What causes elevated Dehydroepiandrosterone (DHEA) levels in women aged 60?

Causes of Elevated DHEA in Women Aged 60

In a 60-year-old woman, elevated DHEA levels are most commonly caused by polycystic ovary syndrome (PCOS), adrenal tumors, or non-classical congenital adrenal hyperplasia (NCAH), and require systematic evaluation to exclude malignancy. 1

Primary Differential Diagnoses

Most Common Cause: Polycystic Ovary Syndrome (PCOS)

• PCOS remains the leading cause of elevated DHEA-S in women, affecting 4-6% of the general female population, even in postmenopausal women. 1
• Look specifically for clinical features including menstrual irregularity history, hirsutism, acne, and obesity. 1
• Note that while PCOS typically presents in reproductive years, the metabolic and hormonal manifestations persist into the postmenopausal period. 1

Adrenal Pathology (Critical to Exclude)

• Adrenal tumors (adenomas or carcinomas) must be ruled out, particularly when DHEA-S levels are markedly elevated or symptoms progress rapidly. 1
• Obtain adrenal CT scan or MRI when DHEA-S is very high or clinical presentation suggests tumor. 1
• Adrenal tumors can autonomously produce DHEA independent of normal regulatory mechanisms. 1

Non-Classical Congenital Adrenal Hyperplasia (NCAH)

• NCAH presents with mild enzyme deficiencies in the adrenal steroidogenesis pathway, most commonly 21-hydroxylase deficiency. 1
• This can manifest later in life with androgen excess symptoms. 1

Clinical Assessment Approach

Signs and Symptoms to Evaluate

• Assess for androgen excess manifestations: hirsutism, acne, male-pattern baldness, and any history of menstrual irregularities. 1
• Evaluate for virilization signs: clitoromegaly, deepening voice, and increased muscle mass (these suggest more severe pathology). 1
• Screen for associated endocrine disorders: truncal obesity, hypertension, and glucose intolerance. 1

Diagnostic Workup Algorithm

1. Pelvic ultrasound to evaluate for ovarian pathology, particularly polycystic ovaries. 1
2. Adrenal imaging (CT or MRI) if DHEA-S is markedly elevated (typically >700 μg/dL) or rapid symptom progression. 1
3. 17-hydroxyprogesterone level if NCAH is suspected (perform ACTH stimulation test if baseline elevated). 1
4. Assess for insulin resistance with fasting glucose and insulin levels. 1

Important Clinical Context

Physiologic DHEA Decline with Age

• DHEA naturally declines by approximately 2% per year and by about 60% between age 30 and menopause. 2
• By age 60, DHEA levels are typically 10-20% of peak levels seen at age 30. 3
• Therefore, truly "elevated" DHEA at age 60 is particularly concerning and warrants thorough investigation, as it goes against the expected physiologic decline. 2

Exogenous DHEA Supplementation

• Always inquire about DHEA supplementation, as it is commercially available over-the-counter in the United States. 4
• Women may be taking DHEA for purported anti-aging benefits, libido enhancement, or bone health. 3, 5
• Typical supplementation doses range from 25-100 mg daily. 3, 5

Critical Pitfalls to Avoid

• Do not dismiss elevated DHEA as "normal aging"—the opposite is true; DHEA should be declining, not elevated. 2
• Do not delay adrenal imaging in cases of very high DHEA-S or rapid symptom progression, as adrenal carcinoma requires urgent intervention. 1
• Do not forget to check medication and supplement lists, as exogenous DHEA is a common and easily reversible cause. 4
• High DHEA levels in postmenopausal women may increase breast cancer risk, so this should be part of your risk assessment. 4

Monitoring Recommendations

• Repeat DHEA-S measurements every 3-6 months until normalized or stable. 1
• Monitor clinical symptoms of androgen excess for improvement or progression. 1
• Long-term follow-up is essential for patients with persistent elevations to detect any changes suggesting developing pathology. 1