After interviewing more than 40 researchers and clinicians familiar with DHEA, I have realized that there is a wide range of opinions concerning testing and dosing. This is because the studies on DHEA in humans are still in their infancy; consequently, the practice of DHEA supplementation is still an art rather than a science. (The practice of medicine is also an art. For instance, if a patient goes to a few different doctors complaining of a particular symptom, there’s no guarantee that the diagnosis, lab tests ordered, and method of therapy will be consistent between all the physicians.)
The following are some general approaches the doctors I interviewed use to evaluate a patient before starting therapy with DHEA.
A few physicians will not do any testing before initiating DHEA because they claim the blood tests are expensive and inconvenient, and the results inconsistent. These doctors assume that almost all older individuals are low in DHEA(S) anyway, and will prescribe 5, 10, 25, or 50 mg to see if there are benefits. If so, they will continue the therapy. If side effects occur, they will lower the dose.
The majority of clinicians will check DHEA levels on almost every patient after a certain age, such as forty or fifty, and then recommend DHEA if levels are low. Some are very conservative in their dosages and will start with 5 or 10 mg initially and titrate up if these doses, after a month or so, do not elevate the blood DHEA(S) levels back to youthful levels, or do not provide any noticeable benefits. It seems that experienced physicians are first opting for this conservative low dose approach before moving on to higher doses.
A few physicians think that 25 or 50 mg of DHEA will not lead to anti-aging outcomes and perhaps higher dosages, such as 200 mg, or more, are more appropriate. At least one scientist believes that the DHEA molecule has to be altered, such as being fluorinated, to have a significant influence on longevity.
As you have probably already gathered having read thus far into this book, Medicine does not always speak with one voice. Rational, intelligent physicians, looking at the same data, may come to different conclusions. Even after studying the simple vitamins and nutrients such as C, E, and beta-carotene for two or three decades, there is still no consensus among physicians how they influence health and longevity and if so, what dosages are best. It will take us many more decades to sort everything out.
In the meantime, I have chosen in this book to present to you, the intelligent reader, all the options; and let you, in consultation with your personal physician, decide whether DHEA is appropriate for your unique circumstance, and if so, how much.
There are at least two types of individuals and physicians. The conservatives who want to patiently wait until all the studies are in before starting a course of action, and the optimists who will take a particular supplement based on an educated guess on its purported benefits from the available, limited studies. These optimists claim they don’t have the patience, or life expectancy, to wait a few decades for the definitive results. Where do you fit in?
Here are some answers to questions I was asked while writing this book.
What forms and in what dosages does DHEA come in?
Capsules are the most common form. Compounding pharmacies can make it in any dosage that a doctor recommends, from 5 mg to 200 mg. They can also make it in creams, ointments, and even lozenges.
If you buy DHEA without a prescription, you can generally find it in 10, 25, and 50 mg capsules.
One of the practical problems of taking DHEA orally is that the blood supply from the stomach and intestines goes through the liver before making its way to the rest of the body. The liver is the chemical factory of the body and it makes good sense for it to have “first crack” at the blood supply from the digestive system. Physicians call this the “first-pass effect.”
One of the liver’s functions is to metabolize sterols and steroids. Cholesterol is a common dietary sterol and the liver bundles it into lipoproteins (fatty globules) for distribution to body tissues. If there’s not enough cholesterol in the foods we eat, the liver makes more of it to make up the difference. The liver also metabolizes DHEA. Because of this, DHEA pills that you swallow will first be metabolized by the liver and the amount that reaches the general circulation will likely be less than the ingested dose. The factors that influence absorption from the intestines and metabolism by the liver vary significantly with age and health condition. Testing (before and after DHEAS levels) may be the only way to know for sure how much is making it into the bloodstream.
One of the ways that pharmacists minimize liver metabolism of steroids is to use “micronized” preparations. Micronization is a process that creates tiny particles that can be absorbed from the intestines into the lymphatic system and somewhat bypass the liver. Although micronized DHEA is now available on a limited basis, I have seen only limited data supporting its proposed enhanced bioavailability.
Another possible route to minimizing liver metabolism of DHEA is by sublingual administration. Sublingual refers to under-the-tongue use which allows a significant amount of DHEA to be absorbed into the tiny capillaries of the mouth whose blood supply passes into the general circulation before going to the liver. Sublingual preparations of many vitamins, drugs and herbal extracts are common. Even melatonin comes sublingually. However, I have not seen any research to indicate whether the sublingual approach to DHEA supplementation is preferable to the oral route.
It’s been difficult to predict serum levels of DHEAS based on dosages from oral administration since the absorption rates are often variable.
Our studies indicate that micronized DHEA gets absorbed more easily from the intestinal system by being absorbed through the lymphatic system, partially bypassing the liver. This form of DHEA also does not seem to be converted to testosterone as much thus possibly reducing negative androgenic effects on the prostate gland or lipids (Casson and Buster, 1995).
I am not aware of any data comparing saliva tests versus blood tests. As to the ideal time of dosing, again, I’m not aware of any data to indicate what time of day is best.
Our knowledge with DHEA is where estrogen was about two or three decades ago.
What’s the best dosage to start with?
There is a wide range of opinions on the ideal starting dosage. I am generally conservative in my approach and prefer most medicines to be started at a low dose. For instance, my feeling about melatonin is that 0.3 mg is a safe dose for the first night. This dose is low compared to the fact that most pills in the vitamin stores come in 3 mg. If this low dose is not effective, then it can be increased the following night.
As to DHEA, most of the pills on the market come in 25 and 50 mg. I feel that 5 or 10 mg is a good starting dose. If you can only find the higher dosages, you could open the capsules and take a small portion. Of course, much depends on your initial DHEAS levels, along with your unique rate of absorption and metabolism.
What time of day should I take my DHEA?
The adrenal gland makes lots of DHEA in the early (pre-dawn) morning, and production drops dramatically throughout the day. Most doctors recommend taking DHEA first thing in the morning upon awakening to act in concert with this natural circadian (daily) pattern. Although I am inclined to agree with this, I could not find any data to support morning dosing as being better than other times.
How quickly is DHEA absorbed?
When a group of postmenopausal women were given 1,600 mg of this steroid, DHEA and DHEAS blood levels rose within 60 minutes (Mortola, 1990). There was a rapid rise in androgen levels but a much slower rise in estrogens.
At what age should I get my DHEAS levels tested?
Most physicians who incorporate DHEA replacement therapy in their practice will test people starting in their 40’s. If the levels are found to be low, DHEA is started and the levels monitored every month or two until the desired plateau is reached. From then on, DHEA levels are monitored every few months. Some physicians will also order a regular blood test to check levels of other blood chemistries. Just to be completely safe, a few physicians may even do mammograms and pap tests in women and check a prostate cancer blood test (PSA) in men.
A blood test is the standard and routine way to check levels, however, at least one clinical director of a laboratory, Elias Ilyia, Ph.D., from Diagnostechs Labs in Seattle WA, says he has examined tens of thousands of blood and salivary levels and feels saliva tests are simpler and just as accurate. I could not find any published data to determine which method was preferable.
Over the last ten years serum DHEA and DHEAS testing services have evolved from obscure research tools to readily available clinical tests. Although a lot of doctors have never ordered DHEA(S) levels, more likely than not the laboratory they use for standard blood tests also does testing for this steroid.
How are DHEA levels measured?
When a doctor orders a blood test for you, the results will often come back in micrograms per 100 ml. The laboratory will print on its lab result sheet what the normal ranges are for different age groups. Usually this ranges anywhere from 40 mcg/100 ml which is very low and found in very old people to 400 mcg/100 ml found in young people at their prime. Some labs will also provide the results in nanograms per ml. A nanogram is one thousandth of a microgram.
1 mg = 1000 micrograms = 1,000,000 nanograms = 1,000,000,000 picograms.
Ron von Vollenhoven, M.D., Ph.D., Division of Immunology and Rheumatology, Stanford University Medical Center, CA.
John Buster, M.D., Director, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, has been studying, along with Peter Casson, M.D., the bioavailability of DHEA.