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Sexual Precocity in a 16-Month-Old
" _5 x+ P, }7 W. {( [Boy Induced by Indirect Topical6 T5 n; ], l% W# [, h p3 G$ E; t
Exposure to Testosterone
8 t' `; \1 u; J1 eSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,25 Q6 |: |7 D `( E% j1 _
and Kenneth R. Rettig, MD15 Y0 A. q& H0 p7 r0 x
Clinical Pediatrics
# E% t6 T9 _6 h8 a6 wVolume 46 Number 6
7 {0 M7 h5 A: C2 y# `July 2007 540-543* j$ T6 x( R2 B
© 2007 Sage Publications6 m0 R4 q& {3 c9 V
10.1177/0009922806296651
! s, K" }$ M# T, f P: L4 _5 `) vhttp://clp.sagepub.com
+ a) K6 b5 I" X* m3 i9 E8 Ehosted at* I: ~$ Y+ {: q% C: c( G A
http://online.sagepub.com! m. v$ r& S" t
Precocious puberty in boys, central or peripheral,
2 @9 U) B& \% L% \ ]7 xis a significant concern for physicians. Central
4 w% X2 X$ y2 ~" C' F5 M0 eprecocious puberty (CPP), which is mediated+ a6 P: h( _' J2 D z
through the hypothalamic pituitary gonadal axis, has# [/ ]6 a( Q( A9 v0 o8 |" Y" q
a higher incidence of organic central nervous system
0 d: N7 U8 b$ qlesions in boys.1,2 Virilization in boys, as manifested; P( | G, E! M
by enlargement of the penis, development of pubic) e- V) W6 K3 c3 R' t* X
hair, and facial acne without enlargement of testi-
[4 A* m; _" K+ ucles, suggests peripheral or pseudopuberty.1-3 We$ T8 k5 R/ z) b% E5 |0 _2 g
report a 16-month-old boy who presented with the
: ?, N8 p9 t+ `+ \- ~enlargement of the phallus and pubic hair develop-
+ y3 m3 \3 E1 {1 Q; h/ |ment without testicular enlargement, which was due
: T' L* x- I3 V& D: pto the unintentional exposure to androgen gel used by* `/ s' w* V) s) {& j
the father. The family initially concealed this infor-
8 k0 K( B- Q# m7 q( G8 t, zmation, resulting in an extensive work-up for this. `: X: g; _5 y' t5 ?7 g# R& ], Y9 t
child. Given the widespread and easy availability of
0 K* N4 E' Q" T, L/ \% mtestosterone gel and cream, we believe this is proba-
& v. |! X- B7 H2 b+ Y: }bly more common than the rare case report in the2 \/ O; `. Y4 t4 y. Q% | n- _
literature.4
0 c3 F5 Z8 o( s2 ~# A: GPatient Report" S% E) E* p# w( a- C) w* D$ w
A 16-month-old white child was referred to the
6 L" q" l; p& t; ^5 Iendocrine clinic by his pediatrician with the concern
, i5 Q, ~8 t7 J0 F( Lof early sexual development. His mother noticed
2 u" f; ^3 I9 V7 z: Hlight colored pubic hair development when he was- e; o6 K, b8 N
From the 1Division of Pediatric Endocrinology, 2University of& S- D; b8 L# _5 a
South Alabama Medical Center, Mobile, Alabama.- X2 H7 X g. }7 c/ p
Address correspondence to: Samar K. Bhowmick, MD, FACE,
, V7 R t& m0 O" kProfessor of Pediatrics, University of South Alabama, College of# y* _- N! v+ ^
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
# m8 F0 U/ d) m: e o. P" Qe-mail: [email protected].' R# s h/ m0 x# W5 f% X
about 6 to 7 months old, which progressively became
9 q# ]1 }8 n; P7 |' i* Vdarker. She was also concerned about the enlarge-+ v7 g9 }+ @, i7 \) W: I7 `
ment of his penis and frequent erections. The child' Y8 V8 u7 Q, e5 h% t
was the product of a full-term normal delivery, with
8 k( q/ w5 ?. W* Ba birth weight of 7 lb 14 oz, and birth length of. {: D0 m: o& ]8 p; f2 ?7 \
20 inches. He was breast-fed throughout the first year( W9 C1 t5 h) l" v% h
of life and was still receiving breast milk along with' w% ^; V) B1 e' x1 p( a
solid food. He had no hospitalizations or surgery,) d' d7 g! W j! @
and his psychosocial and psychomotor development
' `) T$ \4 V8 w/ `, Nwas age appropriate.$ r& _ I& e* x9 y" ?" t- C
The family history was remarkable for the father,2 Q* D( W/ P$ d. h
who was diagnosed with hypothyroidism at age 16,
- p7 r' u: Y% b3 x' V) hwhich was treated with thyroxine. The father’s2 ~0 s' X, R- C# ]
height was 6 feet, and he went through a somewhat
2 P1 A d7 A/ a$ C+ Q0 E# nearly puberty and had stopped growing by age 14.$ A- K. L# W" X" Z+ \9 U
The father denied taking any other medication. The
0 A8 a* A3 f- q, P' E; ]5 O5 ?7 _child’s mother was in good health. Her menarche" P* e$ X4 s$ _7 D+ f8 X
was at 11 years of age, and her height was at 5 feet" f3 H) \* [- o- Q' r
5 inches. There was no other family history of pre-
, A% N. e+ K% }# W+ Ecocious sexual development in the first-degree rela-7 e& J. \6 a- D- x9 I
tives. There were no siblings.
% V7 I) V% q5 F$ aPhysical Examination) C7 F& i6 z y* X, F. J: T7 [
The physical examination revealed a very active,
' M4 e t9 k: q5 E4 f2 O. Tplayful, and healthy boy. The vital signs documented
4 d/ h% T \1 _4 E& i4 k, m( A& S. \) L. Aa blood pressure of 85/50 mm Hg, his length was6 @" C, n0 `8 p/ m7 c
90 cm (>97th percentile), and his weight was 14.4 kg h0 f3 ]' L" w0 s1 z
(also >97th percentile). The observed yearly growth
/ x8 N1 ~: D J; Vvelocity was 30 cm (12 inches). The examination of
5 D3 D# g; k5 r1 U" e0 kthe neck revealed no thyroid enlargement.
: x; t8 P. ? w0 A& @) XThe genitourinary examination was remarkable for+ p4 `; E# E) P! J/ f& F
enlargement of the penis, with a stretched length of8 M! J. ?/ V$ R( d3 J* P
8 cm and a width of 2 cm. The glans penis was very well5 ~; v9 L$ o9 R/ ~' Y5 }7 ^
developed. The pubic hair was Tanner II, mostly around- C W+ z: l. A1 b0 T) d9 D# ]! s
5409 J n' T# R8 s: N e1 K6 g
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
8 |$ J3 o$ {2 S# q8 k, I) ythe base of the phallus and was dark and curled. The
+ d" e% C6 K. m# Otesticular volume was prepubertal at 2 mL each.4 P! B. _, [0 F9 Q
The skin was moist and smooth and somewhat, f& F3 @; J* `9 p7 n: w% u0 n1 i
oily. No axillary hair was noted. There were no
6 J& h+ p' q+ y5 n- mabnormal skin pigmentations or café-au-lait spots.9 q' y6 J$ l' e, {) z! t+ J, Q
Neurologic evaluation showed deep tendon reflex 2+& q- D* n' S; i, S# O5 J9 A" ^( _& t
bilateral and symmetrical. There was no suggestion& P7 ?0 v! ~% K8 c. ~, u% A
of papilledema.
) A! S: {9 |0 B, j! @4 j1 {Laboratory Evaluation c0 `0 Q8 N, { D) n
The bone age was consistent with 28 months by
+ a( G, i8 I9 ausing the standard of Greulich and Pyle at a chrono-# ^0 Z2 V# x( u
logic age of 16 months (advanced).5 Chromosomal
4 p5 I( o& C( vkaryotype was 46XY. The thyroid function test
8 m- n! [& K0 c1 {; k8 A) t# v" R, _showed a free T4 of 1.69 ng/dL, and thyroid stimu-2 U6 ]) V* W' u; h
lating hormone level was 1.3 µIU/mL (both normal).
, E: a% i5 ?/ jThe concentrations of serum electrolytes, blood
: i/ X& e& O2 O* a1 k) B( gurea nitrogen, creatinine, and calcium all were8 n' R8 \$ v; }1 d2 c
within normal range for his age. The concentration( p8 U7 y; T0 v2 X8 o
of serum 17-hydroxyprogesterone was 16 ng/dL3 @1 G7 c6 c) J. k# Q# U
(normal, 3 to 90 ng/dL), androstenedione was 200 Z* a* a+ f- x9 ?% W
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-/ Y" E/ E* k& Q3 t% F( W1 z$ e
terone was 38 ng/dL (normal, 50 to 760 ng/dL),7 y; y& a$ h7 x- S3 }
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
+ ~6 a4 T4 x4 W9 f3 @" z, Z% z49ng/dL), 11-desoxycortisol (specific compound S)7 P7 q: R5 b* s" o
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-" H- j" I5 B* ~3 M
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
9 H0 r u ]6 z X6 T7 @& ptestosterone was 60 ng/dL (normal <3 to 10 ng/dL),$ d& e# K. e% L/ z& l
and β-human chorionic gonadotropin was less than
+ n( _5 y1 k+ s6 J( I5 mIU/mL (normal <5 mIU/mL). Serum follicular1 c7 U9 W t- {( X- M$ e5 x( J
stimulating hormone and leuteinizing hormone
# e. Z- d, P+ o, ]7 Rconcentrations were less than 0.05 mIU/mL% l0 P& I3 w d6 @
(prepubertal).
7 P& v! ]( e' g% |+ I' NThe parents were notified about the laboratory+ F: ^' o+ K+ d
results and were informed that all of the tests were
/ h3 e4 D, q* l+ Z3 N8 m pnormal except the testosterone level was high. The9 k- t0 R! j8 x* R: J2 G
follow-up visit was arranged within a few weeks to
* ~+ z* ^2 M0 _6 F8 _, n2 i, Robtain testicular and abdominal sonograms; how-5 Y4 N E6 j6 c, w: ^# O/ D0 D
ever, the family did not return for 4 months.
h0 W+ |- m8 L- ^- y4 X1 bPhysical examination at this time revealed that the
$ H! H; K+ _( \2 x- ]child had grown 2.5 cm in 4 months and had gained
* i% H* _: C9 `7 T2 kg of weight. Physical examination remained: ~6 J9 q. O1 B& J6 F) E& @' C
unchanged. Surprisingly, the pubic hair almost com-7 S5 Y3 n0 Q- E3 h/ l* y$ A
pletely disappeared except for a few vellous hairs at7 h w* h& L* K) ]3 C5 g. ?
the base of the phallus. Testicular volume was still 2
& |5 X% w- H, y r! E5 H8 @% kmL, and the size of the penis remained unchanged.
v t+ w) g8 M% [8 b) XThe mother also said that the boy was no longer hav-1 b( U" B% M* c6 b% V0 w! _- E
ing frequent erections.
" T" J( W+ S% \: p" C! zBoth parents were again questioned about use of( O5 f6 U W( l% `$ i
any ointment/creams that they may have applied to
! H& |+ x" k; W' ~% R4 nthe child’s skin. This time the father admitted the
. o* \5 G8 p- b* E$ z& ?Topical Testosterone Exposure / Bhowmick et al 541! D9 z l2 s. H% P* e( A
use of testosterone gel twice daily that he was apply-
+ ~. ]. D( n2 m( A) b% Qing over his own shoulders, chest, and back area for2 n$ p0 R( l+ ^3 H( W
a year. The father also revealed he was embarrassed; k; d6 k( J. j$ c" X8 g! H ]
to disclose that he was using a testosterone gel pre-
1 U j- m6 a+ P! |, i; zscribed by his family physician for decreased libido: m, R+ m( H+ [, g
secondary to depression.5 i" p- q [* }0 f
The child slept in the same bed with parents.( S/ q4 A* F9 Z0 g; u# K0 I I
The father would hug the baby and hold him on his R8 X, y4 o/ v. U
chest for a considerable period of time, causing sig-
/ I( D; Q3 [ j; M" p$ o$ N( cnificant bare skin contact between baby and father.
! h7 u5 `/ u; G) T r# z9 TThe father also admitted that after the phone call,, A' P6 w+ d+ x$ _: B0 g
when he learned the testosterone level in the baby
7 S* V: L$ X$ Owas high, he then read the product information
: n6 ^8 J+ m) q2 J9 Rpacket and concluded that it was most likely the rea-
- c" I7 p& F6 \! y* Y9 ~# ?+ bson for the child’s virilization. At that time, they/ e& h' U. a# K( s7 {8 {4 ?, _
decided to put the baby in a separate bed, and the
5 q, d7 A1 b4 R. A" Qfather was not hugging him with bare skin and had K9 k9 U- @: ?# e# G7 N" S
been using protective clothing. A repeat testosterone+ ]3 b% w" A) E* `( S$ T5 ^
test was ordered, but the family did not go to the$ a" H' y9 Y/ p8 V
laboratory to obtain the test.5 Q* i! @1 e4 G
Discussion3 W* b4 m' G/ I, s% p
Precocious puberty in boys is defined as secondary5 d% \3 v, l8 U9 K8 u
sexual development before 9 years of age.1,4* v- B* R6 }1 K5 Q9 u6 w8 R
Precocious puberty is termed as central (true) when
6 P# R1 }$ _) B+ v1 X8 ait is caused by the premature activation of hypo-% r/ F0 Z$ I4 x
thalamic pituitary gonadal axis. CPP is more com-" j' v# R! f7 O+ M4 e1 D7 w
mon in girls than in boys.1,3 Most boys with CPP
6 o. i2 v8 d7 G3 Hmay have a central nervous system lesion that is. S2 B6 Y7 k3 C! S; \- S0 Y
responsible for the early activation of the hypothal-) V, c; v6 Z/ o
amic pituitary gonadal axis.1-3 Thus, greater empha-
! v. [$ _9 j0 t" |sis has been given to neuroradiologic imaging in/ C' {, A! z% N6 r0 c
boys with precocious puberty. In addition to viril-
6 I8 [, o7 I" F, ]; Y& Sization, the clinical hallmark of CPP is the symmet-9 ^ G7 U6 j) ]) I) \
rical testicular growth secondary to stimulation by& Y$ j3 K P+ ^+ B, W
gonadotropins.1,3- q+ g' a2 O$ E3 b" f0 Q
Gonadotropin-independent peripheral preco-: e. N ? j H* ~5 h
cious puberty in boys also results from inappropriate( h u& C1 ^! r: i) F
androgenic stimulation from either endogenous or
) M- ?/ b# D9 ~3 ]$ L5 u. f, Mexogenous sources, nonpituitary gonadotropin stim-# ]! ]7 ~8 m! c O% W& K
ulation, and rare activating mutations.3 Virilizing7 N; `/ D% i9 ?. T2 B: v; a
congenital adrenal hyperplasia producing excessive
( k% k$ b' D' z/ ^adrenal androgens is a common cause of precocious9 m7 O6 c3 i! }5 x. T
puberty in boys.3,4
1 M, K( J$ K, B, H9 |/ [9 q" [$ JThe most common form of congenital adrenal
! _# r7 |! O/ A. G( S) z8 o; Mhyperplasia is the 21-hydroxylase enzyme deficiency.+ ~' ~7 `$ A p/ x, e0 |
The 11-β hydroxylase deficiency may also result in
8 C+ Z+ B9 x6 Y( _excessive adrenal androgen production, and rarely,
9 z: V( r2 }. i' g }3 _an adrenal tumor may also cause adrenal androgen
' @1 T) D/ r8 G# I: [; Sexcess.1,3( a8 y' O- @+ M1 I' G) ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: C! X ]; {* i+ f2 L
542 Clinical Pediatrics / Vol. 46, No. 6, July 20079 l0 M+ o4 ]7 a* r, ?2 J& z
A unique entity of male-limited gonadotropin-
7 X( U; x7 ?; P& T7 ~+ J( k, x) W) Oindependent precocious puberty, which is also known: Z o7 L8 K U, y& z* s
as testotoxicosis, may cause precocious puberty at a$ t8 \3 J2 I; t7 q0 a0 t
very young age. The physical findings in these boys, G3 \5 [0 n5 c2 ^( L. F
with this disorder are full pubertal development,
7 t% D4 H9 V3 ~ u( K( Yincluding bilateral testicular growth, similar to boys
, W" j) @% A I1 U1 lwith CPP. The gonadotropin levels in this disorder
" D3 d6 J0 V. q2 u. C! @are suppressed to prepubertal levels and do not show7 O( p2 [; k1 ]' I4 `# W E( @
pubertal response of gonadotropin after gonadotropin-) C; }7 g6 x! Q- f8 l2 x
releasing hormone stimulation. This is a sex-linked
$ A5 z& D# u! Y7 tautosomal dominant disorder that affects only) v. i3 n# E. j J; Q6 U0 L+ r
males; therefore, other male members of the family
3 o) S) e7 |; Omay have similar precocious puberty.3
% Q$ F6 Z7 a' R& a8 eIn our patient, physical examination was incon-
1 a, a. f' g& X* j( usistent with true precocious puberty since his testi-
$ b$ ^' G4 J" {2 N- u! X7 icles were prepubertal in size. However, testotoxicosis6 F. h. }5 }& n/ r: i# F; P1 [
was in the differential diagnosis because his father
0 l" N; R4 ]. |1 s! X l* wstarted puberty somewhat early, and occasionally,
$ o4 T5 Z$ n9 ~- c9 m( Ctesticular enlargement is not that evident in the
: Y8 g; l7 t/ U/ ^beginning of this process.1 In the absence of a neg-7 k8 Z* N6 r; O- t3 E9 ]
ative initial history of androgen exposure, our
1 I2 z- h6 F; A1 D7 \3 K! D$ obiggest concern was virilizing adrenal hyperplasia,
; O0 o6 _% o# k b% T: p1 s* reither 21-hydroxylase deficiency or 11-β hydroxylase
8 J3 ?% m! T; r* X' Cdeficiency. Those diagnoses were excluded by find-
$ m- g; [- q. U& }/ ^! N) king the normal level of adrenal steroids.6 K. Q4 G8 N# K8 ?, H
The diagnosis of exogenous androgens was strongly
# d9 y& B$ h R5 g" v( I8 Bsuspected in a follow-up visit after 4 months because9 b3 T0 b0 l4 ^
the physical examination revealed the complete disap-
: S: Q" o2 D# `. ~1 spearance of pubic hair, normal growth velocity, and
p$ p2 o* O* U: ~, p+ o7 S1 Ldecreased erections. The father admitted using a testos-6 B3 f- _3 G) P* M
terone gel, which he concealed at first visit. He was
( m0 h/ x8 D0 g( c+ H! Eusing it rather frequently, twice a day. The Physicians’
' `4 P4 O( } L8 q+ ]Desk Reference, or package insert of this product, gel or
6 p5 O" r; R0 p0 V- gcream, cautions about dermal testosterone transfer to
3 t- p) K& X0 p. o8 I) i/ p) yunprotected females through direct skin exposure." g2 k% E/ E t3 S) x
Serum testosterone level was found to be 2 times the
+ G& I/ ~+ f+ p1 }3 a! Dbaseline value in those females who were exposed to- `. W* Q1 i6 K' S! S6 e: g
even 15 minutes of direct skin contact with their male' c( d& C: _4 A
partners.6 However, when a shirt covered the applica-
: X5 z7 a( R) C) `+ gtion site, this testosterone transfer was prevented.* `+ Z. u w( Y) N3 O
Our patient’s testosterone level was 60 ng/mL,( a k* @2 _4 d5 |0 c0 |
which was clearly high. Some studies suggest that
2 ^0 z0 S ?6 z: k( tdermal conversion of testosterone to dihydrotestos-
" t- i* l5 `# K: b" j8 tterone, which is a more potent metabolite, is more6 Y U2 C/ t2 I/ i2 U! K/ C/ q2 B% U
active in young children exposed to testosterone6 ^: N3 c/ y4 y8 ]% e, b
exogenously7; however, we did not measure a dihy-: y2 j7 D& _8 Q6 L* x( f
drotestosterone level in our patient. In addition to
! ?1 O4 U/ R$ X0 Y* ^virilization, exposure to exogenous testosterone in3 X }7 ?& }! r1 N. C
children results in an increase in growth velocity and
: n1 U Z6 R6 n* zadvanced bone age, as seen in our patient.
8 r) p e) a- X3 ], VThe long-term effect of androgen exposure during
+ C. M% e' J# v$ ?5 pearly childhood on pubertal development and final
& D; @7 S( M; q: Gadult height are not fully known and always remain
) H, c6 ~) U5 r( a* Pa concern. Children treated with short-term testos-. |6 W' Y/ ]+ S
terone injection or topical androgen may exhibit some& J# V4 R P d1 \1 y
acceleration of the skeletal maturation; however, after
2 ]7 l! T; |: Q$ f" Qcessation of treatment, the rate of bone maturation& [- s1 U% y" r8 z% `% {* | M
decelerates and gradually returns to normal.8,9$ p2 m. I, G' \* i3 z" e
There are conflicting reports and controversy
2 |5 n( O U* ]+ ~: ~+ nover the effect of early androgen exposure on adult
9 e! H" g) n6 U d% upenile length.10,11 Some reports suggest subnormal
5 D6 N5 e& k# y( Tadult penile length, apparently because of downreg-
9 I( W7 n3 @: ^& z5 @ulation of androgen receptor number.10,12 However,
, v9 B- p( \5 |) c+ mSutherland et al13 did not find a correlation between; {& T" V! i) M5 ?6 ?4 x
childhood testosterone exposure and reduced adult7 |! t9 R5 U, O0 G) w# u
penile length in clinical studies.8 Q% x' ? s% c1 v
Nonetheless, we do not believe our patient is
; ?# a5 g4 y+ s& B" g/ N- E. X zgoing to experience any of the untoward effects from6 d" c& x+ L5 k, i! [2 j
testosterone exposure as mentioned earlier because, O$ z( \3 m6 k! b4 T: @& j
the exposure was not for a prolonged period of time.( h* ^' Q7 x5 }; O0 f3 \+ J- D! X/ J
Although the bone age was advanced at the time of% p8 |& e9 A+ h& |! U
diagnosis, the child had a normal growth velocity at7 h; n' I/ \- ?$ k
the follow-up visit. It is hoped that his final adult
+ v" k: F o& n6 J) sheight will not be affected.+ d0 u" k9 ?" t# A v- X/ P
Although rarely reported, the widespread avail- b4 i% M/ U4 Z, X; p" K; o- `
ability of androgen products in our society may
6 w+ Q3 d1 b% F2 N+ M. d Zindeed cause more virilization in male or female' Q2 R6 M# f2 m$ [# b a! e
children than one would realize. Exposure to andro-
0 Q6 U: S1 c+ s4 y! C# ^& Zgen products must be considered and specific ques-
- J4 x, q {+ _+ d$ K$ ^9 rtioning about the use of a testosterone product or
5 ~5 a* l/ j: s- v' ~# _" @gel should be asked of the family members during% l C1 h0 \% i' {, h. `
the evaluation of any children who present with vir-
3 v `! k" D& E0 f ^( y# Eilization or peripheral precocious puberty. The diag-
# \5 ^$ \- X: Ynosis can be established by just a few tests and by
3 }% s4 W; f7 Nappropriate history. The inability to obtain such a
1 O+ ]/ C& ^) Z3 N' K8 X* |history, or failure to ask the specific questions, may
+ V) w9 q1 t! h, [- _' ^result in extensive, unnecessary, and expensive
' L8 h) Z2 L& Iinvestigation. The primary care physician should be' n3 H! ?! r& ~1 l0 E$ T
aware of this fact, because most of these children
5 B! F. S/ `# a1 ^3 }* Nmay initially present in their practice. The Physicians’
' r2 E2 G0 s2 E' J$ kDesk Reference and package insert should also put a
8 m5 V& W& G6 @5 G) W9 fwarning about the virilizing effect on a male or
$ L- q) [# s, @5 l- n# v7 q' ]) Ofemale child who might come in contact with some-
( \, f* }, J3 k% I8 f- cone using any of these products.8 e5 S* M- N9 Y: }
References
- A' S% i3 S z/ s8 x l8 M& A G1. Styne DM. The testes: disorder of sexual differentiation7 L( E6 q6 D- V9 z; Y8 e
and puberty in the male. In: Sperling MA, ed. Pediatric5 K2 r0 W! P3 e* b1 K1 L
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
; S/ `; f& D1 t" N" n2 p; p2002: 565-628.2 r, v; a8 C2 S
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
* r/ e: K }0 d& j5 mpuberty in children with tumours of the suprasellar pineal |
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