Long Term Side Effects From Propecia - Post Finasteride Syndrome - Does it Exist?

[Bill - Seemiller]

For years, the members of this community have been recommending Propecia (finasteride) to hair loss sufferers as a way of attempting to preserve existing hair and even attempt to regrow thinning hair in the crown and mid regions of the scalp. However, a small percentage of men experience side effects of a sexual, physical and mental nature. More recently, enough men have shared concerns of ongoing or "permanent" side effects even after stopping treatment. This phenomenon has become known as Post Finasteride Syndrome or PFS. The question remains, is this even possible?

 

Well, the FDA seems to think so. In April of 2012, the FDA mandated Merck to make crucial labeling changes to finasteride related products regarding the possibility of long term side effects. Yet, there are many who remain skeptical and believe that Post Finasteride Syndrome doesn't exist and any ongoing sexual issues after stopping treatment are most likely a result of other non-related causes.

 

You can read more by visiting the following articles:

 

Propecia Side Effects: How Serious is the Risk of Post Finasteride Syndrome or PFS?

 

Propecia Hair Loss Treatment

 

Propecia: Is it Right for You?

 

But I want to know what YOU think and what YOUR experiences are. What is your experience with Propecia? For those of you who have side effects, did they stop after treatment? How many of you had persistent sexual issues or other finasteride related side effects after stopping treatment?

 

Personally, I was one of the lucky ones who didn't experience any side effects. However, the scare of potential long term side effects has given me enough pause for thought and as a result, I have personally cut down the use of Propecia.

 

I look forward to everyone's input :-).

 

Best wishes,

 

Bill

[Dr Blake Bloxham]

Bill,

 

I applaud you for writing this piece! I'm never the guy who doubt studies, and I think side effects are many times amplified by things like the internet, TV ads for class action lawsuits, et cetera. However, I don't feel this way about the side effects related to finasteride.

 

Frankly, I've seen far, far too many cases of patients with persistent sexual side effects years and even decades after stopping the medication.

 

And the important thing to understand is this: for many men, experiencing reduction in libido or erectile dysfunction as you age isn't necessarily pathological. So some men will naturally begin to experience these issues while taking Propecia, but it isn't necessarily from the finasteride itself. It would have happened as they aged regardless. But I've seen numerous, numerous scenarios where this was not the case.

 

I'll give you a recent example: I consulted with a man in his 40s two weeks ago. He underwent a hair transplant procedure with another clinic in his mid 20s, and was also started on finasteride at the same time. The procedure was a small case to lower the corners of his hairline, and the theory was that the finasteride would help him retain the rest. He then began experiencing sexual side effects closer to his late 20s. This was unfortunate because, thus far, the planned worked; the patient kept his existing hair and the temple corner case still looked natural.

 

He stopped the finasteride, and two things happened: his existing hairs in the frontal and midscalp shed, and the grafts from the fronto-temporal corner case were now surrounded by bald scalp and looked unnatural. And, the side effects from the finasteride never went away.

 

By the time he came to see us, he was 10 years off the finasteride. In these 10 years, he had not seen a reversal of the side effects and still had severe erectile dysfunction.

 

Very sad case.

[mahhong]

This is a very pertinent topic for me. I started balding at the age of 26 in what was/is a diffuse NW V pattern. I'm now 32 and I've lost a lot of the hair up top. I have just enough to use some concealer to make it look "thin" instead of largely absent, and the sides and back seem to have held up fairly well (I do have crown loss but it doesn't, as yet, look expansive like a lot of people's). I would like to think my "pattern" was visible from early on and has remained consistent - but I also know there's no way to confidently say that.

 

I tried Propecia twice; the first time for about 3-4 months and the second for about 6-8 weeks. Both times I had what I would describe as mild but persistent side effects - mostly loss of libido/erection issues. I'm a firm believer in the scientific process and was perfectly well aware this could be a nocebo effect, but ultimately I decided to not use the drug any longer. My hair has continued to thin, which is the bad news, but there would appear to be a relatively stable pattern emerging with a relatively high back and sides.

 

I'm rapidly getting to the point where I have a decision to make now; either begin seriously thinking about starting my HT journey, or shaving down and resigning myself to my fate. I would very much like to go down the HT route and restore my hair and believe, the way it is at the moment, that would be possible. However I could of course end up an NW6 or even 7 and, personally, for me the idea of 6,000 or so grafts smattered thinly across a seriously bald head doesn't fill me with much joy. Don't get me wrong, I know even advanced balding cases can become great results, and I also understand and respect (particularly in older gentleman) that thin coverage and facial framing are more than acceptable goals. But I don't want to be spending my 30s and 40s with that sort of look - I'm realistic about what HTs can achieve but I'd need some assurance I could achieve reasonable density and good coverage, with a mature but acceptable hairline - there are similar case studies out there that I would be very happy with.

 

I've digressed with my own personal story somewhat, so I apologise! Bringing it around to the central question, I think the bottom line is DHT is an important hormone and part of delicate ecosystem that some men disrupt with seemingly serious consequences. I do believe the issue has been sensationalized because there's millions of men taking finasteride worldwide and probably only a handful experiencing the very extreme of these problems. However there would seem no doubt taking finasteride is somewhat playing with fire - especially when you consider it is a lifelong commitment and if, at any stage, you decide for whatever reason you cannot tolerate the drug, you lose the gains or stability you have and have to start planning a contingency.

 

Adding to the question if I may (especially because Dr. Bloxham has posted up); what do you think is a sensible plan of action for men considering hair restoration, in light of the fact some may not or even cannot consider using finasteride?

 

Also, just to edit and add something else I've been thinking about - do you think men who take or are thinking of taking finasteride could benefit from a baseline hormone panel analysis and closer monitoring of their test/DHT/estrogen levels? I had my testosterone levels checked recently and whilst in the normal range they were low. Here in the UK between 9.70 and 38.20nmol/l is considered normal - mine was 13.9. Of course, that "normal" range is calculated from a huge variety of men - some 16, some 85, some diabetic, some obese, some smokers, some drinkers etc. As a 32 year old man in reasonably good health, I would consider mine too low and have been taking steps to improve it (lost 3 stone, go to the gym regularly to weight lift, eating better etc.). I haven't had them re-checked yet but I'm hopeful they will have improved.

 

It got me thinking, though - clearly different men will have quite significantly different hormone levels and someone with a lower testosterone level would (so far as I can tell) also have a lower DHT level? We're living in an age where unfortunately lower testosterone levels are increasingly common for men thanks to lifestyle. Maybe there needs to be more emphasis on baseline hormone and sexual health checkups for men prior to starting finasteride - and better monitoring whilst on the drug? I'm not sure if this would make a massive difference, but it seems strange to alter a man's hormones without knowing what they were to begin with.

 

It's a tough decision. I would love to go on the drug, even if it was .5mg or every other day - but I know it's something I have to take regularly for the next hopefully 40, 50 years of my life. Given the possible side effects and unknowns (and the fact I've experienced them), it's very hard to say yes - but what do we do in the meantime?

Edited August 4, 2015 by mahhong

[BMW1990]

Im not sure guys, I've been on finasteride for about 20 months and haven't had any sexual side effects or any side effects whats so ever, in fact, Im raging for some p***y, 24/7. BTW I'm 25 y/o. Fin has thicken up my existing hair and stabilized my hair loss. I think some people who "experience" any of finasteride side effects might already have some genetic prediopsition, such as erectile dysfunction and the finasteride just accelerates the process. I also workout regular and have a pretty good diet, other than that, Im not really sure why some people might experience side effects and some don't.

[mahhong]

BMW - I think you're right to some extent. The truth is finasteride must be fairly safe in the vast majority of men. There are simply too many people taking it worldwide for some unreported epidemic to be happening.

 

Of course, the problem is, what do we do about the guys who appear to have temporary or perhaps even permanent libido and sexual issues during and after taking finasteride? There's never much rhyme or reason as to why some people get side effects on any drug - some people get the craziest side effects from something as simple as a headache tablet. Granted these are nearly always temporary, but the point still remains.

 

I agree that it's likely some men are probably genetically predisposed to side effects from finasteride - there is possibly some issue with the endocrine, vascular or neurological systems that perhaps finasteride accelerates and/or exacerbates.

 

It's still a scary notion though - and Post Finasteride Symptom, whilst definitely not proven, does seem something of a reality. I'm glad it's working out for you though - you're probably in the vast majority of men who experience a fairly normal life even on the drug. The issue is finding, diagnosing and treating those men who do not seem to tolerate the drug so well.

[Dr Blake Bloxham]

BMW,

 

It definitely doesn't happen to everyone. And when I see a patient doing well on it, I never specifically advise them to get off of it. This is because despite the potential for serious side effects, it is probably the most efficacious preventive hair loss medication.

[Spanker]

Bill,

 

I applaud you for writing this piece! I'm never the guy who doubt studies, and I think side effects are many times amplified by things like the internet, TV ads for class action lawsuits, et cetera. However, I don't feel this way about the side effects related to finasteride.

 

Frankly, I've seen far, far too many cases of patients with persistent sexual side effects years and even decades after stopping the medication.

 

And the important thing to understand is this: for many men, experiencing reduction in libido or erectile dysfunction as you age isn't necessarily pathological. So some men will naturally begin to experience these issues while taking Propecia, but it isn't necessarily from the finasteride itself. It would have happened as they aged regardless. But I've seen numerous, numerous scenarios where this was not the case.

 

I'll give you a recent example: I consulted with a man in his 40s two weeks ago. He underwent a hair transplant procedure with another clinic in his mid 20s, and was also started on finasteride at the same time. The procedure was a small case to lower the corners of his hairline, and the theory was that the finasteride would help him retain the rest. He then began experiencing sexual side effects closer to his late 20s. This was unfortunate because, thus far, the planned worked; the patient kept his existing hair and the temple corner case still looked natural.

 

He stopped the finasteride, and two things happened: his existing hairs in the frontal and midscalp shed, and the grafts from the fronto-temporal corner case were now surrounded by bald scalp and looked unnatural. And, the side effects from the finasteride never went away.

 

By the time he came to see us, he was 10 years off the finasteride. In these 10 years, he had not seen a reversal of the side effects and still had severe erectile dysfunction.

 

Very sad case.

 

Why would a person wait years to address an unnatural result?

[Spanker]

I didn't have sides the first 5 years, so at this point, how could I attribute problems with fin and not aging? I'm quickly approaching 40? Well, I'm pushing 37 anyway. Idk. I try not to think about it.

 

My largest concern with fin is that it would mask symptoms of prostate cancer. I still take it.

 

Being bald isn't an option for me professionally with my lumpy distracting head. I'll have to resort to a system if the bottom fell out, and I really want to pervent that. Something very awesome would have to come out on the market for me to switch.

 

I'm in it for the long haul.

[Dr Blake Bloxham]

Spanker,

 

Fear. He feels burned by the first procedure and worried to do anything -- be it medical or surgical -- after the Propecia issues. He's actually been researching another procedure for years and still can't quite bring himself to pull the trigger. It's hard to blame him too.

[chrisis]

Wow.

 

Thank you to Bill for opening this topic up for discussion. This is one of the biggest issues facing the hair loss industry right now, and one I urge people - particularly in the industry, to educate themselves on. I have personally witnessed this topic coming up on various forums and being roundly ignored and disregarded.

 

I literally shot out of bed at 2am (UK) to respond to this after being notified of this topic through email. At the time I was on Skype chatting with one was talking to one of dozens, if not hundreds of men, who I've met through various PFS related forums and who are victims of this drug. Some have died - in fact 2 participants in an ongoing study conducted by the PFS Foundation have since committed suicide.

 

To be short; yes, PFS exists, after 3/4 years, I know it is true, because I am fighting it every day. And compared to many men I've read about, I have actually got away with it quite lightly. At least I am still here and have a relatively normal life. The same cannot be said for many, who've at worst lost their lives, and others who've lost their livelihoods, while families have been torn apart due to wide ranging ailments from the oft-mentioned sexual, to mental and physical.

 

Feel free to ask me any questions as this is a topic very close to my heart. I work as a patient advisor for a popular European doctor and am also a well known FUE blogger. When people ask me for advice I find myself in something of a difficult position, but I will always give my honest opinion:

 

If you can, I suggest you avoid Propecia until the PFS Foundation complete their studies. They are working on three major initiatives at Universities (Baylor, Brigham and Milan), and I'm confident they are going to shed some light on this syndrome. Regardless of how you feel about this topic, even the naysayer must admit that it is surely in all of our interests that we're well informed when taking this drug. Unfortunately Merck have already backtracked several times in terms of their labelling of side effects, so we cannot rely on them for the truth. And don't forget the scandal of Vioxx, a drug which had side effects that Merck knowingly withheld from doctors and patients for 5 years, killing tens of thousands of people.

 

By the way, the PFS Foundation's annual address for 2015 was just released today and sums up where we currently stand. You can read it here.

Edited August 5, 2015 by chrisis

[Mikey1970]

I have been taking it for 18 months and no sexual side effects yet.

 

I suspect the whole hair loss/insecurity/psychological mindset may be more of a pertinent issue in regards to libido/erectile dysfunction for some but that is just my opinion & not based on any formal analysis.

[ZeoRanger]

I've been on Fin since I'm 22. I'm now approaching 34.

 

I only took it as a precautionary measure - not because I noticed any hair loss. In case DHT affect my follicles, I wanted to beat it to the punch before it even had the opportunity to attack my hair.

 

My sex drive is raging - no complaints here. No moobs either.

 

If my sex drive should slow down I'd blame aging first and foremost.

[Dr Blake Bloxham]

Mikey,

 

Good point. However, there are actually ways to test whether or not erectile dysfunction (ED) is psychological or physiological.

 

Back in the day, they would test this by affixing tissue paper around a man's penis at night. If he was able to achieve a physiological erection at any point during the night, the tissue paper would be ripped in the morning. If it was ripped, the doctors would suspect a psychological cause. If not, they would look into other potential causes. The biggest culprits being: poor vascular supply, poor nerve supply/function (usually secondary to a disease that causes vascular and nerve damage like diabetes), hormonal imbalances, and age.

 

But this test fell out of favor because too many men were ripping the paper when they moved naturally throughout the night. Now doctors essentially ask men if they ever wake up with any semblance of a regular morning erection. If so, then a psychological cause may be to blame. If not, then the other causes must be evaluated.

 

The gentleman I discussed earlier had no semblance of a nocturnal or morning erection in the 10 years after stopping the finasteride.

[chrisis]

 

If my sex drive should slow down I'd blame aging first and foremost.

 

If you develop moderate or severe PFS, your sex drive doesn't just slow down, it can cause severe sexual dysfunction, as well as various physical and psychological manifestations.

 

Your experience is positive and ought to be the typical one, but the real (currently unanswered) questions are:

 

How many people are experiencing side effects related to taking finasteride?

To what extent?

Are these problems reversible?

[Spanker]

I feel like it has been answered, unless you want to throw out Merks double bind study.

 

I'd love th see another one come out.

[aaron1234]

Thought provoking post. I feel in general that we too eagerly highlight the psychological component when someone claims to be experiencing ED while on fin. Of course, the mind is a powerful thing and I'm sure that paranoia could exacerbate the issue. However, everyone is different and responds to medication differently. Not just finasteride, but everything from Advil to Zoloft.

 

In my own experience, I felt pretty strong testicular pain when starting finasteride about 10 years ago. So much so that I almost gave up on it. Then after two weeks, the pain went away and I have never experienced it since. Fin is huge for me. If I stopped taking it my crown would widen significantly and the middle would shed. I would easily be a NW6 with a transplant frontal third without it.

 

Conversely, I tried Rogaine Foam when it came out years ago. I had not had a transplant yet, and I was shaving my head down to stubble. Within 4 weeks my entire scalp was red and irritated, and my ears were chapped! Perhaps, I was too generous in my dosage? Either way, as soon as I stopped Rogaine Foam my skin recovered. I have never heard of anyone having chapped ears with Rogaine Foam. I wasn't crazy or paranoid.... just different. I think we could stand to give the benefit of the doubt to some of these men struggling with post-fin ED. My heart goes out to them, just as easily could have been me.

[Shyguy]

Been taking Propecia since 1997.

 

In 2007 I started experiencing sides such as ED, low libido, loss of morning erections, etc.

 

In 2015 my libido is basically gone. My testosterone levels went to 200. My estradiol went to 70 (way over the limit for a man).

 

Within the last few weeks I started seeing a MD who has given me Clomid to increase T levels and Aromatase Inhibitors to decrease estrogen. Almost immediately I had morning wood after years of not feeling it. It's not daily and strong like I used to be.

 

Propecia could be the root cause of male sexual dysfunction that I am experiencing.

 

I am debating weening off it by taking half a tablet for a week, then a quarter of a tablet and so on until I can get off it. I'm terrified of losing my hair.

 

I've noticed a lot more hair falling out after taking the Clomid. My hair stylist noticed as well. He said hair loss due to increase testosterone is permanent. This stresses me out as I'm not sure what to expect once I totally go off Propecia.

 

Can anyone comment on their experiences when stopping Propecia please?

[htloss]

I have been taking propecia on and off for at least 15 years. When I take it I definitely have side effects such as loss of libido, mild erectile dysfunction and no morning wood. This happens even at the dosage of 0.25 gram every other day. I guess I am just super sensitive to the drug. I am 66 now and I had most of my hair transplants done in my early 40's. My hair is thinning out all over my scalp ( age thing, i guess ) and the really sad thing is that I have been losing transplanted hair for years. I know that propecia helps to retain transplanted hair ( that was supposed to last a lifetime !! ) but I cannot tolerate longterm use of propecia and I worry that I may find that I may not recover the next time I stop taking it. I am basically growing bald all over again, and the transplanted hair is falling out first. Yesterday a friend who does not know that I have had extensive hair transplants made a joke about the bald spot on the crown of my head. That area looked great after i had two scalp reductions and two major hair transplant sessions as well as two later "touch-ups" in that area. Not any more. I would shave it all off if I didn't have so many scars due to the hair transplants.

[HairsGone]

Would Topical Finasteride be of benefit for those who are having side effects to oral Finasteride?

 

As in my post here...

Topical Finasteride + Minoxidil - Forum By and for Hair Loss Patients

 

Or is it not effective like the study claims?

[MAGNUMpi]

I have been taking propecia on and off for at least 15 years. When I take it I definitely have side effects such as loss of libido, mild erectile dysfunction and no morning wood. This happens even at the dosage of 0.25 gram every other day. I guess I am just super sensitive to the drug. I am 66 now and I had most of my hair transplants done in my early 40's. My hair is thinning out all over my scalp ( age thing, i guess ) and the really sad thing is that I have been losing transplanted hair for years. I know that propecia helps to retain transplanted hair ( that was supposed to last a lifetime !! ) but I cannot tolerate longterm use of propecia and I worry that I may find that I may not recover the next time I stop taking it. I am basically growing bald all over again, and the transplanted hair is falling out first. Yesterday a friend who does not know that I have had extensive hair transplants made a joke about the bald spot on the crown of my head. That area looked great after i had two scalp reductions and two major hair transplant sessions as well as two later "touch-ups" in that area. Not any more. I would shave it all off if I didn't have so many scars due to the hair transplants.

Wow. You should really start a thread and detail your story. You have some interesting things happening that might be helpful to this community.

Have you tried Rogaine since the propecia doesn't work for you?

[chrisis]

 

Can anyone comment on their experiences when stopping Propecia please?

 

Hi Shyguy,

 

I took finasteride for about 4-5 weeks and experienced undeniable side effects. I quit the drug and had what is typically referred to as a "rebound recovery", before crashing again several weeks later, and failing to fully recover ever since.

 

I will preface my opinion with the usual disclaimer: I am not a doctor, but it sounds highly likely that your problems are related to taking Propecia. I say this knowing that every doctor I've spoken to on this topic is severely limited in terms of their knowledge, while I on the other hand have been researching it for over 3 years.

 

You mention that you took the drug from 1997 to 2007 without issue. Don't let this fool you. There are many stories on PropeciaHelp.com of men who have taken the drug for years than suddenly experienced side effects - even after 10 and 15 years. People wrongly assume that if you've taken the drug for a few weeks/months without issue, you're home and dry. You can search the forum and find many stories confirming this, there are over 1000 individual stories you can read, from men all over the world. Last year I created a map which helps convey just how widespread this problem is in a visual way:

 

 

I would suggest you go across to that forum to learn about the best way to deal with this, and perhaps seek help from specialist doctors, though they are, sadly, few and far between.

 

It seems logical to ween off the drug, though be aware that even 0.2mg of finasteride impairs 61.7% of DHT, according to this chart:

 

 

It follows that you'd have to cut the tablets into impossible sizes to ween off effectively. Perhaps you could consider increasing the time between each dose as part of your strategy.

 

I know you are concerned about losing your hair, but surely your health is more important? If you need any more help, give me a shout.

 

I have been taking propecia on and off for at least 15 years. When I take it I definitely have side effects such as loss of libido, mild erectile dysfunction and no morning wood. This happens even at the dosage of 0.25 gram every other day. I guess I am just super sensitive to the drug. I am 66 now and I had most of my hair transplants done in my early 40's. My hair is thinning out all over my scalp ( age thing, i guess ) and the really sad thing is that I have been losing transplanted hair for years. I know that propecia helps to retain transplanted hair ( that was supposed to last a lifetime !! ) but I cannot tolerate longterm use of propecia and I worry that I may find that I may not recover the next time I stop taking it. I am basically growing bald all over again, and the transplanted hair is falling out first. Yesterday a friend who does not know that I have had extensive hair transplants made a joke about the bald spot on the crown of my head. That area looked great after i had two scalp reductions and two major hair transplant sessions as well as two later "touch-ups" in that area. Not any more. I would shave it all off if I didn't have so many scars due to the hair transplants.

 

Hi htloss,

 

Please check the graph I posted above. Even at a dose of 0.25mg you are inhibiting over 60% of plasma DHT, so don't assume a lower dose might help. Even if a lower dose helps inhibit less DHT, it follows that it will be less effective at maintaining hair, so what is the point? We're feeling around in the dark here with some very real and dangerous consequences at stake.

 

As I suggested to Shyguy, I'd suggest you visit PropeciaHelp where you will be able to read a lot of information about guys who have been in your position. There are steps you can take to recover your health and improve your chances of recovery, but the long and short of it is that you really need to consider quitting finasteride if it is making you unwell.

 

Would Topical Finasteride be of benefit for those who are having side effects to oral Finasteride?

 

Hi HairsGone,

 

I have considered this and I believe even topical finasteride would be troublesome to someone who is susceptible to PFS. The reason is, even topical minoxidil has been known to cause side effects such as heart palpitations and headaches, so I am almost certain that topical finasteride would be absorbed systematically, and cause side effects in the same way. Whether it is a lower risk or not, I am not able to say because there haven't been any studies conducted that I'm aware of.

[BlackAmish111]

Crazy this is coming to surface now as I just quit Fina about a month ago after maybe 6 years . Definitely was experiencing low libido but was hard to pinpoint as my wife was preggers last year and we all know how that goes. Anyways, had forgotte that it had been literally months at least since had having morning wood coupled with research that no dht also hurts strength I said enough was enough. Had T level measured and while Total was fine 550, Free was a shameful 65. So quit the Fin but still no wood until I sstarted on Vimm Plus which is like a miracle. Libido and M Wood is now literally off the charts -almost embarrassingly so.

 

Fin had always been good for my crown as Rogaine was for my hairline but Rogaine also gave me such hollowed out eyes it utterly defeated the point of having good hair. TBh, after majorly cleaning up my diet and the addition of daily gobs of virgin red Palm oil , my hair health is better than it has been in maybe a decade.

Goods riddance.

[chrisis]

Crazy this is coming to surface now as I just quit Fina about a month ago after maybe 6 years . Definitely was experiencing low libido but was hard to pinpoint as my wife was preggers last year and we all know how that goes. Anyways, had forgotte that it had been literally months at least since had having morning wood coupled with research that no dht also hurts strength I said enough was enough. Had T level measured and while Total was fine 550, Free was a shameful 65. So quit the Fin but still no wood until I sstarted on Vimm Plus which is like a miracle. Libido and M Wood is now literally off the charts -almost embarrassingly so.

 

 

Loads of guys had hormone tests done, and they often don't help. Many men with (apparently) normal hormone levels still have adverse side effects. Unless someone does a full blood panel before taking finasteride, it is impossible to know what impact it has had on an individual.

 

What is Vimm Plus? I searched but can find nothing of that name or similar.

[LondonHTseeker]

I've been on Avodart for nearly 6 weeks. I've had sinus trouble, headaches, brain fog and boner issues. I'm going to stick it out for a while longer yet but so far I hate taking this BS!

[mahhong]

The other aspect of this I've never entirely understood is; surely a hair transplant plan has to be relatively conservative and factor in the possibility that finasteride will one day become reduced in effectiveness, or ineffective altogether?

 

Don't get me wrong, I completely understand the logic of finasteride - the more native hair on your head the better, that's clear any day of the week. But let's say you're mid-thirties, a visible NW4 and seemingly progressing, but you take finasteride and it arrests your hairloss, maybe even thickens up your crown and mid-scalp a little again. If you see a hair surgeon, they're not going to suggest jamming 6,000 grafts in your frontal third because your hairloss has been halted by finasteride. The plan is still going to need to assume that further loss is likely at some stage in the future, and the restoration is going to have to take into consideration the need for further transplants so that coverage and/or density could be returned at a later date if necessary. I appreciate a surgeon would make each procedure "stand alone" so that further procedures weren't necessary just to look natural, but it's a fair bet most men would commit to the idea of future procedures to deal with continuing loss or to refine existing work. And of course finasteride could become ineffective after 3 years, 5 years, 15 years, 20 years. Nobody could look a 35 year old man in the eye and tell him finasteride will maintain his hair until he's 55 - to that extent it seems to me you must plan for the worst whatever the situation, most of the time, in anything less than very limited balding cases with very encouraging family histories.

 

I'm not saying "why bother taking finasteride?", of course. I understand from the cosmetic perspective that it's an important part of hair restoration because any hair you can keep is important. But surely you must always be reasonably confident that you have enough donor available to deal with any eventuality? A man who has a good or likely chance of ending up with 275cm2 of bald scalp and 6,500 grafts over a lifetime would probably never want to head down the restoration route even if finasteride was working well for him, unless he was happy with the possibility of very thin coverage at some point down the line (could be aged 70, could be aged 40). But a man who has a more limited likely pattern, say 180cm2, and maybe 8,000 grafts over a lifetime may be much more amenable to the idea of surgical restoration because even if the "worst case" pans out he could still end up with a good head of hair from surgery alone.

 

I don't know, perhaps I'm thinking wrong about this, but it's always bothered me somewhat. Personally, I don't think I'd want to start down the transplant road unless I thought my goals could be reached even if finasteride one day stopped producing measurable benefit. If there was a fair chance I was going to be a NW6.5 - 7 with not particularly great donor reserves and characteristics, I don't think I'd take a chance on finasteride keeping me stable for decades. I'm 32 and concerned about my hair loss, but if at 52 I had a thin smattering of hair from transplants and finasteride wasn't really doing an awful lot anymore, I'm not sure I'd feel better because I was older. I'd want to know that good coverage and decent density was possible through surgical means alone and finasteride was a good adjunct to that, than the other way around.

 

Perhaps I'm not thinking about it the right way, though! It is a concern - I am reluctant to try finasteride again and am leaning towards not taking the risk. But I would like to consider the transplant route all the same at some stage in the not too distant future. I have seen some encouraging cases of patients having great transplants without the meds, but I guess to go that route you need to really try and figure out how bald you'll be and what donor you have to play with. There's no point going down that road if you're going to be an NW7 and can scrape 6,000 grafts out of a measly donor area (at least not unless you have very conservative goals indeed; most younger men would probably be more ambitious), but if you're NW5 and have 9 - 10,000 grafts through FUT and/or FUE suddenly that looks like a plan that might work even in the absence of medication.