Already a number of years ago, a worldwide survey of IVF centers revealed that approximately half were supplementing selected patients with dehydroepiandrosterone (DHEA). The number must be even bigger by now. Though studies on how widely DHEA is used in fertility practice are lacking, anecdotal evidence suggests that utilization of DHEA has been skyrocketing, though not exclusively because physicians are prescribing it more. At least in the U.S., where DHEA is considered a dietary supplement and, as such, is available without prescription, a significant component of increasing DHEA utilization in female infertility comes from self-medication of patients.
Though CHR basically initiated the worldwide utilization of DHEA in infertile women through a large number of groundbreaking studies, it was never CHR’s intent to encourage such self-medication. Indeed, these pages and other content on CHR’s website have always made the argument that DHEA is a hormone and, like all other hormones, whether under prescription requirement or not, should be treated as a hormone and, therefore, at least when it comes to infertility treatments, should be only taken under physician supervision.
The reason is not that DHEA supplementation has dangerous side effects; DHEA, indeed, does not have any really dangerous side effects at the dosages usually recommended for selected women with infertility. Moreover, since DHEA has rather poor affinity to the androgen receptor, it is not a very effective androgen on its own and, therefore, even if its levels are a little high, one cannot expect any significant side effects. Because our bodies make testosterone from DHEA, it is prescribed in an effort to raise testosterone levels, especially in ovaries. Ovaries must have good testosterone levels in order to produce good egg numbers and quality.
While giving a patient testosterone directly would flush all organs in her body with the same level of testosterone, if testosterone is raised via DHEA administration, every organ, the ovaries included, takes only as much DHEA out of circulation as needed for that specific organ, as different organs require different levels of testosterone. Supplementation with DHEA, therefore, has fewer side effects than direct supplementation with testosterone and is preferable.
The side effect female patients mention most frequently is actually a positive one: They frequently feel more vigorous (sometimes even a bit more “aggressive”) and experience a better sex-drive, general libido and feeling of better general sexual health in all aspects (for more on this subject, see also the article on DHEA for improved sexual female health in this issue of the VOICE).
Negative DHEA side effects we most frequently hear about are overall rare and relatively mild. They include oily skin, acne and hair loss. All three are immediately reversible with lowering of DHEA dosage (usually 25 mg three times daily) or discontinuation of supplementation. Other, even rarer side effects are also reported, and we recommend reading the package insert of the DHEA product you purchase. We also recommend that you carefully choose the DHEA product you purchase since the literature has demonstrated that many DHEA products do not necessarily contain what their label claims.
As already mentioned before, since DHEA is a hormone and our bodies make testosterone from DHEA, supplementation with DHEA can also interact with other medications in many different ways. A small portion of DHEA is also converted to estrogen. DHEA, therefore, should not be used if increases in estrogen levels are contraindicated, as in, for example, certain breast cancer patients.
These are most of the reasons why CHR strongly recommends that DHEA only be taken under physician supervision. Another reason is that, unfortunately, DHEA is frequently taken incorrectly. For example, DHEA will have hardly any effects if taken only during IVF cycles. Because good testosterone levels are important at the so-called small growing follicle stages, and these follicles still need ca. two months before they become available for retrieval in an IVF cycle, in order to realize full DHEA benefits, supplementation must be started at least 6-8 weeks before IVF cycle start.
Obviously, DHEA supplementation should be only used if testosterone levels are relatively low. The lower they are, the more is such supplementation needed. It does, on the other hand, make absolutely no sense to supplement with DHEA if androgen levels are normal or even high. Medical supervision is, therefore, really important and testosterone levels should be monitored together with levels of sex hormone binding globulin (SHBG), which usually goes the opposite direction from testosterone and can be used as a barometer in determining whether testosterone has reached a normal range.
This is a part of the April 2019 CHR VOICE.
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
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