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Sexual Precocity in a 16-Month-Old5 i7 s# T+ U6 d
Boy Induced by Indirect Topical4 a. {0 p& U/ h
Exposure to Testosterone
2 `* D4 K; Z4 r5 lSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
: J5 G/ s& s4 Uand Kenneth R. Rettig, MD15 ?( y: h: O s7 Z
Clinical Pediatrics
1 \( O) y# S7 [& g5 r+ \4 d) IVolume 46 Number 6
( ]( h- a& I; CJuly 2007 540-543
. K, U- F4 b3 Q: a* ^3 M/ ^* N© 2007 Sage Publications6 g r4 q; l% z. v$ r, I$ r
10.1177/0009922806296651
3 `, z, k/ K* O! _0 n1 b# Rhttp://clp.sagepub.com. F1 C* Q9 n8 z* M9 q% ]
hosted at7 [2 D v! h1 n. w' y- i
http://online.sagepub.com9 p4 `% ]0 r' u" F7 U: Z3 Y
Precocious puberty in boys, central or peripheral,
, l9 ]1 [. X- ^/ z3 g% ^is a significant concern for physicians. Central
0 |0 W8 x" Q, e$ Aprecocious puberty (CPP), which is mediated
/ _8 j5 C; \& @+ L& _+ Cthrough the hypothalamic pituitary gonadal axis, has5 e/ k$ T7 Y9 n- i5 {
a higher incidence of organic central nervous system$ [: g# z9 Q4 Y/ ~! I: s M
lesions in boys.1,2 Virilization in boys, as manifested
8 }2 W% Z$ g6 }/ hby enlargement of the penis, development of pubic
' y* z+ ?9 g) T) ^, i5 j5 o: ghair, and facial acne without enlargement of testi-
% [- I. ?/ b0 W- ocles, suggests peripheral or pseudopuberty.1-3 We
, K3 P- _! Y+ _" V" \1 Nreport a 16-month-old boy who presented with the
; Z5 p0 y6 _; [! b+ uenlargement of the phallus and pubic hair develop-1 J0 O6 N/ L O; x7 |+ ?3 x
ment without testicular enlargement, which was due p3 P1 r5 R0 `) L2 V
to the unintentional exposure to androgen gel used by
! n% S9 _0 S7 {the father. The family initially concealed this infor-2 [2 j; F7 Q2 F1 h
mation, resulting in an extensive work-up for this
4 t7 u/ w ^8 H$ g* G6 z6 achild. Given the widespread and easy availability of
$ ]/ v# q7 |8 l2 R) P! ftestosterone gel and cream, we believe this is proba-
4 G5 P! V+ i* Ybly more common than the rare case report in the5 b$ a& T& x" n1 J- d1 S$ _
literature.4
/ z& h! }: W/ H; P1 m; oPatient Report
( v. o/ A; B X, \& h! GA 16-month-old white child was referred to the
1 C0 D- b5 i; L: ~0 D: r. Oendocrine clinic by his pediatrician with the concern6 x& L, ?, }5 p! A/ G$ B
of early sexual development. His mother noticed
' M# p7 X" e3 slight colored pubic hair development when he was' V8 l) O e* B7 ?9 a" n
From the 1Division of Pediatric Endocrinology, 2University of6 p A+ B6 O+ ]5 s% O7 B% p
South Alabama Medical Center, Mobile, Alabama.7 D. E9 z: Q+ u/ A6 U6 }
Address correspondence to: Samar K. Bhowmick, MD, FACE,3 q) Z! t( X( d3 ^
Professor of Pediatrics, University of South Alabama, College of; E9 F; [ }. d- ?
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 v0 b9 E8 b. ~! p c/ H: }' ~4 ^( Oe-mail: [email protected]." O( }2 A& v( s3 N
about 6 to 7 months old, which progressively became4 Z- P0 @+ C$ q9 ]& o
darker. She was also concerned about the enlarge-* s& v) L+ c# a9 h
ment of his penis and frequent erections. The child
3 Z: U& }# B5 A1 Jwas the product of a full-term normal delivery, with
- p& R0 I! y0 u# P( I D" La birth weight of 7 lb 14 oz, and birth length of* ?& D2 M( n# [8 \7 |+ P
20 inches. He was breast-fed throughout the first year4 `, \2 W4 z1 o
of life and was still receiving breast milk along with
5 m, P0 W' V: [+ G, k5 H& Lsolid food. He had no hospitalizations or surgery,( Z: S: P9 D0 g ^
and his psychosocial and psychomotor development
! g4 u3 r6 y* c7 ?was age appropriate., W# E% {4 R: l1 F7 @7 ~
The family history was remarkable for the father,) ^7 V' }1 M' B) v
who was diagnosed with hypothyroidism at age 16,- c( S# ^. e2 ?3 _7 J
which was treated with thyroxine. The father’s9 X( i# Y3 s2 E' [9 K' A# c4 i
height was 6 feet, and he went through a somewhat+ Q5 v' q& V/ P% x
early puberty and had stopped growing by age 14.
( k, |4 ~* o5 z0 e5 Y2 [$ mThe father denied taking any other medication. The; z# a0 y: E# U
child’s mother was in good health. Her menarche
/ b5 r# Z t3 q. d# a4 q1 I9 ?was at 11 years of age, and her height was at 5 feet8 a$ E2 r& m* w9 j. g
5 inches. There was no other family history of pre-
8 H0 p) t+ l# `' |/ ?% N. M% {cocious sexual development in the first-degree rela-; }5 }3 ^* w0 s+ ?' Q. z% R; `& ?* ?
tives. There were no siblings.
2 Y& B# ^! B* C5 z( H: mPhysical Examination
. c7 p" B! @6 b3 I! j+ Q; cThe physical examination revealed a very active,
% W- Z. F6 h% K; eplayful, and healthy boy. The vital signs documented" y: F, u- m0 n) D* S! q) F5 Y7 y
a blood pressure of 85/50 mm Hg, his length was
7 a' m$ y& U9 | x90 cm (>97th percentile), and his weight was 14.4 kg
7 E2 G {& K9 `(also >97th percentile). The observed yearly growth9 F" S# }) I. D% p" A3 w* O
velocity was 30 cm (12 inches). The examination of
4 s3 }; [# H4 @the neck revealed no thyroid enlargement." P; I4 M0 e4 h0 W3 d
The genitourinary examination was remarkable for6 h x6 n1 w- v s- _/ ~
enlargement of the penis, with a stretched length of
6 Y+ M1 w; Y; ~& J' u8 cm and a width of 2 cm. The glans penis was very well
" {' {, s, J4 _developed. The pubic hair was Tanner II, mostly around
1 O/ u5 w+ N& c. C: z, U5408 L6 K( r! ^4 }( s$ |
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) E# f' {3 ?4 i$ Kthe base of the phallus and was dark and curled. The
0 F# h: C! e; g3 w! Y! R w4 Ztesticular volume was prepubertal at 2 mL each.
& j' B5 O5 c Z T- X |The skin was moist and smooth and somewhat
B% f3 ~5 h- [0 v3 K) goily. No axillary hair was noted. There were no# {& |) n" v" i& r' ~9 Q! P
abnormal skin pigmentations or café-au-lait spots.
- W5 p. k0 E. k+ F6 F' t8 b7 jNeurologic evaluation showed deep tendon reflex 2+1 o) Z3 O' p9 F" U C
bilateral and symmetrical. There was no suggestion `9 j9 B( e7 E! m4 _; ?; T
of papilledema.% K, E' _% Y0 k/ p
Laboratory Evaluation. o( D L' W& N% w
The bone age was consistent with 28 months by3 o1 \6 m# U _7 R) `4 H
using the standard of Greulich and Pyle at a chrono-
5 v8 G' ^9 e7 H# ], x, M- P. {/ V9 m# R4 Rlogic age of 16 months (advanced).5 Chromosomal
* z% d+ ]) w/ F9 \2 i$ dkaryotype was 46XY. The thyroid function test
% d1 s r, V6 q% @' n: eshowed a free T4 of 1.69 ng/dL, and thyroid stimu-3 S& _0 z! Q- b# S7 ?
lating hormone level was 1.3 µIU/mL (both normal).+ p; {6 e. o ]$ G
The concentrations of serum electrolytes, blood
( Q9 {" R9 U7 Y4 d% yurea nitrogen, creatinine, and calcium all were
: N. f# F& C8 n) p8 Cwithin normal range for his age. The concentration
}, ^. A. ]# r6 Dof serum 17-hydroxyprogesterone was 16 ng/dL
" c% V" X! C6 v5 l(normal, 3 to 90 ng/dL), androstenedione was 20: Y) `6 b* L3 B6 w
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-: Q* Z1 y& U7 p1 F
terone was 38 ng/dL (normal, 50 to 760 ng/dL), M6 R% f" P8 q' d9 G
desoxycorticosterone was 4.3 ng/dL (normal, 7 to( W$ f4 ~5 ~( `9 L
49ng/dL), 11-desoxycortisol (specific compound S)3 w8 |5 |3 X' T
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
. I: L/ B3 ]1 u7 e0 L1 [* Q! vtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total7 \& Z5 j6 @( Z( { r
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),& x3 A* J3 w. F2 t0 W- N
and β-human chorionic gonadotropin was less than
" h: N9 v/ M( f8 b6 V1 t7 i5 mIU/mL (normal <5 mIU/mL). Serum follicular
6 G p, g0 @+ J7 n6 astimulating hormone and leuteinizing hormone
0 I" B8 R" u+ ]. W( l7 H1 gconcentrations were less than 0.05 mIU/mL$ d6 n+ `5 e. u: H% o
(prepubertal).( t8 J/ W9 R5 e6 i2 A
The parents were notified about the laboratory. \1 M4 K K3 `: c/ z, K8 h W
results and were informed that all of the tests were
2 V5 E H7 g+ n# w1 U( C$ hnormal except the testosterone level was high. The! J5 A9 A s; r6 n- W1 P5 q7 d- u
follow-up visit was arranged within a few weeks to
5 H4 ~; U o# \: F% j1 eobtain testicular and abdominal sonograms; how-
! d6 a# q4 D1 }$ ?8 dever, the family did not return for 4 months.7 ~9 C! i3 h# B% l4 ~1 z" v
Physical examination at this time revealed that the2 y2 F2 K* u/ n3 `
child had grown 2.5 cm in 4 months and had gained3 ^) j8 s# t- t$ n
2 kg of weight. Physical examination remained
" x7 q D8 w# i, l4 T/ ~8 G6 hunchanged. Surprisingly, the pubic hair almost com-
4 s9 Y1 U* v1 c4 Mpletely disappeared except for a few vellous hairs at
8 z0 J1 o; W t3 H8 x/ @0 Athe base of the phallus. Testicular volume was still 2
5 r8 z" ]5 e. y. UmL, and the size of the penis remained unchanged.4 ]: S1 Q4 C: P. N' ?
The mother also said that the boy was no longer hav-
F$ c4 W. Q+ Aing frequent erections./ g% Q9 X; P8 d( h
Both parents were again questioned about use of
0 w$ H3 T0 q/ f# c8 [+ R5 nany ointment/creams that they may have applied to
" R3 T" U7 M6 i! Sthe child’s skin. This time the father admitted the
: @& Y6 v5 l5 D( J) S$ S3 vTopical Testosterone Exposure / Bhowmick et al 5412 o1 f" y7 O2 U/ o9 B4 D
use of testosterone gel twice daily that he was apply-
; a+ Y& r2 @, v4 d3 T2 ^ing over his own shoulders, chest, and back area for; D1 Y: h1 g; t/ @
a year. The father also revealed he was embarrassed
4 e+ c: u- U3 z h) c+ X( ]% _to disclose that he was using a testosterone gel pre-: E9 o) \# I8 U- j) y8 |& w1 I
scribed by his family physician for decreased libido
( B6 h' E( @, k: B( Osecondary to depression.
# o" D/ d* g" Z' X6 ~) W; b0 S1 ?The child slept in the same bed with parents.
! V x8 ?5 H% u; t4 T) I: i$ K& zThe father would hug the baby and hold him on his5 M9 u' G2 u* w# I g$ C, h
chest for a considerable period of time, causing sig-; [- o/ K6 {. n9 P2 q- V
nificant bare skin contact between baby and father., B; \$ {1 }) Z2 t
The father also admitted that after the phone call,
, m. _0 D6 {9 ]& L/ Gwhen he learned the testosterone level in the baby4 S9 r* _; L' P% M7 h' a
was high, he then read the product information
# w% d8 g6 j: ?; N+ opacket and concluded that it was most likely the rea-
9 [, d' q" s, d3 U% ^4 W3 @son for the child’s virilization. At that time, they
6 K3 |9 m' _7 T: Zdecided to put the baby in a separate bed, and the
- Q+ z V1 _0 ]7 o& t( mfather was not hugging him with bare skin and had: R2 j9 T% c, r; x
been using protective clothing. A repeat testosterone
; |$ }& S F0 { rtest was ordered, but the family did not go to the) E/ S1 K! a: O2 W
laboratory to obtain the test.
! a$ A5 H9 }) c5 ?- M& [9 s3 i* XDiscussion
/ C* ~4 z* E8 ePrecocious puberty in boys is defined as secondary5 u, q+ H- q6 y, h9 c* E
sexual development before 9 years of age.1,4
" i6 D# E7 b: Y6 K% ^Precocious puberty is termed as central (true) when
2 d' @: _5 p2 u: ]8 _ [% r. d- mit is caused by the premature activation of hypo-5 h7 x& L9 b( o. X& i( W( B$ m
thalamic pituitary gonadal axis. CPP is more com-! f# ~5 }; I$ H" k7 S3 O9 Z4 a9 s5 L
mon in girls than in boys.1,3 Most boys with CPP
, L3 L7 U% Q- K% \may have a central nervous system lesion that is
) N8 E1 ~9 r8 u7 ^: b% |5 ~responsible for the early activation of the hypothal-, q; X8 M/ a- M+ H3 _
amic pituitary gonadal axis.1-3 Thus, greater empha-
7 y" |( h6 U6 e# K6 hsis has been given to neuroradiologic imaging in
* E& c% X1 _6 O& T1 Wboys with precocious puberty. In addition to viril-$ j5 u( t5 G, P: W
ization, the clinical hallmark of CPP is the symmet-
/ C5 d. w+ v0 s; q1 r* Brical testicular growth secondary to stimulation by
' ^) E4 Q, l" h! l( E* {7 Bgonadotropins.1,3( w7 U9 u' _8 Q2 S, `3 }9 c
Gonadotropin-independent peripheral preco-
4 X, S! b5 a+ C0 ^- H& Y2 gcious puberty in boys also results from inappropriate
5 i. {4 o5 w& a8 P' ]androgenic stimulation from either endogenous or
/ u5 q7 l" U' Z* j) Vexogenous sources, nonpituitary gonadotropin stim-
! A$ \# {. \" k0 S" o# @ulation, and rare activating mutations.3 Virilizing
# S7 h. |: R/ J7 ~ Fcongenital adrenal hyperplasia producing excessive
0 i5 n, @3 \9 W; T* L6 ~adrenal androgens is a common cause of precocious' D- L/ A" ]0 U, S, o7 k
puberty in boys.3,4
" R& e/ z1 ]/ ?" F+ BThe most common form of congenital adrenal
, n7 P; {- V; W8 o. x5 vhyperplasia is the 21-hydroxylase enzyme deficiency., j& W2 Q4 h% [
The 11-β hydroxylase deficiency may also result in/ q( l1 F: u$ ^- x
excessive adrenal androgen production, and rarely,1 h2 g; h. E# Y1 T' S) a2 h
an adrenal tumor may also cause adrenal androgen+ S! C$ ~6 G9 d
excess.1,32 x* n9 s, f0 j( D3 R6 Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
' |% m* E* _2 |/ v1 Q/ x. T542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
1 |) v7 g% S, |! `) AA unique entity of male-limited gonadotropin-
( J% z3 C# Y' z0 ]# i2 t+ lindependent precocious puberty, which is also known- L% G# b) i U# y5 \7 w/ |
as testotoxicosis, may cause precocious puberty at a
1 g5 n" Z: N3 O1 Ivery young age. The physical findings in these boys
2 Y+ ]) F/ y- k& Cwith this disorder are full pubertal development,. U% T; v- `8 y9 u8 [. u4 U) v; V+ E8 J
including bilateral testicular growth, similar to boys
6 m7 m% @5 `$ ~/ z: ~, uwith CPP. The gonadotropin levels in this disorder
' D9 b. R1 I1 r" Q9 Rare suppressed to prepubertal levels and do not show1 X3 e0 H+ x, d& T* T+ R9 B
pubertal response of gonadotropin after gonadotropin-
4 u8 t# T+ A- H2 jreleasing hormone stimulation. This is a sex-linked
( ] ^: D% ~& P/ Nautosomal dominant disorder that affects only
% C' Q7 I6 q7 L( Ymales; therefore, other male members of the family7 ]* a/ q4 \& Y( c
may have similar precocious puberty.3- W- ^+ K( j! c U3 y% t% `
In our patient, physical examination was incon-
! M/ c1 q% e8 y" m( b0 z ksistent with true precocious puberty since his testi-/ C0 \, p& | P; ?/ w4 w
cles were prepubertal in size. However, testotoxicosis( b! ?' M6 M/ [) J3 b
was in the differential diagnosis because his father
$ p; k' Y$ ?' q6 ]& P% mstarted puberty somewhat early, and occasionally,0 s1 v6 T7 S y7 H5 _2 O
testicular enlargement is not that evident in the- R* D+ ?3 C4 N }
beginning of this process.1 In the absence of a neg-
( T1 O2 C! ^% N7 pative initial history of androgen exposure, our8 `4 h" X0 z, V$ n+ k5 r5 c: u
biggest concern was virilizing adrenal hyperplasia,6 x ~, r8 `& i! @! V! o9 H- r/ x$ F
either 21-hydroxylase deficiency or 11-β hydroxylase% Z% m) K: H+ D3 i2 r
deficiency. Those diagnoses were excluded by find-9 Z% X7 S( }" N9 S# I, ?
ing the normal level of adrenal steroids.
# O0 K2 Q. _$ P, ]2 FThe diagnosis of exogenous androgens was strongly& o+ R+ ]5 a& y8 n
suspected in a follow-up visit after 4 months because! R& z0 a* ^! g, [
the physical examination revealed the complete disap-
M6 T4 P5 s J3 l# npearance of pubic hair, normal growth velocity, and' I5 ^: c% P# L% `7 R7 q
decreased erections. The father admitted using a testos-, P! x8 }0 G. t
terone gel, which he concealed at first visit. He was e" |" {6 ^0 c# Y* x" i
using it rather frequently, twice a day. The Physicians’. i$ N1 D ?% x5 @ \
Desk Reference, or package insert of this product, gel or
% z2 z- ]6 n1 d8 T" J7 ?8 a3 Acream, cautions about dermal testosterone transfer to* m4 S$ X& Y3 i$ J6 v
unprotected females through direct skin exposure.! f1 J5 U6 ` ]# k0 i: u7 l
Serum testosterone level was found to be 2 times the* G& _- {6 T2 J( V/ w) `
baseline value in those females who were exposed to3 I: u* D& [0 K
even 15 minutes of direct skin contact with their male! `" Q' |0 L" e! P& s8 d
partners.6 However, when a shirt covered the applica-; K) h M2 W. d2 b* U5 o/ s( n
tion site, this testosterone transfer was prevented.
1 w, Q+ n9 y2 Y5 r+ B! n2 u# pOur patient’s testosterone level was 60 ng/mL,
+ u& W$ C+ D5 L) Y3 Awhich was clearly high. Some studies suggest that
1 ?* u7 D1 A% V; U+ C. `( Rdermal conversion of testosterone to dihydrotestos-
1 ]4 |& ]# {, U( sterone, which is a more potent metabolite, is more2 ~- m# Y2 @4 o2 b: q* j0 E
active in young children exposed to testosterone) l7 M N' h6 \) ~6 y6 u( ~
exogenously7; however, we did not measure a dihy-
. M+ N* F2 t5 F+ v7 G7 j" wdrotestosterone level in our patient. In addition to* f/ e2 X+ q ~( a7 o1 @
virilization, exposure to exogenous testosterone in+ C( n) b4 s6 H
children results in an increase in growth velocity and
; m# ?( y( [( e6 D' U7 B5 O' X: d4 {; b. Oadvanced bone age, as seen in our patient.! H6 R; b& d$ @. u
The long-term effect of androgen exposure during
% ~5 r: Y* }7 L0 ^$ Y- `early childhood on pubertal development and final
7 t9 A/ G) ]9 ~% S0 |7 K, Qadult height are not fully known and always remain, w+ {2 m" T9 D4 y; }6 {* z
a concern. Children treated with short-term testos-1 r1 j. W. A7 Y; X2 G5 T) Z
terone injection or topical androgen may exhibit some1 z5 u' M, T# n
acceleration of the skeletal maturation; however, after6 C$ z* A; b+ F; C; m7 ~" q4 B
cessation of treatment, the rate of bone maturation
( _) m G3 x- i- D: \, {decelerates and gradually returns to normal.8,9+ x3 }- v4 t! F: Z [
There are conflicting reports and controversy
- j( [) Z% e0 z1 R1 fover the effect of early androgen exposure on adult
/ z, r# `. w3 [6 N' V$ D4 Gpenile length.10,11 Some reports suggest subnormal& r; s! ]' \/ p4 D
adult penile length, apparently because of downreg-
& P1 H8 P% M' b- uulation of androgen receptor number.10,12 However," `) l: K$ h( [' {! C: _9 h
Sutherland et al13 did not find a correlation between
6 c/ @6 f5 ` G* ^& I J+ ^: m5 }childhood testosterone exposure and reduced adult. P: a) {' p, h4 l- ]# }
penile length in clinical studies.
" D F' z/ W' c& v) O4 CNonetheless, we do not believe our patient is9 f0 b @2 e5 |
going to experience any of the untoward effects from
! U! @, U# g% j+ c; Y+ }& xtestosterone exposure as mentioned earlier because
/ q' G- \/ U- T9 w, N6 Ythe exposure was not for a prolonged period of time.1 q$ I5 ]# n: F2 L
Although the bone age was advanced at the time of/ r+ d% [% b( ~5 I" f% u
diagnosis, the child had a normal growth velocity at& g/ e( v7 c& v5 Y# v3 Y. F
the follow-up visit. It is hoped that his final adult
, u9 P: V' z" {0 X mheight will not be affected.6 X, V5 |1 k v9 x" l2 U X
Although rarely reported, the widespread avail-
) y1 K. A, [1 l( T4 ^9 O8 a# xability of androgen products in our society may& ~! V! B) K) F! {
indeed cause more virilization in male or female
$ ?% o- J/ S& a q/ \& n2 Schildren than one would realize. Exposure to andro-
9 y {& B. k9 I) s. ~' \, sgen products must be considered and specific ques-
( ]( ?. ^) [2 Y0 \. x/ N. {tioning about the use of a testosterone product or- ?( `8 |/ \! \7 v
gel should be asked of the family members during
1 S7 L2 a5 P% C$ Cthe evaluation of any children who present with vir-
1 ~/ ~7 v) f0 w& Q$ f# c) W& uilization or peripheral precocious puberty. The diag-2 @; e, q* S+ K" Z( K) }5 t- u4 |
nosis can be established by just a few tests and by' I3 c$ R8 | b" ]
appropriate history. The inability to obtain such a
3 b( c5 |- I# y4 jhistory, or failure to ask the specific questions, may
$ P* l. ~$ L5 h; A# W6 a% o7 p" r( @result in extensive, unnecessary, and expensive5 W- `/ q, k( u
investigation. The primary care physician should be
9 x* J8 `( G( _0 _: Uaware of this fact, because most of these children
. X" \: X0 i9 p8 ?8 ?. `. F( rmay initially present in their practice. The Physicians’. n; b' N) l. s, h4 c: Z* ~
Desk Reference and package insert should also put a
3 S4 f) u' e- F7 R* Dwarning about the virilizing effect on a male or
/ J& [/ ?1 f- x9 Q) |. xfemale child who might come in contact with some-% b3 [6 O. Y4 h% O3 m; [
one using any of these products.* p) x/ v, z! e2 L! p
References
9 F" w6 x) {& ^/ @0 L8 }4 L1. Styne DM. The testes: disorder of sexual differentiation* z7 d$ t2 T: k% R
and puberty in the male. In: Sperling MA, ed. Pediatric
9 T) {7 `' ~- p. a; b" e: KEndocrinology. 2nd ed. Philadelphia, PA: WB Saunders;. H8 u S) d4 W4 H. t
2002: 565-628./ b2 i% W7 q) i
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. J5 R# @" R+ x) V1 I' P8 M: @7 }
puberty in children with tumours of the suprasellar pineal |
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