What is vaginal DHEA and who might consider it?
Vaginal DHEA (prasterone) is a low-dose prescription treatment placed inside the vagina. Within the vaginal cells it is converted into small amounts of oestrogens and androgens, helping restore moisture, elasticity and comfort in genitourinary syndrome of menopause (GSM). It can be an option if non-hormonal care is not enough, and in some cases when local oestrogen is not preferred—after personalised discussion. Educational only. Results vary. Not a cure.
Detailed Medical Explanation
What is vaginal DHEA and who might consider it? Vaginal dehydroepiandrosterone (DHEA, generic name prasterone) is a pessary used locally in the vagina to relieve symptoms of genitourinary syndrome of menopause (GSM)—dryness, burning, itching, micro-tears and discomfort with sex (dyspareunia). DHEA is an endogenous precursor hormone. When placed intravaginally, it is converted inside the vaginal cells to very small amounts of oestrogens (e.g., estradiol/estrone) and androgens (e.g., testosterone), which act locally to mature the epithelium, improve blood flow and restore a healthier pH and microbiome. Because conversion is largely intracrine (within cells), whole-body levels remain low at licensed doses.
How it compares with local oestrogen. Both vaginal DHEA and local oestrogen target the same GSM biology—thinner epithelium, raised pH and reduced lubrication—aiming to improve day-to-day comfort and intimacy. Trials and guideline summaries suggest comparable symptom relief for many users; choice often depends on preference, tolerability and clinical context. Some people prefer DHEA if they wish to avoid oestrogen-labelled products, while others prefer local oestrogen for its long track record and multiple formats (cream, tablet/pessary, ring). In practice, clinicians individualise: start with non-hormonal basics, then add either local oestrogen or vaginal DHEA, sometimes switching if response is suboptimal.
Who might consider DHEA first or next? 1) Those with persistent GSM symptoms despite a consistent vaginal moisturiser routine (many prefer hyaluronic acid gels) and the right personal lubricant. 2) People who prefer an option not labelled as oestrogen. 3) Selected cancer survivors after shared decision-making with oncology and menopause teams—particularly when symptoms remain intrusive after non-hormonal care and local oestrogen is not preferred; approaches differ if taking tamoxifen versus an aromatase inhibitor (specialist advice is essential). 4) Those who experienced irritation with a previous local therapy and wish to try an alternative.
How it is used and when it helps. DHEA pessaries are inserted nightly in a short “loading” period, then continued at the lowest effective maintenance (for example, nightly or alternate nights depending on product guidance). Early symptom relief (less “sandpaper” friction, reduced stinging with urine on delicate skin) often appears within 3–4 weeks, with fuller improvements in moisture, elasticity and comfort by 8–12 weeks. Like local oestrogen, many people remain on a simple maintenance plan because GSM is long-term; stopping usually leads to gradual symptom return, and restarting recaptures benefit over weeks.
Combining with non-hormonal care. Foundations remain key: rinse with lukewarm water; use a bland emollient as a soap substitute externally; avoid fragranced washes/wipes; wear breathable underwear; and schedule a vaginal moisturiser several times weekly. For intimacy or examinations, use a suitable personal lubricant—water-based (versatile, condom-friendly), silicone-based (long-lasting glide for dyspareunia) or oil-based (rich feel but may degrade latex condoms and some toys). If pain has led to pelvic floor guarding, pelvic health physiotherapy and, where helpful, psychosexual therapy can restore confidence and comfort.
Safety and cautions. DHEA is local, but discuss use if you have a history of hormone-sensitive cancer; decisions should be made with your oncology and menopause clinicians. Seek assessment before starting or continuing if you have post-menopausal bleeding, ulcers/rapid skin change, malodorous green or grey discharge, fever, severe pelvic pain, or visible blood in urine—these point away from straightforward GSM and towards infection, dermatoses (e.g., lichen sclerosus), UTIs or other causes needing specific care. If you use latex condoms, check lubricant compatibility. Branded products may be mentioned in clinic (e.g., Intrarosa®—® belongs to its owner).
Where this fits in your overall plan. Most people respond well to a stepped pathway: non-hormonal foundations → add local oestrogen or vaginal DHEA if symptoms affect quality of life → review at 6–12 weeks → maintain the minimum effective schedule. For a plain-English overview of what treatment involves and how steps are sequenced, see our clinic guide.
Trusted sources and further reading. The NHS provides practical information on vaginal dryness. The UK’s NICE menopause guideline (NG23) supports offering moisturisers/lubricants and considering local therapies for GSM when symptoms affect quality of life. Prescribing details for prasterone and other local treatments are in the British National Formulary (BNF). Evidence syntheses of local therapies appear in the Cochrane Library, and peer-reviewed overviews of GSM mechanisms and intracrine DHEA action are indexed on PubMed.
Clinical Context
Who may suit DHEA? People with moderate GSM whose main problems are persistent dryness, stinging at the entrance, micro-tears, or dyspareunia despite good moisturiser/lubricant routines; those preferring a non-oestrogen-labelled option; and selected patients after cancer treatment following specialist advice. If penetration remains sharp at the entrance despite better hydration, consider pelvic floor over-activity or vestibulodynia—physiotherapy and paced, comfort-first intimacy help.
Who should seek review first? Anyone with post-menopausal bleeding, visible ulcers/white plaques, severe pain, fever, malodorous discharge, or visible blood in urine. Where endocrine therapy (e.g., aromatase inhibitor) is in use, do not start or change local therapy without oncology input. Plan a 6–12-week review to check technique, response and maintenance dosing.
Evidence-Based Approaches
Guidelines emphasise a step-wise pathway. The NICE NG23 menopause guideline recommends information on vaginal moisturisers and lubricants and considering local therapy when GSM affects quality of life; local options include oestrogen preparations and, in appropriate contexts, prasterone (DHEA). Patient-facing advice on symptoms and red flags is available via the NHS. UK prescribing information (indications, cautions, dosing) can be checked in the BNF.
Cochrane reviews report improvements in dryness, soreness, dyspareunia and vaginal pH with local therapies versus placebo. Peer-reviewed summaries on PubMed describe GSM physiology (thinner epithelium, raised pH, loss of lactobacilli) and the intracrine conversion of vaginal DHEA to low-level sex steroids within tissue, supporting symptom relief with low systemic exposure at licensed doses. Together, these sources support a personalised choice between local oestrogen and vaginal DHEA after non-hormonal measures, with periodic review and attention to safety signals.