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Sexual Precocity in a 16-Month-Old( V, P! C9 @$ r
Boy Induced by Indirect Topical
( `6 i( I1 d' ]1 L% f6 n: y( ?Exposure to Testosterone
3 z g- D: S5 _( b: j: LSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
3 h; Y# T$ D$ X* r( y% ?and Kenneth R. Rettig, MD1
& _' Q; n: {0 ]0 N+ S& _+ aClinical Pediatrics2 B" a( V& T0 C h1 Y2 \
Volume 46 Number 6! s6 ?9 X1 _0 d( c% r
July 2007 540-5433 G" }' a2 C( J. F# {
© 2007 Sage Publications1 Q; t! J3 u; ^) b) U" J8 F) h
10.1177/0009922806296651 F1 t3 i$ s% Z
http://clp.sagepub.com
- h7 K9 [. o( q/ O- W4 Jhosted at% {9 l% r/ d) u7 J6 Q8 k
http://online.sagepub.com
b2 z( ?" e# J* v) ?; ]; ?/ JPrecocious puberty in boys, central or peripheral,! Y4 s2 F& ?6 ?8 W; T3 x- A
is a significant concern for physicians. Central) H& e. X/ }, r( n G( i
precocious puberty (CPP), which is mediated
1 T* ?" x; q9 xthrough the hypothalamic pituitary gonadal axis, has% A$ E/ O2 y, G
a higher incidence of organic central nervous system
i( w9 q0 e, |. _" m( _ a% dlesions in boys.1,2 Virilization in boys, as manifested
6 t6 f3 l& r2 J( T" A+ u/ I" @by enlargement of the penis, development of pubic
6 `, k0 Q U2 O4 M6 y6 y; G/ uhair, and facial acne without enlargement of testi-7 {* I! f& u/ P: E, l9 I8 p/ J
cles, suggests peripheral or pseudopuberty.1-3 We
" }6 z/ k6 x* Z/ m4 E* `& k% i' ]report a 16-month-old boy who presented with the
6 m& L$ }. N: Q: \# h4 oenlargement of the phallus and pubic hair develop-
! g) v' i. T: Gment without testicular enlargement, which was due5 U+ M) Y* ~# ` o, @
to the unintentional exposure to androgen gel used by/ Z# n7 F W5 Y0 G
the father. The family initially concealed this infor-
0 V a }, D8 b. K9 @% {, H- Pmation, resulting in an extensive work-up for this
) H( L- Z2 T. W6 I% kchild. Given the widespread and easy availability of4 s/ Y" Z: K$ M+ U& H3 [( F& P% X; p
testosterone gel and cream, we believe this is proba-+ L5 W7 \2 S: [1 p+ L
bly more common than the rare case report in the4 L0 j$ Y7 q7 n* y0 e- R
literature.4
2 k' _ H1 ?" @. `. Y! {Patient Report+ Q8 B& |$ @/ ^# X& A9 R: q
A 16-month-old white child was referred to the3 }! [& w1 Z. N' {1 D
endocrine clinic by his pediatrician with the concern' p6 E- P: d5 l4 H9 K( a D/ j
of early sexual development. His mother noticed
4 y2 P9 W0 a4 H/ T8 nlight colored pubic hair development when he was/ [& O2 z: h; {- o& O" `
From the 1Division of Pediatric Endocrinology, 2University of: g Q' c* [2 _2 W2 @3 ]' K4 f8 S
South Alabama Medical Center, Mobile, Alabama.3 R7 V O1 q( D8 r
Address correspondence to: Samar K. Bhowmick, MD, FACE," _- R, l- `4 Q+ L. W, Y
Professor of Pediatrics, University of South Alabama, College of9 j5 e$ g4 d! G
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;
1 E7 U! {. I6 T0 i: S5 R7 C" he-mail: [email protected].; r. f: u4 ^4 b1 x0 X! d2 W
about 6 to 7 months old, which progressively became
4 R: ]$ s7 _' U1 }/ n* ?2 sdarker. She was also concerned about the enlarge-8 k3 a0 c- P. v$ H3 G. e) I3 N6 l4 w Y
ment of his penis and frequent erections. The child4 ]& F, H% _5 \: H2 M+ R: l6 ]2 Q
was the product of a full-term normal delivery, with
* |% i% F0 t. N# ]3 c) B! Ya birth weight of 7 lb 14 oz, and birth length of
' R9 v3 ~1 E/ c; J1 T S20 inches. He was breast-fed throughout the first year
$ v0 T+ m7 F! \" {# N1 Nof life and was still receiving breast milk along with; y9 V, r( m5 W, l |8 Y) F5 \
solid food. He had no hospitalizations or surgery,0 z. {( O' j: x4 W. m0 E
and his psychosocial and psychomotor development
5 U$ I: G2 k* |& mwas age appropriate.
0 W% J, K9 j5 d$ J2 LThe family history was remarkable for the father,
" v, u. y* I! H7 G/ ~# Iwho was diagnosed with hypothyroidism at age 16,: N6 [' M( Z6 l; a' C9 P
which was treated with thyroxine. The father’s
; ~) t# l1 I/ f+ A% L( @# b5 [height was 6 feet, and he went through a somewhat+ z# y4 x4 ^) t8 @6 I9 K) n$ g4 Z
early puberty and had stopped growing by age 14.) I D" f* f$ K Q E, G
The father denied taking any other medication. The
/ e# B% T* ^- ?& f6 v% A/ h Dchild’s mother was in good health. Her menarche
( m; h5 [; z, m- K5 s( @% cwas at 11 years of age, and her height was at 5 feet
( R' N' l* B' q. \& a5 inches. There was no other family history of pre-4 c3 n& [- P* E
cocious sexual development in the first-degree rela-
/ W/ Y, ?8 I: I1 l9 V atives. There were no siblings.
8 w2 z5 ^! T) SPhysical Examination3 V9 a5 F M& |8 _, X
The physical examination revealed a very active,
( B' d; |( q0 Z; R1 g* b( [4 q: oplayful, and healthy boy. The vital signs documented
) H3 T. {+ O) j9 x3 \$ C* `; ?a blood pressure of 85/50 mm Hg, his length was
; o! U) A6 ]' M2 d& O, z, e2 a90 cm (>97th percentile), and his weight was 14.4 kg
H/ X* [: I9 ^(also >97th percentile). The observed yearly growth; q w7 ?* D4 C X# }" \
velocity was 30 cm (12 inches). The examination of
. `% V$ b4 @* K9 gthe neck revealed no thyroid enlargement.
% d# }4 I$ e1 Q, d R+ DThe genitourinary examination was remarkable for9 G+ r; c( x2 i2 N9 {1 M5 F- S
enlargement of the penis, with a stretched length of0 M2 u) C5 o# Q) {( h' s v& i
8 cm and a width of 2 cm. The glans penis was very well
* @% U+ P2 U0 V( f1 ~1 tdeveloped. The pubic hair was Tanner II, mostly around
$ ]+ M4 B3 o: Q; k" F; A# L- D540
# ] L! Z( |1 [3 `; y/ |; g3 W- sat University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
( t9 \) v/ z3 z4 k9 w) U5 t/ jthe base of the phallus and was dark and curled. The+ I% a* X: G$ ]
testicular volume was prepubertal at 2 mL each.
, _9 V- n& J7 A3 BThe skin was moist and smooth and somewhat+ T( a( B6 ^- Z
oily. No axillary hair was noted. There were no1 P: b; v9 J5 H2 S
abnormal skin pigmentations or café-au-lait spots.7 f9 S- l* V5 d, ]6 x$ A. ^! Q
Neurologic evaluation showed deep tendon reflex 2+
. B$ P& K8 Y: b5 c" obilateral and symmetrical. There was no suggestion
: ~- y0 F; Q5 O1 s0 o e' W7 hof papilledema.: I! A7 K) v7 e" e+ c! N% K" k
Laboratory Evaluation
* u+ |/ B$ q$ t' C. oThe bone age was consistent with 28 months by
5 u% }- I3 ~" e0 uusing the standard of Greulich and Pyle at a chrono-# z% i/ N* m/ B5 i8 ^
logic age of 16 months (advanced).5 Chromosomal
9 y+ d: j- d' h [; T+ s& S( {" h# mkaryotype was 46XY. The thyroid function test9 z& H; y S2 b8 } M$ i
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% Z. y* ^. d9 ~6 klating hormone level was 1.3 µIU/mL (both normal).& P3 v8 q" y1 r o
The concentrations of serum electrolytes, blood! ~4 ?( o4 i% D4 b1 A) D. X
urea nitrogen, creatinine, and calcium all were4 s* {$ L% Y' I2 a& N0 M( Q y
within normal range for his age. The concentration. T K% c) k2 B, [
of serum 17-hydroxyprogesterone was 16 ng/dL! x0 c. F' Z W+ o, n
(normal, 3 to 90 ng/dL), androstenedione was 20: z' U' Q* m. d( o1 z
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
) S. ]# @2 Q' p/ G. Rterone was 38 ng/dL (normal, 50 to 760 ng/dL),
3 M4 | Y. z! R( D8 Ydesoxycorticosterone was 4.3 ng/dL (normal, 7 to* {5 a' h9 F9 L/ @% A2 v# G+ M: c, R
49ng/dL), 11-desoxycortisol (specific compound S)$ |2 |" |% o5 b; c+ s6 Y q' R
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-8 D" x2 D# L& B) n
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
2 f# [9 d/ @: Y+ w* itestosterone was 60 ng/dL (normal <3 to 10 ng/dL),
6 o3 e& R# h, \ S4 _* r2 V4 y2 G+ B2 ^ Pand β-human chorionic gonadotropin was less than- p2 K! f: o! I; Z @- g
5 mIU/mL (normal <5 mIU/mL). Serum follicular
( Z9 b& {, [8 ] istimulating hormone and leuteinizing hormone. h" A1 G- u$ }, ?8 ]' }' D$ `4 Z
concentrations were less than 0.05 mIU/mL
4 A3 B) u/ V8 m( j(prepubertal).* K3 I! h/ u* B
The parents were notified about the laboratory3 j l( U* n# g& n
results and were informed that all of the tests were7 r) H0 P/ t4 F! N L3 c
normal except the testosterone level was high. The5 ?6 ^- ]5 h; B
follow-up visit was arranged within a few weeks to! T! p% w4 \7 F4 J
obtain testicular and abdominal sonograms; how-
5 e# \2 k* J* Xever, the family did not return for 4 months.) `& B% l) d( f
Physical examination at this time revealed that the
: S# [+ h) ~; z# bchild had grown 2.5 cm in 4 months and had gained' H2 x* w6 K0 V7 F8 K/ r3 e
2 kg of weight. Physical examination remained
) K5 s. T1 V, [* p9 a% Hunchanged. Surprisingly, the pubic hair almost com-
0 ~8 O, X7 I% ]pletely disappeared except for a few vellous hairs at
* g8 D* k1 W( _5 ethe base of the phallus. Testicular volume was still 2* h _- s7 L3 |
mL, and the size of the penis remained unchanged.
+ h: M) W+ }6 Y# W8 PThe mother also said that the boy was no longer hav-
* t& q7 v0 P" C. N* U& ting frequent erections.
* ]) T: b! S4 k9 OBoth parents were again questioned about use of/ s0 z% g( ?0 x9 [3 J. g7 |3 k* X3 O& W
any ointment/creams that they may have applied to
& z+ }2 J$ M8 uthe child’s skin. This time the father admitted the, b+ V+ H1 n3 i9 M
Topical Testosterone Exposure / Bhowmick et al 541) }. p2 S- ]8 N" v* A5 w
use of testosterone gel twice daily that he was apply-
& T3 ^" r! `5 |# v$ a V0 X# e, oing over his own shoulders, chest, and back area for" ]1 `" } [' X1 v' Y* R9 W
a year. The father also revealed he was embarrassed2 N4 Q6 D. G" n3 Z6 T" C+ ]6 x
to disclose that he was using a testosterone gel pre-
! ] M9 f+ o( k! }scribed by his family physician for decreased libido8 J6 t8 R3 [4 n
secondary to depression.1 X( V: c) R& H$ F' a
The child slept in the same bed with parents.
7 u( K/ m! p" K" [$ M: fThe father would hug the baby and hold him on his
2 R/ ^ ^, U: Ichest for a considerable period of time, causing sig-
& C p8 Y5 C4 b9 Anificant bare skin contact between baby and father.- C8 Q- [$ L" w; u I
The father also admitted that after the phone call,; S1 S c0 @/ G+ V
when he learned the testosterone level in the baby
- V; M7 y4 p: ywas high, he then read the product information' H' C+ G) l5 T6 G- F4 ?+ R
packet and concluded that it was most likely the rea-
5 n9 W: S- G. e- @son for the child’s virilization. At that time, they/ K- a) X5 D+ a1 f) a
decided to put the baby in a separate bed, and the
. L- [/ q7 o" W# Z1 }6 ofather was not hugging him with bare skin and had
: t* E" M; I: v& s' r" v4 E# l; |been using protective clothing. A repeat testosterone
- ^6 j9 W+ s* t; ctest was ordered, but the family did not go to the
* H& a4 G0 a6 b! c5 `" ]laboratory to obtain the test.* j) B. F% x* d. L- V
Discussion
' f: W5 |$ C- O( d) p. SPrecocious puberty in boys is defined as secondary% X Y" y. p6 f1 T
sexual development before 9 years of age.1,4# ?3 X6 t D1 m- _3 `# b
Precocious puberty is termed as central (true) when
4 H( V3 e* J- rit is caused by the premature activation of hypo- P& P+ l- k8 U( ]& d+ v# {
thalamic pituitary gonadal axis. CPP is more com-
. r! t5 T4 ^$ ^1 x& Wmon in girls than in boys.1,3 Most boys with CPP
% `8 y% Q- o$ v. x* kmay have a central nervous system lesion that is
% J( |: e( R: M5 r( U& a* R8 Zresponsible for the early activation of the hypothal-
4 T% n% K: M8 l4 Ramic pituitary gonadal axis.1-3 Thus, greater empha-) t/ b' b" E) R3 x* s& F
sis has been given to neuroradiologic imaging in, f) |" m9 `+ |. B6 F4 x$ e
boys with precocious puberty. In addition to viril-6 P% d! B [! i3 k; T) u' x) y
ization, the clinical hallmark of CPP is the symmet-- K4 |) B. G; S" J
rical testicular growth secondary to stimulation by4 r$ H% m' `/ I7 V% v0 i$ K, }0 r: ]
gonadotropins.1,3
o7 L: m- I4 ?Gonadotropin-independent peripheral preco-
5 C' G/ C3 w+ G. Qcious puberty in boys also results from inappropriate0 `3 G6 s" n' b- X/ e* G7 _
androgenic stimulation from either endogenous or/ M k& F4 Z {! |, [- F h x/ k
exogenous sources, nonpituitary gonadotropin stim-
/ W, y. |* j5 y9 Aulation, and rare activating mutations.3 Virilizing9 n9 u$ \& I9 p- v: q# z, O
congenital adrenal hyperplasia producing excessive
# |6 s' o9 o& d* Qadrenal androgens is a common cause of precocious1 r- I. N& w! ^6 T7 N7 K4 H# @; \
puberty in boys.3,4
' L* c/ |, H1 J7 a7 S# gThe most common form of congenital adrenal- r1 E, k! y0 e6 q( t" u
hyperplasia is the 21-hydroxylase enzyme deficiency.. p- w3 V4 c/ d, D1 A; V$ K; a
The 11-β hydroxylase deficiency may also result in; ~; {' S( f( r$ U3 c- t
excessive adrenal androgen production, and rarely,
/ v! B8 V: U& f0 p5 k: A; _8 Qan adrenal tumor may also cause adrenal androgen
7 T8 n( N7 d2 a+ Fexcess.1,39 d5 J4 }+ F% m% A4 {$ \3 t) Z
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from! B1 }3 L2 P: Q) I* J3 h
542 Clinical Pediatrics / Vol. 46, No. 6, July 20074 t/ a" d0 c% P4 H0 S
A unique entity of male-limited gonadotropin-3 y6 ?6 U: Z6 N( A2 r' P
independent precocious puberty, which is also known
/ C! _& Z+ `8 K4 D- B+ w% Bas testotoxicosis, may cause precocious puberty at a; @. n, @ |: d/ y5 W
very young age. The physical findings in these boys
. n+ T. H0 M2 H% e, Awith this disorder are full pubertal development,
, o" p0 W$ q, Aincluding bilateral testicular growth, similar to boys' F" R, Q& l$ x6 e& `
with CPP. The gonadotropin levels in this disorder
+ J3 s4 x5 `. m5 h3 U/ W+ b. ]0 G# ~5 g" Sare suppressed to prepubertal levels and do not show
/ {# q$ l0 c+ ipubertal response of gonadotropin after gonadotropin-5 @& I) N$ s4 F( p+ x* ?
releasing hormone stimulation. This is a sex-linked& m& ~; j/ p' h* M- F
autosomal dominant disorder that affects only! j Y8 _+ O* ]3 W% u9 q! e; O
males; therefore, other male members of the family
S! c9 f% s7 n1 q" c' Tmay have similar precocious puberty.37 B- Y8 y6 o& Q$ \4 o |
In our patient, physical examination was incon-" n- s4 p- r$ n, `4 |+ x
sistent with true precocious puberty since his testi-% x# I: U N0 U$ ?
cles were prepubertal in size. However, testotoxicosis
4 }+ u, r- v- N U. n/ ~was in the differential diagnosis because his father
9 q7 Q, g+ z# }8 a" kstarted puberty somewhat early, and occasionally,0 C' p% t' Q/ P: d6 }
testicular enlargement is not that evident in the5 F3 n' H5 b$ G( F
beginning of this process.1 In the absence of a neg-
" F1 d( Q/ M( wative initial history of androgen exposure, our
% f3 ?; _: {: d2 x6 dbiggest concern was virilizing adrenal hyperplasia,( l- }: v. \& w7 u! m1 g
either 21-hydroxylase deficiency or 11-β hydroxylase
; j, c" `% M' E' s' Edeficiency. Those diagnoses were excluded by find-* K& n1 l5 r4 s7 F3 g2 z% E% F# {
ing the normal level of adrenal steroids.& S P5 ?% w5 U
The diagnosis of exogenous androgens was strongly
, L* W' V$ Z4 y+ U) [- S* ]suspected in a follow-up visit after 4 months because
; F. r& V7 s" O+ L) ^+ F, \the physical examination revealed the complete disap-( Q2 p9 B1 T, E# a* q
pearance of pubic hair, normal growth velocity, and
% z5 \+ S( Q( i4 [$ ]decreased erections. The father admitted using a testos-* O5 Q9 U: P- \ y m
terone gel, which he concealed at first visit. He was
: A }" U( ~$ l4 ^- A/ |+ y5 }using it rather frequently, twice a day. The Physicians’4 C/ x: v# a! J3 e1 c
Desk Reference, or package insert of this product, gel or4 H1 I9 h B1 v! C0 E/ ?& l- ? |: W
cream, cautions about dermal testosterone transfer to7 M3 y0 x9 Y/ z; y. R
unprotected females through direct skin exposure.
1 v7 w/ l1 [7 e& [' B CSerum testosterone level was found to be 2 times the
1 {& D7 x. v9 R4 S0 Dbaseline value in those females who were exposed to2 p# }" X) e1 H- j
even 15 minutes of direct skin contact with their male. v3 @. b0 x/ g
partners.6 However, when a shirt covered the applica-, x, z' @ W9 I6 M: _
tion site, this testosterone transfer was prevented.' _9 M' Z7 x' p$ B/ K6 j
Our patient’s testosterone level was 60 ng/mL,! e* ]$ h3 p+ \/ v4 h
which was clearly high. Some studies suggest that
1 ~; S6 r1 w0 L2 ` `dermal conversion of testosterone to dihydrotestos-) B4 B) H+ E2 }. V: i+ ~
terone, which is a more potent metabolite, is more
9 H* L; I! z/ i! j; lactive in young children exposed to testosterone" {" [' }: l" `: c! x, p Q
exogenously7; however, we did not measure a dihy-
- Q- T# s$ }% n1 h ^( udrotestosterone level in our patient. In addition to
. ^& S! O; r# @( j0 xvirilization, exposure to exogenous testosterone in b) ^: u% m8 o. B
children results in an increase in growth velocity and
4 Q3 K1 N. {2 g- @4 r$ padvanced bone age, as seen in our patient.
/ V/ W2 d! k, s1 gThe long-term effect of androgen exposure during; l1 T) L' J6 B4 I: K
early childhood on pubertal development and final, c: @. o5 P% y. A; P1 c
adult height are not fully known and always remain1 Y, F6 l' C6 e) z b& a
a concern. Children treated with short-term testos-
1 O8 ^7 D% s# ^( ]' {9 yterone injection or topical androgen may exhibit some0 q1 k8 W7 b7 p/ x+ @# O
acceleration of the skeletal maturation; however, after
- a7 R3 m' D) d8 ]' Vcessation of treatment, the rate of bone maturation4 c( d1 l% L2 a }, C
decelerates and gradually returns to normal.8,9
0 K0 W, v! V+ h/ FThere are conflicting reports and controversy
0 K+ c$ C$ H6 I& O6 S0 k' \over the effect of early androgen exposure on adult
& X% }! A5 E7 O1 n+ n4 Wpenile length.10,11 Some reports suggest subnormal
3 @4 D/ T- I( y3 h U& ]* |adult penile length, apparently because of downreg-1 w* a8 a7 |4 c0 t
ulation of androgen receptor number.10,12 However,5 q8 D5 |7 t) {6 V* ~3 c& P4 b v
Sutherland et al13 did not find a correlation between
( y0 I8 @0 Y0 C5 @0 ]2 J- r1 Pchildhood testosterone exposure and reduced adult
9 g. ~- U9 n. K# spenile length in clinical studies.6 O2 N' ?% Y/ _2 P$ ^5 }5 ]+ u! T
Nonetheless, we do not believe our patient is4 _% J1 @) f/ ~& I# M
going to experience any of the untoward effects from
. j- w. N9 `/ d9 R$ g- V8 etestosterone exposure as mentioned earlier because
0 n- w% O) T' ^the exposure was not for a prolonged period of time.
4 H( K9 B7 C! i: X. rAlthough the bone age was advanced at the time of& n1 _0 |: t( I' o- g
diagnosis, the child had a normal growth velocity at& R& s% \4 Q6 L2 `4 d
the follow-up visit. It is hoped that his final adult
& ]& e* C7 [" z% [5 Nheight will not be affected.
3 h$ P% o" ^- D% s: [2 C) BAlthough rarely reported, the widespread avail-
8 r5 t: N. i# u0 D. uability of androgen products in our society may0 f2 P; ~$ `3 W% ^: ~/ ?
indeed cause more virilization in male or female
6 p, k, |: @7 H3 d6 ^4 x, D) C9 Zchildren than one would realize. Exposure to andro-
! g& R9 t- v5 _6 \9 i; _8 wgen products must be considered and specific ques-
+ O0 h4 x' L/ C( dtioning about the use of a testosterone product or' W) ~3 Z- r4 G& j. C' v
gel should be asked of the family members during
, m4 |' `" {; kthe evaluation of any children who present with vir-
5 B/ B+ N- I" C5 E1 g0 Silization or peripheral precocious puberty. The diag-" J' Z3 M. _0 @# G
nosis can be established by just a few tests and by H& W9 U7 }: E2 j. d
appropriate history. The inability to obtain such a6 \/ M8 }2 z3 Y: d. |
history, or failure to ask the specific questions, may
) P" {7 [& Q1 ^1 E7 W+ {, Dresult in extensive, unnecessary, and expensive
0 X/ [1 L# Q8 g, A4 x& _) ]+ hinvestigation. The primary care physician should be4 e5 J$ u3 L5 A
aware of this fact, because most of these children
j3 a7 n9 A' x7 C, B6 B; o6 smay initially present in their practice. The Physicians’
' x; E0 c0 V) o9 v% f' Q7 uDesk Reference and package insert should also put a
. J' R! \! s. Y+ e& I& I8 N+ P0 \ mwarning about the virilizing effect on a male or
; K( B$ Y2 J# ~0 B6 tfemale child who might come in contact with some-9 w& n0 Y- m6 d' S9 p, e
one using any of these products.9 q8 F4 K2 ?) Z8 k" R
References2 R& Q8 e b; e& o. ^, _9 {. U: s
1. Styne DM. The testes: disorder of sexual differentiation4 S3 [" \$ Q% ~$ L/ B, d' P" j
and puberty in the male. In: Sperling MA, ed. Pediatric& C. U( {$ z5 G# Z
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
8 H8 u% u3 [! k2002: 565-628.
0 F# h. t2 W5 o4 F5 p+ L+ n) L8 y2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious1 E3 D% ^( l! t! x' }: ?
puberty in children with tumours of the suprasellar pineal |
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