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Frontal Fibrosing Alopecia: The Early Stages

When FFA First Begins 

FFA-early

Frontal fibrosing alopecia (FFA) is a scarring alopecia that affects women to a greater extent than men. The cause remains unknown although hormonal and immune-based mechanisms are clearly relevant.

The disease causes loss of hairs in the frontal hairline, sides and back of scalp, eyelashes, eyebrows and body hair. What is interesting about FFA is that the very earliest stages are associated with destruction of the tiny “vellus” hairs. This destruction leaves behind the thicker terminal hairs. 


In the earliest stages of FFA, the hair loss can be completely unnoticeable. There are frequently no symptoms and there is simply a subtle thinning in the area rather than complete loss. 

This photo of a patient with FFA shows a relatively normal looking scalp that is easily mistaken for androgenetic alopecia. (In fact this photo could easily be a picture of androgenetic alopecia were it not for the loss of all vellus hairs in this area over a 3 month period). In androgenetic alopecia, there is a gradual (slow!) conversion of thick hairs to thin hairs (a process called miniaturization). In FFA, we often do not see the miniaturized and vellus hairs as they are preferentially destroyed by the immune system. We see mainly single terminal hairs in FFA. Over time (without treatment) there may be some redness that develops in this area and even some scaling. About 40 % of women with FFA have androgenetic alopecia as well, so the two conditions frequently co-exist.

It is often not a decision “is this FFA or AGA ...but rather is it FFA, AGA or both.” The goal of treatment however is to stop that from occurring and the patient was started on topical fluocinonide gel, pimecrolimus cream, steroid injections and oral finasteride.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Finasteride, Dutasteride and Insulin Resistance

Do 5 alpha reductase inhibitors affect insulin sensitivity?

insulin-resistance

The topic of insulin resistance induced by 5 alpha reductase (5αR) inhibitors like finasteride and dutasteride is interesting.  Finasteride inhibits 5αR2 selectively, whereas dutasteride inhibits both 5αR1 and 5αR2. There is evidence that dutasteride has a more potent effect on insulin resistance than does finasteride. Finasteride may even reduce insulin resistance in some studies. 

It appears that the inhibition of 5αR1 is the relevant enzyme when discussing insulin resistance. Interestingly, Dowman and colleagues showed that increased liver fat and decreased insulin sensitivity are seen in mice with targeted disruption of 5αR1, but not 5αR2.

Upreti and colleagues performed a double-blind randomized controlled study of 46 men (20–85 years) with oral dutasteride (0.5 mg daily; n = 16), finasteride (5 mg daily; n = 16), or control (tamsulosin; 0.4 mg daily; n = 14) for 3 months. Dutasteride, but not finasteride, showed evidence of insulin resistance. There were no effects of dutasteride, finasteride or controls on BP, heart rate, body weight, BMI, or waist-to-hip ratio. However, there was an increase in body fat with dutasteride, but not finasteride. There were no differences in serum lipid profile

Hazlehurst and colleagues conducted a randomized study in 12 healthy male volunteers with detailed metabolic phenotyping performed before and after a 3-week treatment with finasteride (5 mg od) or dutasteride (0.5 mg od). Dutasteride, not finasteride, increased hepatic insulin resistance and hepatic lipid accumulation.

 

Clinical studies on Finasteride and Insulin Resistance

Duskova  and colleagues performed one of the most thorough studies examining the relationship between finasteride and insulin resistance. They examined 12 men with androgenetic alopecia who used finasteride for 12 months. Hormonal levels, metabolic parameters  and insulin tolerance tests performed for all individuals.  The authors observed an initial increase in total cholesterol and HDL- and LDL-cholesterol, which stabilized with prolonged treatment. However, they found a significant decrease in glycated hemoglobin HbA1c and decreased insulin resistance. The authors concluded that finasteride improves blood sugar parameters.

 

Conclusion

Dutasteride appears to have different effects on insulin sensitivity than finasteride likely due to its inhibitory effects on 5 alpha reductase type 1.  There are limited studies available on insulin resistance mediated by these drugs. However, the data would point to a slight insulin resistance effect with dutasteride and possibility slight improvement in insulin sensitivity with finasteride. 

 

References

Dowman et al. Loss of 5α-reductase type 1 accelerates the development of hepatic steatosis but protects against hepatocellular carcinoma in male mice. Endocrinology 2013; 154: 4536-4547

Duskova M, et al. Changes of metabolic profile in men treated for androgenetic alopecia with 1 mg finasteride. Endocr Regul. 2010.

Hazlehurst JM, et al. Dual-5α-Reductase Inhibition Promotes Hepatic Lipid Accumulation in Man. Randomized controlled trial. J Clin Endocrinol Metab. 2016.

Rita Upreti et al. 5α-Reductase Type 1 Modulates Insulin Sensitivity in Men. The Journal of Clinical Endocrinology & Metabolism, Volume 99, Issue 8, 1 August 2014, Pages E1397–E1406,  

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Using Dutasteride in Male Pattern Balding.

Use of Dutasteride in Previous Finasteride users. 

Currently used 5 alpha reductase inhibitors include finasteride and dutasteride. Finasteride is FDA approved for hair loss at 1 mg. Dutasteride is not formally FDA approved for treating balding. However, the medication can can be used off label. 

Finasateride is an inhibitor of the enzyme 5 alpha reductase type 2  and dutasteride is an inhibitor of both 5 alpha reductease type 1 and type 2. Dutasteride is more potent and leads to greater reductions of dihydrotestosterone (DHT). Studies from 2004 showed that dutasteride lowers serum DHT by up to 90% whereas finasteride lowers it by about 70 %. Side effects are also potentially greater with dutasteride than finasteride.

Options for Using Dutasteride

Patients using finasteride who find that the medication has not given them the growth they hoped for or who feel that their hair loss has progressed slowly over time should speak to their physicians about options. There are several points to discuss with your health care provider. Many individuals who have a “partial” response to finasteride often wonder if they should switch to dutaseteride or add dutasteride to thr finasteride they are already taking.

1. Adding dutasteride on weekends.

Adding a very small dose of dutasteride on the weekends can often be an option for some men.  An Australian study in 2013 reported a male who was initially treated with finasteride for androgenetic alopecia (male balding). Despite good compliance with the medication, the patient noted his hair density was not as good as previous years, and low-dose dutasteride at 0.5 mg once per week was added to the finasteride therapy. Interestingly, this treatment plan resulted in a dramatic increase in his hair density, demonstrating that combined therapy with finasteride and dutasteride can improve hair density in patients already taking finasteride.

 

2. Switching to dutasteride altogether

Another option that patients may wish to discuss with their physicians is whether to stop finasteride altogether and start dutasteride.  In 2014, Jung and colleagues from South Korea studied 31 men with male balding who took dutasteride after finasteride did not help them. Well over three quarters of these men  (77 %) improved their hair density by making the switch (17 improved slightly, 6 moderately, 1 markedly).

 

Conclusion

The use of dutasteride is among the treatment options for men with incomplete responses to finasteride. 

 

 

Reference:

 

Jung et al. Effect of dutasteride 0.5 mg/d in men with androgenetic alopecia recalcitrant to finasteride. Int J Dermatol. 2014 Nov;53(11):1351-7

 

Boyapati A and Sinclair R. Combination therapy with finasteride and low-dose dutasteride in the treatment of androgenetic alopecia. Australasian J Dermatol 2013


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Finasteride Use in Women: Yes or No?

Finasteride & Women

Finasteride is FDA and Health Canada approved for men with hair loss. Although it's not formally FDA approved for use in women, the medication has been prescribed to women with androgenetic alopecia for nearly two decades.  When a physician prescribes finasteride for androgenetic alopecia in women, they are said to be using these medications in an 'off label' manner.  The following is the key point about using finasterde for women : it's only prescribed on a case by case basis. 

 

Polar Views on Finasteride Use

The public needs to understand there are many views among physicians  on finasteride. There are some physicians that will never prescribe this medication to women -  period.  There are some physicians who will prescribe it only to post-menopausal women. There are some who will prescribe to some pre-menopausal and some post-menopausal women - but only on a case by case basis - and only with full counselling of risks and benefits.   

Much of the concern around use of finasteride in pre-menopausal women stems from the significant harm that would come to any fetus that was born to to a mother who used finasteride during pregnancy. These risks and real - and serious. Finasteride is given the highest category of risk during pregnancy - so called "category X." Women who are pregnant or who could become pregnant must never use finasteride.

The other concern that some physicians have pertains to cancer risk. To date, we actually don't have any good evidence to suggest that finasteride increases a woman's risk of cancer. In fact, reasonably well conducted studies in men would suggest that breast cancer risk is not increased. Good studies have not been done in women. However, women with strong histories of estrogen dependent cancers (breast, ovarian, gynaecological cancers) should also review use of finasteride with their doctors.  In some cases, use may not be appropriate.  I'll discuss other side effects below. 

 

Does Finasteride Help Genetic Hair Loss in Women?

So does it help women with genetic hair loss? Studies from nearly two decades ago said no. A study by Dr vera Price and colleagues in 2000 suggested a 1 mg dose in post menopausal women did not help androgenetic alopecia.  But just 2 years later, in 2002, Shum and colleagues presented 4 women (2 pre and 2 post menopausal) who did respond to a higher dose of finasteride - this time 2.5 mg finasteride. All 4 women had hyperandrogenism (one or more of elevated hormones, hair on the face, infertility issues). This refueled interest in the role of finasteride for women. 

In 2006, Dr Iorizzo and colleagues from Bologna, Italy published a study which further renewed interest in the use of finasteride for the treatment of female pattern hair loss. Iorizzo and colleagues looked at the benefit of finasteride at a dose of 2.5 mg in 37 women diagnosed with female pattern hair loss. All women in the study were also using a birth control pill to prevent pregnancy.  After 12 months of follow up, 62 % of women using finasteride had an improvement in hair density. 13 patients (30 %) hair loss had stabilized -   it did not get worse but  did not improve. Only 1 of 37 patients experienced a worsening of their hair density.
 

What are the side effects of finasteride in women?

I'm often asked about the range of side effects that are possible for women who use finasteride. Side effects of finasteride in women include, but are not limited to: harm to a fetus (finasteride can not be used in pregnancy), fatigue, weight gain, depression, anxiety, decreased libido, sexual dysfunction, hair shedding, breast tenderness, breast enlargement.  Other side effects can occur but are less common. These include changes in platelet counts and muscle injury (myopathy).

 

Reference


Iorizzo M1, Vincenzi C, Voudouris S, Piraccini BM, Tosti A. Finasteride treatment of female pattern hair loss. Arch Dermatol. 2006.


Shum et al. Hair loss in women with hyperandrogenism: Four cases responding to finasteride. Journal of the American Academy of Dermatology 2002; 47: 733-9

Bird ST et al. Male breast cancer and 5 alpha reductase inhibitors finasteride and dustasteride. J Urology; 190:1811-4

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Is topical finasteride completely free of side effects?

Topical finasteride is lower risk

Finasteride is a medication which blocks an enzyme known as 5 alpha reductase. It reduces DHT levels. Some of the side effects that are possible come from this reduction in DHT in the blood stream.  These include mood changes, sexual dysfunction, weight gain. In effort to reduce the risk of side effects there are increasing efforts around the world to create topical finasteride. Some of it is made up by compounding pharmacies. In some countries, it is commercially available (as in MorrF in India (Intas Pharmaceuticals).  

 

Topical Finasteride Gets Absorbed and Reduces Serum DHT

It's important for any user of topical finasteride to be aware that there is some small degree of absorption of finasteride into the blood stream even with topical finasteride. Studies have shown that the amount is low but one needs to keep in mind that if an individual is extremely sensitive to small fluctuations in serum DHT, this could still be relevant. 

Studies have suggested that with some formulations of topical finasteride about 1/10th to 1/20th of the amount gets absorbed into the blood compared tot he amount if the pills were used.  Studies have shown that topical finasteride still reduces serum DHT. Instead of reducing DHT by 70 % (as in the case of the pills), DHT is still reduced 25 %. Of course the degree of reduction is not the same as oral finasteride but nevertheless topical finasteride does reduce serum DHT.

 

Conclusion

I am not of the opinion that topical finasteride thas zero side effects. However, I am of the opinion that the chances of side effects are very low and significantly lower that oral finasteride. However, we still don't know if topical finasteride works quite as well as oral finasteride. Those "good" studies have not been done despite the rapid increase in world wide use of topical finasteride.  One must always keep in mind that there is no such thing as "standard" topical finasteride. Some pharmacies compound finasteride that can easily get into the blood stream and yet others use other chemicals in the formulation that make it more difficult for the finasteride to enter the blood stream. A variety of chemical constituents, including so called "liposomes", make it more difficult for finasteride to enter the blood all the while providing benefit in the scalp (and to the hair loss).  I always tell my patients that the topical finasteride they buy at their pharmacy may not be the same as another person buys at their pharmacy. We need to stop referring to this group of medications by the general term topical finasteride and referring to it by the specific formulation (i.e. 1% liposomal finasteride, or 0.1 % finasteride in soy phosphatidylcholine, ethanol, water). There is no such thing as standard topical fiansteride.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Gynecomastia in Finasteride Users: The Basics

What is Gynecomastia?

Gynecomastia refers to the enlargement of breast tissue in men.  It's extremely common and throughout life, a majority of men will be affected. For some, it will occur during infancy or puberty and resolve. For others it will start in puberty and persist and for others it will occur in older ages.

 

Gynecomastia by Age

Gyneomastia is common in newborns. Due to estrogens from the mother, 60-90% of male babies have enlarged swollen breast tissue. It resolves in a matter of weeks for most. For young male adolescents, gynecomastia is embarrassing but common. It can start at age 10-12 but typically it starts around 13 or 14 years of age.  About 50 % of male adolescents may be affected.  The breast swelling goes away on its own in 6 months to 2-3 years. In 20 % of affected teens, the swelling persists into adulthood. In men, gynecomastia is present in men 20-40, but particularly peaks in incidence after age 50. In the 50 plus age group, about 25-30 % of men are affected.  The number may rises to well over 50 % in 60 + age groups.

 

What causes gynecomastia?

Gynecomastia is caused by a variety of factors including genetics, drugs and physiological causes. Regardless of the precise cause, it is though that some hormonal imbalance (especially favouring estrogen and increasing the estrogen to androgen ratio) triggers breast tissue enlargement.  The actual level of hormones in the blood stream is typically normal and it's the ratio of these drugs at the actual level of the breast tissue itself that is important. Drugs cause about 10-25 % of cases. Pubertal gynecomastia that persists into adulthood is responsible for another 25 % of cases. The causes is generally unknown in about 25 % of cases as well.  But the list of potential causes is long and a full review is needed for anyone with concerns about gynecomastia. A variety of genetic syndromes (i.e. Klinefelter syndrome), metabolic problems, cancers all reduce the bodies production of testosterone and increase the estrogen to androgen ratio.

 

Drugs causing Gynecomastia

For hair specialists, it's well know that finasteride is among the causes of gyneocmastia. About 4 to 10 out of every 1000 men using finasteride will develop gynecomastia on account of the drug. But a variety of other medications and products can cause gynecomastia including:

1. Anti-androgens. (Finasteride Dutasteride). This anti-androgens is commonly used for treating male pattern balding. 

2. Anti-androgens. (Spironolactone). This anti-androgens is typically used for women with hair loss but not typically for men. 

3. Ketoconazole (anti-fungal). Generally speaking the risks is greatest with oral ketocoanzole rather than topical products. Oral ketoconazole is rarely used nowadays in North American due to safer anti-fungal agents. 

4. Heart burn medications (H2-receptor blockers). Drugs used to treat ulcers and heart burn including Cimetidine has the greatest evidence as a drug of this class being implicated. The others less so.

5. Tea tree oil and lavender oils. These essential oils have been reported to increase the risk of gynecomastia in children. Tee tree and lavender are found in soaps, shampoos and lotions. 

6. Other drugs. A variety of other drugs may also be implicated. A 2012 review classified drugs into two main groups including those 'definitely associated with gynecomastia" and those "probably associated with gynecomastia." The first group (drugs definitely associated with the onset of gynecomastia) inlcuded spironolactone, cimetidine, ketoconazole, hGH, estrogens, hCG, anti-androgens, GnRH analogs and 5-α reductase inhibitors.  The second group of drugs "probably associated with gynecomastia" include risperidone, verapamil, nifedipine, omeprazole, alkylating agents, HIV medications (efavirenz), anabolic steroids, alcohol and opioids.

 

Finasteride Induced Gynecomastia

Finasteride is FDA approved for treating male balding at a dose of 1 mg daily. It is among the medications known to cause  gynecomastia. The risk is likely about 4 to 10 out of every 1,000 users. Finasteride induced gynecomastia is often one-sided but can be both sides. This is especially true at lower doses like 1 mg compared to 5 mg. Finasteride induced gynecomastia can start as early as a 1-2 weeks after staring the drug but is typically a few months delay. It can also be 1-2 years before the phenomenon is appreciated. Pain is not uncommon in men with finasteride induced gynecomastia - and this pain/tenderness can occur prior to any actual enlargement. The 1 mg dose is less likely than the 5 mg dose to cause breast enlargement in men. Finasteride induced gynecomastia can reverse completely in many individuals provided the drug is completely stopped in the early stages when the breast enlargement is noted. If the drug is not stopped, it can enter a irreversible stage (where only surgical treatment will provide treatment). Finasteride induced gynecomastia is more likely in obese indivdiuals and with advanced age. Most of the time blood tests and various hormonal tests are normal in men with finasteride - induced gynecomastia. 

 

 

Treatment: How is gynecomastia treated?

The treatment of gynecomastia depends on the precise causes. For most adolescents, a conservative (watch and wait) approach is usually taken as the condition usually resolves in most cases. Only 20 % of adolescent cases of gynecomastia persist into adulthood.  Medical treatments are usually not effective. However, in some hormonal abnormalities, medications such as aromatase inhibitors can be used.  Usually surgery is needed to remove the excess tissue if that is what is so desired by the patient.

 

REFERENCES

Rodriguez et al.  Risk of gynaecomastia associated with cimetidine, omeprazole, and other antiulcer drugs. BMJ. 1994 Feb 19; 308(6927): 503–506. 

Bera F, et al. [Impotence and gynecomastia secondary to hyperprolactinemia induced by ranitidine].Therapie. 1994 Jul-Aug.

Deepinder F, et al. Drug-induced gynecomastia: an evidence-based review. Review article. Expert Opin Drug Saf. 2012.

Fentiman IS, et al. Managing Male Mammary Maladies. Eur J Breast Health. 2018.

Soliman AT, et al.  Management of Adolescent Gynecomastia: An Update.Acta Biomed. 2017

 

 

 

 

 

 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Using Finasteride with Pre-existing Gynecomastia

Does finasteride make gynecomastia worse?

I'm often asked if finasteride could make gynecomastia worse if one has gynecomastia to begin with.  The short answer is that it could. There are a large number of  anecdotal reports of finasteride worsening pre-existing gynecomastia. The challenge in giving good hard facts to the question is that a good clinical trial has not been done in men who have gynecomastia and start finasteride. 

Most studies have looked at the risk of gynecomastia in men starting finasteride who don’t have gynecomastia to begin with. Most men with gynecomastia to begin with are excluded from these trials so we don’t have good data on how gynecomastia worsens in finasteride users. Finasteride raises estrogen levels and it would make sense from a mechanistic and pathophysiological point of view that that small increase in estrogen could trigger hyperplasia of breast tissue in susceptible men. I encourage all males with concerns about gynecomastia to discuss these issues with their physicians. Serial photography of breast tissue is essential although frequently not done.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Gynecomastia in Finasteride Users: Lessons from Early Trials

Waxing and Waning Gynecomastia from Finasteride

Finasteride is used for the treatment of androgenetic alopecia. Gynecomastia or enlargement of breast tissue is one of the side effects and occurs in every 4 to 10 out of every 1000 men. Gynecomastia can be one side or affect both breasts. It usually starts after a few months in affected men.  Breast tenderness and pain are not uncommon. Finasteride-induced gynecomastia can reverse in many affected patients provided the drug is stopped in the early stages when the gynecomastia is noted. If the drug is not stopped, it can enter a irreversible stage (where only surgery will provide treatment).

A nearly two decade old report in the medical literature described two cases of recurrent gynecomastia in men enrolled in a placebo-controlled trial of finasteride. The report indicated that each of the two patient's  breast tissue hyperplasia diminished when the patients become noncompliant with their study medication and then resumed therapy.   In my opinion, these studies also provide an important lesson for physicians who see patients with gynecomastia and that is that the tissue enlargement itself as well as the pain should diminish relatively quickly in most patients if the phenomenon is recognized early and the medication is stopped.

When I see patients with breast pain who are using finasteride, I ask them to stop for a period of time. If breast pain does not quickly resolve, further evaluation may be needed. Breast pain is typically much quicker to resolve that the tissue enlargement. As far as the actually breast tissue enlargement goes, that too should resolve relatively quickly in a matter of months for most men - provided it's recognized early. In some men, it can even resolve within a week or two. 

It's important to understand the side effects spectrum of any medication that one prescribes. That is certainly true of finasteride.

 

Reference

Miller JA, et al. Waxing and waning gynecomastia: an indication of noncompliant use of prescribed medication. South Med J. 1999.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Does Finasteride Help All Causes of Hair Loss?

Finasteride: FDA approved for Male Balding

Finasteride is FDA approved for androgenetic alopecia in males but may also help hair loss from other conditions.

Finasteride for Male Balding

Finasteride was approved in 1997 for male balding at a dose of 1 mg. This approval came 5 years after finasteride was approved for treating prostate enlargement at a dose of 5 mg. Although generics are now available, the finasteride pills was initially marketed only as Propecia. For males with balding, it helps all areas that are thinning with the crown helped somewhat more than the front. Young males under 40 seems to get more benefit in the frontal areas of hair loss than men over 40.  Side effects of finasteride should always be reviewed before starting. 

Finasteride Side Effects - Donovan Hair Clinic

 

What conditions does finasteride help?

Finasteride is approve for male balding but may help several other conditions. These conditions include frontal fibrosing alopecia, some types of female patterned hair loss and very rare cases of lichen planopilaris including fibrosing alopecia in a pattern distribution (FAPD). Such uses are "off-label" and prescribed only in select cases.

 

What conditions does finasteride not help?

Finasteride does not help other types of hair loss. It does not appear to have benefit in alopecia areata, trichotillomania, telogen effluvium,  infectious causes of hair loss, and scarring alopecias such as folliculitis decalvans.  

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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DHT LEVELS AND FINASTERIDE

How do DHT levels change with one dose of finasteride?

yellow or red.png

Understanding how DHT levels change with finasteride is important in order to best counsel patients - especially those experiencing side effects. 


After taking 1 pills of finasteride, the drug itself is largely eliminated from the body in 1-2 days given that the half life of finasteride is about 4-6 hours (after five half lives a drug is significantly reduced in the body). However the same is not true of DHT levels. After a single dose of finasteride, DHT levels are reduced by 60 % (ie from 65 ng/dL to 25 ng/dL). However, the DHT levels don't rise back up quickly even though the drug is out of the body. Rather, DHT levels rise slowly increasingly just 15-20 % after the second day (ie from 25-30 ng/dL up to 30-35 ng/dL). Now back to the original question.

Of the two lines in the diagram, red or yellow, which best depicts how finasteride levels change with a single pill?

The answer is the yellow line! This concept is important since patients who are experiencing finasteride related side effects may still benefit from dosing every second or third day. It may not be quite as effective but as we can see from the graph, DHT levels are still being suppressed by this dosing schedule.
 

Reference

Vermeulen et al. Eur Urol 1991.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Can I eliminate the possibility of side effects from finasteride?

Eliminating a Drug is the only way to Eliminate the Possibility of Side Effects

I'm often asked how one can eliminate the side effects of a medication. "I want to take it doctor if it weren't for the side effects."  The reality is that it is possibility to eliminate the chances of side effects from any drug - and that is by not taking the drug.

 

Reducing Side Effects from Finasteride

The only way to really eliminate side effects from finasteride is not to take the drug. The chances of side effects with oral finasteride are low and in the order of 1-2 %. Nevertheless, all men need to be aware of the possibility of sexual dysfunction, mood changes, gynecomastia and other potential side effects as well.  The chances of side effects tend to be depenent on the amount of finasteride absorbed into the blood stream which in turn affects the degree of reduction in DHT.

 

1. Reducing the dose

Reducing the dose to 0.5 mg or 0.25 mg may be associated with reduced chances of side effects. DHT is still inhibited at these doses, albeit not as effectively as a 1 mg dose. Studies have suggested that DHT inhibition at 0.2 mg is about 80 % the level of 1 mg pill.

 

2. Reducing how often it is taken

Even though the drug half life is 6-8 hours, one needs to consider how long 5 alpha reductase inhibition in the scalp is actually occurring. Studies have suggested that 1 mg finasteride daily and 1 mg finasteride every other day are fairly similar in effectiveness although good studies still have yet to be done to really back this up definitely. Taking every other day can reduce side effects but may potentially alter effectiveness as well.

 

3. Using topical compounded finasteride

The other way to minimize finasteride side effects is to consider topical finasteride applied to the scalp. Absorption into the blood stream may still occur with topical finasteride (as systemic DHT levels are still reduced) but side effects are much less.

 

4. Taking time to understand the risk and benefits, long term studies

Studies also show that a broad and objective understanding of finasteride, its proper use also reduces side effects. Men who are alarmed about the drug and proceed into taking the drug without a full and balanced view of the risks and benefits also have a higher incidence of side effects. Studies have shown that risks increase in this situation from 2-5 % to above 60 % (i.e. nocebo effects).

 

Conclusion

Anyone wishing to minimize side effects of finasteride should have a thorough discussion with their physician. For more information on finasteride, download our handout. 

FINASTERIDE - HANDOUT


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Topical Finasteride: Are side effects possible?

Topical Finasteride: Don't forget the placebo studies!

If one is going to use topical finasteride,  they must be 'prepared' for the possibility of side effects. For patients to use topical finastseride (or physicians to prescribe topical finasteride) with the complete expectation that it comes with zero chance of side effects is simply incorrect. The "chances" of side effects in my experience are certainly very, very, very low (probably well under 1 in 1000) and much, much lower than oral finasteride. But they are likely not zero especially if one considers that even placebo pills have side effects! Side effects with topical finasteride have not been reported to date.

 

Topical finasteride: What is the risk of side effects?

Common sense dictates that someone will have a side effect to topical finasteride. Whether it's 1: 1000 men or 1 in 10,000 or 1: 1,000,000 is unknown but there is little doubt in my mind that side effects are possible. We know that DHT is still inhibited in the blood by up to 25 % with some topical finasteride formulations and about one tenth of the amount of finasteride is still absorbed. In other words, a lot less gets into the blood, but it's far from zero. 

fin

 

Analogies I use in my clinic

I completely understand that many physicians and many patients assume that topical finasteride is 100 % free of side effects (or at least close to it). But let's use a few analogies which help us all understand that a 25 % reduction in DHT is going to be a bit much for a small proportion of men.

Humans have a delicate physiology. There are some individuals that are sensitive to small changes in blood levels of anything. There are some individuals that are sensitive to small amounts of alcohol in the blood. Some individuals are sensitive to small amounts of caffeine.

Sexual physiology is likely even more complex. There is no doubt that some will be sensitive to small reductions in DHT. We see similar "DHT" related side effects even with saw palmetto - which is not supposed to even effects DHT at all! We even see DHT related side effects (erectile dysfunction, decreased libido) in 0.7 % of men using "placebo pills" in clinical studies - which inhibit DHT 0 %!! By age 30, about 30 % of men have some degree of sexual dysfunction. By age 50, it's 50 % , and by age 80, it's well over 80 % of men.  Factor this into the 0.7 % chance of sexual-related side effects with placebo pills and it's easy to understand that at least someone is going to present with concerns about side effects from topical finasteride. 

Consider now the following table. We know that oral finasteride inhibits DHT by 70 % based one studied done in the 1990s. The chances of side effects with oral finasteride are around 2 %. This includes sexual dysfunction and mood changes. A drug that inhibits DHT to no degree at all (i.e. 0%) would likely have lower chances of "DHT-related" side effects. But clinical studies using placebo pills in clinical trials of finasteride have suggested this could be as high as 0.7 %. Of course, other side effects could be possible.  We are then left with considering the chances of side effects in a drug that inhibitors DHT levels in the blood by 25 %. Are the chances of side effects zero? Probably not given that not even the placebo has a 0 % chance of side effects.. But fortunately, they are likely very low. We don't yet know that number. In my experience using topical finasteride, I have formed the opinion that it is likely very low and probably well under 1:000. But what is the real number? Is is 1:1000 men?  1:10,000 men?

topical fin

 

.Many different Topical Finasteride Formulations

If a male is very sensitive to a reduction in DHT then side effects may occur. If a formulation can be created with zero penetration into the blood then systemic DHT will not be affected. That does not exist yet. One must keep in mind that there is no "one" topical finasteride formula - there are dozens of different formulations. Some pharmacies just make it up however, they like. Polychem is studying a specific formulation. MorrF is available in India already through Intas Pharmaceuticals and consists of topical minoxidil and topical finasteride together. .

Topical finasteride is clearly safer than oral finasteride and we have used for several years in our clinic. To say it has zero possible side effects would be incorrect. In my opinion, it is just a matter of time before we hear of possible side effects.  There are side effects even with placebo (and it's as high as 0.7 %!).But overall, topical finasteride is much much safer than oral finasteride. But anyone who uses it must be aware that it is off label and long term effects are not known. There have been millions of prescriptions for oral finasteride to date and well over 1 million men use it every year for treating hair loss. This does not include finasteride use in prostate issues. Compare this to the fact that there are probably under 200,000 men worldwide (maybe quite a bit less) that have used topical finasteride. 

Physicians and patients need to be aware of the 'unknowns' of topical finasteride use and  counsel patients on the reduced chances of side effects but the possibility that a very small proportion of men will report side effects. Overall, the drug appears to have a very good safety profile in the topical formulation.

 

REFERENCES

M Caserini, et. al.  A novel finasteride 0.25% topical solution for androgenetic alopecia: pharmacokinetics and effects on plasma androgen levels. Int J Clin Pharm Th July 30, 2014 (1-8).

BS Chandrashekar, et. al. Topical minoxidil fortified with finasteride: An account of maintenance of hair density after replacing oral finasteride. Indian Dermatol Online J 2015 Jan-Feb; 6(1): 17-20.

S Sheikh, et. al.  A new topical formulation of minoxidil and finasteride improves hair growth in men with androgenetic alopecia. J Clin Exp Dermatol Res 2015, 6:1.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Treating Frontal fibrosing Alopecia (FFA): Are retinoids better than finasteride?

Retinoids in FFA Treatment

FFA 102

Frontal fibrosing alopecia ("FFA") is an autoimmune disease that mostly affects women. It is classified as a "scarring" hair loss condition and hair loss is often permanent for many women. A variety of treatments are available including topical steroids, topical calcineurin inhibitors, steroid injections as well as oral treatments like finasteride, doxycycline, hydroxychloroquine and isotretinoin.

A new study from Poland set out to compare benefits of finasteride and "retinoids" (isotretinoin and acitretin) in women with FFA. The study included 29 women who were treated with a dose of 20 mg isotretinoin, 11 women treated with 20 mg acitretin and 14 treated with oral finasteride at a dose of 5 mg/daily.  Interestingly, 76% of patients treated with isotretinoin, 73% of patients treated with acitretin, and 43% of patients treated with finasteride had their disease halted over a 12 month observation period. 

 

Comments

This study is small and should be interpreted with caution for this reason. Nevertheless it is interesting and points to a potentially valuable role for retinoids that we really don't seem to see with classic lichen planopilaris (a closely related condition). The data in this present study however do not match other much larger studies of finasteride use in FFA which have suggested that a much higher proportion of FFA benefitted from use of this drug.

For now, this study provides us with evidence that retinoids can benefit some patients and should be at considered. Many women with FFA do have a tendency for increased cholesterol levels and the use of retinoids can significantly worsen this so caution and monitoring are needed.


Reference

Rakowska A, et al. Efficacy of Isotretinoin and Acitretin in Treatment of Frontal Fibrosing Alopecia: Retrospective Analysis of 54 Cases. J Drugs Dermatol. 2017.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Androgen Blockade For FPHL: Can I use more than I medication?

Androgen blockade has the potential to be help female pattern hair loss. Caution is needed with any hormone blocker due to significant harm that can come to a developing baby were a woman to become pregnant on any hormone blocker. For this reason they are frequently used with various strict contraceptive methods.

 

Hormone Blocking Medications for FPHL

Female Pattern Hair Loss (also called female androgenetic alopecia) affects 40 % of women by age 50. There are a variety of treatment options including minxodil, anti-androgens, laser and PRP. 

Anti-androgens can help some women with female pattern hair loss. A long list of anti-androgens exist including spironolactone, finasteride, cyproterone acetate, flutamide, dutasteride. The combination of anti-androgens can sometimes work even better than one alone provided the patient actually has a truly androgen responsive hair loss condition. Most men do. But not all women have a form of FPHL that is truly responsive to anti-androgens.

 

Anti-androgen Side Effects

The decision to use two or more anti-androgens must always be weighed against potential side effects. The combination of androgen blocking pills has the potential to be associated with side effects such as depression, worsening fatigue, breast tenderness, breast enlargement, weight gain, decreased libido.

 

 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Treating Female Pattern Hair Loss: Options for Women Over 60

Treatments for AGA in Women over 60

I'm often asked about treatment options for women over 60 who present with a diagnosis of androgenetic alopecia (female pattern hair loss). There is some degree of confusion as well as misconceptions which exist in this subject area.

My approach in this situation is to first confirm the diagnosis and then base treatment decisions according to the patient's medical history. The importance of the first step can not be overemphasized.

 

1: Confirming the Diagnosis

It is extremely important to confirm the diagnosis and ensure that a) another diagnosis is not more appropriate and b) to determine whether other diagnoses are also present. A patient need not have only one diagnosis.

A. Senescent Alopecia

Women who present with hair thinning in their 60s and 70s with no evidence whatsoever of thinning in the 30s, 40s or 50s may have senescent alopecia (age related hair loss) rather than true androgenetic alopecia. This distinction is important as senescent alopecia is less likely to be androgen-driven and therefore responds less to antiandrogens such as finasteride. The main treatment for senescent alopecia is minoxidil although agents such as low level laser and less commonly finasteride can be considered.

I typically ask patients if their hair density on their 50th birthday was more or less the same as their 30th birthday. If that answer is yes one should at least consider the possibility that senescent alopecia or even another diagnosis other than androgenetic alopecia is present.

 

B. Scarring Alopecia

Scarring alopecias are far more common than we currently diagnose. They range from subtle asymptomatic scarring alopecia to fibrosing alopecia in a pattern distribution to markedly symptomatic lichen planopilaris. Scarring alopecias are easy to miss but need to be considered in all patients with sudden onset of itchy hair loss or a more rapid decline in density from what they may have experienced in the past. A biopsy can help better evaluate these conditions. 

 

C. Hair shedding issues

Both acute and chronic telogen effluvium (CTE) need to be considered in women with hair concerns. Stress, thyroid problems, new illnesses and newly prescribed medications can all contribute to increased hair shedding and hair loss. Anyone with new shedding needs a very detailed examination and workup not only by the dermatologist but by the family physician. Blood tests are especially as is a full medical examination. One must also ensure that routine mammograms and colonoscopies are up to date.

Chronic telogen effluvium (CTE) is among the more challenging to diagnose conditions. Patients present with increased shedding that waxes and wanes. To an outsider it generally appears that the person has fairly good density. A hair collection or biopsy can help with the diagnosis.

 

Treatment Options

The main treatment options for patients with confirmed androgenetic alopecia is minoxidil, finasteride and low level laser. If the pattern of hair loss is localized frontal loss, and donor density in the occipital scalp is good, a hair transplant can be considered as well.

Minoxidil is formally approved for women 18-65. It may, of course, be used off label for women over 65 with proper evaluation by a physician.  Women with heart disease, heart failure or previous heart attacks for example may or may not be good candidates for minoxidil. One is not obligated to use the full recommended dose of minoxidil. Starting with one-quarter or one-half the recommended amount is often a good way to ease in to the treatment in patients with underlying medical issues.

Finasteride may also be a good option. Studies support the notion that higher doses of 2.5 mg and 5 mg are needed for post-menopausal women and doses of 1 mg are ineffective. Finasteride is relatively contraindicated in women with previous history of breast, ovarian or gynaecological cancer. Given the rare effects of finasteride on mood, this medication is also relatively contraindicated in women with depression.

Low level laser therapies are safe but may be less effective than minoxidil or finasteride.  A number of laser devices are available in the market for use by patients in their home. None have proven superior to another and so one must balance cost with ease of use. A helmet based device may be easier for some compared to the hand-held devices.

Scalp Inflammation. Scalp inflammation must be attended to fully when caring for patients with AGA. Many women with AGA have seborrheic dermatitis and this is best controlled with periodic use of an anti-dandruff shampoo. I frequently prescribe a trial of a mild cortisone lotion if there is scalp redness if the redness does not respond to anti-dandruff therapies.

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Finasteride and Gynecomastia (Male Breast Enlargement)

Finasteride: What are the myths are realities when it come to gynecomastia?

 

Gynecomastia or enlargement of breast tissue in men can occur with a number of causes. These include hormonal issues that affect testosterone production (like Klinefelter’s syndrome or a pituitary problem), normal aging, tumors of the adrenal glands, testes or pituitary gland, thyroid problems, liver and kidney problems. A variety of medications can cause gynecomastia as well. Overall about 10-25 % of cases of gynecomastia have a drug cause. Some of the drugs known to cause gynecomastia include spironolactone, other anti-androgens, cimetidine, ketoconazole, estrogens. For a full list of implicated drugs, click here. In all of these different causes there is an underlying hormonal issue  - typically an increase in the estradiol/testosterone ratio.

 

Finasteride-Induced Gynecomastia: Myths and Misconceptions

Finasteride, which is FDA approved for treating male balding at a dose of 1 mg daily, is a medication that can sometimes cause gynecomastia. The risk is likely about 4 to 10 out of every 1,000 users. There are a number of misconceptions about finasteride-induced gynecomastia. The following points help clarify some of these.

 

1. Gynecomastia can be one sided or both. It is very commonly one-sided.

Finasteride induced gynecomastia is often one-sided but can be both sides. This is especially true at lower doses like 1 mg compared to 5 mg. 

 

2. Gynecomastia typically starts after 2-4 months

Finasteride induced gynecomastia can start as early as a few weeks but is typically a few months delay (if it is going to occur). It can also be 1-2 years before the phenomenon is appreciated.

 

3. Finasteride-induced gynecomastia can start with breast tenderness or even pain

An important sign to watch for is the presence of pain or tenderness. This can occur prior to any actual enlargement.

 

4. Finasteride-induced gynecomastia lower doses are less likely than higher but can occur any dose

The 1 mg dose is less likely than the 5 mg dose to cause breast enlargement in men. The concept of the dose response is important because it means than for some men, 0.5 mg daily (or every other day) could be assocated with a lower risk of gynecomastia (while still potentially benefitting their hair).

 

5. Finasteride-induced gynecomastia reverses in many with immediately stopping the drug but not all

Finasteride induced gynecomastia can reverse in many individuals provided the drug is stopped in the early stages when the gynecomastia is noted. If the drug is not stopped, it can enter a irreversible stage (where only surgery will provide treatment).

 

6. Finasteride-induced gynecomastia increases with age and obesity

Finasteride induced gynecomastia is more likely in obese indivdiuals and with advanced age.

 

7.  Most men with Finasteride induced gynecomastia have normal blood tests

Blood tests may be appropriate  for some men depending on their history. However, most of the time blood tests and various hormonal tests are normal.

 

CONCLUSION and FINAL POINTS

Gynecomastia is common in the population so one must be careful to immediately ascribe their gynecomastia to a drug or health reason without a full evaluation. Finasteride induced gynecomastia occurs in 4 to 10 out of every 1000 men using finasteride. It is dose dependent so risk may be less with 0.25 mg compared with higher doses. Anyone with concerns about this phenomenon should see their physician immediately to discuss.

A link is more likely to a drug cause when the breast enlargement is one sided and tender/painful. One way to determine a link is to stop the drug and wait for the tissue to return to normal before starting the drug again (this is called a rechallenge). If gynecomastia occurs again, one has more confidence of a link. This may not be appropriate for all individuals so one should always discuss with their physician.

 

REFERENCE

[1] Nuttall F (1979) Gynecomastia as a physical finding in normal man. J Clin Endocrinol Metab 48:338–340

9. Green L, Wysowski DK, Fourcroy JL. Gynecomastia and breast cancer during finasteride therapy. N Engl J Med. 1996;335:823.  

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Finasteride Side Effects in Women

What are the side effects of finasteride in women?

First off, finasteride is not FDA approved for women. Any such use is therefore "off label" and any female considering finasteride will want to be guided by a knowledgeable and experienced physician if this is a route you wish to take. Depending in the patient's current age, type of hair loss and medical history and family history this may or may not be a good option.

Side effects

i'm often ask about the range of side effects that are possible for women who use finasteride. Side effects of finasteride in women include, but are not limited to: harm to a fetus (finasteride can not be used in pregnancy), fatigue, weight gain, depression, anxiety, decreased libido, sexual dysfunction, hair shedding, breast tenderness, breast enlargement.  Other side effects can occur but are less common. These include changes in platelet counts and muscle injury (myopathy).


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Hair Weights with Finasteride

Hair Weights with Finasteride.png

One of the most carefully conducted studies investigating the benefits of finasteride in treating male pattern balding was in 2002. It was a 96 week study by Vera Price and colleagues. This study not only looked at changes in hair numbers before and after starting finasteride but also hair weights- the actual mass of hairs in a square centimetre area before and after treatment. These studies showed that after using finasteride, hair weights were greater than placebo (25.6% +/- 3.6% [18.5, 32.7] and 35.8% +/- 4.6% [26.7, 44.8] at 48 and 96 weeks, respectively; P <.001 for both time points). This data is important because it showed that finasteride helped men with hair loss by thickening many hairs - which we know now to represent a conversion of some of the vellus-like and miniaturized hairs to thicker terminal hairs. 

Reference

Price VH, et al. Changes in hair weight and hair count in men with androgenetic alopecia after treatment with finasteride, 1 mg, daily. Randomized controlled trial J Am Acad Dermatol. 2002.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Should I Use Finasteride for Hairline Maturation?

There are two common changes to the frontal hairline that young men can observe. One is known as hairline maturation and the second is male pattern hair loss (also known as androgenetic alopecia). Both are a cause of worry to patients and both are commonly misdiagnosed.

 

Hairline maturation

Hairline maturation is a normal process that occurs between age 15-27 whereby a small amount of hair recession occurs in the very frontal hairline and a slight amount of recession of the temple is observed. This is generally 1 cm above the highest forehead wrinkle in the centre and 1.5 inches in the temples. In male balding recession occurs to greater degrees.

 

Treatment of hairline maturation and male balding

The distinction between the two conditions (hairline maturation vs balding) is important as there are no medical treatments for hairline maturation. Male balding can be addressed with treatments such as finasteride or minoxidil as well as others too.

Finasteride (Propecia and generics) and minoxidil (Rogaine and generics) are FDA approved for male pattern balding. These treatments do not have any effect on normal male hairline maturation. One may want to check with a physician of concerns exist about signs of early male balding. The best thing that can be done in early stages of hair loss is frequent scalp photography every 4-6 months. This is extremely helpful to track changes in the hairline and get a sense of the degree of hairline maturation and balding a person might have.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Valproate and Hair Loss: Does valproate cause hair loss through an androgen mediated mechanism?

There are many different types of drugs used as mood stabilizers is women with bipolar disorder. Many of these drugs can cause hair loss, albeit with different mechanisms. Common medications used in treating bipolar disorder include lithium, valproate, lamotrigine, topiramate, gabapentin, carbamazepine, oxcarbazepine.

 

Vaproate and Hyperandrogenism

There is increasing evidence suggests that valproate is associated with isolated features of polycystic ovarian syndrome (PCOS). To study this further, researchers studied three hundred women 18 to 45 years old with bipolar disorder. A comparison was made between the incidence of hyperandrogenism (including hirsutism, acne, male-pattern alopecia, elevated androgens) with oligoamenorrhea that developed while taking valproate versus other types of anticonvulsants drugs (like lamotrigine, topiramate, gabapentin, carbamazepine, oxcarbazepine) and lithium. 

 

What were the results?

It was interesting that among 230 women who could be evaluated, oligoamenorrhea with hyperandrogenism developed in 9 (10.5%) of 86 women on valproate compared to just 2 (1.4%) of 144 women on nonvalproate anticonvulsants or lithium. This translated into a nearly 8 fold risk of these hyperandrogenism and menstrual cycle changes with valproate. Oligomenorrhea happened within 12 months with valproic acid users.

 

Conclusion

Once needs to be aware of a possible PCOS like clinical phenomenon and for hair specialists - the development of hyperandrogenism and accelerated AGA in women using valproate for bipolar disorder. More studies are needed to confirm these findings.

Reference

Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism in women with bipolar disorder.

Joffe H, et al. Biol Psychiatry. 2006.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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