By Allison Romero, DPT
“If you “play with sex steroid hormones” using finasteride (propecia) – the goal of finasteride (propecia) is to reduce the synthesis of the sex steroid hormone – dihydrotestosterone – then you will likely “play with your sex life” – as sexual function is very much related to sex steroid hormone levels”, says sexual medicine expert and urologist Dr. Irwin Goldtsein.
Propecia (aka finasteride) is the only FDA-approved oral drug on the market prescribed for treating androgenetic alopecia-more commonly called male pattern baldness (MPB). Unfortunately, many unsuspecting men concerned about hair loss do not know that using Propecia can result in side effects much more devastating than a bald spot. At PHRC, we are seeing increasing numbers of men with sexual dysfunction following Propecia use. If you are considering taking Propecia you need to read this article.
MPB is widespread.
According to the American Hair Loss Association, by age 35, 66% of all men have experienced some degree of hair loss and by age 50, approximately 85% of men have significantly thinner hair. Roughly 33 million men. This is a huge number! And, until the late ‘90s most men reported that they felt that physicians were dismissing their concerns about hair loss. For some men, hair loss can cause serious psychological distress. Researchers at Charité – Universitätsmedizin Berlin, one of the largest university hospitals in Europe, found that MPB can result in decreased self confidence, depression, anxiety, and impaired quality of life. This is a troublesome issue and the reality is that there are not that many affordable and/or effective options for people going through this.
So when Propecia was approved by the FDA to treat MPB in 1997, it was momentous. Millions of men began taking it since that time, with countless individuals having utilized it to combat hair loss. What’s more is that during the period it is being taken, it actually works! But as always, there are side effects to consider. Thus, it is in situations like this that we need to ask ourselves, do the benefits outweigh the potential costs?
Before we go into the side effects of Propecia, let’s first discuss the mechanism of how this drug works: it prevents the conversion of testosterone into dihydrotestosteorne (DHT) which is the active form of testosterone in hair follicles and in the prostate. What does that have to do with hair loss? While scientists have yet to fully understand the mechanism of MPB, they do know that it is largely genetic and those who have inherited this condition have hair follicles that are sensitive to DHT. As these hair follicles are exposed to DHT over time, they begin to shrink, decreasing the integrity and lifespan of these follicles until eventually they become dormant and stop producing hair. So when Propecia is introduced to our system, it stops testosterone from breaking down into DHT, which significantly reduces the amount of DHT in the body. Now the hair follicles that are present can thrive and produce hair–problem solved.
But there’s a hitch…
Although Propecia has been proven effective for treating MPB, our patients will tell you that the most common side effects greatly override any benefits. Propecia use can cause erectile dysfunction, decreased libido, and a decrease in semen production. A large percentage of men that take Propecia have reported these symptoms. The Journal of Sexual Medicine published a study that interviewed 71 men recruited from propeciahelp.com, ranging in age from 21 to 46 years. “Subjects reported new-onset persistent sexual dysfunction associated with the use of finasteride [Propecia]: 94% developed low libido, 92% developed erectile dysfunction, 92% developed decreased arousal, and 69% developed problems with orgasm.” The study also found that the average number of sexual episodes per month was lower and the “total sexual dysfunction score increased according to the Arizona Sexual Experience Scale (P < 0.0001 for both).” The average length of Propecia use was 28 months and the average duration of persistent sexual side effects was 40 months from the time of discontinuation.1
Obviously these side effects are a serious problem for men. Erectile dysfunction is known to be a major cause of decreased quality of life in men. A clinical series published in 2012, found that 89% of the sample size (n = 54) reported some degree of sexual dysfunction with the use of Propecia. 20% of subjects who had used Propecia to treat MPB reported persistent sexual dysfunction for ≥6 years. This same study found that most men who developed persistent sexual side effects lasting ≥3 months with the use of Propecia continued to experience erectile dysfunction for many months or years despite stopping the drug, which lead the researcher to suggest the possibility that the dysfunction may be permanent.2
A retrospective analysis using the the US Food and Drug Administration Adverse Event Reporting System data was published this month. Disturbingly, low-dose finasteride was associated with reports of sexual dysfunction that were more than expected. Among the reports of serious sexual dysfunction, 43% led to disability, 28% required medical intervention (including hospitalization) and 5% were life-threatening.3
We asked some of the nation’s leading specialists on sexual medicine to give us their take on prescribing Propecia as a treatment for MPB and here is what they had to say:
Dr. Seth Cohen, urologist and sexual medicine specialist in NYC stated: “Propecia is a scary drug that should be cautiously used after exhausting all other treatments for MPB. Propecia or 1mg of finasteride irreversibly binds to the enzyme 5 alpha reductase (the enzyme that converts testosterone to dihydrotestosterone) irreversibly turning the enzyme OFF causing DHT levels to plummet close to zero. Signs of Post Finasteride Syndrome (PFS) include mood swings, mental fog, depression, anxiety, erectile dysfunction, orgasm and ejaculation dysfunction. This is a scary drug and we have no idea who might be affected worse by it. Some men taking propecia for MPB seem to have little to no side-effects, whereas others suffer for years. In addition, many doctors don’t understand or even recognize PFS as a real disease and these patients will suffer alone. Luckily, social media and the internet have been able to provide a safe haven for these patients. Propeciahelp.com is a great resource for men suffering from PFS.”
Dr. Joshua Gonzalez, urologist and sexual medicine specialist in Los Angeles, states: “ I will not prescribe finasteride to young men with MPB because of the potential side effects. In my clinical experience, the length of time on the medication does not correlate with the severity or duration of the side effects. There are numerous hormonal and nonhormonal treatment options for men with PFS.”
Find Your Solution:
An individualized, interdisciplinary approach to treatment will result in the best outcome. First, find a physician with a particular interest in sexual medicine. The Sexual Medicine Society of North America offers a ‘Find a Provider’ link on their website: SexHealthMatters.
Pharmacologic treatment options include hormonal regulation, antidepressants, and psychostimulants, all of which should be brought up with your physician.
Nonpharmacologic treatment options include psychotherapy, meditation, and pelvic floor physical therapy. We know that musculoskeletal health of the pelvic floor is necessary for erectile function and orgasm. So, even if the primary cause of erectile dysfunction is due to hormonal changes caused by Propecia use, there is evidence to suggest that pelvic floor muscle strengthening can improve erectile function and orgasm intensity. A pelvic floor physical therapist can evaluate the musculoskeletal structures associated with sexual function and provide you with a treatment plan to address any and all areas that are impaired.
Finally, know that you are not alone. Many men are dealing with the adverse effects of taking Propecia and while the medical community is still working on perfecting the most effective plan for treating these issues, it may help to be able to connect with others that may be going through a similar situation. Online support groups are available at these websites: Post Finasteride Syndrome Foundation and Propeciahelp.com.
Each person will have a different combination of symptoms and treatment needs which will affect the prognoses. Stay persistent and work closely with your health care providers until you find the therapeutic combination that is right for you.
Allison Romero, DPT
Allison earned a bachelor’s degree in kinesiology at Sonoma State University and then attended the University of Southern California where she received a doctorate in physical therapy. Allison is currently part of our Berkeley team, where she treats both adult and pediatric patients. Outside of the office Allison loves to spend time reading, trying out new restaurants, and learning to be handy around the house.
- Irwig, M. S. and Kolukula, S. (2011), Persistent Sexual Side Effects of Finasteride for Male Pattern Hair Loss. Journal of Sexual Medicine, 8: 1747–1753. doi:10.1111/j.1743-6109.2011.02255.x
- Irwig, M. S. Persistent sexual side effects of finasteride: could they be permanent? J Sex Med. 2012 Nov;9(11):2927-32. doi: 10.1111/j.1743-6109.2012.02846.x. Epub 2012 Jul 12.
- Ali AK et al Persistent Sexual Dysfunction and Suicidal Ideation in Young Men treated with Low-Dose Finasteride: A Pharmacovigilance Study, Pharmacotherapy, July 2015.
- Laumann, E., Paik, A., et al. Sexual Dysfunction in the United States: Prevalence and Predictors. JAMA. 1999;281(6):537-544. doi:10.1001/jama.281.6.537.