Make America Hairy Again: The Truth About Post-Finasteride Syndrome

27:38I have a side question for you. Yeah, no, bring it. If this is a total sidebar, then we can circle back to it later. We'll fix it in post. We will fix it in post. There is no post. The other treatment that I often see for hair loss is, I'm probably going to butcher the pronunciation, medoxidil. No, that's good. Does that have a similar, my very loose understanding, just from researching for this episode is that the side effects for that is less of a concern than an asteride. Yeah. How do you balance those two? What are the pros and cons of both? Well, they're synergistic because you don't have to balance in anything.

28:13I mean, so minoxidil is, it was originally studied as a hypertensive drug or a blood pressure drug. And so again, it goes back to one of these great things where, you know, we started taking minoxidil. I mean, this drug's been around for 40 years. I can't even tell you how long it's been around. But also we noticed not only did blood pressure go down, although not very much, but guys retaining hair. And it's actually a very effective treatment by helping open up the blood vessels so that the hair follicle is seeing better blood flow, better nutrients. And so they actually can work synergistically.

28:47And there's a topical form of minoxidil that you put on like a mousse or nobody uses mousse anymore. It's what is it, 1985 mils? But anyway, you put it on as a hair accoutremal and you rub it in and it works. And there's also a pill for him. Medoxidil comes in two and a half and five milligrams. And I think that actually has a very clean side effect profile from sexual side effects because it's non-hormonal. You know, it works on the blood flow system. And so if you came to a physician that was treating hair loss, then maximal medical therapy would be some combination of medoxidil and finasteride and usually orally.

29:23You know, there are sort of, you know, potions and lotions and things that aren't really FDA approved where people will compound, you know, finasteride, put it in the hair follicle, never really studied. There's no data that it works. There may be some transdermal absorption. But for the most part, you know, you need a prescription to get both of these drugs, thank goodness. And actually, I think, you know, it's time to then, now that we have a little bit of a background on how these drugs work, hormone blocker, pros and cons, it is to say, well, why is this becoming a thing again? I mean, first of all, because, you know, we've worried as men for centuries, if not eons about hair loss.

30:05Why? It's kind of, you know, it's central to who we are. And it also is one thing we didn't talk about in our nitric oxide episode. but it's one of the first signs of aging. And if you're 19 years old, with some men that have very early male pattern baldness, that can devastate us, right? It's one thing, I mean, out of all the things I do urologically that guys are self-conscious about, you can hide that with underwear and a belt and a pair of pants, right? But you can't. It's very difficult to mask hair loss unless you're wearing hats or wearing some kind of hair accessory. And so it's front and center.

30:38Every day you wake up, brush your teeth, wash your face and you look at your hairline thinning and so it makes us very vulnerable as men and women too i mean obviously female hair loss is a whole nother thing which which is even less socially accepted and so therefore even more traumatizing to our women out there that that may be listening and interestingly enough both minoxidil and finasteride can work in women as well totally different side effect profiles totally different podcasts we'll have to bring somebody on that is on that side of the treatment spectrum but it's a devastating issue right and it has not had a lot of research into it.

31:14It's as far as we know, not associated with any long-term other health concerns. And so it falls into the, into the category of cosmetics, which I would say is not true because anything that affects our psychology and our mental health is not a psychological problem, but it is, is a true mental health problem. And so, so we do need solutions for this, right? And the other thing is if there's a market for it, what do you think happens? Just like you said, I mean, so talk to me about, you know, a day in your, in your Instagram feeds and your social media feeds. What are you seeing? You don't have to name companies, but the bottom line, you mentioned it is that people are out there trying to sell you something to maintain that lustrous hair you have.

31:59Yeah. I mean, I noticed a lot of my friends are of similar age to me, just seeing it get served up more and more often. And it definitely puts the thought in your head. I mean, I've thought more about it in the last six months than I ever have just because it's been brought to my attention. And, you know, I find myself now at age 38, you know, staring in the mirror thinking, wait, is this thinner than it used to be? And my dad, God bless him, would always say, you know, his hair is thinning. And he would always say, it just means it's more highly evolved. There you go. I always liked. That's right.

32:29Yeah. So somebody is trying to sell you something somewhere. And I think that's what has happened. I mean, we've known about post-finasteride syndrome, which we'll get into here in a sec for years. And what it is, we'll talk about. But definitely the side effect profile has, I think, been buried a little bit because there's this rush to sell you something. And there's multiple direct-to-consumer venues that the business model is if you don't log out without a prescription, then they're not going to make money off you. And so I think any listener that out there listening, I want you to make sure that the people that are prescribing you hair loss drugs at least have told you some of the side effects.

33:13And I think that's where this is making the news again is that as these companies have higher and higher valuations, they're becoming more and more a part of our daily dinner table discussions, which is, you know, this is American capitalism. I cannot possibly say anything bad about it because we all live and breathe this every day, but I can say caveat emptor. And so I think that's what I want is to make sure that people are informed before they make the decision. Because as I led this podcast off with, I think these are amazing drugs. And I think they're in general for most men really are fantastic.

33:45I mean, it decreases the number of surgeries we have to do on men as we age for prostate enlargement. There's no doubt. so if you can take a pill to stay out of my operating room so i don't have to to do some procedure to reduce your prostate size then take a pill as long as it works for you and eventually you'll probably end up in my or but that's okay i got time i'm busy and so i'll wait patiently as you're taking that finasteride and dutasteride but if i didn't have the conversation at the beginning and say hey jordan these are great drugs but here's the deal let's just really break it down this is what i've seen over 20 plus years of practice in treating thousands of men on an annual basis, if they come in asking for an Asteride, or if I notice that they are concerned about their rapidly thinning hairline or rapidly enlarging prostate, we're going to talk about it.

34:32And we're going to say, here's the deal. I have no idea. I can give you this pill. And I can give this pill to 100 guys. And 98 of those guys are going to say, Mills, that was fantastic. I'm peeing better. My hair is thicker. And this is the greatest drug ever. And two of those guys are going to say, oh man, like, I mean, yeah, prostate's better, hair is thicker, but I have no sex drive anymore. I'm feeling kind of grumpy, moody, actually even feeling like I don't really have much reason to live. And I certainly have noticed that I'm not getting erections anymore. Those are the guys that very small percentage, and I'm not going to put a number on it because the number is very, very difficult to quantify in the original clinical trials even that was part of the problem is that they excluded men early on that started to have severe symptoms and they sort of cast them aside to the point where they didn't want them to be in the cohort so we don't actually know what that number is but it's small but if that guy comes into my office then that is a life that we've seriously affected not for the better and all the pursuit of and in most cases uh hair hair restoration or or hair maintenance and so that's a tough trade-off is that you know if i ask a guy like we led with you know can you keep your hair and your erections the answer is most likely yes and and yes you're probably going to be okay if we start this medicine you have those side effects we stop it so let's talk about post-finasteride syndrome is it do you know about this have you heard this term before at all is it is it making it into the zeitgeist only recently actually i've heard it more sort of described as depression and brain fog.

36:09Yeah. Yeah. I think that's real. I mean, that that's a pretty good description of what some of these men are suffering with. So it's 2026. I mean, the first paper that came out on PFS was 2012. You know, so it's not, it's not again, overnight, it's been out for a long time. And it's a syndrome, meaning it's not a disease, meaning a disease is you have appendicitis. If we don't take your appendix out and it ruptures, you're going to die. Syndrome, meaning it's a constellation of symptoms, doesn't have a clear etiology or a clear pathway for why happens. And I think that's critical. And I think that any person that may be suffering from this, if you go to the doctor and they automatically discount you, which I see all the time and say, you know, this isn't real.

36:51It is, it's real because you're feeling it. And there is enough of a mechanism that it may actually be something that is real that we have to address. And so let's talk about what it is. It's interesting to me, I'm just thinking right now, if there is any kind of diagnostic panel or something that can be done to kind of decide whether or not you would be somebody who'd be likely to be adversely affected by this? Yeah, you know, I mean, we don't at this point, you know, one of the things that is kind of this new frontier in medicine is this personalized pharmacology, where there are some available tests for certain drugs that you can screen to see if somebody is going to be a better responder, or worse responder, It usually has to do with the way liver metabolizes certain drugs and there's enzymatic pathways that are upregulated or downregulated in certain people, but nothing yet for this.

37:43And so that would be amazing if I could say, hey, look, before I start you on this drug, which could be amazing for you, I want you to take this test. And if the test shows that you would be at risk for this, then you're not going to do it. And you remember we had Dr. Sandlow on a couple episodes ago and we talked about post vasectomy pain syndrome again another syndrome we don't understand it and we don't know who's going to get that and who isn't and again you take a very simple operation that 600 plus thousand guys go through every year the vast majority do amazingly well with it and then every once in a while a guy gets this debilitating pain post vasectomy that we don't understand and we don't know i don't know who that guy's going to be it's just really is a roll of the dice.

38:26But I mean, thankfully, thankfully, thankfully, the dice are very loaded for a good outcome. But if you're one of those guys that suffers from it, you're one of those guys that suffers from it. And the goal for you out there listening is you're not suffering alone. There are resources and there are groups out there that can do some good. But I will say this. So one up your question, Jordan, and say that there are tests that if a guy comes in, and again, I am not an expert in post-finasteride syndrome. Please, you know, find somebody that is, although there are very few people out there that treat it.

38:56So if my office is flooded next week with guys that have this disease, I'm going to work it up for you. But ultimately, just know that as a urologist, there are very few things in my tool chest, but there are things that we're going to look at. We're going to look at a full hormone panel, right? Because it does go back to the fundamentals that if you started finasteride and you had any changes in your testosterone, maybe your testosterone is already low and it was inappropriately low for how high those DHT levels are, yet an unfavorable ratio. Well, we're going to at least look at that because I have had a little bit of success in treating guys hormonally in a couple of ways, either optimizing their testosterone or remember that other enzyme we talked about, aromatase and the estradiol pathway.

39:40There are blockers that we use mostly in male fertility to boost sperm function. But if I block estradiol, then what do you think happens? The sink goes the other way and the drain goes down DHT. We elevate DHT levels and we see if that works. Now, what's the biggest downside to that? Hair loss. And so then you're back to like this whole, gosh, dang it. I mean, like I can't get out of this without the whole reason I went into this in the first place. And I have treated some men, believe it or not. In fact, I'm thinking of one guy very recently who had a very low exposure to finasteride and he had the effects.

40:15And yet he was willing to kind of dance a hormonal dance where he had a little bit of finasteride side effects, but able to stay on it, maintain his hair by me optimizing testosterone. So again, there's not this binary world of where I have the worst symptoms of finasteride syndrome and I have nothing going on at all. In fact, there's a spectrum where there may be an opportunity to optimize hormone balance. Let me throw something else out there at you. There's a guy, good friend and researcher, Erwin Goldstein, who's looked at ultrasounds of men that have, propostably have PFS and has seen that there are some structural changes in the penis of some guys where the DHT receptor there again is active until, you know, we're late in puberty and then it shuts down.

41:02therefore you know your penile growth sadly for some of us sets down at some place where that's as good as you're going to get right whether you're 19 or 22 but if those receptors are still open you hit them with finasteride then they may actually develop smooth muscle atrophy which looks kind of like almost a swiss cheese looking appearance on an ultrasound and so there may be some data directly showing that finasteride can be bad for penile health and development they weren't controlled in other words they weren't blinded where you would take an ultrasound of a guy that doesn't have it and you look at that and and you have to guess who's got finasteride syndrome and who doesn't so it's interesting but not not level one evidence but the bottom line is again there may be anatomic issues with a very small subset of guys that take finasteride so so then that brings me to the penis so if i can treat a guy from some of the libido issues the depression issues with some other kind of pharmacologic or hormonal intervention?

42:00Is there anything we can do to the penis? And the one thing that we haven't talked about a lot, and it does fall into this newly approved, still not amazing data of something called low intensity shockwave therapy. And I'm throwing out all kinds of terms that people are going to have to look up and we'll have episodes on it. But shockwave therapy can help decrease the amount of collagen deposition in any structure, whether it's a penis or the joint. And what that does is it allows for better smooth muscle development because one of the signs of atrophy anywhere is increase in collagen deposition.

42:35And in the penis, that looks like where the smooth muscle becomes less elastic and more fibrotic and less able to trap blood in there and give us good erections. And so shockwave actually may be a reasonable adjunct to hormonal therapy to help reverse some of the effects of PFS. So again, it goes back to, you're probably going to be okay if you have even the worst of this. There are therapies out there for you. And again, the goal is to find people, physicians, providers, therapists, even because you are going to need therapy for this. I mean, this is a devastating psychological condition that has physical manifestations.

43:10So you need a good team around you. And again, as I said, there are support groups out there to help people, find people in your area that may be able to help. But I want to leave guys with, and then obviously open up to all kinds of your questions because your brain, I can tell, is going into Jordan rapid-fire question mode. But the bottom line is that this, for the vast majority of guys, is a, you know, it's a really safe, really effective medication. But if you're one of those guys that has this effect and this PFS, it can be pretty rough, you know? And so we have to acknowledge that. But again, get the help you need.

43:46It's out there. And most likely, you know, it's either, if not reversible, at least treatable. So that's my soapbox is medicine has to be individualized. We're not all the same. This is not a new phenomenon by any means just because it's making the social media rounds now. It's been around for 30 plus years. Papers have been out since 2012. But I do have to say that if a guy wants to start this, if he clicks on one of those feeds and he's able to get finasteride delivered in a nice discreet envelope to his doorstep, then bully for that company. but make sure you understand what you're getting yourself into.

44:22And I just don't recommend this is a drug that you should be ordering online. I do think you can find a physician to have the actual conversation with in person that can really help you navigate some of the downsides. Because what happens if you do have an adverse reaction and you're going through an online company, you're going to end up in my office anyway. And by that time, damage has been done that we may have been able to thwart earlier. So that is my shout out to all of us hardworking brick and mortar physicians that are still punching a clock and taking care of guys when we're not podcasting in our oodles of spare time.

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47:08focus on what matters most, your patients. Visit labcorp.com to partner with LabCorp and simplify complex patient profiles. 2%. That is the number of people who take the stairs when there is also an escalator available. I'm Michael Easter, and on my podcast, 2%, I break down the science of mental toughness, fitness, and building resilience in our strange modern world. I'll be speaking with writers, researchers, and other health and fitness experts and more to look past the impractical and way too complex pseudoscience that dominates the wellness industry. We really believe that seed oils were inherently inflammatory.

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48:25Lay it on me, brother. What you got for me? I know you just did our patented, you'll probably be okay segment. So I'm not trying to be alarmist, but I just wanted to - Can we patent that? We better have. We should. We should. I'll get to a lot of lawyers on that. Thank you. I wanted to put two points together and just explicitly ask you this. We mentioned earlier in the episode that within as little as six weeks after you stopped taking the medication, a lot of the issues that you could have, a lot of the side effects will work their way out of your system. Is there a scenario where that's not the case?

48:55Yeah. Oh, yeah. Yeah. So exactly. I mean, I think, and by the way, this is 100 % Mills hypothesis, right? And I alluded to it earlier. But what I've noticed in all my years of practice is that the younger the guy is when he gets his first exposure to finasteride, the more likely he is to exhibit these symptoms that may not get better. and I think it goes back to this receptor activity in DHT that we know it turns off in the penis after a certain age we don't know what's happening in the hypothalamus and the prefrontal cortex as much because again those are not areas that we can study except for maybe with you know again this would be a great study which nobody would ever sponsor because these are all generic drugs and and I don't think any of the DTC companies are going to want to put forward 800 million dollars in a study.

49:44But imagine if you did a functional MRI study where you put two guys in an MRI, one on finasteride, the one not that then one that has potentially PFS. And then, you know, you give them explicit material to look at or some way to stimulate them, see what lights up in the brain. And my hypothesis is that guys that have the PFS or that early exposure, that DHT part of the prefrontal cortex, it's not going to light up as much. You're just like, man, whatever, you know, I'd rather have a sandwich now. And I think that probably would be the only way to really study this to know are the guys that have a much more difficult time reversing this or the guys that are going to have to relearn neural pathways.

50:24I mean, one of the great things, you know, we, we're going to have some neuroscientists on this show in the next few weeks and also some therapists that talk about changing habits and redoing neural pathways because there is this idea of neuroplasticity where if something gets knocked out your brain can find other ways to make those pathways connect and so maybe that's the direction we need with these guys that have the devastating psychiatric psychological complications of pfs but i do think the younger the exposure the more devastating it is now i've seen guys older guys that and i think of one in particular is a very very prominent man that has a very healthy wonderful sex life well into his 70s who was started by his well-intentioned urologist on finasteride because he was having difficulty with his prostate, as happens to us as we age.

51:16And immediately, it was like a switch turned off. He lost his libido. He lost his ejaculate. And it just, it wrecked him for a little while. But again, he came to me, we stopped it, we rebalanced his hormones, and all faculties came back online. I think by the time you hit 70, you have compensatory mechanisms and altered pathways, And also your exposure may be a little bit more dose responsive as opposed to irreversible from something that's happening in the brain to younger brains. But I don't know. You know, there's never been, that's my hypothesis. I don't think anybody else has shared that to my knowledge because if you try to do a PubMed search on post-finasteride syndrome, it'll barely fill a page.

51:55You know, there's not a lot of high research and certainly no level one research on it. There's no new randomized placebo-controlled trials putting guys on it and actually targeting those questions. In the initial clinical trials that got to market, you know, the sexual side effects were just kind of meh. You know, they weren't really the target end goal. It was much more, you know, what's your hair production and what is your prostate scores? In other words, you know, your urination improvements, all that stuff. So, yeah, so, I mean, we need to do that study, but it's never going to get done, Jordan.

52:25I mean, you know, with NIH funding at an all time low and no company wanting to take this up, it's just going to have to be trial and error, unfortunately, for the guys out there as sad as that sounds for somebody that may be suffering from this condition. But again, don't give up hope because we can try a lot of things before we say there's just nothing else we can do. But it's not going to be from your urologist. It's going to be from a multidisciplinary group of people that are going to have to work together, or at least in tandem, to figure out how to get you back to where you're feeling some degree of yourself again.

52:58A lot of considerations there. So I guess the ending point is maybe don't click the Instagram ad and buy it from a doctor who maybe isn't even a doctor. It could be Chad GPT just sending you stuff in a discreet box. Yeah. Yeah. You know, the other thing that really bugs me about that is that these drugs are, you know, they're generic and they're cheap as water. And so the whole business model of just having a telehealth visit where, you know, you don't make money until you sell a drug, it just hurts a little bit. I've spoken about this before. Yeah, I've published on this in medical journals about the fact that we lose something with this interaction.

53:35But I also understand the entrepreneurial spirit that made this country great. And so it's really a call to action for my other physicians out there to see these guys, make yourself accessible, come up with an algorithm or pathway that you can see them and then be able to screen for these side effects and do something about it if they have it. Because there's nothing probably more alone feeling than a guy out there that gets a prescription online thinking that it's going to change his life because the guys on the sports commercials look amazing when they do whatever it is they're doing and taking.

54:07and then realized they had a bad reaction. And what do you do? You don't go to the ER. Do you call your primary doc and say, hey, by the way, I mean, you know, in no judgment zone, I would say, yeah. You know, even if a guy's, you know, I have made a career out of taking care of guys that do things that they wish they hadn't, but we can still, you know, salvage a pretty darn good life if we figure out how to break it down into the fundamentals. And so, yeah, don't give up hope. And if you click on it, just know that this could be one of the bad side effects. Wow. Dude, this was heavy. I was going to say, yeah, this got a lot heavier than long, luscious hair.

54:42Yeah. Yeah. Yeah. I mean, it's important, I think, is, you know, there's a lot of times to have fun and make light of things. And I think this is one of these things that almost is more of a, I don't want to use the word political, but at least something au courant that I had to talk about to say, look, you know what? This is out there. you need to be armed as a consumer and as a patient with the knowledge so that you can make really good healthcare decisions when sometimes you're not even having your doctor in the room to make those decisions for you or with you. And I think that's the take-home message.

55:16And that makes it worth it. I'm not discouraging anybody out there from seeking treatment to keep that beautiful head of hair as long as you can and seek alternatives to if you can as well. And again, we meet people where they're at. And that's the goal of this whole venture, my practice, as well as my podcast, is to meet guys where they're at, not be judgmental, figure out a solution that works for everybody, and deliver. And deliver on the mailroom. And offline, I got to ask you, what moose do you use? Your hair looks great. Oh, yeah. I don't know. I have a guy for that. I can't remember, honestly.

55:53Well, let me see. We'll look at sponsorship first. That's right. Yeah. Yeah. Brill cream, just a dab will do you, you know, the girls will flock right to you. I don't even think brill cream is on the market anymore, but vitalis, vitalis. Yeah. That in a, and then a Burma shave, you know, those are, uh, that's what I, that's my go-to. We're going to be sponsored purely by companies that no longer exist. That's right. You're dang right. And I'm proud of it. That keeps it real. Too much fun. Well, all right. We did it. And really, I hope everybody out there got a little bit of something out of this, that if you're a guy or loves a guy that is having issues either with reactions to finasteride, dutasteride, or are interested in hair restoration, there's lots and lots of resources out there for you.

56:41just vet them first, man, just like anything else. If it's too good to be true, damn it, it's too good to be true. Jordan, man, I'll see you next time, brother. Dr. Mills, you delivered. Thank you, sir. Hell yeah. Yeah.

57:12Let's talk about it in the mailroom. Let's talk about it. Let's talk about it in the mailroom. The Mailroom with Dr. Jesse Mills was a production of iHeartRadio. It was executive produced by Jordan Runtog. It was edited, mixed, and mastered by Bahid Frazier. And the theme was provided by Long Transit. If you liked what you heard, please subscribe and leave a review. For more podcasts from iHeartRadio, check out the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows. This program is intended for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment.

57:59Consult your health care provider for any medical or other related questions or concerns. The views and discussions aired on this podcast are those of Dr. Mills and do not represent the official positions of UCLA or UCLA Health.

58:33or some adults with overweight who also have weight-related medical problems to lose excess body weight and keep the weight off. ZepBound is approved as a 2.5, 5, 7.5, 10, 12.5, or 15 milligram injection. ZepBound contains terzepatide and should not be used with other terzepatide-containing products or any GLP-1 receptor agonist medicines. It is not known if ZepBound is safe and effective for use in children. Don't share needles or pens or reuse needles. Don't take if allergic to it, or if you or someone in your family had medullary thyroid cancer, or if you've had multiple endocrine neoplasia syndrome type 2.

59:10Tell your doctor if you get a lump or swelling in your neck. Stop ZepBound and call your doctor if you have severe stomach pain or a serious allergic reaction. Severe side effects may include inflamed pancreas or gallbladder problems. Tell your doctor if you experience vision changes before scheduled procedures with anesthesia, if you're nursing, pregnant, plan to be, or taking birth control pills. Taking ZepBound with a sulfonylurea or insulin may cause low blood sugar. Side effects include nausea, diarrhea, and vomiting, which can cause dehydration and worsen kidney problems. Talk to your doctor.

59:42Call 1-800-545-5979 or visit zepbounds.lily.com. 2%. That's the number of people who take the stairs when there is also an escalator available. I'm Michael Easter, and on my podcast, 2%, I break down the science of mental toughness, fitness, and building resilience in our strange modern world. Put yourself through some hardships, and you will come out on the other side a happier, more fulfilled, healthier person. Listen to 2%. That's T-W-O percent on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts. This is an iHeart Podcast. Guaranteed human.