How to manage elevated Dehydroepiandrosterone sulfate (DHEAS) in perimenopause?

Management of Elevated DHEAS in Perimenopause

Elevated DHEAS in perimenopausal women should not be routinely treated with DHEA supplementation as there is insufficient evidence supporting its effectiveness for improving quality of life or menopausal symptoms.

Understanding DHEAS in Perimenopause

Perimenopause is characterized by:

• Vasomotor symptoms
• Vaginal dryness
• Sexual dysfunction
• Sleep disturbances
• Mood changes
• Cognitive dysfunction
• Arthralgias/myalgias
• Fatigue
• Changes in menstrual patterns 1

DHEAS (Dehydroepiandrosterone sulfate) is one of the main precursors of androgens, which are converted to testosterone and estrogens. DHEAS levels naturally decline with age, with perimenopausal women having approximately 50% of peak DHEAS levels 2.

Evidence on DHEAS Management

Effectiveness of DHEA Supplementation

The evidence does not support routine DHEA supplementation for elevated DHEAS in perimenopause:

• Quality of Life: No evidence that DHEA supplementation improves quality of life compared to placebo (standardized mean difference 0.16,95% CI -0.03 to 0.34) 3

• Menopausal Symptoms: Results from trials are inconsistent regarding the effect of DHEA on menopausal symptoms 3

• Sexual Function: While some evidence suggests slight improvement in sexual function with DHEA compared to placebo (standardized mean difference 0.31,95% CI 0.07 to 0.55) 3, other studies found no benefits for sexual function, well-being, or cognitive performance 4

• Metabolic Parameters: No favorable effects on lipids and carbohydrate metabolism have been demonstrated 4

Potential Risks

• DHEA is associated with androgenic side effects, primarily acne (OR 3.77,95% CI 1.36 to 10.4) 3
• High DHEAS levels may be linked to increased breast cancer risk 5

Management Approach for Elevated DHEAS in Perimenopause

1. Rule out pathological causes of elevated DHEAS (e.g., adrenal tumors, congenital adrenal hyperplasia)

2. For symptomatic management of perimenopausal symptoms, consider evidence-based alternatives:

   • For vasomotor symptoms:

     • Menopausal hormone therapy (MHT) with combination estrogen and progestins for women with intact uterus or estrogen alone for women without a uterus 1
     • Non-hormonal alternatives: SSRIs/SNRIs, gabapentin, clonidine 1

   • For vaginal dryness:

     • Vaginal moisturizers and lubricants
     • Low-dose local estrogen preparations (rings, suppositories, creams) 1

3. Monitoring:

   • Annual follow-up to evaluate symptoms
   • Monitor blood pressure, weight, and lipid profile 1

Special Considerations

DHEA supplementation may be considered in specific circumstances:

• Women with adrenal insufficiency
• Women chronically treated with exogenous glucocorticoids
• Postmenopausal women with low bone mineral density/osteoporosis
• Women with vulvovaginal atrophy due to menopause 6

Caution

DHEA should be used with caution in:

• Women receiving aromatase inhibitor therapy, as vaginal DHEA increases levels of circulating androgens 7
• Women with a history of hormone-dependent cancers 1

The benefits and adverse effects of DHEA administration in perimenopausal women increasingly resemble those of conventional hormone replacement therapy, suggesting that standard HRT protocols may be more appropriate when hormonal treatment is indicated 5.