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Sexual Precocity in a 16-Month-Old
2 j- }$ {* h3 ^5 p7 i R2 RBoy Induced by Indirect Topical' U& x5 B. [2 A* b# y
Exposure to Testosterone
P( a! ` d: R( f9 }6 p9 iSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,24 b+ D8 H3 [% f% W: _
and Kenneth R. Rettig, MD1; c( D- u, I4 C2 f. X$ @- U) ` v3 j
Clinical Pediatrics
) ^( c" D4 \9 j0 K- ~8 CVolume 46 Number 6
" Q. |; u" j* g4 g8 p' ]July 2007 540-5438 k9 n( z0 A8 N$ C8 D! Y" a, ]
© 2007 Sage Publications* W3 k& U$ m8 k. \' p; u6 Y2 Y( A
10.1177/0009922806296651
/ W/ A+ g4 d6 q4 e5 I' [http://clp.sagepub.com: `; t5 p6 T5 f1 x# T& M, g0 e
hosted at
* o7 E1 e+ |9 }% W) chttp://online.sagepub.com1 w y, ?: P2 ?3 Z$ B
Precocious puberty in boys, central or peripheral,, Y, L! e/ S* ?
is a significant concern for physicians. Central4 x6 k/ r* G7 k9 S" F
precocious puberty (CPP), which is mediated
2 F& y% o" q- M% {* N( h) M. _through the hypothalamic pituitary gonadal axis, has' ?" f4 O: y8 }; \2 [
a higher incidence of organic central nervous system3 R. e5 s5 E! X
lesions in boys.1,2 Virilization in boys, as manifested5 P: Q g' ^; X% I# r5 M" x+ `: D( g
by enlargement of the penis, development of pubic
$ _& ^+ t3 t) O3 j0 L8 y& jhair, and facial acne without enlargement of testi-
6 A% J7 m7 `- ]) Ccles, suggests peripheral or pseudopuberty.1-3 We, |5 b, X/ \1 Z/ M/ a
report a 16-month-old boy who presented with the3 @& N3 p* u) j% G
enlargement of the phallus and pubic hair develop-
' h6 g# B% W+ @: @. k) ]3 p2 oment without testicular enlargement, which was due
" j) c6 z1 c. [/ qto the unintentional exposure to androgen gel used by3 b0 M" m2 {; Y
the father. The family initially concealed this infor-
# J% `7 u9 y, E! |mation, resulting in an extensive work-up for this- B+ p. U/ h' b+ e+ u* e6 P
child. Given the widespread and easy availability of
) k g3 L) M* R1 V8 W3 utestosterone gel and cream, we believe this is proba-5 p$ w3 M: w) h! w! \. X" M
bly more common than the rare case report in the
1 @8 ^! ^) |- t9 e7 Xliterature.4
3 T9 S* W! c9 }% U' ~& i; @Patient Report
7 o) ?% K' [$ I. iA 16-month-old white child was referred to the* R" a+ ^' E1 M* ^* J8 M
endocrine clinic by his pediatrician with the concern
u2 Y, Z) K5 g$ {* Y! Oof early sexual development. His mother noticed% d* ~8 j6 Z# }1 O. L& t
light colored pubic hair development when he was0 K% B% z/ Z# Q
From the 1Division of Pediatric Endocrinology, 2University of
0 I( `! f- P+ nSouth Alabama Medical Center, Mobile, Alabama.. e9 W9 @0 {( x2 q7 Q3 d
Address correspondence to: Samar K. Bhowmick, MD, FACE,/ a" S1 Z, \& W; q
Professor of Pediatrics, University of South Alabama, College of! w# f5 \: _1 Z, I5 _
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
" A' N9 q F# \; ]( me-mail: [email protected]." k# o( \6 U- _4 v2 O/ z
about 6 to 7 months old, which progressively became
! H3 Q# {2 |0 F# H9 udarker. She was also concerned about the enlarge-
$ s5 D7 N( J; M5 q. v; Vment of his penis and frequent erections. The child' z* o) [' o; w4 m5 n# l$ R
was the product of a full-term normal delivery, with
& A! E: K# O" P0 G* ~a birth weight of 7 lb 14 oz, and birth length of! c3 N7 t; f& k* _; R
20 inches. He was breast-fed throughout the first year
! i4 g' L1 e& q/ n; }. x: s8 hof life and was still receiving breast milk along with' C, f; {& h3 n1 a H) L0 M$ {
solid food. He had no hospitalizations or surgery,% _8 b! q; b8 E @5 F6 i
and his psychosocial and psychomotor development/ n$ _- X# o: f
was age appropriate.5 B/ u: v2 h% s- e3 r- N
The family history was remarkable for the father,
# a6 V. E+ Z) A5 n& rwho was diagnosed with hypothyroidism at age 16,
% b: G1 k3 X6 B( w! x, Y& x5 nwhich was treated with thyroxine. The father’s7 u/ u% U- j1 F0 U. N
height was 6 feet, and he went through a somewhat9 C% U) }* L8 _% {% G! T
early puberty and had stopped growing by age 14.+ u! A6 D, P M, H
The father denied taking any other medication. The
7 r' [) }( j1 `' o+ m1 N6 @' schild’s mother was in good health. Her menarche
9 q& x0 D7 C5 K4 \# ^was at 11 years of age, and her height was at 5 feet9 L- t9 r W1 |- ~) l
5 inches. There was no other family history of pre-
& c- X7 U3 p$ k" J0 M/ f, }6 Scocious sexual development in the first-degree rela-
4 F o" |/ C% ?tives. There were no siblings.
( R6 U$ G- b; L. L* W) rPhysical Examination
" m. z/ l2 I( _7 {! P# OThe physical examination revealed a very active,
* {$ h" Q [$ I6 gplayful, and healthy boy. The vital signs documented# r4 x% R# k8 T4 z9 d
a blood pressure of 85/50 mm Hg, his length was
7 X- j- g8 c! J1 [90 cm (>97th percentile), and his weight was 14.4 kg3 c& U1 `( D( L# O
(also >97th percentile). The observed yearly growth6 I4 x. s* {% T2 _& C8 s, q, Y: m3 l
velocity was 30 cm (12 inches). The examination of! D% P3 W7 P! f9 d' V
the neck revealed no thyroid enlargement.( j4 B5 h" \7 a: h# {% B5 [
The genitourinary examination was remarkable for( |) }6 w. q0 L+ x2 H) `$ W/ y
enlargement of the penis, with a stretched length of
: }* F- D \5 ~: W$ x8 x. @8 cm and a width of 2 cm. The glans penis was very well
1 y. G$ g2 _, {: z: i* Odeveloped. The pubic hair was Tanner II, mostly around& ^! Z' I. p/ G( E6 @
540; s* K7 q3 b9 I6 C% R0 Q
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
9 o E& X( e+ U5 g! y4 H, @7 {4 nthe base of the phallus and was dark and curled. The- j# h5 G' ?. ?' ~
testicular volume was prepubertal at 2 mL each.
' L4 E8 |# A( k5 `( a, n, W5 _1 W1 nThe skin was moist and smooth and somewhat
! n9 M' t' S3 B( k" Eoily. No axillary hair was noted. There were no
: N: U) [: t$ k3 m$ |! q6 F+ [* @abnormal skin pigmentations or café-au-lait spots.
8 [0 e, | V6 NNeurologic evaluation showed deep tendon reflex 2+
1 R3 P& o: w7 D, I& T( @& {- obilateral and symmetrical. There was no suggestion
' g( h$ S# S4 f: |5 C* {of papilledema.
/ n+ @# }8 q: ]0 W& v+ eLaboratory Evaluation, J* M' ~; G+ A3 ~: B+ I+ a
The bone age was consistent with 28 months by
* J( ^, @1 B2 R1 `$ x6 \using the standard of Greulich and Pyle at a chrono-
) k5 B! @ Q- r# Plogic age of 16 months (advanced).5 Chromosomal- O! m* q n$ q, s
karyotype was 46XY. The thyroid function test; N' N$ O3 w9 m
showed a free T4 of 1.69 ng/dL, and thyroid stimu-, n2 t4 h0 O+ g7 m
lating hormone level was 1.3 µIU/mL (both normal).
# {+ T: a9 d- `6 f5 MThe concentrations of serum electrolytes, blood
3 }; r9 y" l, c; G Z w. F9 [urea nitrogen, creatinine, and calcium all were1 k# X, \+ D# F9 o2 U% I$ v6 \
within normal range for his age. The concentration" h' L( h6 G! p/ R g; Q
of serum 17-hydroxyprogesterone was 16 ng/dL8 E' i+ Q* G1 ]- ]7 _$ O
(normal, 3 to 90 ng/dL), androstenedione was 208 L4 D" d( L P' a% Q' I7 c
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-( q9 l5 u9 W+ ?" b
terone was 38 ng/dL (normal, 50 to 760 ng/dL),
- @- n+ j3 N: l. t3 w2 \desoxycorticosterone was 4.3 ng/dL (normal, 7 to
7 ?& F) \. u6 |! U2 h49ng/dL), 11-desoxycortisol (specific compound S)
5 W( R/ W9 i5 W! _) {3 twas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
5 x, Q- f2 y8 ?. V! v: c1 Ttisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total0 z+ l, ^, q0 p4 V0 C0 p; q
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
! e6 _5 `! q, q$ U7 F6 H+ G4 j. jand β-human chorionic gonadotropin was less than. L+ U6 n: G+ g/ \
5 mIU/mL (normal <5 mIU/mL). Serum follicular
# E W. \# k8 Y+ tstimulating hormone and leuteinizing hormone. W D2 `9 \5 D# g. Q e
concentrations were less than 0.05 mIU/mL2 O C0 K: ?& d# J
(prepubertal).
0 R9 Z6 ^' B9 ^8 g; P Q: FThe parents were notified about the laboratory
: Q% g( s: p+ j6 w a2 _results and were informed that all of the tests were
?. Q& {4 x W8 qnormal except the testosterone level was high. The
( k, X% S" l* v* B7 nfollow-up visit was arranged within a few weeks to& |( W; H$ z1 c7 g9 l
obtain testicular and abdominal sonograms; how-
R2 U0 e- i- \4 S' z; ]1 W& hever, the family did not return for 4 months.# ~ k6 J; m# B* g- Y# @
Physical examination at this time revealed that the. H: P. \* T$ Z3 D& w
child had grown 2.5 cm in 4 months and had gained
; W. y5 I3 `: I" T& ^- B2 kg of weight. Physical examination remained
m; Y4 J) P; u- c/ r4 b) _unchanged. Surprisingly, the pubic hair almost com-+ P3 [; r7 T: M
pletely disappeared except for a few vellous hairs at# h! }; `; Y+ n2 m1 M* J# j' e
the base of the phallus. Testicular volume was still 2- _, s0 c ~1 i0 C' Y' ^& g
mL, and the size of the penis remained unchanged.
! `! ^2 i+ t( J" U5 s" q* CThe mother also said that the boy was no longer hav-
- v4 n+ U: a M* s+ aing frequent erections.
m! c) A: o5 O7 D1 P3 |4 H' LBoth parents were again questioned about use of. Q4 O/ l6 I0 O( l& w
any ointment/creams that they may have applied to
+ A5 m! V' h% B; z: U3 s7 H5 d1 Ithe child’s skin. This time the father admitted the
6 O% z% M$ `! H- v7 T$ @+ ITopical Testosterone Exposure / Bhowmick et al 541
7 L% N- ?* X. d$ P1 V0 z, ~6 v, Yuse of testosterone gel twice daily that he was apply-9 g) [* |! h& K, q$ c
ing over his own shoulders, chest, and back area for
1 j7 f) B r8 | Z" z0 c4 {a year. The father also revealed he was embarrassed" c. o. A2 H* d5 ^) ~$ e& @! D r
to disclose that he was using a testosterone gel pre-
. T9 V* h! F, ^: kscribed by his family physician for decreased libido7 G. s0 o+ F) }( `% p
secondary to depression.6 a5 K5 u: g& U, q* p
The child slept in the same bed with parents.
+ z' P* j X' b1 j7 a5 V) Q# S+ ZThe father would hug the baby and hold him on his+ r( M- R+ i3 J! O) k" [
chest for a considerable period of time, causing sig-5 V& [ v; H+ I4 X
nificant bare skin contact between baby and father.1 P1 E. f* m r5 i) f& |
The father also admitted that after the phone call,
1 c8 S$ F6 ^" q5 Qwhen he learned the testosterone level in the baby
/ s, l/ N5 \5 n4 p6 K" B$ x* cwas high, he then read the product information" O" |) z7 L% K/ y; l& ?2 h& d2 j
packet and concluded that it was most likely the rea-$ o* Q9 s4 Q _4 A( t+ B" [2 I
son for the child’s virilization. At that time, they: }0 w; }2 |* B o( t
decided to put the baby in a separate bed, and the/ ]9 e$ g4 d) j2 m4 G
father was not hugging him with bare skin and had2 U$ s8 F/ n% S: a# R# ^3 H
been using protective clothing. A repeat testosterone5 c2 `1 ~4 K2 Y7 ~
test was ordered, but the family did not go to the
$ y0 x, d7 _1 R- N4 I2 Q5 \laboratory to obtain the test.' L! V8 l0 Q( K/ X& U/ f9 B
Discussion; D! o( r1 P. e6 [4 r& S
Precocious puberty in boys is defined as secondary
5 W8 ?: G& R( r9 Dsexual development before 9 years of age.1,4
0 ?3 [4 c) G+ }- A1 Z9 p5 u5 [5 gPrecocious puberty is termed as central (true) when" y6 I3 o5 q3 B4 y# k, v& y+ G1 U
it is caused by the premature activation of hypo-
/ @5 A$ W6 c7 f6 t$ p6 s& f# ?thalamic pituitary gonadal axis. CPP is more com-
S# k% Z6 ~9 C6 v$ j6 q8 J: cmon in girls than in boys.1,3 Most boys with CPP3 I& }& K+ v8 @' F; x8 F
may have a central nervous system lesion that is! u- B& c$ \: }1 F, s
responsible for the early activation of the hypothal-, A/ o% r" m2 J2 Y
amic pituitary gonadal axis.1-3 Thus, greater empha-
- y( ^* K* b+ v7 C: G& S, K2 hsis has been given to neuroradiologic imaging in
: X0 m4 m3 w4 m1 ?1 u+ C; `, zboys with precocious puberty. In addition to viril-
8 w P: W. n& e& Zization, the clinical hallmark of CPP is the symmet-4 ]9 ?9 Q0 D, w$ D- A- o
rical testicular growth secondary to stimulation by
# y" A0 C. ]7 q9 q8 i! rgonadotropins.1,3( X9 Z- u- G0 x3 C
Gonadotropin-independent peripheral preco-
. m' d/ b8 I' z' M# H0 r0 Tcious puberty in boys also results from inappropriate
* m' R% Q; Z! E: Q* Yandrogenic stimulation from either endogenous or
# U7 R0 ~7 f/ ?% Y1 H7 v" ~7 nexogenous sources, nonpituitary gonadotropin stim-
* L) `! t! K- V0 ]& Tulation, and rare activating mutations.3 Virilizing
9 T+ w) R. s# K3 F* Kcongenital adrenal hyperplasia producing excessive
7 n( K9 J& \" Q: |! A8 aadrenal androgens is a common cause of precocious
0 ^1 G8 p& H1 Q6 K6 Ppuberty in boys.3,4+ \( ^+ R/ x% Y4 l. o
The most common form of congenital adrenal+ s6 ~, l& V1 N3 p6 b
hyperplasia is the 21-hydroxylase enzyme deficiency.4 S* P( ^" |% J2 W% Q W* @1 Q
The 11-β hydroxylase deficiency may also result in1 P7 c8 u- y2 v4 R
excessive adrenal androgen production, and rarely,
1 @$ W8 A; v W2 p8 {5 Aan adrenal tumor may also cause adrenal androgen
" D2 b3 ^/ j+ d7 v5 ^* oexcess.1,3- p" N( h/ `2 D# A
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) C. l# H4 S4 ]3 ^7 v542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
, ?& m; e0 {$ C# |) I: ZA unique entity of male-limited gonadotropin-( [- M; I7 ~" ], M+ F( ?
independent precocious puberty, which is also known' f3 L% w7 S0 ]# o
as testotoxicosis, may cause precocious puberty at a3 ]7 h# ] J1 s9 C8 |
very young age. The physical findings in these boys
+ N. M# h2 y, pwith this disorder are full pubertal development,
7 [) p& |( Y% Sincluding bilateral testicular growth, similar to boys
* u8 L1 K6 K' F& q+ c( Fwith CPP. The gonadotropin levels in this disorder
6 ?2 j) R/ s! V# P1 F: ?1 qare suppressed to prepubertal levels and do not show
* s) k" j. e- o3 Npubertal response of gonadotropin after gonadotropin-" I4 u. |' I2 D' I/ i* V
releasing hormone stimulation. This is a sex-linked
) I9 R7 N: Z B' R* D/ `autosomal dominant disorder that affects only# J9 q, l5 r2 ?
males; therefore, other male members of the family
1 y3 H# {/ G( k" \, e5 S/ Xmay have similar precocious puberty.3" T! A3 E% ~2 @( X
In our patient, physical examination was incon-
0 X" n9 f& o$ y8 Esistent with true precocious puberty since his testi-, ?& I/ \5 H$ b0 V1 R/ d
cles were prepubertal in size. However, testotoxicosis7 B9 Y5 x/ Q1 ]7 y/ u, r
was in the differential diagnosis because his father
6 j4 b) ^+ ~+ k( T+ y7 O6 Istarted puberty somewhat early, and occasionally,; S7 e/ B; {9 ~' S6 G
testicular enlargement is not that evident in the2 n& b5 y m! x; b
beginning of this process.1 In the absence of a neg-
; _7 K% q. M' x% p! u( \) Cative initial history of androgen exposure, our
" Q$ U# }2 a/ h4 q/ }biggest concern was virilizing adrenal hyperplasia,, l: _! e* q0 p4 g
either 21-hydroxylase deficiency or 11-β hydroxylase
4 d0 J6 F- S: Rdeficiency. Those diagnoses were excluded by find-
) \( T/ s6 j& u8 Ving the normal level of adrenal steroids.. y' \8 d& ]6 q/ l3 V
The diagnosis of exogenous androgens was strongly
, C" A( C1 n: ~+ ~9 T. h9 Xsuspected in a follow-up visit after 4 months because% J' s! ~6 E1 t6 y! W/ f/ |
the physical examination revealed the complete disap-; j! C7 ?, p/ Q3 @% A
pearance of pubic hair, normal growth velocity, and
; L- i( u3 e3 mdecreased erections. The father admitted using a testos-+ _; s' B# d2 Y* O- o
terone gel, which he concealed at first visit. He was; p: n' q6 u- y' c6 y- P
using it rather frequently, twice a day. The Physicians’1 v- y3 e6 b- R) T7 l6 |' P
Desk Reference, or package insert of this product, gel or/ @" X# f% I2 B: U% n4 \
cream, cautions about dermal testosterone transfer to2 \. R0 u/ C Q5 g4 H: \- D$ e
unprotected females through direct skin exposure.- W8 @' f a* a3 c5 n
Serum testosterone level was found to be 2 times the* r7 j& G6 l; k6 J7 }; ]/ N4 o
baseline value in those females who were exposed to
& ^/ A! I4 {4 leven 15 minutes of direct skin contact with their male5 Q+ l0 z/ Z" R. G4 w
partners.6 However, when a shirt covered the applica-
9 h6 r% G: c$ K) ?tion site, this testosterone transfer was prevented.0 w# D6 L; X' j) @, @" f: `
Our patient’s testosterone level was 60 ng/mL,
5 ^' j& G: r* E" ewhich was clearly high. Some studies suggest that
. }4 y: ^: D4 T6 B9 adermal conversion of testosterone to dihydrotestos-
% J+ ~) q( c z; Nterone, which is a more potent metabolite, is more
3 I2 T/ }# W9 h- c3 S; L" Xactive in young children exposed to testosterone
8 A5 A' I4 S# l) D2 z! ~exogenously7; however, we did not measure a dihy-
$ y& c l) r) |0 c& s) O) w) _+ Ldrotestosterone level in our patient. In addition to* m* k8 g" {6 q: K' N, G" a
virilization, exposure to exogenous testosterone in
/ ^$ Y0 V8 y5 `8 Y$ w8 echildren results in an increase in growth velocity and
" S4 W6 T; ]8 |% Z- o: B7 Jadvanced bone age, as seen in our patient.
: Z. L, p7 u" I5 U/ ]The long-term effect of androgen exposure during
( B0 i& m2 E" y3 O4 {, M4 ]early childhood on pubertal development and final
! @$ x5 J" ~2 N" N- Ladult height are not fully known and always remain
5 W/ S% {- A8 u& Ya concern. Children treated with short-term testos-
" K$ ~$ m0 W3 O1 k rterone injection or topical androgen may exhibit some; W: R: L! u. H t3 n- n& k
acceleration of the skeletal maturation; however, after1 ~3 b" y; d, j
cessation of treatment, the rate of bone maturation: U) m, J+ Z& {. u, U
decelerates and gradually returns to normal.8,9: H0 e' a$ G6 A) v1 u
There are conflicting reports and controversy
7 i% x* C' s1 v9 `' Yover the effect of early androgen exposure on adult$ D( U1 a: q6 F
penile length.10,11 Some reports suggest subnormal* S0 o" C( Z) ~ ]( v2 H$ a
adult penile length, apparently because of downreg-
- H' J7 n, k% l7 yulation of androgen receptor number.10,12 However,! G! H) }- N! ^- ]9 z! \9 E& ~9 Y
Sutherland et al13 did not find a correlation between. b0 s! F/ T# v" h# J
childhood testosterone exposure and reduced adult
8 H" U) b& Y- h5 Npenile length in clinical studies.7 n) P2 K+ X7 D w; O: k
Nonetheless, we do not believe our patient is
3 o4 D$ G; I V0 rgoing to experience any of the untoward effects from; W$ F0 a+ W8 |& }/ T
testosterone exposure as mentioned earlier because" A( `- H% ~$ M9 B2 p
the exposure was not for a prolonged period of time.
9 P/ J2 N0 j4 c" lAlthough the bone age was advanced at the time of
' F3 C; q/ U4 d$ r5 c% cdiagnosis, the child had a normal growth velocity at* ]0 ?( ^5 b$ G9 Q7 f4 V
the follow-up visit. It is hoped that his final adult
0 D2 |( `+ w4 j O2 v( V% Gheight will not be affected.
. m- p' Y- I3 B6 W, xAlthough rarely reported, the widespread avail-$ P7 B7 R. Y+ p/ a j3 w& n
ability of androgen products in our society may. M, X0 x+ E3 l& ?5 S
indeed cause more virilization in male or female
0 U0 @/ e3 v+ E3 mchildren than one would realize. Exposure to andro-! Q& L, M7 y4 \% {% X: X
gen products must be considered and specific ques-
: s3 R" R1 q; |; T6 c; N% ]/ V& Dtioning about the use of a testosterone product or
1 n1 W* k( T$ a4 H1 L9 J5 Hgel should be asked of the family members during3 L3 l# i" a; s& `: r! D% C
the evaluation of any children who present with vir-
( A7 [) V: j4 G" T2 y. [9 Zilization or peripheral precocious puberty. The diag-
: N; h& X9 A$ F0 h/ }9 {) pnosis can be established by just a few tests and by
7 l$ p) h' I) E4 ]appropriate history. The inability to obtain such a
& b' \( G6 H8 i$ K; ~8 e& @' Whistory, or failure to ask the specific questions, may
# z1 @& |7 ^' q Eresult in extensive, unnecessary, and expensive& a' b0 R( e4 G4 Q
investigation. The primary care physician should be2 u, E$ `9 M4 m. [
aware of this fact, because most of these children |( c, D3 m1 l% a- T) E
may initially present in their practice. The Physicians’
9 ~7 u9 {& m8 _+ O* s- j1 C: p, R: |5 JDesk Reference and package insert should also put a
$ b/ x- V' c7 [8 pwarning about the virilizing effect on a male or, r- @* O( G4 H6 i7 W
female child who might come in contact with some-
3 j7 r0 Q f0 n7 _* mone using any of these products." F! z4 a# _$ n3 A J2 v& H
References3 X1 c; E G) z8 Z2 F. e$ A' B$ ~, ~
1. Styne DM. The testes: disorder of sexual differentiation
/ l* w+ j& O0 J/ t7 h, kand puberty in the male. In: Sperling MA, ed. Pediatric
6 @0 j( h! m2 K9 H4 M( {2 N |Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
4 c7 b# G1 i' ~7 B9 N" k" l2002: 565-628.. H2 o+ I( o) {8 `8 M( R, W! b
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
! c+ ], F6 x0 o9 Q6 V% i* K, {' W5 spuberty in children with tumours of the suprasellar pineal |
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