Management of Elevated DHEA at 280
The priority is to rule out an androgen-secreting adrenal tumor through urgent adrenal CT imaging, as this represents a potentially life-threatening malignancy that requires surgical intervention. 1, 2
Immediate Diagnostic Workup
The elevated DHEA level of 280 requires systematic evaluation to identify the underlying cause:
Obtain adrenal CT imaging immediately to assess for adrenal neoplasm, particularly if accompanied by virilization symptoms (hirsutism, deepening voice, menstrual irregularities, clitoromegaly in women, or rapid onset of symptoms). 2
Complete hormone panel including free and total testosterone, DHEAS (not just DHEA), androstenedione, LH, FSH, morning ACTH, and morning cortisol to distinguish adrenal from other sources. 2
Assess for Cushing syndrome features including weight gain, proximal muscle weakness, hypertension, psychiatric disturbances, centripetal obesity, purple striae, and buffalo hump. 2
Check electrolytes to evaluate for concurrent aldosterone excess. 2
Surgical Management (First-Line for Adrenal Tumors)
If imaging confirms an adrenal neoplasm:
Laparoscopic adrenalectomy is recommended for benign-appearing tumors (typically <4-5 cm, regular margins, homogeneous appearance). 1, 2
Open adrenalectomy is preferred when malignancy is suspected based on size >4-5 cm, irregular margins, heterogeneous appearance on imaging, lipid-poor characteristics, lack of contrast washout, or secretion of multiple hormones. 1, 2
Urgent referral to surgical oncology is warranted for rapidly progressive virilization, as this strongly suggests malignancy. Adrenocortical carcinomas show peak incidence in the fourth to fifth decades with female predominance (1.5:1 ratio). 2
Medical Management (For Functional Excess Without Surgical Indication)
When adrenal tumor is excluded or surgery is not feasible:
Ketoconazole 400-1200 mg/day can inhibit adrenal steroidogenesis and reduce DHEA production for functional DHEA excess. 1, 2
Monitor liver function tests regularly in patients on ketoconazole due to hepatotoxicity risk. 1
Serial DHEA/DHEAS measurements are necessary to assess treatment efficacy. 1
Watch for signs of adrenal insufficiency with high-dose steroid suppression therapy. 1
Consider spironolactone if hyperaldosteronism is present concurrently, though this addresses mineralocorticoid excess rather than DHEA directly. 3
Critical Pitfalls to Avoid
Do not delay imaging in the presence of rapidly progressive virilization symptoms, as delay in diagnosing adrenocortical carcinoma significantly worsens prognosis. 2
Do not assume benign etiology based solely on DHEA level; approximately 60% of androgen-secreting adrenocortical tumors present with evidence of adrenal steroid hormone excess with or without virilization. 2
Do not confuse elevated DHEA with low DHEA seen in primary adrenal insufficiency, where DHEA supplementation may be considered (particularly in women with low libido/energy who are otherwise well-replaced). 4
Context-Specific Considerations
The research evidence on DHEA supplementation for aging, depression, or general well-being 5, 6, 7, 8, 9 is not applicable to your situation of pathologically elevated endogenous DHEA, which requires evaluation for tumor or hyperplasia rather than supplementation.