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Sexual Precocity in a 16-Month-Old
, A5 S2 h; {8 pBoy Induced by Indirect Topical
: [ j: E/ j9 k, K! z# uExposure to Testosterone) |8 K+ O! c3 G. r8 t9 t* Q0 P7 K4 d) e9 `
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
9 T2 g y. J( d; ?8 M; Iand Kenneth R. Rettig, MD1
! `, b6 j! K" ?% b- EClinical Pediatrics9 |' A0 A, C N
Volume 46 Number 6
% H9 g, f( C: E( pJuly 2007 540-543$ K# o7 |+ {: z
© 2007 Sage Publications
' v6 z" c0 j" ?! J$ R10.1177/00099228062966513 g) ^$ ?" K4 T" Y* M% I: z( |/ P
http://clp.sagepub.com2 f! j" V( D2 R2 `7 o
hosted at
: U6 ^8 g9 W3 ^+ thttp://online.sagepub.com' k- V2 \7 N4 T& U8 w
Precocious puberty in boys, central or peripheral, Y+ y, l# u6 t. b. E- j
is a significant concern for physicians. Central# Q! K9 w+ C7 x; ]- V7 o) _
precocious puberty (CPP), which is mediated
z6 V! {8 Q3 d$ f3 T# Nthrough the hypothalamic pituitary gonadal axis, has8 P* l* L, H9 [9 I( x+ F$ q( n8 i$ H
a higher incidence of organic central nervous system% v! z3 h# U! f
lesions in boys.1,2 Virilization in boys, as manifested' w$ a. \/ l' a
by enlargement of the penis, development of pubic- X* c# a8 Z2 `0 b3 o0 t
hair, and facial acne without enlargement of testi-$ X9 [" Y0 a8 J7 |. ~ m
cles, suggests peripheral or pseudopuberty.1-3 We4 }7 G; D3 Z2 ~0 g
report a 16-month-old boy who presented with the2 }- l# n" Q7 J O7 B' l
enlargement of the phallus and pubic hair develop-" c) h3 I) p5 k6 F6 ?$ P
ment without testicular enlargement, which was due; |! x4 H$ q! d4 x
to the unintentional exposure to androgen gel used by7 i* m- F3 @# U5 E b
the father. The family initially concealed this infor-+ y$ t* N2 q7 M. ^
mation, resulting in an extensive work-up for this/ e0 q' h) [6 Y1 Z! X8 c& v( }1 D
child. Given the widespread and easy availability of
8 Q" p5 K3 B( {6 d b% q& A) ctestosterone gel and cream, we believe this is proba-0 \5 T, R# o$ B' R$ y& r
bly more common than the rare case report in the- j# f. ~( K' v" u( [' d
literature.4
$ Z) S8 \ L3 [Patient Report# V) l# M z$ P, F. d, q8 a
A 16-month-old white child was referred to the7 r# r4 |* n: E" T2 a+ j- T
endocrine clinic by his pediatrician with the concern
! F( @, P; M0 q) {! Sof early sexual development. His mother noticed$ {& P0 H$ }8 V; M0 m+ Y
light colored pubic hair development when he was
0 Q3 x9 F* C- u7 J/ c. hFrom the 1Division of Pediatric Endocrinology, 2University of
9 o6 f! r- z! G6 ~3 r" g9 YSouth Alabama Medical Center, Mobile, Alabama.- @' Q f" T6 T6 \, H0 x- s
Address correspondence to: Samar K. Bhowmick, MD, FACE,$ |& y/ E) H2 e# s- w
Professor of Pediatrics, University of South Alabama, College of3 Z0 c" \7 x+ x( E* o3 S
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
5 R* z* L. Q% u( t) [7 Je-mail: [email protected].: y$ I; C5 H. U( n' r- v% Y5 R! j c$ j
about 6 to 7 months old, which progressively became5 W+ b5 Y; d1 N
darker. She was also concerned about the enlarge-
4 J% w. r) Q6 J/ T/ Fment of his penis and frequent erections. The child! H) K" `* w0 t& v, y8 W
was the product of a full-term normal delivery, with
: T/ @" e/ l5 U# ea birth weight of 7 lb 14 oz, and birth length of& |: F0 u! j& Z/ ]4 W
20 inches. He was breast-fed throughout the first year- \+ @4 A \# M4 S
of life and was still receiving breast milk along with
4 N1 Z/ Q L, C% g( y; |solid food. He had no hospitalizations or surgery,
7 ~/ t: g' h ^( A' dand his psychosocial and psychomotor development
6 J: ~, K8 E. V$ u# ]was age appropriate.
) i% d' E) T2 i) M' nThe family history was remarkable for the father,
& G+ u7 C' W. }- D( S" Ywho was diagnosed with hypothyroidism at age 16,( x1 Q1 C* S7 a. ~) ~; [
which was treated with thyroxine. The father’s
' D# I& \1 I' y- Bheight was 6 feet, and he went through a somewhat+ p( @ R: e6 G- K w2 T: u( Y
early puberty and had stopped growing by age 14.
% e1 B3 f- z0 R, H( C6 V7 ?, B' `The father denied taking any other medication. The
% u3 b+ W: R9 _child’s mother was in good health. Her menarche
0 s& B/ L3 z8 ]8 }8 O0 X" Swas at 11 years of age, and her height was at 5 feet9 O1 T7 M: F' P& M8 B
5 inches. There was no other family history of pre-$ o* }8 y" K0 u* s
cocious sexual development in the first-degree rela-, u; P$ `1 c# y, N, S
tives. There were no siblings.
' n9 d1 f" b: }' A6 l0 N: IPhysical Examination+ U8 e1 j2 p! l: Z) Z8 E0 e
The physical examination revealed a very active,9 ?, _; g! A6 S: `0 ?
playful, and healthy boy. The vital signs documented
$ \: \2 ^9 X" ya blood pressure of 85/50 mm Hg, his length was, b; L1 P+ o# ^! [) D
90 cm (>97th percentile), and his weight was 14.4 kg3 c' O4 b: _% v$ N$ @2 |" c' p
(also >97th percentile). The observed yearly growth
3 {- p$ n7 A, k1 ?5 i) z4 Mvelocity was 30 cm (12 inches). The examination of/ f4 ~& O0 E) V! P$ d5 r( _
the neck revealed no thyroid enlargement.' S& W3 X) C; @5 B2 f/ u
The genitourinary examination was remarkable for
# k' Y7 A( e0 O( t8 V: Ienlargement of the penis, with a stretched length of2 B0 |, k( }, ]/ B4 p% Y
8 cm and a width of 2 cm. The glans penis was very well
& }5 @& B* {/ ?1 Y" T2 y2 \developed. The pubic hair was Tanner II, mostly around" N& K( s8 i" s6 `9 J1 H
540
8 }# {! G E9 Uat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from8 s5 z8 |# f; E0 I# g1 y- C9 H
the base of the phallus and was dark and curled. The& f1 T+ a- [7 m% M A* n
testicular volume was prepubertal at 2 mL each.3 @( w& j( x2 _' o. i0 y
The skin was moist and smooth and somewhat
0 g. A: P; n+ O$ ioily. No axillary hair was noted. There were no/ ?; K6 l) N' ~# D) p" h, o2 ~ H# H9 }
abnormal skin pigmentations or café-au-lait spots.
$ D5 |! P+ {+ Y; {' L0 Y6 y% JNeurologic evaluation showed deep tendon reflex 2+' L E, l; ? Z
bilateral and symmetrical. There was no suggestion# G; E/ K8 H ^9 j, n/ L
of papilledema.
: |/ {+ q3 z/ s9 ]: t1 J/ yLaboratory Evaluation
8 s, s' y; _+ lThe bone age was consistent with 28 months by
8 x. F( B+ j, ?6 ` vusing the standard of Greulich and Pyle at a chrono-4 i# T* _2 [% N+ p1 P
logic age of 16 months (advanced).5 Chromosomal n. e) c6 v. V! E/ X
karyotype was 46XY. The thyroid function test
: S' D5 k9 q2 C" d& Jshowed a free T4 of 1.69 ng/dL, and thyroid stimu-% q. m/ _8 _" N+ x& [5 a) P7 E3 s
lating hormone level was 1.3 µIU/mL (both normal).
1 j, I h" N, Y& MThe concentrations of serum electrolytes, blood+ m9 c2 o4 A! I
urea nitrogen, creatinine, and calcium all were
* p! M# E Y! P3 m$ vwithin normal range for his age. The concentration
3 ]7 |( `& q- p0 s e& wof serum 17-hydroxyprogesterone was 16 ng/dL
2 J" d3 S" J; d2 J$ j/ n7 j(normal, 3 to 90 ng/dL), androstenedione was 20( [* ^! T3 {: t( [1 S
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
% F' y3 s- k Q. {* n4 nterone was 38 ng/dL (normal, 50 to 760 ng/dL),# D4 w: a& P2 M. _7 }' ]+ K
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
- h$ z" z! M1 A+ u/ Z h49ng/dL), 11-desoxycortisol (specific compound S)
8 _6 @/ W; U; k' M4 awas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
' H/ {' k6 T* q/ ^! Y) g- ftisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total J: i, x9 X Y3 x% f7 L- x
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
/ Q9 T* n0 l: R1 [ s* Tand β-human chorionic gonadotropin was less than
$ z) q2 [. ]- Q/ b3 n* ^0 p5 mIU/mL (normal <5 mIU/mL). Serum follicular: ?* m: Z( p H
stimulating hormone and leuteinizing hormone; x& n" h1 \" V5 O @# f5 Y
concentrations were less than 0.05 mIU/mL
) m: S7 z M5 o' K( Q3 i# r(prepubertal).. t# T7 e i/ N
The parents were notified about the laboratory1 W: ~6 i0 D D; h }4 A; p/ y9 S
results and were informed that all of the tests were
! [1 u$ y( `& O3 V% [8 l9 [4 `normal except the testosterone level was high. The
+ r( g9 J$ E9 n4 N, J/ i4 Ffollow-up visit was arranged within a few weeks to
% |4 a$ P9 ?% X7 i4 Yobtain testicular and abdominal sonograms; how-! M* Q1 x& Y8 v4 o
ever, the family did not return for 4 months.
' _3 }# [5 `: o: {, U* uPhysical examination at this time revealed that the
. [, i4 Y( y _9 A6 o# p- cchild had grown 2.5 cm in 4 months and had gained
( L& p }& m) U& b2 kg of weight. Physical examination remained) x, j/ K- | K6 r& m
unchanged. Surprisingly, the pubic hair almost com-7 T8 x- d# h# u$ F9 ^2 e
pletely disappeared except for a few vellous hairs at
8 W0 m" e' p/ x% a0 r4 e8 Athe base of the phallus. Testicular volume was still 2# e! J/ d. T/ f7 c9 `0 m
mL, and the size of the penis remained unchanged.
5 o& y! A" g* P9 s! s: |4 RThe mother also said that the boy was no longer hav-
& \/ b+ R. ]/ f8 n5 ling frequent erections.* H2 U, R5 i, e% h. u$ J
Both parents were again questioned about use of
! v6 G1 W) h6 l: `: R* }any ointment/creams that they may have applied to1 y! c2 R+ B. a& p- @: u
the child’s skin. This time the father admitted the% O, v, x8 X+ W: Q$ G# G
Topical Testosterone Exposure / Bhowmick et al 541
% j7 G6 O4 r( E; N4 u$ Wuse of testosterone gel twice daily that he was apply-8 V( r6 x6 i8 R3 m" N" _8 Z
ing over his own shoulders, chest, and back area for
* J! `6 w6 z5 M2 L1 v3 Q- la year. The father also revealed he was embarrassed2 C. Q8 q* B6 l2 W6 Y P+ o1 [
to disclose that he was using a testosterone gel pre-( _' c8 \* u; X8 n
scribed by his family physician for decreased libido- \0 o+ f7 ?3 K2 O8 z* X4 q( f2 `+ S
secondary to depression.
9 a) t1 T/ ?5 M& p: MThe child slept in the same bed with parents.
; m& e4 m2 o: |8 x* |+ sThe father would hug the baby and hold him on his
% w8 Y5 n$ ^* O/ n3 rchest for a considerable period of time, causing sig-% a& b; p8 L' b M1 [7 T
nificant bare skin contact between baby and father.& u' {0 [# {; O0 a0 z9 a; }
The father also admitted that after the phone call,
: k. H8 p$ V2 L) zwhen he learned the testosterone level in the baby
6 [/ o" @5 x8 B: \2 x& G: \was high, he then read the product information0 r8 _ G' O% j: _- }
packet and concluded that it was most likely the rea-' q- ~/ W: v1 N
son for the child’s virilization. At that time, they
: b. J d8 g* cdecided to put the baby in a separate bed, and the
- b2 n/ `* \6 n4 f3 R$ E P2 b( |father was not hugging him with bare skin and had
. y2 P" M9 | u$ H# S1 k; \' L% fbeen using protective clothing. A repeat testosterone
4 L. _# p, m/ Wtest was ordered, but the family did not go to the
1 I' q/ `, T, Q# _7 q4 f* Klaboratory to obtain the test.
* U3 g7 B" A- P% `2 B$ p& h! wDiscussion
3 U6 Z& {$ V" f% V) P& x1 ?; D1 MPrecocious puberty in boys is defined as secondary
6 q- t: h% Z( }$ f bsexual development before 9 years of age.1,4# t1 D, l" p0 S1 s
Precocious puberty is termed as central (true) when
. H+ { @( b @. q) V+ Xit is caused by the premature activation of hypo-% Q2 W p. F; U* v! C4 M- N
thalamic pituitary gonadal axis. CPP is more com-- @& r0 S5 e$ B& R* V5 y: L- m4 k
mon in girls than in boys.1,3 Most boys with CPP5 Z" ^ ^$ f8 Z. K; R" {
may have a central nervous system lesion that is' ]0 P. k( f& V+ t9 W9 G/ B8 ?
responsible for the early activation of the hypothal-
5 v) m# g3 v9 P' R0 C/ C0 xamic pituitary gonadal axis.1-3 Thus, greater empha-) b8 }& N @4 m- s" U
sis has been given to neuroradiologic imaging in' d$ U' y; B+ P
boys with precocious puberty. In addition to viril-
" X7 ~8 R F/ t2 F& G" mization, the clinical hallmark of CPP is the symmet-
- K, h5 H+ g! q, grical testicular growth secondary to stimulation by
5 `* @. [- l- `gonadotropins.1,3
% y9 N1 h' A J$ L# s7 E% c: ZGonadotropin-independent peripheral preco-
/ @, O! z" W7 mcious puberty in boys also results from inappropriate
8 s' b H* S, W% v ?( _3 D5 zandrogenic stimulation from either endogenous or
1 X0 e2 A. `3 D2 ?. M7 oexogenous sources, nonpituitary gonadotropin stim-9 p, z1 Z" j; j: r1 m! C
ulation, and rare activating mutations.3 Virilizing
; F( T% T6 ~" v, _congenital adrenal hyperplasia producing excessive
0 @; E& ^$ n5 R/ x0 j; ]0 D- |) Z& Qadrenal androgens is a common cause of precocious* ]1 D. l: ?5 l j/ I6 O
puberty in boys.3,4
8 d) B3 Z5 m3 H$ Y- kThe most common form of congenital adrenal: c4 f4 U; q4 J* Y- X& \ S
hyperplasia is the 21-hydroxylase enzyme deficiency.
8 z7 D: W9 i/ R3 @, ~* S; I. F/ yThe 11-β hydroxylase deficiency may also result in
, K5 O* b% n0 cexcessive adrenal androgen production, and rarely,
/ k+ ~5 b: F% ian adrenal tumor may also cause adrenal androgen) a3 T7 C3 o) h, ~: M
excess.1,3
2 j2 ^" o1 p4 r, W( |9 k5 R. j5 K) Iat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from: ^, C* O @4 d. ~2 G
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
7 M- }5 m/ f7 `0 y5 lA unique entity of male-limited gonadotropin-
- s% |( s6 D, v, o" mindependent precocious puberty, which is also known9 o$ e* |7 n% N
as testotoxicosis, may cause precocious puberty at a7 K6 t4 b; \3 M( z# [
very young age. The physical findings in these boys
7 m9 ^2 j% h8 [# swith this disorder are full pubertal development,1 _- R: X% [- ]/ Q$ }8 I
including bilateral testicular growth, similar to boys, A& ~' l$ I4 w, V0 s
with CPP. The gonadotropin levels in this disorder! ?- i5 U/ ?/ `. q7 d
are suppressed to prepubertal levels and do not show
9 Q# `. m. D, Tpubertal response of gonadotropin after gonadotropin-7 Y& ~) W+ u9 x; w9 \9 K) _
releasing hormone stimulation. This is a sex-linked) s7 `: j' _& T9 o/ P% d, ]# Z
autosomal dominant disorder that affects only
' Y3 i3 u, }" s; E8 p! m( Wmales; therefore, other male members of the family
9 e# g% k4 e+ F8 smay have similar precocious puberty.3
; E/ O5 C7 r# m' t8 h* A4 m kIn our patient, physical examination was incon-
/ A8 L3 J4 G2 q9 Z8 Dsistent with true precocious puberty since his testi-
( H( V8 m8 T) p- M% t7 i2 Ycles were prepubertal in size. However, testotoxicosis9 _; m t# A4 e
was in the differential diagnosis because his father, L, [- Q6 n" D/ T
started puberty somewhat early, and occasionally," d* M: E% e( |1 h
testicular enlargement is not that evident in the
/ G& N! e5 s7 Y4 K, i9 [/ ?9 Vbeginning of this process.1 In the absence of a neg-
& f& |; }, J! z+ cative initial history of androgen exposure, our5 E5 g! x& o8 G) T- |: q1 ?
biggest concern was virilizing adrenal hyperplasia,- ~: f- Q7 b9 Y/ J8 p8 O
either 21-hydroxylase deficiency or 11-β hydroxylase
) X4 i9 k+ I1 r" X- u+ N R0 I7 wdeficiency. Those diagnoses were excluded by find-
5 I, m( _1 d0 W8 @ing the normal level of adrenal steroids.
0 N$ k/ y" g+ YThe diagnosis of exogenous androgens was strongly
U9 ` t. r# b2 |# Q& h% Xsuspected in a follow-up visit after 4 months because
4 e6 u, N- \! `+ [. ^' ~+ G4 e/ Gthe physical examination revealed the complete disap-
1 {+ r+ g" A% S7 z; f" spearance of pubic hair, normal growth velocity, and
% j3 Q- H" ~9 f* Z* n9 w1 ydecreased erections. The father admitted using a testos-
" r1 T1 r# D( O8 S; e. P) d/ c+ tterone gel, which he concealed at first visit. He was! K0 X+ Z( [# e9 k; W
using it rather frequently, twice a day. The Physicians’
3 B1 I; [& w* j1 C) D* w9 CDesk Reference, or package insert of this product, gel or
! s7 p/ t! F2 B1 ]cream, cautions about dermal testosterone transfer to0 @* x7 S, W6 Y9 e' W
unprotected females through direct skin exposure.
% t/ {3 i% T4 s+ n+ T3 YSerum testosterone level was found to be 2 times the
$ m" x: W: y7 g! kbaseline value in those females who were exposed to
, z N* f: ?' v weven 15 minutes of direct skin contact with their male
! b7 p1 n4 k2 V. m" z9 ]4 Vpartners.6 However, when a shirt covered the applica-
4 c$ D7 M+ d8 k( D# m' y. Ztion site, this testosterone transfer was prevented.
6 R: a( P6 C" L* {8 Q5 wOur patient’s testosterone level was 60 ng/mL,
" ]4 H0 P9 B: Z; lwhich was clearly high. Some studies suggest that
: c1 `- P2 I0 \7 I; G6 |dermal conversion of testosterone to dihydrotestos-
, |9 @! S# j5 e+ w1 rterone, which is a more potent metabolite, is more/ e |- ] Y4 u, Q! \
active in young children exposed to testosterone
8 `, c* I; N8 g9 ?% ~( ^$ texogenously7; however, we did not measure a dihy-
: ]" z6 X/ T9 H( A, cdrotestosterone level in our patient. In addition to1 t7 |/ c% |" ?. d! }
virilization, exposure to exogenous testosterone in
! K7 }$ r, K0 I# A! V* Ochildren results in an increase in growth velocity and0 h; E' j$ @$ X4 o5 H- O$ I2 o( _
advanced bone age, as seen in our patient.
/ [: X( k) K1 P& ?0 [" ~6 d" ?The long-term effect of androgen exposure during
6 A- {* C2 G: X' p- \5 wearly childhood on pubertal development and final
- S" u5 g$ }1 O6 j; p3 `9 [adult height are not fully known and always remain
6 t8 E4 d1 h3 pa concern. Children treated with short-term testos-
! J) Z$ K* d$ g1 Y5 D" `terone injection or topical androgen may exhibit some
# s3 g( g1 I9 \) \2 uacceleration of the skeletal maturation; however, after
6 J5 P- X6 t( @cessation of treatment, the rate of bone maturation
: V) ^& a2 b: |# u4 T4 [decelerates and gradually returns to normal.8,99 ^- m% C7 ]# e8 H
There are conflicting reports and controversy
. S5 V2 a8 h$ yover the effect of early androgen exposure on adult
* w; S: A! T9 _5 fpenile length.10,11 Some reports suggest subnormal1 V+ e/ N1 R2 y. v( h+ C
adult penile length, apparently because of downreg-! q) N8 h5 t6 o/ o8 M" Z7 b: Q1 y
ulation of androgen receptor number.10,12 However,
; I! U+ f% Q' l Y/ ?Sutherland et al13 did not find a correlation between, l8 B6 m8 A/ B1 x+ E
childhood testosterone exposure and reduced adult
2 `2 x0 k$ M1 v6 Cpenile length in clinical studies.6 }2 J* \5 K' O1 _- f; r
Nonetheless, we do not believe our patient is$ ?+ n; b& T! I% A! \9 o: F
going to experience any of the untoward effects from) m. m5 ?1 v4 e4 S/ c
testosterone exposure as mentioned earlier because& t7 Y4 h9 S0 [- V& T
the exposure was not for a prolonged period of time.
% L. H7 o9 Y( _- B) R& x6 tAlthough the bone age was advanced at the time of/ K0 r5 h+ ? z2 y# F
diagnosis, the child had a normal growth velocity at2 ^) Y& a- K) e& Z3 ~- S6 C1 }
the follow-up visit. It is hoped that his final adult- w8 _8 p( y& W. Y7 s6 K
height will not be affected.
& C" O, d& y5 j. k, e1 DAlthough rarely reported, the widespread avail-# U7 ]4 N, g: n, }: z( S, P5 k
ability of androgen products in our society may
) Y# {% x2 p8 K+ tindeed cause more virilization in male or female! O& H n* B" M8 p+ w
children than one would realize. Exposure to andro-: s- E U. b3 z: E9 u2 h. f
gen products must be considered and specific ques-
6 P+ R* q, n3 T+ c* \5 Wtioning about the use of a testosterone product or
# L. Y$ M1 V' Mgel should be asked of the family members during- \0 B8 D" w1 X8 F* j& I
the evaluation of any children who present with vir-
; j8 k- I* Z% O5 f- `4 xilization or peripheral precocious puberty. The diag-
0 P" [5 B9 Q, y) ]" O; Bnosis can be established by just a few tests and by1 @( Y* _7 P$ B7 B u1 [- m
appropriate history. The inability to obtain such a$ z- e% K G% P# \8 m
history, or failure to ask the specific questions, may
# R9 l7 _% r$ F3 e$ ~result in extensive, unnecessary, and expensive
* g5 ~1 s \* X Zinvestigation. The primary care physician should be
" L/ J" W/ o* ]! Naware of this fact, because most of these children2 B5 x! y, D" b
may initially present in their practice. The Physicians’6 W( g3 q1 w: ? t% v$ f9 l6 B% \
Desk Reference and package insert should also put a* b% f4 H& I u; O/ u9 n
warning about the virilizing effect on a male or) m8 `9 @+ V: |4 _ n4 P! b' r
female child who might come in contact with some-
9 ^0 s1 J* ?/ G* h: m$ qone using any of these products.
7 v0 T2 M5 G& K; v i+ aReferences
5 P2 M, v% a4 ^% U! P# j# ?+ B1. Styne DM. The testes: disorder of sexual differentiation
* @5 u4 K5 A0 k8 U- i* t& b- jand puberty in the male. In: Sperling MA, ed. Pediatric0 E/ Q i% E3 j
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;( _0 E8 [* ] N6 _. Y# v& p0 e s
2002: 565-628.* ?+ |/ f3 c) g2 p7 R
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious) l$ x6 q0 q, r( o) p. L0 k
puberty in children with tumours of the suprasellar pineal |
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