- 註冊時間
- 2023-5-6
- 精華
- 在線時間
- 小時
- 米币
-
- 最後登錄
- 1970-1-1
|
發表於 2025-1-4 03:27:02
|
顯示全部樓層
Sexual Precocity in a 16-Month-Old
! e8 Q) S+ L9 u; k3 U1 J5 wBoy Induced by Indirect Topical. E& | M9 K1 m
Exposure to Testosterone5 ~3 ^5 Z( C8 d4 J- h
Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
$ I/ l4 _1 R* o1 ?9 {and Kenneth R. Rettig, MD1* d$ a* O E/ C2 H
Clinical Pediatrics
9 c7 _5 h" g6 K" m8 lVolume 46 Number 6
0 a |1 F( O' ]: X2 H- h0 {July 2007 540-543
* K# c9 n; s4 Q% g$ f' B/ k. o, N© 2007 Sage Publications
9 B) N& m, x8 d( \10.1177/0009922806296651; h2 y1 _/ d8 \0 m6 q
http://clp.sagepub.com( j! J3 f8 G! F& @( J+ H
hosted at. F) ~3 p! S2 E6 X
http://online.sagepub.com
9 ]# N! l0 X6 p5 {9 `6 j1 dPrecocious puberty in boys, central or peripheral,1 S. F1 M2 T; V8 D
is a significant concern for physicians. Central
9 [. f: O( L" ]6 y( [' V. I- Pprecocious puberty (CPP), which is mediated9 f9 l) e0 z5 K K% w
through the hypothalamic pituitary gonadal axis, has4 ~3 z: j- P- u% t+ | v
a higher incidence of organic central nervous system0 S/ U, ?/ C# C+ f# r3 r3 c* y6 ~* v
lesions in boys.1,2 Virilization in boys, as manifested$ ?2 h0 A- [6 P% A6 T# `% j9 r
by enlargement of the penis, development of pubic
6 q0 A/ x( D$ j4 p3 G* B9 L9 w: vhair, and facial acne without enlargement of testi-
/ b& O+ Z! R( v4 Wcles, suggests peripheral or pseudopuberty.1-3 We( s& Y- \' y0 U* j r
report a 16-month-old boy who presented with the! P" s! P. r# u; G. H- f
enlargement of the phallus and pubic hair develop-7 b4 C i- a, _, k* u+ J: U
ment without testicular enlargement, which was due# W3 L. U4 j: }9 `
to the unintentional exposure to androgen gel used by
# r$ h4 Z" {( D/ M( Hthe father. The family initially concealed this infor-4 i; {2 q/ b" W9 c8 O+ ]
mation, resulting in an extensive work-up for this
% p- _6 T. v( zchild. Given the widespread and easy availability of
: V! U2 g: U+ h) q" I* S, Otestosterone gel and cream, we believe this is proba-
1 Z5 z1 }* E1 |3 B8 y1 I/ n! Mbly more common than the rare case report in the2 K/ F7 b( W# X0 ]6 I3 Q
literature.4; \7 L. {/ L) a4 g6 ~
Patient Report
2 F h! o) @5 j8 B" F- p/ I' qA 16-month-old white child was referred to the: i% |$ m; ^; y$ t) b: [' H
endocrine clinic by his pediatrician with the concern; N: q. G- `8 T
of early sexual development. His mother noticed* z6 J3 |/ E0 o K/ L* A3 Y
light colored pubic hair development when he was
) B+ P4 P$ \, N/ x- l O, Z" f6 _5 a! G: gFrom the 1Division of Pediatric Endocrinology, 2University of
2 W' r# H9 S: ]9 V: kSouth Alabama Medical Center, Mobile, Alabama.
, n! O# s1 ~' y0 ~! XAddress correspondence to: Samar K. Bhowmick, MD, FACE,
& ]/ R3 K+ q3 v8 i7 N' {Professor of Pediatrics, University of South Alabama, College of8 ~2 Y+ x* M2 D% i( |
Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;# z: o# M# A4 j2 a3 d: @
e-mail: [email protected].
3 [3 N0 B! X8 a/ E: n2 mabout 6 to 7 months old, which progressively became
& Y8 v) Z* ?: V+ p Ldarker. She was also concerned about the enlarge-1 f/ W& a, V8 X/ E F5 F+ H4 D
ment of his penis and frequent erections. The child* Y8 S: c6 `5 C$ U: X# O
was the product of a full-term normal delivery, with
' R- q% C# k- {9 xa birth weight of 7 lb 14 oz, and birth length of
/ {2 \, N3 }/ ?8 N# v20 inches. He was breast-fed throughout the first year
( v: @1 K; Q& F! Nof life and was still receiving breast milk along with
8 c) ]* J6 L6 `4 M3 ysolid food. He had no hospitalizations or surgery,
5 p4 G, n% l% \9 x7 r( R0 Oand his psychosocial and psychomotor development0 y% {7 ]# Q" }5 U, l. W; L
was age appropriate.
7 S& A( C8 M+ Y+ zThe family history was remarkable for the father,
* u* {6 F- } S& e; Q6 Twho was diagnosed with hypothyroidism at age 16,
0 Q6 b* b6 k awhich was treated with thyroxine. The father’s, z8 \% k( h0 }0 A7 r7 w
height was 6 feet, and he went through a somewhat- }# i6 @1 P) }3 z5 }2 B' E
early puberty and had stopped growing by age 14.
+ l( {+ ~: ?& Q3 n7 ]The father denied taking any other medication. The4 v" f# z, z+ L+ V" P, t8 d
child’s mother was in good health. Her menarche
. f: e+ F& I1 v; i# x) s( Zwas at 11 years of age, and her height was at 5 feet" z# _. L# z) c# y6 J
5 inches. There was no other family history of pre-7 a8 Y9 N$ ~5 C; J. v$ `9 h! l
cocious sexual development in the first-degree rela-) ^& g! d0 U. c3 [; y: F" U" O
tives. There were no siblings.
$ K( _+ c8 T: W+ aPhysical Examination
& j# F( D% [0 W9 f" g9 `0 i, zThe physical examination revealed a very active,
" b, m: H# P* |" }0 c, U: D& G" kplayful, and healthy boy. The vital signs documented" j: b, H: d$ [2 U- w1 N- O( p0 E
a blood pressure of 85/50 mm Hg, his length was3 z& _4 n2 b- c2 T
90 cm (>97th percentile), and his weight was 14.4 kg
+ i k4 u9 f* u4 A/ `(also >97th percentile). The observed yearly growth
! q. W6 l f6 ~" Gvelocity was 30 cm (12 inches). The examination of
- y$ o; X2 N4 L. nthe neck revealed no thyroid enlargement.
. |( z& v4 U6 o/ }The genitourinary examination was remarkable for
( K* N" \3 N7 n2 R8 X. h4 Fenlargement of the penis, with a stretched length of' A; z% n) Q% T" ]
8 cm and a width of 2 cm. The glans penis was very well/ _( B! L+ Y1 m N5 y; U/ a0 h- H; k8 q
developed. The pubic hair was Tanner II, mostly around/ n0 ]7 s- h& H$ O; _/ t2 q
5408 d# |2 X+ w% l7 s
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
* x/ l2 x, p' N& }- [% Athe base of the phallus and was dark and curled. The
2 w3 p+ U" t0 q. i4 dtesticular volume was prepubertal at 2 mL each.
8 a. u* `+ Y/ k2 L9 _The skin was moist and smooth and somewhat
8 X8 q; X. m2 ?1 y: |oily. No axillary hair was noted. There were no6 i7 a6 r. R) L" J
abnormal skin pigmentations or café-au-lait spots.
/ H/ C- L( T6 fNeurologic evaluation showed deep tendon reflex 2+
s+ `$ D6 P/ k8 s' b6 ?: q5 Jbilateral and symmetrical. There was no suggestion
) g4 \9 E0 n1 @: F2 d" V4 kof papilledema.
9 z9 @ @' f' t- K8 z. M9 [Laboratory Evaluation
P( G, f9 }" Y/ Q5 XThe bone age was consistent with 28 months by
: F& d! J4 w' x" _using the standard of Greulich and Pyle at a chrono-
) G! `3 y/ I; x: J* g7 Rlogic age of 16 months (advanced).5 Chromosomal
/ }, x X8 }/ M* j- A- pkaryotype was 46XY. The thyroid function test, T1 K: G: x$ u7 H
showed a free T4 of 1.69 ng/dL, and thyroid stimu-/ f m4 A, K: g0 V, [0 f A
lating hormone level was 1.3 µIU/mL (both normal).
* ?3 A7 m+ D1 z" GThe concentrations of serum electrolytes, blood0 j5 O: c& S# |5 i
urea nitrogen, creatinine, and calcium all were0 o1 _( E8 ^* R1 ~8 t
within normal range for his age. The concentration
h) R' W$ N; i+ {( ?of serum 17-hydroxyprogesterone was 16 ng/dL. ^3 T' G# w* D& c2 B( I( a
(normal, 3 to 90 ng/dL), androstenedione was 20
: Q: e/ Q* o. d7 D7 O* X7 Kng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
$ B& z* B) x& V. {8 Q3 O Bterone was 38 ng/dL (normal, 50 to 760 ng/dL),8 O2 z; A- Q1 w; k1 ?( U {' Q; k
desoxycorticosterone was 4.3 ng/dL (normal, 7 to2 x7 Q1 l, l K/ K* s- z
49ng/dL), 11-desoxycortisol (specific compound S)
0 w9 `; a! Q; r3 Q) m n4 Uwas 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-. i; |( l3 `2 X$ H& L% X. V+ Y
tisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total! ~4 j% b& i" u3 E3 h
testosterone was 60 ng/dL (normal <3 to 10 ng/dL),; Z, y" D6 Q/ f
and β-human chorionic gonadotropin was less than
# {; k( V/ t4 |0 ?: \5 j3 a5 mIU/mL (normal <5 mIU/mL). Serum follicular8 d9 U- L( |! w# W+ k
stimulating hormone and leuteinizing hormone
5 k& O* R; W, P- Y: H2 nconcentrations were less than 0.05 mIU/mL
6 ^$ V; c3 N+ u$ r0 t$ }(prepubertal).
( B, b& c. B3 Z' wThe parents were notified about the laboratory
$ K; u' V4 A; U9 u+ |4 eresults and were informed that all of the tests were( l4 H! U% ? z
normal except the testosterone level was high. The1 H1 f- ?$ y9 c
follow-up visit was arranged within a few weeks to) `. \$ Q, v& O/ y @
obtain testicular and abdominal sonograms; how-
; |( |" n; s" x% L5 f, lever, the family did not return for 4 months.
" N. e8 D& i7 A( v- TPhysical examination at this time revealed that the' c3 T6 p, h5 @5 F4 G3 y5 Y0 |) [% B
child had grown 2.5 cm in 4 months and had gained; x% l* Y- v7 Y( M* w( M# f$ y7 \4 D
2 kg of weight. Physical examination remained6 i7 ~5 C8 {6 Q' O, [
unchanged. Surprisingly, the pubic hair almost com-
) e6 _& v: j7 Epletely disappeared except for a few vellous hairs at
" ^% |( E/ {! b* Zthe base of the phallus. Testicular volume was still 28 T4 h+ j B4 ]3 U* u2 E
mL, and the size of the penis remained unchanged.8 g- B d: k P% Y4 n: s# w8 [
The mother also said that the boy was no longer hav-( ^$ V3 ?6 u' o+ A, J
ing frequent erections.
. ~( f: D% ^$ l/ s8 X9 L) ~Both parents were again questioned about use of6 N$ x* P, ~8 D3 h/ R# \/ z
any ointment/creams that they may have applied to/ p/ X \0 r' w6 ?0 k2 w! L" i
the child’s skin. This time the father admitted the* }* y6 l/ e/ P9 \; }
Topical Testosterone Exposure / Bhowmick et al 541
; L3 g% V! q& r2 U% ?- Q/ Luse of testosterone gel twice daily that he was apply-9 S$ H6 }6 [ S5 V5 f
ing over his own shoulders, chest, and back area for
$ J( V& m4 j7 \a year. The father also revealed he was embarrassed) o/ M2 ~/ T5 {, V$ A3 z8 n: ?
to disclose that he was using a testosterone gel pre-
. `, k O8 ]2 o% A4 w7 Gscribed by his family physician for decreased libido
) Y# R& _1 V: U. B. |' t0 K8 dsecondary to depression., S& {( `% S* A
The child slept in the same bed with parents.
7 n; K, e3 M4 l$ @' o9 @) j- ]" `The father would hug the baby and hold him on his& _7 S, I/ W( {( }) \9 t
chest for a considerable period of time, causing sig- c9 O, ^4 {, V3 G/ w. K1 X5 _
nificant bare skin contact between baby and father.
9 l: K6 P5 {& n, p7 h, sThe father also admitted that after the phone call,$ D: I+ I( A4 N: D
when he learned the testosterone level in the baby3 O; P ?% ~& E/ `, U( Z" Y
was high, he then read the product information
# i4 n; p0 @$ _packet and concluded that it was most likely the rea-1 q9 r" A7 a1 r9 Y8 e: L
son for the child’s virilization. At that time, they7 r; O8 m2 M* {- D; Y. i
decided to put the baby in a separate bed, and the& s) C0 l- K% g
father was not hugging him with bare skin and had
+ t# `* M, H" b7 t' y# ]- kbeen using protective clothing. A repeat testosterone
. s. U, b. ^' ^ {6 L0 ~0 W- H3 jtest was ordered, but the family did not go to the# c) q Q6 g/ r$ Z6 i- g( s' b
laboratory to obtain the test.
3 ? ^5 e9 U }1 }: `$ V; ~4 UDiscussion
2 r( t, y, _& Q2 e1 FPrecocious puberty in boys is defined as secondary& }6 L7 N* }6 B+ g5 x% X8 [7 V" z R
sexual development before 9 years of age.1,4
/ c8 K, b9 M. q1 m7 }3 nPrecocious puberty is termed as central (true) when" `* o6 g4 d8 t3 c4 i
it is caused by the premature activation of hypo-7 R+ n; J, D" d W( s
thalamic pituitary gonadal axis. CPP is more com-
# {" t) g3 c. V! d2 G# kmon in girls than in boys.1,3 Most boys with CPP3 v q5 j9 q! K& e: U! a
may have a central nervous system lesion that is
8 y5 K- _# V7 Z: f, y2 G- Y9 [) Hresponsible for the early activation of the hypothal-
: R3 }0 x' }" i% h: C. [+ m; kamic pituitary gonadal axis.1-3 Thus, greater empha-
8 C; G$ |/ h% ]: G2 @sis has been given to neuroradiologic imaging in- P9 m+ Y, G( ?8 {7 L
boys with precocious puberty. In addition to viril-
9 m/ u I) B7 i* C& Bization, the clinical hallmark of CPP is the symmet-& e6 E+ q4 A) S4 V
rical testicular growth secondary to stimulation by
, Q, V W7 B& X9 _) a( O# ?gonadotropins.1,3
: a! I8 ~! `( HGonadotropin-independent peripheral preco- Y: b/ [* @* G$ ]4 W/ B
cious puberty in boys also results from inappropriate* U' q9 [' f- E6 W
androgenic stimulation from either endogenous or
7 b+ v" r9 e. f- t; R( M$ ?) Rexogenous sources, nonpituitary gonadotropin stim-
4 I9 h. _9 C ^( ^2 s2 iulation, and rare activating mutations.3 Virilizing
] H3 @5 N' \+ Ccongenital adrenal hyperplasia producing excessive
8 G) ?! G6 c: Badrenal androgens is a common cause of precocious* f! S" [0 c% @( q
puberty in boys.3,4! {' W' h0 ~* e" q, r. S# b, @
The most common form of congenital adrenal, ^- q+ e4 b( V. n
hyperplasia is the 21-hydroxylase enzyme deficiency.+ H# d: J8 z) H, }0 `- b
The 11-β hydroxylase deficiency may also result in
' E: }! Z0 b5 Fexcessive adrenal androgen production, and rarely,3 x. P. o3 Q3 ?- n$ V8 o. b; m
an adrenal tumor may also cause adrenal androgen
. c9 P6 \- h$ k! nexcess.1,3! a( Z1 G5 e- R
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from
! t5 V! h1 s9 s. y2 p* S542 Clinical Pediatrics / Vol. 46, No. 6, July 2007
4 ?2 \& | L$ y+ q! W$ \3 ZA unique entity of male-limited gonadotropin-, o' ^. M7 e, [ a
independent precocious puberty, which is also known
7 q1 f' z4 L; ^0 [$ b" was testotoxicosis, may cause precocious puberty at a
4 e/ o/ }' J M) ^very young age. The physical findings in these boys8 x N' m+ M' a6 F& z" ~- @
with this disorder are full pubertal development,1 N. ~. R6 m! `, h
including bilateral testicular growth, similar to boys
6 E* g, h b3 r2 d: l9 ywith CPP. The gonadotropin levels in this disorder
$ W4 I% f8 W) _. w0 pare suppressed to prepubertal levels and do not show$ r% [4 n" X' u, N1 u+ i9 \. S
pubertal response of gonadotropin after gonadotropin-
0 v ~; _3 R/ Y8 Wreleasing hormone stimulation. This is a sex-linked K' u) c* ?' X4 Q, e
autosomal dominant disorder that affects only- J, q' y; V5 N0 m+ R" \
males; therefore, other male members of the family3 q$ j8 D$ }9 F
may have similar precocious puberty.3& c3 _ [2 ?% R: b, ^
In our patient, physical examination was incon-
, C7 [4 ]- |* W) z4 W1 F {' ?/ ~sistent with true precocious puberty since his testi-4 [3 }+ M# V6 c
cles were prepubertal in size. However, testotoxicosis
7 |% J- e+ E, M* h( h7 dwas in the differential diagnosis because his father
. Z4 T6 S6 c n$ y7 W3 i6 Qstarted puberty somewhat early, and occasionally,' V/ s3 g9 n" o( G, Q; l
testicular enlargement is not that evident in the% J# G3 H' n) Y& Q; S' K+ A
beginning of this process.1 In the absence of a neg-
6 u& W; p1 D+ Q2 X# m. J. x; kative initial history of androgen exposure, our V$ z& `& J' S/ T+ \
biggest concern was virilizing adrenal hyperplasia,
% m0 D4 t) Q' g e2 m c# ^either 21-hydroxylase deficiency or 11-β hydroxylase
- [4 i% ^0 c: zdeficiency. Those diagnoses were excluded by find-
% \3 q/ K; G7 I8 d9 L8 h7 Bing the normal level of adrenal steroids.9 \: l" g) r Y: D" f: @
The diagnosis of exogenous androgens was strongly
) R2 u2 g- \( t: H6 {' Ysuspected in a follow-up visit after 4 months because
% S4 K$ N* N$ y) wthe physical examination revealed the complete disap-
! G6 j+ _. @- ]& U- apearance of pubic hair, normal growth velocity, and. v- @1 ^* |, X F
decreased erections. The father admitted using a testos-
* q2 c/ i2 s( e$ B- Mterone gel, which he concealed at first visit. He was
. L3 V. l J6 T' R$ q3 d- vusing it rather frequently, twice a day. The Physicians’
. I/ d6 ?# [5 T" \7 tDesk Reference, or package insert of this product, gel or
' y# g/ G* ?2 f! z3 }% Lcream, cautions about dermal testosterone transfer to
1 e& ]: o8 n% T. Ounprotected females through direct skin exposure.5 a4 \' O |* F3 H* m h9 O7 X& O
Serum testosterone level was found to be 2 times the5 {5 p. q6 C& G
baseline value in those females who were exposed to
% R% h3 ^' F. b" \) I4 e- w; }even 15 minutes of direct skin contact with their male
! ^$ [( w; l5 b; d; Epartners.6 However, when a shirt covered the applica-
; j+ [1 C$ Z% z; Stion site, this testosterone transfer was prevented.
& y& b6 [3 I; I4 d' ?9 _5 y% W! NOur patient’s testosterone level was 60 ng/mL,
2 U7 w7 F$ d( n) H" lwhich was clearly high. Some studies suggest that
6 V$ u8 f) _7 xdermal conversion of testosterone to dihydrotestos-0 d n0 I. ]* e
terone, which is a more potent metabolite, is more
5 g0 N* G: x) H) P& P6 Iactive in young children exposed to testosterone
& P+ ]1 o) y+ kexogenously7; however, we did not measure a dihy-; G8 V3 A+ j) Z
drotestosterone level in our patient. In addition to3 @# G- o) z( I- z) y8 K1 `
virilization, exposure to exogenous testosterone in
: e4 q) J- o/ x# a7 ^ C3 wchildren results in an increase in growth velocity and
& w' |$ w& ^. tadvanced bone age, as seen in our patient.
L7 A; ?, J. ^5 k, E( s, B; R' U6 [The long-term effect of androgen exposure during9 V. N. D/ N( x
early childhood on pubertal development and final
) l- o9 Z9 h$ b, i8 K! c, B% X; |/ Wadult height are not fully known and always remain
6 U* L% W) w8 _9 _a concern. Children treated with short-term testos-
, ]; `. ?. B' R1 }5 ^1 A4 ?terone injection or topical androgen may exhibit some f- h, U- W) b- y; f
acceleration of the skeletal maturation; however, after; Z g9 R' O# q Z1 o7 E
cessation of treatment, the rate of bone maturation
+ p( p" }# k* \ v% L4 Z" Xdecelerates and gradually returns to normal.8,97 Z( c1 K+ z$ d3 g2 C; J
There are conflicting reports and controversy
- t& i) |7 s& j& [5 y' s# jover the effect of early androgen exposure on adult
" m4 |- P* v; e0 T! w5 K" U1 npenile length.10,11 Some reports suggest subnormal
$ P k0 ?. _+ N) G( [ _adult penile length, apparently because of downreg-7 k2 I# Y6 ]% @6 p3 K5 k
ulation of androgen receptor number.10,12 However,7 A5 J7 F7 Y+ ?1 q: T( P
Sutherland et al13 did not find a correlation between
0 g( z% Z+ h" j& uchildhood testosterone exposure and reduced adult
! r, M, V* a: Q" {penile length in clinical studies.5 x, L6 o/ U$ ~, N
Nonetheless, we do not believe our patient is
8 q1 ^4 w% Z3 n. n! M4 x& ] fgoing to experience any of the untoward effects from
8 |' c1 r. Z- X+ j6 z: X; Ytestosterone exposure as mentioned earlier because, h, |6 a7 Y" w8 D
the exposure was not for a prolonged period of time.
5 v& H4 Z9 P# IAlthough the bone age was advanced at the time of
2 ]3 X7 J) F/ V9 Z" l: V/ q" rdiagnosis, the child had a normal growth velocity at$ \) r5 X6 v8 Y6 T: Z
the follow-up visit. It is hoped that his final adult
7 T1 e4 k3 m9 }height will not be affected.
; q) a s- P; ^ z$ cAlthough rarely reported, the widespread avail-
" g; J7 F! Z& b# y0 {ability of androgen products in our society may
0 C( Q5 s* c- aindeed cause more virilization in male or female$ {9 W% d" F& f* G
children than one would realize. Exposure to andro-
$ o8 h0 [1 _5 l# I- E% c4 wgen products must be considered and specific ques-
% U! I% w7 e qtioning about the use of a testosterone product or4 ]9 |) t+ h. @. X7 p
gel should be asked of the family members during, K+ r! H! {/ T) X+ L% ]1 }
the evaluation of any children who present with vir-5 q+ ]9 M5 e5 o: X) e5 t& K
ilization or peripheral precocious puberty. The diag-
4 L3 L0 M; n$ bnosis can be established by just a few tests and by
/ o. \7 E; ?6 p5 ^appropriate history. The inability to obtain such a
6 \6 z6 K# |" {' v* Lhistory, or failure to ask the specific questions, may2 |) u# T: @# P/ [/ g) `0 H, B
result in extensive, unnecessary, and expensive+ V4 P, d% b- T ?2 }
investigation. The primary care physician should be; k o1 P$ v5 x/ ~3 |; ^
aware of this fact, because most of these children
. `. ]* c0 J! Xmay initially present in their practice. The Physicians’9 z" y& {0 K. t9 d7 M
Desk Reference and package insert should also put a- N8 j& r7 m% e- J
warning about the virilizing effect on a male or
% ]+ ], J) [# D* k, yfemale child who might come in contact with some-
6 l3 `, g5 e/ a" b; O q6 Lone using any of these products.9 x0 u4 i7 l8 G6 P
References
5 ^3 o. E9 ]. t" s1. Styne DM. The testes: disorder of sexual differentiation# \) K6 p! B9 f* F6 X
and puberty in the male. In: Sperling MA, ed. Pediatric% V% D7 N( _( U& n, P( A; E9 T
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;0 m& C( c, i. b9 y
2002: 565-628.
6 K, W8 I4 r5 u- v1 X. q2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious. L- e- j. m6 ~4 a$ P; q
puberty in children with tumours of the suprasellar pineal |
|