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Sexual Precocity in a 16-Month-Old: ~, q4 h' M5 s I" M6 E
Boy Induced by Indirect Topical
. D+ V' h% [* @4 k% S! K6 c. @1 iExposure to Testosterone
+ X8 z- V. A$ RSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
" _' D6 `4 ?' C7 [+ W4 Land Kenneth R. Rettig, MD1
& {: ~8 L5 O8 M" n4 c: oClinical Pediatrics; P7 ~6 [: Z! {- ?1 @/ c! R; g
Volume 46 Number 6
; j: A; C( M. F8 v: K% [July 2007 540-5432 e" ~ N0 }2 [$ Z( F' H$ x3 S
© 2007 Sage Publications7 M: u0 F1 A: d: t6 W
10.1177/0009922806296651
% O+ b; X Y9 s# W+ ?& |! chttp://clp.sagepub.com+ q4 n# d, r+ f, T$ z/ _
hosted at
3 C6 W' j* E# Rhttp://online.sagepub.com% W* h. W+ F1 y: }
Precocious puberty in boys, central or peripheral,
3 n+ |3 K9 g* z1 nis a significant concern for physicians. Central
/ I; I9 B3 ]% N0 ? T( t8 x. qprecocious puberty (CPP), which is mediated) Q; O ?) W4 |4 ]$ ]" s
through the hypothalamic pituitary gonadal axis, has
0 a. J6 N j) D& c: Z( |, K: na higher incidence of organic central nervous system
! ?4 c' L& N, L9 C5 F7 F: alesions in boys.1,2 Virilization in boys, as manifested
. Y! W: I; }6 v5 xby enlargement of the penis, development of pubic: ~1 u9 S* R, D, W/ P* W1 [2 D
hair, and facial acne without enlargement of testi-
" E1 R0 q) o: W; R% A o+ M4 M: ~) xcles, suggests peripheral or pseudopuberty.1-3 We6 v5 s/ Y& B4 w/ b
report a 16-month-old boy who presented with the
9 x6 U. ~# |7 `4 C/ v. K: X( kenlargement of the phallus and pubic hair develop-
2 e, s- S# s" f: G# Ement without testicular enlargement, which was due
. V1 J' W3 [* o8 J, Q0 J6 jto the unintentional exposure to androgen gel used by
3 @3 c8 ]8 `. q% T; I, |% `the father. The family initially concealed this infor-' _! B; c! f3 f. G! I; h
mation, resulting in an extensive work-up for this
1 p$ K. @, h. m( X# Q+ ichild. Given the widespread and easy availability of8 g9 J* Q- V2 `% a% |: }; y
testosterone gel and cream, we believe this is proba-! ?" {: u. q f& j/ m
bly more common than the rare case report in the4 t) l: `& w3 e1 [4 m+ [
literature.4* p5 U$ G4 F( q- J$ l ]; b. ~
Patient Report
3 v( m+ m F9 W5 U; XA 16-month-old white child was referred to the2 m/ J; L& z& U h) h1 l
endocrine clinic by his pediatrician with the concern
" _8 t7 O. q) q) y, Wof early sexual development. His mother noticed
- }4 p4 P& ^: y7 Alight colored pubic hair development when he was
+ V: q2 X3 o' l, mFrom the 1Division of Pediatric Endocrinology, 2University of
5 W7 y, a% ~6 X& X* K/ YSouth Alabama Medical Center, Mobile, Alabama.
& z, H" q/ K) i5 dAddress correspondence to: Samar K. Bhowmick, MD, FACE,
/ ~! E V$ Y7 ~2 c; {/ c! xProfessor of Pediatrics, University of South Alabama, College of
# z- D R" a2 x+ l7 wMedicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;. ~* s: A. o* j- x7 D
e-mail: [email protected].
+ x5 B, A! K7 ?- P9 x$ u6 U! @about 6 to 7 months old, which progressively became
; U: [ k$ B; U5 c) Gdarker. She was also concerned about the enlarge-
8 y! M! U) w4 Iment of his penis and frequent erections. The child
) M3 Y, k+ P2 _. C( m: ]was the product of a full-term normal delivery, with
7 [5 n1 f4 P6 l( B$ }a birth weight of 7 lb 14 oz, and birth length of: Y1 m2 W% ?" i" o( M" x; N
20 inches. He was breast-fed throughout the first year
6 B* k/ g% Z3 B) s8 Tof life and was still receiving breast milk along with5 [4 `# A \! H/ C
solid food. He had no hospitalizations or surgery,
- [" `& Z* H! n+ q/ |3 l8 Y! _and his psychosocial and psychomotor development
K) T2 f3 s5 c, N6 L, T* dwas age appropriate.
* m+ N+ q# i2 {8 o. r+ _& PThe family history was remarkable for the father,; i" J4 C- q. K9 _
who was diagnosed with hypothyroidism at age 16,6 r% I2 F( ]7 Q" m
which was treated with thyroxine. The father’s
& j3 d" \% x% \) Q7 c+ y6 F1 L1 Vheight was 6 feet, and he went through a somewhat( E. V y+ y1 S. w
early puberty and had stopped growing by age 14.
" N }! i# ?" T. zThe father denied taking any other medication. The/ q+ a- ?# s1 { n! l
child’s mother was in good health. Her menarche
9 @# F- v& K n/ Z4 m9 Uwas at 11 years of age, and her height was at 5 feet
. ?& Q ]4 V+ X5 inches. There was no other family history of pre-
7 ^$ ^1 f4 {) [8 H3 G3 v6 Fcocious sexual development in the first-degree rela-8 H% E3 n4 p% s# Z$ s
tives. There were no siblings., \0 ~. Q, o" L/ l' x5 H5 D" G
Physical Examination
: `7 a, p' k9 j2 ?! E* h. VThe physical examination revealed a very active,$ N9 E4 ]8 e% |: u4 D s
playful, and healthy boy. The vital signs documented2 p( Z$ o6 E* l$ c
a blood pressure of 85/50 mm Hg, his length was
- v# s7 U2 w+ b; g0 C" Y8 [( [- |90 cm (>97th percentile), and his weight was 14.4 kg
* R7 U% B6 x, A; v8 F; V" V% O(also >97th percentile). The observed yearly growth7 f$ }! C* t/ s9 n/ K
velocity was 30 cm (12 inches). The examination of
: r' O h" j: @' ^. `$ wthe neck revealed no thyroid enlargement.
/ \2 f' O2 W* y* E% g9 xThe genitourinary examination was remarkable for& ?( i' @) I j. i+ y3 w9 k/ o
enlargement of the penis, with a stretched length of
& ^# J W! x; B5 _: U8 cm and a width of 2 cm. The glans penis was very well G, o. o2 |& \/ x/ y, Z
developed. The pubic hair was Tanner II, mostly around5 s, Q, z3 o' P
540
; |* {7 R: v; S1 Y& H5 h* V& Dat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) D- e% q9 h! ~- z" jthe base of the phallus and was dark and curled. The
O* h* d) d7 Gtesticular volume was prepubertal at 2 mL each.
; |6 e, ?2 ~3 _! `, J& O( rThe skin was moist and smooth and somewhat
' {" s$ t7 [( r0 Noily. No axillary hair was noted. There were no9 K: G2 g+ r$ V
abnormal skin pigmentations or café-au-lait spots.
' e8 A* A6 A4 i+ b& @6 M: l) {0 FNeurologic evaluation showed deep tendon reflex 2+" E; L) `8 o8 j4 E
bilateral and symmetrical. There was no suggestion
. k7 ?/ q& a5 R( K; ], i) iof papilledema.
3 I! j$ e. O% j5 Q5 m4 |: QLaboratory Evaluation
- S$ x. Y3 i7 eThe bone age was consistent with 28 months by
9 j2 g9 T, L& F1 B Yusing the standard of Greulich and Pyle at a chrono-- v' w- R" A# |5 S/ q
logic age of 16 months (advanced).5 Chromosomal
( ~+ l7 L+ [$ w) [# h8 nkaryotype was 46XY. The thyroid function test) g5 u) [& {( M8 [# t3 k; H/ O' H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-; u$ J% |1 ^7 y, b* w' w& Y. } S
lating hormone level was 1.3 µIU/mL (both normal).
% P2 f8 h9 o: B/ L. m" k* NThe concentrations of serum electrolytes, blood
- i( C; G: R2 @% _6 v2 d# Gurea nitrogen, creatinine, and calcium all were* O* v0 ]1 j% r2 ~( ~
within normal range for his age. The concentration% [/ {; p7 S7 b6 D: [
of serum 17-hydroxyprogesterone was 16 ng/dL% O- @6 s; x4 C& h0 T
(normal, 3 to 90 ng/dL), androstenedione was 20: w H# u x& d T7 @* Z2 p
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
/ @' D! e. k E9 O& W) ^terone was 38 ng/dL (normal, 50 to 760 ng/dL),
+ i8 d! T# G6 G( O$ Mdesoxycorticosterone was 4.3 ng/dL (normal, 7 to
" U \' u8 j0 V( B; b49ng/dL), 11-desoxycortisol (specific compound S)# D/ `8 O# w* _, _: e, H
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-! {/ e/ p; J+ D7 W
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
% I) j9 L4 i/ Jtestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
0 v0 `0 O) V4 R& m2 O" } P, i O/ [and β-human chorionic gonadotropin was less than
/ N9 O+ q/ K }! L v5 mIU/mL (normal <5 mIU/mL). Serum follicular0 d! t. T. D6 S/ w
stimulating hormone and leuteinizing hormone$ R1 K( N7 y, c0 m! _
concentrations were less than 0.05 mIU/mL2 v8 s. p! w. Q% s. L) u
(prepubertal).
( E6 ~# x6 J' ]. y! e& v- tThe parents were notified about the laboratory7 Z a% T) v2 H x* i
results and were informed that all of the tests were2 W9 q h+ A5 I3 [) f: r& i
normal except the testosterone level was high. The
2 }2 A) x) F4 X3 cfollow-up visit was arranged within a few weeks to
! { s, Q0 L; `: C' |2 \* ^5 ^' n, jobtain testicular and abdominal sonograms; how-
3 ~. W& v, A$ Y& {. yever, the family did not return for 4 months.
9 G2 v# @( D; a: DPhysical examination at this time revealed that the
9 M+ s% k) n% {: E- z6 _4 Pchild had grown 2.5 cm in 4 months and had gained
|* z, f k, C$ r8 o2 kg of weight. Physical examination remained
. P4 O2 J. K1 h( m, Qunchanged. Surprisingly, the pubic hair almost com-4 O) } S, ] J# \; o3 o
pletely disappeared except for a few vellous hairs at
0 z* V) u# {: m: U" _ }the base of the phallus. Testicular volume was still 2. C+ _0 t' G; b# r: x
mL, and the size of the penis remained unchanged.
- N& y; _- d$ u7 A eThe mother also said that the boy was no longer hav-5 X( G9 c& w. Z. { b$ b) X0 `
ing frequent erections. ~: b- m9 U% U! B. Z
Both parents were again questioned about use of, d0 s* T/ N/ |& C9 k! X6 M1 @
any ointment/creams that they may have applied to
3 E3 O- }/ w4 W. m, a, Z: Ethe child’s skin. This time the father admitted the
# S% ?3 I% _- @; P8 A8 |0 Q5 `Topical Testosterone Exposure / Bhowmick et al 541
0 x2 c# }/ M; e c) F5 w+ Iuse of testosterone gel twice daily that he was apply-. `9 Y+ x, K' \
ing over his own shoulders, chest, and back area for: [, J. D/ b c, X
a year. The father also revealed he was embarrassed
( I, P, Q2 g+ |. D" Y0 h- xto disclose that he was using a testosterone gel pre-8 \- I1 @% L2 l5 A1 A& y% U2 \
scribed by his family physician for decreased libido: p; H0 g7 h- J- n0 k
secondary to depression.- K; |7 y1 ]+ X1 O7 d
The child slept in the same bed with parents.1 q3 m# d: J. b% u
The father would hug the baby and hold him on his6 q/ j7 l* N+ a/ _5 G( P
chest for a considerable period of time, causing sig-
, z, D5 g1 j8 l& @7 Hnificant bare skin contact between baby and father.4 N: L' a# q- m0 K( T1 R
The father also admitted that after the phone call,
7 D, y6 u3 F* t6 Pwhen he learned the testosterone level in the baby
, R% b, Q' w1 A, {4 z( `( L: awas high, he then read the product information1 A, a! p( y/ @& `" p
packet and concluded that it was most likely the rea-
( B& c1 A; j' u9 [1 F4 U. Tson for the child’s virilization. At that time, they
^) F5 y4 ?! @! K8 I& L ?decided to put the baby in a separate bed, and the% ?7 p" A' n' T7 N1 g& f6 U
father was not hugging him with bare skin and had. y: y, ?) H: p3 s
been using protective clothing. A repeat testosterone8 r4 B+ G7 \6 N2 x
test was ordered, but the family did not go to the% G: W" _3 T5 _2 c# Q3 y
laboratory to obtain the test.
3 ?, x9 Z" m4 \/ ?6 v3 M8 YDiscussion, m7 T ~: h9 {8 Q3 v7 [- ^+ n0 o
Precocious puberty in boys is defined as secondary; N8 R8 @+ z A# h. |6 U5 {7 ]
sexual development before 9 years of age.1,4& ^" B1 U! l }
Precocious puberty is termed as central (true) when4 I$ K6 V" S; B$ S, V1 U
it is caused by the premature activation of hypo-
) o( r/ Y# |- ]- r- M. D- I: Bthalamic pituitary gonadal axis. CPP is more com-
9 g7 @$ I2 M# a7 Mmon in girls than in boys.1,3 Most boys with CPP
# s/ e; P8 @$ |* v) O }7 [; }may have a central nervous system lesion that is
+ P; ^- q# F# G0 _- b* Zresponsible for the early activation of the hypothal-
$ u( P( x" `( Q- y# r# r9 ~amic pituitary gonadal axis.1-3 Thus, greater empha-; W5 ?7 p+ N# m
sis has been given to neuroradiologic imaging in b' n$ s% B' Z
boys with precocious puberty. In addition to viril-4 H5 H9 b( \5 d
ization, the clinical hallmark of CPP is the symmet-5 ^; L# t: ?* L6 f9 C) ^5 ?2 E: G
rical testicular growth secondary to stimulation by8 P! p* S: Q% q7 ]8 j" A3 X
gonadotropins.1,3
7 m7 `2 g) f! f8 |! h7 N: eGonadotropin-independent peripheral preco-+ V, ?$ S/ J0 ~3 V0 j5 Q4 \, @
cious puberty in boys also results from inappropriate- p) B" Y& j: t+ g0 r# D: T3 Y
androgenic stimulation from either endogenous or
* ]1 h2 m) s$ D/ ^4 Y& Oexogenous sources, nonpituitary gonadotropin stim-( m. \5 }3 V* `( s( K( I
ulation, and rare activating mutations.3 Virilizing9 V; x4 F, J- X1 _3 ~8 U P
congenital adrenal hyperplasia producing excessive, d4 }1 e6 R+ Y8 O
adrenal androgens is a common cause of precocious( A3 h4 P; E* A8 R0 B
puberty in boys.3,4; x& \- T6 D& L0 r5 U2 o' K
The most common form of congenital adrenal
* e# R- A/ Z# v0 T! M& D, Ghyperplasia is the 21-hydroxylase enzyme deficiency.9 m& h' a3 z3 M
The 11-β hydroxylase deficiency may also result in
) F" L& Z. T& \$ l% _excessive adrenal androgen production, and rarely,- E# s3 c3 D, Z0 p, q- ?
an adrenal tumor may also cause adrenal androgen5 p8 ~! d. Y4 P3 y5 ^" Y0 ~% p
excess.1,34 B; F+ j) r2 }
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from) A& }: b% m" ], I6 Z
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, Q5 T6 Y6 [2 [( D) gA unique entity of male-limited gonadotropin-
2 o8 w* f- G2 ^4 k/ g+ qindependent precocious puberty, which is also known6 J: h: {$ ^, b* k/ g" P
as testotoxicosis, may cause precocious puberty at a
; B! P$ Z+ G7 Rvery young age. The physical findings in these boys) |9 X4 V: c: y- S0 y$ a
with this disorder are full pubertal development,
8 }5 u4 C& M4 r& k4 v C/ q+ S7 Rincluding bilateral testicular growth, similar to boys ~6 H8 Y K! P) f' _+ K2 n
with CPP. The gonadotropin levels in this disorder9 B J( H5 f+ C; R1 g
are suppressed to prepubertal levels and do not show
6 A# u0 ^- L8 T3 [) \# }# k$ G5 ]# e1 vpubertal response of gonadotropin after gonadotropin-3 X# G, }5 R2 O* G
releasing hormone stimulation. This is a sex-linked
" c/ t( [) {; C4 B* Dautosomal dominant disorder that affects only3 x. c7 \/ B6 M; ?2 B
males; therefore, other male members of the family
, S5 ?3 T4 @5 i, Tmay have similar precocious puberty.3; r! H8 G) T7 k# J+ k! k
In our patient, physical examination was incon-; F2 }2 A7 ]/ y
sistent with true precocious puberty since his testi-( C' J b1 k% W b! G
cles were prepubertal in size. However, testotoxicosis4 R4 P. x- l1 G0 [9 D
was in the differential diagnosis because his father' t6 j- Q# G& a8 r2 M6 T6 ?
started puberty somewhat early, and occasionally,5 e y( F) k$ q4 E$ a0 B; y `
testicular enlargement is not that evident in the' `& q+ T0 b, y4 d0 k6 z% g
beginning of this process.1 In the absence of a neg-7 y, i, d' H9 t2 j3 W
ative initial history of androgen exposure, our! t0 L! s5 p( H/ F
biggest concern was virilizing adrenal hyperplasia,
& o# B! W% d, p, H( D6 P$ zeither 21-hydroxylase deficiency or 11-β hydroxylase
6 K$ z$ M+ m) Zdeficiency. Those diagnoses were excluded by find-) C. |/ v* }( {! e8 Q1 x. N3 ^
ing the normal level of adrenal steroids.
8 G% i h; C2 v! m8 w wThe diagnosis of exogenous androgens was strongly
6 c4 e; j" j1 ~2 h7 B' i( gsuspected in a follow-up visit after 4 months because, W, ]5 O6 }* \0 G) E9 X
the physical examination revealed the complete disap-& c1 ^. m2 U" q6 q
pearance of pubic hair, normal growth velocity, and
2 ~+ _# X# F' d2 y5 @2 j* W0 idecreased erections. The father admitted using a testos-: ^( T3 k6 q: j/ N$ [6 H: z
terone gel, which he concealed at first visit. He was
: H6 k$ D+ e0 |3 T, v qusing it rather frequently, twice a day. The Physicians’
/ m* z) y# i; t# Y7 oDesk Reference, or package insert of this product, gel or. ^& S8 }1 a3 R" W: ^8 P6 |5 s
cream, cautions about dermal testosterone transfer to
4 n7 u" V2 L1 z8 runprotected females through direct skin exposure.. E& |/ E% g5 n9 h7 C
Serum testosterone level was found to be 2 times the
! h) I" Q% e& W5 G% B; a% k1 p6 hbaseline value in those females who were exposed to! `+ M8 G$ M" E; G! c
even 15 minutes of direct skin contact with their male
4 A% s3 v7 F; m; c, K, x( B1 cpartners.6 However, when a shirt covered the applica-
- s+ @/ q0 I1 u1 }( `tion site, this testosterone transfer was prevented.
. o) Y% c' Z7 z1 D: W' b) P. }( \Our patient’s testosterone level was 60 ng/mL,5 f, U3 O6 C2 `9 y
which was clearly high. Some studies suggest that
* n* v9 Z& ]. Y# rdermal conversion of testosterone to dihydrotestos-
7 G m( p0 X r& c: F aterone, which is a more potent metabolite, is more
! `( @% U1 X0 Z4 x6 H, Aactive in young children exposed to testosterone
* Q& H: I: Y& L* w6 rexogenously7; however, we did not measure a dihy-0 Z* D9 g2 q2 a
drotestosterone level in our patient. In addition to6 x6 ]; _& U+ z
virilization, exposure to exogenous testosterone in; m2 `* b; k) }% [/ g, }4 u) i
children results in an increase in growth velocity and
! t2 m I' X# F7 B# `" @# Uadvanced bone age, as seen in our patient.
7 y; d4 p8 b- l! v7 q9 `4 L# X) {The long-term effect of androgen exposure during+ z* _* ~7 N$ Z/ y: u
early childhood on pubertal development and final* a4 T" X4 D- Z( Q! O
adult height are not fully known and always remain& j" n9 s* T/ d% i
a concern. Children treated with short-term testos-. `, b; G5 a" `3 z+ d- X7 p1 \
terone injection or topical androgen may exhibit some
1 h3 |% v! r( i& a& b0 ?" t1 Oacceleration of the skeletal maturation; however, after
8 K. \3 H6 t/ kcessation of treatment, the rate of bone maturation! B& a% W5 L% S
decelerates and gradually returns to normal.8,9 ?$ ^% A0 B. ?" I% @& k
There are conflicting reports and controversy
8 z8 @1 ?+ T- f' L# wover the effect of early androgen exposure on adult
$ w6 _1 r$ `- a) k" i5 epenile length.10,11 Some reports suggest subnormal
; l! y2 X( l& z# C% padult penile length, apparently because of downreg-+ `# p- E6 p6 n6 n: n& Q! l0 ?+ o
ulation of androgen receptor number.10,12 However,
% w9 l3 x; E! P; Q+ ~ \; U7 eSutherland et al13 did not find a correlation between
& o* j5 ?% P! u4 p, lchildhood testosterone exposure and reduced adult* N) z3 h4 M9 |
penile length in clinical studies., ~8 |) B7 l) t3 o4 E
Nonetheless, we do not believe our patient is' V. a" p# u5 U) s
going to experience any of the untoward effects from
7 v# X# U5 ?- ~. Ytestosterone exposure as mentioned earlier because
/ c7 J# P: j7 w. P4 n3 x/ `) nthe exposure was not for a prolonged period of time., W7 o! v; k J; s
Although the bone age was advanced at the time of* Y8 z$ b% R& o: U, X' I2 L5 x
diagnosis, the child had a normal growth velocity at
7 O: M8 C3 ?+ l* m- `; X& |! Ethe follow-up visit. It is hoped that his final adult" p+ L$ y! @9 C/ ?
height will not be affected.0 q( k" U& z6 M3 B$ F& U# B7 Y
Although rarely reported, the widespread avail-! T$ P; \9 W. ^* m7 F' q
ability of androgen products in our society may- }" ^: D# h- B% D8 X$ q. e4 ~
indeed cause more virilization in male or female8 B f$ O7 G; B$ F2 d& v* Y
children than one would realize. Exposure to andro-% d* V2 \) @! H2 S( E; S
gen products must be considered and specific ques-' u: m5 K% U: U( z- C
tioning about the use of a testosterone product or
- Q' t; ~+ K, i: Q. ` K7 tgel should be asked of the family members during
' Z- j# G. W) R# l) C, Sthe evaluation of any children who present with vir-" j1 L# I& b. _
ilization or peripheral precocious puberty. The diag-
' \0 p5 ?1 } m2 B/ ?nosis can be established by just a few tests and by
5 P' ]1 P/ T. q( {* P0 G/ o) a' fappropriate history. The inability to obtain such a
3 ^! x6 T# h- L/ I$ Zhistory, or failure to ask the specific questions, may2 k7 D9 A' _! r5 T$ q7 h2 N% r
result in extensive, unnecessary, and expensive
' j* u, f+ E6 q9 Einvestigation. The primary care physician should be5 N2 b. l! o4 C4 [
aware of this fact, because most of these children8 g7 L9 G2 w$ d4 C( b
may initially present in their practice. The Physicians’
3 w: ~) a& z5 a, EDesk Reference and package insert should also put a
" v7 y8 W$ f. }warning about the virilizing effect on a male or9 M/ e2 c5 i" m2 u1 E% K5 g7 k8 c
female child who might come in contact with some-
; s" A$ e0 q4 s2 _0 a/ ? _3 aone using any of these products.
' g! M2 l& _* h& oReferences
5 N. h3 q+ A9 _- c1. Styne DM. The testes: disorder of sexual differentiation
1 B/ A! E+ B) V' V9 Land puberty in the male. In: Sperling MA, ed. Pediatric Z( S/ p5 ]9 m
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;$ f' j9 _: q! j0 V' i# c, p, n4 R: R
2002: 565-628.' d& B2 N! W+ x4 g. D9 X3 F
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
1 o4 C9 o m3 Vpuberty in children with tumours of the suprasellar pineal |
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