What are the guidelines for DHEA (Dehydroepiandrosterone) supplementation?

DHEA Supplementation Guidelines

For postmenopausal women with sexual dysfunction, low libido, or low energy, initiate DHEA at 25 mg orally once daily in the morning, with dose adjustments between 10-50 mg based on clinical response after a 6-month trial period. 1, 2, 3

Primary Clinical Indications

Female Sexual Dysfunction

• Vaginal DHEA significantly improves sexual desire, arousal, pain (dyspareunia), and overall sexual function in postmenopausal women, including cancer survivors. 4, 1
• A randomized controlled trial of 464 breast and gynecologic cancer survivors demonstrated significant improvements across all sexual function domains, though plain moisturizer also showed benefit. 4
• Vaginal DHEA is particularly effective for vaginal dryness and dyspareunia in postmenopausal women. 4, 1, 2

Low Libido and Energy in 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. 1, 2, 3
• DHEA supplementation at 10-50 mg daily can be offered for persistent lack of libido and/or low energy levels in postmenopausal women. 1, 2

Dosing Protocol

Standard Dosing

• Start with 25 mg orally as a single daily morning dose. 1, 2, 3
• Adjust dose between 10-50 mg daily based on clinical response and laboratory monitoring. 1, 2, 3
• For women, the typical range is 25 mg/day, while men may use 50 mg/day when indicated. 5

Monitoring Requirements

• Establish baseline serum DHEA sulphate (DHEAS), androstenedione, and testosterone levels before initiating therapy. 1, 3
• Obtain morning measurements prior to DHEA ingestion for accurate dose adjustment. 1, 3
• Monitor for signs of virilization including hirsutism, voice deepening, or clitoral enlargement. 2, 3

Treatment Duration and Evaluation

• Implement a 6-month trial period before determining long-term use. 1, 2, 3
• Evaluate treatment effect after 3-6 months based on subjective improvement in target symptoms. 2, 3
• Continue therapy only if the patient reports clinical benefit in libido, energy, or sexual function. 1, 2, 3
• Consider limiting therapy to 24 months due to limited long-term safety data. 2

Critical Safety Considerations

Cancer Survivors and Hormone-Sensitive Conditions

• DHEA should be used with extreme caution in survivors receiving aromatase inhibitor (AI) therapy, as vaginal DHEA increases circulating androgens that may impact AI activity. 4, 2
• DHEA is generally contraindicated in breast cancer survivors due to potential risks of hormone-dependent cancers. 2, 3
• For women with hormone-positive breast cancer on AIs who have not responded to lubricants and moisturizers, vaginal DHEA may be offered only after thorough discussion of risks and benefits. 2
• Women with BRCA1/2 mutations without personal history of breast cancer may consider DHEA after prophylactic bilateral salpingo-oophorectomy. 2

Hormonal Effects and Monitoring

• In women, DHEA supplementation at 100 mg daily significantly increases serum androstenedione, testosterone, and DHT to levels above young adult ranges. 6
• DHEA decreases sex hormone-binding globulin (SHBG) levels, with greater response in women (-40%) than men (-5%). 6
• For women on concurrent hormone therapy, recognize that DHEA and testosterone have additive effects; monitor total androgen levels carefully. 2, 3

Long-Term Safety

• Long-term effects of DHEA replacement therapy are not fully known, so treatment should be used with caution. 1, 2
• No significant adverse effects on lipid profiles, glucose metabolism, or bone density have been observed in 6-month trials. 6, 7

Expected Clinical Benefits

Sexual Function

• Improvements in sexual desire, arousal, lubrication, orgasm, and reduction in dyspareunia. 4, 1
• Enhanced vaginal health and function in women with vulvovaginal atrophy. 4

Well-Being and Energy

• Potential improvements in libido and energy levels, particularly in women with adrenal insufficiency. 1, 3, 8
• A 100 mg daily dose for 6 months increased serum IGF-I levels in both men (16%) and women (31%). 6

Body Composition (Gender-Specific)

• In men, 100 mg daily for 6 months decreased fat body mass by 6.1% and increased knee muscle strength by 15% and lumbar back strength by 14%. 6
• In women, an increase in total body mass of 2.1% was noted, with reduction in body fat percentage. 6, 7

Alternative and Complementary Options

Non-Hormonal Interventions

• Pelvic physical therapy (pelvic floor muscle training) may improve sexual pain, arousal, lubrication, orgasm, and satisfaction. 4, 1
• Vaginal moisturizers and lubricants can help alleviate vaginal dryness and sexual pain. 4, 1
• Vaginal dilators are an option for survivors with pain during sexual activity and vaginal stenosis from pelvic radiation. 4

FDA-Approved Pharmacologic Alternatives

• Flibanserin is FDA-approved for acquired, generalized hypoactive sexual desire disorder in premenopausal women, resulting in approximately 1 additional satisfying sexual event every 2 months. 4, 1
• Bremelanotide is FDA-approved for premenopausal women with low sexual desire, showing statistically significant increases in sexual desire and reduction in distress. 4
• Ospemifene (a SERM) effectively treats vaginal dryness and dyspareunia in postmenopausal women without history of estrogen-dependent cancers. 4

Hormonal Alternatives

• Vaginal estrogen is the most effective treatment for vaginal dryness leading to sexual dysfunction in postmenopausal women. 4
• Intravaginal testosterone cream has been shown safe and effective in improving vaginal atrophy and sexual function in breast cancer survivors on AI therapy. 4

Common Pitfalls to Avoid

• Do not prescribe DHEA without establishing baseline hormone levels, as this prevents appropriate dose titration. 2, 3
• Do not ignore signs of virilization, as these indicate excessive androgen exposure requiring immediate dose adjustment. 2, 3
• Do not use DHEA in men currently trying to conceive, as it can suppress normal sperm production. 1
• Do not assume cognitive benefits—current evidence shows no support for improvement in memory or cognitive function following DHEA treatment. 9, 5

Evidence Quality Assessment

The strongest evidence supports DHEA use for female sexual dysfunction in postmenopausal women, based on 2024 NCCN guidelines 4 and 2025 high-quality guideline summaries. 1, 2, 3 The evidence for cognitive enhancement or general anti-aging benefits remains insufficient, with Cochrane reviews finding no support for these indications. 9, 5