Dear Dr. Rassman,

I found this blog a very interesting read, and I appreciate you taking the time to answer questions online like this. It has been a wonderful resource in coming to terms with the somewhat shocking discovery of my hair loss.

I am about to start treatment with propecia for my thinning top, but there’s something that has been nagging me:

I want to heed this blog’s earlier recommendation and wait until after a year on propecia before trying Rogaine. But isn’t it “the earlier, the better” even with propecia working in the background? Wouldn’t this delay risk my potential for improvement? Wouldn’t it risk killing miniaturized or dormant hair?

It is my hope to completely eliminate the visible thinning with medical treatment. I realise my odds aren’t super great, but I also feel it wouldn’t take much improvement to achieve this. My hairline has receded to mature levels but seems stable. I will be 25 this year and I only noticed my thinning a month ago.

Generally, when I recommend a medical treatment for androgenic alopecia (AGA), I only have two proven medications I can recommend: (1) Rogaine (topical minoxidil), and (2) Propecia (oral finasteride 1mg). While you can start taking both treatments at once, it would be difficult to assess which medication had more or no benefit. So I usually give the patient a choice on one medication and they use it for 6 to 12 months to assess how it is helping their hair loss issue before we add on the second medication.

Also, in practical (real world) terms, it is a hassle for men who are not used to taking any medication to stick with the regimen of taking a pill every day (Propecia) and putting on a topical medication twice a day (Rogaine). Before they know it, most patients get lazy, forget to take the medication, or forget to resupply the medication when they run out. I find that in a good percentage of time, the failure of a medication is related to the poor compliance issue. This not only applies to Propecia, but many other medications.

So yes, while starting both at the same time allows you to potentially see your maximum benefits begin sooner, it’s a lot for most men to keep up with every day. And who knows — since you just noticed your thinning, only one of the meds might be all you need.

Hi Dr.Rassman, what are your opinions regarding the safety and effectiveness of topical spironolactone? Is it a safe alternative to proprecia or does it pose harmful side effects?

It does work for the treatment of balding, but the side effects are significant and far more common than Propecia, including the scope of side effects.

Spironolactone causes an increased risk of bleeding from the stomach and duodenum, gynecomastia, and testicular atrophy (kills off the testicles or makes them smaller and less effective). Erectile dysfunction would be common and it can cause a serious rise in potassium in the body (hyperkalemia). The side effects and complications go on and on.

It should never be used to treat the benign condition of male pattern hair loss.

Dear Dr.

Link: Study Shows Saw Palmetto Extract Does Not Improve BPH Symptoms

It says: There is no different between Saw Palmetto and Placebo. if it’s correct, then maybe there is absolutely no benefit for inhibiting 5-alpha-r/DHT? Please tell us your comment. thank you.

I believe if you search BaldingBlog over the years, we have always maintained that saw palmetto is just an herb and there is no scientific proof of its efficacy (for MPB or BPH). Informal studies, differing dosages, and duration of use have all been issues with clearing up once and for all if saw palmetto does anything to treat hair loss.

Regardless, as I have said too many times here, “Buyer beware”.

Dear Dr. Rassman:

I am a bit concerned about continuing with Propecia in light of the recent finding on the risk of high grade prostate cancer. At the FDA hearing in June of last year, the FDA statistician estimated that the risk of getting high grade prostate cancer using 5mg of Finasteride over a 7 year period was 1 in 200. I realize that Propecia is one fifth that, but even a 1 in 1,000 risk when it comes to an aggressive cancer seems, well, risky. If you told me that there was a 1 in 200 or 1 in 1,000 chance the plane I was about to board would crash, I would not board. So, my question is this: is there anything in the study you see that makes you think it’s safe to keep going with this drug?

I believe you are reading things out of context. The FDA site states:

“The labels of all 5-alpha reductase inhibitors (5-ARIs) are being revised based on FDA’s review of two large studies examining whether these drug products (Proscar, Avodart) reduce the risk of prostate cancer. The studies did find an overall reduction in the risk of lower-grade forms of prostate cancer, but both studies also showed an increased risk of high-grade prostate cancer.

As a result of these two studies, the labels of all FDA-approved 5-ARIs will be revised to include new information that these drug products may increase the risk of high-grade prostate cancer. The product labeling will also state that 5-ARIs are not approved for the prevention of prostate cancer.” [Source]

I did a quick Google search and found prostate cancer statistics, unrelated to finasteride use. “Based on rates from 2006-2008, 16.48% of men born today will be diagnosed with cancer of the prostate at some time during their lifetime.” That is about 16 in a 100 or 1 in 6 men.

My point is: Propecia does not cause cancer. The studies that the FDA quotes and the media has latched on to point to how those men who ended up with prostate cancer while on finasteride had a higher grade prostate cancer than men who did not take finasteride… but the controversy of why this is, was not clear from the studies.

A final point is that if you are concerned about the medication, you do not have to take it. It is an option I give to all my patients. This is one of the many reasons why a doctor should prescribe you the medication, because each and every patient is different and the prescribing doctor should be there to address all of these issues one on one with the patient.

What if I take Propecia for a while and then get side effects? Do I just stop taking it or should I take less of it?? I havent had any issues yet but I just want to know what I should do if I have good effects from Propecia and then see bad effects down the road. Thanks

One of my patients (age 43) spoke to me about the developing sexual side effects of Propecia. He has been on the drug for 10 years and his libido seemed to slowly reduce over the past year or two. While it is possible that the libido change was influenced by his age, I recommended that he reduce the finasteride dose to 0.25mg.

The idea was that if that reduced his sexual side effects to a level he is satisfied with, he can up the dose to 0.5mg. He did this over a two month course (one month of 0.25mg and one month of 0.5mg). Now the sexual side effects he has had in the past at the 1mg level, have disappeared. He hasn’t reported any benefits from the medication disappearing, which was one of his biggest concerns. It’s only been a couple of months, though.

I’m not suggesting this is the proper course for everyone, and you should talk to your prescribing doctor about changes to your medication.

It’s summer here in Australia and I’ve been keeping my Propecia in the refrigerator because it says store below 30 degrees celsius on the packaging. I recently read that it actually needs to be stored between 15 and 30 degrees. Does the drug become ineffective when it’s stored outside it’s recommended temperatures? I’m concerned because fridge temperature is obviously under 15 degrees (usually around 4 if I’m not mistaken).

Thanks! This site is such a great resource!

I’ve answered a similar question about the medication freezing after being left in a car overnight, and years ago I did answer a similar question about storing it in the refrigerator.

Ideally, it should be kept in a dry place at room temperature. If you are concerned that you’ve rendered your Propecia ineffective, talk to your pharmacist about replacing the pills.

Dr. Rassman:
What is your opinion on Rogaine? Do you think it should be used with Propecia or is Propecia by itself sufficient?

Some people use both together, but I recommend using one at a time so you can figure out which one is providing benefits. If you see some results from Propecia, you can add Rogaine later to try for a maximum benefit. If you start with both and see results, you’re committing to a lifetime of using both medications (otherwise you won’t know which one is providing the results).

Rogaine can work, but I’ve seen better results from Propecia… particularly in men with early hair loss.