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 (vaginal dryness, dyspareunia) and persistent lack of libido/low energy in women with adrenal insufficiency, typically at doses of 10-50 mg daily, though long-term safety data remain limited and caution is warranted in hormone-sensitive conditions. 1, 2

Primary Indications

Female Sexual Dysfunction

• Vaginal DHEA (prasterone) is an effective option for postmenopausal women experiencing vaginal dryness or dyspareunia, with randomized controlled trial data showing significant improvements in sexual desire, arousal, pain, and overall sexual function in 464 breast and gynecologic cancer survivors 1
• DHEA should be positioned after first-line treatments (lubricants, vaginal moisturizers) and can be considered when these conservative measures fail 1
• The mechanism involves local conversion to both androgens and estrogens, improving vulvovaginal tissue quality 1

Adrenal Insufficiency with Low Libido/Energy

• DHEA supplementation is most appropriate for female patients with primary adrenal insufficiency who exhibit persistent lack of libido and/or low energy despite optimized glucocorticoid and mineralocorticoid replacement 2
• A 6-month trial should be offered, continuing only if clinically effective 2

Dosing Protocol

Standard Dosing

• Start with 25 mg as a single daily morning dose 2
• Dose range: 10-50 mg daily based on clinical response 1, 2
• For vaginal DHEA specifically, follow product-specific dosing instructions for intravaginal administration 1

Monitoring Requirements

• Establish baseline serum DHEA sulfate (DHEAS), androstenedione, and testosterone levels before initiating therapy 2
• Obtain morning measurements prior to DHEA ingestion for accurate assessment 2
• Maintain hormone levels in the normal range through dose adjustments 2
• Reassess clinical effectiveness at 6 months to determine continuation 2

Critical Safety Considerations and Contraindications

Hormone-Sensitive Cancers

• Use DHEA with extreme caution in survivors of estrogen-dependent cancers, as safety has not been firmly established in this population 1
• DHEA should be used with particular caution in patients receiving aromatase inhibitor (AI) therapy, as vaginal DHEA increases circulating androgens that may potentially impact AI activity 1
• Limited safety data exist for androgen-based therapy in survivors of hormonally mediated cancers 1

Male Fertility

• Do not prescribe DHEA to men currently trying to conceive, as it can suppress normal sperm production 2

Long-Term Safety Unknown

• Long-term effects of DHEA replacement therapy are not fully known; use with caution for extended periods 2
• Quality control varies significantly between over-the-counter preparations, with different brands containing different amounts of active ingredient 3

Clinical Effectiveness Data

Positive Outcomes

• In the DHEAge Study of 280 healthy elderly individuals (60-79 years), 50 mg daily DHEA for one year showed improved bone turnover in women >70 years, increased libido parameters in older women, and improved skin status 4
• A study using 100 mg daily for 6 months in age-advanced adults showed increased IGF-I levels in both genders, decreased fat mass and increased muscle strength in men (but not women) 5

Limited or Negative Findings

• A systematic review concluded it is uncertain whether vaginal DHEA improves vaginal dryness, though it does reduce dyspareunia 1
• Short-duration trials (≤2 weeks) showed no significant effects on mood, well-being, or cognitive function 6
• Cognitive function benefits are not supported by current evidence 6

Alternative and Complementary Options

When DHEA is contraindicated or ineffective, consider:

• Vaginal estrogen remains the most effective treatment for vaginal dryness and sexual dysfunction in postmenopausal individuals 1
• Ospemifene (SERM) for dyspareunia in survivors without estrogen-dependent cancer history 1
• Flibanserin (FDA-approved) for hypoactive sexual desire disorder in premenopausal women 1
• Pelvic floor physical therapy may improve sexual pain, arousal, lubrication, orgasm, and satisfaction 1
• Vaginal moisturizers and lubricants as first-line conservative management 1

Common Pitfalls to Avoid

• Do not assume DHEA is safe simply because it is available over-the-counter in the United States; it is considered a true hormone requiring medical supervision in many European countries 7
• Do not prescribe without baseline and follow-up hormone monitoring, as supraphysiologic levels can occur, particularly in women 5
• Do not continue therapy beyond 6 months without documented clinical benefit 2
• Do not use in women on AI therapy without thorough discussion of potential risks to cancer treatment efficacy 1