DHEA: What It Is, What the Research Shows, and Why Athletes Should Be Careful
Table of Contents
Key Takeaways: DHEA
- DHEA (dehydroepiandrosterone) is an adrenal hormone that the body converts into active sex hormones. Its sulfated form, DHEA-S, is what is usually measured in blood.
- DHEA-S levels peak in early adulthood and then decline steadily. In a large cross-sectional study, the log mean in men fell from 3470 ng/mL at ages 20–24 to 670 ng/mL after age 70.
- In a 2-year randomized trial in older men and women with low DHEA-S, restoring DHEA levels did not improve body composition, muscle strength, aerobic capacity, insulin sensitivity, or quality of life.
- A meta-analysis of systemic DHEA in postmenopausal women found no statistically significant improvement in sexual function (low-certainty evidence), and in women with adrenal insufficiency the effect on quality of life was small.
- The clearest clinical niches are narrow: a supervised 6-month trial in selected women with primary adrenal insufficiency, and vaginal DHEA (prasterone) for painful intercourse after menopause.
- In my clinical experience, DHEA-S is not a first-line test even in hormonal work-ups, and I do not see it as worth ordering for screening or simply at a patient’s request.
- For typical vasomotor menopausal symptoms, menopausal hormone therapy has a much stronger evidence base than DHEA and is, in my experience, the better option, provided there are no contraindications.
- The most recent Cochrane review found that DHEA likely makes little or no difference to live birth rates in IVF poor responders.
- DHEA is on the World Anti-Doping Agency (WADA) list of prohibited substances. Small trials in young men and women have not shown performance or training benefits.
- For athletes, the indications for DHEA testing are, in my view, the same as for everyone else: a medical reason comes first.
Introduction: DHEA
DHEA has been widely promoted as an anti-aging supplement.[1] The logic sounds simple: levels fall with age, so replacing them should turn back the clock. Controlled trials, however, tell a more modest story.
This article explains what DHEA is, how its levels change across life, what randomized trials show for aging, women’s health, fertility and mood, and what athletes in particular need to know.
In my clinical experience, however, DHEA comes up fairly rarely in patients’ laboratory panels, and patients seldom ask about it. With many other sex hormones, patients often arrive with a ready opinion, but DHEA remains fairly unfamiliar to patients and, to some extent, to general practitioners as well.
What Is DHEA?
DHEA is a steroid hormone produced by the adrenal glands that acts largely as a precursor for sex hormones. According to the Endocrine Society’s adrenal insufficiency guideline, in women the adrenal androgen precursors DHEA and androstenedione are a major source of androgen production, and DHEA is activated to sex steroids in a wide variety of peripheral tissues and in the gonads. The same guideline notes that DHEA has also been shown to have neurosteroidal properties in the brain, with potential antidepressive action.[2]
Its sulfated form, DHEA-S, is the version usually measured in blood tests.
How DHEA Levels Change With Age
The classic reference study measured DHEA-S in 981 men and 481 women aged 11 to 89. Levels peaked at ages 20–24 in men (log mean 3470 ng/mL) and at 15–19 in women (log mean 2470 ng/mL), then declined steadily. After age 70, the log mean was 670 ng/mL in men and 450 ng/mL in women, and men had significantly higher levels than women between ages 20 and 69.[3]
Two practical points follow. First, the Endocrine Society guideline notes that serum DHEAS concentrations physiologically peak between ages 20 and 30 years, followed by a gradual decline that is independent of menopause. Second, the same guideline cautions that DHEAS levels may be low in some individuals, especially in older age groups, without primary adrenal insufficiency.[2]
In practice, DHEA-S is a relatively uncommon test in general medicine, and in my clinical experience it is not a first-line test even in hormonal work-ups. When hormone tests are needed in primary care, the choice depends on the clinical question. In my experience, testosterone is often the first test in men, and in women with menstrual disturbances, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and prolactin are common first tests; prolactin is often measured in men as well. General practitioners order these first-line tests themselves from time to time. A woman may also want to know whether menopause is starting, although these tests cannot settle that question on their own, and in my understanding of current Finnish guidance they are often not needed in women of typical menopausal age with typical symptoms.
DHEA-S, by contrast, is more often measured for specialist-care indications. When I come across a DHEA-S result in primary care, it has usually been ordered as part of a broader hormone panel, in my experience more often on the gynecology side. It can also come up when hypogonadism is being investigated, although in my view less often, because urological work-ups tend to focus on testosterone and related measurements. I have never ordered the test myself, which perhaps says something about how limited its role is in everyday general practice.
In my experience, general practitioners rarely order it, and I suspect its limited familiarity may be one contributing factor. In my view, DHEA-S is not worth ordering as a screening test, because it is often unclear what further clinical action the result would lead to. It is better reserved for situations where a hormonal work-up genuinely points to it, and as a rule it does not need to be added to a laboratory panel simply because a patient asks for it.
DHEA Supplements and Aging: What the Trials Show
A key test of the “anti-aging” idea is a 2-year, placebo-controlled, double-blind trial published in the New England Journal of Medicine. It enrolled 87 older men with low DHEA-S and low bioavailable testosterone, and 57 older women with low DHEA-S. Compared with placebo, DHEA increased DHEA-S by a median of 3.4 µg/mL in men and 3.8 µg/mL in women, but a separate analysis of men and women showed no significant effect on body composition, and neither DHEA nor testosterone changed peak oxygen uptake, muscle strength or insulin sensitivity. Women taking DHEA had a bone density increase at the ultradistal radius, and men in both active groups had an increase at the femoral neck. Neither treatment improved quality of life. The authors concluded that DHEA replacement in older people has no physiologically relevant beneficial effects on body composition, physical performance, insulin sensitivity or quality of life.[1]
A systematic review of DHEA in adults aged 50 and older reached a similar conclusion for muscle: the benefit on strength and physical function remained inconclusive, some strength measures may improve, and DHEA did not appear to routinely benefit physical function or performance.[4]
There is one interesting exception worth noting. In a randomized, placebo-controlled trial of frail older women who were also doing a gentle exercise program of chair aerobics or yoga, DHEA improved lower-extremity strength (from 459 ± 121 N to 484 ± 147 N) and Short Physical Performance Battery scores (from 10.1 ± 1.8 to 10.7 ± 1.9). No change in bone density was found.[5] This is a narrow, selected population, and it does not change the overall picture from the larger trial above.
For men, the hormone discussion usually centers on testosterone rather than DHEA. Testosterone replacement therapy is an established treatment for appropriately diagnosed hypogonadism. In my view, it has nevertheless become something of a fashionable treatment, and some private-practice settings may apply the diagnostic criteria for hypogonadism too loosely, potentially leading to inappropriate testosterone prescribing.
DHEA for Women: Menopause, Sexual Function and Adrenal Insufficiency
Postmenopausal women with normal adrenal function
A systematic review and meta-analysis included 23 randomized trials enrolling 1188 postmenopausal women with normal adrenal function. In the pooled data, systemic DHEA was not associated with significant improvement in libido or sexual function (standardized mean difference 0.35; 95% CI −0.02 to 0.73). It also had no significant effect on serum lipids, glucose, weight, body mass index or bone mineral density. The included trials had moderate to high risk of bias, and the authors rated the evidence as warranting low confidence.[6] A separate Cochrane review in peri- and postmenopausal women reached a slightly different conclusion: DHEA may slightly improve sexual function compared with placebo (SMD 0.31, 95% CI 0.07 to 0.55; 5 studies, 261 women; moderate-quality evidence), although in the subgroup of trials using oral DHEA there was no significant difference (SMD 0.11, 95% CI −0.13 to 0.35; 5 studies, 340 women). There was no evidence that DHEA improves quality of life, and there was some evidence that it is associated with androgenic side effects.[7]
The Endocrine Society recommends against the routine prescription of testosterone or DHEA for women with low androgen levels due to hypopituitarism, adrenal insufficiency, surgical menopause, glucocorticoid treatment or similar conditions, citing limited data on symptom improvement and no long-term studies of risk.[8] For more on hormonal change after menopause in active women, see menopause in female athletes.
From a clinical perspective, menopausal hormone therapy has a much stronger evidence base than systemic DHEA for typical vasomotor menopausal symptoms such as hot flashes, and in my experience it is the better option, provided there are no contraindications. In Finland, current treatment guidelines support starting menopausal hormone therapy in primary care for appropriately assessed women with symptoms. In my experience, starting estrogen therapy used to involve a gynecologist’s assessment more often, whereas today general practitioners can usually start it after assessing the symptoms, contraindications and the patient’s overall situation. Many of my patients experience substantial relief of menopausal symptoms with it, and in my view this is a far more sensible approach than trying to treat symptoms with a DHEA product whose effectiveness is uncertain.
Women with adrenal insufficiency
In women, adrenal production of DHEA and androstenedione is a major source of androgens, so adrenal insufficiency is frequently associated with androgen deficiency.[2] Even so, the benefit appears modest. A meta-analysis of 10 trials in women with primary or secondary adrenal insufficiency found only a small improvement in health-related quality of life (effect size 0.21; 95% CI 0.08 to 0.33) and a small effect on depression, with no significant effect on anxiety or sexual well-being. The authors described the effect as small and perhaps trivial, and judged the evidence insufficient to support routine use.[9]
The 2016 Endocrine Society guideline on primary adrenal insufficiency takes a cautious middle position. It suggests a trial of DHEA in women with primary adrenal insufficiency who have low libido, depressive symptoms and/or low energy despite otherwise optimized glucocorticoid and mineralocorticoid replacement. It suggests an initial 6-month period, with DHEA discontinued if the patient does not report a sustained benefit, and monitoring with a morning DHEA-S level aiming at the mid-normal range.[2] This is a weak recommendation based on low-quality evidence, made for a specific diagnosed condition.
Outside these narrow indications, DHEA plays a very small role as a medication. In my clinical experience, I have not come across a patient using DHEA as a medication, either as a drug treatment or as part of hormone replacement therapy. In my view, this reflects how limited its medical indications are in practice.
Vaginal DHEA for painful intercourse after menopause
Vaginal DHEA (prasterone) is a different product from oral supplements. In a randomized, double-blind, placebo-controlled phase III trial, daily intravaginal prasterone 6.5 mg for 12 weeks reduced the severity of the most bothersome dyspareunia by 46% over placebo (P = 0.013). Serum steroids remained within postmenopausal reference concentrations, which the investigators interpreted as being in line with a strictly local action of the treatment.[10] This finding applies to a local vaginal treatment, not to DHEA capsules taken by mouth.
DHEA and Fertility
Androgens, including DHEA, are commonly prescribed as an adjunct to assisted reproduction.[11] The evidence has shifted over time. The 2015 Cochrane review reported that DHEA pre-treatment, compared with placebo or no treatment, was associated with higher live birth or ongoing pregnancy rates in women identified as poor responders (OR 1.88; 95% CI 1.30 to 2.71; eight RCTs, N = 878; moderate-quality evidence). However, in a sensitivity analysis removing trials at high risk of performance bias, the effect size was reduced and no longer reached significance (OR 1.50, 95% CI 0.88 to 2.56; five RCTs, N = 306).[12] The 2024 update reached a different conclusion: in women identified as poor responders, pre-treatment with DHEA likely results in little to no difference in live birth and clinical pregnancy rates, while testosterone pre-treatment likely improves them.[11]
DHEA and Mood
A 2018 systematic review and meta-analysis of randomized trials in people with depression not caused by other psychiatric or medical conditions found a significant effect in favor of DHEA compared with placebo. The authors also noted that few studies had been conducted in this specific population.[13] Although the review reported a positive signal, the limited trial evidence does not establish DHEA as a routine treatment for depression.
Is DHEA Safe? Side Effects, Quality and Unknowns
In the 2-year NEJM trial, neither DHEA nor low-dose testosterone had major adverse effects.[1] In the postmenopausal meta-analysis, DHEA had no significant effect on serious adverse effects.[6]
That is reassuring in the short term, but it is not the same as proven long-term safety. The Endocrine Society notes that studies on long-term outcomes of chronic DHEA supplementation in women with primary adrenal insufficiency are lacking, and are unlikely to appear soon partly because DHEA is readily available over the counter or through internet orders.[2] Product quality is a further concern: a review in the Cleveland Clinic Journal of Medicine concluded there was not enough evidence to recommend routine DHEA treatment, and noted that different brands may contain different amounts of the active ingredient.[14]
The same review notes that DHEA’s potential adverse effects on some cancers need to be considered in patients at risk.[14] Because DHEA is converted into sex hormones, it is not a neutral “vitamin-like” supplement, and anyone considering it may benefit from discussing it with a doctor first.
DHEA in Athletes
DHEA appears on the WADA list of prohibited substances; one research group notes that this is because it is assumed that athletes expect a significant increase in testosterone through DHEA administration.[15] For tested athletes, that alone settles the question. Medical use does not automatically change this: prasterone, used in vaginal DHEA products, is the same substance, and a scientific review examining the justification for Therapeutic Use Exemptions (TUEs) in female athletes with adrenal insufficiency concluded that a TUE for DHEA is not justified by a definite health benefit in either primary or secondary adrenal failure.[16]
The available trials also do not show performance benefits. In young men, a single 50 mg dose of DHEA raised serum androstenedione by 150% within 60 minutes but did not affect serum testosterone or estrogen. In an 8-week resistance-training study, men taking 150 mg/day (during six of the eight weeks) gained strength and lean body mass to the same extent as men taking placebo, with no change in free or total testosterone.[17]
In young recreationally trained men and women, DHEA did raise DHEA, DHEA-S, androstenedione, testosterone, DHT and estrone, with a more marked testosterone increase in women. The researchers noted that these hormonal changes can be used as biomarkers of doping.[15] Yet in a double-blind trial of 11 young recreationally trained women, 100 mg/day for 28 days did not improve performance in running-based anaerobic sprint tests or produce an anabolic effect, despite the rise in androgens.[18]
In short, DHEA can change an athlete’s hormone profile enough to matter for anti-doping, without clear evidence that it improves performance. For a broader look at how hormone levels should be read in training athletes, see testosterone in athletes, and for supplement contamination risks, see which supplements may help athletes.
From a clinical perspective, DHEA is classified as a doping substance, and I see no supplementation benefit for athletes. In my view, measuring it rarely leads to any clinical decision in athletes either, and athletes do not need separate DHEA testing. The indications are the same as for sedentary people: there should be a medical reason first. DHEA does not belong in the basic blood tests athletes actually need or in routine periodic check-ups. If an athlete is undergoing a hormonal work-up, DHEA-S may naturally be measured as part of it, just as it would be for anyone else. In my practice, regular training alone is not a reason to change the indications for DHEA-S testing. Athlete status is taken into account in the overall assessment, but it does not create any special testing requirements.
One possible exception is a high-level female athlete who has lost her menstrual periods, for example because of low energy intake or very heavy training. In my view, that situation may call for a broader hormonal work-up, but as a rule athletes are investigated in the same way as the general population. In functional hypothalamic amenorrhea, the Endocrine Society recommends that clinicians obtain total testosterone and DHEA-S levels in patients with clinical hyperandrogenism, so DHEA-S becomes relevant mainly when there are signs of androgen excess.[19] For more on this situation, see RED-S blood work.
Conclusion: DHEA
DHEA levels fall predictably with age, but the idea that restoring them slows aging has not been supported by the controlled trials reviewed here. In older adults, a 2-year randomized trial found no physiologically relevant beneficial effects on body composition, physical performance, insulin sensitivity or quality of life. In postmenopausal women, systemic DHEA did not clearly improve sexual function, and in IVF the latest Cochrane evidence points to little or no benefit.
Two clinically relevant uses discussed here are narrow and medically supervised: a time-limited trial in selected women with primary adrenal insufficiency, and vaginal prasterone for painful intercourse after menopause. For athletes, DHEA is a prohibited substance, and the small controlled trials reviewed here have not demonstrated a performance benefit.
In my own practice, DHEA plays a very small role: I have not seen it used as a medication, and DHEA-S is rarely a first-line test. For typical vasomotor menopausal symptoms, menopausal hormone therapy has a much stronger evidence base and is, in my experience, a far more sensible option than a DHEA product, and for athletes the indications for testing are the same as for anyone else.
For most people, the practical message is simple: DHEA-S concentrations generally decline with age, and a low value in an older adult does not by itself establish adrenal insufficiency or justify starting a hormone supplement.
References
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