DHEA for Vaginal Dryness: How Prasterone Inserts Work

Vaginal DHEA, sold as prasterone (brand name Intrarosa), is a prescription vaginal insert used once a day at bedtime for painful sex caused by menopause-related vaginal dryness and thinning. It is not an estrogen cream, but it is a hormonal treatment: the insert delivers DHEA, which vaginal cells convert into small amounts of estrogens and androgens right where they are needed. Here is how it works, what the research shows, who it may suit and what to ask your doctor.

Key takeaways

Prasterone (vaginal DHEA) is an FDA-approved nightly insert for moderate to severe painful sex due to menopause-related vaginal changes.
It works locally: vaginal cells turn DHEA into small amounts of estrogens and androgens. It is hormonal, but it is not an estrogen product.
The most common side effect is vaginal discharge. It has not been studied in women with a history of breast cancer, so that decision belongs with your oncologist.

By the numbers

In the REVIVE survey (Kingsberg et al., Journal of Sexual Medicine, 2013, 3,046 U.S. postmenopausal women), 44% of women with menopause-related vaginal symptoms reported pain during sex, yet only 11% were using a prescription vaginal therapy.
Vaginal discharge, the most common side effect of prasterone, affected about 6% of women in the 12-week trials (vs. about 4% with placebo).

What is vaginal DHEA (prasterone)?

DHEA (dehydroepiandrosterone) is a steroid made mainly by the adrenal glands. Levels fall steadily with age, and after menopause DHEA becomes one of the main raw materials the body uses to make sex hormones inside individual tissues. Prasterone is the drug name for DHEA made as a medicine.

The vaginal form, prasterone 6.5 mg, was approved by the U.S. Food and Drug Administration in 2016. Its official use is the treatment of moderate to severe dyspareunia (pain during sex) that comes from vulvar and vaginal atrophy due to menopause [1]. Vulvar and vaginal atrophy is part of what clinicians now call genitourinary syndrome of menopause (GSM), the group of dryness, irritation, urinary and sexual symptoms that follow the drop in estrogen.

How does vaginal DHEA work?

DHEA on its own is inactive. Once the insert melts, vaginal cells take up the DHEA and convert it into active estrogens and androgens inside the cells themselves, a process researchers call intracrinology. The exact way this improves vaginal symptoms is not fully understood [1], but in trials it changed the vaginal cell makeup and lowered vaginal pH toward premenopausal levels.

Because the conversion happens locally, blood hormone levels in studies stayed within the normal range for postmenopausal women. That is one reason some clinicians consider it for women who want a vaginal option that is not a direct estrogen product. It is still a hormonal medicine, though, and it is not a “natural” or hormone-free choice.

How it is used

Dose: one 6.5 mg insert placed in the vagina with the supplied applicator, once daily at bedtime [1][2].
Timing: use it at about the same time every night. Do not change the dose on your own.
Discharge: the insert melts at body temperature, so some discharge is expected. Many women wear a panty liner.
Pap tests: tell the person doing your Pap test that you use prasterone [2].

What the research shows

Two 12-week randomized, placebo-controlled trials in postmenopausal women supported approval. Women using prasterone had a greater reduction in pain during sex than those using placebo, and their vaginal cells and pH improved significantly [1]. A longer 52-week open-label study looked at safety over a full year.

The Menopause Society lists vaginal DHEA among the effective prescription options for GSM, alongside low-dose vaginal estrogen and the oral medicine ospemifene [3]. Head-to-head comparisons with vaginal estrogen are limited, so neither one is clearly “better” for everyone. The right fit depends on your symptoms, health history and preferences.

Side effects and safety

Vaginal discharge was the most common side effect: about 6% of women in the 12-week trials (vs. about 4% with placebo) and about 14% over 52 weeks [1].
Abnormal Pap smear results were reported in about 2% of women in the year-long study [1].
No boxed warning. Unlike estrogen products, the prasterone label does not carry a boxed warning [1].
Not for undiagnosed bleeding. It should not be used if you have genital bleeding that has not been checked by a doctor [1].

Vaginal DHEA and breast cancer

Estrogen is one of the byproducts of prasterone, and the drug has not been studied in women with a history of breast cancer [1]. ACOG’s guidance for people with a history of estrogen-dependent breast cancer recommends starting with nonhormonal options and notes that vaginal DHEA may be considered for some patients when those aren’t enough, after discussion with their oncologist [4]. Read more in our guide to vaginal dryness after breast cancer.

Prescription vaginal DHEA vs. DHEA supplements

DHEA is also sold over the counter as an oral supplement. These pills are not the same as the prescription insert: they act throughout the body, are regulated as supplements rather than drugs, and have not been shown to relieve vaginal dryness the way the insert has. Talk with your clinician before taking any DHEA supplement.

How DHEA compares with other options

Vaginal moisturizers and lubricants: the first step for most women with mild symptoms. Moisturizers are used on a schedule for everyday comfort, and lubricants reduce friction during sex. See how to choose a vaginal moisturizer.
Low-dose vaginal estrogen: the most studied prescription option. Compare it with other choices in vaginal estrogen vs. hormone-free options.
Ospemifene: a daily oral, non-estrogen pill (a SERM) approved for painful sex due to menopause.
Pelvic floor physical therapy: helpful when pain has led to muscle tension or guarding.

For a full overview of hormone-free and prescription choices, see our guide on how to treat vaginal dryness and our roundup of non-hormonal alternatives to estrogen.

Who might consider vaginal DHEA?

Prasterone may be worth asking about if you are postmenopausal, sex has become painful, and moisturizers and lubricants alone are not giving you enough comfort. Some women choose it because they prefer a local treatment that is not an estrogen product, or because they want an alternative after trying vaginal estrogen. It is not meant for women who are still having periods or who could be pregnant.

Questions to bring to your appointment:

Is my pain caused by vaginal dryness and thinning, or could something else be involved?
How does prasterone compare with vaginal estrogen for my health history?
Is it covered by my insurance, and is there a lower-cost option?
How long should I try it before we reassess?
Can I keep using my lubricant or moisturizer alongside it?

Our guide on how to talk to your doctor about vaginal dryness has more tips, and our resources page lists directories for finding a menopause specialist.

When to see a doctor

Vaginal DHEA is prescription-only, so a clinician visit is the first step. Make an appointment sooner if you notice:

Any vaginal bleeding after menopause, or bleeding after sex
Pain during sex that is getting worse or keeps you from intimacy
Burning, itching or unusual discharge with an odor, which can signal an infection
Burning with urination, frequent urges or repeated urinary tract infections
Dryness that does not improve after several weeks of using a moisturizer or lubricant

Looking for everyday, hormone-free comfort?

AIRS Advanced Intimate Renewal Serum is a hormone-free cosmetic serum with hyaluronic acid in single-use applicators. It helps moisturize and soothe delicate intimate skin to support everyday comfort. If you use a prescription treatment such as prasterone, ask your provider how a cosmetic serum fits into your routine.

Learn about AIRS

FAQ

Is DHEA (prasterone) a hormone?

Yes. Prasterone is a form of DHEA, a steroid the body makes naturally. Inside vaginal cells it is converted into small amounts of estrogens and androgens, so it is considered a hormonal treatment even though it is not an estrogen product.

How long does vaginal DHEA take to work?

In the clinical trials, results were measured after 12 weeks of nightly use. Some women notice changes sooner, but most clinicians suggest giving it about three months before deciding whether it is helping.

Can I take DHEA supplements instead of the vaginal insert?

Oral DHEA supplements are not the same as the prescription insert. They act throughout the body, are not regulated as drugs, and have not been shown to relieve vaginal dryness the way the insert has. Talk with your clinician before taking any DHEA supplement.

Can I use vaginal DHEA if I had breast cancer?

Prasterone has not been studied in women with a history of breast cancer, and the label notes that estrogen is one of its byproducts. Some oncology and gynecology guidelines say it may be considered after nonhormonal options, but this is a decision to make with your oncologist.

Can I use a moisturizer or lubricant while using vaginal DHEA?

Many women do use a lubricant for intimacy and a moisturizer for daily comfort. Ask your clinician or pharmacist how to space them around a nightly insert.

DHEA (Prasterone) for Vaginal Dryness: How It Works and Who It Suits