What is the recommended dose of Dehydroepiandrosterone (DHEA) for women in menopause?

DHEA Dosage for Menopausal Women

For menopausal women experiencing vaginal dryness or sexual pain, vaginal DHEA (prasterone) is recommended at FDA-approved doses, while oral DHEA supplementation at 25-50mg daily may be considered for systemic symptoms, though evidence for oral supplementation is less robust.

Vaginal DHEA (Prasterone)

• Vaginal DHEA (prasterone) has received FDA approval for treating dyspareunia in postmenopausal women 1
• Several studies have shown prasterone to be effective at reducing dyspareunia in postmenopausal women 1
• A randomized controlled trial of 464 survivors of breast or gynecologic cancer showed that vaginal DHEA led to significant improvements in sexual desire, arousal, pain, and overall sexual function 1

Safety Considerations for Vaginal DHEA

• The FDA label for prasterone warns that exogenous estrogens are contraindicated in women with a history of breast cancer 1
• DHEA should be used with caution in survivors receiving aromatase inhibitor therapy, as vaginal DHEA increases levels of circulating androgens 1
• Overall, safety data for androgen-based therapy in survivors of hormonally mediated cancers are limited 1

Oral DHEA Supplementation

Research studies have used various doses of oral DHEA:

• 25mg daily: A 12-month study showed increased levels of androgens, estrogens, and neurosteroids with improvement in climacteric symptoms 2
• 50mg daily:
  • A 52-week safety study found no significant adverse effects on lipid profile, insulin sensitivity, or endometrium 3
  • However, a 3-month study showed no improvements in perimenopausal symptoms or well-being compared to placebo despite significant endocrine changes 4
• 100mg daily: A 6-month study showed elevation of circulating DHEA and DHEA sulfate with gender-specific responses - men experienced decreased fat mass and increased muscle strength, while women showed increased total body mass 5

Endocrine Effects of Oral DHEA

• Oral DHEA supplementation increases serum levels of DHEA, DHEA sulfate, androstenedione, testosterone, and dihydrotestosterone 2, 6, 5
• It may also increase estradiol and estrone levels 2, 6
• These hormonal changes can potentially affect menopausal symptoms

Alternative Options for Menopausal Symptoms

If DHEA is not appropriate, consider:

1. For vaginal dryness and sexual pain:

   • Vaginal moisturizers and lubricants for daily comfort and sexual activity 7
   • Ospemifene (a SERM) for dyspareunia in women without history of estrogen-dependent cancers 1

2. For vasomotor symptoms:

   • SNRIs/SSRIs (venlafaxine preferred) 7
   • Gabapentin or clonidine as alternatives 7
   • Non-hormonal approaches: paced respiration, meditation, acupuncture, lifestyle modifications 7

Clinical Recommendation

Based on the available evidence:

• For vaginal symptoms: Use FDA-approved vaginal DHEA (prasterone) at prescribed doses
• For systemic symptoms: If oral supplementation is desired, start with 25mg daily and monitor for 3 months, with the option to increase to 50mg daily if needed and well-tolerated
• Monitor hormone levels, lipid parameters, and symptom improvement during treatment
• Discontinue if adverse effects occur or no benefit is observed after 3-6 months

Caution

DHEA supplementation should be avoided in women with:

• History of hormone-dependent cancers
• Active liver disease
• History of abnormal vaginal bleeding
• Previous venous thromboembolism or stroke
• Coronary heart disease 7