Is Dehydroepiandrosterone (DHEA) effective for treating menopause?

DHEA for Menopause: Limited Evidence of Benefit with Potential Risks

DHEA is not recommended as a primary treatment for menopausal symptoms due to limited evidence of effectiveness and potential androgenic side effects.

Evidence Assessment

The most recent and highest quality evidence from guidelines indicates that DHEA (dehydroepiandrosterone) has limited proven benefits for most menopausal symptoms:

• The 2024 NCCN Guidelines note that vaginal DHEA (prasterone) may help with vaginal dryness or pain during sexual activity, but its effectiveness for general menopausal symptoms remains uncertain 1.
• A 2015 Cochrane systematic review found no evidence that DHEA improves quality of life in menopausal women and showed it is associated with androgenic side effects, primarily acne 2.
• The FDA label for DHEA only indicates it "temporarily supports the body to rebalance Adrenal and DHEA output" but does not specifically approve it for menopausal symptom management 3.

Specific Considerations for DHEA Use

Potential Benefits

• Vaginal symptoms: Vaginal DHEA may improve sexual function, particularly for dyspareunia (painful intercourse) and vaginal dryness 1.
• Sexual function: Some evidence suggests DHEA may slightly improve sexual function compared to placebo 2.
• Bone health: Limited evidence suggests possible benefits for women with low bone mineral density 4, 5.

Significant Risks and Concerns

• Androgenic side effects: DHEA is associated with acne and other androgenic effects 2.
• Hormone-sensitive conditions: DHEA should be used with caution in women receiving aromatase inhibitor therapy as it increases circulating androgens 1.
• Safety concerns: The safety of DHEA has not been firmly established in survivors of estrogen-dependent cancers 1.
• Limited regulation: As a supplement, DHEA products may have inconsistent quality and potency.

Alternative Options for Menopause Management

First-line treatments for menopausal symptoms:

1. Traditional hormone therapy (when appropriate): Estrogen therapy (with progestin if uterus intact) remains the most effective treatment for vasomotor symptoms and vaginal dryness 1, 6.

2. Non-hormonal medications:

   • Venlafaxine, desvenlafaxine, paroxetine, citalopram, and escitalopram for vasomotor symptoms 6
   • Vaginal moisturizers and lubricants for vaginal dryness 6

3. Non-pharmacological approaches:

   • Cognitive behavioral therapy and hypnosis for vasomotor symptoms 6
   • Regular weight-bearing exercise, maintaining healthy weight, and smoking cessation 6

Clinical Decision Algorithm

1. Assess symptom profile:

   • For primarily vaginal symptoms (dryness, dyspareunia): Consider vaginal estrogen first, vaginal DHEA if estrogen contraindicated
   • For primarily vasomotor symptoms (hot flashes): DHEA not recommended; consider systemic HRT or non-hormonal alternatives

2. Screen for contraindications:

   • History of hormone-sensitive cancers: Avoid DHEA
   • Receiving aromatase inhibitors: Use DHEA with extreme caution, if at all

3. Monitor for side effects if DHEA is used:

   • Watch for androgenic effects (acne, hirsutism)
   • Discontinue if side effects become problematic

Conclusion

While vaginal DHEA may have a role in treating specific vaginal symptoms in menopausal women, particularly when estrogen therapy is contraindicated, there is insufficient evidence to recommend oral DHEA for general menopausal symptom management. The risk-benefit profile favors established treatments like traditional hormone therapy or non-hormonal alternatives for most women experiencing menopausal symptoms.