From the Guidelines
DHEA-S levels should be ordered when first-line laboratory tests such as TT, FT, and FAI are not elevated, but clinical suspicion of polycystic ovary syndrome (PCOS) or other androgen excess disorders remains high, as recommended by the 2023 International PCOS Guidelines informed by the systematic review and diagnostic meta-analysis 1. When evaluating patients for androgen excess disorders, particularly in women with symptoms of hyperandrogenism such as hirsutism, acne, male-pattern baldness, or virilization, DHEA-S levels can provide valuable information.
- The test is particularly useful because DHEA-S is produced almost exclusively by the adrenal glands, making it an excellent marker for adrenal androgen production.
- Elevated DHEA-S levels may suggest an androgen-secreting adrenal tumor, while moderately elevated levels might indicate polycystic ovary syndrome, adrenal hyperplasia, or Cushing's syndrome.
- It is essential to note that DHEA-S measurement should be performed using highly accurate LC-MS/MS methods, as direct androgen immunoassays have limited accuracy 1. In children, DHEA-S testing may be indicated when evaluating precocious puberty or adrenarche.
- The test should ideally be performed in the morning due to diurnal variation, and patients should be informed that certain medications, including glucocorticoids, insulin, and oral contraceptives, can affect results.
- No special preparation is typically required before testing, though fasting may be recommended by some laboratories. It is crucial to prioritize the single most recent and highest quality study, which in this case is the systematic review and diagnostic meta-analysis published in 2025 1, to inform evidence-based guidelines for ordering DHEA-S levels.
From the Research
DHEA-S Level Ordering
When to order DHEA-S level is based on several factors, including:
- Diagnosis of adrenal insufficiency: DHEA-S measurements are valuable in patients suspected of having adrenal insufficiency 2
- Polycystic ovary syndrome (PCOS): Between 20 and 30% of patients with PCOS have adrenal androgen excess, detectable primarily by elevated DHEA-S levels 3
- Hirsutism: DHEA-S levels can be used to diagnose androgen excess disorders, which are commonly associated with hirsutism 4
- Adrenal androgen excess: DHEA-S levels can be used to diagnose adrenal androgen excess, which is characterized by elevated levels of DHEA-S 5, 3
Clinical Scenarios
The following clinical scenarios may require ordering DHEA-S levels:
- Patients with symptoms of adrenal insufficiency, such as fatigue, weight loss, and hypotension 2
- Patients with PCOS and symptoms of androgen excess, such as hirsutism, acne, and male pattern baldness 3
- Patients with hirsutism and suspected androgen excess disorders 4
- Patients with adrenal androgen excess and symptoms of androgen excess, such as hirsutism, acne, and male pattern baldness 5, 3
Laboratory Tests
DHEA-S levels can be measured using laboratory tests, including: