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Sexual Precocity in a 16-Month-Old
' t# d: I, U! g) Q8 v3 ^/ cBoy Induced by Indirect Topical
! k. t5 V/ ^9 L% oExposure to Testosterone1 `% s$ {5 @5 W0 K1 s+ o0 G
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
/ F6 t' c6 ~/ `0 Q1 L4 x1 Kand Kenneth R. Rettig, MD1
$ o7 W0 G. X% r7 @Clinical Pediatrics
: Q( R0 P8 ?! c u& ~# x6 cVolume 46 Number 6+ J* N- a- q: Y3 r4 n
July 2007 540-5437 D6 F- O! r z- H6 r. l# l& R
© 2007 Sage Publications+ {" r0 j8 P4 L* n+ X
10.1177/0009922806296651
3 }; _4 y& E; Z) f, }http://clp.sagepub.com' B# l5 U$ i; |2 X( ?/ T$ C
hosted at
- F3 x, Q1 N; H8 Mhttp://online.sagepub.com; T5 o. G6 d$ u6 }" D' ~- _/ P2 F: h
Precocious puberty in boys, central or peripheral,2 l, B7 I/ E/ A" p3 G1 s. L2 b; B
is a significant concern for physicians. Central
) q2 }$ ~* s, D! m. C A# Bprecocious puberty (CPP), which is mediated
- S; t3 t9 t P2 Y" Jthrough the hypothalamic pituitary gonadal axis, has% p' q/ {% _; D7 V7 ]
a higher incidence of organic central nervous system) V3 O% E5 l0 |
lesions in boys.1,2 Virilization in boys, as manifested8 L, V; C, ^* |% e* }+ M+ [8 B
by enlargement of the penis, development of pubic
' t+ n$ ]; J2 Hhair, and facial acne without enlargement of testi-
9 K! e+ [9 @9 \1 _( o1 Lcles, suggests peripheral or pseudopuberty.1-3 We" o3 s9 U1 K4 P# x! ?
report a 16-month-old boy who presented with the
% O' `0 j ]3 `; y& x* g. u f( N% Penlargement of the phallus and pubic hair develop-' N% t* Y+ o. @- Z& q
ment without testicular enlargement, which was due
, W" v* {7 C; v& l7 s$ t) \to the unintentional exposure to androgen gel used by
' K. p0 V( p1 `9 V+ {the father. The family initially concealed this infor-
+ H4 \, a: Y4 |) O P% @mation, resulting in an extensive work-up for this
! P" Y- U( t1 @/ Z6 }7 e8 \1 d7 bchild. Given the widespread and easy availability of f. N+ g" M1 H7 { I7 c. D
testosterone gel and cream, we believe this is proba-" b( r3 i# D. l) n" y
bly more common than the rare case report in the
4 Y5 {5 v' n( d& C/ n& _& \/ |literature.4
$ S' B3 I) S, i5 u/ TPatient Report8 v8 V; e0 Y2 y8 n5 }% y
A 16-month-old white child was referred to the
2 a9 A+ {. c& x1 ^" I' wendocrine clinic by his pediatrician with the concern
2 {' q4 ~% K8 x# t% h) Hof early sexual development. His mother noticed
# m: h7 u- y) ]# U0 {' L5 xlight colored pubic hair development when he was
, V0 I% G6 s' h, h# P0 @; qFrom the 1Division of Pediatric Endocrinology, 2University of
+ Y' d7 E$ C! A. x) d4 w5 l2 nSouth Alabama Medical Center, Mobile, Alabama.
3 @' g+ j+ P# v2 BAddress correspondence to: Samar K. Bhowmick, MD, FACE,* o9 _2 P/ n' C2 F! @& l: `: X
Professor of Pediatrics, University of South Alabama, College of5 i9 `4 c, {4 Y8 U5 O; i0 V
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
# V0 |% |3 y. w/ u) Ne-mail: [email protected].& A6 [) g; B: e* B* O
about 6 to 7 months old, which progressively became
/ x0 G; B4 C4 \) i) p" Adarker. She was also concerned about the enlarge-$ c1 s; a4 s5 V0 `
ment of his penis and frequent erections. The child1 c C3 z0 q8 d* I- N1 D# H, G
was the product of a full-term normal delivery, with! [4 Z0 v4 z( a; d/ B
a birth weight of 7 lb 14 oz, and birth length of Q( y0 K, D' f" Q
20 inches. He was breast-fed throughout the first year
$ C( ~4 D+ u/ M9 O% u5 I5 aof life and was still receiving breast milk along with
$ j; M3 H q9 ?' U& v8 P4 z7 Vsolid food. He had no hospitalizations or surgery,
" B8 R* P4 V. @9 C1 @. Sand his psychosocial and psychomotor development5 d7 w: z) \+ m+ t9 r: L) u! l V
was age appropriate.
5 s7 c. m: {6 u7 CThe family history was remarkable for the father,
' W1 e3 S' p& z0 B' G/ pwho was diagnosed with hypothyroidism at age 16,
" j. Z5 k L" s ~3 _1 ~which was treated with thyroxine. The father’s
5 i7 X( U# O. R. P% O9 Fheight was 6 feet, and he went through a somewhat+ d [! ^3 l- Q; D% M
early puberty and had stopped growing by age 14.! l' B) Y! V) T7 z. C" k
The father denied taking any other medication. The
- [# c* a0 C6 d1 Dchild’s mother was in good health. Her menarche! Z, F* [2 v5 o$ k$ _% F! V
was at 11 years of age, and her height was at 5 feet
. Z$ K7 V' c' \: G, H: d3 V! n5 inches. There was no other family history of pre-
) q/ _2 j+ N1 h" Dcocious sexual development in the first-degree rela-' e8 p0 U# U: d' F- H
tives. There were no siblings.
1 a- ^5 I i! K& |) BPhysical Examination3 a8 r) P1 L; T
The physical examination revealed a very active,5 q4 v. Y# ^7 ~
playful, and healthy boy. The vital signs documented6 S7 f( L) Q8 c& H; P' }
a blood pressure of 85/50 mm Hg, his length was) P3 l5 \! R6 \7 ^; v( O
90 cm (>97th percentile), and his weight was 14.4 kg, s9 ], U, l3 l# ]1 X
(also >97th percentile). The observed yearly growth" ]6 C3 F" v5 o
velocity was 30 cm (12 inches). The examination of
) y8 I5 z2 n4 s% L& \the neck revealed no thyroid enlargement.: A4 Z7 D* H A6 t- ?( r
The genitourinary examination was remarkable for2 L/ V" u% g& M- \' f ^
enlargement of the penis, with a stretched length of
' Z: R$ l4 ~! c2 d, O8 cm and a width of 2 cm. The glans penis was very well0 T/ x7 f5 w6 y" P8 b3 ^
developed. The pubic hair was Tanner II, mostly around
2 G5 }. y0 W/ A. P \540
7 h5 H9 q7 m0 I, a7 t+ a* p1 }9 o) Gat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
% n C/ a0 V8 ~the base of the phallus and was dark and curled. The, W H" |' y: g9 \5 a
testicular volume was prepubertal at 2 mL each.' V, A# f7 D7 c+ ~* e4 K* d s
The skin was moist and smooth and somewhat
+ K9 U8 m5 D$ w" ~$ Q7 A! O1 |oily. No axillary hair was noted. There were no
! B8 D4 a$ C* b- ^abnormal skin pigmentations or café-au-lait spots.: q# q8 y& ?1 @9 u3 p. I
Neurologic evaluation showed deep tendon reflex 2+
2 q1 `% ?" l# z# ~bilateral and symmetrical. There was no suggestion
9 E; o' ?( q# J) Q0 Lof papilledema., f! ^* z- E$ M$ t
Laboratory Evaluation
0 \$ ?0 ~+ q( ]+ o- c% S* a6 tThe bone age was consistent with 28 months by. w' g( p5 A4 r' h; z, ?( @, B
using the standard of Greulich and Pyle at a chrono-
8 C0 ^' f- l! @) Zlogic age of 16 months (advanced).5 Chromosomal1 ]! y- [4 h! ? e7 @5 W: x! `# G
karyotype was 46XY. The thyroid function test- V3 Y+ M E! e$ h( x4 R, @$ q
showed a free T4 of 1.69 ng/dL, and thyroid stimu-% w% G1 ]0 i- [- D& H
lating hormone level was 1.3 µIU/mL (both normal).! Q0 q4 o Y# d6 f# E( X! p
The concentrations of serum electrolytes, blood
' p( d. p9 L7 u4 q/ kurea nitrogen, creatinine, and calcium all were
9 I. Z o2 e; D" dwithin normal range for his age. The concentration2 G. R$ K8 q9 V1 C' [
of serum 17-hydroxyprogesterone was 16 ng/dL/ }/ f- B0 P: I, n* u& r
(normal, 3 to 90 ng/dL), androstenedione was 20- b9 w6 ~! L L4 f; f1 g) s6 @3 i( l$ Q
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
" Z) J+ x+ w9 O0 ?+ Eterone was 38 ng/dL (normal, 50 to 760 ng/dL),1 T' G: _8 o: `* B
desoxycorticosterone was 4.3 ng/dL (normal, 7 to. C" Z" o- {: P& t L3 ]3 |! {
49ng/dL), 11-desoxycortisol (specific compound S)
+ k9 p2 f- q3 wwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-- y5 R2 `; a: g; F. h' @
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
6 ?( {; v" S6 G! y' }/ |- h, x! `testosterone was 60 ng/dL (normal <3 to 10 ng/dL),5 _; ?! h2 |2 |. J5 O
and β-human chorionic gonadotropin was less than
v; x( A+ ^6 R5 mIU/mL (normal <5 mIU/mL). Serum follicular
- ~8 v; g# b8 `( t& T2 B z+ Hstimulating hormone and leuteinizing hormone
5 q! h# t4 q% I! S- A1 U& Xconcentrations were less than 0.05 mIU/mL
* T2 D6 m# K D g' c4 M3 R(prepubertal)." j8 T# C1 J$ J, G
The parents were notified about the laboratory
) _, d5 o0 E; k% {- Presults and were informed that all of the tests were
4 U' c g' a8 L3 nnormal except the testosterone level was high. The
% p, K2 \+ z9 [7 y) g" i' d- zfollow-up visit was arranged within a few weeks to
" s m3 R/ |9 N# z0 Fobtain testicular and abdominal sonograms; how-8 ?% @$ t/ W. F" L8 m6 C( K
ever, the family did not return for 4 months., Y% H. E7 {* K Y
Physical examination at this time revealed that the
' w) ^: @! h( R* w0 achild had grown 2.5 cm in 4 months and had gained) ^, B: G( ^0 o4 p# m3 X* D
2 kg of weight. Physical examination remained
, {& }% M& B& J& \6 g4 y- uunchanged. Surprisingly, the pubic hair almost com-, A% U. |3 z @
pletely disappeared except for a few vellous hairs at, w# r# o/ z8 b# g2 P+ C
the base of the phallus. Testicular volume was still 2
5 S# ?' u! U; P5 \8 VmL, and the size of the penis remained unchanged.
, ~- N( M4 I' t. U j0 u4 f# PThe mother also said that the boy was no longer hav-
5 Q9 \, Y: @4 |2 Eing frequent erections.
4 O1 p# z/ {9 ]6 dBoth parents were again questioned about use of
) A, \# ~, z: L6 r# t y* iany ointment/creams that they may have applied to
" S0 ]2 S7 b- ~: o) y* a4 M$ rthe child’s skin. This time the father admitted the
3 ]; L8 A# e1 c& O. OTopical Testosterone Exposure / Bhowmick et al 541- ^: [% p! u$ u, E
use of testosterone gel twice daily that he was apply-* z( N3 d2 C: `
ing over his own shoulders, chest, and back area for1 `: C; ^7 m- ^5 m# E
a year. The father also revealed he was embarrassed, Y! Z& V. u1 k# l' M
to disclose that he was using a testosterone gel pre-( B9 H; l+ |9 K5 T' t
scribed by his family physician for decreased libido
& q. r5 t7 L' _' W! p* fsecondary to depression.
; O7 O% }0 \2 t$ RThe child slept in the same bed with parents.
# a8 e% S) d5 j* m& [The father would hug the baby and hold him on his
, y! ^2 y0 h, F; p* _chest for a considerable period of time, causing sig-) M5 ?" Z0 a u, P5 ~1 q% m
nificant bare skin contact between baby and father.: M* m& X5 _- D
The father also admitted that after the phone call,% d; n1 w2 T5 J: _1 M {* J! N
when he learned the testosterone level in the baby x8 C* {4 _! X7 M+ t# k5 M# f
was high, he then read the product information
' [, ~- K3 t( l$ d* epacket and concluded that it was most likely the rea-6 }, C1 @5 |" x7 q
son for the child’s virilization. At that time, they$ d: i! y6 m; ~
decided to put the baby in a separate bed, and the
& C3 X1 l8 n* j7 a2 v- mfather was not hugging him with bare skin and had5 z0 \3 y/ [9 E1 D5 s" k
been using protective clothing. A repeat testosterone
/ k7 i) K \; n8 s9 _+ z; r% C% otest was ordered, but the family did not go to the
5 S0 [2 Z: \* f G. A1 @9 @laboratory to obtain the test.) r2 b( ?5 r& t. b6 X
Discussion
8 v7 a7 q& Z+ j+ ~Precocious puberty in boys is defined as secondary
" N8 j: |5 w/ Q. F- \+ Qsexual development before 9 years of age.1,4
( Z! j& \6 }+ L+ ^Precocious puberty is termed as central (true) when
6 i- ]1 X# R Nit is caused by the premature activation of hypo-6 @% P1 F* x% ?( B9 h: q
thalamic pituitary gonadal axis. CPP is more com-
- @6 L a4 X2 ymon in girls than in boys.1,3 Most boys with CPP
2 }- B- s3 {# A7 emay have a central nervous system lesion that is* @- f$ L! V2 s: X
responsible for the early activation of the hypothal-
1 R7 a2 y6 Z# b3 wamic pituitary gonadal axis.1-3 Thus, greater empha-. h0 k! E" u- m
sis has been given to neuroradiologic imaging in$ Y/ N% B$ u) Q$ U7 m/ a! C+ j
boys with precocious puberty. In addition to viril-9 ~7 {- y1 Y, P0 I/ G; W
ization, the clinical hallmark of CPP is the symmet-! ~! x7 q! `# D" R
rical testicular growth secondary to stimulation by: }; c- S$ F# a0 J5 ?( v! _. B" ~
gonadotropins.1,3# b0 u; L4 f _/ l$ v+ N" l
Gonadotropin-independent peripheral preco-; j. E! u, f$ I7 I& x8 \ K' q3 r
cious puberty in boys also results from inappropriate
! {- s/ k" g2 C$ tandrogenic stimulation from either endogenous or
: y3 n! n& I3 fexogenous sources, nonpituitary gonadotropin stim-$ S3 }' P8 h3 K1 T+ z
ulation, and rare activating mutations.3 Virilizing) x. [- c @& j& c+ t; x
congenital adrenal hyperplasia producing excessive6 K# U( u6 }, e4 X" j }5 ]# P
adrenal androgens is a common cause of precocious2 M5 V( c+ Q# b' p1 d/ ]8 Y
puberty in boys.3,4
) I* D% ~$ G8 W$ n8 }0 }5 ?8 HThe most common form of congenital adrenal$ \! n* m* `/ A3 d8 \
hyperplasia is the 21-hydroxylase enzyme deficiency.7 {0 p& q' E) i8 [3 r0 T5 r: P3 A) h
The 11-β hydroxylase deficiency may also result in1 h% X) b5 Y) u8 [
excessive adrenal androgen production, and rarely,
4 u2 M1 {* `' ian adrenal tumor may also cause adrenal androgen9 u% @$ d: s e0 s0 ?; D# M3 |
excess.1,3+ S/ Q% s) `* A& @& c2 ]
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
h5 I+ m% R v r! j) P0 J542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 X! D9 n) }* A6 Y3 A7 ^+ E
A unique entity of male-limited gonadotropin-8 ^' W5 T: T, J C+ r& G# z- C6 P% x
independent precocious puberty, which is also known
( A' n+ T6 G& V% Zas testotoxicosis, may cause precocious puberty at a
' o" s4 M) T. Svery young age. The physical findings in these boys
8 V3 i+ q$ j( v+ R/ I& I+ ^' P" Xwith this disorder are full pubertal development,
% a1 M( R" W; s# t A! P6 P/ T5 Pincluding bilateral testicular growth, similar to boys7 J; g1 j2 ~. T l& D
with CPP. The gonadotropin levels in this disorder! O- e3 L5 C2 {/ o2 [/ Q
are suppressed to prepubertal levels and do not show0 C! E, a" T/ w
pubertal response of gonadotropin after gonadotropin-
/ L% x# p5 j/ j3 t8 Vreleasing hormone stimulation. This is a sex-linked
& e# }! v" [1 t# sautosomal dominant disorder that affects only
" e; U1 [& B/ c4 m, {males; therefore, other male members of the family
5 ^, F# P0 i7 O9 p; Q* Rmay have similar precocious puberty.3 p+ _9 h- Y- h- X0 [( u
In our patient, physical examination was incon-
' S# P0 g/ P) ?: Z/ I1 i7 k4 I/ Jsistent with true precocious puberty since his testi-0 J& l! }4 ?2 B! ~6 ^) j2 u
cles were prepubertal in size. However, testotoxicosis; v2 N# C/ J+ Y/ O3 J
was in the differential diagnosis because his father* L' J2 ~9 p+ N6 V @. w
started puberty somewhat early, and occasionally,, z4 F& S' D" X; V3 p# I2 \0 Z' R
testicular enlargement is not that evident in the
! D7 \- s* I* W8 m% O( ubeginning of this process.1 In the absence of a neg-
& l! |, v1 O3 [" y9 M: Gative initial history of androgen exposure, our& s3 G' Y8 e- ?8 G, a+ C: C) H) K
biggest concern was virilizing adrenal hyperplasia,+ w( ?& z/ i% q3 j: T
either 21-hydroxylase deficiency or 11-β hydroxylase) L8 u9 q( t8 n
deficiency. Those diagnoses were excluded by find-9 F/ `0 H4 v2 ]6 U# ~( g
ing the normal level of adrenal steroids.) c) R6 {5 v0 ~
The diagnosis of exogenous androgens was strongly! S ~) [) |1 Y! v' k% o
suspected in a follow-up visit after 4 months because) D, b+ }9 n6 {: j, X$ m
the physical examination revealed the complete disap-3 _: E! C+ P$ {3 J
pearance of pubic hair, normal growth velocity, and
9 ?8 T. X# L6 u e( A. [2 D+ B3 bdecreased erections. The father admitted using a testos-' n& r1 `, \6 N5 R
terone gel, which he concealed at first visit. He was
) `2 h& O) J7 b' g5 |, P* Gusing it rather frequently, twice a day. The Physicians’
$ }2 @- w3 O7 m) i% xDesk Reference, or package insert of this product, gel or" C" `$ z$ D# o
cream, cautions about dermal testosterone transfer to# F: k3 A7 N( v
unprotected females through direct skin exposure.* o$ r% I/ }* E `. A& w s) D
Serum testosterone level was found to be 2 times the
- ~1 I7 P. _' Xbaseline value in those females who were exposed to
! i, t' h8 g& `- S! H% Ueven 15 minutes of direct skin contact with their male! D O, l5 m9 n8 [, \2 o! b* z: V
partners.6 However, when a shirt covered the applica-5 Z% @% L, l' A3 F0 q7 c2 X
tion site, this testosterone transfer was prevented.
7 X+ z& c5 m- V9 N+ gOur patient’s testosterone level was 60 ng/mL,5 {) n8 f$ W- T
which was clearly high. Some studies suggest that1 i3 d8 g" g; ^, {5 ]. p* P! p5 ~
dermal conversion of testosterone to dihydrotestos-
K9 ]5 W# o4 K7 E) bterone, which is a more potent metabolite, is more
7 A9 w, f( a; G: R6 P7 P$ g$ ^active in young children exposed to testosterone
8 o/ A D/ M' V) Kexogenously7; however, we did not measure a dihy-* o+ d* b8 U, V9 m( j) G
drotestosterone level in our patient. In addition to. D2 }2 V2 `: D: z. c) o6 p
virilization, exposure to exogenous testosterone in( H7 q) G8 s4 L$ i( t3 x8 T6 p
children results in an increase in growth velocity and. n' W$ w9 u% n( Y$ M7 ^
advanced bone age, as seen in our patient.
, Q7 A4 C! J ?3 J5 m! W- f. Z) ]The long-term effect of androgen exposure during6 |8 F; }) L* k) m' o \
early childhood on pubertal development and final
1 Q9 T5 H, T9 v* [/ L9 J Z @adult height are not fully known and always remain
. ]( V% A* x8 {" a% z" @- ^, sa concern. Children treated with short-term testos-
; y& e! r( `' hterone injection or topical androgen may exhibit some
, c4 Q# B' a+ k* p2 t% V0 Tacceleration of the skeletal maturation; however, after" _1 N% Z3 ]+ i
cessation of treatment, the rate of bone maturation
5 r6 v [2 t) h( w4 U* I/ pdecelerates and gradually returns to normal.8,92 h4 A! U J2 |1 [- r% J K0 o4 c- q
There are conflicting reports and controversy8 A7 X4 O& u# a) C) A, c
over the effect of early androgen exposure on adult8 ~+ ^2 p; o, u% e
penile length.10,11 Some reports suggest subnormal# x0 E- x5 j6 P6 v
adult penile length, apparently because of downreg-
+ ?9 W- w& Q( qulation of androgen receptor number.10,12 However,- V0 i+ `* i5 `' x+ Z3 h
Sutherland et al13 did not find a correlation between: J- w6 t$ l: q# i |& I: C
childhood testosterone exposure and reduced adult
' a3 x/ L+ r9 F) S! T x7 X5 Rpenile length in clinical studies.9 K% L2 b. l& {! |! j# z
Nonetheless, we do not believe our patient is% z9 h O$ O7 @; N& e, J0 m
going to experience any of the untoward effects from
3 w1 A2 [- `9 W; K4 m- utestosterone exposure as mentioned earlier because) m7 ~- h4 }( \* N0 S
the exposure was not for a prolonged period of time.
6 Z3 Q2 K% u2 l K/ jAlthough the bone age was advanced at the time of
" q! { [9 V' `, F7 l7 Wdiagnosis, the child had a normal growth velocity at
$ J( A& I, H0 ^" bthe follow-up visit. It is hoped that his final adult/ d; b2 M# u. v# h+ Z
height will not be affected.
5 q# O0 Z" U; t( V9 L+ YAlthough rarely reported, the widespread avail-& k. B/ q! {8 N# D1 ~' v
ability of androgen products in our society may
& f$ {; ?0 c6 [2 b! e2 pindeed cause more virilization in male or female
. h& d0 c( v/ C& _* Gchildren than one would realize. Exposure to andro-3 G9 G5 P# X0 t( l; u4 ~. o
gen products must be considered and specific ques-
" F+ M/ l4 [( Ftioning about the use of a testosterone product or
& k: u3 H6 X5 b8 [& C0 o+ Egel should be asked of the family members during
- z+ X2 G, D7 l. z) c' Athe evaluation of any children who present with vir-
, h6 J8 T2 ]# q0 V8 Lilization or peripheral precocious puberty. The diag-
) \; P# _6 q1 B) H" Qnosis can be established by just a few tests and by2 z) L8 }+ a: K( Z/ `/ q0 h
appropriate history. The inability to obtain such a# c; i9 w1 k% E: }! f, g
history, or failure to ask the specific questions, may
8 p6 M C b. M, hresult in extensive, unnecessary, and expensive4 K' S( R* k# a0 O( b5 \/ q
investigation. The primary care physician should be
9 A, \7 K& S1 T9 [, W* p9 `aware of this fact, because most of these children
7 t( }. L5 c( _$ L, vmay initially present in their practice. The Physicians’, U# u) T# r7 N( N4 ?$ v
Desk Reference and package insert should also put a" N" X) k. S* G. W" P2 Z
warning about the virilizing effect on a male or
" m; k2 ^5 ^* ?7 ?7 qfemale child who might come in contact with some-+ G1 H9 D: ?2 X3 r Q# ?
one using any of these products.7 E1 t% y' f! H1 l
References3 e5 E }- M* [8 m6 u
1. Styne DM. The testes: disorder of sexual differentiation
; T4 w4 l8 M4 Y4 cand puberty in the male. In: Sperling MA, ed. Pediatric7 }! V0 i+ D+ H& C2 f; A0 O/ L" k
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
7 ]! B L$ h. o3 c6 U+ N( l2002: 565-628.& D* U) j! D4 F$ [: R
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
' Q* W1 ~3 _/ v9 |, Tpuberty in children with tumours of the suprasellar pineal |
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