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Sexual Precocity in a 16-Month-Old1 o* H& [. F1 y4 X4 z) Q
Boy Induced by Indirect Topical
. m3 D/ H3 v; s! r9 N" P, {Exposure to Testosterone
2 E+ j p* G& @' {Samar K. Bhowmick, MD, FACE,1 Tracy Ricke, MD,2
, e( v% V7 |4 d1 gand Kenneth R. Rettig, MD1. X6 {: H5 V4 ~3 [
Clinical Pediatrics4 N! k5 k& G6 c6 ^, K% l
Volume 46 Number 6# D5 L! Y3 ]3 u0 n/ J2 |
July 2007 540-543
9 p8 Y( _8 x. `1 ^7 k2 S* L- z© 2007 Sage Publications
9 h. s' v2 H5 Q; W1 @8 M3 O10.1177/0009922806296651
1 H M; o6 n Zhttp://clp.sagepub.com
$ h* n- J" E9 @; M% n( B3 N# nhosted at
3 }: b2 [/ U. M9 Y! t& Zhttp://online.sagepub.com. c9 N5 C$ ], R
Precocious puberty in boys, central or peripheral,0 Q2 N! @0 x5 n" o; [& g( R& W
is a significant concern for physicians. Central+ a3 N9 c. a& v. e
precocious puberty (CPP), which is mediated8 l" |3 \$ B& x4 x6 I
through the hypothalamic pituitary gonadal axis, has
" A/ s5 f8 V7 `a higher incidence of organic central nervous system
" W4 T, d# y. ?! q* v G0 e7 zlesions in boys.1,2 Virilization in boys, as manifested* U- |: E7 G, g4 e
by enlargement of the penis, development of pubic
2 i! a% U+ H. I. ?: Yhair, and facial acne without enlargement of testi-
8 A5 k9 h8 U3 v7 bcles, suggests peripheral or pseudopuberty.1-3 We
4 s0 ~8 @4 n0 X$ G: @; Hreport a 16-month-old boy who presented with the
' P4 I5 Q( b+ L' _: uenlargement of the phallus and pubic hair develop-# t- N$ X/ f; y7 p
ment without testicular enlargement, which was due3 Q3 c2 s* ~! P3 J& M, _# K
to the unintentional exposure to androgen gel used by# y# N. S9 g: a5 e* }) |8 z9 ], P
the father. The family initially concealed this infor-
1 k+ v( ]3 E F0 u: h$ |mation, resulting in an extensive work-up for this) \' S9 d% d/ T& x3 |( o* t
child. Given the widespread and easy availability of0 l9 \1 F3 i9 Q, |2 l0 f
testosterone gel and cream, we believe this is proba-" |7 D7 \# M0 Z" y. @/ M
bly more common than the rare case report in the! I# J3 @ `7 W, d m0 P0 T2 h
literature.4
# J6 {1 M# h4 G, t4 f7 U9 ePatient Report9 N' ]) r- v3 n
A 16-month-old white child was referred to the
; y: X! ~1 m( s0 N' f# Jendocrine clinic by his pediatrician with the concern0 l/ R: S8 S, r8 y. n
of early sexual development. His mother noticed( G2 {4 ~% l) j% }
light colored pubic hair development when he was
; x! h( }- m! c; W3 @From the 1Division of Pediatric Endocrinology, 2University of- q* l/ h P0 [$ o8 R
South Alabama Medical Center, Mobile, Alabama.
" `& u/ a! G/ |2 R' ~Address correspondence to: Samar K. Bhowmick, MD, FACE,
8 t$ s4 U' g' K; ~7 j" y. GProfessor of Pediatrics, University of South Alabama, College of
- {' O! w8 J7 D$ n, S# ]Medicine, 2451 Fillingim St. Mastin 212, Mobile, AL 36617-2297;4 Q8 u4 {: I$ E$ ~
e-mail: [email protected].
$ m( f% H/ ]" i6 N# k, H Rabout 6 to 7 months old, which progressively became
, b, j1 y/ G7 z/ kdarker. She was also concerned about the enlarge-
4 m+ ` p' ^ sment of his penis and frequent erections. The child
& P+ d$ z8 `# a% O. |& _6 Rwas the product of a full-term normal delivery, with1 K2 C3 J; {/ p0 r
a birth weight of 7 lb 14 oz, and birth length of) E4 _0 Y. `5 O3 Z; j
20 inches. He was breast-fed throughout the first year3 B4 |6 _6 ]( y. o! n. ^8 M
of life and was still receiving breast milk along with/ s @2 Y( u+ f3 }5 ?
solid food. He had no hospitalizations or surgery,& O" s8 G1 q0 l Y
and his psychosocial and psychomotor development
: f0 Y) T+ b' cwas age appropriate.
# B# C3 o" _+ l8 \The family history was remarkable for the father,$ Y- C: Y8 E# g* a5 A, _
who was diagnosed with hypothyroidism at age 16,8 ]! G1 E# m7 D$ D' I- K l& D* O! l
which was treated with thyroxine. The father’s
4 a: x+ P5 F! A# g' W" eheight was 6 feet, and he went through a somewhat: R" o8 e L2 i+ R0 e
early puberty and had stopped growing by age 14.
. b* C4 b: l# g- h) h1 O, C# D. [The father denied taking any other medication. The$ a |$ D/ Q: D4 J; l! t4 r
child’s mother was in good health. Her menarche
$ G" E* M0 \1 a* q/ x* }was at 11 years of age, and her height was at 5 feet4 G, L- Q- W0 @( H: C6 c6 W; }3 `! {
5 inches. There was no other family history of pre-- \$ N2 e7 W p6 S
cocious sexual development in the first-degree rela-$ u; }* A9 s T8 R& ~
tives. There were no siblings.
8 S; @9 X9 X/ RPhysical Examination
3 i+ Z" |5 q, \/ kThe physical examination revealed a very active,
2 r; L8 d' y7 i# x7 I! {8 z# @1 o$ Yplayful, and healthy boy. The vital signs documented
, \; p x8 A$ [; qa blood pressure of 85/50 mm Hg, his length was7 A0 ^) B' a. v o+ u
90 cm (>97th percentile), and his weight was 14.4 kg5 ]' V1 b7 e. T A
(also >97th percentile). The observed yearly growth) |+ ^$ \9 ^& D" g. @) r' L
velocity was 30 cm (12 inches). The examination of
8 z6 c d7 h4 H9 y# Nthe neck revealed no thyroid enlargement.
$ \; E+ ^6 M) B+ `' [" o I NThe genitourinary examination was remarkable for }* e3 x* [) c: A+ L% E! t3 s4 ^" f
enlargement of the penis, with a stretched length of3 m$ L" H+ k; u$ e" O# `
8 cm and a width of 2 cm. The glans penis was very well9 _# s8 B& n+ ~+ j* _; c/ y; X
developed. The pubic hair was Tanner II, mostly around, p8 @; e K$ Z# \& N
540( F( n. S! a* S' M) v
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from/ g6 B8 c2 F/ u% t" P% ]1 b
the base of the phallus and was dark and curled. The# J1 Z2 M9 Z3 u& v
testicular volume was prepubertal at 2 mL each.7 y3 f; b. E( X
The skin was moist and smooth and somewhat
5 S9 F! `$ P- ^% @% |oily. No axillary hair was noted. There were no/ Y9 i+ o4 H M- H/ P
abnormal skin pigmentations or café-au-lait spots." B8 A: |& |: ]9 y: @) z2 |
Neurologic evaluation showed deep tendon reflex 2+( H9 M& Z+ o7 q5 p M0 B
bilateral and symmetrical. There was no suggestion! M7 ]! Z6 X0 I8 G" `
of papilledema./ J6 [2 W9 ]6 ^
Laboratory Evaluation
( y( @& U9 M3 a8 @The bone age was consistent with 28 months by: g7 k q! E& ^1 v8 f/ [
using the standard of Greulich and Pyle at a chrono-
' Z/ E) L. P' b* W! B& M9 U' s" [1 @logic age of 16 months (advanced).5 Chromosomal
7 Z' O" a6 z2 ]+ f+ Y1 _8 z6 Q: Ckaryotype was 46XY. The thyroid function test
- F1 ~5 d+ R/ e/ i' wshowed a free T4 of 1.69 ng/dL, and thyroid stimu-
( d% A5 {7 t* V6 Olating hormone level was 1.3 µIU/mL (both normal).( w( s1 D; @1 f. t4 b& \1 c
The concentrations of serum electrolytes, blood
0 u, V0 x$ l2 Nurea nitrogen, creatinine, and calcium all were+ z0 _3 f5 H, n- T" W5 d! e" U
within normal range for his age. The concentration
$ k+ ^* t; h% Q5 }3 b; Dof serum 17-hydroxyprogesterone was 16 ng/dL# E5 Q3 s/ _* l0 t E9 k( B
(normal, 3 to 90 ng/dL), androstenedione was 20
# z) a# B" m1 V& {ng/dL (normal, 18 to 80 ng/dL), dehydroepiandros-
8 X |3 E9 y% \4 dterone was 38 ng/dL (normal, 50 to 760 ng/dL),$ n. Q( k2 x1 p4 z- [
desoxycorticosterone was 4.3 ng/dL (normal, 7 to
5 r, b$ {3 w8 d H3 x49ng/dL), 11-desoxycortisol (specific compound S)/ I; y. Z0 c( L/ g. D2 N$ N
was 43 ng/dL (normal, 10 to 156 ng/dL), serum cor-
, O6 K, Y1 n' e) o. f* Jtisol was 7.6 µg/dL (normal, 2.8 to 23 µg/dL), total
, Q0 C# _- b# W5 q. htestosterone was 60 ng/dL (normal <3 to 10 ng/dL),+ ?$ C& O& L8 [1 `. q
and β-human chorionic gonadotropin was less than
, w: j/ w! `6 L$ u! |! ]5 mIU/mL (normal <5 mIU/mL). Serum follicular
% ?2 n+ e2 u# O& j- w# C5 jstimulating hormone and leuteinizing hormone
- s' P) n+ T% n8 a) N' hconcentrations were less than 0.05 mIU/mL
" @$ f" e/ U. e* s z, l: k! T(prepubertal).5 v1 M( y. N) F6 {( r6 f, T
The parents were notified about the laboratory
2 V Z2 x9 ~+ p2 i# |5 \% k! u) ^results and were informed that all of the tests were( ^; P6 W4 A- G9 M' u5 M! x+ ]8 {
normal except the testosterone level was high. The! r6 u' v8 ~+ ]; z( v2 x% B
follow-up visit was arranged within a few weeks to( p. B( U' |! T8 {/ A' X
obtain testicular and abdominal sonograms; how-
% y4 E) i& a& Lever, the family did not return for 4 months.
. X" ?& j: [3 ?3 g+ JPhysical examination at this time revealed that the
# n: k v9 u4 ~: J) ?child had grown 2.5 cm in 4 months and had gained
# d' K! @+ q, K* X; P7 |/ y2 kg of weight. Physical examination remained8 T4 `: U- @4 j( f# S7 Z
unchanged. Surprisingly, the pubic hair almost com-3 L4 h' B6 `/ x7 N, _' E; `
pletely disappeared except for a few vellous hairs at) h2 L, V7 p7 b& N2 \! ^- y1 P: ~
the base of the phallus. Testicular volume was still 22 k* U" G9 z( \, J2 p6 c
mL, and the size of the penis remained unchanged.
J8 c8 @; s! F# M7 P5 L( x$ IThe mother also said that the boy was no longer hav-7 Z" G( W# J" J% g E; Z* [( m
ing frequent erections.
, v3 I2 _' `" J5 M* W5 ?Both parents were again questioned about use of
9 \, `0 x; H8 n' Y! U+ T$ Tany ointment/creams that they may have applied to4 V$ o) c7 C u1 a& a( X
the child’s skin. This time the father admitted the
2 C) m/ Z( b1 g1 X# N+ a* _4 ITopical Testosterone Exposure / Bhowmick et al 541
0 N; x4 y# v/ B& |4 quse of testosterone gel twice daily that he was apply-
, X9 ]% k. T. g: Hing over his own shoulders, chest, and back area for' r. _# k2 A( w4 l$ e: V+ P
a year. The father also revealed he was embarrassed. q9 c u& S- ^) v
to disclose that he was using a testosterone gel pre- G# p/ Q* k+ X% j$ k: w# |
scribed by his family physician for decreased libido: \! s& \( b9 E! G( {* z1 k! S
secondary to depression.% F; c5 L- q. L1 Z
The child slept in the same bed with parents.
% M$ @. a9 z* R7 k- x+ _! _The father would hug the baby and hold him on his( N+ ~, i. c* x0 L& ]
chest for a considerable period of time, causing sig-
; J) \# l: w" [" inificant bare skin contact between baby and father., X/ X* C+ g# P( `/ D3 G, J/ b' \
The father also admitted that after the phone call,
1 c) H8 e5 P* i/ ^: Uwhen he learned the testosterone level in the baby7 M; Y# e7 Q; n* r4 l' z1 \7 z T
was high, he then read the product information( y$ w- z, p M6 D+ E; m
packet and concluded that it was most likely the rea-8 y3 Q- O9 P+ y& ^$ \
son for the child’s virilization. At that time, they
3 U1 W1 V8 z, E( I$ L' Odecided to put the baby in a separate bed, and the
& p0 k2 L. O2 Afather was not hugging him with bare skin and had9 m+ P. c! _6 B# u% T
been using protective clothing. A repeat testosterone& R6 q' n- l! ~; A
test was ordered, but the family did not go to the
2 v- w. R2 g% U6 N1 klaboratory to obtain the test.
/ K, g/ p$ e% ~$ b' a4 fDiscussion
`$ |) J; S- E. L0 T' q( F/ |Precocious puberty in boys is defined as secondary
$ t9 X( U1 c7 I. @4 o+ Tsexual development before 9 years of age.1,4
% J- f8 V3 o/ f \* U3 SPrecocious puberty is termed as central (true) when
/ z1 x. l2 u- `/ _& C; b: Xit is caused by the premature activation of hypo-
) x: U6 Q% O& g1 tthalamic pituitary gonadal axis. CPP is more com-
; c6 h5 D4 b f$ a, l$ B: omon in girls than in boys.1,3 Most boys with CPP
g' q4 R6 Q* k: i/ O1 U3 ymay have a central nervous system lesion that is: q7 @* x" I8 E
responsible for the early activation of the hypothal-
# C! i9 V: u6 W* B* J# t+ i( Y* Vamic pituitary gonadal axis.1-3 Thus, greater empha-6 V9 m( S8 H8 v: W% R$ V
sis has been given to neuroradiologic imaging in
4 p( ^/ E6 q9 Z& Bboys with precocious puberty. In addition to viril-
6 x, f4 t8 C9 Y: B- mization, the clinical hallmark of CPP is the symmet-8 R( J% b6 p% E- {& f
rical testicular growth secondary to stimulation by
/ f8 { j. Q7 vgonadotropins.1,3
" d; p6 o; w. W$ S$ y; ^Gonadotropin-independent peripheral preco-
( ]# o# V4 Z& l3 `cious puberty in boys also results from inappropriate; h& r6 g' I, e7 p
androgenic stimulation from either endogenous or
) k8 M, S7 @: }2 B3 N% t" bexogenous sources, nonpituitary gonadotropin stim-" O+ v- L0 U" n- |0 B/ `" f. u& u
ulation, and rare activating mutations.3 Virilizing
7 g3 w% b& p" L* C: T# Wcongenital adrenal hyperplasia producing excessive
& M1 q3 q ?. m; [1 G( N- Uadrenal androgens is a common cause of precocious
; s+ O# ^: @: v& M q: S1 kpuberty in boys.3,4
9 B. `$ P( N. V5 d1 U6 `8 Z2 }6 ^The most common form of congenital adrenal K/ U8 j3 L( _3 ~
hyperplasia is the 21-hydroxylase enzyme deficiency.
8 _' H8 U+ r4 L3 N- y( YThe 11-β hydroxylase deficiency may also result in
I6 x% c8 J8 t8 L5 }2 Hexcessive adrenal androgen production, and rarely,
- z$ ~) E0 B# P, W3 `5 San adrenal tumor may also cause adrenal androgen0 k4 U+ u: S$ e
excess.1,3* w$ x- R4 \- ^& X% P
at University of Manchester Library on May 25, 2015 cpj.sagepub.com Downloaded from' T$ Q' I( L# b+ G! j7 m
542 Clinical Pediatrics / Vol. 46, No. 6, July 20078 b; o9 o2 O, k2 ]$ L5 K6 b& Y
A unique entity of male-limited gonadotropin-& U# R. [* |9 E! E+ }
independent precocious puberty, which is also known
9 ^! b5 S/ ?) F3 r3 ^0 b9 v' Bas testotoxicosis, may cause precocious puberty at a/ l7 A( h5 l4 y9 u- p. L3 g
very young age. The physical findings in these boys
, B8 o$ [ T+ a' t+ d kwith this disorder are full pubertal development,/ c% X$ M4 S: T) @2 L+ A
including bilateral testicular growth, similar to boys0 F$ ~9 v1 i/ J& R
with CPP. The gonadotropin levels in this disorder% ^; T0 U% D% ?
are suppressed to prepubertal levels and do not show
K8 g" C" a$ t- Z- ?pubertal response of gonadotropin after gonadotropin-
; l4 i9 S" c5 Y) l0 \5 T# d9 ereleasing hormone stimulation. This is a sex-linked
7 f0 H4 }/ q% D' Y! h7 c/ iautosomal dominant disorder that affects only
& I' X* X' Q+ s! E* }4 M# s3 Pmales; therefore, other male members of the family' r) Z; t) s2 N! p0 ?" m
may have similar precocious puberty.34 a: A. e+ w# F6 _, \- v+ @
In our patient, physical examination was incon-
3 O: l, x. V# R- ]2 U2 Xsistent with true precocious puberty since his testi-( \( x& J; V. G, y+ k7 N
cles were prepubertal in size. However, testotoxicosis( W. B* x9 \7 g2 T, I* `; i! u
was in the differential diagnosis because his father/ B. b) c8 o6 f' W3 W0 G
started puberty somewhat early, and occasionally,
q% R: k, t @testicular enlargement is not that evident in the
, G7 g. r8 J3 L1 s6 zbeginning of this process.1 In the absence of a neg-
! E) Z- X; ?, yative initial history of androgen exposure, our9 ~# ~8 i- ~/ ?5 Q' Y9 b: {& H4 s
biggest concern was virilizing adrenal hyperplasia,/ | p0 z6 x7 Z" I, F% b
either 21-hydroxylase deficiency or 11-β hydroxylase
4 p- E9 d2 H- \7 l. G Z$ Xdeficiency. Those diagnoses were excluded by find-) d9 T" v0 ~( B0 X, H, ]
ing the normal level of adrenal steroids./ a: T4 E1 V' Y+ H
The diagnosis of exogenous androgens was strongly: F% @6 \0 `5 e* T2 w. J' l% w' ]
suspected in a follow-up visit after 4 months because7 n" b! q- c0 I% }
the physical examination revealed the complete disap-+ ?, |9 { ]/ w! {9 z, v
pearance of pubic hair, normal growth velocity, and
+ u$ O A$ L. r* j! tdecreased erections. The father admitted using a testos-8 R/ H9 h$ L _" T
terone gel, which he concealed at first visit. He was
: M# v3 N4 M' r- cusing it rather frequently, twice a day. The Physicians’& g! p7 o8 |/ A9 j: ?
Desk Reference, or package insert of this product, gel or- A1 G4 t9 e) d' k- T4 x
cream, cautions about dermal testosterone transfer to! J; L% s2 A ^) Z% D @$ } \5 _& n
unprotected females through direct skin exposure.) b7 X6 j$ F% l, r) Y( W
Serum testosterone level was found to be 2 times the9 I" _- ^. j0 S8 z7 q. X
baseline value in those females who were exposed to
( g2 r1 x# {% b: l7 P5 Jeven 15 minutes of direct skin contact with their male& E# {- k3 {, \1 ] Z
partners.6 However, when a shirt covered the applica-3 s& k. a% Z9 n
tion site, this testosterone transfer was prevented.
: [$ |/ e$ v$ h4 _( M2 P0 jOur patient’s testosterone level was 60 ng/mL,- f; k" r' c. r, \- h
which was clearly high. Some studies suggest that
6 ] r1 t* G- ?9 Ddermal conversion of testosterone to dihydrotestos-
9 D1 {8 ~9 g5 T# Z! o* K G! Aterone, which is a more potent metabolite, is more
: L# b! U P mactive in young children exposed to testosterone
, ]" M! N9 o s" A* i. q+ y I' E( rexogenously7; however, we did not measure a dihy-/ H- l+ K, m/ x% `$ P/ G" i
drotestosterone level in our patient. In addition to. F$ r9 |' k, G9 ^4 L
virilization, exposure to exogenous testosterone in' F2 M1 c2 q( H& I* I. N e! r
children results in an increase in growth velocity and" n* N: u- s0 O4 n
advanced bone age, as seen in our patient.6 q- F4 U( ~- N0 B/ w' |4 e1 r
The long-term effect of androgen exposure during
2 Y h, w" q1 R4 Eearly childhood on pubertal development and final# g+ O) Z% w4 g$ \. t# n/ K: f- q
adult height are not fully known and always remain3 c+ P; p, x% N
a concern. Children treated with short-term testos-
, a3 n% h2 v! X* F5 E4 n7 e& iterone injection or topical androgen may exhibit some
# V( b$ v/ B) S% B2 yacceleration of the skeletal maturation; however, after
! K: T8 X0 N* u+ [( M' \" z- hcessation of treatment, the rate of bone maturation( ]7 h/ N1 ], E O" ^, @
decelerates and gradually returns to normal.8,92 b1 d. @! A* A+ r4 T, C( B
There are conflicting reports and controversy
0 S t/ y7 P5 s* b/ \3 h$ gover the effect of early androgen exposure on adult9 C1 g o. ]" s+ f/ n( G7 e
penile length.10,11 Some reports suggest subnormal
- i @( H! e& k$ S3 i3 u0 Uadult penile length, apparently because of downreg-
1 t, ` u6 ^+ a1 \ulation of androgen receptor number.10,12 However,4 g+ F; J L9 m- w
Sutherland et al13 did not find a correlation between2 C- m, T& T$ ]
childhood testosterone exposure and reduced adult+ e8 q0 ]* G3 O
penile length in clinical studies.
( [% K3 e' T. h0 y. J' P* `9 nNonetheless, we do not believe our patient is0 `$ v( o+ ]3 N3 V! W k
going to experience any of the untoward effects from* j) t; F: i. _$ S% d* Q* f
testosterone exposure as mentioned earlier because
+ L5 F3 L3 r+ K4 W3 Ithe exposure was not for a prolonged period of time.
4 T# ~6 G0 h8 Z1 f9 zAlthough the bone age was advanced at the time of# X, @7 ]) u' D/ W* F' L
diagnosis, the child had a normal growth velocity at& s2 Q6 {/ E2 {5 v S: \: p n
the follow-up visit. It is hoped that his final adult1 v& [: w5 T6 M1 T2 v
height will not be affected.3 ~2 @$ v+ F1 B6 O( C! i- ]0 [ M
Although rarely reported, the widespread avail-
5 X$ a/ M8 \' Y8 ]: m: z0 Oability of androgen products in our society may
$ Q% f* J; @3 q Yindeed cause more virilization in male or female& y5 h3 v6 X. [+ z6 V+ W
children than one would realize. Exposure to andro-/ y2 C# N% h6 H, k3 E6 ~
gen products must be considered and specific ques-. t" J! s. i$ c3 d% s% k% Q
tioning about the use of a testosterone product or
& R$ @- _& d! F' u- d7 Ugel should be asked of the family members during. j" Q6 z& x* F3 w" O( _
the evaluation of any children who present with vir-& H u1 ~* F& j \& y+ P/ _7 M3 t
ilization or peripheral precocious puberty. The diag-
8 X7 X+ M( t* c, r: xnosis can be established by just a few tests and by
/ P, e x/ Y$ c# i0 r! Sappropriate history. The inability to obtain such a: Q4 s0 V* r$ e' a9 }1 c
history, or failure to ask the specific questions, may
# q- p' Q4 N+ ^, O: k: l* aresult in extensive, unnecessary, and expensive* R4 @# Q! R: ^# W+ m
investigation. The primary care physician should be
$ m. ]( M4 p) Jaware of this fact, because most of these children
4 s! K" w1 S/ X4 Gmay initially present in their practice. The Physicians’; c6 }5 U4 | R$ I
Desk Reference and package insert should also put a4 Q/ I) T R+ D3 {" i! B$ K ~! [
warning about the virilizing effect on a male or. z! r- r! X5 Q( g
female child who might come in contact with some-
& ]; b# j4 O5 k% v0 gone using any of these products.% w% \3 c. Q2 B9 h U2 i/ L. Z
References( H0 C/ Y+ t/ `1 G/ L; |$ ?) w
1. Styne DM. The testes: disorder of sexual differentiation( D) [) {* a2 k6 Q! Y
and puberty in the male. In: Sperling MA, ed. Pediatric0 R# i6 C; L% [/ t8 ~# [$ J. f% x
Endocrinology. 2nd ed. Philadelphia, PA: WB Saunders;
- @; ?3 ]& X& `5 K; ]2002: 565-628.
5 w" z* u" b7 _. s* r9 x2. Rivarola M, Belgorosky A, Mendilaharzu H, et al. Precocious
2 I! J5 F1 ?2 O9 v1 u1 V6 Lpuberty in children with tumours of the suprasellar pineal |
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