Finasteride: medical treatment for hair loss
What is it?
Finasteride has been around since 1992, when it was first introduced as Proscar in the 5mg form to treat men who had problems with urination. It worked by helping to partly shrink the enlarged prostate gland. It was discovered that many men with thin hair who took this drug noticed that their hair loss was greatly slowing down or even reversing, with the appearance of thicker and longer hair. After studies were completed, it was approved in 1998 by the FDA for hair loss and was released in the 1mg form by Merck as Propecia to be taken one tablet daily as their recommended dose.
How does it work?
Finasteride works by blocking DHT. There are two kinds of DHT in the body; one is referred to as DHT1 and the other DHT2. DHT2 is the one that affects hair loss and prostate gland enlargement. Another newer DHT blocker, called Dutasteride (Avodart is the brand name) is available which blocks both DHT1 and DHT2. In our bodies testosterone breaks down into DHT. There is an enzyme called 5-alpha reductase which helps this happen. Finasteride inhibits this enzyme, thus slowing up the production of DHT. In most of the doses that we use in our practice, it reduces DHT2 by around 62-67%. Many people come to us saying they heard it only works in the crown/vertex area (the round bald area in back). This is not true. It works wherever there is residual hair on top of the head. Merck was told by the FDA that, since they did all of their studies on the crown area, they could only say in their ads that it worked here, but in fact it works everywhere on the balding scalp, as long as it isn’t shiny bald with no hair follicles to salvage.
What can I expect in the way of benefits by taking finasteride?
Merck’s 5-year study showed that 48% of men who took finasteride had an increase of hair at the end of 5 years, 42% had no further loss then, and the remaining 10% showed some increase of hair loss. It takes 6-12 months to visibly see the results from the medication, so don’t make an early judgment before 12 months and quit taking it. My own clinical impressions in my own practice are higher than the above statistics. I sense that around 60% of patients show an increase in hair during those first few years, sometimes dramatically.
One of my favorite ways of explaining the value of taking the medication is to imagine two twin brothers who both have a transplant session, but one takes finasteride and the other doesn’t. They both come back to see me 4-5 years later to assess their progress. The brother who was transplanted and took finasteride will have an ADDITION of two things on his head, the newly moved transplanted hairs PLUS the increase in hair mass that most patients get from finasteride. The other brother will present with a SUBTRACTION on his head: the newly moved transplanted hairs MINUS the ongoing loss of native hair on top due to male pattern baldness. There is a huge difference between what those two scenarios look like. Many patients ask me: how long do I need to take this medication? My answer is: “until the next wonderful thing comes along” or until you don’t care that much about losing the rest of your native hair on top. It has its greatest effect and benefit the first five years, but still keeps the rate of hair loss much lower thereafter than if one goes off of it.
What side effects are there?
Around 2.9% of patients will experience some sexual side effects, most commonly either slightly weaker erections or decrease in libido. Stopping or reducing the dose of the drug always makes this return to normal. A very rare occurrence is the appearance of a small lump of breast tissue from local enlargement. This is never cancer and goes away also with stopping the drug. I have seen it once in 12 years and heard of one other case from a colleague. It reduces prostate cancer incidence by 25%. If a man is over 40 and starts on finasteride, we usually recommend getting a PSA prostate cancer screening test first to make sure one doesn’t have prostate cancer. If you have a PSA test later while on finasteride, the measurement at which the test is positive is 50% lower. (In other words, instead of 5 being the borderline for suspicion, it is 2.5. That doesn’t mean you are at any increased risk for the disease. It just has a slight affect on the chemicals that are measured.). I have prescribed it to over 800 men over the past 15 years and have only had around 5-6 tell me of any side effects that required a dosage change or stoppage of the medication. I realize that some men just don’t want to put any medicine in their body and we respect that. In the past year or two there has been some buzz on the internet that some patients might experience permanent sexual side effects as a result of taking finasteride. There is no scientific proof for this presently, and we feel that class-action lawyers are feeding on this, as there obviously is a fairly good percentage of men over 50 who do have sexual erectile dysfunction, and they are trying to hit the “deep pockets” of the Merck pharmaceutical company to say the two things are related, when there has been virtually no cause and effect noted in the past 15 years’ experience by hundreds of hair transplant physicians. I urge you to read our more detailed pages that follow concerning patient information on finasteride.
How do I take the medication?
Both the 1mg and the 5mg form of finasteride are now available in generic form. For the past five years we have been having our patients get the 5mg tablets and use a “pill cutter” (Wal-Mart has a good one for $3.17, last I looked) to cut the tablet into quarters. Some of these tablets are round and some are oblong. The round pill only needs to be cut in half, and then can be made into quarters with your fingers. The oblong one requires the pill cutter for both divisions. Patients under 30 we have take ¼ tablet every other day, and patients over 30 generally we relax the dose to Mon-Wed-Fri only. The medication is in the body for a good 3 days, so daily dosage is overkill in my opinion. Some older men, in order to minimize the chance of side effects, we sometimes will have them get the 1mg tablets and take ½ tablet every other day, but that’s only a small percentage of our patients. We usually prescribe 30 pills at a time and give you refills. Each pill covers you for 8-10 days, so it is fairly economical, probably costing no more than 10 cents a day. Call our office if your prescription runs out. We are happy to see you every 1-2 years to judge your progress and review things. If you are a current transplant patient, there is no charge for such visits. If you are only being treated medically, we do make a small charge after the initial free consultation.
Why don’t you prescribe dutasteride instead of finasteride for me?
While dutasteride suppresses DHT around 95%, I currently don’t recommend its use for hair loss. My reasons are as follows: It is not FDA approved for hair loss treatment. It suppresses not only DHT2, but also DHT1, which is found in significant amounts in the human brain, and we don’t know what that does to a person taking it over many years. I’m a believer that most chemicals in our body are there for a purpose for our body to work right and am a little nervous about knocking out 95% of an important hormone.
Michael Beehner, M.D.
Additional Patient Information on Finasteride
Basic Information: Finasteride will help maintain your hair, but over a long period of time, further hair loss may still occur. In 1992, Finasteride was approved by the FDA to treat prostate gland enlargement, and approved by the FDA to treat male hair loss in 1997. Finasteride is in the class of drugs called 5 alpha reductase inhibitors, which prevent the conversion of testosterone to dihydrotestosterone (DHT). In men DHT promotes genetic hair loss and benign enlargement of the prostate, which generally begins after the age of 50.
The PSA Blood Test: Finasteride can affect a PSA blood test, a screening test for prostate cancer. Because it shrinks a man’s prostate gland, it will lower the PSA level by about 50%. Whenever you have a PSA test performed, always advise your doctor you are taking Finasteride.
Prostate Cancer: There have been many reports associating Finasteride with prostate cancer. Data was gathered from a 7-year study involving over 18,000 men, which showed a slightly higher incidence of aggressive forms of prostate cancer in the Finasteride group compared to the placebo group, 1.8% (Finasteride) vs. 1.1% (Placebo). Finasteride was also found to be protective against the early forms of prostate cancer. This data is very difficult to analyze, because on one hand it showed a reduction of early prostate cancers, and on the other hand, it showed a slight increase of aggressive prostate cancers. Many urologists feel this was the result of an increased sensitivity of the prostate biopsy test to finding the more aggressive tumors, because the Finasteride prostates being tested were smaller in size. Regardless, if you are on Finasteride, all men over 50 should have a yearly rectal exam for prostate cancer screening.
Breast Cancer: Very rare cases of male breast cancer have been reported in men using Finasteride. The relationship between long term use of Finasteride and male breast cancer is currently unsubstantiated. Because of the rarity of male breast cancer, we recommend routing self-breast exams in men to check for lumps, bumps, pain or nipple discharge.
Sexual Adverse Events: There is much clinical data derived from various studies that consistently demonstrate Finasteride tablets will have about a 2% incidence of sexual adverse events, such as decreased libido, difficulty in achieving an erection, and a decrease in the amount of semen produced. In these studies the side effects stopped not only in men who discontinued Finasteride, but also in most who continued taking the drug. Since the initial studies began, there have been reports of erectile dysfunction that continued after stopping the drug. The validity of these reports and the medical explanations for this are not known. (See further comments to follow, on “Key Messages about Finasteride related to sexual side effects”)
Rare Side Effects: *Breast tenderness and enlargement *Allergic reactions *Depression *Testicular pain
Donating Blood: Patients on Finasteride should not donate blood because the blood can then be potentially given to females in pregnancy. No females of child bearing age should ever take Finasteride.
KEY MESSAGES ABOUT FINASTERIDE AND CURRENT CONTROVERSY OF POSSIBLE PERMANENT SEXUAL SIDE EFFECTS (Position paper from the I.S.H.R.S.)
*As two of the 900 physician members of the International Society of Hair Restoration Surgery (ISHRS), the health and well-being of our patients is our utmost concern. That’s why we feel that recent anecdotal reports of sexual dysfunction by some Propecia (finasteride) users who have used the drug to treat hair loss need to be addressed, as our collective experience with prescribing this drug to millions of patients around the world does not support these claims.
*Members of the ISHRS devote an average of 72% of their practices to medically and surgically treating hair loss (100% for the two of us!) While we firmly believe that any adverse events experienced by men taking Propecia for hair loss should be taken seriously and discussed with a physician, we do not believe that anecdotal reports should define the proven safety and effectiveness of a drug that we know from our own practices has helped countless men combat hair loss.
*From a scientific standpoint, there are no evidence-based data substantiating the link between Propecia and persistent sexual side effects in the numerous, double-blinded, placebo controlled studies conducted evaluating the use of Propecia for hair loss. As such, we owe it to our patients to address valid concerns in a scientific manner and to clarify any misleading reports so that men can make informed choices regarding the use of this medication.
*Propecia (Finasteride) is the only oral medication approved by the U.S. Food and Drug Administration for the treatment of hair loss in men. Since receiving FDA approval in December of 1997, 20.5 million and 6.7 million patient-years of exposure using Proscar (5mg form) and Propecia (1mg) respectively are recorded with a low adverse event profile. This is the most current and reliable data available until further studies are conducted.
*One recent article published in the Journal of Sexual Medicine, “Persistent Sexual Side Effects of Finasteride for Male Pattern Hair Loss,” fails to define the high incidence of sexual dysfunction in the general population for men not taking finasteride. In fact, one study suggests that the incidence of erectile dysfunction in the general population may be as high as 49% in men ages 40-88 (Archives of Internal Medicine,2006 Jan 23:166o(2): 213-9).
*As the world’s leading medical authority on hair loss and hair restoration, the ISHRS has called on the medical communities of dermatologists, hair loss physicians, urologists, endocrinologists and sexual medicine specialists to join in a colloquium to share all data and experiences with finasteride in a fact-based manner. |
