What is the recommended treatment for a 67-year-old woman with low Dehydroepiandrosterone (DHEA) levels while on pellet hormone therapy?

Management of Low DHEA in a 67-Year-Old Woman on Pellet Hormone Therapy

Primary Recommendation

Initiate DHEA supplementation at 25 mg orally once daily in the morning, as this patient's low DHEA levels while on pellet hormone therapy indicate she may benefit from DHEA replacement to address symptoms of low libido and/or energy. 1, 2

Clinical Context and Rationale

This 67-year-old postmenopausal woman on pellet hormone therapy (likely testosterone pellets) presents with low DHEA levels, which is a common scenario requiring supplementation:

• DHEA levels naturally decline by approximately 60% from age 30 to menopause and continue decreasing thereafter, making supplementation physiologically appropriate in symptomatic older women 3
• The pellet hormone therapy she is receiving does not provide DHEA, so supplementation addresses a separate hormonal deficiency 4
• DHEA supplementation is most appropriate for postmenopausal women with persistent lack of libido and/or low energy levels despite being otherwise hormonally optimized 1, 2

Specific Treatment Protocol

Starting Dose and Administration

• Begin with 25 mg DHEA orally as a single daily morning dose 1, 2
• The dose range can be adjusted between 10-50 mg daily based on clinical response and laboratory monitoring 1, 2

Baseline and Monitoring Laboratory Tests

Before initiating DHEA, obtain morning fasting levels of:

• DHEA-sulfate (DHEAS) 1, 2
• Androstenedione 1, 2
• Testosterone 1, 2
• These measurements establish baseline values and guide subsequent dose adjustments 1

Follow-Up Monitoring Schedule

• Recheck hormone levels in the morning (before DHEA ingestion) after starting therapy 1, 2
• Target hormone levels should be maintained in the normal range for the patient's age 1, 2
• Conduct a 6-month trial to assess clinical effectiveness, continuing therapy only if symptoms improve 1, 2

Expected Clinical Benefits

• Improvements in libido and energy levels are the primary therapeutic targets 1, 2
• Sexual function may improve, including sexual desire, arousal, and overall satisfaction 1, 5
• Quality of life benefits may be observed, though evidence for general wellbeing is less robust 1, 5

Safety Considerations and Monitoring for Adverse Effects

Common Androgenic Side Effects

• Acne is the most common adverse effect, occurring approximately 3.77 times more frequently than placebo 6
• Monitor for other signs of virilization including hirsutism, voice deepening, or clitoral enlargement 2, 7

Special Precautions in This Patient

• If the patient is on aromatase inhibitors (for breast cancer history), use DHEA with extreme caution as vaginal DHEA increases circulating androgens 1, 2
• For women with estrogen-dependent cancer history, DHEA should be avoided or used only after careful risk-benefit discussion 2
• Long-term safety data for DHEA replacement remain limited, so ongoing monitoring is essential 1, 2

Red Flags Requiring Dose Adjustment or Discontinuation

• Clinical signs of virilization indicate excessive androgen exposure and require dose reduction 7
• DHEAS levels exceeding normal range warrant evaluation for adrenal pathology 7
• Irregular bleeding or breakthrough bleeding may indicate hormonal imbalance 7

Interaction with Current Pellet Hormone Therapy

• DHEA supplementation is complementary to testosterone pellet therapy, as they address different aspects of hormonal deficiency 1, 2
• The testosterone from pellets and DHEA-derived androgens will have additive effects, so monitor total androgen levels carefully 7
• Elevated DHEA in the context of exogenous hormone therapy is expected and not pathologic unless accompanied by virilization 7

Evidence Quality Assessment

The recommendation is based on:

• Recent high-quality guideline evidence (2025) from the Journal of Internal Medicine and National Comprehensive Cancer Network supporting DHEA use in postmenopausal women with low libido and energy 1, 2
• Moderate quality evidence showing DHEA improves sexual function but not necessarily overall quality of life 6
• Consistent evidence from multiple sources supporting the 25 mg starting dose and monitoring protocol 1, 2, 8

Treatment Duration and Discontinuation Criteria

• Implement a 6-month trial period as the standard approach 1, 2
• Continue therapy only if the patient reports subjective improvement in libido, energy, or sexual function 1, 2
• If no benefit is observed after 6 months, discontinue DHEA as continued use without clinical benefit is not justified 1

Common Pitfalls to Avoid

• Do not prescribe DHEA without establishing baseline hormone levels, as this prevents appropriate dose titration 1, 2
• Do not measure hormone levels in the afternoon or after DHEA ingestion, as this provides inaccurate assessment 1, 2
• Do not continue therapy indefinitely without reassessing clinical benefit at 6 months 1, 2
• Do not ignore signs of virilization, as these indicate excessive androgen exposure requiring immediate dose adjustment 7