Management of Low DHEA Sulfate Levels in Patients on Testosterone Therapy

Diagnostic Evaluation

Confirm low DHEA sulfate levels with a morning blood test, as a single low reading is insufficient for diagnosis 1
Measure serum luteinizing hormone (LH) levels to help establish the etiology of testosterone deficiency and determine if additional tests are needed 2
Measure serum prolactin levels in patients with low testosterone and low/normal LH levels to screen for hyperprolactinemia 1, 2
Consider pituitary MRI if total testosterone is low with low/normal LH levels, as non-secreting adenomas may be present 1, 2
Evaluate for conditions that may cause secondary hypogonadism and low DHEA levels: obesity, diabetes, pituitary dysfunction, HIV/AIDS, chronic narcotic use, chronic corticosteroid use 1

Exogenous testosterone therapy may suppress endogenous DHEA production through feedback mechanisms on the hypothalamic-pituitary-adrenal axis 1

Monitor for potential side effects including changes in estradiol levels and potential breast symptoms 2, 3
If breast symptoms or gynecomastia develop, measure serum estradiol 3

Adjust testosterone therapy dosing to achieve total testosterone levels in the middle tertile of the normal reference range (450-600 ng/dL) 4
Counsel patients about lifestyle modifications such as weight loss and increased physical activity, which may help improve both testosterone and DHEA levels 4

Monitor PSA in men over 40 years of age who are receiving both testosterone and DHEA supplementation 5
Monitor hemoglobin/hematocrit, as testosterone therapy can increase these values, and the addition of DHEA might potentially enhance this effect 3, 5