Elevated DHEA in Women: Diagnostic and Management Considerations

Primary Pathological Causes

The National Comprehensive Cancer Network recommends that an androgen-secreting adrenal tumor be ruled out in a 50-year-old woman with elevated DHEA, particularly if accompanied by virilization symptoms, with urgent imaging using adrenal CT to assess for malignancy 1, 2
Androgen-secreting adrenocortical tumors present in approximately 60% of cases with evidence of adrenal steroid hormone excess, with or without virilization, and can induce hirsutism, deepening of the voice, and oligo/amenorrhea in women 1, 2
Adrenocortical carcinomas show peak incidence in the fourth to fifth decades of life with a female-to-male ratio of 1.5:1 2
Malignancy should be suspected if the tumor is larger than 4-5 cm, has irregular margins, is lipid-poor, does not wash out on contrast-enhanced CT, or secretes more than one hormone 1, 3

The National Comprehensive Cancer Network suggests evaluating for hyperandrogenism signs, including hirsutism, acne, menstrual irregularities, androgenetic alopecia, and clitoromegaly, as part of the clinical assessment 4
Assess for Cushing syndrome features, such as weight gain, proximal muscle weakness, hypertension, psychiatric disturbances, centripetal obesity, purple striae, and buffalo hump, during the clinical assessment 1, 2
Obtain a comprehensive hormone panel, including free and total testosterone, DHEAS, androstenedione, LH, and FSH, as part of the laboratory evaluation 4
Measure morning ACTH and cortisol to distinguish adrenal from pituitary sources, and check electrolytes to assess for concurrent aldosterone excess 1, 2

The National Comprehensive Cancer Network recommends laparoscopic adrenalectomy for benign adrenal tumors when feasible, and open adrenalectomy for suspected malignant tumors >4-5 cm with irregular margins or heterogeneous appearance 3
Ketoconazole (400-1200 mg/day) can inhibit adrenal steroidogenesis and reduce DHEA production for functional excess, requiring regular monitoring of DHEA/DHEAS levels and liver function tests 3

Do not delay imaging in the presence of rapidly progressive virilization symptoms, as this suggests malignancy, according to the National Comprehensive Cancer Network 1, 2