Symptoms and Treatment of Elevated DHEA in a 55-Year-Old Female
In a 55-year-old female with elevated DHEA, the primary concern is identifying an underlying adrenal androgen-secreting tumor, particularly adrenocortical carcinoma, which requires urgent imaging and endocrine evaluation. 1, 2
Clinical Manifestations of High DHEA
Elevated DHEA in postmenopausal women manifests through androgenic symptoms that reflect excessive androgen exposure:
Virilization Signs
- Hirsutism (excessive facial and body hair growth) 1
- Deepening of the voice 1
- Androgenetic alopecia (male-pattern baldness) 2
- Clitoral enlargement (clitoromegaly) 2
- Oligomenorrhea or amenorrhea (though less relevant in a 55-year-old postmenopausal woman) 1
Dermatologic Manifestations
Metabolic Effects
Diagnostic Approach
The critical first step is distinguishing between benign and malignant causes of DHEA elevation, as this fundamentally determines treatment strategy. 2
Initial Hormone Panel
- Free and total testosterone 2
- DHEA-sulfate (DHEAS) to confirm elevation 2
- Cortisol levels (24-hour urine cortisol if Cushing syndrome suspected) 1
- ACTH level to determine if hypercortisolism is ACTH-dependent 1
- 17-hydroxyprogesterone to rule out non-classical congenital adrenal hyperplasia 2
Imaging Studies
Adrenal CT with contrast is mandatory when DHEA elevation suggests adrenal pathology. 1 Look for:
- Tumor size >4 cm (highly suspicious for malignancy) 1
- Irregular margins or heterogeneous appearance 1
- Hounsfield units >10 on unenhanced CT (lipid-poor lesions suggest malignancy) 1
- Poor contrast washout 1
- Adjacent lymph node involvement or liver metastases 1
Treatment Based on Etiology
Adrenocortical Carcinoma (Malignant)
If imaging reveals features suspicious for adrenocortical carcinoma (size >5 cm, irregular margins, heterogeneous appearance), open adrenalectomy is the definitive treatment. 1
- Avoid laparoscopic approach for suspected malignancy due to rupture risk 1
- Complete staging with chest, abdomen, and pelvis imaging to evaluate for metastases 1
- Postoperative corticosteroid supplementation is required until HPA axis recovery 1
Benign Adrenal Adenoma
For benign-appearing androgen-secreting adenomas, laparoscopic adrenalectomy is the treatment of choice when feasible. 1
- Tumors <5 cm with homogeneous appearance and regular margins suggest benign pathology 1
- Postoperative glucocorticoid replacement is necessary until the contralateral adrenal recovers 1
Medical Management for Palliation
When surgery is not feasible or for symptom control, medical management targets the androgenic manifestations. 1
Anti-Androgen Therapy
- Spironolactone (50-200 mg daily) for hirsutism and acne 1
- Combined oral contraceptives (though less applicable in a 55-year-old) 1
- Finasteride (5 mg daily) for androgenic alopecia 1
Adrenostatic Agents (for unresectable tumors)
- Ketoconazole (400-1200 mg/day) is most commonly used due to tolerability 1
- Mitotane for adrenocortical carcinoma 1
Symptomatic Treatment
- Antihypertensives for blood pressure control 1
- Metformin for hyperglycemia and insulin resistance 1
- Potassium supplementation if hypokalemia present 1
Critical Pitfalls to Avoid
Never dismiss elevated DHEA in a postmenopausal woman as benign without imaging, as approximately 60% of adrenocortical carcinomas present with hormone excess. 1
Do not perform laparoscopic adrenalectomy if malignancy is suspected, as these tumors are prone to rupture. 1
Do not delay endocrine consultation when DHEA elevation is confirmed, as timely diagnosis of adrenocortical carcinoma significantly impacts mortality. 1, 2
Monitor for signs of Cushing syndrome concurrently, as tumors secreting multiple hormones are more likely malignant. 1