I tried taking Proscar, cut into quarters, for 3 months and at the three month mark quit as I felt I was experiencing side effects (frequency of erections dropped drastically, morning wood gone, very difficult to maintain an erection, etc.) After quitting, within approximately 2 weeks I felt that sexual functions were back to normal. I had done tons of research prior to taking it, and was very worried about sexual side effects, and cannot rule out the possibility that the side effects were psychological in nature; however, the lack of morning wood I felt to be pretty significant.

I can’t get the idea of trying it one more time for a little longer than 3 months out of my mind. If I were to try it again, would you recommend sticking with 1/4 a pill a day, or do you think I could get by with taking 1/4 a pill every other day or just on Monday, Wednesday, Friday?

It does not sound like your erections have been “tested in the field”. Just the absence of morning erections does not fit the “field test”. The libido issues certainly could’ve been prompted from psyching yourself up about side effects, but it would be impossible for me to say one way or the other. I don’t know how old you are or anything about your medical history, but there’s some info at WebMD that you might find interesting.

In general, you can try a lower daily dose to see if that helps, but you need to discuss this with your prescribing doctor.

Hello doctor William

why don’t doctors ever mention that testosterone by its self can cause hairloss as well. I know its metabolite DHT is more potent at causing hairloss but we all know testosterone on its own can cause hairloss as well.

I mentioned this before, propecia increases testosterone by about roughly 15%. A persons front region/temple/hairline is more sensitive to testosterone and has more testosterone receptors.

Doctors always fail to mention that propecia has a possibility to accelerate hairline thinning. Yes it help the crown but at the expense of the hairline. For example if a person has mild hairloss, then by simply taking propecia it will jump start his hairline thinning.

I enjoy a good conspiracy as much as the next guy, but come on…

Doctors do not mention testosterone causing hair loss, because testosterone does not cause hair loss… except by its conversion to DHT. If the body has testosterone, it automatically has DHT. Genetics cause androgenic alopecia that is precipitated by DHT, and that is why finasteride works. It is not a hormone issue, it is a genetic issue. If you do not have the gene for hair loss, you can have all the testosterone or DHT or whatever hormone you want to blame and you will still have a full head of hair.

Also Propecia does not cause hair loss. It slows down hair loss. I can see why you think this, but your logic is flawed.

First of all, I just wanted to let you know that I have found your blog very useful.

I am a 24 male and for the last couple of years I have noticed my hairline receding and then my hair getting much thinner. I look back at pictures from 3 or 4 years ago and I am in awe at how much my hair looks different. Anyway, I have tried rogaine for about 4 months and have not seen much of a difference, plus it is kind of a pain to use. In fact my hair seems to just continue getting thinner.

I would like to try Propecia, however, I am in medical school and I really cannot justify using that much loan money for propecia, if you know what I mean. I have noticed that you and others suggest using 5mg generic Finasteride normally used for BPH as an economic alternative. I would like to ask my doctor about this option. My question is whether this is considered ethical/legal and how physicians usually respond to this.

Thank you for your time

There are no ethical or legal issues associated with prescribing finasteride for androgenic alopecia. There is however a financial issue, as finasteride 5mg is about $30-$60 for 90 pills and finasteride 1mg is about $150 to $200 for 90 pills. If you cut the 5mg finasteride in four parts, the 90 pills should last you 360 days! This drastic difference is based on U.S. Patent laws that give protection to Merck, as they have the rights to manufacture the 1mg dose of finasteride up until mid-2013. The 5mg finasteride is available as a generic because the 5mg patent expired already, so the prices are way, way lower.

As far as doctors are concerned in prescribing medications, as a medical student, I hope you will soon find that there are hundreds of medications with generic versions that are exactly the same and just as effective as their branded counterpart. Consider this when you prescribe branded medications to patients after the drug companies wine and dine you.

On a final note, there is an ethical issue to the patient if they decide to cheat the system by getting the generic finasteride 5mg using their insurance card. The insurance companies may approve finasteride 5mg thinking you are treating a prostate problem. Finasteride used for androgenic alopecia is not covered by insurance.

I understand that a 1mg dose of Propecia is recommended. What I want to know, however, is how much more hair grew at a 2mg dose vis-a-vis the 1mg dose — 10% more? 15% more? I know these data exist. So, what incremental improvement might there be with a 2mg dose?

While it’s quite possible that the data for 2mg finasteride hair loss treatment benefits exists, I don’t have it, I don’t recall seeing it, and I’m not sure if it was ever made available to the public.

I do know that there were studies that looked at high dose and low dose finasteride (prior to Propecia becoming available) for treating hair loss. More is not better and I am not aware of a 2mg study showing any additional benefit. The stories that I do hear are anecdotal.

Snippet from the article:

A class action was filed today in the Supreme Court of British Columbia by Vancouver resident, Michael Miller, against Merck Frosst Canada and its affiliated companies. The lawsuit has been brought on behalf of Canadian men who used Propecia or Proscar and suffered continuing sexual dysfunction.

Propecia and Proscar are prescribed as a cosmetic treatment for male pattern hair loss also known as androgenic alopecia. The product monograph discloses that some men may experience sexual dysfunction but states that the symptoms disappear after cessation of the drug.

Mr. Miller, who is in his early 20s, was concerned when his hair started to thin in some areas. He was prescribed Proscar which he hoped would stop his hair from thinning.

Read the full story — Class action filed against manufacturer of Propecia & Proscar

If this young man was in his early 20s and prescribed Proscar without being told to cut the pill into a smaller daily dose to treat hair loss, his chances for side effects would’ve increased. Proscar is 5mg finasteride used to treat prostate issues. Propecia is 1mg finasteride used to treat hair loss. So if you’re taking 5x the recommended dose, what would you expect?

We’ll see how this class action suit plays out…

NOTE: The following comes to us from a longtime reader that wishes to remain anonymous. He’s gifted us with some insightful posts in the past about the FDA, LLLT, and clinical trial regulations. His email is as follows:

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The Journal of Sexual Medicine recently published an article that has been the source of several Balding Blog posts, including one that answered a reader who wondered if, “the study suggests up to 15% of men taking the drug might experience some form of sexual dysfunction” in context of “the warning label on Propecia (that) … only 2 percent of men might experience erectile dysfunction while using the drug…”.

As a fan of the Balding Blog and a clinical trialist (someone who interprets clinical trial data), and one who has no relationship to Merck or financial interest in finasteride use, I have reviewed the article:

• Dr. Rassman has correctly pointed out that this article is not a study per se, but a review of data in the literature from completed and published finasteride studies that included placebo groups.
• The review included 3 studies of men using finasteride (1 mg daily) for alopecia, 15 studies of men using finasteride (mainly 5 mg daily) for benign prostatic hyperplasia, and 2 for “none” listed as the condition.
• The 3 studies of men using finasteride for alopecia included a combined total of 1196 men receiving finasteride, and 1035 men receiving placebo.
• As Dr Rassman has nicely emphasized before, the “true” incidence of an adverse event (attributable to a drug) is the percentage of men who experience a side effect receiving an active drug minus the percentage of men who experience a side effect via placebo. It is important to emphasize that this equation implies no causality (i.e., if a man receiving a drug gets a side effect, it is attributable to his active drug or placebo regardless of other factors – such as diabetes – that may be causally involved).
• The largest incidence of sexual side effects among the 3 studies involving men with androgenic alopecia is from the smallest study involving only 286 men who received finasteride and were a considerably higher age (41-60 years) than men in the 2 other studies (ages 18-40 years). In older men, factors that contribute to sexual side effects (diabetes, coronary artery disease, and aging) are considerably more frequent. In this small study of 286 men, changes in sex drive were observed (over a period of 1 year of treatment and 1-year of follow-up) in 4.9% receiving finasteride and 4.4% receiving placebo (treatment effect of 0.5%). In the same study, erectile dysfunction was observed in 3.8% of men receiving finasteride and 0.7% of men receiving placebo (treatment effect of 3.1%). In the two larger studies – involving younger men – the incidence of erectile dysfunction was 0.5% (1.4 minus 0.9) in one study, and 0.75% (0.75% minus 0) in the other study.
• Taken together, these results are consistent with the incidence of sexual side effects noted in the finasteride (Propecia) US product label: decreased sex drive (1.8% finasteride vs. 1.3% placebo) and erectile dysfunction (1.3% vs. 0.7%).
• The “15%” figure contained in the Balding Blog post by a reader was based in part on the cited (and misleading) newspaper commentary from a business reporter that stated ”…up to 15% of men taking (Propecia) might experience some sort of sexual dysfunction.” Indeed, The Journal of Sexual Medicine article cites a study of 613 men aged 45-80 taking 5 mg finasteride daily for benign prostatic hypertrophy for 2 years. In this study, 15.8% of men receiving finasteride (compared with 6.3% of men receiving placebo) reported erectile dysfunction. This is 5 times the recommended dose for treating hair loss, though. The largest study, involving 2315 men aged 45 years or older (with prostate hypertrophy), showed the next largest effect on erectile dysfunction: 8.1% (finasteride) vs. 3.8% placebo. This latter figure is almost identical to the incidence of erectile dysfunction noted in the finasteride (Proscar) US label.

In summary, one can’t properly mix “apples and oranges” involving clinical trial data involving different doses of drugs with different patient populations and for different indications. The journal article offered no major insights to me but is a nice review of currently published work. To me, a significant issue of side effects is reversibility. Even a minor headache is devastating if due to an active drug and is not reversible.

Despite anecdotes from blogs, I have seen no case histories published in the medical literature of men using finasteride for androgenic alopecia who have developed irreversible erectile dysfunction that has been attributed to use of finasteride. I am not saying that such a phenomenon does not exist; I just have not read any well-documented case history. A newspaper commentary from a business writer that references a blog where a 32-year old man developed erectile dysfunction (“had pretty lousy quality erections otherwise”) of unknown duration 12 years after starting finasteride and who cites “(recent) experiences with a new sexual partner” is not compelling (to me).