Bernstein Medical - Center for Hair Restoration - Propecia (Finasteride)
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Q: My hair is starting to thin in the front, but it is not yet bald. I have been going back and forth about whether to get a hair transplant or use Propecia. I’m not sure what my first step should be. What do you think? — N.K. ~ Pleasantville, N.Y.

A: In general, patients who are thinning, but not actually bald, should begin with combined medical therapy (finasteride and minoxidil) for at least a year prior to considering surgery. In many cases, with this regiment, surgery can be postponed or even avoided completely. Unfortunately, some patients cannot tolerate finasteride or choose not to take it due to concern about potential side effects. Minoxidil, although useful, does not significantly alter the long-term course of hair loss when used alone.

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Q: I had a good friend get a transplant at your practice and it seems that your practice is the industry leader in hair transplantation. I may one day be looking for one. That being said, my friend said I shouldn’t trust anyone else. I wanted to know if you may be able to tell me what tests/specific labs you have your patients do prior to starting Propecia. I am having my doctor put me on it but he does not recommend any labs but I don’t trust this. So I’m not looking for medical advice, just what your practice may advise a patient to get (in terms of labs/blood tests) prior to starting Propecia. I’m really hoping you can help as I have already contacted a number of other sources and can’t seem to get an answer. — M.B. ~ Upper East Side, N.Y.

A: Blood tests are not required before starting finasteride and we do not routinely perform them. If a patient requests test then Total and Free Testosterone, DHT, and Prolactin are reasonable to obtain, but there is no consensus on what the appropriate tests might be. If a patient requests tests because he has symptoms (i.e. such as lack of energy associated with low T), he should see his internist, urologist, or GP. That said, patients 50 and over (40 and over in patients with a high risk of developing prostate cancer) should have a PSA before starting finasteride.

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Dr. Bernstein Interviewed in NY Japion Pt 1

Dr. Bernstein Interviewed in NY Japion Pt 2

Dr. Bernstein was featured in a wide-ranging interview published in the New York City-based, Japanese language magazine NY Japion. Among the topics discussed were the differences between FUT and FUE hair transplants, updates on robotic hair transplant technology, the type of procedure most beneficial for Asian patients, criteria that determine candidacy for a hair transplant, and more. Below are some selections from the interview.

On FUT vs FUE:

FUT is more economical than FUE and also more beneficial for patients who wear their hair longer. However, if your plan is to have the option of wearing your hair short, FUT is not for you. That is because with FUT you will have a fine linear scar after the donor area (the area where strip is removed) is sutured, and this may be seen visible with short hair.

On robotic FUE hair transplantation and the ARTAS Robot:

In the case of ARTAS, an advanced camera system and a computer analyzes images of the scalp and calculates angle and direction of individual hairs, hair density and number of hairs in each follicular unit instantly. Then, based on that calculation, the computer controls the punch so that it goes into the skin at the right angle and depth so that it will not damage hair root and/or surrounding tissues. So far, 135 systems of ARTAS have been installed worldwide. About half of them are in the United States and 11 are in Japan. Currently, 5% of hair transplant treatments are performed with ARTAS worldwide.

On which type of hair transplant is more beneficial for Asian people:

FUE is especially good for Asians, including Japanese. With Asians, scars tend to widen. In addition, Asians usually have coarse hair that grows more perpendicular to the skin than in Caucasian scalps, so a linear scar in the donor area (using FUT) may be more visible — especially if the hair is worn short.

On who is a good candidate for a hair transplant:

Some people are candidates for hair transplantation, but some are not. Since a hair transplant uses a patients’ own hairs and relocates them from the permanent zone in the back of the scalp to areas that are thinning or bald, it is necessary that patients have good and sufficient hairs for that.

On the appropriate age to consider hair transplant surgery:

Hair transplants are not for young people since their future balding is so difficult to predict. Young patients should not consider hair transplant as a technique to prevent hair loss. Prevention is best accomplished by medications. The most effective are Propecia (finasteride) and Rogaine (minoxidil). These medications do have some side effects that need to be considered before starting. In general, hair transplant surgery should not be performed for people under 25. There are exceptions, but I prefer for patients to wait until 30 and over.

Dr. Bernstein’s wife Shizuka Bernstein was born in Tokyo, and the two travel to Japan frequently. Shizuka is a master-aesthetician and owns an award-winning day spa by Rockefeller Center in New York City called Shizuka NY. Shizuka developed her own line of skin-care products based on powerful natural anti-aging ingredients and pure Mt. Fuji spring water. She has been seen on CNN, CNBC, Fox News, The Today Show, The Early Show, CBS’s The Doctors, and E!’s red carpet special leading up to the Primetime Emmy Awards.

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Q: Does minoxidil play any role in the survival of the grafts after a Neograft/FUE procedure? — J.W., Philadelphia, PA

A: When a doctor performs a hair transplant, the hair should be taken from the permanent zone so, by definition, that hair is not affected by medication (i.e. does not need to be maintained by either minoxidil or finasteride). If the doctors using Neograft are suggesting that minoxidil increases survival, then they are probably harvesting hair outside the permanent zone. To clarify, I use the ARTAS robotic system for our FUE procedures, not Neograft, as the former is a far more accurate device for harvesting.

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Q: Does a man’s height and weight affect the dose of finasteride or Propecia he should take? i.e. will a 6’4″ man need a higher dose than a 5’7″ man. — T.B., Rye Brook, NY

A: The dose of finasteride is the same (i.e. 1mg) regardless of a person’s height or weight. The reason is that one needs only 0.5mg a day for it to be effective, so there is much leeway built into the dose (but the rate of non-responders is slightly higher at the 0.5mg/day dose). That said, after 5 years or so, finasteride seems to be less effective and doctors often increase the dose a bit. The next step-up is generally to take 1/3 of a 5mg pill each day. Keep in mind that the dosing we are speaking about is for hair loss (androgenetic alopecia). When finasteride is used for prostate enlargement, the dose is 5mg a day.

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Currently, only two FDA approved medical treatments exist for androgenic alopeciaminoxidil (Rogaine) and finasteride (Propecia) — but these drugs are not effective in all individuals, and to remain effective, both require consistent, daily, life-long use. Additionally, finasteride is not FDA approved for use in women.

Because of the need for additional hair loss treatment options, researchers have begun to look at low-level light laser therapy (LLLT), specifically red and near-infrared LLLT, due to its ability to promote hair growth by stimulating hair follicle cells ((Mester E, Szende B, Tota JG. Effect of laser on hair growth in mice. Kiserl Orvostud 1967;19:628–631.)) — a process called cellular photo-biostimulatiostimulation.

While many studies have investigated the effects of red and near-infrared LLLT on hair loss, specifically in the ranges of 635 to 780nm, there’s been no comprehensive survey of these studies to see if this treatment option has a consistent, positive effect on androgenic alopecia (genetic balding) for men and women.

To answer this question, researchers from the Harvard Medical School surveyed ((Avci P, Gupta GK, Clark J, Wikonkal N, Hamblin MR. Low-level laser (light) therapy (LLLT) for treatment of hair loss. Lasers Surg Med. 2014 Feb; 46(2):144-51.)) five clinical studies designed to measure the effects of LLLT on androgenic alopecia in both men and women. In each case, they found that red and near-infrared LLLT was a safe and effective treatment option for both men and women with genetic balding.

The authors propose that LLLT may work by supporting the anagen (growth) phase of the hair follicles affected by androgenic alopecia while also protecting them from alopecia’s inflammatory effects.

While the results in the studies were positive overall, the authors did note that the most therapeutic light wavelength and dosing remain to be determined.

Read more about Laser Therapy for Hair Loss

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Q: Hi. I am 52 years old and wish to know if Propecia will work for people my age. I have started losing some hair a couple of years ago and it’s thinning out. Thank you very much for your help. — K.E., Boca Raton, FL

A: Propecia (Finasteride 1 mg) can hold on to hair at any age, but works best to re-grow hair in those who are younger.

The reason is that finasteride works to reverse miniaturization (the thinning and shortening of hairs due to DHT). Younger patients, with early hair loss, generally have more hair in the early stages of miniaturization where the changes are readily reversible.

Older patients are more likely have more advanced miniaturization or areas that are totally bald and will thus not regrow with medical therapy.

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Q: Does finasteride need to be taken every day? — M.B., Atlanta, GA

A: Finasteride (Propecia) is a competitive inhibitor of Type II, 5 alpha-reductase (5AR is the enzyme that converts Testosterone to DHT which then causes hair to miniaturize and eventually be lost). Finasteride is 100x times more selective in inhibiting the Type II enzyme (present in hair follicles) than the Type I enzyme (present in other body tissues). The turnover (T1/2) of the finasteride/5AR Type II complex is 30 days and the finasteride/5AR Type I complex is 15 days. This explains why finasteride does not need to be taken every day and why, after stopping finasteride, the effects may take a month or longer to begin to disappear.

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Q: Can Propecia (finasteride) completely halt androgenic alopecia for the duration of your lifetime, or does it just slow down the progression of androgenic alopecia? — L.B., Scarsdale, N.Y.

A: In many patients we have found finasteride to hold on to a patient’s hair for at least 15 years. We don’t have much longer data than that since it was approved for hair loss in 1998. Although finasteride will usually continue to work as long as you take it, it may lose some of its efficacy over time. Generally after about 5 years we may notice that the patient’s hair is starting to thin again and we will increase the dose slightly. It is important to understand that even if someone thins on finasteride it doesn’t mean the medicine is not working, because they might have thinned much more without it. To my knowledge, there are no studies that have looked at the effects of finasteride for such an extended period of time.

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Q: I’ve heard that using Propecia and/or Rogaine is a good idea after having a hair transplant, but are they mandatory? — B.M., Short Hill, N.J.

A: Neither finasteride (brand name: Propecia) nor minoxidil (brand name: Rogaine) will have any effect on transplanted hair. That said, while you don’t need them to protect your transplanted hair, you will likely have original hair interspersed among your transplanted hair that will continue to thin and fall out over time. This vulnerable hair can be protected by finasteride which has been shown to reduce future hair loss significantly; additionally, you can add Rogaine for extra benefit.

However, with Propecia, you should only use it if you can commit to it long-term because it takes up to a full year to see any effect. With Rogaine, you should only use it if you can commit to using it continually and regularly – you should not stop and start it.

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Could the 5α-reductase inhibitors (5ARIs) dutasteride and finasteride increase the risk of developing male breast cancer?

In 2012, male breast cancer was identified as a possible new risk of 5ARIs by the FDA; however, a 2013 study published in the Journal of Urology ((Bird ST, Brophy JM, Hartzema AG, Delaney JA, Etminan M. Male breast cancer and 5α-reductase inhibitors finasteride and dutasteride. J Urol. 2013 Nov;190(5):1811-4. doi: 10.1016/j.juro.2013.04.132.)) found no evidence for a relationship between male breast cancer and finasteride (Proscar®) and dutasteride (Avodart®), both of which are used to treat enlarged prostate (benign prostatic hyperplasia).

The study excluded finasteride (Propecia®), used to treat androgenic alopecia, because previous research considered a relationship between Propecia 1mg and male breast cancer unlikely.

So how did dutasteride and finasteride become implicated in the possible development of male breast cancer?

The Hypothesized Link Between Finasteride & Dutasteride and Male Brest Cancer

Going back to 1992, researchers ((Thomas DB, Jimenez LM, McTiernan A, Rosenblatt K, Stalsberg H, Stemhagen A, Thompson WD, Curnen MG, Satariano W, Austin DF. Breast cancer in men: risk factors with hormonal implications. Am J Epidemiol. 1992 Apr 1;135(7):734-48.)) had hypothesized that an increased ratio of estrogen-to-testosterone could lead to an increase risk of male breast cancer.

This hypothesis seemed to be supported when, in 2009, the Medicines and Health care products Regulatory Agency (MHRA) in England ((Niraj K Shenoy, Sangolli M Prabhakar. Finasteride and male breast cancer: Does the MHRA report show a link? J Cutan Aesthet Surg 2010; 3: 102.)) received reports of male breast cancer developing in patients using 5ARIs, which are known to alter the normal estrogen/testosterone balance. Specifically, as of November 2009, MHRA had received 50 worldwide reports of male breast cancer developing within an average of 44 months after starting treatment with 5mg finasteride for enlarged prostate. MHRA also received three reports of male breast cancer developing in men using Propecia ® 1 mg for hair loss, but because of relatively short onset times of the disease after starting treatment, the MHRA considered any link between Propecia and male breast cancer unlikely.

Even though both finasteride and dutasteride alter the normal estrogen/testosterone balance in men, the fact that 50 individuals developed male breast cancer after starting to use a 5ARI does not constitute evidence that 5ARIs contribute to the development of male breast cancer: it is possible that these 50 individuals would have developed cancer whether or not they used a 5a-reductase inhibitor.

The Study: Male Breast Cancer and 5a-Reductase Inhibitors Finasteride and Dutasteride

To ascertain whether or not a link exists between the use of 5a-reductase inhibitors and subsequent development of male breast cancer, one would want to look at two groups of men where one group has been exposed to a 5a-reductase inhibitor and where one group has not, and then one would compare the incidence of the development of breast cancer in the two groups. However, one would also need the two groups to be matched on as many known risk factors for male breast cancer as possible, such as alcoholism, gynecomastia, Klinefelter syndrome, liver damage, obesity, oral estrogen, orchiectomy and prior radiation; in short, one would want to control for all the known risk factors for male breast cancer to see if 5ARIs were contributing any additional risk.

And this is exactly what the 2013 study did. As a result, it found that 5a-reductase inhibitors were not a significant predictor of developing male breast cancer 1 to 3 years after exposure.

Because no link between 5ARIs and male breast cancer was found, the authors of the study advised doctors to prescribe finasteride and dutasteride without fear of introducing additional risk for the development of male breast cancer in their patients.

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Q: I have done a lot of research over the past year including seeing a dermatologist and receiving consultation from a surgeon. Both recommended Propecia and Rogaine. After my consults I researched these products online and read that they do not work on the front of the scalp to improve my receding hairline, only to regrow hair in the crown area. Can you settle the issue once and for all? Do Propecia and Rogaine work on the front of the scalp? Can they improve my receding hairline? — J.S., Great Falls, Virginia

A: Both Propecia and Minoxidil definitely can work in the front of the scalp as long as there is some hair in the area. Although their mechanisms of action are different, both Propecia (finasteride) and Rogaine (minoxidil) act to thicken miniaturized hair regardless of where it is on the scalp. In fact, there are published data ((Leyden, James et al. “Finasteride in the treatment of men with frontal male pattern hair loss.” J Am Acad Dermatol. 1999 Jun;40(6 Pt 1):930-7.)) demonstrating this improvement with finasteride in a controlled clinical trial of men with frontal hair loss.

The source of the confusion is that the FDA limited the application of the drugs to the crown on the package inserts for both Propecia and Rogaine. The FDA did this because Upjohn (the company that introduced Rogaine) and Merck (Propecia) only tested the medications on the crown in the clinical trials. Logically, the fact that DHT causes frontal hair loss and Propecia works by blocking DHT gives a reasonable explanation for the efficacy of the drug on the front of the scalp. Also, a side effect of the use of minoxidil is facial hair, so how could it not also work on the front of the scalp? It is regrettable that some doctors and many patients think that these medications won’t work on the front of the scalp. Unfortunately, many hair restoration surgeons have done little to educate the public and dispel this myth.

To reiterate, yes, both of these medications can work on the front of the scalp to prevent hair loss and thicken a thinning hairline. However, it is important to note that neither of these medications can grow hair on a totally bald scalp or lower an existing hairline. Hair follicles must exist for the medications to work. It is also important to stress that the best results come from using both finasteride and minoxidil together.

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Recent news reports, coupled with warnings from Merck and the FDA, about Propecia’s possible persistent sexual side effects have caused growing concern about this popular hair loss treatment. An increasing number of men now fear that Propecia (finasteride 1mg) will cause permanent sexual dysfunction.

Merck’s and the FDA’s warning, however, was based on a small number of random self-reports, not on empirical studies that showed a cause and effect relationship between finasteride and sexual dysfunction. There are two possible reasons that existing studies have not found a significant relationship between finasteride use and persistent sexual dysfunction: 1) the effect of finasteride on sexual function is too small to significantly measure in any one study, or 2) finasteride has no significant negative effect on sexual function.

To address the first possibility, Aditya K Gupta and Andrew Charrette ((Gupta AK, Charrette A. The efficacy and safety of 5α-reductase inhibitors in androgenetic alopecia: a network meta-analysis and benefit-risk assessment of finasteride and dutasteride. J Dermatolog Treat. 2014;25(2):156-61.)) at the University of Toronto recently conducted a large scale meta-analysis across 16 controlled studies, studies designed to test the efficacy of finasteride, to see if a significant number of patients in those studies reported persistent sexual side effects. The rationale of a meta-analysis is that if there is an effect (of finasteride on sexual function) that is too small to measure in any one particular study, then it may be possible to detect the effect if one pools data from many different studies.

Gupta and Charrette analyzed the results of 16 studies that compared various doses of finasteride against a placebo and found that finasteride consistently proved effective in stopping or slowing hair loss. They also found that the number of self-reported cases of persistent sexual dysfunction by patients given finasteride was statistically no different from the number reported by patients given a placebo.

In other words, they found that finasteride was no more likely to cause persistent sexual dysfunction than a placebo.

This study supports the conclusion of existing literature that there is no correlation between finasteride use and persistent or permanent sexual dysfunction. That said, this is an important issue that still needs to be studied.

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Q: I’ve heard that FDA added a description of reports of male infertility to the side effect labels of both Propecia and Proscar (finasteride). Is this a likely side effect in your experience? — S.S., Rolling Hills, California

A: Propecia (finasteride 1mg) may lead to male infertility not only by changing the consistency of the male ejaculate but by decreasing the sperm count as well, but this is uncommon.

Ejaculate is a combination of sperm produced by the testes and a viscous fluid made by the prostate. Since finasteride shrinks the prostate, it can make the ejaculate less viscous (more watery).

Most patients trying to conceive will have no issues while taking Propecia.

If one is having difficulty trying to conceive for 4-6 months, then it is reasonable to stop taking Propecia.

It is important to know that taking Propecia while trying to conceive will not lead to congenital deformities or issues with the fetus as long as the woman does not come in direct contact with the medication.

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Q: I have been using an increased dosage of Propecia now for around 8 months and Rogaine for about 6 months. I know that shedding can be expected for the first 3-6 months, but I believe I am now beyond that timeframe. Have you seen cases in which these products merely exacerbate hair loss without the expected regrowth? — N.E., Travilah, Maryland

A: It is a bit long to still see shedding, but from my experience, either the medications are working (and you are still in the shedding phase) or you are not responding to them. I have not seen minoxidil or finasteride worsen hair loss. My advice would be to continue the same course for at least a year before re-evaluating their use.

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The 21st Annual Scientific Meeting of the International Society of Hair Restoration Surgery was held in San Francisco from October 13 through 26, 2013. The meeting covers the most important scientific and clinical advances in the field of surgical hair restoration.

As a member of the panel on “Difficult Cases,” that explored challenging and atypical medical conditions and their treatment, Dr. Bernstein presented the “Management of Frontal Fibrosing Alopecia.” This condition is a form of primary scarring hair loss. Dr. Bernstein chose to discuss this disease because it can be mistaken for common baldness; however, since the transplanted hair will be destroyed by the disease process, it is a contra-indication for hair transplantation. Since missing this diagnosis can lead to unnecessary and ineffectual surgery, an awareness of its signs and symptoms are important for every physician managing patients with hair loss.

On the panel on “Post Finasteride Syndrome,” Dr. Bernstein was part of a group that reviewed the latest studies on the efficacy and safety of finasteride in the treatment of androgenetic alopecia. They discussed possible adverse events including claims of persistent sexual dysfunction (Post Finasteride Syndrome) and concerns relating to prostate cancer. They also discussed the challenges that arise in caring for patients when scientific research and the mass media give conflicting information.

In the Symposium “Question the Expert,” Dr. Bernstein presented a case of Diffuse Un-patterned alopeica (DUPA). This condition was first detailed by Dr. Bernstein in his landmark paper “Follicular Transplantation: Patient Evaluation and Surgical Planning,” that was published in Dermatologic Surgery in 1997. DUPA is a form of androgenetic alopecia that presents as rapid generalized hair loss in young adults. Besides being a significant psychological burden for young men and women, its identification is extremely important since medical intervention can have a significant positive impact when instituted early. On the other hand, a misdiagnosis that leads to surgery can result in a failed hair transplant and donor scarring that may become visible over time.

Dr. Bernstein was also the Keynote Speaker for the ARTAS International Users Forum. His presentation, titled “Follicular Unit Extraction: Then and Now,” discussed the evolution of FUT, FUE and Robotic-FUE and how it relates to today’s hair restoration practice. Of particular significance was the natural progression of FUE instrumentation from hand-held manual tools to robotic assisted hair transplantation. Dr. Bernstein explained that in the future, robotic capabilities will not be limited to graft extraction, but eventually will perform each aspect of the transplant including recipient site creation, and graft placement. See “Dr. Bernstein Gives Keynote Presentation On Robotic Hair Transplantation” for more details on the presentation and some photographs of the event.

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Q: I read your 20 pages of FAQs but could not find this question addressed. I’m currently taking Finasteride 5 mg (one-fourth tablet per day), but since some drug companies make an oblong tablet that is hard to cut into four pieces, I found a plastic bottle with four equal measurements and I dissolve the tablet in water, shake it up and drink one-fourth of the liquid each day. I read somewhere that you’re not really supposed to dissolve the pill in water. Is that correct or is it OK to keep doing it the way I’m doing? — W.I., Winnetka, Illinois

A: I would cut up the pills with a pill-cutter – they do not need to be in equal parts. Just finish a whole pill every four days. You can also take ½ pill every other day and achieve the same effect. I am not sure of the stability of the medication in water over several days. It is probably OK, but why take the chance?

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The results of an 18-year study, just published in the New England Journal of Medicine, showed that finasteride does not increase the likelihood of death from prostate cancer in men who take the drug. Early results from the same study had suggested that finasteride might increase the risk of developing higher grade tumors; however, follow-up results from the long-term study show that men taking the drug do not have an increased risk.

Additionally, the results of the study show that taking finasteride actually decreases the likelihood of a diagnosis of prostate cancer in men by 30% and a diagnosis of “low-grade” cancer in men by 43%. By shrinking the healthy prostate tissue, finasteride decreases the chances of a false positive result in PSA screening tests and can avoid unnecessary surgery.

From the article in the NEJM:

“Finasteride reduced the risk of prostate cancer by about one third. High-grade prostate cancer was more common in the finasteride group than in the placebo group, but after 18 years of follow-up, there was no significant between-group difference in the rates of overall survival or survival after the diagnosis of prostate cancer.”

Read a summary of the NEJM article below:

Long-Term Survival of Participants in the Prostate Cancer Prevention Trial

Ian M. Thompson, Jr., M.D., Phyllis J. Goodman, M.S., Catherine M. Tangen, Dr.P.H., Howard L. Parnes, M.D., Lori M. Minasian, M.D., Paul A. Godley, M.D., Ph.D., M. Scott Lucia, M.D., and Leslie G. Ford, M.D.
N Engl J Med 2013; 369:603-610 August 15, 2013

BACKGROUND
In the Prostate Cancer Prevention Trial (PCPT), finasteride significantly reduced the risk of prostate cancer but was associated with an increased risk of high-grade disease. With up to 18 years of follow-up, we analyzed rates of survival among all study participants and among those with prostate cancer.

METHODS
We collected data on the incidence of prostate cancer among PCPT participants for an additional year after our first report was published in 2003 and searched the Social Security Death Index to assess survival status through October 31, 2011.

RESULTS
Among 18,880 eligible men who underwent randomization, prostate cancer was diagnosed in 989 of 9423 (10.5%) in the finasteride group and 1412 of 9457 (14.9%) in the placebo group (relative risk in the finasteride group, 0.70; 95% confidence interval [CI], 0.65 to 0.76; P<0.001). Of the men who were evaluated, 333 (3.5%) in the finasteride group and 286 (3.0%) in the placebo group had high-grade cancer (Gleason score, 7 to 10) (relative risk, 1.17; 95% CI, 1.00 to 1.37; P=0.05). Of the men who died, 2538 were in the finasteride group and 2496 were in the placebo group, for 15-year survival rates of 78.0% and 78.2%, respectively. The unadjusted hazard ratio for death in the finasteride group was 1.02 (95% CI, 0.97 to 1.08; P=0.46). Ten-year survival rates were 83.0% in the finasteride group and 80.9% in the placebo group for men with low-grade prostate cancer and 73.0% and 73.6%, respectively, for those with high-grade prostate cancer. CONCLUSIONS
Finasteride reduced the risk of prostate cancer by about one third. High-grade prostate cancer was more common in the finasteride group than in the placebo group, but after 18 years of follow-up, there was no significant between-group difference in the rates of overall survival or survival after the diagnosis of prostate cancer.

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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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Q: I’ve noticed from the chatter on blogs, that it is not uncommon for men to go through multiple FUE procedures over 10+ year time-frame. It seems to be that after the initial FUE procedure to address moderate hair loss, the patient continues their natural balding to where they must undergo another FUE procedure in order to get back to their desired look. I’m almost 33 and while I take Propecia, my hair loss has been very gradual since I was about 26. I still have what many would consider a full head of hair, although very thin and with noticeable loss at my temples and crown. I’d always thought that a hair transplant would be a “1 and done” procedure, and now I’m concerned that if I do an FUE procedure now to replace what’s been already lost, I’ll just have to revisit a subsequent FUE down the line. Are ongoing FUEs simply part of the hair maintenance that a patient needs to accept about hair restoration process? — A.A., New Hyde Park, N.Y.

A: Your concerns are correct and would apply to any hair transplant procedure; FUT or FUE. That is why it is best not to begin hair restoration surgery too early.

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Q: As a Propecia user, I was alarmed when I read headlines last year about a new study indicating very high rates of depression and erectile dysfunction caused by Propecia, with symptoms persisting even after the drug was stopped. However, when I read the articles, this “study” appeared to be survey of 61 men who had taken Propecia and already reported sexual problems who were then asked about symptoms of depression. These rates of depression were compared to a small survey of men who had hair loss but had never taken Propecia.

Anyone with a basic understanding of statistics would know such a survey was deeply flawed. First, it is a textbook example of a bad data sample — to get sound results you have to start with an unbiased and random group of people who took the drug, not a self-selected group of men already suffering symptoms. The study also confuses correlation with causation — because these men are suffering from ED or depression does not necessarily mean it was caused by the drug. Am I missing something here, or did the media just report these “findings” with no scrutiny on what was actually studied? — Jonathan, Brooklyn, NY

A: Jonathan, I think you’re right on the mark. The way the study was conducted raises a lot of concern about the accuracy of the findings. It is really important that additional data is obtained in a controlled way, as this will be most useful for physicians in advising patients. I addressed concern on these reports last year. The issue of persistent sexual dysfunction as a side-effect of finasteride (Post-Finasteride Syndrome) is an on-going issue that we take very seriously. I sit on the International Society of Hair Restoration Surgery (ISHRS) Task Force on Finasteride Adverse Events, so this is an issue that we watch very closely.

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Q: I have been taking finasteride for several years and I seem to be doing well. Does finasteride generally work long-term? — A.C., West University Place, Texas

A: With regard to efficacy, a recent long-term, uncontrolled study by Rossi et al. reported that the beneficial effects of finasteride on hair growth continued as time goes on and that a significant proportion of patients, unchanged after 1 year, improved later on. In addition these patients maintained a positive trend over time -– up to ten years. When comparing different age groups, they found that subjects older than 30 years showed a better hair growth in the long term than those who were younger. Of the 113 patients in the study followed for 10 years, only 14% worsened, whereas the remaining 86% had benefits.

Read more details about the Rossi study

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Dr. Bernstein Leads Robotic FUE 'Coffee With Experts' At ISHRS 20th Annual Meeting

Dr. Bernstein heads discussion on Robotic FUE at the 20th annual meeting of the International Society of Hair Restoration Surgery (ISHRS) which took place October 17-20, 2012.

Dr. Bernstein led a roundtable discussion in the ‘Coffee with the Experts’ session on robotic follicular unit extraction. See above photo of the session (click on it to view a larger version). Some of the topics he covered were; the proper indications for FUE, the advantages of Robotic FUE over other methods, how doctors can best implement robotic hair transplants in their practices and recent advances in robotic technology. He was also a panelist at the Finasteride Symposium and gave a presentation on protocol in prescribing Finasteride to hair restoration patients.

Program biography on Dr. Bernstein

Robert M. Bernstein, M.D., F.A.A.D., A.B.H.R.S., Clinical Professor of Dermatology, Columbia University, is an early adopter of the ARTAS System for Robotic-FUE. Bernstein Medical, PC, serves as a beta-site to study new product features and enhancements. Dr. Bernstein’s contributions and expertise have materialized in making the ARTAS System more user friendly, improving the harvesting technique and making the ARTAS procedure more compelling for patients at this early stage of commercialization of the product. Pre-Making Recipient Sites to Increase Graft Survival in Manual and Robotic FUE Procedures, has been submitted for publication.

Dr. Bernstein’s comments on roundtable discussion

One of the most important new advances in hair transplantation is Robotic Follicular Unit Extraction (R-FUE). I have been using the new ARTAS Robot, manufactured by Restoration Robotics, for almost a year now. It has made FUE a more exacting and reliable procedure. The “Coffee with the Experts” session that I gave on the topic of Robotic FUE at the ISHRS was standing room only, attesting to the great interest that members of our society have in this new technology.

The theoretical advantage of using a robot to minimize human error in a very repetitive procedure was acknowledged by most members of the discussion group. The ARTAS system has the advantage of using a combination of sharp punch and blunt dissection, a model that was based on Dr. Jim Harris’ SAFE System and one that we have found to work best with the hand-held devices. It also allows us to remove grafts with forceps, rather than by suction. This feature is important since strong suction used to remove the grafts can be more damaging than mechanical removal with forceps.

Its dissection technique uses two punches which are concentrically arranged – a small diameter, sharp bi-beveled punch is nested within an outer, dull punch. The inner punch has a cutting end to score the upper most part of the skin and the outer punch has a blunt edge that dissects the follicular units from the surrounding tissue. We have also found that grafts harvested with Robotic FUE showed less transection compared to other devices that we have used and contained more of the surrounding protective tissue, so it is assumed that this will lead to improved graft survival, but this has not yet been proven.

We find that the robot is more versatile in its ability to harvest grafts from patients with different hair characteristics and from different parts of the scalp. Although there is still variability in the ease of extraction among patients of different racial backgrounds, in our experience, the differences are less when compared to a hand-held system. Also, with the robotic system it seems easier to extract grafts from the sides of the scalp where the hair lies flatter on the skin.

In our practice, we are now able to comfortably extract 2,000 grafts in one day and over 2,500 grafts in two consecutive days. Some of the doctors at the discussion claimed to be able to consistently extract far greater numbers in a single session using manual methods, but it is hard to compare speed without comparing graft quality and transection rates.

One of the exciting things about the new device is that it is continuously evolving. As a beta-site studying new enhancements and features, we have seen all the nuanced changes that continually improve the technique. The initial version of the robot required many intra-operative adjustments to depth, angulation, and the speed of punch rotation, so there were a number of adjustments to monitor. The current system needs far less human intervention than with earlier versions and is simpler to operate, but significant experience is still needed to get the best results. Of course, all the other issues of a hair transplant including; planning, design, site creation, atraumatic graft insertion, etc. persist.

One of my special interests had been to offer patients Robotic FUE with a smaller punch size. We have been working with a 0.9mm punch (the standard is 1.0mm) and have found that this shortens healing time, decreases donor scarring and increases the number of follicular units that can safely be harvested in a specific area. It also creates grafts that require less trimming. On the other side of the coin, some patients, especially African-Americans have less transection with the larger punch, so it is important to be able to customize the technique to the particular person.

Another important modification of the technique that we have implemented since the introduction of the ARTAS system, but that is also applicable to FUE in general, is pre-making recipient sites. This is done either prior to extraction in a one-day procedure or at the beginning of the first day in a two-day procedure. With this change, as soon as the grafts are harvested, they can be placed immediately into the recipient scalp. Not only does this minimize the time that grafts are outside the body, but; by allowing the healing process to begin in the recipient area; it minimizes popping, increases visibility when placing (due to less bleeding), and may create a better environment in which the newly transplanted grafts can grow.

Some of the concerns that doctors had were the relatively high start-up cost in purchasing the robot, the amount of set-up time at the beginning of each procedure and the need, at present, to use two ORs – one for robotic harvesting and one for placing. At present, the patient can only lie on the robotic device face-down. While this position is necessary for the robotic arm to have full access to the donor area, it does not allow easy access to the front or top of the scalp. As a result, graft placement must be performed using a separate operating chair, necessitating the use of two operating rooms for one patient. It is anticipated that within a year, the robotic operating table will be re-designed so that harvesting and placing can be performed in the same room.

Besides some set-up time, one of the things that slows down the robotic process is the tensioner mechanism used to stretch the scalp. Although this feature has the advantage of decreasing damage to follicles, it must be moved every 100 to 150 grafts. With a larger and easier to use tensioner already designed, the delay from its re-positioning should be significantly decreased.

Another concern expressed was that the robot harvests grafts in a somewhat geometric pattern. With experience, one is able to overlap grids and feather the edges so that this appearance, even if temporary, is minimized. New software is planned which can do this automatically.

At the time of the meeting, there were twelve centers in the United States offering Robotic FUE with additional practices in the queue. There was also a strong interest in Robotic FUE among physicians outside the US, particularly in South Korea, Taiwan and Japan.

Read about the latest in Robotic FUE

Read about how Dr. Bernstein has improved Robotic FUE procedures

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Q: Dr. Bernstein, I am an attending at Mass General Hospital in Boston and would like to ask you regarding your experiences using finasteride for male androgenetic alopecia. While I have not noticed any side effects in the patients that I have been treating, I increasingly get questions regarding side effects based on the recent media attention to reports of potentially permanent problems regarding libido or erectile dysfunction. I know that in the literature there is a slight increase of reversible sexual dysfunction (~4% vs. ~2% in placebo) with Propecia, and no convincing evidence to date in the medical literature that have used controlled studies regarding permanent problems even after discontinuing Propecia. — S.Z., Boston, Massachusetts

A: That is correct.

Q: I know that you have treated many patients over a long period of time, and I was thus wondering what your take is on potentially permanent sexual dysfunction after taking finasteride. Have you seen any convincing reports/patients or do you have any concerns regarding irreversible side effects?

A: I have seen 5 cases in over 10,000 patients on finasteride that complained of this but, of course, there is no way to know for sure if there is a cause and effect relationship. As you know, real side effects may be followed by psychological ones and if the sexual dysfunction has another cause, then stopping finasteride would have no effect on the symptoms. The incidence of intermittent or persistent sexual dysfunction in the general population of men is about 30%, so one would expect these numbers to be much higher just due to the normal incidence. It is really a difficult situation to understand. The experience that my colleagues and I have in our practices is much different than one would expect after reading the numerous anecdotal reports on the internet.

Q: Would you think it is safe to say that any potential sexual dysfunction is reversible after discontinuing the use of finasteride?

A: I don’t think that anyone knows at this point. The FDA is coming down on the side of caution and saying that it is possible, although it is not based on any new studies. If the phenomenon is real, the possible mechanism is not yet known.

Q: In the relatively few patients that I have treated with Propecia, they did not even report temporary problems regarding libido or erectile dysfunction. Do you think they are real or rather attributed to Propecia simply because the patient is made aware of these potential side effects?

A: I think that psychological effects may account for many cases. At this time, it is still not clear if a physiologic “post-finasteride syndrome” is real. A lot more work needs to be done before we have a definitive answer to this question.

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Q: I recently visited my dermatologist regarding my hair loss, and after checking my hair he said I am showing signs of Androgenetic Alopecia (common baldness), and said if I don’t treat it, it will progress. From my research on the net, I figured he will put me on Propecia. In fact he put me on Avodart. When I told him it is not FDA-approved for hair loss, and Propecia is, he said Avodart is better and brings DHT down more, and Propecia is nothing next to Avodart. He told me to take it every day for 2 weeks, then every other day from then on as it has a long half life. From researching on the net, many hair restoration doctors rarely prescribe Avodart for hair loss due to some dangers. What is your opinion on this? — T.G., Darien, Connecticut

A: Although dutasteride (Avodart) can be more effective for male pattern hair loss, I would start with finasteride (Propecia) as many patients do great with it and the safety profile is better. The following are things I would consider before starting dutasteride:

  1. As you point out, dutasteride is not FDA-approved for hair loss.
  2. There is no data on its safety when used for hair loss. This is important since dutasteride has been only tested on an older population of patients (with prostate disease) rather than a younger population of patients needing medical treatment for androgenetic alopecia.
  3. These is no natural model for dutasteride’s combined blockage of both type 1 and 2 5-alpha reductase (finasteride blocks only type 2 5-AR and there are families that have this deficiency and have no long-term problems. This, by the way, is how the drug was discovered).
  4. The type 1 enzyme which dutasteride blocks is present in many more tissues of the body (including the brain) compared to type 2 (which is more localized to the skin).
  5. Although so far unproven, there is a concern that finasteride may produce side effects than can be persistent after stopping the medication (post-finasteride syndrome). It this does turn out to be true, the effects from dutasteride would most likely be significantly more persistent.
  6. If you start with finasteride and do have side effects, you will most surely have side effects from dutasteride; therefore, by taking finasteride first you will have avoided the potentially more problematic side effects from dutasteride
  7. You may respond well to finasteride, and so do not need to consider dutasteride
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Q: I have been finasteride for several years. My wife and I are currently trying to conceive our first child and it is unclear to me if it is safe to continue taking finasteride during this period. Unfortunately, I have not been able to get a clear position via the Internet. Most people commenting on it are on blogs and the response goes both ways — some say it’s ok, others say stop. While I know that it’s imperative that a pregnant woman not touch the medicine, can you please let me know if I can continue taking the medicine while trying to conceive? — M.K., Edgeworth, PA

A: It is OK for you to continue finasteride while your wife is trying to conceive. However, there is some data to suggest that it may slightly decrease fertility since, by shrinking the prostate (the prostate produces 25-30% of semen volume) it slightly changes the overall composition of semen. These effects appear to be temporary and finasteride has no direct effect on sperm. If you and your wife were to have difficulty conceiving, at that point is might be reasonable to temporarily discontinue the medication.

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The central finding of a 2004 study led by Italian researcher Dr. Antonella Tosti, in which he and his team investigated sexual dysfunction in hair loss patients being treated for androgenetic alopecia, was that there was no statistically significant change in sexual function after four to six months of treatment with finasteride 1mg (Propecia).

The researchers used a questionnaire, called the abridged 5-item version of the International Index of Erectile Function (IIEF-5), to measure sexual function in the men in the study. The questionnaire, which is considered an internationally valid diagnostic tool for distinguishing between men with and without erectile dysfunction, asks the patients 15 questions on the topics of: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall sexual satisfaction. By administering the questionnaire both before and after treatment with finasteride, the researchers were able to determine if sexual function was impaired by the treatment.

The result of this investigation in the sexual function of 186 patients was that, “the erectile function of all patients remained stable after 4 to 6 months of treatment with finasteride 1 mg.”

Interestingly, the research team found that sexual side effects were actually less common than reported in the clinical trials of the drug. They suggest that this difference was potentially due to the fact that subjects in the clinical trials were made aware of the potential for sexual side effects, and were asked about these side effects upon each visit, which led to higher reporting of side effects than what would otherwise be the case.

Reference:

Tosti A, Pazzaglia M, Soli M, Rossi A, Rebora A, Atzori L, Barbareschi M, Benci M, Voudouris S, Vena GA. Evaluation of Sexual Function With an International Index of Erectile Function in Subjects Taking Finasteride for Androgenetic Alopecia. Arch Dermatol. 2004;140:857-858.

Download the Tosti study of erectile function and finasteride

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The 2011 study published by a research team led by Dr. Alfredo Rossi, is the first comprehensive investigation on long-term safety and efficacy of finasteride 1mg (Propecia).

In “Finasteride, 1 mg daily administration on male androgenetic alopecia in different age groups: 10-year follow-up,” the Italian research team sought to fill a gap in our understanding of the long-term effects of treating hair loss with Propecia. The study tracked hair growth in 118 men between the ages of 20 and 61, with mild to moderate hair loss, who were treated with 1mg finasteride. These patients were evaluated before treatment and then again at 1, 2, 5, and 10 years on treatment.

The result of testing found not only that Propecia works and is safe for use, but there were some other interesting findings as well. Only 14% patients experienced a worsening of hair loss, while 86% benefited from the treatment over this extended time period and efficacy of the drug was found not to reduce over time for the majority of patients.

One of the most interesting findings is that patients who had hair growth in their first year of treatment are more likely than others to have better hair growth after 5 years. About half of patients experienced good hair growth in their first year, and about 53% of those patients went on to see improved growth over time. However, of the group with unchanged or worse results in their first year, only 25% saw improved hair growth after 5 years. After 10 years, almost 69% of patients who experienced growth in their first year experienced continued growth. Only 32% of those who saw unchanged or worse results after their first year had growth at 10 years.

The authors concluded that a patient’s response to finasteride in the first year is a pretty good indicator of how effective long-term treatment will be for the patient. The better growth he experiences in his first year, the more likely he will have continued growth beyond 5 years of treatment.

Among other findings, the age of a patient did have a statistically significant effect on the outcome, as patients older than 30 years had better hair growth in the long term. On the topic of side effects, 7 subjects (5.9%) experienced them, and some of those patients remained in the study because of what they perceived as the benefits of the treatment.

In conclusion, the authors found that Propecia is a safe and effective hair loss medication, even when used long-term. It is effective in patients older than 40 years and it is particularly beneficial for patients over 30 and who are in early stages of hair loss. Perhaps the most important finding is that a patient’s response to finasteride after the first year of treatment can be an indicator of the patient’s success with the drug in the long-term.

Reference:

Rossi A, Cantisani C, Scarnò M, Trucchia A, Fortuna MC, Calvieri S. Finasteride, 1 mg daily administration on male androgenetic alopecia in different age groups: 10-year follow-up. Dermatol Ther 2011; Jul-Aug;24(4):455-61.

Download the Rossi study of finasteride long-term effects

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Q: Doctor Bernstein, I was looking at your website and saw the photos of medical hair loss treatments only, with Rogaine and Propecia. Doctor, are all those pictures just with medical treatments or is there concealers as well? I don’t mean to sound rude or disrespectful, but are the pics all real and genuine? Those are some impressive responses to medical treatment. — A.D., Scarsdale, NY

A: The photos are un-retouched and without concealers. These are responses to medical treatment alone. Yes, medications (finasteride and minoxidil) can work really well in select patients. Patients with early stages of thinning usually respond the best. Contrary to popular belief, the medications can work in the front part of the scalp, as long as the area is not shiny bald.

Perhaps about 1/3 of patients respond well enough to be put on the site. Most others have a good response, but not necessarily improvement significant enough to be easily noticeable in photos.

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Q: Are the “result” photos from taking Propecia and using Rogaine legitimate? Some of the after photos look too good to be real and a few patients looked like they combed their hair to look like they had more coverage. — T.Y., Darien, Connecticut

A: The before and after photos of patients using Propecia and Rogaine are my patients. All photos on our website are un-retouched. When patients have a good response to medical therapy, they often have more flexibility in how they can groom and style their hair. This is reflected in the photos.

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Q: You prescribed Propecia for my hair loss. I was wondering if the news report on Propecia side effects has altered your opinion regarding the safety of this drug? — N.D., Belle Meade, Tennessee

A: It has not changed. I believe you are referring to Dr. Michael Irwig’s study at George Washington University published in the Journal of Sexual Medicine. I was already aware of the study when I prescribed the medication for you and we discussed the risk of persistent side effects at your consult.

Although all types of data should be considered, it is important to realize that this was not a scientific study, but a survey. It had very significant selection bias. From this type of study, one can’t prove cause and effect relationships or even get a sense of actual incidences. These were patients who were recruited because they already had persistent sexual dysfunction. Since it is not clear if their persistent problems were directly due to the medication or from other factors, and since these patients were selected, rather than randomly assigned, the additional information can be gained from the report is very limited.

That said, the reporting of persistent side effects should not be taken lightly, but should be viewed in the context of all available data. It is extremely important for us to continue to be vigilant, as this is a very significant issue, but it is equally important not to make decisions on data sensationalized in the media. As a result of the finasteride data, some are presenting surgery as a more reasonable alternative than medication. For a young person, that is usually not the case.

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On April 11, 2012, the U.S. Food and Drug Administration (FDA) announced changes to the professional labels for Propecia (finasteride 1 mg) and Proscar (finasteride 5 mg) to expand the list of sexual adverse events reported to FDA as some of these events have been reported to continue after the drug is no longer being used (note that erectile dysfunction after stopping use of these drugs was added as a known event in 2011). The new label changes include:

  • A revision to the Propecia label to include libido disorders, ejaculation disorders, and orgasm disorders that continued after discontinuation of the drug.
  • A revision to the Proscar label to include decreased libido that continued after discontinuation of the drug.
  • A revision to both the Propecia and Proscar labels to include a description of reports of male infertility and/or poor semen quality that normalized or improved after drug discontinuation.

Despite the fact that clear causal links between finasteride (Propecia and Proscar) and sexual adverse events have NOT been established, the cases suggest a broader range of adverse effects than previously reported in patients taking these drugs.

Propecia

Only a small percentage of men using these drugs have experienced a sexual adverse event. During treatment with Propecia, 3.8% of men had reported one or more adverse sexual experiences as compared to 2.1% men who did not receive Propecia (received placebo). This represents a 1.7% difference.

For Propecia, the FDA’s Agency’s Adverse Events Reporting System (AERS) database between 1998 and 2011 found 59 cases of reported sexual dysfunction that lasted for at least three months following discontinuation of Propecia, and included erectile dysfunction, decreased libido, problems with ejaculation and orgasm disorders.

The FDA has not established a cause and effect relationship between finasteride and the sexual adverse events that continued after stopping drug use. The FDA believes that finasteride remains a safe and effective drug for its approved indications. Healthcare professionals and patients should consider this new label information when deciding the best treatment option.

For more information, read this PDF document: Questions and Answers: Finasteride Label Changes.

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Q: Can shock loss be eliminated by using special surgical techniques? — R.P., Short Hills, NJ

A: Although there have been no scientific studies proving this, shock hair loss can most likely be minimized by keeping the recipient sites parallel to the hair follicles, by not creating a transplanted density too great in areas of existing hair, and by using minimal epinephrine (adrenaline) in the anesthetic. We implement all of these techniques. Finasteride may also decrease shock hair loss, or at least help any (miniaturized) hair that is lost to re-grow. That said, some shock hair loss from a hair transplant is unavoidable regardless of the technique as it is a normal physiologic response to stress.

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Q: I am 27 years old and I have been on Propecia for 12 months now. Honestly, I have seen no response from it. In my dermatologist’s opinion I am a non-responder. I asked about Avodart and he said, since Propecia didn’t help then Avodart won’t help as well since both are DHT blockers, and if one didn’t work the other won’t either. In your opinion do you think Avodart is better? I have read that it blocks more DHT than Propecia. What is the dosing for Avodart? If someone does not respond to Propecia will they also not respond to Avodart? — A.C., West University Place, Texas

A: Avodart (dutasteride) is more effective than Propecia (finasteride) and some patients will respond to dutasteride who do not respond to finasteride. Dutasteride decreases serum DHT about 90% compared to 70% for finasteride. The usual starting dose of Avodart is 0.5mg a day.

That said, dutasteride is not FDA approved for use in hair loss and if a person has sexual side effects, the side effects are more likely to be persistent after stopping the medication compared to finasteride.

Read more about Avodart (dutasteride)

Read more about Propecia (finasteride)

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In response to anecdotal evidence of sexual side effects continuing after stopping Propecia (finasteride 1mg), the International Society of Hair Restoration Surgery (ISHRS) has published a press release for the hair restoration community about the safety and efficacy of the drug.

The release notes that scientific data gathered from extensive testing finds no correlation between persistent sexual dysfunction and Propecia:

The ISHRS reports that there is no evidence-based data substantiating the link between finasteride and persistent sexual side effects after discontinued use of the drug in numerous, double blinded, placebo controlled studies conducted evaluating the use of Propecia 1mg for hair loss.

The ISHRS statement also touches on the fact that the exact cause of sexual dysfunction can be difficult to diagnose:

Sexual dysfunction is a complex disorder, and Dr. Martinick noted that it often can be hard to pinpoint the exact cause – particularly when multiple factors such as nicotine, alcohol, prescription medications, stress, anxiety, fatigue and depression can contribute to erectile dysfunction (ED).

In the interest of hair loss patients around the world, the ISHRS has formed a task force to examine the anecdotal reports of persistent sexual dysfunction by Propecia users. It has also called on medical communities from a variety of disciplines — dermatologists, hair loss physicians, urologists, endocrinologists and sexual medicine specialists — to share data and experiences.

Visit our section on Propecia to learn more about the medication, its use, and side effects.

Read the full ISHRS press release here.

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Q: I am taking finasteride as you prescribed. You also suggested using minoxidil liberally over the entire front and top of my scalp once a day. During our meeting I think that you said that once I start using this I would not be able to stop it, and, if I did, it might lead to further hair loss. Hence, I decided to use the laser comb three times a week in addition to the finasteride. Having said that, if you still feel I should start using minoxidil daily, I will start doing so. — H.K., Brooklyn, NY

A: Stopping therapy doesn’t lead to further hair loss in that it doesn’t accelerate it; you just continue on the path that you would have been without the treatment. When you stop, there may be an initial shedding as you quickly lose any benefits that you had from the treatment.

The following applies to all three treatments: finasteride, minoxidil, and laser therapy:

  1. Only work when you use it
  2. Reversion to where you would have been when you stop (but not worse)

However, the important issue is efficacy:

Finasteride >> minoxidil > laser therapy

This is the reason I recommended finasteride and minoxidil.

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Q: I heard that Propecia stops working after five years. Is this true and why in five years? — B.P., Stamford, CT

A: That is not correct. Although the effects of Propecia (finasteride 1mg) will diminish over time, it does continue to work. Using finasteride long-term will still be better than stopping it at some arbitrary interval. In clinical practice, I often increase the dose of finasteride, after someone had been on the medication 3 to 5 years, to help maintain its effectiveness.

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Q: I have been reading various articles and forum postings and it would seem that a person utilizing Propecia might experience increased “shedding” of hairs (outside of the normal hair cycle) around the 12 week mark after a hair transplant and lasting around 2-4 weeks. The forum postings suggest that one will not only see the miniaturized hairs being lost, but also normal terminal hair in greater than expected levels. Does an explanation exist to explain this increase in shedding hairs? — B.T., Manhattan, NY

A: Our understanding is that finasteride only affects miniaturized hairs — i.e. hair affected by DHT — and that this is all that should be shed. Remember, however, that much of the thinning a bald person experiences is due to thousands of partially miniaturized hair, and these can look very much like a full terminal hair in its early stages.

See our page on Shedding After A Hair Transplant.

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Q: Although I was prescribed Propecia, I have not yet started to take it. I would like to take it now, but my wife wants me to wait until after we have our second baby so as to avoid having the drug in my system when we conceive. She’s concerned that if it’s so harmful to pregnant women, that having it in my sperm is an issue. — L.V., Bellmore, New York

A: There is no evidence that if you take the medication it will affect the fetus. However, your wife should not ingest the drug or handle broken pills during pregnancy.

Read more about Propecia and Side Effects.

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After trading anecdotes with fellow hair loss physicians about how finasteride can reduce body hair in some patients, Sharon A. Keene, M.D. took the next logical step and asked whether finasteride might have a negative effect on patients who have body hair transplant (BHT) procedures.

In a review of scientific literature on whether finasteride effects body hair growth, Dr. Keene finds that current research is inconclusive.

Finasteride, the drug in the hair loss medication Propecia, works by blocking the 5-alpha-reductase type 2 enzyme (5-AR Type 2) which is needed by the body to covert testosterone to DHT. DHT causes common baldness, by making hair follicles shrink and eventually die.

In looking at DHT’s effect on body hair growth, current research strongly suggests that it does play a key role. Males born with a deficiency of 5-AR Type 2, and thus no DHT, have reduced, or absent, body hair growth (and no loss of scalp hair).

It would seem logical then, that when finasteride is used to re-grow hair on the scalp, it would also inhibit the growth of hair on the body. However, the genetic variation among people is too great to determine exactly how much of an influence it plays.

With this uncertainty of DHT’s effects on body hair, it is impossible to say, without further study, if finasteride would have the same effect on body hairs which are transplanted to the scalp. In Dr. Keene’s conclusion, she suggests:

A patient on finasteride for at least a year who undergoes BHT is probably safe to continue it, as remaining body hairs are apparently not sensitive to the effects of this drug.

You can read the full discussion and review of current research in the January/February 2011 issue of Hair Transplant Forum International, the official newsletter of the International Society of Hair Restoration Surgery (ISHRS).

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Q: I am about 3 months post-op after my hair restoration procedure. I have noticed some hair shedding in the frontal part of my scalp. I have continued both Propecia and Minoxidil. Is there anything I can do and should I be concerned? — M.B., Chicago, IL

A: Shedding of some of the patient’s existing hair in, and around, the area of a hair transplant is a relatively common occurrence after a hair transplant and should not be a cause of concern. The mechanism appears to be a normal response of the body to the stress of the hair restoration surgery -– i.e., site creation, adrenaline in the anesthetic etc. Some doctors claim that their hair transplant techniques are so “impeccable” that their patients do not experience shedding. This is a false claim. Although using very small recipient sites and limiting the use of epinephrine may mitigate shedding somewhat, shedding is a normal part of the hair transplant process and the risk is unavoidable.

It appears that a person’s normal, non-miniaturized hair, as well as transplanted hair, is somewhat less subject to shedding than hair that is actively miniaturizing (thinning from the effects of DHT). In addition, if transplanted hair or non-miniaturized hair is shed, it will grow back. If miniaturized hair is lost, however, it may or may not return.

Since both finasteride and minoxidil reverse the miniaturization process, they should decrease the amount of hair at risk from shedding after hair transplant surgery. This has been our clinical experience, but it is important to note that as yet there have been no scientific studies to support this view.

At this time there is not much you can do except to be patient and wait for the newly transplanted hair to grow in and for the shed hair to return. Of course, make sure you continue to take finasteride and/or minoxidil if the doctor has prescribed it for you.

Read more on the topic of Shedding After a Hair Transplant.

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Q: I started using both Propecia (finasteride) and Rogaine for roughly the past 15 weeks. In the last month I’ve been experiencing pain in my left testicle area. At first I thought this may be due to Varicocele; however, after some quick internet searches I thought it may also be the Propecia. The pain doesn’t seem to be in the testicle itself as much as the surrounding veins on the left side. What should I do? — B.L., Houston, TX

A: Your symptoms are the classic ones of a varicocele, namely pain on the left side that is adjacent to the testicle. Symptoms of finasteride would more likely be bilateral, although the discomfort does not need to be in the testicle itself. If your symptoms are worse at the end of the day when you have been standing, and less in the AM when you first arise, these suggest a varicocele.

In your pain is consistently worse towards the end of the day, I would see a urologist, as surgical intervention might be warranted, particularly if it is affecting sperm counts – which should be checked as part of the evaluation.

If this is not the case, then stop finasteride for a least a month and see if the symptoms subside. If they do go away off finasteride, I would not take the medication again. If the symptoms persist off finasteride, I would still see a urologist.

Read more about Propecia in our section on hair loss medications.

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Q: I have been on finasteride for about 7 months. After my latest haircut I can see that my scalp is shiny. I read that is from sebum buildup and it can cause a layer that clogs the growth of hair. I was wondering if this is true and, if so, how can it be treated? — T.C., Philadelphia, PA

A: It is not true. Hair loss is caused by the miniaturizing effects of DHT on the hair follicle, not by blocked pores.

For more on this topic, view our pages on the causes of hair loss in men or the causes of hair loss in women.

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Men's Health - Hair HealthMen’s Health has published a new spotlight, called “Hair Health.” The multi-article spotlight is featured on the magazine’s website homepage and covers a wide variety of topics related to men’s hair loss and hair transplant surgery. Dr. Bernstein was asked to contribute to the series of articles, including an “expert advice” feature which answers five commonly-asked questions about hair loss myths.

The centerpiece articles in the spotlight include the article, “Scalped,” which details the best treatments for hair loss in men, and, “Keep Plugging Away,” about best-practices on finding a great doctor who can treat your hair loss.

In “Scalped,” Dr. Bernstein speaks to the urgency of halting your hair loss using Propecia and Rogaine, while he cautions younger patients on the side effects of the drug Dutasteride:

“Start [Propecia and Rogaine] as soon as your hair begins to thin for the best results.”

[…]

“The reproductive side effects [of Dutasteride] — decreased libido and ejaculation disorders — may be persistent, so I don’t usually recommend this medication for younger patients.”

On hair transplantation, Dr. Bernstein says:

“Hair transplants are most appropriate for people who have not responded to medical treatments.”

“Keep Plugging Away,” centers on hair transplant surgery and the repair of hair transplants that used out-dated, large, “pluggy” hair grafts. Dr. Bernstein – the hair transplant physician most responsible for the new pioneering techniques of follicular unit transplantation and follicular unit extraction – had this to say about hair transplant repair:

“Reversing the unnatural appearance of older plugs is more involved than using the right technique in the first place,” he says. “But in most cases, it can be accomplished with excellent results.”

Visit the “Hair Health” feature online at MensHealth.com.

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