What are the suitable dosages of progesterone, testosterone, and DHEA (Dehydroepiandrosterone) for a post-bilateral adrenalectomy female patient to achieve normal hormone balance?

Hormone Replacement Dosing After Bilateral Adrenalectomy

Primary Recommendation

A 38-year-old female post-bilateral adrenalectomy requires hydrocortisone 15-20 mg daily in divided doses for glucocorticoid replacement, fludrocortisone 0.05-0.1 mg daily for mineralocorticoid replacement, and DHEA 25 mg daily for androgen replacement, with progesterone and testosterone not routinely indicated unless specific deficiency symptoms persist after optimization of these three core replacements. 1

Glucocorticoid Replacement (Essential for Survival)

Hydrocortisone is the preferred glucocorticoid because it provides both glucocorticoid and mineralocorticoid activity 1:

• Dosing: 15-20 mg daily in divided doses (typically 10 mg upon awakening, 5 mg at lunch, and 2.5-5 mg in early afternoon) 1
• Rationale: This mimics physiologic cortisol secretion patterns and prevents both under-replacement (adrenal crisis risk) and over-replacement (metabolic complications) 1
• Critical safety point: All patients need education on stress dosing (doubling doses during illness), emergency injectable hydrocortisone, medical alert identification, and when to seek emergency care 1

Mineralocorticoid Replacement (Essential for Survival)

Fludrocortisone replacement is mandatory after bilateral adrenalectomy 1:

• Dosing: 0.05-0.1 mg daily as a single morning dose 1
• Monitoring parameters: Salt cravings, orthostatic blood pressure changes, serum electrolytes, and peripheral edema 1
• Common pitfall: Under-replacement is frequent and often compensated by over-replacement of glucocorticoids, which predisposes to adrenal crises 1
• Drug interactions to avoid: Diuretics, NSAIDs, acetazolamide, liquorice, and drospirenone-containing contraceptives may require dose adjustments 1

DHEA Replacement (Conditional Based on Symptoms)

DHEA 25 mg daily is appropriate for women with persistent low libido and/or energy despite optimized glucocorticoid and mineralocorticoid replacement 1, 2:

• Dosing range: 10-50 mg daily, typically starting at 25 mg as a single morning dose 1, 2
• Monitoring: Measure morning serum DHEA-sulfate, androstenedione, and testosterone levels to maintain normal ranges 1
• Trial period: Implement a 6-month trial and continue only if subjective improvement occurs 1, 2
• Evidence quality: Limited objective evidence of clinical benefit from large studies, but pragmatic approach supports trial in symptomatic patients 1
• Safety monitoring: Watch for virilization signs (hirsutism, voice deepening, clitoral enlargement) indicating excessive androgen exposure 2

Progesterone Replacement (Not Routinely Indicated)

Progesterone replacement is not standard after bilateral adrenalectomy because:

• The adrenal glands contribute minimally to progesterone production in premenopausal women with intact ovarian function 1
• Ovarian progesterone production remains intact after adrenalectomy in women with functioning ovaries 3
• Consider only if the patient has concurrent ovarian failure or is postmenopausal and requires hormone therapy for menopausal symptoms (this would be managed separately from adrenal insufficiency) 1

Testosterone Replacement (Not Routinely Indicated)

Direct testosterone replacement is not standard in women post-bilateral adrenalectomy because:

• DHEA serves as the androgen precursor and converts peripherally to testosterone and other androgens 1
• If DHEA replacement at 25-50 mg daily fails to normalize testosterone levels or improve symptoms, only then consider direct testosterone therapy 1
• Contraindications: Avoid in patients with breast cancer history, prostate concerns, or history of DVT 1
• Monitoring: If prescribed, monitor for signs of virilization and maintain testosterone levels in the normal female range 1, 2

Critical Management Algorithm

Step 1: Initiate hydrocortisone first (15-20 mg daily in divided doses) before adding other hormones, as other hormones accelerate cortisol clearance and can precipitate adrenal crisis 1

Step 2: Add fludrocortisone (0.05-0.1 mg daily) once glucocorticoid replacement is stable 1

Step 3: After 2-3 months of optimized glucocorticoid and mineralocorticoid replacement, assess for persistent low libido and/or energy 1

Step 4: If symptoms persist, measure morning DHEA-sulfate, androstenedione, and testosterone levels 1

Step 5: If levels are low and symptoms present, initiate DHEA 25 mg daily for a 6-month trial 1, 2

Step 6: Continue DHEA only if subjective improvement occurs; discontinue if no benefit after 6 months 1, 2

Essential Patient Education

Stress dosing protocol (life-saving information) 1:

• Double hydrocortisone dose during febrile illness, significant injury, or major stress 1
• Administer hydrocortisone 100 mg intramuscularly or intravenously if unable to take oral medications due to vomiting 1
• Seek immediate emergency care for signs of adrenal crisis (severe weakness, confusion, hypotension, abdominal pain, vomiting) 1
• Wear medical alert identification at all times 1

Common Pitfalls to Avoid

Do not delay glucocorticoid replacement to assess other hormones, as this risks life-threatening adrenal crisis 1

Do not use dexamethasone alone in primary adrenal insufficiency, as it lacks mineralocorticoid activity 1

Do not prescribe DHEA without first optimizing glucocorticoid and mineralocorticoid replacement, as symptoms may resolve with proper core hormone replacement 1

Do not ignore signs of under-replacement (salt cravings, orthostatic hypotension, fatigue) or over-replacement (hypertension, peripheral edema, weight gain) 1

Do not assume the patient understands stress dosing even if previously educated; verify understanding at every encounter 1

Ongoing Monitoring Requirements

Clinical assessment at each visit should include 1:

• Blood pressure in supine and standing positions to detect orthostatic changes 1
• Assessment for salt cravings, lightheadedness, and peripheral edema 1
• Evaluation of energy levels, libido, and overall quality of life 1
• Review of stress dosing knowledge and emergency preparedness 1

Laboratory monitoring should include 1:

• Serum electrolytes (sodium, potassium) to assess mineralocorticoid adequacy 1
• Morning DHEA-sulfate, androstenedione, and testosterone levels if on DHEA replacement 1
• Fasting glucose and lipid profiles to monitor metabolic effects 1

Endocrinology consultation is essential for initial management and should be part of planning before any surgery or high-stress treatments 1