Spironolactone vs Finasteride: Which is more likely to cause weight gain? Concerns about low ALP?

Spironolactone vs Finasteride: What are the chances of weight gain?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to finasteride and spironolactone related weigth gain and important issues related to low ALP levels.

Question

I am a 53 year old female. I have progressive thinning of hair but also ongoing shedding. I have used minoxidil without success. I’m thinking about using finasteride. I am concerned about weight gain with finasteride vs spironolactone.  I am quite an inactive person.  I’d like to know your thoughts.

As far as my health goes, I have been diagnosed with osteoporosis. I have also been diagnosed with fibromyalgia and have chronic fatigue, muscle and bone pain.  I am somewhat limited in my mobility due to joint pains (feet) and difficulty walking.  My blood tests have shown low ALP all my life (around 11-17 U/L) so that is not new.  Recent tests show have low estrogen (<40)  and high FSH 56. My testosterone is low. TSH is 1.25, Ferritin is 55. ESR is 2 and CRP is 0.4. My zinc and vitamin D normal.

I am interested to know if finasteride or spironolactone is more likely to weight gain. Is low ALP associated with androgenetic alopecia?

Answer

Thanks for this question. This is a very interesting question for a reason I’ll come to in a minute.

First, the short answer is that spironolactone and finasteride can both cause weight gain in women – but overall chances are fairly low. The chances seem to be lower on spironolactone than finasteride but really good comparative studies are lack. Some estimates have suggested that 1 out of 75 users on spironolactone gain weight. We don’t have great data on finasteride, but I would guess that around 1 in 8 to 1 in 15 users have some weight gain.

We’ve compared some of the side effects of spironolactone and finasteride in the past.   I’ll link the article below.

Low ALP with Musculoskeletal Issues.

Before I leave the question, I’d like to mention a few things about your blood tests, Certainly the low estradiol,  high FSH and low testosterone are consistent with a perimenopausal transition or menopausal state. These numbers are not concerning.

What is a bit concerning is your chronically low ALP – especially in the setting of these bone and muscle issues. I do think that you should speak to your doctors about your lifelong low ALP. No, these are not associated with AGA. What’s so important here is that a condition known as hypophosphatasia at least needs to be considered by your doctors. It’s not a cause of hair loss but I thought I’d mention it as it often goes misdiagnosed and getting an accurate diagnosis could be really important. We’ve actually had a question of the week realted to low ALP in the past. The link is here: Low ALP and Hair Loss.

A variety of medical conditions can cause low ALP. I’ll direct you to a Patient Information Sheet we have for Hypophosphatasia (HPP) which outlines some of those conditions. It does not seem too likely that you have any of these other conditions on the list that cause low ALP but of course I don’t have all your story.

With your history, I think it’s important that a basic work up be done.  I have suspected HPP in several patients in the past with a simple rule “patients with persistently low ALP and bone, joint, muscle or teeth concerns often benefit from further investigation by an endocrinologist, genetics specialist or specialist in these metabolic issues.”

Your history of a fibromyalgia like presentation together with the muscle and bone pain make me wonder if HPP could be present. You should have someone review this

Here are the tests I would typically recommend to my own patients with persistently low ALP without a clear cause have done.  (I also recommend that patients stop all vitamins for 1-2 weeks before having these tests done)

1.    ALP ( in your case, not needed to repeat)

2.    AST, ALT bilirubin

3.    Ferritin and anti TTG - probably not needed for you

4.    Vitamin B6 and vitamin B12

5.    Calcium and 25 hydroxyvitamin D, Phosphate

6.    PTH, if indicated

7.    TSH - probably not needed for you.

8.    AM cortisol

9.    Glucose

10. Hemoglobin A1c

11. Ascorbic acid

12. Magnesium and Zinc

13. Creatinine

14. Urinary calcium (if needed) – not usually helpful.

15. Copper and ceruloplasmin (if appropriate)

In general, a persistently low ALP level on two or more occasions (less than 40 U/L) with the right clinical story along with confidence that other diseases have been ruled out increases the likelihood that HPP may be present.  

Diagnosis of HPP is important for several reasons.

First, proper diagnosis may help get patients connected with the right experts. I see that you have osteoporosis. I don’t know if you receive any kind of treatment for the osteoporosis but I would point out that it’s now appreciated that typical treatments for osteoporosis like bisphosphonates are not the ideal treatment if “hypophosphatasia (HPP)” is your diagnosis. This is simply because bisphosphonates use may worsen outcomes in patients with HPP.

Second, many adults with HPP have been misdiagnosed with other conditions and having a diagnosis of HPP offers validation for their symptoms. Some patients with HPP are diagnosed with depression, sleep disorders, joint problems, fibromyalgia and more. Getting an accurate diagnosis helps people heal in many aspects of the disease.

Third, HPP is thought by experts to be more common than realized. It’s possible that HPP gets passed down from one generation to another and manifestations may be different from generation to generation. In autosomal recessive forms, it’s possible that two parents with HPP who don’t know they have HPP could have a child with severe forms of perinatal, infantile or childhood HPP. Getting the diagnosis of HPP as early as possible in an adult, will help allow for appropriate genetics counseling in the event that a patient with HPP wishes to have children. In your case, it could be helpful in the event you have children and they have any bone, joint, teeth or muscle and neurological issues. If you are found to have the condition, you might discuss with your children more about the condition and if your children want to be evaluated.  Again, I’d like to make it clear that I don’t know for sure you have this but I do think someone needs to rule this out with 100% certainty. Anyone with chronically low ALP with bone and muscle issues needs to have HPP ruled out.

Thank you again for the question.