Can Dehydroepiandrosterone (DHEA) cause hair loss?

DHEA and Hair Loss: Clinical Evidence

DHEA (dehydroepiandrosterone) can contribute to hair loss in genetically predisposed individuals by serving as a precursor to more potent androgens, particularly dihydrotestosterone (DHT), which drives androgenetic alopecia through follicular miniaturization.

Mechanism of DHEA-Related Hair Loss

DHEA functions as a weak androgen that undergoes intrafollicular conversion to more potent androgens within hair follicles 1, 2. The key pathophysiological pathway involves:

• Local androgen metabolism: DHEA and its sulfate (DHEAS) are converted within the dermal papilla of hair follicles to testosterone and subsequently to DHT via 5-alpha-reductase enzymes 1, 2
• DHT-mediated miniaturization: DHT binding to androgen receptors causes progressive miniaturization of genetically sensitive hair follicles, the hallmark of androgenetic alopecia 3, 4
• Steroidogenic enzyme activity: The dermal papilla exhibits multiple steroidogenic isoenzymes (including 5-alpha-reductase type 2, 17beta-HSD, 3beta-HSD) that facilitate conversion of weak androgens like DHEA to DHT 1, 2

Clinical Context and Risk Assessment

The relationship between DHEA and hair loss depends critically on the estrogen-to-androgen ratio, particularly in women:

• Hormonal balance matters more than absolute levels: Women with female pattern hair loss often have normal absolute androgen levels (including DHEAS) but significantly lower ratios of estradiol to free testosterone and estradiol to DHEAS 5
• Genetic predisposition is essential: DHEA only triggers hair loss in individuals with genetic susceptibility to androgenetic alopecia 3, 4
• Postmenopausal women face higher risk: Estrogen deficiency during menopause removes protective effects against androgen-mediated hair loss, making DHEA supplementation potentially more problematic 4

Safety Considerations for DHEA Supplementation

The National Comprehensive Cancer Network recommends using DHEA with caution due to its conversion to circulating androgens, particularly in patients receiving aromatase inhibitor therapy 6. This caution extends to hair loss risk:

• DHEA increases circulating androgen levels, which can exacerbate androgenetic alopecia in susceptible individuals 6
• Typical supplementation doses of 10-50 mg daily (with 25 mg as a common starting dose) should be monitored via serum DHEAS, androstenedione, and testosterone levels 6
• The American College of Obstetricians and Gynecologists approves DHEA (prasterone) for vaginal symptoms in postmenopausal women, but hair loss risk should be discussed 6

Clinical Pitfalls to Avoid

When evaluating DHEA-related hair loss, avoid these common errors:

• Don't dismiss normal androgen levels: Absolute DHEAS levels may be normal; calculate the estradiol-to-DHEAS ratio to assess true androgenic effect 5
• Don't overlook other causes: In patients presenting with hair loss on DHEA, check thyroid function (TSH, free T4), iron stores (ferritin), vitamin D, and zinc levels to rule out alternative etiologies 7
• Don't confuse with other alopecia patterns: DHEA-related androgenetic alopecia presents as crown thinning with frontal/bitemporal recession in women, distinct from diffuse telogen effluvium 7

Management Algorithm

If hair loss develops during DHEA supplementation:

1. Discontinue or reduce DHEA dose to minimize androgen substrate availability 6
2. Monitor hormone levels: Measure DHEAS, testosterone, and androstenedione to confirm elevated androgens 6
3. Consider anti-androgen therapy: 5-alpha-reductase inhibitors (finasteride, dutasteride) or spironolactone may counteract DHT effects in appropriate candidates 3, 4
4. Apply topical minoxidil 5%: This can support hair regrowth independent of androgen effects 8, 3

The evidence clearly establishes DHEA as a contributor to androgenetic alopecia through its role as an androgen precursor, making hair loss a legitimate concern for supplementation in genetically predisposed individuals.