What are the guidelines for using Dehydroepiandrosterone (DHEA) supplementation?

DHEA Supplementation Guidelines

DHEA can be offered as a treatment option for specific indications including female sexual dysfunction (particularly vaginal dryness and dyspareunia) and adrenal insufficiency with persistent libido/energy issues, using doses of 10-50 mg daily, though vaginal DHEA formulations are preferred for sexual dysfunction in postmenopausal women. 1

Primary Indications

Female Sexual Dysfunction

• Vaginal DHEA (prasterone) is recommended for postmenopausal women with vaginal dryness or dyspareunia, showing significant improvements in sexual desire, arousal, pain, and overall sexual function 2
• This should be considered after first-line treatments (lubricants and vaginal moisturizers) have failed 2
• A randomized controlled trial of 464 breast and gynecologic cancer survivors demonstrated significant improvements, though plain moisturizer also showed benefit 2

Adrenal Insufficiency

• Systemic DHEA (10-50 mg daily, typically starting at 25 mg) can be offered to women with primary adrenal insufficiency who have persistent lack of libido and/or low energy despite optimized glucocorticoid and mineralocorticoid replacement 1
• Treatment should be offered as a 6-month trial and continued only if clinically effective 1
• Small benefits in quality of life and mood have been demonstrated, but not for anxiety or sexual function 3

Dosing Recommendations

Systemic DHEA

• Start with 25 mg as a single daily morning dose 1
• Dose range: 10-50 mg daily based on clinical response 1
• Monitor serum DHEA sulphate (DHEAS), androstenedione, and testosterone levels to guide dosing 1
• Morning measurements prior to DHEA ingestion provide the most accurate assessment 1

Vaginal DHEA

• Use as directed for local vaginal application 2
• Specific dosing follows product labeling for prasterone vaginal inserts

Critical Safety Considerations

Hormone-Sensitive Cancers

• Use vaginal DHEA with extreme caution in patients receiving aromatase inhibitor (AI) therapy, as it increases circulating androgens that may interfere with AI activity 2
• Overall safety of vaginal hormones has not been firmly established in survivors of estrogen-dependent cancers 2
• Limited safety data exist for androgen-based therapy in survivors of hormonally mediated cancers 2

Long-Term Safety Unknown

• Long-term effects of DHEA replacement therapy are not fully known; use with caution 1
• One study suggested high incidence of prostate, breast, colon, lung, and stomach cancers in those taking 25-50 mg daily for more than 3 months, though this requires further validation 4

Male Fertility

• DHEA should not be prescribed to men currently trying to conceive, as it can suppress normal sperm production 1

Monitoring Protocol

• Establish baseline hormone levels (DHEAS, androstenedione, testosterone) before initiating therapy 1
• Obtain follow-up measurements in the morning before DHEA ingestion 1
• Assess clinical effectiveness after 6 months to determine continuation 1
• Maintain serum hormone levels in the normal range 1

When NOT to Use DHEA

Insufficient Evidence

• No consistent beneficial effects for menopausal symptoms, sexual function, cognition, or overall wellbeing in normal women 3
• Not recommended for improving ovulation response in women with diminished ovarian reserve 3
• No demonstrated long-term health benefits in "replacement" doses for general anti-aging purposes 5

Men Without Specific Indications

• DHEA administration in men with adrenal insufficiency increases circulating androgens, but benefits are less clear than in women 6
• The 2018 AUA Erectile Dysfunction guideline does not recommend DHEA for male sexual dysfunction 2

Alternative Options to Consider First

For female sexual dysfunction, the following should be considered before or alongside DHEA:

• Vaginal estrogen is the most effective treatment for vaginal dryness and should be considered first in appropriate candidates 2
• Pelvic floor physical therapy may improve sexual pain, arousal, lubrication, orgasm, and satisfaction 2, 1
• Vaginal moisturizers and lubricants for first-line management 2, 1
• Flibanserin (FDA-approved for premenopausal women with hypoactive sexual desire disorder) 2, 1
• Ospemifene for dyspareunia in women without estrogen-dependent cancer history 2

Common Pitfalls to Avoid

• Avoid excessive dosing: Studies show that doses above the optimal individual dose (which may be as low as 1.25-12.5 mg in some individuals) can decrease normal cell telomeres while increasing cancer cell telomeres 4
• Do not assume DHEA works for general anti-aging: Despite marketing claims, evidence does not support routine use for age-related decline 3, 5
• Do not use as monotherapy for erectile dysfunction in men: The evidence does not support this indication 2
• Recognize that DHEA is unregulated as a dietary supplement in the US, leading to potential dosage inaccuracies and impurities 5