Finasteride, a 5-alpha reductase Lee joon ki wife sexual dysfunction, widely used in the medical management of male pattern hairloss, has been reported to cause sexual side effects. This article critically examines the evidence available and makes recommendations as to how a physician should counsel a patient while prescribing the drug.
Some of the commonly faced questions by a physician while treating a patient of pattern hairloss are about the possible sexual side effects caused by finasteride. Reports in the press, internet sites, and misinformation by practitioners of alternative medicine, all have contributed to this image of the drug, and has lead to apprehension in the minds of patients. Often even dermatologists seem to hesitate to prescribe the drug on a long term basis. This article examines this subject in the light of evidence available.
Pattern hair loss in males is androgenic in etiology. Antiandrogens such as finasteride are therefore useful in the management of the condition. Androgens, especially testosterone increases the libido.
Any drug which interferes with the action of androgens is therefore assumed, by the lay person, to induce impotence. However, the precise role of androgen in penile Lee joon ki wife sexual dysfunction needs to be fully elucidated.
In addition to androgens, visual, olfactory, tactile, auditory, and imaginative stimuli influence the libido. The penile erection is mainly under the control of parasympathetic nervous system. Ejaculation and detumescence require an intact sympathetic system.
The androgens testosterone and dihydrotestosterone DHT have somewhat different actions. It exists in two isoenzyme forms. While type I is predominant in liver, type II is predominant in prostate, seminal vesicles, epididymes, hair follicles, and liver. Type I 5AR, is present in the sebaceous gland, while type II 5AR is found on the outer "Lee joon ki wife sexual dysfunction" sheath of the hair follicles and dermal papillae.
At all these sites, the testosterone is converted to DHT. Finasteride is a specific and competitive inhibitor of Type II 5—AR, and has therefore a selective action on hair follicles. This explains why relatively small dose of finasteride may be adequate therapeutically.
The bioavailability of finasteride is not related to food intake. Finasteride is extensively metabolized in liver by Cytochrome P 3A4 enzyme subfamily and excreted both in urine and feces.
The terminal half-life is approximately hours in men between years of age and 8 hours in men more than 70 years of age.
A number of studies have looked at the problem of side effects caused by finasteride. These effects occurred early in the therapy and returned to normal on stopping or over a time on continuous use of the drug. The only causal relation between finasteride and sexual adverse effects is decreased ejaculatory volume because of predominant action of DHT on prostate. A comprehensive review of a total of 73 papers on medical therapies for BPH was conducted, with a focus on the effects of different pharmacological agents on sexual function.
The role of nocebo effect in the causation of ED due to finasteride has been investigated. In this study, the group informed about the sexual adverse effects of finasteride reported increased incidence of ED, when compared to the group without information. Two studies in and showed that the incidence of these side effects with finasteride therapy was generally comparable to that observed with the treatment with placebo,[ 89 and there was no evidence of dose dependency or increased incidence with longer therapy out to 12 months.
In addition, the side effects ceased in patients even when they continued to receive finasteride. The incidence of side effects were comparable to that of placebo both at one year and at 5 years. A large prospective study in as many as 17, patients was conducted to look into the effects of finasteride and other covariates on sexual dysfunction as part of the analysis of The Prostate Cancer Prevention Trial PCPT. Finasteride increased sexual dysfunction only slightly even at 5 mg dosage which is much higher than the 1 mg administered in pattern hair loss and its impact diminished over time.
The authors concluded that the effect of finasteride on "Lee joon ki wife sexual dysfunction" functioning is minimal for most men and should not impact the decision to prescribe or take finasteride.
A recent review of the available literature too arrived at similar conclusions. However, there are more recent studies, which seem to have documented contrary findings.
The study revealed that the subjects reported new-onset persistent sexual dysfunction low libido, ED, and problems with orgasm associated with the use of finasteride. The mean duration of finasteride use was 28 months and the mean duration of persistent sexual side effects was 40 months from the time of finasteride cessation to the interview date. However, there were many limitations in the study, such as small number of patients, selection bias, recall bias for before finasteride data, and no serum hormone analysis.
The study recommended that physicians treating male pattern hair loss MPHL should discuss the potential risk levels with patients while prescribing the drug. An important earlier study by Mella et al ,[ 14 ] conducted a systematic review of twelve randomized trials evaluated the efficacy and safety of finasteride therapy in male patients.
Moderate-quality evidence was found for an increase in erectile dysfunction RR, 2. A number of isolated case reports Lee joon ki wife sexual dysfunction also been published on the effect of low dose finasteride Lee joon ki wife sexual dysfunction DNA changes in sperms,[ 15 ] on motility, and sperm counts.
Significantly, these parameters improved after stopping the drug. Another small study[ 17 ] reported three cases of young men, who had used finasteride for five years, investigated for "Lee joon ki wife sexual dysfunction" Infertility.
Semen quality was investigated by light microscopy to evaluate sperm concentration and motility, sperm morphology by transmission electron microscope TEMpresence of Y microdeletions by PCR, and meiotic segregationby fluorescence in situ hybridization FISH.
TEM analysis revealed altered sperm morphology consistent with necrosis and FISH data revealed elevated diploidy and sex chromosome disomy frequencies. One year after the men had stopped the use of finasteride without receiving any other treatment, a recovery of spermatogenetic process was observed.
Motility and morphology improved whereas the meiotic pattern did not change. Traish[ 18 ] conducted a review of different published studies and concluded that altered sexual functions such as erectile dysfunction and diminished libido are reported by a subset of men receiving finasteride, raising the possibility of a causal relationship.
The review suggested discussion with patients on the potential sexual side effects and possible alternate treatments before administration of the drug. The taskforce posted their initial update on the subject as follows:. Reports of persistent sexual side effects have come from a variety of sources with some internet sites attracting individuals claiming to have sexual and psychological issues related to finasteride.
While continued difficulty having erections after discontinuing finasteride has been reported in post-marketing surveillance the incidence of this problem remains unknown.
Also, little data is available concerning the medical and psychological work-up of these patients to exclude other potential causative factors.
At the present time, the mechanism of interaction between the brain, 5 alpha-reductase metabolism, and hormones on sexual dysfunction is speculative and poorly understood. Clearly, this is a complicated issue, which overlaps with other disciplines in medicine such as Endocrinology, Urology, and Psychiatry. More research is needed to assess the actual incidence of side effects, to determine if there is a true causal relationship for persistent side effects and if so, to identify who may be at risk.
We hope to participate in a multidisciplinary forum to further evaluate this topic. Millions of patients have benefitted from finasteride with no side effects at all, or minimal and reversible side effects.
It is important for the medical community to verify anecdotal reports and if necessary, conduct further studies so that accurate information may be given to our patients to enable them to make informed choices regarding the use of this medication. Thus, the evidence available about the safety of the drug can be considered as questionable, but cannot certainly be ignored. The matter needs further systematic investigation and documentation. However, there is no doubt that to the lay man the prospect of impotence while taking a drug for hairloss is daunting, however theoretical and small the risk may be.
The drug brochures mention the possibility of the side effect and the patient is often unable to distinguish between the effects of 1 mg and 5 mg. Several websites give a rather unfavorable opinion about the side effects, contrary to the evidence presented above.
Several blogs also discuss the side effects, and individual and anecdotal experiences are highlighted and often exaggerated. Any patient who reads such reviews is understandably apprehensive, and therefore may stop therapy with in a few weeks of starting or, in other instances, do not start the treatment at all.
Losing potency for gaining hair is not an attractive proposition, however remote that possibility is! In view this, it is very important to properly counsel patients about the treatment. In particular, the following facts need to be stressed:. In addition, the author also feels that in patients who are apprehensive about the side effects, it is worthwhile considering administration of lower daily doses or staggered pulse doses of the drug, to enhance patient compliance.
As discussed earlier, there is sound rationale for such regimens. Plasma half life of finasteride is hours and tissue binding is days. Efficacy has been demonstrated for all end points for finasteride at doses of 0.