dromlakhani Limit DHEA Replacement Trial to Six Months; Discontinue if No Benefit
STEP 1 — Gather Information
Confirm PAI diagnosis, female sex, presence of low libido, depressive symptoms, or low energy despite optimized glucocorticoid (hydrocortisone 15‑25 mg/day or equivalent) and mineralocorticoid (fludrocortisone 50‑100 µg/day) replacement. Obtain baseline morning DHEAS level and document symptom severity using a validated scale (e.g., HADS, FACT‑F).
STEP 2 — Rule In / Rule Out
Is the patient a woman with PAI reporting persistent low libido, depressive symptoms, or low energy despite adequate glucocorticoid and mineralocorticoid replacement?
- Yes → proceed to DHEA trial.
- No → do not initiate DHEA replacement.
STEP 3 — Classify or Stratify
Baseline symptom score establishes a threshold for “sustained beneficial effect” (e.g., ≥2‑point improvement on HADS depression subscale or ≥1‑point increase on libido visual analogue score). Record baseline DHEAS to ensure replacement targets mid‑normal range for age.
STEP 4 — Decide
After 6 months of DHEA (25‑50 mg daily, taken morning), reassess symptoms.
- If sustained beneficial effect is present (pre‑defined improvement maintained), consider continuing DHEA with periodic review.
- If no sustained benefit, discontinue DHEA.
Clinical Guardrails / Mimics / Pitfalls
Do not use DHEA in men, pregnant patients, or those with hormone‑sensitive malignancies. Avoid doses >50 mg/day (supraphysiologic). Monitor for androgenic side effects (acne, hirsutism, voice deepening). Do not continue DHEA beyond 6 months without documented benefit. Do not rely on DHEAS alone to guide therapy; clinical response is primary.
Concrete Clinical Example
A 48‑year‑old woman with PAI on hydrocortisone 20 mg AM + 10 mg PM and fludrocortisone 100 µg reports low libido (VAS 3/10) and fatigue (HADS‑D 8). Baseline DHEAS is low. She starts DHEA 25 mg daily. At 6‑month visit, libido VAS remains 3/10 and HADS‑D 8; she reports no improvement. DHEA is discontinued.
Source: Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2015-1710
TODO: consider adding scripts/calc.py for the enda-dhea-six-month-trial calculator