Hypopituitarism and Growth Hormone Deficiency in Adults

  • Sofia LlahanaEmail author
  • Anne Marland
  • Mila Pantovic
  • Vera Popovic


Pituitary conditions are associated with several physical, psychological, and social symptoms. Treatment involves surgery, medical treatment, and/or radiotherapy. Most patients with pituitary conditions have permanent hypopituitarism (congenital or acquired) and require lifelong hormone replacement therapy. Polypharmacy with multiple daily dosing and complex treatment regimens are common and patients may often require more than five different medications daily.

The treatment goal is to achieve normal physiological hormone levels with minimal side effects and to avoid adverse effects associated with deficiency or over-replacement. Growth hormone (GH) deficiency is very common in adults with hypopituitarism and requires replacement with daily subcutaneous injections. A provocative stimulation test is required to establish the diagnosis of GH deficiency in adults with the insulin tolerance test being regarded as the “gold standard”. Individualised selection of a suitable injecting device is important in improving adherence to medication and optimal replacement. Treatment with GH in adults improves quality of life, body composition, and bone density. Long-acting GH formulations are in development and aim to improve adherence and convenience with treatment via weekly or monthly injections.


Hypopituitarism Pituitary disorders Growth hormone deficiency Hormone replacement therapy Daily injections Quality of life 



Adreno-corticotropic hormone


Antidiuretic hormone


Diabetes insipidus


Follicle-stimulating hormone


Growth hormone


GH-releasing hormone


Glucagon stimulation test


Insulin-like growth factor-1


Insulin tolerance test


Long-acting growth hormone


Luteinising hormone




Quality of life


Recombinant human growth hormone


Thyroid-stimulating hormone



Special thanks to Pat McBride, Head of Patient and Family Services, The Pituitary Foundation (, for her contribution to this chapter with case studies, patient resources, and information on the Patient Advocacy Group


  1. Abdi L, Sahnoun-Fathallah M, Morange I, Albarel F, Castinetti F, Giorgi R, et al. A monocentric experience of growth hormone replacement therapy in adult patients. Ann Endocrinol. 2014;75(3):176.Google Scholar
  2. Adelman DT, Liebert KJ, Nachtigall LB, Lamerson M, Bakker B. Acromegaly: the disease, its impact on patients, and managing the burden of long-term treatment. Int J Gen Med. 2013;6:31–8.PubMedPubMedCentralGoogle Scholar
  3. Agha A, Walker D, Perry L, Drake WM, Chew SL, Jenkins PJ, et al. Unmasking of central hypothyroidism following growth hormone replacement in adult hypopituitary patients. Clin Endocrinol (Oxf). 2007;66(1):72–7.Google Scholar
  4. Ahmid M, Perry CG, Ahmed SF, Shaikh MG. Growth hormone deficiency during young adulthood and the benefits of growth hormone replacement. Endocr Connect. 2016a;5(3):R1–r11.PubMedPubMedCentralGoogle Scholar
  5. Ahmid M, Fisher V, Graveling AJ, McGeoch S, McNeil E, Roach J, et al. An audit of the management of childhood-onset growth hormone deficiency during young adulthood in Scotland. Int J Pediatr Endocrinol. 2016b;2016:6.PubMedPubMedCentralGoogle Scholar
  6. Aimaretti G, Attanasio R, Cannavo S, Nicoletti MC, Castello R, Di Somma C, et al. Growth hormone treatment of adolescents with growth hormone deficiency (GHD) during the transition period: results of a survey among adult and paediatric endocrinologists from Italy. Endorsed by SIEDP/ISPED, AME, SIE, SIMA. J Endocrinol Invest. 2015;38(3):377–82.PubMedGoogle Scholar
  7. van Aken MO, Lamberts SW. Diagnosis and treatment of hypopituitarism: an update. Pituitary. 2005;8(3-4):183–91.PubMedGoogle Scholar
  8. Andela CD, Scharloo M, Pereira AM, Kaptein AA, Biermasz NR. Quality of life (QoL) impairments in patients with a pituitary adenoma: a systematic review of QoL studies. Pituitary. 2015;18(5):752–76.PubMedGoogle Scholar
  9. Atkinson MJ, Sinha A, Hass SL, Colman SS, Kumar RN, Brod M, et al. Validation of a general measure of treatment satisfaction, the Treatment Satisfaction Questionnaire for Medication (TSQM), using a national panel study of chronic disease. Health Qual Life Outcomes. 2004;2:12.PubMedPubMedCentralGoogle Scholar
  10. Biller BM, Ji HJ, Ahn H, Savoy C, Siepl EC, Popovic V, et al. Effects of once-weekly sustained-release growth hormone: a double-blind, placebo-controlled study in adult growth hormone deficiency. J Clin Endocrinol Metab. 2011;96(6):1718–26.PubMedGoogle Scholar
  11. Bleicken B, Hahner S, Loeffler M, Ventz M, Decker O, Allolio B, et al. Influence of hydrocortisone dosage scheme on health-related quality of life in patients with adrenal insufficiency. Clin Endocrinol (Oxf). 2010;72(3):297–304.Google Scholar
  12. Brignardello E, Felicetti F, Castiglione A, Fortunati N, Matarazzo P, Biasin E, et al. GH replacement therapy and second neoplasms in adult survivors of childhood cancer: a retrospective study from a single institution. J Endocrinol Invest. 2014;38(2):171–6.PubMedGoogle Scholar
  13. Burman P, Mattsson AF, Johannsson G, Hoybye C, Holmer H, Dahlqvist P, et al. Deaths among adult patients with hypopituitarism: hypocortisolism during acute stress, and de novo malignant brain tumors contribute to an increased mortality. J Clin Endocrinol Metab. 2013;98(4):1466–75.PubMedGoogle Scholar
  14. Burt MG, Ho KKY. Chapter 11 - Hypopituitarism and Growth Hormone Deficiency. In: Jameson JL, De Groot LJ, de Kretser DM, Giudice LC, Grossman AB, Melmed S, et al., editors. Endocrinology: adult and pediatric. 7th ed. Philadelphia: W.B. Saunders; 2016. p. 188–208.e5.Google Scholar
  15. Chapman SC, S L CP, Horne R. Glucocorticoid therapy for adrenal insufficiency: nonadherence, concerns and dissatisfaction with information. Clin Endocrinol (Oxf). 2016;84:664–71.Google Scholar
  16. Christiansen JS, Backeljauw PF, Bidlingmaier M, Biller BM, Boguszewski MC, Casanueva FF, et al. Growth Hormone Research Society perspective on the development of long-acting growth hormone preparations. Eur J Endocrinol. 2016;174(6):C1–8.PubMedPubMedCentralGoogle Scholar
  17. Clayton PE, Cuneo RC, Juul A, Monson JP, Shalet SM, Tauber M. Consensus statement on the management of the GH-treated adolescent in the transition to adult care. Eur J Endocrinol. 2005;152(2):165–70.Google Scholar
  18. Cook DM, Ludlam WH, Cook MB. Route of estrogen administration helps to determine growth hormone (GH) replacement dose in GH-deficient adults. J Clin Endocrinol Metab. 1999;84(11):3956–60.PubMedGoogle Scholar
  19. Cooper V, Metcalf L, Versnel J, Upton J, Walker S, Horne R. Patient-reported side effects, concerns and adherence to corticosteroid treatment for asthma, and comparison with physician estimates of side-effect prevalence: a UK-wide, cross-sectional study. NPJ Prim Care Respir Med. 2015;25:15026.PubMedPubMedCentralGoogle Scholar
  20. van der Meij N, van Leeuwaarde RS, Vervoort SCJM, Zelissen PMJ. Self-management support in patients with adrenal insufficiency. Clin Endocrinol. 2016; Scholar
  21. Dwyer A, Quinton R, Morin D, Pitteloud N. Identifying the unmet health needs of patients with congenital hypogonadotropic hypogonadism using a web-based needs assessment: implications for online interventions and peer-to-peer support. Orphanet J Rare Dis. 2014;9:83.PubMedPubMedCentralGoogle Scholar
  22. van Eck JP, Gobbens RJ, Beukers J, Geilvoet W, van der Lely AJ, Neggers SJ. Much to be desired in self-management of patients with adrenal insufficiency. Int J Nurs Pract. 2014; Scholar
  23. Ehrnborg C, Hakkaart-Van Roijen L, Jonsson B, Rutten FF, Bengtsson BA, Rosen T. Cost of illness in adult patients with hypopituitarism. Pharmacoeconomics. 2000;17(6):621–8.PubMedGoogle Scholar
  24. Fernandez-Rodriguez E, Lopez-Raton M, Andujar P, Martinez-Silva IM, Cadarso-Suarez C, Casanueva FF, et al. Epidemiology, mortality rate and survival in a homogeneous population of hypopituitary patients. Clin Endocrinol (Oxf). 2013;78(2):278–84.Google Scholar
  25. Filipsson H, Johannsson G. GH replacement in adults: interactions with other pituitary hormone deficiencies and replacement therapies. Eur J Endocrinol. 2009;161(Suppl 1):S85–95.PubMedGoogle Scholar
  26. Flemming TG, Kristensen LO. Quality of self-care in patients on replacement therapy with hydrocortisone. J Intern Med. 1999;246(5):497–501.PubMedGoogle Scholar
  27. Fleseriu M, Hashim IA, Karavitaki N, Melmed S, Murad MH, Salvatori R, et al. Hormonal replacement in hypopituitarism in adults: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(11):3888–921.PubMedGoogle Scholar
  28. Forss M, Batcheller G, Skrtic S, Johannsson G. Current practice of glucocorticoid replacement therapy and patient-perceived health outcomes in adrenal insufficiency - a worldwide patient survey. BMC Endocr Disord. 2012;12:8.PubMedPubMedCentralGoogle Scholar
  29. Gasco V, Prodam F, Grottoli S, Marzullo P, Longobardi S, Ghigo E, et al. GH therapy in adult GH deficiency: a review of treatment schedules and the evidence for low starting doses. Eur J Endocrinol. 2013;168(3):R55–66.PubMedGoogle Scholar
  30. George J, Kong DC, Thoman R, Stewart K. Factors associated with medication nonadherence in patients with COPD. Chest. 2005;128(5):3198–204.PubMedGoogle Scholar
  31. Giavoli C, Libé R, Corbetta S, Ferrante E, Lania A, Arosio M, et al. Effect of recombinant human growth hormone (GH) replacement on the hypothalamic-pituitary-adrenal axis in adult GH-deficient patients. J Clin Endocrinol Metabol. 2004;89(11):5397–401.Google Scholar
  32. Gurel MH, Bruening PR, Rhodes C, Lomax KG. Patient perspectives on the impact of acromegaly: results from individual and group interviews. Patient Prefer Adherence. 2014;8:53–62.PubMedPubMedCentralGoogle Scholar
  33. Hahner S, Loeffler M, Fassnacht M, Weismann D, Koschker AC, Quinkler M, et al. Impaired subjective health status in 256 patients with adrenal insufficiency on standard therapy based on cross-sectional analysis. J Clin Endocrinol Metab. 2007;92(10):3912–22.PubMedGoogle Scholar
  34. Hahner S, Spinnler C, Fassnacht M, Burger-Stritt S, Lang K, Milovanovic D, et al. High incidence of adrenal crisis in educated patients with chronic adrenal insufficiency: a prospective study. J Clin Endocrinol Metab. 2015;100(2):407–16.PubMedPubMedCentralGoogle Scholar
  35. Ho KK. Consensus guidelines for the diagnosis and treatment of adults with GH deficiency II: a statement of the GH Research Society in association with the European Society for Pediatric Endocrinology, Lawson Wilkins Society, European Society of Endocrinology, Japan Endocrine Society, and Endocrine Society of Australia. Eur J Endocrinol. 2007;157(6):695–700.PubMedGoogle Scholar
  36. Hou L, Chen ZH, Liu D, Cheng YG, Luo XP. Comparative pharmacokinetics and pharmacodynamics of a PEGylated recombinant human growth hormone and daily recombinant human growth hormone in growth hormone-deficient children. Drug Des Devel Ther. 2016;10:13–21.PubMedGoogle Scholar
  37. Hoybye C, Pfeiffer AF, Ferone D, Christiansen JS, Gilfoyle D, Christoffersen ED, et al. A phase 2 trial of long-acting TransCon growth hormone in adult GH deficiency. Endocr Connect. 2017;6(3):129–38.PubMedPubMedCentralGoogle Scholar
  38. Janssen YJ, Helmerhorst F, Frolich M, Roelfsema F. A switch from oral (2 mg/day) to transdermal (50 microg/day) 17beta-estradiol therapy increases serum insulin-like growth factor-I levels in recombinant human growth hormone (GH)-substituted women with GH deficiency. J Clin Endocrinol Metab. 2000;85(1):464–7.PubMedGoogle Scholar
  39. Jonsson B, Nilsson B. The impact of pituitary adenoma on morbidity. Increased sick leave and disability retirement in a cross-sectional analysis of Swedish national data. Pharmacoeconomics. 2000;18(1):73–81.PubMedGoogle Scholar
  40. Kepicoglu H, Hatipoglu E, Bulut I, Darici E, Hizli N, Kadioglu P. Impact of treatment satisfaction on quality of life of patients with acromegaly. Pituitary. 2014;17(6):557–63.PubMedGoogle Scholar
  41. Lee P, Ho K. Hypopituitarism and growth hormone deficiency. In: Jameson L, De Groot L, editors. Endocrinology: adult and pediatric. Neuroendocrinology and the Pituitary gland. 6th ed. Amsterdam: Elsevier Health Sciences; 2010.Google Scholar
  42. Linn AJ, van Weert JC, van Dijk L, Horne R, Smit EG. The value of nurses’ tailored communication when discussing medicines: Exploring the relationship between satisfaction, beliefs and adherence. J Health Psychol. 2016;21:798–807.PubMedGoogle Scholar
  43. Littley MD, Shalet SM, Beardwell CG, Ahmed SR, Applegate G, Sutton ML. Hypopituitarism following external radiotherapy for pituitary tumours in adults. Q J Med. 1989;70(262):145–60.PubMedGoogle Scholar
  44. Llahana S, Conway G. Knowledge of testosterone replacement therapy is significantly correlated with patient satisfaction suggesting greater need for education. 8th European Congress of Endocrinology, Glasgow, UK. Endocrine Abstracts 2006:11 P201.Google Scholar
  45. Llahana S, Conway G, Mumuni A, Baldeweg S, Osz M, Horne R, editors. Patients’ beliefs and concerns about growth hormone replacement therapy are associated with their satisfaction with treatment, medication side effects and quality of life. In: 18th International congress of endocrinology, 1–4 Dec 2018, Cape Town, South Africa; 2018.Google Scholar
  46. Losa M, Scavini M, Gatti E, Rossini A, Madaschi S, Formenti I, et al. Long-term effects of growth hormone replacement therapy on thyroid function in adults with growth hormone deficiency. Thyroid. 2008;18(12):1249–54.PubMedGoogle Scholar
  47. Mackenzie S, Craven T, Gattamaneni HR, Swindell R, Shalet SM, Brabant G. Long-term safety of growth hormone replacement after CNS irradiation. J Clin Endocrinol Metabol. 2011;96(9):2756–61.Google Scholar
  48. Martinez-Momblan MA, Gomez C, Santos A, Porta N, Esteve J, Ubeda I, et al. A specific nursing educational program in patients with Cushing’s syndrome. Endocrine. 2016;53:199–209.PubMedPubMedCentralGoogle Scholar
  49. McKenna SP, Doward LC, Alonso J, Kohlmann T, Niero M, Prieto L, et al. The QoL-AGHDA: an instrument for the assessment of quality of life in adults with growth hormone deficiency. Qual Life Res. 1999;8(4):373–83.PubMedGoogle Scholar
  50. Melmed S. Idiopathic adult growth hormone deficiency. J Clin Endocrinol Metab. 2013;98(6):2187.PubMedPubMedCentralGoogle Scholar
  51. Melmed S, Jameson JL. Hypopituitarism, chapter 4. In: Jameson JL, editor. Harrison’s endocrinology. 4th ed. New York: McGraw Hill Education; 2017. p. 25–34.Google Scholar
  52. Molitch ME, Clemmons DR, Malozowski S, Merriam GR, Vance ML. Evaluation and treatment of adult growth hormone deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96(6):1587–609.PubMedGoogle Scholar
  53. NICE. Human growth hormone (somatropin) in adults with growth hormone deficiency. London: National Institute for Clinical Excellence; 2003.Google Scholar
  54. Ntali G, Capatina C, Fazal-Sanderson V, Byrne JV, Cudlip S, Grossman AB, et al. Mortality in patients with non-functioning pituitary adenoma is increased: systematic analysis of 546 cases with long follow-up. Eur J Endocrinol. 2015;174(2):137–45.PubMedGoogle Scholar
  55. Olsson DS, Nilsson AG, Bryngelsson IL, Trimpou P, Johannsson G, Andersson E. Excess mortality in women and young adults with nonfunctioning pituitary adenoma: a Swedish Nationwide Study. J Clin Endocrinol Metab. 2015;100(7):2651–8.PubMedGoogle Scholar
  56. Omori K, Nomura K, Shimizu S, Omori N, Takano K. Risk factors for adrenal crisis in patients with adrenal insufficiency. Endocr J. 2003;50(6):745–52.PubMedGoogle Scholar
  57. Pappachan JM, Raskauskiene D, Kutty VR, Clayton RN. Excess mortality associated with hypopituitarism in adults: a meta-analysis of observational studies. J Clin Endocrinol Metab. 2015;100(4):1405–11.PubMedGoogle Scholar
  58. Patterson BC, Chen Y, Sklar CA, Neglia J, Yasui Y, Mertens A, et al. Growth hormone exposure as a risk factor for the development of subsequent neoplasms of the central nervous system: a report From the Childhood Cancer Survivor Study. J Clin Endocrinol Metabol. 2014;99(6):2030–7.Google Scholar
  59. Peacey SR, Pope RM, Naik KS, Hardern RD, Page MD, Belchetz PE. Corticosteroid therapy and intercurrent illness: the need for continuing patient education. Postgrad Med J. 1993;69(810):282.PubMedPubMedCentralGoogle Scholar
  60. Pekic S, Popovic V. GH therapy and cancer risk in hypopituitarism: what we know from human studies. Eur J Endocrinol. 2013;169:R89–97.PubMedGoogle Scholar
  61. Phelan N, Conway SH, Llahana S, Conway GS. Quantification of the adverse effect of ethinylestradiol containing oral contraceptive pills when used in conjunction with growth hormone replacement in routine practice. Clin Endocrinol (Oxf). 2012;76(5):729–33.Google Scholar
  62. Prabhakar VKB, Shalet SM. Aetiology, diagnosis, and management of hypopituitarism in adult life. Postgrad Med J. 2006;82(966):259–66.PubMedPubMedCentralGoogle Scholar
  63. Ragnarsson O, Mattsson AF, Monson JP, Filipsson Nystrom H, Akerblad AC, Koltowska-Haggstrom M, et al. The relationship between glucocorticoid replacement and quality of life in 2737 hypopituitary patients. Eur J Endocrinol. 2014;171(5):571–9.PubMedGoogle Scholar
  64. Regal M, Paramo C, Sierra SM, Garcia-Mayor RV. Prevalence and incidence of hypopituitarism in an adult Caucasian population in northwestern Spain. Clin Endocrinol (Oxf). 2001;55(6):735–40.Google Scholar
  65. Repping-Wuts HJWJ, Stikkelbroeck NMML, Noordzij A, Kerstens M, Hermus ARMM. A glucocorticoid education group meeting: an effective strategy for improving self-management to prevent adrenal crisis. Eur J Endocrinol. 2013;169(1):17–22.PubMedGoogle Scholar
  66. Rosenfeld G, Bakker B. Compliance and persistence in pediatric and adult patients receiving growth hormone therapy. Endocr Pract. 2008;14(2):143.PubMedGoogle Scholar
  67. Ruiz MA, Pardo A, Rejas J, Soto J, Villasante F, Aranguren JL. Development and validation of the “Treatment Satisfaction with Medicines Questionnaire” (SATMED-Q). Value Health. 2008;11(5):913–26.PubMedGoogle Scholar
  68. Schoenfeld MJ, Shortridge E, Cui Z, Muram D. Medication adherence and treatment patterns for hypogonadal patients treated with topical testosterone therapy: a retrospective medical claims analysis. J Sex Med. 2013;10(5):1401.PubMedGoogle Scholar
  69. Schulz J, Frey KR, Cooper M, Zopf K, Ventz M, Diederich S, et al. Reduction in daily hydrocortisone dose improves bone health in primary adrenal insufficiency. Eur J Endocrinol. 2016; Scholar
  70. Sklar CA, Mertens AC, Mitby P, Occhiogrosso G, Qin J, Heller G, et al. Risk of disease recurrence and second neoplasms in survivors of childhood cancer treated with growth hormone: a report from the Childhood Cancer Survivor Study. J Clin Endocrinol Metabol. 2002;87(7):3136–41.Google Scholar
  71. Sklar CA, Antal Z, Chemaitilly W, Cohen LE, Follin C, Meacham LR, et al. Hypothalamic-pituitary and growth disorders in survivors of childhood cancer: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103:2761–84.PubMedGoogle Scholar
  72. Sprogoe K, Mortensen E, Karpf DB, Leff JA. The rationale and design of TransCon Growth Hormone for the treatment of growth hormone deficiency. Endocr Connect. 2017;6(8):R171–R81.PubMedPubMedCentralGoogle Scholar
  73. Stochholm K, Kiess W. Long-term safety of growth hormone-a combined registry analysis. Clin Endocrinol (Oxf). 2018;88(4):515–28.Google Scholar
  74. Strasburger CJ, Vanuga P, Payer J, Pfeifer M, Popovic V, Bajnok L, et al. MOD-4023, a long-acting carboxy-terminal peptide-modified human growth hormone: results of a Phase 2 study in growth hormone-deficient adults. Eur J Endocrinol. 2017;176(3):283–94.PubMedGoogle Scholar
  75. Tiemensma J, Andela D, Pereira M, Romijn A, Biermasz R, Kaptein A. Patients with adrenal insufficiency hate their medication: concerns and stronger beliefs about the necessity of hydrocortisone intake are associated with more negative illness perceptions. J Clin Endocrinol Metab. 2014;99(10):3668.PubMedGoogle Scholar
  76. Toogood AA, Stewart PM. Hypopituitarism: clinical features, diagnosis, and management. Endocrinol Metab Clin North Am. 2008;37(1):235–61. xPubMedGoogle Scholar
  77. Wolthers T, Hoffman DM, Nugent AG, Duncan MW, Umpleby M, Ho KK. Oral estrogen antagonizes the metabolic actions of growth hormone in growth hormone-deficient women. Am J Physiol Endocrinol Metab. 2001;281(6):E1191–6.PubMedGoogle Scholar
  78. Woodmansee WW, Zimmermann AG, Child CJ, Rong Q, Erfurth EM, Beck-Peccoz P, et al. Incidence of second neoplasm in childhood cancer survivors treated with GH: an analysis of GeNeSIS and HypoCCS. Eur J Endocrinol. 2013;168(4):565–73.PubMedGoogle Scholar
  79. Yuen CJ, Conway S, Popovic V, Merriam R, Bailey T, Hamrahian H, et al. A long-acting human growth hormone with delayed clearance (VRS-317): results of a double-blind, placebo-controlled, single ascending dose study in growth hormone-deficient adults. J Clin Endocrinol Metab. 2013;98(6):2595.PubMedPubMedCentralGoogle Scholar
  80. Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826–34.PubMedGoogle Scholar

Key Reading

  1. 1.
    Burt MG, Ho KKY. Chapter 11 - Hypopituitarism and growth hormone deficiency. In: Jameson JL, de Groot LJ, de Kretser DM, Giudice LC, Grossman AB, Melmed S, Potts JT, Weir GC, editors. Endocrinology: adult and pediatric. 7th ed. Philadelphia: W.B. Saunders; 2016.Google Scholar
  2. 2.
    Clayton PE, Cuneo RC, Juul A, Monson JP, Shalet SM, Tauber M. Consensus statement on the management of the GH-treated adolescent in the transition to adult care. Eur J Endocrinol. 2005;152:165–70.Google Scholar
  3. 3.
    Fleseriu M, Hashim IA, karavitaki N, Melmed S, Murad MH, Salvatori R, Samuels MH. Hormonal replacement in hypopituitarism in adults: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101:3888–921.PubMedGoogle Scholar
  4. 4.
    Molitch ME, Clemmons DR, Malozowski S, Merriam GR, Vance ML. Evaluation and treatment of adult growth hormone deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96:1587–609.PubMedGoogle Scholar
  5. 5.
    Toogood AA, Stewart PM. Hypopituitarism: clinical features, diagnosis, and management. Endocrinol Metab Clin North Am. 2008;37:235–61.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Sofia Llahana
    • 1
    Email author
  • Anne Marland
    • 2
  • Mila Pantovic
    • 3
  • Vera Popovic
    • 4
  1. 1.School of Health Sciences, CityUniversity of LondonLondonUK
  2. 2.Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of MedicineUniversity of OxfordOxfordUK
  3. 3.Department of Neuroendocrinology, Clinic for EndocrinologyClinical Center SerbiaBelgradeSerbia
  4. 4.Medical FacultyUniversity of BelgradeBelgradeSerbia

Personalised recommendations