From the Guidelines
Elevated DHEA-S levels require a comprehensive hormonal workup, including measurements of cortisol, 17-hydroxyprogesterone, androstenedione, testosterone, and sex hormone binding globulin (SHBG), as well as imaging studies like adrenal CT scans to evaluate for adrenal tumors or hyperplasia. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of a thorough diagnostic workup in patients with suspected adrenal disorders 1.
Key Components of the Workup
- Measuring other adrenal and gonadal hormones to determine the underlying cause of the elevated DHEA-S level
- Imaging studies, particularly an adrenal CT scan, to evaluate for adrenal tumors or hyperplasia
- For women, transvaginal ultrasound may be needed to assess for polycystic ovary syndrome (PCOS) or ovarian tumors
- A thorough clinical assessment to evaluate for signs of androgen excess, such as hirsutism, acne, or menstrual irregularities in women
Importance of Clinical Assessment
The pattern of hormonal abnormalities helps distinguish between common causes of elevated DHEA-S, such as PCOS, congenital adrenal hyperplasia, adrenal tumors, or Cushing's syndrome. In some cases, genetic testing for enzyme deficiencies may be warranted, particularly if congenital adrenal hyperplasia is suspected 1.
Tailoring the Testing Approach
The specific testing approach should be tailored based on the patient's age, sex, clinical presentation, and degree of DHEA-S elevation, as mild elevations may sometimes represent normal variants or laboratory errors requiring repeat testing for confirmation. It is also crucial to consider the potential for other underlying conditions, such as primary adrenal insufficiency, and to follow a diagnostic algorithm that includes cosyntropin testing if necessary 1.
Prioritizing Patient Care
In all cases, the testing approach should prioritize the patient's morbidity, mortality, and quality of life outcomes, ensuring that any potential underlying conditions are promptly identified and treated to prevent long-term complications.
From the Research
Additional Testing for Elevated DHEA-S Levels
When Dehydroepiandrosterone sulfate (DHEA-S) levels are elevated, such as in the case of a level of 531, additional testing is necessary to determine the underlying cause.
- ACTH Stimulation Tests: These tests can help identify defects in adrenal steroidogenesis, which may be contributing to the elevated DHEA-S levels 2.
- Measurement of Other Androgen Levels: Assessing the levels of other androgens, such as testosterone, androstenedione, and 17-hydroxyprogesterone, can provide insight into the source of the excess androgens (adrenal or ovarian) 3, 4.
- Imaging Studies: Transvaginal sonography and adrenal computed tomography scans may be used to evaluate the adrenal glands and ovaries for any abnormalities, such as tumors 4.
- Dexamethasone Suppression Test: This test can help determine if the elevated DHEA-S levels are due to adrenal hyperandrogenism, which would be suppressed by dexamethasone administration 3, 5.
- Evaluation for Congenital Adrenal Hyperplasia: In some cases, elevated DHEA-S levels may be indicative of non-classical congenital adrenal hyperplasia, which would require specific testing and evaluation 2, 5.
Considerations for Testing
It is essential to note that the predictive value of these tests for androgen-secreting tumors is limited, and clinical evaluation alone may be sufficient for screening in many cases 4. Additionally, the results of these tests should be interpreted in the context of the individual's clinical presentation and medical history.