Hair Restoration Blog

Q:

I have read online that Propecia can cause depression as a side effect. Some articles I read say it is a very rare side effect and others say it can occur in 75-80% of the time. Which is correct?  Thanks.

A:

The primary clinical trials on finasteride (Propecia) were conducted with a large number of patients over a period of 5 years. These initial trials did not reveal any evidence of depression in the participants. However, subsequently a few more recent reports indicate the possibility of depression occurring after taking finasteride.

A prospective study on 174 young men in 2004 suggested a higher chance of depression in men who used finasteride. The authors of the study concluded that finasteride might induce depressive symptoms. The recommendation from this study was that finasteride should be prescribed cautiously in patients who have higher risk of depression. This could be further underscored by the studies on psychology of hair loss and hair transplant in patients which notes alteration in self image and esteem and possibility of improvement of depression. The 2004 study emphasized that further clinical research is necessary to evaluate the behavioral effects of finasteride in higher doses in patients who are more susceptible to depression.

Based on the results of this study, we cannot suggest a percentage for depression in patients taking finasteride. Obviously, if you are experiencing mood disorders or any other symptoms while taking finasteride, you need to discuss it with your doctor for further diagnosis and treatment.

Medical hair restoration: Hair transplants are the most successful form of hair restoration.

The advanced modern techniques used today in hair transplant surgery are a proven, natural  and preventative method to slow down and/or stop further hair loss. It could be used with or without hair transplant surgery. When you talk to friends and family about hair loss treatments, you will find a lot of do-it-yourself hair loss methods or products such as creams, ointments, lotions, nutrition supplements, scalp products and other herbal, all promising to stop hair loss and re-grow hair.

Among all the many so called remedies for hair loss  for nonsurgical treatment of hair loss for men and women (pattern baldness), you will find that only two that have been approved by the U.S. Food and Drug Administration, and are recommended by physician hair restoration specialists. Hair loss products not approved by the FDA are often enriching the manufacturer but too little to help the man or woman suffering with hair loss. Some actually even harm the individuals who experiment with these unproven methods.

The FDA approved finasteride (Propecia) and minoxidil (Rogaine) are the only two medications presently that directly address hair loss. The other products that are considered effective as hair loss treatment usually contain either of these medications or similar chemicals as ingredients.

There are many other options that are touted out in the marketplace. These products do not have enough evidence based information.  It is best to consult with your doctor about all options before committing to any of these types of treatments.

US Hair restoration combines medical treatment of hair loss with surgical options or hair transplant to create a master plan for obtaining the best final results.

Q:

Hi Dr. Mohebi,

Trust you are well.

It was a pleasure meeting you in Los Angeles back in June. I had a few concerns about taking Finasteride and wanted to have your opinion before taking the medication.

I read few articles that side effects of finasteride include impotence, abnormal ejaculation, decreased ejaculatory volume, abnormal sexual function, gynecomastia, erectile dysfunction, ejaculation disorder and testicular pain of which I experienced some of them when using the medication back in 2010. It was also stated that patients have reported persisting erectile dysfunction despite discontinuing the drug. I do feel this is also the case for me at times. Do I need to consult with a Urologists?  Would taking 1/4 of the pill every other day have any impact on slowing down/ prevent the hair loss and at the same time not damage sperm quality?

I am still looking at a few dates to come back and get my hair transplant as I don’t want to depend on medications for long. I am aiming for either this Nov. or April at the latest.

Regards,

A:

The initial double blind study of Propecia (finasteride) did not reveal any evidence of permanent side effects from it.  This research was done on over 1000 patients and around the same number of people who were enrolled in placebo arm of the study. In fact it showed that the adverse effects of Propecia in people who initially experienced sexual side effects and decided to continue the medication improved over one year from the time they started experiencing the side effects.

There have been recent reports from smaller studies that focus on possible long term or permanent side effects of Propecia, The reported side effects included erectile dysfunction, lack of sex drive or even mood changes.  After reviewing the cited articles and their methodology, I was not convinced that the data was collected and documented properly.  The International Society of Hair Restoration Surgery (ISHRS) also assembled a group of hair restoration doctors to evaluate the validity of some of these reports regarding the side effects of Propecia.  The group’s evaluation did not support the claims of the new reports on irreversible side effects of Propecia.

It should be noted that, Merk & Co. Inc, pharmaceuticals now include an insert in Propecia packaging. This insert discusses the possibility of long term side effects. We also review this with our patients.   My thought is that a more significant study on a large group of people who took finasteride for a long period of time is needed to confirm the new claims.

If you have any sexual side effects such as changes in sex desire, erection or sperm count, you need to be evaluated by your primary doctor or a urologist instead of assuming that it is only a side effect of finasteride.

Here at US Hair Restoration, we are constantly hearing about the concerns of our many patients who have been prescribed the popular hair loss preventative medication known as Propecia (finasteride). Most patients with concerns have seen recent news reports, commercials, or magazine ads talking about the dangers of taking Finasteride. Since this is an effective medication proven to aid in the sustainment of receding or thinning hair, it is important to explain the facts in comparison with the rumors.

Early side effects (1 year)

The reported side effects based off of precise medical research for Finasteride at the 1-mg dose are uncommon and reversible. The one- year drug related side effects were over 1% greater than in the control group. The data showed that 3.8% of men taking Finasteride 1mg experienced some form of sexual dysfunction verses 2.1% in men treated with a placebo.

Most reported rumors center around sexual dysfunction occurring after beginning use of the medication, but there have been reports of sexual dysfunction that have occurred at later points in time. When studies were performed based through proper research methods, the sexual side effects were reversed by all the men who discontinued therapy, and in 58% of those who continued treatment. Once the medication was stopped, side effects generally disappeared within only a few weeks.

The initial studies done on finasteride for 12 months show that 1.4% of patients taking Propecia (945 patients) were discontinued due to adverse experiences which may have been drug related.

Here is the break down on the sexual side effect of finasteride in the patients who used it for one year only.

The men who continued using finasteride resolved some of the side effects in many cases. The resolution of the side effects was compared in the drug and placebo group. The incidence of each of the above adverse experiences decreased to ≤0.3% by the fifth year of treatment with Propecia.  This shows improvement of the side effects in the patients who took it over time.

In a study of finasteride 1 mg every day in men showed some decrease in volume to ejaculate of 0.3 mL (-11%) compared with 0.2 mL (–8%) for placebo in 48 weeks after beginning the treatment. Decrease in ejaculate was shown more significantly in higher doses (5mg) of finasteride which is approximately 0.5 mL (-25%) compared to placebo in ejaculate volume.  However, the decrease in ejaculate has been seen to be reversible after the treatment has been stopped.

In the clinical studies with Propecia, the incidences for breast tenderness and enlargement, hypersensitivity reactions, and testicular pain in finasteride-treated patients were not different from those in patients treated with placebo.

Long term side effects (up to 4 years)

Long term side effects of Finasteride were extensively studied in the Finasteride 5mg (Proscar) Long-Term Efficacy and Safety Study for 4 years in 3040 patients (1524 on Finasteride 5 mg/day and 1516 on placebo). 3.7% (57 patients) treated with finasteride 5 mg and 2.1% (32 patients) treated with placebo discontinued therapy as a result of adverse reactions related to sexual function, which are the most frequently reported adverse reactions.

Although the initial side effects of Finasteride has been higher than placebo over time the difference decreases to the point that in years 2-4 of this research, no significant difference between the two groups (treatment groups and placebo) was reported in terms of the incidences of impotence, decreased libido and ejaculation disorder.

Q:

I went to a couple different hair transplant doctors for evaluations when I was 24/25 and was told I have a juvenile hairline and that i have a good donor area and scalp laxity. The doctors recommended around 2000 grafts to fill in the diffused area at the time.

One of the doctors I visited told me to give propecia another try which I did for an additional six more months, but stopped because it seemed to have no effect and from my understanding it doesn’t really help with hair in the frontal area which was my main problem. I also did not want to risk getting any more health side effects from taking propecia.

During this time I was also taking biotin supplements which I had read are good for hair but they didn’t have any noticeable effects. I decided against getting a hair transplant because of my age and I wanted to see if the hair might grow back naturally (some people who have lost hair from accutane reported regrowing their hair several years after taking the medication).

I have a history of MPB in my family but it seems to be hit or miss. My grandfathers both had full heads of hair, my dad and 1 of his brothers are completely bald but another brother has a full head of hair. My mom has 1 brother who is bald and another with very thick hair and a low hairline (which my hair most closely resembled before taking accutane). I also have a brother who is 21 and has extremely thick hair like I used to with no signs of hair loss whatsoever.

A:

Male patterned baldness (MPB) is a progressive condition and it generally won’t get better without treatment.  The medications that are being used for the treatment of hair loss are generally for maintaining your existing hair and have preventative effects rather than restoring your hair at its full thickness like what you had in previous years.

A good hair transplant surgeon can help you realize what the best options for hair restoration are; whether it is a surgery or medication.  Using Accutane could cause hair loss as one side effect, but that is reversible within a few months after stopping it.  That is the most common case for medication related hair losses.

It is important for you to develop a good relationship with a qualified hair transplant surgeon whom you can trust.  Then let him walk you through this process.  Using medications for a while is a good idea and some patients respond well to using them.  Unfortunately the results are not permanent and most hair loss sufferers continue losing hair, but at a slower rate.

You can use medications such as Propecia or Rogaine to minimize the speed of hair loss. When it is the time for a hair transplant you can consider that as another option as well.

Q:

My doctor put me on propecia at 21 when I told him about the hair loss and I took it for about six months but it had no effect on my hair loss. I also started to use rogaine around age 23/24 for a couple of months but stopped because it made my hair loss worse (before rogaine the majority of my hair loss was in the front area of my head and after using rogaine I started to lose hair on my crown as well). My hair loss has been pretty stable over the past 2-3 years and I have continued to lose some hair but nowhere near the amount I lost initially.

I wash my hair every 2-3 days and only notice about 20-30 hairs lost compared to the hundreds I lost early on. My hairline has not really been effected at all and my hair loss doesn’t seem to match any on the norwood scale, it is just diffused loss throughout and matches the description of many accutane users who have lost hair. I have also been using the ProThik concealer spray for the past 3 years which works great because my hair loss is diffuse and makes it unnoticeable, but the process of applying it in and combing through it causes my hair to get tangled and pulled out so I think over time that has also contributed to my hair loss. I lose far more hair putting in the concealer than I do washing it and combing through it naturally.

For the first 2 years of using it I would wash my hair and re-apply it daily, although over the past 6-8 months I have gone 2-3 days between washing and reapplying it and only lose 10-20 hairs when I comb through it in the morning. I am not sure how much of my hair loss in recent years has been caused by this but I suspect that is has had some effect, especially during the time I was applying the concealer every day.

A:

Many young hair loss patients may start taking finasteride or minoxidil when they see the signs of active hair loss in their early 20s.  That is the time most people lose hair at its maximum speed.  Medications such as finasteride or minoxidil are only to prevent hair loss or even in some cases slow down the process.  They are not to bring your hair back to where it was before you started the process of hair loss.

I recommend you visit a hair specialist who can perform microscopic evaluation of your scalp (miniaturization study).  That can give you more information about the type of your hair loss and the treatment methods. Having regular follow up visit with your hair doctor helps you to know whether or not your hair loss medication works.  You may also need a hair transplant when the time come and the time and type of the restoration surgery could be discussed with your hair transplant surgeon.

Dihydrotestosterone (DHT) is a byproduct of the hormone testosterone, which is formed in different areas such as the prostate gland and hair follicles.  Hair follicles which are susceptible to genetic male patterned baldness contain DHT receptors.  Over time as males produce more and more DHT the molecules affect hair follicles and cause them to become decrease in size, and eventually fall out permanently.

DHT and having the gene of male pattern baldness are the primary contributing factors for male pattern baldness. Women with female-pattern baldness, unlike men with male-pattern baldness, are usually not characterized by increased production rates of DHT due to their low levels of testosterone.  However if for any reason a woman has increased testosterone, she may develop female patterned baldness just like a man does with the same mechanism.

Hair in the areas that are prone to male patterned baldness such as corners, top and crown areas are loaded with DHT receptors in men with Androgenetic Alopecia.  However, the hair on donor areas such as back and sides do not have as much DHT receptors.  This is why hair is more permanent on the sides and back as opposed to the top and front.

The distinction in hair quality on different areas (donor vs. recipient) allows a hair transplant surgeon to remove hair from one area and transplant it to the balding portions of the scalp.  These transplanted hairs are permanent and won’t be affected by circulating DHT. Finasteride (Propecia) is a drug that blocks the conversion of testosterone to DHT by blocking the enzyme alpha reductase.  DHT levels in hair loss patients decrease when they are on Propecia and this helps maintain healthy hair, and this helps some of the miniaturized hair become stronger.

We recommend medical treatment with DHT blockers in many of our patients who undergo a hair transplant procedure to help maintaining their own hair in addition to restoring the balding areas with hair restoration surgery.

Avodart (dutasteride) and Propecia (finasteride) have recently been in the news for the report of some studies regarding their role in increased or decreased risk of prostate cancer.  Avodart and Propecia are both 5-alpha reductase inhibitors (5-ARI), which help prevent production of DHT (dihydrotestosterone).  This class of medications is indicated for the treatment of benign prostate (BPH) hypertrophy.  These DHT blockers also help with the prevention of male patterned hair loss and have been recommended and prescribed for hair loss treatment, for many years.

On one hand, several studies have indicated that DHT blockers could decrease the rate of prostate cancer.  On the other hand,  there are some studies that indicate they may increase the incidence of high-grade prostate cancers.  Those studies performed on both finasteride (7 years study) and dutasteride (4 years study).  It has been concluded that the patients who take DHT blockers should have prior knowledge of whether they have a lower risk of prostate cancer.  However, if the patient gets prostate cancer it might be in a category which is more advanced.

Doctors should be aware DHT blockers can decrease the levels of PSA artificially, so a small increase in PSA levels might reflect a higher activity of prostate tissue in comparison to patients who are not on DHT blockers. Overall, it is good practice to make sure all patients age 50 and older have a baseline PSA reading before they get started on finasteride.  This will determine their PSA levels before they begin taking medications, and the doctor will be able to monitor changes in PSA with greater precision.

Q:

Dr. Mohebi, this may seem like an unusual question, but I’ve been hearing a lot about Prince William’s hair loss and wondered if you wouldn’t mind letting me know what treatment option(s) you’d recommend. Rogaine? Propecia? Hair transplant surgery, and if so, how many grafts?

Thanks so much!

A:

Prince William is a class IV hair loss in Norwood classification with significant thinning on the top area that indicate he will be heading toward class VI if he does not use any treatment for his hair loss.  Looking at Prince William pictures, you can see that he has had the initial signs of hair loss in his early twenties that is typical for Caucasian hair loss.

Although you may argue that wearing the crown will eventually cover the balding areas on the top, he may still have a few more viable options.  Prince William needs to be on some sort of medical treatment, either Propecia or Rogaine, to minimize his hair loss or at least to prevent or slow further thinning.  He should also consider a hair transplant surgery to reinforce his hairline and add density to his corners.  Restoring his crown balding spot will be the next priority and I think if his donor quality is good all of those goals could be achieved in one session.

I think with one hair transplant he can eliminate the appearance of balding while he might need another procedures to thicken up the frontal density and add more to the volume of top and the crown area.

Q:

Hi doc I have a question.  I really need to get an answer towards this.

I am a propecia (finasteride 1mg) user for hairloss.  I just read an article regarding how the FDA recently(yesturday) rejected finasteride for use as a prostae cancer prevention due to the fact that finasteride sometimes increases high grade prostate cancers in  individuals who take it.  I am a bit scared since I am a healthy 25 year old who has been taking finasteride 1mg for a while and plan to to take it for hairloss.  Is it possible that finasteride can cause prostate cancer for someone who takes propecia for long term?  please help.  the article really freaked me out. I will post the link to the article below.

http://www.nytimes.com/2010/12/02/health/policy/02drug.html

A:

Finasteride is a DHT Blocker that is used both for prevention of male patterned baldness as well as prevention of prostate cancer.  There are several studies that evaluated the rate of prostate cancer in patients who take Finasteride long term.

The reported data from a recent Food and Drug Administration advisory committee evaluates available data on DHT blockers and whether or not the labels should stat that they decrease the rate of prostate cancer.

They evaluated results from two large studies of the drugs. GlaxoSmithKline’s study involved 8,000 men at risk for prostate cancer because their PSA (prostate specific antigen) tests had found elevations of PSA. The men also had prostate biopsies, but at the start of the study none had received a diagnosis of prostate cancer.

The Finasteride study, sponsored by the National Cancer Institute, was done on 18,800 healthy men over age 55 who were randomly assigned to take either the drug or a placebo.

Both above studies indicated the drugs reduced the overall prostate cancer risk by about 25 percent which is a significant improvement.  However, both studies also found small increases in the incidence of higher-grade, riskier cancers, in men taking the drugs as compared with placebos.

There are two suggested reasons for the increase in these numbers.  One is that the drugs reduced the size of a man’s prostate, making it easier to find lethal cancers on biopsies.  Also, both medications reduce the levels of PSA in blood making early diagnosis of prostate cancer in those patients difficult.

In summary we know that DHT blockers such as Finasteride (Propecia or Proscar) reduce the rate of prostate cancer, there are some reports on some slight increase in the higher stages of prostate cancer in patients who were on those medications.  Finasteride (1miligram) is still recommended for prevention of male pattern baldness.

I generally ask the patients who are over 50 to be tested for PSA before they start taking Finasteride.  I also stress that their family doctor be aware of the medication they are using so any slight increases in PSA are able to be taken more seriously (as opposed to people who are not taking the Finasteride medication).