DHEA Supplementation in Women
Primary Recommendation
DHEA supplementation at 25 mg orally once daily in the morning is recommended for postmenopausal women with specific indications: vaginal atrophy/dryness, low libido, or low energy levels, particularly in those with adrenal insufficiency. 1, 2, 3
Established Clinical Indications
Vaginal Atrophy and Sexual Dysfunction
- Intravaginal DHEA (prasterone) is the most evidence-based indication, showing significant improvements in vaginal dryness, dyspareunia, sexual desire, arousal, and overall sexual function in postmenopausal women. 4, 2
- For women with hormone-positive breast cancer on aromatase inhibitors who have not responded to lubricants and moisturizers, vaginal DHEA may be offered after thorough discussion of risks and benefits. 4
- Oral DHEA at 25 mg daily improves sexual function compared to placebo (SMD 0.31,95% CI 0.07 to 0.55). 5
Adrenal Insufficiency
- Women with primary adrenal insufficiency experiencing persistent low libido or low energy despite optimized glucocorticoid/mineralocorticoid replacement should receive 25 mg DHEA daily. 3, 6
- This addresses the complete absence of endogenous DHEA production in these patients. 3
- Small but meaningful benefits in quality of life and mood have been demonstrated in this population. 6
Dosing Protocol
Standard starting dose: 25 mg orally once daily in the morning. 1, 2, 3
- Dose range can be adjusted between 10-50 mg daily based on clinical response and laboratory monitoring. 1, 2, 3
- Monitor morning serum DHEA sulfate, androstenedione, and testosterone levels to maintain them within normal range. 3
- Blood samples should be drawn in the morning prior to DHEA ingestion. 3
Treatment Duration and Evaluation
- Implement a 6-month trial period before determining long-term use. 1, 3
- Evaluate treatment effect after 3-6 months. 3
- Continue therapy only if the patient reports subjective improvement in target symptoms (libido, energy, or sexual function). 1
- Consider limiting therapy to 24 months due to limited long-term safety data. 3
Evidence for Other Potential Benefits
Uncertain or Inconsistent Benefits
- Quality of life improvement: No significant benefit demonstrated (SMD 0.16,95% CI -0.03 to 0.34) in general postmenopausal women. 5
- Menopausal symptoms (hot flashes, night sweats): Results are inconsistent and cannot be pooled to provide clear recommendations. 5
- Bone density, muscle strength, and body composition: Some positive signals in elderly women but insufficient high-quality evidence for firm recommendations. 7, 8
- Cognitive function and well-being in healthy postmenopausal women: No consistent beneficial effects demonstrated. 6
Populations Where DHEA May Be Effective
- Women with chronic glucocorticoid therapy. 7
- Postmenopausal women with low bone mineral density/osteoporosis. 7
- Women with depression and anxiety (probable effectiveness). 7
- Women with obesity and insulin resistance (probable effectiveness). 7
Safety Considerations and Adverse Effects
Androgenic Side Effects
- DHEA is associated with androgenic side effects, primarily acne (OR 3.77,95% CI 1.36 to 10.4). 5
- Monitor for signs of virilization including hirsutism, voice deepening, or clitoral enlargement. 1
- Most adverse effects are dose-related and can be minimized by using the lowest effective dose. 4
Contraindications and Cautions
- DHEA is generally contraindicated in breast cancer survivors due to potential risks of hormone-dependent cancers. 2, 3
- Use with extreme caution in patients receiving aromatase inhibitor therapy, as DHEA increases circulating androgen levels that can be converted to estrogens. 1, 2
- Women with BRCA1/2 mutations without personal history of breast cancer may consider DHEA after prophylactic bilateral salpingo-oophorectomy. 3
- Not recommended for men with breast cancer. 2
Overall Safety Profile
- No serious adverse events related to DHEA have been reported in the world literature despite widespread use. 9
- The excellent safety profile is consistent with its known physiology. 9
Mechanism of Action
- DHEA is the exclusive and tissue-specific source of sex steroids in postmenopausal women (except for the uterus), as ovarian estrogen production ceases at menopause. 9
- DHEA is converted locally in peripheral tissues to testosterone and estrogens through intracrinology—local formation, action, and inactivation of sex steroids. 9
- This tissue-specific conversion eliminates risks of endometrial hyperplasia and cancer from systemic estrogen exposure. 9
- DHEA secretion decreases by approximately 60% by the time of menopause, with large individual variability. 9
Common Pitfalls to Avoid
- Do not prescribe DHEA without establishing baseline hormone levels (DHEA sulfate, androstenedione, testosterone), as this prevents appropriate dose titration. 1
- Do not ignore signs of virilization, as these indicate excessive androgen exposure requiring immediate dose adjustment. 1
- Do not use DHEA as a general "anti-aging" supplement in healthy postmenopausal women without specific symptoms, as evidence does not support broad benefits. 5, 6
- Do not assume DHEA will improve menopausal vasomotor symptoms, as evidence is inconsistent. 5
- For women on concurrent hormone therapy, recognize that DHEA and testosterone have additive effects; monitor total androgen levels carefully. 1