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Why I can’t recommend finasteride for hair loss

In the Bernard Shaw play “Caesar and Cleopatra,” Cleopatra whips up a baldness “cure” for Caesar consisting of a wild mix of ingredients including burnt mice and horse’s teeth. Shaw himself notes that he doesn’t understand the ingredients and of course it doesn’t work because nothing does.

In the decades that have passed since the play and the millennia since the historic Caesar and Cleopatra lived, there hasn’t been much progress in treating androgenic alopecia, the most common form of baldness, especially compared to advances in, say, antibiotics. The 1990s saw the mass release of Rogaine and Propecia as well as markèd improvements in hair transplantation surgery, but a Shavian cure is apparently still far off. None of the current remedies provide a definitive solution and they can at best hold progression of balding at bay for a few years.

I became very interested in androgenic alopecia in the early 2010s when I noticed some thinning of my own hair. During my research, the insufficiency of the associated treatments struck me: Both Rogaine and Propecia have to be taken indefinitely to maintain their benefits, which are often subtle to begin with. Transplantation is expensive and often must be supplemented with Propecia. Other treatments are by and large outlandish and unproven.

The fundamental problem, as I see it, is that baldness requires both a scientific and and an artistic solution. It’s not enough for the underlying scientific process to be sound in disrupting the mechanisms of androgenic alopecia; the results of the treatment must also be dramatic and cosmetically acceptable.

This double requirement is why hair transplantation results vary so much between surgeons, some of whom are good artists and others not. It’s also why many treatments that seemingly work in vitro – like cloning ones hairs – don’t carry over to the real world, since it’s difficult to ensure that the right size, color, and direction can be achieved in vivo. Baldness, at its core, is an artistic concern.

Unsurprisingly, given its unique difficulties, baldness has inspired a truly weird set of treatments:

  • A prescription-only pill that doubles as urinary retention medication for elderly men (Propecia).
  • A blood pressure medication that grows hair for reasons that are still not fully understood (Rogaine, originally known as Loniten).
  • A form of alternative medicine (low-level laser therapy).
  • Re-injection of one’s own processed blood into the scalp (platelet rich plasma).
  • Artistic rearrangement of follicles (transplantation).

Of these treatments, by far the most discussed and the most controversial is Propecia, also known by its chemical name, finasteride. It interrupts the conversion of testosterone to DHT, a more potent compound that attacks follicles in the genetically susceptible. That’s a pretty basic process to screw with, at least in males.

Nevertheless, reactions to finasteride are wide-ranging, with some takers reporting horrible side effects such as permanent erectile dysfunction and depression, while others praise it as the best cosmetic “medication available – a “happy pill. Personally, as someone who took it for years, I think it falls somewhere in between.

Its side effects are considerable and run the gamut from the subtle (difficulty sleeping) to the overt (erectile dysfunction). The original clinical trials for its approval reported very low rates of side effects, which have been repeatedly held up as proof that the many people complaining about its adverse effects are lying. At the same time, its benefits are slight compared to other “lifestyle” drugs such as Accutane, which while boasting an even worse side effect profile can dramatically resolve cystic acne for good; in contrast, finasteride must be taken continuously just to preserve the status quo.

The experience of taking finasteride reminded me of taking antidepressants years ago. I remember feeling lousy on both medications and attributing my feelings to them not having kicked in yet. In reality, they were the sources of my problems, including loss of sex drive and weight gain. I only learned years later that estimates of their sexual side effects in particular were vastly underestimated; my prescribing psychiatrist refused to believe they could have these effects, but later research has drawn similarities between the long term health issues caused by SSRI inhibitors snd finasteride, both of which have complex effects on the brain.

In any case, finasteride’s side effects piled up for me over time, culminating in higher blood pressure and substantial weight gain yet again. I quit cold turkey and felt the same liberation I had back in 2006 when I ditched antidepressants and entered a much better phase in my life.

Finasteride is not an essential medication, even for its other indication for benign prostatic hyperplasia. It doesn’t save lives. Its potential for side effects, especially over the long term, and the possibly wide extent of these effects in the central nervous system and the liver give me pause. I don’t trust it anymore and so I won’t be taking it again. I wouldn’t recommend it to anyone unless he was truly desperate, as apparently I was years ago when I started.

Stopping it has freed from fretting so much about my hair, a concern whose hold on me I didn’t even appreciate until I finally let it go. I still do a few minor things to keep it styled and looking healthy, but if it goes, so what? I feel like hair anxiety is such a 20-something thing and, moreover, such a straight thing – so many message board posts about balding are about “oh women won’t like me anymore once I’m bald.” This doesn’t apply to me, obviously, as a married gay man in his 30s. I don’t want to be chasing my youth instead of simply accepting aging and being grateful for an ongoing healthy life.

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