A decline that starts earlier than you might think
The picture Dr Stéphane Résimont describes is a familiar one: a man aged 45 or 50, tired, with hot flushes, less reliable erections, who gets up at night to urinate, and who is told that this is normal at his age. In his view, this patient often has a DHEA and testosterone deficiency, and one rarely comes without the other.
This decline starts early. Dr Résimont speaks of pre-andropause from around the age of 35, and he points out that a male work-up is not limited to these two hormones: progesterone, cortisol, T3 and sometimes oestradiol also come into play. He cites the case of a 35-year-old man with osteoporosis, who carried a genetic aromatase anomaly that left him unable to produce oestrogens. In men as in women, oestradiol has a role to play, particularly for bone.
Recognising the clinical picture
The signs suggestive of an androgen deficiency are many and often scattered: persistent fatigue, hot flushes, weight gain, lower libido and erectile problems, frequent urination, memory problems, poorer sleep quality.
Dr Résimont insists on an aspect he calls the ailments of the brain: men who become indecisive, change their minds, lose their boldness and let others walk all over them, at work as in their relationship. Faced with this picture, he suggests considering a lack of testosterone rather than concluding that it is stress or age.
For DHEA, he notes a few typical signs: fat settling around the belly, muscles that slacken (the triceps is a good indicator), lower libido, and in women thinning underarm and pubic hair.
DHEA, much more than a prohormone
DHEA has long been presented as a simple precursor. Dr Résimont describes, on the contrary, a hormone with multiple modes of action, genomic and non-genomic, with many receptors throughout the body. In the steroid chain, it sits between pregnenolone and testosterone, itself a precursor of oestrogens through aromatisation.
What DHEA does
- Balance with cortisol: long-term corticosteroid therapy slows the adrenal production of DHEA. In his view, this drop should be monitored and compensated for, or it risks leading to muscle wasting, bone loss, or even diabetes.
- Mitochondria and metabolic ageing: DHEA contributes to energy production, hence its old nickname of the hormone of youth.
- Brain: neuronal plasticity, stress modulation, an effect on mood, particularly in women.
- Immunity: in older people, low DHEA is associated with a poorer response to vaccination.
- Bone: for Dr Résimont, osteoporosis is multifactorial. DHEA, testosterone, oestrogens, progesterone, growth hormone, zinc and magnesium are all involved, and calcium alone does not address the problem.
DHEA does not replace testosterone in men
This is a point he comes back to several times. In women, DHEA raises testosterone in most cases. In men, the conversion exists but remains minimal: "a drop of water in an ocean", since testosterone comes mainly from the testicles. Giving a man a high dose of DHEA in the hope of raising his testosterone does not work.
What holds it back, what supports it
Among the factors that lower DHEA, he cites cereals, alcohol, caffeine, fizzy drinks, milk and long-term corticosteroids. On the dietary side, he recommends a sufficient protein intake, around 1.2 to 1.5 g per kilo of body weight, or about 120 g a day for a man weighing 80 kg, a threshold few patients reach. For practitioners who do not prescribe hormones, he mentions shilajit, an organic extract from the Himalayas to which he attributes androgenic effects.
The markers he uses
- Target level: DHEA above 350 to 400, i.e. above 11 in micromoles per litre, whether the patient is 20, 40, 60 or 80. He draws on a review by Dr Thierry Hertoghe that associates low levels with higher cardiovascular and metabolic risk.
- Time to effect: ten to fifteen days or so on libido, a few months on body composition.
- Follow-up test: ask the patient to take DHEA in the evening rather than the morning for the two days before the blood test, for a more accurate reading of the level.
- Doses mentioned in the Q&A: often 35 to 50 mg in men, 10 to 25 mg in women. In women, excess shows up as acne, oily skin or hair loss; he then switches to 7-keto-DHEA, which is less potent, at a higher dose.
Testosterone, a pillar of muscle, bone and brain
For Dr Résimont, nutrition remains the foundation, correcting deficiencies the second level, and hormones the icing on the cake. He refuses to take on the hormonal care of a patient who has not first reviewed his diet. Once this framework is in place, he details what testosterone supports:
- Muscle: without sufficient testosterone and DHEA, morning squats are not enough to maintain thigh volume. A vitamin B3 or Q10 deficiency can also hold back the maintenance of muscle mass.
- Bone and metabolism: bone density, fat mass, insulin resistance, metabolic syndrome.
- Sexuality and fertility: libido and erection, with nothing automatic about it. Low testosterone does not always abolish libido, and when erection is absent, a circulatory cause should always be considered.
- Brain and mood: memory, irritability, depressive mood. In many patients, he observes an improvement in mood within fifteen days of optimising levels.
Thresholds adjusted to weight
Dr Résimont reasons according to body build. A man of 80 kg and 1.80 m should, in his view, be above 8,000, a man of 40 kg above 4,000, in the units of his reference laboratory. In an overweight patient, he bases himself on the dry weight the patient should have, not on his actual weight. His working range is between 5,000 and 10,000.
Testosterone and cardiovascular risk
He cites a consensus of urologists, including Abraham Morgentaler and Professor Claude Schulman, former head of the urology department at Erasme Hospital: as long as levels stay within physiological values, outside doping, testosterone does not increase cardiovascular risk. He also presents data associating low testosterone with more severe coronary disease.
Aromatisation, DHT and oestradiol: finding the right balance
Testosterone does not stay in a single form. It can be converted into oestradiol by aromatase, an enzyme abundant in adipose tissue, or into dihydrotestosterone (DHT) by 5-alpha-reductase.
Oestradiol
The greater the fat mass, the more marked the conversion into oestrogens. After starting testosterone supplementation, Dr Résimont rechecks oestradiol a few weeks later. Too much oestradiol promotes gynaecomastia, prostatic hypertrophy and cardiovascular risk; too little exposes the patient to osteoporosis and lower libido. He aims for oestradiol between 15 and 35 pg/mL in men.
DHT
DHT that is too high goes hand in hand with androgenic alopecia, marked hair growth and a less favourable prostate terrain. Conversely, he reports a recent series of patients who had testosterone appropriate for their weight, but insufficient DHT and all the symptoms of a deficiency. Hence his advice: when symptoms persist despite good testosterone, measure DHT, which is assessed via one of its metabolites. He aims for 15 to 18 for this marker.
Zinc and progesterone
Low zinc, in his view, goes with less testosterone, more aromatisation and more DHT: zinc therefore needs to be raised. Progesterone also slows both conversions. He ideally aims for progesterone above 1.2 in men, and cites its value in the evening when oestradiol is too high and sleep is disturbed.
Hormonal decline in younger people
Dr Résimont sees a clear change in his practice. For a long time, he never gave DHEA to a patient under 40; today he prescribes it every week, including to young people aged 18 to 20, and sees teenagers who lack testosterone. He attributes this to pollution by endocrine disruptors, notably those from plastics, which have anti-androgenic effects and slow testosterone synthesis. Oestrogens, whether endogenous or from this pollution, also inhibit the production of LH and FSH, with repercussions on spermatogenesis.
The prostate, in the light of the studies he cites
This is one of the most frequent fears, among patients and practitioners alike. Dr Résimont recalls the origin of the idea that testosterone promotes prostate cancer: the work of Charles Huggins in 1941, which earned its author a Nobel Prize, and which he considers called into question today. He draws in particular on the filmed talk by Professor Claude Schulman, shown during the conference.
- Low testosterone does not protect against prostate cancer, and tumours are reportedly more aggressive when initial testosterone is low.
- In the studies he presents, men with prostate cancer have on average lower testosterone than others.
- Well-managed replacement therapy does not increase prostate volume or urinary symptoms, provided aromatisation is monitored.
- Prostate risk also depends on the terrain: insulin resistance, abdominal obesity, chronic inflammation.
For benign hypertrophy, he aims for normal DHT and oestrogen levels and well-maintained testosterone, and mentions saw palmetto and nettle root in herbal medicine, whose effects seem real to him but less marked than those of 5-alpha-reductase inhibitors. On the question of supplementation after care for prostate cancer, raised in the Q&A, he describes a practice that remains debated and that is a medical decision made with a fully informed patient.
Supporting testosterone production
Before any hormone, Dr Résimont draws on several levers:
- Diet: a diet rich in protein, less sugar and less alcohol.
- Zinc, which supports testosterone production and limits its conversion into oestrogens and DHT.
- Vitamins A and D, which he describes as two stimulants of testosterone. The link between low vitamin D and low testosterone is, in his view, widely published; he aims for vitamin D above 80 ng/mL, combined with vitamin K2.
- Magnesium and boron. Boron lowers SHBG, the protein that carries testosterone, and so releases active testosterone. He suggests thinking of it whenever SHBG is high.
- The digestive terrain: SIBO or dysbiosis can lead to malabsorption of zinc, magnesium, B vitamins, vitamin D and cholesterol, the precursor of steroids.
- Moderate physical activity: overtraining, on the contrary, makes testosterone drop, as he observes in some top-level athletes.
- Herbal medicine: he cites in particular tribulus, fenugreek, saw palmetto, African plum, nettle root, shilajit and cordyceps, and prefers combining several plants rather than using just one.
Also to watch: high prolactin, which lowers testosterone, and the factors that promote aromatisation, such as excess fat mass, alcohol and hops. Conversely, he cites broccoli for its value for oestrogen balance in men.
The method: clinical picture, lab tests, trial, follow-up
Dr Résimont says it again and again: the clinical picture comes first. You first need to talk at length with the patient about his symptoms; the blood test then confirms what the history led you to suspect, then a therapeutic trial shows whether the symptoms ease, with a lab check to measure the effect.
The work-up he suggests
- Total testosterone in men (free testosterone in women), DHEA, oestradiol, progesterone and DHT.
- Zinc, vitamin D, red blood cell magnesium, Q10 and T3.
- For cortisol, a profile over the day rather than a single morning measurement.
He does not use 24-hour urine tests, which give him nothing in practice, and considers that too many tests are sometimes requested while the essentials are forgotten.
When hormones come into play
When testosterone supplementation is decided on, he prefers transdermal forms, with injections as a second option. A lab check is systematic a few weeks after starting: testosterone, DHT and oestradiol. He also points out that testosterone supplied from outside suppresses LH through negative feedback, which can reduce testicular volume and disrupt fertility; in a patient who wants to have a child, lowering the dose, or even stopping it for a few weeks, should be considered.
DHEA and testosterone are hormones: prescribing them is a matter for the doctor and their regulatory status varies from country to country.
What the practitioner takes away
The decline of DHEA and testosterone is not just a question of libido. It affects energy, muscle, bone, metabolism, mood and cognition, and it often starts earlier than you might think. For Dr Résimont, spotting it relies on careful clinical listening, a targeted work-up read with functional markers, and a clear order of care: diet, deficiencies, then hormones if necessary.
Watch the webinar
The full replay (in French) is available below. The last part is devoted to practitioners' questions: DHEA doses in men and women, fertility, pregnenolone, testosterone after prostate cancer and DHEA at menopause.
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