DHEA

DHEA is short for dehydroepiandrosterone, a hormone the body makes and converts into other hormones. The British Menopause Society's guidance on testosterone notes that DHEA is turned into testosterone in the brain, which is one reason it comes up in discussions about desire.

It is used in menopause care in two quite different ways:

• As a vaginal treatment, under the name prasterone. The Pakistan Menopause Society lists prasterone among the hormones used in vaginal treatments (section 5.5), and NICE NG23 includes it in its recommendations for genitourinary symptoms.
• As a tablet, swallowed. This is the form the British Menopause Society says needs more research.

Which one someone means when they say DHEA makes all the difference to what the guidance says about it.

Vaginal prasterone

Genitourinary syndrome of menopause, or GSM, is the medical name for the vaginal, vulval and bladder changes that the Pakistan Menopause Society links to falling estrogen: dryness, burning, pain with sex, urgency and repeated urine infections among them (section 1.5.2 and Table 1).

NICE NG23 sets out an order for these symptoms. It recommends offering vaginal estrogen (1.5.5), and says moisturisers and lubricants without hormones can be used alongside it or instead of it (1.5.8 and 1.5.9). Vaginal prasterone comes after those: NICE says it can be considered if vaginal estrogen, or the non-hormonal moisturisers and lubricants, have not worked or have not suited (1.5.10).

The British Menopause Society's statement on GSM also gives both options. For women who can use hormones, it calls replacing the missing hormone the logical approach, and it says moisturisers have been shown to relieve dryness as well as vaginal estrogen.

Oral DHEA

The British Menopause Society's guidance on testosterone says oral DHEA is more commonly used than testosterone in some countries. It then says further research is needed before it can be recommended, because clinical trials and meta-analyses have not definitively proven a benefit for sexual function in women with normal adrenal function.

NICE NG23 does not mention oral DHEA. It does have a general line about hormone products that are not regulated: "Explain to people with menopause-associated symptoms that the efficacy and safety of unregulated hormone preparations are unknown." (1.4.5)

For low libido, the treatment the guidance discusses is testosterone, considered after HRT: NICE says testosterone can be considered for low sexual desire if HRT alone has not helped (1.5.25). More on that in testosterone therapy for women.

If vaginal dryness, pain with sex or low desire are affecting your life or your marriage, that is reason enough to see a doctor. These are among the symptoms the Pakistan Menopause Society says many women may not mention unless they are asked respectfully and in private, so you may have to raise them yourself.

Before starting DHEA in any form, bought or prescribed, talk to a doctor. It is a hormone, and whether it suits you depends on your history and anything else you take. If a clinic or a shop offers it to you, it is fair to ask which form it is, what it is meant to treat, and what the evidence says.

Desire and comfort in marriage matter, and they are among the hardest things to raise with a doctor, or at home. Women ask how to talk about it with a husband, and what their faith says about it. That second question belongs with a qualified scholar you trust.