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Sexual Precocity in a 16-Month-Old9 K5 U8 C: B$ C6 b* k
Boy Induced by Indirect Topical+ h7 m0 m% O4 g' M3 c) B
Exposure to Testosterone
( g2 O3 }! x6 G- E% pSamar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2( r8 q% z# u$ R' B. j
and Kenneth R. Rettig, MD1" E$ e/ J* ]; L( N
Clinical Pediatrics$ o4 i Q8 j5 Z' R5 H! F
Volume 46 Number 6
! t! f$ |% A3 P# eJuly 2007 540-543) ?" ~/ Z3 }: d
© 2007 Sage Publications
- o% a1 s9 `5 r" j$ X3 ]10.1177/0009922806296651
$ e `2 i4 F& l% W& Hhttp://clp.sagepub.com1 N0 c' e0 j0 A
hosted at* W2 }+ j* V& v/ d7 y. v0 Y4 h
http://online.sagepub.com
# {2 S0 A6 z0 u g" t. I- j* T7 `Precocious puberty in boys, central or peripheral,
( z& {7 |' r, H2 Nis a significant concern for physicians. Central% w( G# t7 K1 i5 v P; a# h3 L
precocious puberty (CPP), which is mediated
* V8 P* C4 e! i7 Q. w+ q5 O. P% ?through the hypothalamic pituitary gonadal axis, has
/ c3 x+ V* y. @a higher incidence of organic central nervous system6 `& ]# M0 `; y! V
lesions in boys.1,2 Virilization in boys, as manifested( W* X; M1 Q* w# X8 A
by enlargement of the penis, development of pubic
! s4 V. D1 n5 o1 V' fhair, and facial acne without enlargement of testi-
/ ?) R9 S0 v0 p( A/ o& jcles, suggests peripheral or pseudopuberty.1-3 We
; q; j1 m3 k0 Mreport a 16-month-old boy who presented with the
/ ] ~7 q( w( r% t+ j& i, renlargement of the phallus and pubic hair develop-; N0 {" }3 `. g* e) w' E
ment without testicular enlargement, which was due) `* t2 v" a0 B3 D. d) K9 z
to the unintentional exposure to androgen gel used by! O, f! g! @- z' Y% }! m
the father. The family initially concealed this infor-
6 A4 U7 e5 N5 _( Z# |mation, resulting in an extensive work-up for this
) ?/ f9 N& |; s. Kchild. Given the widespread and easy availability of
! w6 [) ]" N* P1 T; S" [testosterone gel and cream, we believe this is proba-
' h+ G" h4 U$ L- R. G; O$ @6 V, Gbly more common than the rare case report in the7 y- @* t1 o' k% r( o3 ^
literature.40 c! p: i( |6 @- z9 G8 I7 L
Patient Report H- s/ A f+ K
A 16-month-old white child was referred to the/ e3 D7 Y; ?8 L# f; y- G7 s
endocrine clinic by his pediatrician with the concern- s$ Y) V9 i2 W' L+ u
of early sexual development. His mother noticed
$ t. z8 @/ k4 b. Alight colored pubic hair development when he was5 F5 t; S `3 b! Z3 O2 V: C: e: s
From the 1Division of Pediatric Endocrinology, 2University of
1 P5 I$ H4 @! g7 K3 O5 ], s# XSouth Alabama Medical Center, Mobile, Alabama.- D1 p2 z, e! I' r* m$ c3 u" y+ M& B
Address correspondence to: Samar K. Bhowmick, MD, FACE,
2 l- ?% P d4 X4 pProfessor of Pediatrics, University of South Alabama, College of2 k* P1 ?0 |: G) K/ G; M, S
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;3 X: x8 A/ l7 S( p; l. l( q
e-mail: [email protected].! K! L, l* _( w
about 6 to 7 months old, which progressively became
2 A+ H. W' R: ~; o# l( D# Ndarker. She was also concerned about the enlarge-
e$ J# g' f. @ment of his penis and frequent erections. The child/ G% z( V' ]5 [' t+ d( z# ]; h9 m4 E; P
was the product of a full-term normal delivery, with, s$ B0 |, b0 ]/ T4 o3 B6 D3 h+ q- ~# @
a birth weight of 7 lb 14 oz, and birth length of
0 \5 K4 z( C% ?# X% u' g: J20 inches. He was breast-fed throughout the first year
( M9 G+ m6 m* k) G1 \3 Oof life and was still receiving breast milk along with
% w @1 x7 B" L3 N# ?8 a5 C: R: w( Asolid food. He had no hospitalizations or surgery,
4 h. M4 k# |1 Z nand his psychosocial and psychomotor development1 U0 I0 }; s3 D
was age appropriate.
" f* v# ]2 g/ f& i5 rThe family history was remarkable for the father,
, R% E2 G ]3 t+ ]: J" ]who was diagnosed with hypothyroidism at age 16,
% {& D; Q% u5 \4 Cwhich was treated with thyroxine. The father’s
6 B" s( O2 d% A# K' ?2 `height was 6 feet, and he went through a somewhat2 B- e+ i/ p4 k0 V4 i! j& K
early puberty and had stopped growing by age 14.; ^ R1 a t; q
The father denied taking any other medication. The8 O! H% W; z) x& M# v
child’s mother was in good health. Her menarche
: Q8 z" z6 L9 E2 A1 Y) j+ j# @. ]was at 11 years of age, and her height was at 5 feet+ A' z# ~! w" S
5 inches. There was no other family history of pre-
1 m: r! z% ~6 n4 k& t# e/ _cocious sexual development in the first-degree rela-
! W7 b, N0 Y$ z/ E1 O8 atives. There were no siblings.0 j! t9 i2 S, u5 | V# K) p1 v1 A
Physical Examination* [, X; o* b, ~5 J3 w* `
The physical examination revealed a very active,
8 t6 B' @1 x7 E1 g. fplayful, and healthy boy. The vital signs documented) }8 h% T6 u6 G/ Z' U' j$ p6 P3 y
a blood pressure of 85/50 mm Hg, his length was+ }$ m! C, l4 _- t; A
90 cm (>97th percentile), and his weight was 14.4 kg7 b; G/ e7 i' d) ?' A& p q
(also >97th percentile). The observed yearly growth
8 W/ n+ Y! @9 l7 zvelocity was 30 cm (12 inches). The examination of
0 Q/ {. n% S% i1 v, A, a2 ~the neck revealed no thyroid enlargement.
2 q" v& Z7 A- @* w# o0 l) Y, bThe genitourinary examination was remarkable for
; m0 J( f0 w4 X. denlargement of the penis, with a stretched length of- r# E/ u% a) b e
8 cm and a width of 2 cm. The glans penis was very well
) |6 g/ d1 v5 Wdeveloped. The pubic hair was Tanner II, mostly around5 p0 e1 s$ n0 f" D, K
5407 u6 D& {0 Y8 D6 |$ f- _3 I P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
) X. x, `2 O) R& xthe base of the phallus and was dark and curled. The
, A9 x9 r& U! j* p0 Gtesticular volume was prepubertal at 2 mL each.
) }& R: t( Q! jThe skin was moist and smooth and somewhat9 c4 N0 |- C; G# v" Q# u7 B
oily. No axillary hair was noted. There were no
8 }$ B3 e- h; C- ^1 fabnormal skin pigmentations or café-au-lait spots.
+ A+ M6 m% `$ G1 \& CNeurologic evaluation showed deep tendon reflex 2+
& z$ {7 h6 i0 R. Kbilateral and symmetrical. There was no suggestion
: x( p" `# @6 z4 r% m* bof papilledema.
1 l/ T/ m$ i4 |' R/ ILaboratory Evaluation
$ ?- P3 {: ]/ O3 f" {The bone age was consistent with 28 months by5 ~, R% x8 [) _* L% U
using the standard of Greulich and Pyle at a chrono-
. g( o1 X: h. x9 jlogic age of 16 months (advanced).5 Chromosomal
3 _ \2 K. p/ e0 V/ S5 f2 B+ I Bkaryotype was 46XY. The thyroid function test; t j; U: M8 o# j5 v8 Q5 v6 o
showed a free T4 of 1.69 ng/dL, and thyroid stimu-
% W( l2 |4 }$ K2 E% Glating hormone level was 1.3 µIU/mL (both normal).
4 a$ {0 A9 z" U$ m% S6 j2 r. T: o0 xThe concentrations of serum electrolytes, blood
* H0 V) c, j! |2 }/ Vurea nitrogen, creatinine, and calcium all were+ g6 ~3 x( k8 |
within normal range for his age. The concentration
$ ?" r9 \0 V6 F n+ w5 m# ]of serum 17-hydroxyprogesterone was 16 ng/dL* t$ s q# m4 Q& U/ h' }
(normal, 3 to 90 ng/dL), androstenedione was 201 ?( j+ e! Q+ i0 p* A5 x
ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
8 s% k+ E7 I' ^. |4 V5 ?1 rterone was 38 ng/dL (normal, 50 to 760 ng/dL),% D5 K. z5 Z( \% z! S
desoxycorticosterone was 4.3 ng/dL (normal, 7 to/ P5 C1 J% t% f% c5 D/ W
49ng/dL), 11-desoxycortisol (specific compound S)% N6 A( b8 N7 H( I# w/ B
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
8 Q/ Q. i! g8 A% Y4 htisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total* b S" q7 x; t `! g
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),
) @2 \1 r- I3 z: b- r% S/ i/ Sand β-human chorionic gonadotropin was less than& a* T& }0 n& w" u4 P3 x
5 mIU/mL (normal <5 mIU/mL). Serum follicular* a; K% Y+ u: Z
stimulating hormone and leuteinizing hormone
$ L6 R h6 E. oconcentrations were less than 0.05 mIU/mL
% \* W/ F" m3 r4 q6 F+ U; b$ B(prepubertal).) r* x7 @0 \, @, ?
The parents were notified about the laboratory, E9 {$ r+ \, Y
results and were informed that all of the tests were4 N* O8 f, M; f# H! ~
normal except the testosterone level was high. The9 W1 F! w2 I' u9 u
follow-up visit was arranged within a few weeks to
2 X, Q2 B4 [$ |7 Lobtain testicular and abdominal sonograms; how-
: ?: w6 B; z! ^/ L' Lever, the family did not return for 4 months.
& f% i) C7 }# Z( jPhysical examination at this time revealed that the
8 i7 p) w. n+ s7 [child had grown 2.5 cm in 4 months and had gained6 H' {3 S4 V2 C7 q
2 kg of weight. Physical examination remained- q+ |3 m% o# h2 E7 p/ u0 L! e
unchanged. Surprisingly, the pubic hair almost com-3 g' a1 d2 g6 O' X; j. p
pletely disappeared except for a few vellous hairs at, u. Y# _7 `. o/ `1 k, w
the base of the phallus. Testicular volume was still 2
. e/ r& }# }6 e* |+ n5 P2 ImL, and the size of the penis remained unchanged.. X3 b3 A0 C1 }; S, I2 G1 C8 s- K
The mother also said that the boy was no longer hav-, u: V: _- Q: ^7 U0 N
ing frequent erections.0 O, A& ~( O4 n8 @% w5 ]
Both parents were again questioned about use of
2 P/ s$ }0 ^. _/ M* G& Vany ointment/creams that they may have applied to
/ T5 ?) N5 f% x: q( C; j- N, Zthe child’s skin. This time the father admitted the
6 z# s2 ^/ a$ c+ B% Z$ A" [Topical Testosterone Exposure / Bhowmick et al 541
% Q. L0 j0 r' f5 P( \2 b0 ?4 ]- Ause of testosterone gel twice daily that he was apply-: m5 [. r$ M% J, z/ e' Y4 z5 T
ing over his own shoulders, chest, and back area for+ o! d m8 S' H6 t: ?
a year. The father also revealed he was embarrassed$ V, [0 `2 J# L
to disclose that he was using a testosterone gel pre-% r" |9 Y) @: t7 P" i
scribed by his family physician for decreased libido) ~; P# ?, g' ]/ ^6 d0 S
secondary to depression.+ W; G0 j. x: ^& r! T, e W
The child slept in the same bed with parents.
& s. g2 C* l& U0 {% C$ o2 z, jThe father would hug the baby and hold him on his# x1 ~7 j' K5 S) a
chest for a considerable period of time, causing sig-% }4 X0 }* O" m5 J2 Y5 D
nificant bare skin contact between baby and father.5 f+ v4 l: m+ ^0 k; p; ~" T
The father also admitted that after the phone call,, n/ `9 G: x1 V5 l, I S
when he learned the testosterone level in the baby
# z; g* E& U) y3 r. ewas high, he then read the product information* N" ]' ^; f" }" Q1 h" k
packet and concluded that it was most likely the rea-
9 m$ U Z: d7 \$ d3 m4 l# Z. Gson for the child’s virilization. At that time, they5 i$ ?+ m+ T6 R% W! A+ f9 {
decided to put the baby in a separate bed, and the
" Z& m$ a% h4 D. Ofather was not hugging him with bare skin and had1 H9 A+ P& N$ p4 }5 o
been using protective clothing. A repeat testosterone7 G3 ]! U' O4 ~6 ~
test was ordered, but the family did not go to the
8 O' G% h! O* F; D; z& Olaboratory to obtain the test.8 C( U" G2 S) O) s+ C) C1 ^
Discussion* w! O9 P) N. j- F1 ?$ x
Precocious puberty in boys is defined as secondary$ A& u' Y4 d3 o. [) S6 t
sexual development before 9 years of age.1,4) d9 t. E! Q) Z7 E
Precocious puberty is termed as central (true) when$ R8 G/ j7 @6 M+ r& Y% W
it is caused by the premature activation of hypo-
( Z. w; I! E* t! J8 z2 xthalamic pituitary gonadal axis. CPP is more com-/ \ L2 y0 {! n }! l
mon in girls than in boys.1,3 Most boys with CPP) s" {! F$ v8 f" ^5 b# r
may have a central nervous system lesion that is
* t, \1 \( F- f% c( A$ p$ {responsible for the early activation of the hypothal-
" }5 T. L. `/ ^" J: o2 P5 bamic pituitary gonadal axis.1-3 Thus, greater empha-
/ N8 D! q" U3 m, a3 Gsis has been given to neuroradiologic imaging in, ] b0 S# W. @
boys with precocious puberty. In addition to viril-7 I, a6 K! d7 K. q( d1 b
ization, the clinical hallmark of CPP is the symmet-
6 H+ y' ]2 \. m# J* Erical testicular growth secondary to stimulation by
, {+ S, H8 o3 e; X2 a- D rgonadotropins.1,3
1 w7 C3 s1 w2 N* R& k' x! o! rGonadotropin-independent peripheral preco-
( u) ]# m/ U8 N% @cious puberty in boys also results from inappropriate
) _4 E7 i& N( v4 I# @androgenic stimulation from either endogenous or" r& e0 s* }- e; z' u5 I+ F
exogenous sources, nonpituitary gonadotropin stim-3 T1 @% t' V) ~0 i; m4 c
ulation, and rare activating mutations.3 Virilizing
8 w0 L# x6 r: F% B8 f' j% E' Mcongenital adrenal hyperplasia producing excessive
0 J) a$ I' j8 u8 [adrenal androgens is a common cause of precocious/ K7 [+ t+ I: j5 U0 _3 @- Y
puberty in boys.3,4% V8 H# k) R, S0 I; ~0 ]) n* U% N) K
The most common form of congenital adrenal, o5 ~! l9 e; D
hyperplasia is the 21-hydroxylase enzyme deficiency.
/ K! E' M9 [4 QThe 11-β hydroxylase deficiency may also result in8 M# }, e) v3 q) ^, c9 D* B
excessive adrenal androgen production, and rarely,
! j# R! z6 m, [) @/ Zan adrenal tumor may also cause adrenal androgen# j, ^* q. y- S. g$ Y1 O# M. ^
excess.1,3$ Y/ D1 T' k5 @/ G/ J+ w
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from- q3 u9 \) o: a5 k! R
542 Clinical Pediatrics / Vol. 46, No. 6, July 2007, Y' d7 ^% t1 j" ^ I7 {( @5 h- ~
A unique entity of male-limited gonadotropin-4 B7 s: u, f! F6 ^7 k( _4 f* P
independent precocious puberty, which is also known/ Z( ]% o2 p4 M) Y7 l
as testotoxicosis, may cause precocious puberty at a
' P1 d1 M% `1 Z/ w1 ^very young age. The physical findings in these boys- }/ W0 b; m$ a
with this disorder are full pubertal development,
' ?( [( N* N, @& u, {including bilateral testicular growth, similar to boys* V {7 u* J/ M) @- [
with CPP. The gonadotropin levels in this disorder% _! z! L& b4 y: [
are suppressed to prepubertal levels and do not show/ u# K$ ]' y% F/ ~- d. _
pubertal response of gonadotropin after gonadotropin-
( ^+ { j( W- o+ h1 b/ Lreleasing hormone stimulation. This is a sex-linked
) y' p. s" f4 T' m6 z! K5 iautosomal dominant disorder that affects only" b9 p3 q; z/ K' a; g3 f7 r" ~! }9 F
males; therefore, other male members of the family/ y$ J7 c8 A, i8 R6 m
may have similar precocious puberty.3
/ v+ [ S' @* [ n [# {; xIn our patient, physical examination was incon-& l' @4 X5 D& c, W$ _& X3 a
sistent with true precocious puberty since his testi-6 w- z, ~- r9 S3 A/ a. z* c, L' p& }
cles were prepubertal in size. However, testotoxicosis+ u4 c6 h7 o0 ]- p
was in the differential diagnosis because his father
9 d Y' h# M0 ]# c" Sstarted puberty somewhat early, and occasionally,
0 x% Q7 p9 g9 F2 `- O0 utesticular enlargement is not that evident in the* Y: Y& H/ L3 v g
beginning of this process.1 In the absence of a neg-7 y& P- D; X- h/ e0 [8 `0 S* R
ative initial history of androgen exposure, our# J) D2 y, \5 q( V1 |* n
biggest concern was virilizing adrenal hyperplasia,
7 ^! ?! n/ P- H( |+ b7 o4 S/ X' Veither 21-hydroxylase deficiency or 11-β hydroxylase
" z% ~2 v1 S3 y H' zdeficiency. Those diagnoses were excluded by find-* N: A8 L* I. M6 l& d
ing the normal level of adrenal steroids.
1 r$ ?5 a3 C( pThe diagnosis of exogenous androgens was strongly
& }6 F$ w( w& osuspected in a follow-up visit after 4 months because
7 B- l8 _, ^8 o4 u8 Q* cthe physical examination revealed the complete disap-* l: ^; x2 S9 A- d
pearance of pubic hair, normal growth velocity, and
& ?, a, y7 c6 t6 C2 O6 kdecreased erections. The father admitted using a testos-
8 b+ ]! q; S; R7 e; u. `! oterone gel, which he concealed at first visit. He was
' h% d, \1 _* U U/ N2 {' Vusing it rather frequently, twice a day. The Physicians’
" i$ g5 K5 J% p% R- xDesk Reference, or package insert of this product, gel or. H& o, C8 H3 g: B" k
cream, cautions about dermal testosterone transfer to
/ X: s9 J3 U- K8 w% [( J, qunprotected females through direct skin exposure.
. y. X( @% t% u) [Serum testosterone level was found to be 2 times the& O+ ~$ b; x( F" n. ]
baseline value in those females who were exposed to7 }5 p% k5 e3 M
even 15 minutes of direct skin contact with their male
5 K, i2 K: \( t- D0 zpartners.6 However, when a shirt covered the applica-
/ N! @& S% I; A S8 D$ ^5 ation site, this testosterone transfer was prevented.
: t! Y- Y' \) J" D# MOur patient’s testosterone level was 60 ng/mL,+ X& l7 D8 k$ ^9 |" E( j/ s
which was clearly high. Some studies suggest that1 \1 I" [: n- \9 W
dermal conversion of testosterone to dihydrotestos-% p2 d* ?# i" |' ^" j6 h
terone, which is a more potent metabolite, is more/ b9 ^; J6 G- S9 A9 Q1 u6 O4 A5 s
active in young children exposed to testosterone
1 Y, v' j" k, W- S, a; kexogenously7; however, we did not measure a dihy-( \6 O; T' H$ J3 G
drotestosterone level in our patient. In addition to
5 v6 O$ |! W: w) ]) \4 ~virilization, exposure to exogenous testosterone in- s$ f+ ^% ~7 |# D" f
children results in an increase in growth velocity and- |6 s& B5 C. l( L( ]% _
advanced bone age, as seen in our patient.; H3 Z* C1 t z6 k2 k
The long-term effect of androgen exposure during6 g% H; J. g9 `
early childhood on pubertal development and final
2 |% E+ A4 z! i; p( e$ ^/ Cadult height are not fully known and always remain
6 c( n q3 b" a3 Na concern. Children treated with short-term testos- a0 v! B& [7 U: Q6 o" T
terone injection or topical androgen may exhibit some
+ v7 s6 W% r$ b/ O' ?; Kacceleration of the skeletal maturation; however, after! O2 j; u& K8 @: o6 a
cessation of treatment, the rate of bone maturation
' z" v! r( j5 I" c+ [5 ydecelerates and gradually returns to normal.8,9
1 P) U/ f$ Z. i$ q, k+ O6 R2 xThere are conflicting reports and controversy
4 d, t- G! W2 D# y! jover the effect of early androgen exposure on adult+ N) [! ^8 G' o5 A# h x( Q/ A2 b
penile length.10,11 Some reports suggest subnormal
9 k2 V: m) X4 R# [adult penile length, apparently because of downreg-
# ~7 Y2 D; A0 Yulation of androgen receptor number.10,12 However,5 L" y1 Y: h% i% q
Sutherland et al13 did not find a correlation between) A" F5 @9 I2 p- l% k8 }
childhood testosterone exposure and reduced adult
; ?0 l- h& v, `, c9 Cpenile length in clinical studies.' | e# k9 B) M9 T: F. i3 r
Nonetheless, we do not believe our patient is1 A; f; {" x& q2 \1 C+ m; z
going to experience any of the untoward effects from- ?0 G2 V5 D v, L1 }* v* r
testosterone exposure as mentioned earlier because+ {3 j( a9 ?4 @1 {
the exposure was not for a prolonged period of time.
- W+ q0 O/ n; p1 A1 E! d7 uAlthough the bone age was advanced at the time of
3 s. u. f& {9 [* _diagnosis, the child had a normal growth velocity at
( O2 u( L6 o1 h0 Wthe follow-up visit. It is hoped that his final adult
' S# r4 {6 l; W) Iheight will not be affected.5 l& ~1 A# a# i! q
Although rarely reported, the widespread avail-
; E! }2 e( X g' O5 j6 m# v( `ability of androgen products in our society may
$ z: n* n5 u$ g8 `indeed cause more virilization in male or female8 f! v) W' @. X9 j
children than one would realize. Exposure to andro-$ M, a8 Y1 q+ G9 n' `+ ?
gen products must be considered and specific ques-
) B. p( E0 Q8 c2 X- qtioning about the use of a testosterone product or
. C8 K- R9 R7 T Q. `% Qgel should be asked of the family members during
" p0 {# M& }( h4 v4 L5 Z4 jthe evaluation of any children who present with vir-
( A* i0 x, y) s, y7 |2 Z* U0 |ilization or peripheral precocious puberty. The diag-
7 x0 \' D3 m: J+ w# R) R: Wnosis can be established by just a few tests and by
0 U+ g( ]7 i( z( g! v4 Tappropriate history. The inability to obtain such a
0 F# E: k! K1 _& o8 H4 jhistory, or failure to ask the specific questions, may& N( R. P& s9 y8 W2 ~) L
result in extensive, unnecessary, and expensive
, t+ X( G1 A9 X, @( X' k8 I! linvestigation. The primary care physician should be V3 x+ ]$ n* _
aware of this fact, because most of these children( T! P9 P: w4 c2 L1 `
may initially present in their practice. The Physicians’& z& _( b! ]) V1 o
Desk Reference and package insert should also put a6 C$ v, ^% L. P- K! ]2 _# Q2 z, @
warning about the virilizing effect on a male or/ C l0 w' m: H; E
female child who might come in contact with some-
1 y+ p* t3 \& b, V0 d3 T' \one using any of these products.
: L& Z3 u" K1 u% P1 [- eReferences
2 F$ _5 r7 n# @5 R1. Styne DM. The testes: disorder of sexual differentiation
/ V) o4 g6 G# V4 Zand puberty in the male. In: Sperling MA, ed. Pediatric6 V! w! T( b: G3 E) j' O8 y
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;/ V0 |* o5 _" k4 n9 [
2002: 565-628.+ @( D7 C; G# w# K7 p: Y+ U, y3 H& B: E8 {
2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious5 C0 I0 b8 P( E& H0 o# @/ a5 \
puberty in children with tumours of the suprasellar pineal |
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