DHEA/DHEAS Supplementation: Clinical Considerations
Primary Indications
DHEA supplementation has established benefit in three specific populations: postmenopausal women with genitourinary symptoms, women with primary adrenal insufficiency experiencing persistent low libido/energy despite optimized replacement, and potentially in elderly individuals for specific age-related conditions. 1
Postmenopausal Women with Genitourinary Symptoms
- Intravaginal DHEA (prasterone) is recommended for treating vaginal dryness and pain with sexual activity in postmenopausal women, with significant improvements in sexual desire, arousal, pain, and overall sexual function. 1
- This represents the strongest evidence-based indication with FDA approval for this specific use. 1
Primary Adrenal Insufficiency in Women
- For women with primary adrenal insufficiency who have persistent lack of libido and/or low energy despite optimized glucocorticoid and mineralocorticoid replacement, offer a 6-month trial of DHEA replacement (10-50 mg daily, typically 25 mg). 2
- Continue treatment only if clinically effective after the trial period. 2
- This pragmatic approach addresses the severe androgen deficiency that occurs in female patients with adrenal insufficiency. 2
Dosing and Monitoring
Standard Dosing Protocol
- Start with 25 mg daily as a single morning dose, with a typical range of 10-50 mg daily for women. 2, 1
- Guide dosing by monitoring serum DHEA sulfate (DHEAS), androstenedione, and testosterone levels measured in the morning prior to DHEA ingestion. 2
- Target levels should be maintained in the normal range for the patient's age and sex. 2
Monitoring Parameters
- Measure DHEAS, androstenedione, and testosterone levels to assess adequacy of replacement and avoid over-replacement. 2
- In women, monitor for signs of androgen excess (acne, hirsutism, voice changes). 2
Safety Considerations and Contraindications
Cancer Risk Concerns
- Use DHEA with extreme caution due to potential risks of hormone-dependent cancers, as DHEA increases circulating androgen levels that can be converted to estrogens. 1
- DHEA should not be used by men with breast cancer. 1
- Use with caution in patients receiving aromatase inhibitor therapy. 1
Long-Term Safety Unknown
- The long-term effects of DHEA replacement therapy are not known, so use with caution and only when clinically indicated. 2
- This is particularly important given that DHEA is widely available as a dietary supplement without medical oversight. 3
Potential Benefits in Elderly Populations
Evidence for Age-Related Conditions
- In elderly individuals (60-79 years), DHEA 50 mg daily for one year demonstrated improvements in bone turnover (particularly in women >70 years), libido parameters in older women, and skin status including hydration and epidermal thickness. 4
- DHEA exerts immunomodulatory effects, increases certain immune cell populations, and may improve physical and psychological well-being, muscle strength, and bone density while reducing body fat. 3
- In men over 90 years, higher DHEAS levels correlated with better functional status on Activities of Daily Living testing. 5
Limitations of Evidence
- Despite these findings, there is only limited objective evidence of clinical benefit from large-scale studies, particularly for routine anti-aging use. 2
- Results remain inconsistent across different studies due to heterogeneous receptor distribution, various action pathways, and distinct tissue responses in different systems. 6
Common Pitfalls and Caveats
Inappropriate Use
- Do not prescribe DHEA as a general "anti-aging" supplement without specific clinical indications. 2, 3
- The aggressive marketing of DHEA as a "superhormone" and "anti-aging panacea" is not supported by sufficient evidence for routine use. 3
Monitoring Failures
- Failure to monitor hormone levels can lead to excessive androgen exposure with potential adverse effects. 2
- In adrenal insufficiency, do not use DHEA as a substitute for proper glucocorticoid and mineralocorticoid replacement—optimize these first. 2