What assessments are recommended before starting Dehydroepiandrosterone (DHEA) therapy, such as cortisol and sleep evaluations?

Pre-DHEA Therapy Assessment

Before initiating DHEA therapy, measure morning serum DHEA-sulfate (DHEAS), androstenedione, and testosterone levels to establish baseline values, and critically, ensure adequate cortisol replacement is optimized first if the patient has adrenal insufficiency. 1

Essential Baseline Assessments

Hormonal Evaluation

• Morning cortisol and ACTH levels must be assessed to rule out or confirm adrenal insufficiency before starting DHEA 1
• Baseline DHEAS, androstenedione, and testosterone should be measured in the morning prior to any DHEA administration to guide dosing 1
• In women specifically, measure these androgens as DHEA biotransformation to potent androgens can exceed normal ranges 2
• Sex hormone binding globulin (SHBG) levels, as DHEA significantly reduces SHBG, particularly in women (up to 40% reduction) 2

Critical Cortisol Considerations

• DHEA lowers plasma cortisol concentrations, with more pronounced effects in women than men 3
• If adrenal insufficiency exists, corticosteroid replacement must be initiated and stabilized several days before any other hormone therapy to prevent precipitating adrenal crisis 1
• The cortisol/DHEA molar ratio should be evaluated, as DHEA therapy alters this balance 4

Sleep and Functional Assessment

While the guidelines don't explicitly mandate formal sleep studies before DHEA initiation, consider:

• Subjective assessment of energy levels, fatigue patterns, and sleep quality as these are key indicators for DHEA therapy candidacy 1
• DHEA has functions associated with sleep regulation, so baseline sleep complaints should be documented 4
• Mood and well-being questionnaires (such as Kupperman score) to objectively track response 5

Clinical Context for DHEA Initiation

Primary Indication

• DHEA replacement is specifically indicated for women with primary adrenal insufficiency who have persistent lack of libido and/or low energy despite optimized glucocorticoid and mineralocorticoid replacement 1
• The evidence for clinical benefit remains limited, warranting a pragmatic 6-month trial approach 1

Contraindications to Screen For

• Prostate cancer in men and breast cancer or history of DVT in women are contraindications to androgen therapy 1
• Patients on estrogen replacement therapy may have confounding responses to DHEA 2

Monitoring Strategy Post-Initiation

Once DHEA is started at 25 mg daily:

• Measure morning DHEAS, androstenedione, and testosterone levels (before DHEA ingestion that day) to maintain values in the normal range 1
• Reassess cortisol levels as DHEA can reduce cortisol by 13-40% depending on gender 3, 6
• Monitor for androgenic side effects, particularly in women who may develop supraphysiologic androgen levels 2
• Lipid profiles should be checked, as DHEA may reduce HDL by 10% and Lp(a) by 18% 6

Common Pitfalls to Avoid

• Never start DHEA before ensuring adequate cortisol replacement in patients with adrenal insufficiency—this can precipitate life-threatening adrenal crisis 1
• Don't assume DHEA will benefit all patients; research shows no improvement in perimenopausal symptoms or well-being compared to placebo despite hormonal changes 6
• Be aware that DHEA's cortisol-lowering effect is more pronounced in women, potentially requiring glucocorticoid dose adjustments 3
• Long-term safety data for DHEA replacement remains limited, so use cautiously 1