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Sexual Precocity in a 16-Month-Old
1 N2 f; [2 @- j" pBoy Induced by Indirect Topical
4 l8 G) D6 s0 x, c0 F; MExposure to Testosterone, ^ A$ Q$ e: }" f9 u
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2. ]' ]- r. r& J7 X& B
and Kenneth R. Rettig, MD1
. s1 O; A: I+ cClinical Pediatrics4 Z4 V3 F# D9 ?
Volume 46 Number 6: w- C3 d, o8 ~% \7 u- u* g6 z. K' G
July 2007 540-543. F \3 I1 \2 ]4 P& S/ n
© 2007 Sage Publications' P- `0 ]$ F# x7 P/ u& T0 a7 f1 j% v
10.1177/0009922806296651
* A& k3 n3 S2 U7 e' Ehttp://clp.sagepub.com9 W2 v# s/ P6 h! J }5 a: `
hosted at
8 |2 E" \1 R: U1 {http://online.sagepub.com
; l% _3 H9 S9 i* P' GPrecocious puberty in boys, central or peripheral,
2 v V- X9 M: r5 D( uis a significant concern for physicians. Central2 A+ t# s5 R: p M; p
precocious puberty (CPP), which is mediated# S; }' X, y! i; Q/ z
through the hypothalamic pituitary gonadal axis, has t. w, C: L! R: f( A
a higher incidence of organic central nervous system# U g& b9 H7 z+ m% F: k
lesions in boys.1,2 Virilization in boys, as manifested/ L8 T2 Y- `$ S6 q9 j
by enlargement of the penis, development of pubic
! ^6 y l$ V' x: ahair, and facial acne without enlargement of testi-
5 s* H: B/ K1 A) w" Q$ vcles, suggests peripheral or pseudopuberty.1-3 We
- s4 h+ [2 V3 I6 j& F$ l: Lreport a 16-month-old boy who presented with the
) k4 U. V8 p; o9 benlargement of the phallus and pubic hair develop-" f- U7 j: W4 }9 u0 p% h1 p
ment without testicular enlargement, which was due) J# b3 T2 E# z5 M6 X
to the unintentional exposure to androgen gel used by7 i, b k( @( h: T7 y' b
the father. The family initially concealed this infor-
5 M: W6 g5 ]6 [- w+ wmation, resulting in an extensive work-up for this
& O" t3 D3 ]4 s6 W6 }( s. [9 Pchild. Given the widespread and easy availability of1 i9 `& f+ @+ x% u% S! i
testosterone gel and cream, we believe this is proba-* [# R$ T3 a5 x) ?
bly more common than the rare case report in the, r& Y9 r u2 Z) C w5 T
literature.4
T4 U8 h+ ~$ ~2 f; ]Patient Report' ]% W+ J! D6 m( c
A 16-month-old white child was referred to the( ]0 y, W7 h: k( c/ Q. V. L: q
endocrine clinic by his pediatrician with the concern F, Z: X' k7 k. T9 o" M4 l
of early sexual development. His mother noticed6 e% A2 E- D! \* C" h; y
light colored pubic hair development when he was
" r; @9 C! g7 G$ {/ ]From the 1Division of Pediatric Endocrinology, 2University of, E5 E6 t4 ]9 A, R; B# }
South Alabama Medical Center, Mobile, Alabama.
1 J4 Q' Y; G4 F rAddress correspondence to: Samar K. Bhowmick, MD, FACE," H* f% u+ ^% O2 Q5 [, @7 u
Professor of Pediatrics, University of South Alabama, College of3 U2 t) c. ~) R+ P! v
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;' B' x; a, s5 K4 c
e-mail: [email protected].
* b, \5 d4 H- @9 vabout 6 to 7 months old, which progressively became
: `2 ~) W7 [3 R7 S( g8 Vdarker. She was also concerned about the enlarge-
$ |$ ]1 C0 A+ N0 k( [ment of his penis and frequent erections. The child3 }. j0 |# E7 b
was the product of a full-term normal delivery, with
% w; C- L" D( w$ s) d$ ]3 za birth weight of 7 lb 14 oz, and birth length of
& f1 D8 W( v0 q& F) `! }20 inches. He was breast-fed throughout the first year3 h2 i l( c9 k; `6 k' Z$ X
of life and was still receiving breast milk along with7 V- O" f1 X! Y G" n2 q
solid food. He had no hospitalizations or surgery," _; C8 n% H4 N8 s8 S
and his psychosocial and psychomotor development
6 {. T, H4 }5 K3 `: \6 r! D. Qwas age appropriate.
/ R( v7 z8 s2 j- DThe family history was remarkable for the father,9 w3 U1 R1 _* N5 S- J; X
who was diagnosed with hypothyroidism at age 16,( H% q6 v& j/ E$ v
which was treated with thyroxine. The father’s
9 c4 ~% }2 ~- i# r! `height was 6 feet, and he went through a somewhat9 U9 c( S3 W% ^3 R! j8 y9 m
early puberty and had stopped growing by age 14.
" ~3 R1 c# A& O D) m2 ^ Y2 aThe father denied taking any other medication. The
- N& C4 m/ \& U, f* Uchild’s mother was in good health. Her menarche
) ^% A# n) g% ]$ v! rwas at 11 years of age, and her height was at 5 feet
2 L, _4 `& z O# x0 a" L5 inches. There was no other family history of pre-
8 u4 b3 p! `3 l& A. J5 `# ?/ qcocious sexual development in the first-degree rela-7 A# p5 W1 ]' Y/ F6 ?) y
tives. There were no siblings.0 e8 i- W. K! w( g0 s1 k# c8 L
Physical Examination
# P4 n6 m; V5 W+ i+ d- cThe physical examination revealed a very active,
* v" k) K) t6 W8 I. p1 ` Aplayful, and healthy boy. The vital signs documented, O+ ?% V+ s/ a* K) |
a blood pressure of 85/50 mm Hg, his length was' N* k" \ e) ^/ [; S3 T% M
90 cm (>97th percentile), and his weight was 14.4 kg5 x: y1 U0 X# H0 W/ N9 Q% u
(also >97th percentile). The observed yearly growth
# J6 K* ^# c, V! t( g5 V# |+ cvelocity was 30 cm (12 inches). The examination of
3 g0 j4 m. f4 t& L: Lthe neck revealed no thyroid enlargement.
) n/ U" ?/ h, eThe genitourinary examination was remarkable for( M* u" N% K$ M ~
enlargement of the penis, with a stretched length of
+ g6 s G9 E/ m- H2 m3 e0 _# r8 cm and a width of 2 cm. The glans penis was very well0 G0 F$ V! u Z2 h; X* v
developed. The pubic hair was Tanner II, mostly around& l" i! D1 a, m( K, b
540) m" l1 y* v' ], q3 h
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
" f+ T x2 K! `) h3 |( S9 Zthe base of the phallus and was dark and curled. The
2 ^# ~- ?; d5 T* dtesticular volume was prepubertal at 2 mL each.
\) Z, |2 A( N4 ^- L% OThe skin was moist and smooth and somewhat
6 D; ` t5 ~* a2 e7 C) _/ l) Toily. No axillary hair was noted. There were no
& i# c8 p2 [) }" ]0 uabnormal skin pigmentations or café-au-lait spots.3 G4 F7 g- ^6 l
Neurologic evaluation showed deep tendon reflex 2+6 t. p! r9 q, f' R$ {: U. p9 K# H
bilateral and symmetrical. There was no suggestion
' e2 q2 a& k- q7 f; n$ rof papilledema.
/ {" u0 T1 s3 J1 oLaboratory Evaluation
) z' i! M, X2 uThe bone age was consistent with 28 months by
! H& ? `' g& |& i# wusing the standard of Greulich and Pyle at a chrono-
9 g& t5 c P$ p1 F2 y. Vlogic age of 16 months (advanced).5 Chromosomal `0 v" d- p( g& ~
karyotype was 46XY. The thyroid function test: l5 N3 \" n* B- ~
showed a free T4 of 1.69 ng/dL, and thyroid stimu-" w' I' R3 q( g# E- u
lating hormone level was 1.3 µIU/mL (both normal).
8 e) ]& @) t& A: ~$ o: HThe concentrations of serum electrolytes, blood8 v5 w/ z" Q( V0 g, D
urea nitrogen, creatinine, and calcium all were
3 D3 o: A) Z" ~ u' [" \8 P+ Dwithin normal range for his age. The concentration
5 c. }0 [! |: Vof serum 17-hydroxyprogesterone was 16 ng/dL
9 z) M2 S* ?+ V+ A; ?- p2 A1 Y( P(normal, 3 to 90 ng/dL), androstenedione was 204 V0 {$ t, J) K
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
! t# j3 F9 G. I4 V, B9 {1 z5 Bterone was 38 ng/dL (normal, 50 to 760 ng/dL),
' ~9 }2 D8 z% L6 }: kdesoxycorticosterone was 4.3 ng/dL (normal, 7 to; N+ j6 O- b; N3 u9 X! M. C
49ng/dL), 11-desoxycortisol (specific compound S)) p x$ p, q' J- H8 N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 I l+ N F% w# U4 v+ _
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
/ f2 T: g# t5 itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ P0 L$ \; L* h: f- j w$ f) u& |4 d, d s
and β-human chorionic gonadotropin was less than' C" `: Y* ^1 V
5 mIU/mL (normal <5 mIU/mL). Serum follicular6 R' W2 H5 N: r4 ?' e3 E* c
stimulating hormone and leuteinizing hormone- {4 k: k* N5 {+ U2 D8 g4 U4 ?
concentrations were less than 0.05 mIU/mL2 I9 X( ?0 s) I$ U
(prepubertal).7 j- j# T- B, O0 F2 P1 z
The parents were notified about the laboratory+ b/ _+ ?) F/ A* N2 b7 j& z7 k
results and were informed that all of the tests were- \! X& o, j. s
normal except the testosterone level was high. The, L. k+ s% b- H S; e! c, r9 @
follow-up visit was arranged within a few weeks to# i3 a- \/ @- u8 W) W3 \
obtain testicular and abdominal sonograms; how-$ z: ?( q3 [7 f6 ?
ever, the family did not return for 4 months.: }$ `# k; r! T! E
Physical examination at this time revealed that the! O: E9 T' W1 |- J: f% s \& C
child had grown 2.5 cm in 4 months and had gained
4 R4 j% {) [& ]# t. t% k2 kg of weight. Physical examination remained
$ ?# ]5 {; r4 i" V$ D# @' o) Hunchanged. Surprisingly, the pubic hair almost com-
6 d1 H0 k6 ]3 Q$ V2 Y. ^# ^8 qpletely disappeared except for a few vellous hairs at% U1 a, ~1 ?' V l* k2 R4 r
the base of the phallus. Testicular volume was still 2
5 w- W9 n: T( n+ n) E1 }mL, and the size of the penis remained unchanged.' T6 h, \' j/ L. z+ ?
The mother also said that the boy was no longer hav-
; C2 e& E6 h! a: ^* jing frequent erections.
+ K6 `( S7 j: w( ~9 _' L% n7 S3 p2 TBoth parents were again questioned about use of9 F7 _9 m- r( f& P9 _
any ointment/creams that they may have applied to1 j1 k8 Y' ~! K3 z/ Y$ d
the child’s skin. This time the father admitted the0 @+ b5 I( b/ _, y. ~! E$ J; L x
Topical Testosterone Exposure / Bhowmick et al 541$ x1 A: t) a6 h: } [' J# z
use of testosterone gel twice daily that he was apply-* C- a4 x w9 n3 S/ b
ing over his own shoulders, chest, and back area for$ u+ v; Q8 f7 \+ j
a year. The father also revealed he was embarrassed
; `' u" ~5 L7 W7 n% bto disclose that he was using a testosterone gel pre-
6 `3 `# M$ G4 i3 ^5 G5 U6 qscribed by his family physician for decreased libido
3 S, i9 G- z) R ~1 Q, Ksecondary to depression.
5 @0 y9 Y7 E. K) `The child slept in the same bed with parents.% k" F" v) L' _; _
The father would hug the baby and hold him on his5 W$ h0 O6 l8 c \' V3 B
chest for a considerable period of time, causing sig-
! L2 x% {5 P( ?0 j1 ?$ Jnificant bare skin contact between baby and father.0 q: n0 y7 d! H& l& K5 c% E
The father also admitted that after the phone call,
1 V* u% Y) V, ~ |when he learned the testosterone level in the baby( o) W4 [# g; `1 H2 C* L9 K
was high, he then read the product information* z5 R. e& E4 j/ V* _0 l
packet and concluded that it was most likely the rea-
# Z d0 F: @5 n1 |9 B* z L7 wson for the child’s virilization. At that time, they' k4 q8 R" K6 Y, F$ b) ^) z
decided to put the baby in a separate bed, and the& O2 l' F( d1 @! g! q
father was not hugging him with bare skin and had
1 e8 |5 H1 j6 |" l, @2 b) sbeen using protective clothing. A repeat testosterone
! V* Z: g* t, K. dtest was ordered, but the family did not go to the" e. Q1 {1 b# ~
laboratory to obtain the test.
4 L- w$ A8 @ K1 U3 CDiscussion
% [, x% z% v( x0 k8 l) i2 }Precocious puberty in boys is defined as secondary
2 _' E" g) W0 D. k: vsexual development before 9 years of age.1,4$ }% x9 B2 O9 P
Precocious puberty is termed as central (true) when3 x, B. |& R1 E3 D6 D
it is caused by the premature activation of hypo-9 e" I+ P" y& J# c
thalamic pituitary gonadal axis. CPP is more com-
6 Q9 s0 G! M( `/ n0 P4 }5 _& Rmon in girls than in boys.1,3 Most boys with CPP3 L x4 Q9 ^+ U; F& j' l* U
may have a central nervous system lesion that is
# n* X8 s) L% uresponsible for the early activation of the hypothal-
' Z! [2 l' l4 \% U' Y& j$ pamic pituitary gonadal axis.1-3 Thus, greater empha- p1 f$ _- z1 S! j% O
sis has been given to neuroradiologic imaging in. W8 k0 P" g* Z& }; I: v7 Y
boys with precocious puberty. In addition to viril-
" ?' F; z* |4 x/ N- W* n" i9 i& tization, the clinical hallmark of CPP is the symmet-! e3 }1 K2 e6 O+ \6 h$ R
rical testicular growth secondary to stimulation by
, U; p& g( A$ m, Z8 \gonadotropins.1,3
$ z* Y- I- o8 T! k$ HGonadotropin-independent peripheral preco-7 e, Z' Y# x& _7 g5 m2 s: \1 F
cious puberty in boys also results from inappropriate, S0 W2 d4 M: H) V3 C8 _! E9 |+ Z4 y
androgenic stimulation from either endogenous or/ V. p- n3 ^) M2 H
exogenous sources, nonpituitary gonadotropin stim-
3 _8 J2 J. J: X# kulation, and rare activating mutations.3 Virilizing
( N/ g+ }0 v5 t zcongenital adrenal hyperplasia producing excessive+ `8 O$ q6 z+ I
adrenal androgens is a common cause of precocious
2 f+ k' x; q8 c4 e$ N {. \puberty in boys.3,4# d) X, p9 z4 Y/ I
The most common form of congenital adrenal
( |. [7 { j1 ~( e- X# Shyperplasia is the 21-hydroxylase enzyme deficiency.# V$ E4 ~2 x! |% |# ^, k; k% K
The 11-β hydroxylase deficiency may also result in7 s2 r; p& N! O& n1 T; W
excessive adrenal androgen production, and rarely,
2 y) l; k' _! R$ i5 p: Wan adrenal tumor may also cause adrenal androgen
6 c! s+ @ x! v& t3 z5 Z! T! M/ Aexcess.1,3 l( ^- ]0 Q7 ?- _8 _* `* J
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from* u ]% d: ^2 a
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007' m: d, Q& Z- F7 O0 v* j! h
A unique entity of male-limited gonadotropin-
7 _; h6 j9 {6 |/ rindependent precocious puberty, which is also known
8 B$ d' X4 o# ~; y1 b0 K5 e8 pas testotoxicosis, may cause precocious puberty at a, {4 p& z" l0 Q+ J6 h
very young age. The physical findings in these boys ?# \3 O4 P: V& q
with this disorder are full pubertal development," G* E3 _2 E& ~; B- a) e
including bilateral testicular growth, similar to boys% A' a9 k# P9 i5 F% J4 y
with CPP. The gonadotropin levels in this disorder
F e% D4 z, V. l6 |6 bare suppressed to prepubertal levels and do not show3 h5 V, {6 }) R4 B/ A
pubertal response of gonadotropin after gonadotropin-+ m! m7 g8 q) E
releasing hormone stimulation. This is a sex-linked9 y$ g# U+ P q, k0 S
autosomal dominant disorder that affects only e8 R; R& N9 m' W6 ~+ g) q3 x
males; therefore, other male members of the family' S+ w$ r* i" d7 m6 b' I: Y. x
may have similar precocious puberty.3! |: M% H1 T& W5 j+ o4 v2 _
In our patient, physical examination was incon-* ]$ q. O; p' @: `( c
sistent with true precocious puberty since his testi- z4 X4 b3 j S! Q- ~% V
cles were prepubertal in size. However, testotoxicosis
: J/ p% a$ }! ~was in the differential diagnosis because his father+ L; O. x! B2 H% ~; o# @
started puberty somewhat early, and occasionally,. I+ ?; m9 e- o. g4 P% _2 \, ^" y
testicular enlargement is not that evident in the! m- [: b+ M) A0 c. ?4 A" C* a, y" J
beginning of this process.1 In the absence of a neg-
) t- x$ [% ]* B7 ^4 Uative initial history of androgen exposure, our
T6 p- E- f. s! F9 hbiggest concern was virilizing adrenal hyperplasia,: v, I4 ]$ m! ~* P$ s% X& Z! l
either 21-hydroxylase deficiency or 11-β hydroxylase
# c/ p$ e, d* N& P8 g f9 @deficiency. Those diagnoses were excluded by find-
3 N* d+ J3 h$ j$ }- z4 z) n$ oing the normal level of adrenal steroids." t. ~( M/ s( T* H! l
The diagnosis of exogenous androgens was strongly
5 K/ U2 H% ~1 \# m% l0 Csuspected in a follow-up visit after 4 months because
, V- m4 y T$ L: g# a1 K5 x2 Uthe physical examination revealed the complete disap-9 X$ O. i6 V4 g# [
pearance of pubic hair, normal growth velocity, and
: z( H. l' w: B2 mdecreased erections. The father admitted using a testos-' l' G3 t+ G% k% F5 N- ~
terone gel, which he concealed at first visit. He was! c/ u7 y6 f- j2 o
using it rather frequently, twice a day. The Physicians’
) K5 s6 z) J2 q! y7 J8 J4 xDesk Reference, or package insert of this product, gel or
?6 x' y, }' c5 Fcream, cautions about dermal testosterone transfer to
- Y' B. ?- |; u+ A* Q, Eunprotected females through direct skin exposure.
0 H. }7 J% {1 z/ B! {Serum testosterone level was found to be 2 times the
2 i# Z' u/ f6 L' n+ \baseline value in those females who were exposed to& D+ }: ^8 i8 |& f) ~
even 15 minutes of direct skin contact with their male
6 W/ ~& _5 x6 b1 H7 b1 Opartners.6 However, when a shirt covered the applica-
3 g* z. b) M( Ztion site, this testosterone transfer was prevented.1 \2 O: x4 t* x' S* y o4 O" B" ^
Our patient’s testosterone level was 60 ng/mL,
8 M$ k8 y5 }3 a) C4 v# N/ Ywhich was clearly high. Some studies suggest that* U, |; X3 W$ P4 F( C# n3 c: {
dermal conversion of testosterone to dihydrotestos-
& [( W! P) ]( lterone, which is a more potent metabolite, is more
$ p& y! B" v" h2 tactive in young children exposed to testosterone
9 {) L$ w) z3 C1 O' p! ^exogenously7; however, we did not measure a dihy-& w" B- j& H( E. \- c
drotestosterone level in our patient. In addition to
' n; j% c+ Q. t" N* Ivirilization, exposure to exogenous testosterone in% k# j# R a& w2 a6 d8 B, M
children results in an increase in growth velocity and
6 X3 E* |5 H* Y. K0 j( {9 sadvanced bone age, as seen in our patient.$ H. l) ?9 O8 I) R2 v# d% j
The long-term effect of androgen exposure during' G" a" S+ q( _) V
early childhood on pubertal development and final! N' f0 a. W5 p. ]
adult height are not fully known and always remain9 x. ^- x0 Y8 _. p h% B
a concern. Children treated with short-term testos-: n7 t' @7 x4 ^6 Q# J3 A- ]) f
terone injection or topical androgen may exhibit some1 d6 o1 R) }* k m; u* e
acceleration of the skeletal maturation; however, after" ?( K5 u' }; O7 ~* t
cessation of treatment, the rate of bone maturation
1 n& D) u- H, d! e+ gdecelerates and gradually returns to normal.8,9
1 F& i3 |, M% ^8 t9 \" I7 l( |# wThere are conflicting reports and controversy
+ L5 ~% i" ?2 `2 Qover the effect of early androgen exposure on adult
' d5 A) V. Y) c0 Kpenile length.10,11 Some reports suggest subnormal7 H7 @6 Q- M2 D- b( k, X; _
adult penile length, apparently because of downreg-
0 C- q1 W5 Q& y! |: e3 d! T- M! ]ulation of androgen receptor number.10,12 However,: T( W( M9 S: E2 I2 _, a" J9 b8 z
Sutherland et al13 did not find a correlation between4 }# w, P1 x7 D3 H
childhood testosterone exposure and reduced adult% }- | b% n% ^& Y
penile length in clinical studies.
5 Z, w U) u4 l) m2 `. d jNonetheless, we do not believe our patient is
2 d& d6 m3 p% k4 q& y; sgoing to experience any of the untoward effects from
& [' h+ h; B% ~ r3 f- ptestosterone exposure as mentioned earlier because
( {8 o5 o- @. Y; \- s& @the exposure was not for a prolonged period of time., m! O$ P: d3 P6 q& c+ X8 d
Although the bone age was advanced at the time of
" J: J+ O" p# `0 z$ idiagnosis, the child had a normal growth velocity at
, s0 A1 ~* W7 I2 f0 q* _( l% R$ jthe follow-up visit. It is hoped that his final adult/ N$ r* z4 y0 I
height will not be affected.% \* t- Z- j( U7 Z9 G f/ p" P
Although rarely reported, the widespread avail-
1 P& ?' k1 D! A- I& t4 fability of androgen products in our society may4 {) k6 e Z' E' W6 d9 M* `" N
indeed cause more virilization in male or female" [; P! T2 f! x0 [ B" J
children than one would realize. Exposure to andro-
4 ]+ D3 S0 g. x1 H! dgen products must be considered and specific ques-
) r% ?6 p) g' F& \tioning about the use of a testosterone product or7 p1 C' X+ S9 D. j( ~
gel should be asked of the family members during: U- U/ E2 o' N& T9 O, ~3 w
the evaluation of any children who present with vir-
) y3 }- V. M! g1 I1 D* @0 i' O4 pilization or peripheral precocious puberty. The diag-
( o$ K, f% v) ~! v8 L, Inosis can be established by just a few tests and by
2 [. Q& P2 v6 w3 x: W7 u1 [appropriate history. The inability to obtain such a3 W8 Q. y. Z& c* W* t' ?0 k% V3 F
history, or failure to ask the specific questions, may
! _1 E* W+ g& N, d% M1 d0 E* zresult in extensive, unnecessary, and expensive
0 f6 B; ]% k8 sinvestigation. The primary care physician should be
j7 g s4 d& q0 H) h+ paware of this fact, because most of these children9 ]- l/ \- G1 A5 C1 R, V0 \
may initially present in their practice. The Physicians’
T* d( O9 \8 j% h0 O! WDesk Reference and package insert should also put a
0 u* G1 G, t4 D, p+ E& b. lwarning about the virilizing effect on a male or
. ~% \& m* i: i9 o8 Z e ]! f5 @$ Lfemale child who might come in contact with some-
- O; Y2 _8 m1 @; K5 O. Vone using any of these products.! p- w/ X! Z" O& `. e- c
References
) s( p$ X- u. J, c" i P1. Styne DM. The testes: disorder of sexual differentiation
. v# `$ U& Q' S/ J, Uand puberty in the male. In: Sperling MA, ed. Pediatric) ~9 a8 C& W$ f" i) x1 \% \, l8 I" I
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;& _( c8 ?0 W8 _. B2 E
2002: 565-628.4 _/ G( y$ W6 r# N- F
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
; C) I/ Y: j0 n5 L6 |( Spuberty in children with tumours of the suprasellar pineal |
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