Vaginal DHEA vs Oral DHEA for Vaginal Atrophy

For vaginal dryness and painful sex after menopause, DHEA helps when it goes into the vagina, not when you swallow it. A nightly 6.5 mg vaginal DHEA insert (prasterone, sold as Intrarosa) is FDA-approved for moderate to severe painful sex caused by menopausal vaginal atrophy. Trials of DHEA pills in postmenopausal women did not show a significant improvement in sexual function. Compounded DHEA vaginal suppositories put the same hormone in the same place for less money, but the trial results come from the 6.5 mg prasterone insert.

Does vaginal DHEA work for vaginal dryness and painful sex?

Yes, if you are past menopause. Vaginal DHEA (prasterone) is approved to treat moderate to severe pain during sex caused by menopausal changes in and around the vagina. Doctors call those changes vulvar and vaginal atrophy. You use one 6.5 mg insert at bedtime.

It works locally. After you put it in, vaginal cells convert prasterone into estrogens and androgens (the testosterone family of hormones). That increases the number of vaginal cells and brings the vaginal pH back down. After menopause, this lining thins and dries out, which is why sex can start to hurt.

Across three 12-week trials, 436 women used the 6.5 mg insert nightly and 260 used a placebo. Pain during sex fell by 0.46 points more than with placebo on a 4-point scale, and dryness improved too. The reviewers called the advantage over placebo modest.

The benefit lasted. In a year-long open-label study of 154 women, sexual function improved, including lubrication and pain. When reviewers compared results across separate studies, the 6.5 mg insert looked like it may work about as well as 10 micrograms of vaginal estradiol. That comparison is indirect. No trial put the two side by side.

Do DHEA pills help vaginal atrophy or sex after menopause?

The trials say no for sex. A review of 23 randomized trials with 1,188 postmenopausal women found that systemic DHEA, mostly 50 mg pills, did not significantly improve libido or sexual function. The reviewers rated their confidence in that evidence as low.

The same review notes that in one trial, oral DHEA did not improve menopause symptoms on a standard quality-of-life questionnaire. When researchers studied vaginal DHEA in women with vaginal atrophy, the sexual part of that questionnaire did improve.

In one randomized trial of 93 postmenopausal women with low desire, women took 50 mg of DHEA or a placebo every day. Over 26 weeks, the DHEA group had no more satisfying sex than the placebo group. More of the women on DHEA got acne and extra hair growth.

Bottom line: a pill sends DHEA through your whole body, and in the trials it did not help sex. If dryness and pain are the problem, an insert puts the hormone where the problem is.

How do compounded DHEA suppositories, Intrarosa and DHEA pills compare?

Is a compounded DHEA suppository the same as Intrarosa?

It is the same hormone in the same place, but not the same product. Intrarosa's effectiveness was tested in 12-week placebo-controlled trials of the 6.5 mg insert. Compounded versions are made to order in other strengths and with added ingredients such as hyaluronic acid and vitamin E.

The dose range has some support. In a 12-week trial of 218 postmenopausal women aged 42 to 74, nightly vaginal DHEA from 3.25 to 13 mg caused little or no change in blood levels of DHEA and its hormones, and all levels stayed within the normal postmenopausal range. The researchers reported that the signs and symptoms of vaginal atrophy were corrected across that range. Common compounded strengths of 5 and 10 mg fall inside it.

So the trade-off is cost against evidence. Without insurance, the compounded version costs a fraction of the cash price. The approved insert has the trial results behind it, and with commercial insurance and the savings program it may cost as little as $35 a month. Ask your clinical team which strength makes sense for you and whether your insurance changes the math.

Who should not use vaginal DHEA, and what side effects happen?

• Bleeding that has not been checked. Do not start vaginal DHEA if you have abnormal genital bleeding without a diagnosis. It is meant for women past menopause, not for women who are pregnant or breastfeeding.
• Breast cancer history. Your body turns DHEA into estrogen, so tell your clinical team if you have had, or might have had, breast cancer. Intrarosa has not been studied in women with a history of breast cancer.
• Discharge and Pap smear changes. In the trials, 8.3% of women on DHEA reported vaginal discharge versus 3.4% on placebo, and very few stopped because of it. In the year-long safety study, some women had abnormal Pap smear results.
• Condoms, bleeding and check-ins. The Intrarosa insert can weaken latex condoms. Any bleeding after menopause needs to be checked, and your need to continue should be reviewed at least every 6 months.

If dryness or painful sex is getting in the way of the sex you want, take the quiz. Our clinical team will look at your symptoms and history, and can prescribe bioidentical estrogen if it fits your goal.