NEW YORK (Reuters Health) - Men who report persistent sexual symptoms after using finasteride for hair loss do not show abnormalities in androgens or their receptors, according to a new report.
Because of reports of persistent sexual symptoms, low mood, anxiety, and cognitive complaints in some men who used finasteride for hair loss, its label includes a warning about persistent libido, ejaculation, and orgasmic problems after discontinuation of finasteride.
Despite the large number of men who report the symptoms, as well as ongoing litigation and an abundance of anecdotal information available on the Internet, these claims have not been rigorously investigated, researchers note in The Journal of Clinical Endocrinology & Metabolism, online September 23.
Dr. Shalender Bhasin from Harvard Medical School in Boston and colleagues compared 25 men who reported persistent sexual symptoms after discontinuation of finasteride therapy for hair loss with 13 men who were finasteride users but did not experience symptoms and 18 healthy men who had never used finasteride.
Serum total and free testosterone, dihydrotestosterone, luteinizing hormone, follicle stimulating hormone, estradiol, and sex hormone binding globulin levels were within the normal range for healthy young men and did not differ among the three groups, the team found.
The groups did not differ in markers of peripheral androgen action or in androgen receptor and steroid 5-alpha reductase genes.
Men with persistent symptoms after finasteride use had significantly worse International Index of Erectile Function (IIEF) composite and individual domain scores, compared with the other two groups of men.
Depression scores were significantly higher in men with persistent symptoms after finasteride use than in other men, and these scores were not significantly related to either the duration of finasteride treatment or to the time elapsed since the discontinuation of finasteride treatment.
Symptomatic men were also more likely than men in the other two groups to report subjective memory complaints.
The groups did not differ significantly in body composition, strength, or physical function.
Functional MRI experiments identified underlying neurobiological abnormalities in symptomatic finasteride users, which could be linked to circuitry that has been implicated in both depression and in sexual arousal.
"The clinical implications of these findings are that symptomatic finasteride users are unlikely to benefit from treatment with testosterone, DHT, or any other androgen because these patients do not have evidence of androgen deficiency, persistent SRD5A inhibition or androgen insensitivity," the researchers conclude.
"Attention may be focused instead on the treatment of depression and sexual symptoms," they add. "Furthermore, as men seeking treatment for alopecia have higher prevalence of depression and sexual dysfunction than the general population, it would be appropriate to ascertain history of depression or sexual dysfunction before starting treatment."
Dr. Ralph M. Trueb from Center for Dermatology and Hair Diseases at the University of Zurich, Switzerland, told Reuters Health by email, "Personally, I don't find the results surprising, since I anticipated that there would be no evidence of persistent abnormalities of androgen metabolism or expression levels of androgen-dependent genes in the skin, but rather of an underlying psychiatric disorder, such as depression, in patients with persistent sexual symptoms after finasteride use for hair loss (so called post-finasteride syndrome)."
"The frequency of depression as an adverse effect of oral finasteride treatment is accordingly significantly higher in a psychiatric than in a dermatologic setting," he added.
"As yet, the post-finasteride syndrome is not recognized by the scientific community, although individuals who suffer from the syndrome do present with very distinctive and relatively homogenous symptoms," Dr. Trueb said. "Since up to date there is no predictive factors for the risk of development of post-finasteride syndrome and no known treatment for the disorder, for the time being, as a general rule, one should refrain from prescribing oral finasteride to a patient with a personal history of depression or sexual dysfunction."
Dr. Alan Jacobs from Hunter-Bellevue School of Nursing in New York, who specializes in helping men with post-finasteride symptoms, told Reuters Health by email, "By far, the most surprising result of this study is the lack of any measured difference in the levels of testosterone between the 3 groups, and the subsequent conclusion that treatment with hormones is not of value in post-finasteride syndrome (PFS) patients."
"My experience is the exact opposite, and the reason is that this group amazingly failed to use bioavailable testosterone, which is a measure of the free and weakly bound fractions of the man's testosterone pool, and excludes the SHBG-bound portion, since this latter portion is unavailable to the tissues and total testosterone does not correlate at all with men's clinical symptoms, and nor does free testosterone, as it represents only 3% of the total pool," he said.
"I universally find PFS men with clinical hypogonadism and an abnormal hormone profile diagnostic of hypogonadotropic hypogonadism (HH), and optimization of this, with control of estradiol levels, quite often yields meaningful sexual and emotional benefits to these men," he said.
"As for what to make of the findings," Dr. Jacobs said, "I strongly advise men to lose any nihilism and seek quality neuroendocrine assessment and treatment for their PFS. Moreover, the fMRI findings, whether causal or an effect, add to my view that men with emotional disorders, or family histories of emotional disorders, may be more at risk for injury from finasteride and probably should avoid it."
Dr. Bhasin did not respond to a request for comments.
SOURCE: http://bit.ly/2dRTAB9
J Clin Endocrinol Metab 2016.
