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Bernstein Medical - Center for Hair Restoration
Hair Restoration Answers

What is your Opinion of Nutrafol?

Q: What’s your honest take on Nutrafol? It is a product my dermatologist has recommended for my hair loss. — N.S. ~ New York, N.Y.

A: The traditional thinking is that that male pattern alopecia (androgenetic alopecia) is due to follicular sensitivity to DHT causing miniaturization and eventual loss of hair. The premise of Nutrafol is that hair loss is multi-factorial with an important inflammatory component and that it is important to address the inflammation as well as the DHT sensitivity.

This is a relatively new and important concept (I would like to stress this point!). However, the big leap is their conclusion: Since hair loss is multi-factorial, then broad, rather than targeted treatments would be most beneficial, and since naturally occurring “phytochemicals” are broader in action than targeted, FDA approved drugs (like finasteride and minoxidil), they should offer benefit in the treatment of hair loss and Nutrafol is the elixir that can accomplish this.

Although this makes sense in concept, there is no scientific evidence that Nutrafol can actually reverse or/mitigate androgenetic alopecia or any other type of hair loss. We need independent, blinded, controlled studies to show that Nutrafol actually works. Until then, it is very difficult to recommend this product and, more importantly, to recommend it over other treatments known to be effective.

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Hair Restoration Research

Study More Accurately Predicts Severe Balding Risk Using New Genetic Profile

What are the chances that I will go bald? How bald will I be? Can I know for sure? These are among the most common questions we get from patients in our hair loss consultations. Despite extensive knowledge about the mechanisms and causes of androgenetic alopecia (common baldness), the answers to these questions have been a bit hazy. New research has sharpened the focus on the genetic mix that results in hair loss and has enabled more accurate predictions. A study published in February 2017 in the journal PLoS Genetics identified over 250 gene locations newly linked to hair loss. Using this information, researchers more accurately predicted severe balding compared to previous methods.

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Hair Restoration Answers

Can Andro Gel Cause Hair Loss?

Q: The last few months my friend and I experimented with andro gel thinking it would make our T levels go up and make our work outs better. We got the andro gel online with no prescription (which I know is really stupid on our behalf). The past couple of months I have been experienced a lot of acne and hair loss. I went to the doctor and confessed and said what I did, and he was very disappointed and lectured me on how dangerous it was and stupid on my behalf – which I totally agree. He told me the rise in testosterone from andro gel contributed to the acceleration of hair thinning and acne. I had mild hair loss prior but the andro gel seem to have accelerated it. The doctor put me on Propecia and gave me some acne cream for the acne. He said the Propecia will undo some of the damage it did for the hair. In your experience, can Propecia reverse some of the damage? I am 28 years old.

A: Your doctor is giving you the right course of action. Testosterone supplements can accelerate hair loss, particularly in those with underlying genetic hair loss. Finasteride 1mg (Propecia) should help you to grow your hair back. You may also want to consider using minoxidil (Rogaine) in addition.

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Bernstein Medical In The News

Fat Cell Discovery An “Important Step” In Understanding Hair Loss

In what might be another illuminating discovery on the inner-workings of hair growth, Yale University scientists have discovered that cells from the fat layer in the skin of mice contribute to the stimulation of hair follicles.

Dr. Bernstein, who was interviewed for the ABC News article, called the findings, “An interesting development in understanding why millions of people go bald.”

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Hair Restoration Answers

Does Scalp Med Prevent Hair Loss By Unclogging Pores?

Q: Scalp Med is supposed to unclog pores. How does this prevent hair loss?

A: The active ingredient of Scalp Med is Minoxidil, which will help reverse miniaturization, the process that causes androgenetic hair loss. Hair loss is not caused by clogged pores, so unclogging them will not prevent going bald. Minoxidil, which is also the active ingredient in Rogaine is over-the-counter so it is a less expensive way to use the active ingredient.

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Hair Restoration Answers

Is Nizoral An Effective Hair Loss Medication?

Q: I use Nizoral for my dandruff. Does it work for hair loss too? — M.D., Danbury, CT

A: The active ingredient in Nizoral is Ketoconazole. This medication, originally developed to treat fungus infections, has slight anti-androgen action. It is supposed to work in hair loss by inhibiting the action of DHT on hair follicles. Although, in theory, it should be useful for androgenetic hair loss, there have not been conclusive scientific studies to show that it works to treat balding when used as a topical application for balding.

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Hair Restoration Research

Hair Loss Cure A Possible Result Of Stem Cell Communication Research

Following some new research on stem cells, and their relationship with androgenetic alopecia (genetic hair loss), an article on stem cells and the way they organize hair growth was published in the April 29th issue of the journal Science. At issue is the way in which large numbers of stem cells coordinate the cycle of hair growth over thousands of hair follicles. How do all of those hair follicle stem cells know when to grow hair, and how do they know what their “neighbor” hair follicles are doing?

Chuong C, et al. 2011

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Bernstein Medical In The News

Press Release: Hair Transplant Pioneer Studies Hair Cloning, Hair Restoration Procedures Using ACell’s Extracellular Matrix

Hair Cloning with ACell MatriStemRobert M. Bernstein, M.D., F.A.A.D., the renowned hair transplant surgeon and founder of Bernstein Medical – Center for Hair Restoration in New York, is studying four different applications of ACell MatriStem™ extracellular matrix in a type of hair cloning, called hair multiplication, as well as current hair restoration procedures. Click the link to read the whole press release.

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Hair Restoration Answers

Is Genetic Hair Loss Linked to Other Diseases?

Q: There was a retrospective study by Lotufo et al. linking male pattern baldness to heart disease. Do you think there are other links like this for androgenetic alopecia?

A: Family studies revealed both the androgen receptor locus on the X chromosome, as well as a new locus on chromosome 3q26. Association studies performed in two independent groups revealed a locus on chromosome 20 (not near any known genes) as well as the androgen receptor on the X chromosome. Read on for the rest of the answer.

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Hair Restoration Research

Dr. Christiano Interviewed on Alopecia, Hair Loss Genetics by New York Times

Dr. Angela Christiano, a colleague of Dr. Bernstein’s at Columbia University, has been studying the causes of alopecia areata and genetic hair loss for many years. She, in fact, suffers from the disease as well.

The New York Times has published a question and answer interview with Dr. Christiano which covers her own struggle with alopecia, her research into the causes of genetic hair loss, and where she sees the field going in the future.

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Hair Restoration Answers

Why Am I Losing Hair Despite Taking Avodart For Hair Loss?

Q: I am currently taking Avodart and have done so for around 8 months. Last night I had a significant loss of hair after taking a shower, nothing like I have ever seen before and found it very distressing. Can you tell me if this is hair loss or could it be something known as shedding and could you please tell me what is the difference between hair loss and hair shedding? — M.S., New York, NY

A: Hair loss is a very general term that can refer loss of hair for any reason. Genetic hair loss is caused by the effects of DHT on hair follicles that result in miniaturization -– i.e. a slowly progressive change in hair diameter that starts with visible thinning and that may gradually end in complete baldness. Hair shedding is more sudden where hair falls out due to a rapid shift of hair from its growth phase into the resting phase. The medical term for this is telogen effluvium. This process is usually reversible when the offending problem is stopped. It can be due to stress, medication, or other issues. You should see a dermatologist to figure out which process is going on. Dutasteride can cause some shedding when it first starts to work, but it would be unusual to do this after being on treatment for eight months.

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Hair Restoration Research

Dr. Christiano at Columbia University Identifies APCDD1, A Newly Discovered Gene Associated With Hair Loss

Dr. Angela Christiano of Columbia University in New York and a team of scientific researchers, have identified a new gene involved in hair growth. Their discovery may affect the direction of future research for hair loss and the diagnosis and ultimate prevention of male pattern baldness.

The condition, which leads to thinning hair, is called hereditary hypotrichosis simplex. Through the study of families in Pakistan and Italy who suffer from this condition, the team was able to identify a mutation of the APCDD1 gene located in chromosome 18. This chromosome has been linked to other causes of hair loss.

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Hair Restoration Answers

What are the Most Common Causes of Hair Loss in Women?

Q: What are the most common causes of hair loss in women other than genes?

A: The most common causes for localized hair loss in women are traction (due to tight braiding) and alopecia areata (an autoimmune disease that produces smooth round patches of hair loss).

Other than genetic (hereditary) thinning; generalized hair loss is most commonly caused by medications, anemia, and thyroid disease.

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Hair Restoration Answers

How Do You Treat General Thinning in Women ?

Q: I’ve been losing my hair just around the front of my scalp for years, but now it’s bad enough that I need to wear a wig to hide the top and back. Do you transplant women?

A: If you have thinning in such a broad area, most likely your donor area is also thin and you would not be a good candidate for surgery.

An examination can determine this and also determine if there is some other cause of your hair loss other than genetics.

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Hair Restoration Answers

Dr. Bernstein Answers Questions On HairDX Genetic Test To Predict Hair Loss

The HairDX genetic test for hair loss offers information that can aid you and your doctor in making an informed decision about the treatment of your hair loss. It offers one more bit of information that, in the context of other data (such as hair loss pattern, scalp miniaturization and family history) can help guide you and your doctor to formulate an appropriate treatment plan. How does it work? How accurate is the test? How does the test compare to information obtained from a history and physical exam by your physician? Dr. Bernstein answers these questions and more on the HairDX genetic test for hair loss.

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Hair Restoration Answers

Can Hair Loss Be Induced By Acne Medication Accutane?

Q: I have hair loss due to a treatment of Accutane. I have been off this medication for about a year and a half now, yet my hair has not recovered. The texture of my hair has completely changed. Given the fact that there is no family history linking me to male pattern baldness, I attribute my hair loss exclusively to Accutane. What should I do? — H.F., Eastchester, NY

A: If the texture alone has changed there is nothing you can do except to wait. The texture should improve over time even though it has already been 18 months.

If there are signs of genetic hair loss (i.e. male pattern alopecia), then finasteride should be considered.

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Hair Restoration Answers

Can Stress Cause Hair Loss or is that a Myth?

Q: I’ve been dealing with daily mental stress for the past few months. I’ve noticed that during that time, I’ve experienced a lot of frontal hair loss and thinning. I thought stress was a myth for causing hair loss. — R.P., Upper East Side, Manhattan

A: Stress may cause temporary shedding, but it generally does not affect the long-term course of genetic hair loss.

It seems that women’s hair is affected by stress more commonly than men’s hair, but the reason is not clear.

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Hair Restoration Answers

Hair Loss Causes: What is Miniaturization and What is Effect of DHT on Hair Follicles?

Q: I have read that in the evaluation of a patient for hair restoration surgery some doctors use a densitometer to measure miniaturization – the decrease in size of hair diameters. I read that miniaturization is a sign of genetic hair loss, but when there is miniaturization of greater than 20% in the donor area, a person may not be a good candidate for hair transplants. Is this correct and does 20% miniaturization mean that 20% of the population of terminal hairs have become fine vellus-like hairs or that there is a 20% decrease in the actual diameter of each of the terminal hairs? — B.A., New Albany, Ohio

A: Miniaturization is the decrease in hair shaft length and diameter that results from the action of DHT on healthy, full thickness terminal hairs. The hairs eventually become so small that they resemble the fine, vellus hair normally present in small numbers on the scalp and body. Miniaturized hairs have little cosmetic value. Eventually miniaturized hairs will totally disappear. Twenty percent miniaturization refers to the observation, under densitometry, that 20% of the hairs in an area show some degree of decreased diameter.

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Hair Restoration Answers

Can My Hair be Thinning Without Shedding?

Q: I seem to be thinning, but I never shed hair as such in the shower. I cannot see my hair falling out. Can it be androgenetic hair loss? — R.C., Cambridge, MA

A: In androgenetic hair loss one rarely sees hair falling out in mass, but rather the thinning is due to the hair decreasing in diameter and length (a process called “miniaturization”).

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Hair Restoration Answers

Is Laser Therapy a Revolutionary Hair Loss Treatment?

Q: The makers of the HairMax LaserComb have claimed that it will “revolutionize the hair growth industry.” What do you think?

A: This claim is obviously overstated.

Since the Low Level Laser Therapy (LLLT) doesn’t affect the action of DHT on hair follicles, it doesn’t affect the underlying cause of genetic hair loss, and thus would be expected only to have limited effectiveness. The company’s own studies show that this is, indeed, the case.

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Hair Restoration Answers

Can Hair Loss Increase on Propecia for Four Months?

Q: I believe I am an “early” IIIA or IVA. I am not losing any hair on the back of the scalp. There is no substantial hereditary hair loss on either side of the family, but I began taking Propecia four months ago and recently noticed a dramatic thinning of hair on the top (front) of the scalp, extending back to the rear of the head. — B.M., Lower East Side, N.Y.

A: Often people experience some shedding the first six months on finasteride as the new hair essentially pushes out some of the old. I would wait a full year before making any judgments about a hair transplant since you may see significant regrowth from finasteride in the second six months and may not need surgery at this point, particularly if the hair loss is early.

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Hair Restoration Answers

Can Hair Loss in Women be Caused by Pregnancy, Prozac, or Hyperactive Thyroid?

Q: I had a baby 12 weeks ago and have recently been diagnosed with a hyperactive thyroid, although only slightly. I was also taking Prozac for 7-10 days. I am 27 and have been experiencing a significant amount of hair loss from all over my scalp. What are the chances that this would be permanent?

A: Based upon your history, you have three possible reasons for having a type of hair loss called telogen effluvium; thyroid disease, medication induced (Prozac) and pregnancy.

Telogen effluvium is diagnosed by a hair pull test and observing club hairs under the microscope. It is generally a reversible condition, regardless of the cause. Telogen effluvium most often occurs 2-3 months after the inducing event, so your pregnancy is the most likely cause. Prozac would less likely be the problem since you have only been on it for a short time. Besides causing Telogen effluvium, thyroid disease can also alter your hair characteristics, which can make your hair appear thinner.

Other causes of hair loss, such as genetic female pattern hair alopecia, must be ruled out. Please see the Hair Loss in Women page on the Bernstein Medical – Center for Hair Restoration website for more information.

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Hair Restoration Answers

Why Should Hair Transplant Doctor Measure Miniaturization in Donor Area Before Transplant?

Q: Why should a doctor measure miniaturization in the donor area before recommending a hair transplant? — E.B., Key West, F.L.

A: Normally, the donor area contains hairs of very uniform diameter (called terminal hairs). In androgenetic hair loss, the action of DHT causes some of these terminal hairs to decrease in diameter and in length until they eventually disappear (a process referred to as “miniaturization”). These changes are seen initially as thinning and eventually lead to complete baldness in the involved areas.

These changes affect the areas that normally bald in genetic hair loss, namely the front and top of the scalp and the crown. However, miniaturization can also affect the donor or permanent regions of the scalp (where the hair is taken from during a hair transplant). If the donor area shows thinning, particularly when a person is young, then a hair transplant will not be successful because the transplanted hair would continue to thin in the new area and eventually disappear. It is important to realize that just because hair is transplanted to another area, that doesn’t make it permanent – it must have been permanent in the area of the scalp it initially came from.

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Hair Restoration Answers

Which Contributes More to Hair Loss: Stress or Genetics?

Q: Can stress accelerate hair loss? I am 25 and there is balding on my dad’s side of the family. I never had any thinning or hair loss till this year. I guess you can say I’ve been under a lot of stress. When I did notice shortly after my 25th birthday I started stressing even more, which led to more hair loss. It is thinner up front and it is thin on top. I have heard of some hair docs mapping your head for miniaturization, do you do this too? — E.W., Miami, FL

A: Yes. The presence of miniaturization (decreased hair diameter) in the areas of thinning allows us to distinguish between hair loss due to heredity (i.e. androgenetic alopecia) — in which hair progressively decreases in diameter under the influence of DHT — and other causes. The degree of miniaturization can be assessed using a hand-held instrument called a densitometer.

The pattern of hair loss and the family history are also important in the diagnosis.

Stress more commonly produces telogen effluvium, a generalized shedding that is not associated with miniaturization and is often reversible without treatment.

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Hair Restoration Answers

Is Asymmetrical Hair Loss from Telogen Effluvium or Androgenetic Alopecia?

Q: Over the past three months, my hair seems to be thinning more on one side. Is it common in male pattern hair loss for it to be more on one side? I had a lot of stress about three months ago and have heard that this could be the cause. Is this possible? Should I use Rogaine to treat it? — B.R., Landover, MD

A: Regardless of the cause, hair loss is usually not perfectly symmetric. This applies to male pattern hair loss as well.

In your case, it is important to distinguish between telogen effluvium (shedding that can be due to stress) and hereditary or common baldness. The three month interval from the stressful period to the onset of hair loss is characteristic telogen effluvium, but you may have androgenetic alopecia as an underlying problem.

The two conditions are differentiated by identifying club hairs in telogen effluvium and miniaturized hair in androgenetic alopecia. In addition, a hair pull will be positive in telogen effluvium (when a clump of hair is grasped with the fingers, more than five hairs pull out of the scalp at one time) and will be negative in common baldness. The hair loss diagnosis can be made by a dermatologist.

Hair cuts do not affect either condition.

Rogaine (Minoxidil) is only effective in androgenetic hair loss and only marginally so. Finasteride is the preferred treatment if your hair loss is genetic when it is early and a hair transplant may be indicated if the hair loss progresses.

Shedding from telogen effluvium is reversible and does not require specific treatment.

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Hair Restoration Answers

How Does Densitometry Help Diagnose Hair Loss?

Q: Dr. Bernstein, I was reading about a densitometer on your website. What is it and what is it actually used for? — Z.A., Westchester, NY

A: The hair densitometer was introduced to hair restoration surgeons by Dr. Rassman in 1993. It is a small, portable, instrument that has a magnifying lens and an opening of 10mm2.

To use it, the doctor clips the hair short (~ 1-mm) and the instrument is then placed on the scalp. The doctor counts the total number of hairs in the field, looks at the number of hairs per follicular unit and assesses the diameter of the hair, looking in particular for abnormal levels of miniaturization (decreased hair shaft diameter caused by the effects of DHT).

The densitometer can increase the accuracy of the diagnosis of genetic hair loss by picking up early miniaturization.

It can also better assess a person’s donor hair supply, thus helping to determine which patients are candidates for a hair transplant.

Densitometry has helped us define the conditions of diffuse patterned and unpatterned hair loss (DPA and DUPA) and help to refine the diagnosis of hair loss in women.

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Bernstein Medical In The News

NPR Interviews Dr. Bernstein on Hair Transplantation and Hair Loss

Here is one exchange from the interview:

Moderator: How one can tell the difference between hair loss from hormonal imbalances and common baldness?

Dr. Bernstein: Measuring hormone levels alone, although important for medical management, does not necessarily reveal whether the cause of the hair loss is actually hormone related or is genetic. The diagnosis is made by examining the scalp and looking at the hair under close magnification using an instrument called a “Densitometer.”

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Hair Restoration Answers

Do You Recommend Hair Transplant for Hair Thinning Over Entire Scalp?

Q: I am 19 years old and seem to be thinning all over, including the sides. My father has all of his hair but my grandfather is totally bald. Should I have a hair transplant now or wait until I am older? — T.K., Garden City, NY

A: Most likely you have a type of androgenetic alopecia called Diffuse Unpatterned Alopecia (DUPA).

In this hereditary condition, hair thins all over rather than just on the front, top and back as in the more common male pattern baldness.

The fact that the back and sides of your scalp are thinning (the donor area) precludes you from being a candidate for surgery. The diagnosis can be made by observing a high degree of miniaturization (fine hair) in the donor area under a magnifier. This instrument is called a densitometer.

For further information, please read the article:

Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning, published in the journal Dermatologic Surgery in 1997. Specifically, read the last part of the article.

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Hair Restoration Answers

What is "Shock Fall Out" After a Hair Transplant?

Q: What is “shock fall out”? – D.B., Chappaqua, N.Y.

A: Shedding after a hair transplant is also referred to by the very ominous sounding term “shock fall out.” The correct medical term is “effluvium” which literally means shedding. It is usually the miniaturized hair (i.e. the hair that is at the end of its lifespan due to genetic balding) that is most likely to be shed. Less likely, some healthy hair will be shed, but this should re-grow.

Interestingly, if transplants are spaced less than one year apart, one often notices some shedding of the hair from the first transplant, but this hair grows back completely. For most patients, effluvium is not a major issue and should not be a cause for concern.

Typically, when shedding occurs, a patient looks a little thinner during the several month period following the transplant, before the transplanted hair has started to grow. The thinning is often more noticeable to the patient than to others. Shedding is generally noted as a thinning, rather than of “masses of hair falling out,” as the term “shock fall out” erroneously suggests.

In general, the more miniaturization one has and the more rapid the hair loss, the more likely shedding will be from the hair restoration surgery. Young, actively balding patients would be at the greatest risk. Older patients with stable hair loss would have the least risk. In either situation, since miniaturized hair is eventually going to be lost, the effluvium has no long-term effect on the outcome of the procedure.

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Hair Restoration Answers

Does Hair Grow More Slowly After a Second or After a First Hair Transplant?

Q: This is my second hair transplant and is seems like it is growing more slowly than my first. Is this normal? – J.D., Port Washington, N.Y.

A: It is common for a second hair transplant to take a bit longer to grow than the first, so this should be expected. It is also possible that there is some shedding from the procedure, or a continuation of your genetic hair loss.

Propecia may be helpful in this regard. It is important to wait at least a year for the transplant to grow in fully and to give a chance for any hair that was shed to regrow.

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Bernstein Medical In The News

Hair Loss in Women the Topic in Dr. Bernstein ‘Early Show’ Interview

Excerpt from the interview:

Julie Chen: Dr. Bernstein, I want to go through all the options that are available for women, but what is the difference between female and male hair loss option-wise. What can we do to treat it?
Dr. Bernstein: The main difference medically is that women have hair loss often from hormonal changes and it’s due to an imbalance between progesterones and estrogens. That equilibrium can be reestablished with medication. Often birth control pills can do that.

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