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Finasteride (Propecia) For Hair Loss

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Finasteride (Propecia) For Hair Loss explained by Dr. Gary Linkov. Find out what the side effects of finasteride are, how it is used for hair loss, and if finasteride really works for hair loss!

Hey guys dr gary here i know you’ve been waiting for this video this is on finasteride the outline of this talk is the history the mechanism of action of finasteride the efficacy the topical use of finasteride the decision between dutasteride and finasteride the side effects which i know are very important to talk about here post-finasteride syndrome we’re gonna

Tackle it i know it comes up a lot people are very worried finasteride for women finasteride and hair transplant and make sure you watch till the end of this video because we’ll be covering post finasteride syndrome in as much detail as i could find in literature and trying to give a balanced opinion on that and it’s something that i get asked about a lot and also

How finasteride plays into hair transplant decision making so keep in mind that this is part of our series on non-surgical hair restoration we have also many surgical videos on hair transplants but this is for the non-surgical side of things and just a reminder that with medical therapies whether it be like a pill or a topical or something like prp a procedural

Type of treatment these are all things that you need to be continued in order to continue to see beneficial effects it’s not one and done like with surgery so that’s just something important to keep in mind and i generally recommend at least two modalities of medical therapy when you’re considering you know hair maintenance and regrowth let’s go through some

Brief history of finasteride finasteride was first used to actually reduce benign prostatic hyperplasia or bph by reducing the volume of the prostates this is a situation where usually you know of course men have larger prostates and they have difficulty urinating so if you’re able to shrink down the prostate with the use of this drug then they feel better

And it was approved in 1992 in the u.s for the use of bph then in 1997 it was also approved for the treatment of androgenic alopecia so now let’s talk about the mechanism of action of finasteride testosterone is first synthesized in the lydic cells of the testes and it enters the prostate gland where it’s subsequently converted to dht or dihydrotestosterone and

This reaction of testosterone being converted over to dht is catalyzed by a membrane-bound enzyme called 5-alpha reductase and dht binds then to the androgen receptor and this is what causes the miniaturization of the hair follicles finasteride is a competitive and specific inhibitor of 5-alpha reductase and it’s specific for the type 2 form of 5-alpha reductase

There’s three types of five alpha reductases in our bodies type one two and three so finasteride targets type two five alpha reductase and in so doing it’s blocking that conversion of testosterone to dihydrotestosterone okay so that’s the mechanism of action and for androgenic alopecia it’s typically taken orally at a dose of one milligram per day and by taking

It in that way it has been shown to rapidly lower serum and scalp dht levels by over 60 percent and as you take finasteride it will stabilize hair loss and promotes hair regrowth so some would argue that propecia which is the brand name of finasteride is actually more effective than generic finasteride because the generics are made in different places around the

World that sometimes have quite varied manufacturing protocols and even though there’s the same active ingredient the efficacy of the actual medication has been shown to sometimes be quite different so now how effective is finasteride especially compared to minoxidil and we’re going to display this graph that i found in a really nice review article from 2017 and

It’s been shown to essentially be this is many many different studies compiled into this uh graph and it’s been shown to be almost twice as effective in increasing hair density and thickness and this is based on many many different studies so again finasteride is going to be more effective for you in general again every individual might be a little different but

On the whole finasteride more effective than minoxidil and that’s again why it’s such a commonly prescribed medication especially for someone who’s looking to stabilize their hair loss so that’s why we recommend it for a lot of people right it’s not because it’s one of those things out there it’s actually one of the most effective things out there guys make sure

To subscribe to the channel if you’re not subscribed already and turn on notifications we have a lot more videos in store for you and most of the people who watch our videos are not subscribed so why not just hit that button thank you so much now let’s talk about the topical formulation of finasteride this is off-label use right now has not been fda approved for

Hair loss it has been shown to be safer in patients who especially are looking to avoid those systemic side effects of finasteride currently the topical formulations of finasteride that have been tested are gels and solutions at varying concentrations and all of them which have been tested and obviously reported on have resulted in improved hair growth which is

Great but remember people aren’t going to be publishing the negative studies right there’s a publication bias there just something to keep in mind so far so good the early studies do show some promising results and topical finasteride does appear to be at least non-inferior to the systemic oral finasteride for hair regrowth which is very promising and it can be

Applied alone or in combination with minoxidil you can also combine finasteride with minoxidil and or detasteride and that’s been shown to be more effective at hair regrowth than topical minoxidil alone so there’s a study that shows that and in terms of the doses you’re looking at 100 microliters 200 microliters of topical finasteride which is concentration typically

Of about 0.25 percent solution and that’s applied daily and again it appears to be fairly effective from what we see so far we don’t yet know the most effective concentrations and frequencies and all that but the most frequently done application protocol is that 0.25 concentration and 100 microliters to 200 microliters we need more studies we need more studies

To determine the efficacy of long-term hair regrowth from topical finasteride how safe it is cost effectiveness patient tolerability and satisfaction that’s still pending the final verdict on it but the early studies do look promising which is great now what is dutastriate you may have heard of that so of the three isoforms that i mentioned in the beginning of

The talk of the five alpha reductase dutasteride inhibits not just type 2 like finasteride but also type 1. so it inhibits both type 1 and type 2 5-alpha reductase dutasteride has been shown to be 3 times more potent than finasteride at inhibiting type 2. 5-alpha reductase and 100 times more potent at inhibiting type 1 because finasteride doesn’t really inhibit

Type 1. it’s dosed at 0.5 milligrams per day and at that dose it can reduce dht serum levels by upwards of ninety percent and compare that to the seventy percent from finasteride and the efficacy for hair regrowth is even higher at the higher doses of dutasterides if you go from zero point five milligrams to 2.5 milligrams per day the studies show an even greater

Improvement for hair regrowth so why are we all doing that because the side effects are also worse so there have been studies that have pointed to a higher incidence of side effects from dutasteride especially as you go to those higher doses so it’s more effective but higher you know risk of side effects while the use of detasteride for androgenic alopecia is off

Label in the united states it’s actually approved in south korea and it has been since 2009 at the 0.5 milligrams per day dose so they have i guess enough data as far as their agencies concern their equivalent of the of the fda to have approved that medication at that dose but again the side effect profile in general at any dose is worse than for finasteride and

We’re going to put up a graph here to show you guys sort of the side effect and efficacy dilemma i would say of finasteride and do test ride so as you go from finasteride to dutasteride up into the higher doses of dutasteride the efficacy goes up but so do the risks of side effects the question also that i get a lot is how long do i need to be on finasteride for

As long as you want to maintain your hair in that dht sensitive zone so that’s going to be that frontal mid scalp and crown area so for as long as you want to maintain that hair you need to be on the pill and that goes for all forms of medical therapy now let’s get into the side effects of finasteride most commonly reported side effects as many of you have heard

Of are sexual side effects that includes erectile dysfunction ejaculatory dysfunction and the loss of libido and all the studies on a whole for finasteride you’re looking at about a two percent risk of those sexual side effects it has been shown finasteride to actually lower the risk of prostate cancer and that remember is partly due to the effects on bph as we

Talked about in the beginning of the talk but it can increase the risk of high grade prostate cancer so lowers the risk in total of kind of all prostate cancers except for the high grade it can actually potentiate that type of cancer so that’s again one of those things to to keep in the back your mind depression has been associated with the use of finasteride and

The theory there is that by decreasing dopamine levels you actually are leading to some forms of depression and we have a table here that will show from one of the papers and the side effect profile is actually very similar from finasteride one milligram to finasteride five milligrams so some patients i know they’re worried about even one milligram they’ll cut it

Down to 0.5 milligrams based on a literature review that i’ve done and that i’ve seen there’s really no major benefit most of the studies that are you know done on and for androgenic alopecia are with the one milligram dosage so i would just kind of stick to that if you’re going to take finasteride and the side effect profile for finasteride is worse than men who

Are starting at lower baseline testosterone levels so some people recommend actually checking your testosterone levels before starting this pill and using that as a parameter to decide on whether or not you should take it or not so that’s that’s one other way to go so let’s get into what is post finasteride syndrome this is something that’s in a lot of the forums

Online and people are just worried about it post finance heart syndrome is the occurrence of persistent adverse events including sexual dysfunction and depression in a subset of men who have used five alpha reductase inhibitors such as finasteride and it is important to point out that in 2012 the fda in the u.s required that for finasteride labels they include

Multiple persistent side effects in the past before that that wasn’t a thing no one recognized it now you know people started to at least over the last 10 years it is difficult to size up this syndrome partly because of the multifactorial background of the adverse events partly because of the subjective criteria of diagnosis and also because of the variable reporting

A lot of the studies they didn’t really necessarily ask those questions and they didn’t have the mechanisms in place to figure out if that was really something that was happening to people later on after they stopped finasteride or not but also equally important to point out that sexual dysfunction and depression are sort of common things that also co-exist in

Patients who have never been exposed to finasteride and it’s not always something that’s elicited at the beginning of the study so if you’re finding out later on so you do a study a year later you pull everyone p some people have stopped finasteride and they’ve developed this post-finasteride syndrome but the study never asked them beforehand right at the start

Of the study do they have any sexual issues do they have any depression or anything that might be later related to the depression that they developed you know so that’s part of the problem with figuring out you know how real the syndrome is or how high the incidence of it is i think we know by now that it’s real but we don’t know how prevalent it truly is and the

Other important point to bring up is this nocebo effect it’s the opposite of a placebo effect it’s the notion that if you’re told that you might have a negative experience with something that your risk of having that negative experience goes up so if all you read in the forums is about this post finasteride syndrome and how bad it could be and all these things

That could go wrong when you actually get started on finasteride you might have a higher risk of developing these issues compared to someone who’s never really heard of it or where those risks were kind of minimized to them early on which is interesting i’m not saying we should minimize the risk or not inform people fully before offering them the medication but

It is an interesting phenomenon so there was a study that when patients were treated with finasteride and informed about a possible sexual dysfunction caused by the therapy nocebo effect was significant the fact of the information being given to them at the beginning of the treatment caused a 14.3 percent increase in the reported sexual side effects so it’s a real

Effect and it’s something to keep in mind the other thing to point out there’s a study from 2017 that looked at side effects of finasteride and we’re going to we’re going to scroll through the charts that they have at the at the end of the study and highlight the the column that is showing you the persistent side effects and if you look and you see there are very

Few out of all the studies that this one paper looked at which was many 20 30 studies and there were very few that report on persistent side effects or that had any persistent side effects from the use of finasteride so it is uncommon it is not something that will likely happen to you but there is some remote chance of it happening that’s i guess the best way to

Frame it and there’s even this post finasteride syndrome foundation in summit new jersey that is like a whole support group and they do a lot of other non-profit activities related to this type of scenario so if you want to learn more you can go on their website so is finasteride safe overall yes many people are on it many people have been on it for decades can it

Cause sexual side effects yes if the side effects develop stopping the medication will almost always reverse the side effects that’s what i gather from the review of the literature of course if you’re one of the unfortunate ones to have developed post-finasteride syndrome you know you’re going to have a much stronger opinion on what i just said so given the remote

Possibility of post-finasteride syndrome the individual who is considering starting this pill really needs to properly balance the pros and cons before you know going on the pill and they need to do this in consultation with a trusted doctor now in terms of finasteride for women the evidence is overall positive for the efficacy of finasteride in women though there

Are some randomized studies that actually show no improvement in women and in women who may or may not be pregnant the main risk is birth defects in the male fetus and therefore it should generally be avoided in this group so women who are pregnant or who may become pregnant it’s usually reserved for postmenopausal women primarily you know that’s the only kind of

Group of people that i would consider giving finasteride to and the side effects are somewhat similar with some added ones as well decreased libido is the primary side effect in women along with occasional risk of headache and gi discomfort and finasteride is definitely not the first choice in women for hair restoration but it may be a helpful adjunct for some so

Now let’s just finish off here with the connection between finasteride and hair transplants this is where it gets interesting because a lot of hair transplant surgeons like myself are very pro finasteride because we’re thinking about the final kind of hair result for someone who’s interested in a hair transplant assuming they’re a candidate for a transplant some

People should just start with finasteride or some other medical therapies and they’re not transplant candidates but for those who are especially for those who are under 45 we really rely heavily on maximizing medical therapy to prevent the loss of native hairs because if you have continued loss of your native hairs it’s again that analogy of having a bucket of

Sand you’re pouring sand in but there’s a big hole at the bottom eventually you’re going to run out of sand right so that’s exactly the the look of your hair on your head so we want to preserve what you have with the use of something like finasteride and then augment and on top of it or add it to places where there’s no existing hair with a hair transplant so

Finasteride is really a major part of medical management in every practice and for a younger patient who is interested in a hair transplant but who’s not interested in finasteride it could complicate matters and we just have to be extra cautious because we don’t want to do a large procedure and then they lose all their existing hairs because they don’t want to do

Anything to stabilize it and then it’s a poor result at the end of the day if they don’t want to do finasteride they want they don’t want to be on the pill because the side effects there are some other medical therapies and you can look at you know watch our other videos to find out more we have one nice video out already on minoxidil another one on microneedling

For hair restoration so those are all other options and there are even more options and we’ll be covering those in subsequent videos but they are not as effective as finasteride in preserving your existing hair so it’s just something to think about i hope you enjoyed this video on finasteride if you did please make sure to check out my video on minoxidil click the

Card and i will see you there thank you so much

Transcribed from video
Finasteride (Propecia) For Hair Loss By Dr. Gary Linkov City Facial Plastics