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Making Headway

Oh, the dreaded male-pattern baldness. Chances are it’s happening to you, or at least it’s going to. Whether we like it or not, about 50 percent of men will experience some degree of hair loss by age 50.

That frustratingly conspicuous sign of aging is caused by shrinking hair follicles in certain areas of the scalp. The presence of a chemical called dihydrotestosterone (DHT) is the signal that tells these hair follicles to rest and collapse. DHT is a natural by-product formed during the metabolic breakdown of testosterone, and it’s not terribly useful to adults beyond causing hair loss—as far as we can tell.

Of course, there are lots of medical reasons people lose hair. Thyroid disease, syphilis, stress and immune disorders can all do it. But generally the diagnosis of androgenic alopecia (male-pattern baldness) is pretty obvious on inspection of the scalp. With time, it tends to get worse, and there are many things guys do to try to disguise and treat their hair loss.

One of the more controversial treatments is called finasteride (Propecia) and, not surprisingly, I get asked about it all the time in my clinic.

Finasteride is a molecule that blocks the conversion of testosterone to DHT throughout the body. It was initially used to treat enlarged prostates, since a second annoying feature of DHT is that it overstimulates prostate cells. It was later noted that finasteride was effective for reversing hair loss, and so several large studies were conducted to test it out. The results showed that two thirds of men had an increase in hair counts after two years.  One third had the same amount of hair, and only one percent lost hair. This was dramatically different from the group who received a placebo pill. Researchers also found that finasteride improved the colour, length and thickness of each individual hair.

There’s no question that finasteride is effective; the controversy comes from the potential side effects. Even though finasteride shouldn’t interfere with the function of testosterone, we sometime see problems with erectile dysfunction and decreased libido. In general the risk of these is very low, but some men will have issues with sexual dysfunction that persist even after the medication is stopped. There are also reports of men developing depression, testicular pain and enlargement of breast tissue.

On the upside, the anti-androgen effects of finasteride have been shown to prevent prostate cancer. Those few people who did develop cancer while on the drug tended to have a higher grade of cancer, but after 10 years, there was no difference in survival between those taking active medication versus placebo. So the potential for use as a cancer-prevention tool are still up in the air. The manufacturer of Propecia did apply for a patent on a liquid version of finasteride many years ago—presumably with the hope that topical use may mitigate some of these adverse effects. As it stands, there are no topical preparations currently available.

Despite the risks, I am quite comfortable prescribing finasteride to patients who want it. Similar to the studies, I’ve seen very few side effects in my clinic, and generally people are happy with the results. And while it might decrease your chances of developing prostate cancer, remember that taking finasteride doesn’t exclude you from regular prostate checkups. In fact, extra care must be taken to make sure small cancers don’t get missed.


Dr. Malcolm Hedgcock is a Toronto-trained family doctor living and working in Vancouver. He has a special interest in gay men’s health issues, including the primary care of those living with HIV and AIDS.

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