How are elevated Dehydroepiandrosterone sulfate (DHEAS) levels in perimenopause managed?

Management of Elevated DHEAS Levels in Perimenopause

Elevated DHEAS levels in perimenopausal women should be evaluated for underlying causes, with management focused on treating any identified conditions rather than the DHEAS elevation itself, as there is no evidence that elevated DHEAS alone requires treatment.

Evaluation of Elevated DHEAS

Initial Assessment

• Assess for clinical signs of hyperandrogenism:
  • Hirsutism
  • Acne
  • Androgenic alopecia
  • Menstrual irregularities
  • Infertility
  • Truncal obesity 1

Recommended Laboratory Testing

• Complete hormonal panel:
  • Free and total testosterone
  • Luteinizing hormone (LH)
  • Follicle-stimulating hormone (FSH)
  • LH/FSH ratio (>2 suggests PCOS) 1
  • 17-hydroxyprogesterone (to rule out non-classical congenital adrenal hyperplasia) 1

Differential Diagnosis

1. Polycystic Ovary Syndrome (PCOS)

   • Most common cause of elevated androgens in women
   • Prevalence increases to 10-25% in women with temporal lobe epilepsy 1
   • Diagnosis requires 2 of 3 criteria:
     • Androgen excess (clinical or biochemical)
     • Ovulatory dysfunction
     • Polycystic ovaries on ultrasound 1

2. Non-classical Congenital Adrenal Hyperplasia

   • Can cause recalcitrant acne and androgen excess 1

3. Adrenal/Ovarian Tumors

   • Consider if androstenedione levels >10.0 nmol/L 1

4. Physiologic Perimenopause Changes

   • DHEAS naturally fluctuates during perimenopause 2, 3

Management Approaches

When Treatment Is Indicated

Treatment is indicated when elevated DHEAS is associated with:

1. Symptomatic Hyperandrogenism

   • For acne or hirsutism:
     • Topical retinoids 1
     • Combined oral contraceptives (for women not seeking pregnancy) 1
     • Spironolactone (anti-androgenic properties) 1

2. PCOS

   • Address insulin resistance if present:
     • Monitor glucose/insulin ratio
     • Consider lifestyle modifications 1
   • Hormonal management with combined oral contraceptives 1

3. Vaginal Symptoms in Perimenopause

   • For vaginal dryness or sexual dysfunction:
     • Vaginal moisturizers and lubricants 1, 2
     • Low-dose local estrogen preparations may be considered 2
     • Vaginal DHEA (prasterone) can improve sexual function, but should be used with caution in women on aromatase inhibitors 1, 2

When Not to Treat Elevated DHEAS

• Asymptomatic elevated DHEAS without clinical manifestations does not require treatment 4
• Isolated elevated DHEAS without other hormonal abnormalities or symptoms does not warrant intervention 1

Evidence on DHEA Supplementation

Efficacy

• DHEA supplementation has shown limited benefits in:
  • Women with adrenal insufficiency
  • Postmenopausal women with low bone mineral density
  • Women with vulvovaginal atrophy 4
• Cochrane review found no evidence that DHEA improves quality of life 5
• May slightly improve sexual function compared to placebo 5

Safety Concerns

• DHEA supplementation is associated with androgenic side effects, mainly acne (OR 3.77,95% CI 1.36 to 10.4) 5
• Potential link between high DHEA levels and breast cancer risk 6
• FDA warns that exogenous estrogens (which DHEA can convert to) are contraindicated in women with a history of breast cancer 1

Monitoring Recommendations

For women with treated hyperandrogenism:

• Regular follow-up to assess treatment response
• Monitor for side effects of any prescribed medications
• Annual assessment of hormonal parameters if on hormonal therapy 2

Key Pitfalls to Avoid

1. Don't assume all elevated DHEAS requires treatment
2. Don't miss screening for serious underlying conditions (adrenal/ovarian tumors)
3. Don't overlook the natural decline of DHEAS with age (60% decrease from age 30 to menopause) 3
4. Don't recommend DHEA supplementation for general well-being or anti-aging effects, as evidence doesn't support these uses 6, 7

In conclusion, management should focus on identifying and treating the underlying cause of elevated DHEAS rather than treating the laboratory value itself, with careful consideration of the patient's symptoms and clinical presentation.