Growth hormone deficiency

The diagnosis of adult growth hormone deficiency requires the presence of symptoms as well as a failure of GH to rise appropriately after an insulin or other appropriate stimulation test.

Is the patient known to have pituitary disease, and what treatments have they had in the past?

GH is often the first anterior pituitary hormone to be lost following pituitary damage. Radiotherapy is particularly associated with GH deficiency.

Has the patient received any radiotherapy for cranial, or other malignancies, in the past?

Radiotherapy is widely used and highly effective in cancer management, and many more adults are now survivors of previous cancer. However, cranial and craniospinal irradiation for childhood haematological malignancy, bone marrow transplants, or intracranial tumours, does increase the risk of hypopituitarism developing, and GH deficiency tends to be the first manifestation of this.

Does the patient feel well in themselves?

Multiple, rather non-specific symptoms may occur in the syndrome of adult GH deficiency, though none are diagnostic of it. The QOL-AGHDA disease specific questionnaire has been specifically developed to seek symptoms of adult GH deficiency. Scores above 11/25 are required to qualify for GH replacement therapy according to NICE guidelines.

Do they struggle or take excessive effort to finish things?

This is a commonly reported feature of adult GH deficiency.

Do they complain of fatigue, and need to sleep during the day?

This is a commonly reported feature of adult GH deficiency, as well as a general lack of energy and concentration.

Do they find it difficult to mix with others, or to make new friends?

This may occur in the syndrome of adult GH deficiency, and is most likely to be recognised by completing the QOL-AGHDA questionnaire.

Does the patient find it difficult to concentrate or remember things?

This is a commonly reported feature of adult GH deficiency, as well as a general lack of energy and concentration.

Has the patient developed a low mood, or symptoms of depression?

This may occur in the syndrome of adult GH deficiency, though is obviously not specific to it.

Have they lost confidence or enjoyment in life, or do they struggle to control their emotions?

This may be detected on close questioning.

Is the patient known to have osteoporosis, or do they have symptoms that suggest it?

Osteoporosis is more common in pituitary patients. It often occurs in the context of supraphysiological glucocorticoid replacement, though is also exacerbated by GH deficiency, or thyroxine excess.

Has the patient gained weight or noticed a change in their body shape?

Increased central adiposity, with loss of lean muscle bulk, may occur with GH deficiency.

Has the patient developed hyperlipidaemia?

This may improve with GH replacement therapy.

Does the patient have any symptoms to suggest glucocorticoid, thyroxine or sex hormone deficiency?

GH is frequently the first manifestation of anterior pituitary failure. However, GH replacement should only be considered after all other axes have been tested and replaced if necessary.

Weight loss, fatigue, dizziness, cold intolerance, amenorrhoea, erectile dysfunction, loss of libido and hot flushes are all features suggestive of anterior pituitary hormone deficiency.

Are there any features to suggest an elevated prolactin?

Hyperprolactinaemia occurs in multiple pituitary pathologies, and so may accompany GH deficiency. Gynaecomastia, erectile dysfunction and loss of libido are common presentations in male patients, amenorrhoea and galactorrhoea are the usual early presentations in female patients.

Do they complain of headache, visual disturbance or facial pain?

Non functioning pituitary tumours may also lead to anterior pituitary failure, and so a thorough assessment for mass effects is mandatory.

Are they taking any prescribed or non prescribed medications?

Estrogen replacement therapy of any preparation will lead to elevations in cortisol binding globulin and so effect serum cortisol results.

Inhaled and topical steroids also affect the hypothalamic-pituitary-adrenal axis, and steroids may occasionally be found in preparations thought by the patient to be 'natural' or 'herbal'.

Symptoms of supraphysiological GH replacement therapy

Has the patient developed soft tissue swelling or “puffiness”?

This occurs most frequently during initial dose titration, is usually transient, and if necessary reverses on dose reduction.

Has the patient developed excessive sweating?

This is a symptom of GH excess, but is rare in patients on replacement therapy.

Has the patient developed swelling or tenderness of the joints particularly those of the hands?

This should prompt dose reduction.