% T" ging the normal level of adrenal steroids.4 Z2 e7 g! w$ c$ ~- K' `
The diagnosis of exogenous androgens was strongly/ [9 T" {, G0 z$ m
suspected in a follow-up visit after 4 months because& B9 K! R! ~) n- X3 p& K) s
the physical examination revealed the complete disap-) R$ s8 S) o8 N# X
pearance of pubic hair, normal growth velocity, and
0 {( M# A' A) C ^; d2 G" |9 Cdecreased erections. The father admitted using a testos-
- T' k' q! o- F. e& dterone gel, which he concealed at first visit. He was
7 V9 f; X) ?4 u( E3 \* @3 tusing it rather frequently, twice a day. The Physicians’
3 ?% H- ~$ h5 f- c$ E7 xDesk Reference, or package insert of this product, gel or
& F C; j9 g1 ?0 E* L6 x. z! Acream, cautions about dermal testosterone transfer to
e7 a$ t7 m+ G# I O9 [$ iunprotected females through direct skin exposure.
& @7 U( H2 T( x" fSerum testosterone level was found to be 2 times the9 K- f5 m1 I2 Q0 e
baseline value in those females who were exposed to' M6 V6 b" ] t7 v
even 15 minutes of direct skin contact with their male5 J7 D) r4 b: i5 z$ {2 o
partners.6 However, when a shirt covered the applica-: t" F( S& A8 ?) D3 w+ D% ~
tion site, this testosterone transfer was prevented.+ k5 K4 v" u" Q# D8 c5 u# c& u
Our patient’s testosterone level was 60 ng/mL,% p* D+ G8 r9 y
which was clearly high. Some studies suggest that
4 r$ C1 C2 F, V h) kdermal conversion of testosterone to dihydrotestos-$ U) j3 G$ `; o2 f8 x
terone, which is a more potent metabolite, is more/ D; s; L7 H8 V9 a w7 t: i
active in young children exposed to testosterone
& b' a- {1 A% i* Jexogenously7; however, we did not measure a dihy-7 F9 j) v1 G- N' V+ u
drotestosterone level in our patient. In addition to/ V- h! ]$ ]1 r! z, x
virilization, exposure to exogenous testosterone in
: Q* m8 o, O9 C& O: O% D4 |children results in an increase in growth velocity and) o: o* d2 M, e, J
advanced bone age, as seen in our patient.: p: @: `% H7 ]% n
The long-term effect of androgen exposure during
i9 h$ D Z- r8 \& Dearly childhood on pubertal development and final, ] [2 }: u9 f+ | m \
adult height are not fully known and always remain
( U: X' V X2 c% da concern. Children treated with short-term testos-3 ]% A. g7 K7 L$ v: W: H
terone injection or topical androgen may exhibit some
* a" ?- q8 A6 R: H$ ]acceleration of the skeletal maturation; however, after- Z; a+ n( ]3 c' S+ l9 s
cessation of treatment, the rate of bone maturation
V) m+ y+ C6 ~! Jdecelerates and gradually returns to normal.8,92 `. ]4 ^* R; l% k
There are conflicting reports and controversy
! n. n3 c6 d$ b# N, N, j$ ?( u8 Fover the effect of early androgen exposure on adult
/ Y: R; D) Q1 k! m4 Z) d$ Xpenile length.10,11 Some reports suggest subnormal
) ]- g0 J! u9 a$ W- ]3 e. zadult penile length, apparently because of downreg-* `! e3 u5 U7 E
ulation of androgen receptor number.10,12 However,
; y* {2 G7 u1 i9 p' P" g$ X5 JSutherland et al13 did not find a correlation between( t+ @, T8 A; F5 O/ v% t6 ^
childhood testosterone exposure and reduced adult
* v0 E/ \& s, Y3 npenile length in clinical studies.
- l5 Q0 b8 z0 m& Y0 O0 ?7 mNonetheless, we do not believe our patient is
4 t9 N) x6 j8 Hgoing to experience any of the untoward effects from
`& _7 Q- T$ ^! y& @; x: D' @! k, stestosterone exposure as mentioned earlier because3 O$ m& H3 I$ H. q Z6 f% L
the exposure was not for a prolonged period of time.2 h. k9 f2 _; j; }
Although the bone age was advanced at the time of
2 g4 V7 D2 E" Q( ?, H+ s# @& V1 ndiagnosis, the child had a normal growth velocity at
9 v% l9 ^ W; Vthe follow-up visit. It is hoped that his final adult
) G! k& V9 T1 W1 Fheight will not be affected.( @; S& v# P8 X' O2 O4 P4 X
Although rarely reported, the widespread avail-
C: c7 B6 v6 l; z/ }! kability of androgen products in our society may; G5 O8 k6 W* X% H$ l" R8 b
indeed cause more virilization in male or female' E* a7 N# z2 L3 F4 \5 _" ~
children than one would realize. Exposure to andro-) R# h. [( b; o6 Y
gen products must be considered and specific ques-5 @. h! i# G% W4 s5 b& L
tioning about the use of a testosterone product or: j$ {% |# o( r1 F3 z
gel should be asked of the family members during6 f6 ]+ M0 \- o4 A( a6 Y6 Q
the evaluation of any children who present with vir-8 K1 i6 _: ^$ Z# }
ilization or peripheral precocious puberty. The diag-8 T# g$ ]( G" L( p- [5 Q* t) ]
nosis can be established by just a few tests and by
D/ A; t2 v7 X4 a* {appropriate history. The inability to obtain such a+ c; U6 k. i- t. A2 Z
history, or failure to ask the specific questions, may2 k' i: g% m* ]
result in extensive, unnecessary, and expensive1 f, K9 q0 s% \( ]$ n1 J
investigation. The primary care physician should be: q0 U& A6 N- k3 e2 H4 U
aware of this fact, because most of these children
: Z% l! L& t) I* e1 D: Bmay initially present in their practice. The Physicians’
3 p: Z, l* ]! d; o" eDesk Reference and package insert should also put a
* u1 V7 F6 w3 ]! @. awarning about the virilizing effect on a male or; _# S& k/ e7 }' ^; m
female child who might come in contact with some-6 p+ l5 g5 }! {8 h9 e" x
one using any of these products. P7 K1 y! }4 d- ^, L* _
References
3 q* }# n1 p R, J% f1. Styne DM. The testes: disorder of sexual differentiation
$ O, u' ]9 _" g- \and puberty in the male. In: Sperling MA, ed. Pediatric
" S* q" R" S- E+ DEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( S8 X: F- l1 } m2 C) F) X
2002: 565-628.
- H& i4 F! E9 E8 ~. r% ]; ?2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
( }) G7 D# E. H% hpuberty in children with tumours of the suprasellar pineal |
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