Treatment of Elevated DHEA Levels
For elevated DHEA levels, surgical intervention with laparoscopic adrenalectomy is first-line treatment when an adrenal neoplasm is confirmed, while medical management with ketoconazole (400-1200 mg/day) can be used for functional DHEA excess when surgery is not indicated. 1, 2
Immediate Diagnostic Priorities
Before initiating treatment, the underlying cause must be identified:
Rule out androgen-secreting adrenal tumors urgently, particularly if virilization symptoms are present (hirsutism, voice deepening, menstrual irregularities, clitoromegaly in women), as approximately 60% of androgen-secreting adrenocortical tumors present with evidence of adrenal steroid hormone excess 2
Obtain adrenal CT imaging immediately to assess for malignancy, especially if the patient has rapidly progressive virilization symptoms, as delay in imaging can be catastrophic 2
Suspect malignancy when tumors are >4-5 cm, have irregular margins, are lipid-poor on imaging, show poor contrast washout, or secrete multiple hormones 1, 2
Surgical Management (First-Line for Tumors)
Laparoscopic adrenalectomy is the preferred approach for benign adrenal tumors causing elevated DHEA when technically feasible 1, 2
Open adrenalectomy is indicated for suspected malignant tumors, particularly those >4-5 cm with irregular margins or heterogeneous appearance on imaging 1, 2
Medical Management (For Functional Excess)
When surgical intervention is not indicated or for functional DHEA excess without discrete tumor:
Ketoconazole 400-1200 mg/day inhibits adrenal steroidogenesis and reduces DHEA production 1, 2
Monitor liver function tests regularly in all patients receiving ketoconazole due to hepatotoxicity risk 1
Check DHEA/DHEAS levels periodically to assess treatment efficacy 1
Watch for signs of adrenal insufficiency with high-dose steroid suppression therapy, as excessive suppression can occur 1
Critical Pitfalls to Avoid
Do not delay imaging when virilization symptoms are rapidly progressive, as this pattern strongly suggests malignancy requiring urgent intervention 2
Do not confuse elevated DHEA with primary adrenal insufficiency, where DHEA levels are typically low rather than elevated 1
Do not rely on laboratory parameters alone to guide treatment dosing—clinical response should determine optimal medication doses 3