Growth hormone (GH)

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GH is needed for a child’s normal growth and development. It promotes the growth of the long bones from birth through puberty. Children with insufficient GH production grow more slowly and are small in size for their age; one of the first symptoms of growth hormone deficiency (GHD). It should be noted that short stature can also be related to familial traits or other genetic disorders. Constitutional delay (i.e. temporary delay in growth of no obvious cause) is the most common cause of short stature in childhood.

About

An excess of GH is most often due to a benign GH-secreting pituitary tumour i.e. a tumour that has not spread to other tissues, although larger tumours can have other effects e.g. headaches and impaired vision Gigantism is a disorder resulting from long-term secretion of too much GH, which increases the growth of muscle, bones and connective tissue in childhood or adolescence before the end of puberty. This results in a child becoming excessively tall (e.g. over 2.1 meters). Children with excessive GH production may also have thickening of their facial features, general weakness, delayed puberty, and headaches.


In adults, GH plays a role in regulating bone density, muscle mass, and lipid metabolism. Deficiencies can lead to decreased bone densities, lower muscle mass, and altered lipid concentrations. Excess GH in adults can lead to acromegaly, with bone and skin thickening. Symptoms such as sweating, fatigue, headaches and joint pain can be subtle at first. Increased GH concentrations can lead to enlargement of the hands, feet, facial bones and internal organs and carpal tunnel syndrome (trapped nerves). If untreated, acromegaly in adults and gigantism in children can lead to complications such as type 2 diabetes, increased cardiovascular disease risk, high blood pressure, arthritis, and in general, a decreased life span.


GH stimulates the secretion of the true growth factors, most notably IGF-1. The concentration of which represents the secretion of GH in the previous few days. This is measured prior to stimulation or suppression tests used to diagnose GH abnormalities and to monitor treatment.

Preparation

A GH suppression or stimulation tests is performed after fasting for 10 to 12 hours when a blood sample is taken from a vein in the arm. Patient should resting for 30 mins before sample taking.


Under medical supervision, a standard glucose solution is given to the patient to drink (for a suppression test), or an intravenous (IV) injection of a solution of insulin, glucagon, arginine, clonidine or GH releasing hormone (GHRH, for a stimulation test) is given through a vein in your arm. Blood samples are then taken from your veins at timed intervals. GH is measured on each sample collected to look at the change in levels over time. Sometimes it is necessary to perform a second test.


During treatment for growth hormone excess a sample of blood may be taken, following a fast, to monitor growth hormone production.

Indications

GH stimulation testing is requested when your child has symptoms of GH deficiency (GHD), such as when:
  • Your child's growth rate slows down in early childhood and (s)he is significantly shorter than others of similar age
  • TSH tests show that your child is not hypothyroid (low thyroid concentrations in the bloodstream can also cause slowed growth)
  • X-rays show delayed bone development
  • Your doctor suspects that your child’s pituitary gland is underactive
  • To monitor GH levels in children who have received radiation therapy.
Once GHD is suspected your doctor will use an IGF-1 and GH stimulation tests to confirm the diagnosis. To monitor treatment both measurement of IGF-1 and the pattern of your child’s growth will be looked at. Repeat testing for growth hormone deficiency may occur as a child reaches adulthood to see if a continued replacement is necessary.


Stimulation testing is requested in adults when patients have symptoms of GHD. Suppression testing may be done when a pituitary tumour is suspected and may be used along with IGF-1 levels and other hormone levels to monitor the effectiveness of treatment for these conditions. Monitoring may continue at regular intervals for many years to watch for recurrence.


Since GH is released by the pituitary in bursts, random GH levels are not very useful as there is too much overlap between abnormal results and normal daily variation.

Interpretation

GH suppression test


If your GH levels are not significantly suppressed during a GH suppression test (i.e. they stay higher than they should) and:

  • you have symptoms of gigantism or acromegaly
  • other pituitary hormone levels are normal and/or controlled
  • your IGF-1 levels are high
it is likely that you are producing too much GH and it is causing complications. If you have other pituitary hormones that are abnormal, then you may have a condition causing hyperpituitarism. If a mass shows up on an X-ray, CT scan, or MRI; then you may have pituitary or very rarely another sort of tumour. If you are being monitored for a previous tumour, then you may be having a recurrence.


GH stimulation test


If your TSH is low then that should be addressed first as thyroid deficiencies can cause symptoms similar to GHD.


If your GH levels are not significantly stimulated during a GH stimulation test (i.e. they stay lower than they should be) and:

  • you have symptoms of GHD
  • other pituitary hormone levels are normal and/or controlled
  • your IGF-1 level is low
then it is likely that you have a deficiency of GH and that your doctor may treat the symptoms. You may also have a more general decrease in pituitary function.


Pituitary tumours are the most common cause of excess GH production but these tumours may also cause deficiencies of other pituitary hormones, such as ACTH (Cushing’s syndrome) or prolactin (galactorrhoea). If the tumour is relatively large it may inhibit all pituitary hormone production and cause damage to the surrounding tissues including the optic nerve.


Factors that can interfere with GH testing include:

  • Stress, exercise, and low blood glucose levels
  • Drugs that can increase GH include amphetamines, arginine, dopamine, oestrogens, glucagon, histamine, insulin, levodopa, methyldopa, and nicotinic acid.
  • Drugs that can decrease GH levels: corticosteroids and phenothiazines.
  • A radioactive scan within a week of the test (with some laboratory methods)
Abnormal GH levels can usually be modified once the causes are identified. Synthetic GH is available to treat deficiencies in children (treatment of adults with GHD is more controversial). Combinations of surgery, medication, and radiation can be used to treat pituitary tumours that are causing excess GH production. It is important to identify GH abnormalities as soon as possible to get a good outcome. If left untreated, the GH deficient child will remain short. The bone growth changes associated with gigantism and acromegaly are permanent.


There can be long-term complications from GH abnormalities. Acromegaly, for instance, can cause colonic polyps (increasing a patient’s risk of developing colon cancer), diabetes, high blood pressure, and visual abnormalities. If a pituitary tumour permanently damages pituitary cells, then multiple hormone replacement may be necessary. Increased bone growth may also lead to trapped nerves (carpal tunnel syndrome), arthritis, and weak bones.

Disclaimer

The laboratory test results are NOT to be interpreted as results of a "stand-alone" test. The test results have to be interpreted after correlating with suitable clinical findings and additional supplemental tests/information. Your healthcare providers will explain the meaning of your tests results, based on the overall clinical scenario. Certain medications that you may be currently taking may influence the outcome of the test. Hence, it is important to inform your healthcare provider of the complete list of medications (including any herbal supplements) you are currently taking. This will help the healthcare provider interpret your test results more accurately and avoid unnecessary chances of a misdiagnosis.

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