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Editor—We were surprised that in his editorial to our paper Saenger challenged our conclusions that most patients treated for growth hormone deficiency do not have this condition, and that controlled trials should be organised to evaluate the long term effects of growth hormone in most of the patients currently treated.1 Saenger supports the use of an integrated approach to diagnosing growth hormone deficiency and the wider use of IGF-1 measurements, as suggested by the Growth Hormone Research Society. However, his recent publications, as coauthor or senior author, do not reflect his plea.2,3 This contradiction reflects the widespread contrast between the recommendations in consensus guidelines and current practice or clinical research protocols. In the absence of a gold standard, how can growth hormone deficiency be defined? We propose using long term results of treatment in comparison with spontaneous outcome. The results of our observational study indicate that most patients had no clear benefit. Saenger argues that the patients in our paper were not treated for long enough and therefore do not provide long term results of growth hormone treatment. He contrasts our results with those reported by Blethen et al in 121 patients from the national cooperative growth study database, who were treated for a mean of 6.2 years compared with 3.2 years in our report.4 We included all patients who had started treatment to calculate its mean duration, whereas the 121 patients analysed represent less than 1% of around 14 000 patients in the national cooperative growth study. If we had selected only the 1% of patients with the longest treatment duration, our mean treatment duration would have been 7.9 years. We thought that we had made it clear in our paper that reports focusing on patients with longer treatments give a biased and overoptimistic view of the results. Obviously not clearly enough. We agree with Saenger that you can draw an analogy between the real estate business and use of growth hormone: better location in real estate and longer duration of growth hormone treatment both mean higher costs. However, a good location in real estate generally results in a good long term investment whereas the result of long term growth hormone treatment is still debatable.