Enda Monitor Dhea Replacement

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name: enda-monitor-dhea-replacement
description: Suggests monitoring DHEA replacement in women with primary adrenal insufficiency (PAI) by measuring morning serum DHEAS levels before the daily dose, targeting the mid‑normal range. Consider when evaluating low libido, depressive symptoms, or low energy despite optimized glucocorticoid and mineralocorticoid replacement.
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# Monitor DHEA Replacement via Morning DHEAS Levels Targeting Mid-Normal Range

## STEP 1 — Gather Information
Collect: confirmed PAI diagnosis, female sex, current DHEA dose and timing, symptoms prompting review (libido, mood, energy), morning serum DHEAS drawn pre‑dose, age‑sex specific reference range for DHEAS (mid‑normal), and any concomitant medications affecting adrenal androgen metabolism.

## STEP 2 — Rule In / Rule Out
Rule in: woman with PAI receiving DHEA replacement and presenting with low libido, depressive symptoms, or low energy despite optimized glucocorticoid/mineralocorticoid therapy. Rule out: male patients, those not on DHEA replacement, or absence of the aforementioned symptoms.

## STEP 3 — Classify or Stratify
Stratify by morning DHEAS level relative to age‑sex matched reference: below low‑normal, within mid‑normal (target), or above high‑normal.

## STEP 4 — Decide
If DHEAS < mid‑normal: consider increasing DHEA dose; if DHEAS > mid‑normal: consider decreasing dose; if DHEAS within mid‑normal: maintain current dose and reassess symptoms in 6–12 weeks.

## Clinical Guardrails / Mimics / Pitfalls
Do not draw blood after DHEA ingestion; avoid random timing; do not rely on symptoms alone without lab confirmation; ensure assay uses age‑specific ranges; do not substitute unsulfated DHEA for DHEAS; be aware of assay variability across labs.

## Concrete Clinical Example
A 45‑year‑old woman with PAI on hydrocortisone 20 mg/day, fludrocortisone 100 µg/day, and DHEA 25 mg morning reports low libido and fatigue. Pre‑dose morning DHEAS is 80 µg/dL (lab female 20‑30 yr range 150‑350 µg/dL; mid‑normal ≈250 µg/dL). Below target, DHEA increased to 50 mg; repeat DHEAS in 6 weeks.

**Source:** Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, Section 3.13, DOI:10.1210/jc.2015-1710
> **TODO:** consider adding scripts/calc.py for the enda-monitor-dhea-replacement calculator