Starting Dose of Dehydroepiandrosterone (DHEA)
The recommended starting dose of DHEA for patients with primary adrenal insufficiency is typically 25 mg as a single daily oral dose in the morning. 1, 2
Dosing Guidelines for DHEA
- DHEA is primarily indicated for female patients with primary adrenal insufficiency who experience persistent lack of libido and/or low energy levels despite optimized glucocorticoid and mineralocorticoid replacement 1, 2
- The dosage range for DHEA replacement is 10-50 mg daily, with 25 mg being the most common starting dose 1, 2
- DHEA should be administered as a single morning dose 2, 3
- Dosing should be guided by monitoring serum DHEA sulphate (DHEAS), androstenedione, and testosterone levels, which should be maintained in the normal range when measured in the morning prior to DHEA ingestion 1, 2
Clinical Evidence and Recommendations
- Current clinical guidelines recommend DHEA only for specific situations rather than routine replacement in all patients with adrenal insufficiency 2
- There is limited objective evidence of clinical benefit from large studies regarding DHEA supplementation 1, 2
- A pragmatic approach is to offer female patients with persistent symptoms a 6-month trial of DHEA replacement, which can be continued if clinically effective 1
- Studies have shown that a 25-50 mg daily dose can restore DHEA and DHEAS levels to those comparable to young adults 4, 5
Monitoring and Follow-up
- Baseline and follow-up measurements of DHEAS, androstenedione, and testosterone levels should be performed to guide dosing 2
- Morning measurements (prior to DHEA ingestion) are recommended for accurate assessment 1
- Regular monitoring is important as individual responses to DHEA can vary 3
Cautions and Side Effects
- Long-term effects of DHEA replacement therapy in patients with adrenal insufficiency are not well established, warranting caution in its use 1, 2
- Side effects are mostly mild and related to androgenic activity in women, including increased sebum production, facial acne, and changes in hair status 3
- In women, DHEA can be converted to testosterone and other androgens, potentially causing androgenic side effects if doses are too high 6, 5
- The 2014 consensus statement on primary adrenal insufficiency states there is insufficient evidence to recommend routine replacement of adrenal androgens 1
Special Considerations
- Higher doses (100 mg) have been studied but may result in supraphysiological levels of androgens, particularly in women 7
- Patients with complete panhypopituitarism may convert DHEA to active sex hormones differently than those with primary adrenal insufficiency 5
- Local administration of DHEA shows benefit for vulvovaginal atrophy in postmenopausal women, but this is a different indication than adrenal insufficiency 6
Remember that DHEA supplementation is not considered standard replacement therapy for all patients with adrenal insufficiency but may be beneficial in selected cases, particularly women with persistent symptoms despite optimized conventional replacement therapy.