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enda-dhea-six-month-trial

Initiates a 6‑month trial of DHEA replacement in women with primary adrenal insufficiency (PAI) who have persistent low libido, depressive symptoms, or low energy despite otherwise optimized glucocorticoid and mineralocorticoid therapy. If the patient does not report a sustained beneficial effect after 6 months, discontinue DHEA.

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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

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