This is not a scientific paper. It is a "narrative review", which is another way of saying "editorial". It superficially looks like science, but doesn't do any of the methods, controls or (correct) statistics that you would expect in a legitimate meta-analysis. Do not take it seriously.
The "dedication" at the top should clue readers into what is going on -- it's not even trying particularly hard to look legitimate -- but alas.
Edit: this line, in particular, made me laugh. It is one of the more egregious examples of "pretending to do statistics" that I have seen recently:
> Table 1 summarizes the studies in the last decade examining a potential link between neuropsychiatric reactions and finasteride exposure. When prescribed mainly for AGA, all reports suggest that finasteride can cause depression, anxiety, suicide ideation, and suicides. Assuming a null hypothesis (finasteride does not affect mood) and a 50% chance of 1 result against this hypothesis, the probability of getting all 8 studies concluding against the null hypothesis by chance is 0.58 = 0.0039.
It isn't a review article, though the difference is more subtle, because a review article is also editorial in nature.
The difference here is that this article is someone with an axe to grind (again, see the "dedication", which is never done in a legitimate review; and the clownish application of statistics, which is so completely absurd that it implies incompetence, malice or both). I have no faith that this writer made a legitimate attempt to impartially weigh the evidence on this question.
> TFA cites eight peer-reviewed studies finding a link. Sounds like decent evidence to me.
There have been over 30 randomized controlled trials of this drug, and the author picked only eight papers, none of which were randomized, none of which were controlled, and all of which were based on mining self-reported data from patient databases.
Indeed. This is why the drug passed phase 1 (safety) trials when it was first approved in 1992 for treatment of prostate enlargement. Moreover, it subsequently passed additional rounds of clinical trials for the hair loss indication in 1998, and has been involved in more than 30 different clinical trials overall.
Now, I'm not going to argue that there can't be rare side effects that are only discovered with time. I'm also not going to claim that the original trials were perfect, or that research into the question isn't justified. But you're trying to assert that they didn't test for safety, and that's just factually incorrect.
Concerns about Finasteride are dramatically overblown. It’s one of the most extensively studied and commonly prescribed medications for men. Side effects like these are comparable to placebo. They also conveniently happen to be the same types of effects that can be produced psychosomatically.
I‘m 24 and bald now. I never even considered taking finasteride. A 1% of getting permanent erectile dysfunction without known cause (PFS) nukes the expected value for me
You rolled the dice and got out ok, perhaps just like any other drug technically. There is a small portion of people that will get irreversible damage from it and basically they have no real idea how to find them out first.
Tried finasteride and my sleep quality was altered ; vivid nightmares and tremors in my legs that would wake me up.
I stopped taking it and those disappeared.
Fwiw.
I took Finasteride (1mg) daily for 20 years, because both my GP and my wife had commented on my thinning hair. The pills worked, and I didn't have any side effects (that I can positively attribute).
Five years ago, I was diagnosed with CKD (3A), so I stopped taking Finasteride, which was the only prescription drug I was taking. I cannot claim any causal relationship, but I have been happier for these past five years. Of course, it could be because I'm now retired and financially secure. My hair seems to be thinning again, but it's still there.
Trying finasteride was the worst thing I ever did to myself. Traumatic and horrible experience if you are in that small % of people that it will permanently damage and alter your body.
What permanent damage and alterations have you noticed? I suspect these are all attributable to trauma, in which case psychotherapy might resolve them.
It's one of the most commonly used DTC prescription drugs and is used for a purely cosmetic purpose, so debates about it are common online and full of low-quality motivated reasoning.
Self-perception can have a profound effect on one's physical and mental wellbeing, so even drugs which are for cosmetic purposes can be important for health.
True, and, I'd posit that there are often better and safer alternatives that would be similarly or more beneficial with less potential for harmful side effects.
I have several anecdotes from my own life. When I was ~18 the doctor proposed to give me jaw surgery to fix my overbite by extending my lower jaw. I asked him what the reasons for this were and he said it was mainly cosmetic. I thought this was not a good enough reason for surgery - which while often safe does also often have harmful side effects - I now know way too many people who had surgery complications that often took a long time for them to become aware of. I think I feel better about myself now for having made that choice than I imagine I would if I had a better jaw line.
It's true that some people are going to have a story where they see the cosmetic medical intervention as having been beneficial for their mental wellbeing. I'd still suggest that in many such cases there might have been other ways to get a better outcome. It's for each of us to decide.
Still, burden of proof of the safety of a drug should be on the company profiting from it.
I think to just brush over surgery fixing a malloclusion as "cosmetic" as if it's kind of a trite thing just doesnt seem right. There's definitely risks since there's a lot of nerves that can get botched in jaw surgeries causing different problems.
I can tell you tho I would never consider it just so superficial. A lot of unconscious behavior happens based on facial symmetry that is hard wired into us. Malloclusions can effect breathing especially at night (some problems that will only surface later in life when options to fix limited by your age), the way other parts of your face look such as the nose, oral health, long term root problems, uneven wear etc etc
I had a doctor that just shrugged his shoulders and said the same thing to me. I wish id had a doctor that pressed me a little to really think about the long term picture when I had the chance.
If theres already problems like pain etc then obviously the justification is more than cosmetic.
I dont know if you are still young enough I would reconsider. I think in general overbites are still more bearable than under.
This is the hormone that makes you bald (if you got bad cards in the genetic lottery) and also makes your prostate the size of an apple. Also causes acne as a bonus, again a bit dependent on genetics. Amazing.
The paper mentions that finasteride passes through the blood-brain barrier and affects the conversion of progesterone to allopregnanolone, where low levels of allopregnanolone are associated with depression. Together with the correlational evidence for depression and suicidality, this presents a reasonable picture for concern.
Since there is a known central activity, it also raises the question -- in fact the article explicitly mentions it -- of whether a brain-sparing analogue of finasteride might not show the same side effects.
The apparent connection to "masculinity" or "feminization" may be a red herring. Excessive concern about "sex" effects in biological systems kind of reminds me of the alchemical theory of the four elements. It's not a great way to analyze the complicated effects of medicines.
Exactly what finasteride does is not well understood. It effects the endocrine system, but not in consistent ways, and with some possibly serious side effects. It is being aggressively marketed as a way to stop hair loss, but may do various other things instead.
Yeah - it's a selective testosterone blocker, kind of, and tries to target the part that causes male pattern baldness without lowering overall T Levels.
I assume it still blocks enough hormones to cause mood shifts or other effects?
It’s not a testosterone blocker at all. It blocks 5-alpha reductase, an enzyme that converts testosterone to DHT. It can actually increase serum testosterone by more than 10%.
As for DHT, that hormone doesn’t appear to have much significance for adult males. It’s critically important in puberty, though!
Blocking the conversion of testosterone to DHT (the effect of this medication) causes an indirect and minor increase in both testosterone and œstrogen levels, although DHT is more potent than testosterone for the receptors in many tissues.
> Yeah - it's a selective testosterone blocker, kind of, and tries to target the part that causes male pattern baldness without lowering overall T Levels.
> I assume it still blocks enough hormones to cause mood shifts or other effects?
Endocrinology is a lot more complicated than you're giving it credit for. DHT blockers don't necessarily lower testosterone levels; they can actually increase it (although even then, the mechanism isn't as direct as you might think).
It's neither established nor a given that any side effects of finasteride have anything to do with effects on testosterone or hormone levels at all. A lot of people make that assumption, and there's reason to suspect there's truth to that hypothesis, but it's completely possible it's an unknown side effect of the drug, and there hasn't been enough study into the mechanism to understand it (in part because the side effects are relatively rare and weakly established).
I'm shocked that this wasn't widely known in the US. Reports from trans people, way back in the 1940s, show clear links between sex hormones and depression: a priori, one would assume such a relationship would exist here. The article appears to allege a cover-up:
> It is difficult to imagine what data could justify hiding in a drug safety review.
I've been sceptical of any direct relationship between "post-finasteride syndrome" and sexual function, but I've never doubted the direct effect on mental health of suppressing dihydrotestosterone in cis men. (Even if the pharmacological effects end shortly after cessation, which I suspect, a sudden and unexplained strong feeling of constant wrongness can be traumatic.) The part I find interesting is that most men seem to be just fine with taking finasteride, even orally.
When I got it prescribed (in AU), my doctor told me he had many patients taking it with no side effects, and he also pointed out that the 1mg I was taking was much smaller than the 5mg some took for prostate enlargement. I also did some reading and never noted any links to depression. It just doesn't seem to always come up.
I think many men would also (naively) be happy to risk depression when confronted with impending hair loss. Ironically, maybe more happy chemicals are what's actually needed so we can feel like losing our hair is not the end of the world.
> Reports from trans people, way back in the 1940s, show clear links between sex hormones and depression: a priori, one would assume such a relationship.
We have a lot of data about trans women taking finasteride as part of HRT and depression, and the clear correlation runs in the exact opposite direction from what this article is talking about.
Fin blocks the conversion of T to DHT, that rarely causes lower blood serum testosterone levels and can possibly even increase them depending on what else you've got going on hormonally.
indeed, finasteride raised my T levels slightly, from 18 ng/dL to 30 ng/dL. the same enzyme that converts T to DHT (5α reductase) can also to convert progesterone to DHT via the backdoor pathway, but i reckon that would have a very small effect for most cis men (where normal progesterone levels range from 0.0-0.5 ng/mL, compared to 2.0-24.0 ng/mL in cis women during the luteal phase, and much higher during pregnancy).
a sudden hormonal change can absolutely cause changes to mood and libido, but with finasteride these seem to be rare and generally mild. i would expect them to lessen or even disappear after some time of continued treatment. i wonder how often finasteride is discontinued before the body even has a chance to adjust to the new hormone levels. the claims that the side effects persist after discontinuation are particularly dubious, and they remind me of castration anxiety.
Right, but it's not the serum levels that matter: it's the agonistic effect on various receptors. (Most) hormones don't have direct chemical effects on the body. According to Wikipedia:
> Relative to testosterone, DHT is considerably more potent as an agonist of the androgen receptor (AR).
> Right, but it's not the serum levels that matter: it's the agonistic effect on various receptors. (Most) hormones don't have direct chemical effects on the body. According to Wikipedia:
>> Relative to testosterone, DHT is considerably more potent as an agonist of the androgen receptor (AR).
Judging from this and your other comments in the thread, I'm assuming you're not an endocrinologist.
You're pulling quotes from tertiary sources that at first glance seem to support the argument you're making, but you're missing the broader context, which is that pharmacokinetics and our endocrine systems are way more complicated than you're giving them credit for. It's not as simple as "drug A makes X go down, and X does Y, so A decreases Y".
It would make a lot of people's jobs much easier if that were the case, but the clinical reality is actually much more complicated.
> You might expect trans women to react differently to lower T levels than cis men for various reasons
Sure but that's besides the point. I was responding to - and refuting - the claom:
> Reports from trans people, way back in the 1940s, show clear links between sex hormones and depression: a priori, one would assume such a relationship would exist here.
There's no reason to believe that the effects of hormones on depression in trans people are predictive of hormones taken by cis people in completely different doses for different reasons, but it's especially fallacious to assume that it's not only predictive, but predictive of the the exact opposite effect.
It's possible there's a separate mechanism responsible for gender dysphoria in trans men, and the remarkably similar symptoms in hypoandrogenic cis men, but Occam's razor.
Many trans men who go on testosterone report reductions in suicidality. If the theory is that gender dysphoria related to hormonal incongruence causes depression, then the data from trans women taking the medication supports the theory that cis men might really struggle with it.
> Many trans men who go on testosterone report reductions in suicidality. If the theory is that gender dysphoria related to hormonal incongruence causes depression, then the data from trans women taking the medication supports the theory that cis men might really struggle with it.
This is a really weird argument because it gets so many basic facts wrong. The most fundamental of which is the idea that taking finasteride means lower testosterone levels - it doesn't!
And I'm not even going into the issues with all the other confounding variables at play here, such as the motivations and dosing schedules for HRT being substantially different from other uses of finasteride.
I really don't know why you're bringing up data about HRT for transgender people that's nearly a century old in an article that's not about HRT, when we have plenty of data that's not only far more recent but far more germane to the topic at hand.
A word of caution to anyone trying to take health advice from HN comments: don’t.
Want to debate javascript frameworks and linux distros? sure, there’s great knowledge here.
This is not the case for most topics outside of software.
If you followed the health advice here you’d be living in a shed in Antarctica to avoid microplastics, taking shrooms for your mental health and rejecting all pharmaceuticals when you get an infection.
Might be a good idea to switch to low-dose minoxidil? It seems to have very few side effects, and even then they are benign for most people (slightly lower blood pressure).
the two drugs are complimentary and often prescribed together. finasteride is overwhelmingly well-tolerated, and i suspect that many reports of serious and lasting adverse reactions involve misattribution.
I took it and it was the absolute worst, with side effects that have lingered since and some changes in my body that probably now permanent. I can tell you for this drug if you were in the small unlucky camp it can absolutely ruin you. I can assure you it is NOT misattribution.
Not kidding: What about suicides prevented from not going bald? To paint a fair image, this study should also compare suicide prevalence for bald people.
-------
Results: Compared with the controls, an increased risk of suicide attempts was observed in patients with AA, with an adjusted hazard ratio of 6.28 (95% confidence interval, 4.47-8.81). Suicide risk remained significantly elevated in AA patients when stratified by underlying psychiatric disorders. The mean age of initial suicidal behaviors was also lower in patients with AA.
Conclusions: Patients with AA had a significantly higher incidence of suicidal attempts than controls, regardless of concurrent psychiatric illness. Further studies are needed to elucidate the pathophysiology of the association between AA and suicidality. In addition, dermatologists should be aware of the increased suicidality of patients with AA.
It's also possible that people taking Finasteride might be a more potent selection of people that are distressed about hair loss, and are therefore more likely to exhibit depression, etc. As in, if people with androgenetic alopecia are more likely to be depressed, people who take finasteride may be a sampling of those people who are distressed enough to seek and maintain treatments.
Additionally, the kind of person who would reach for prescription medication vs accepting hair loss may be predisposed to depression. I.e. this may be selecting for people who struggle with self-acceptance generally.
I also wonder whether there's some degree of placebo going on. Patients know finasteride is anti-androgenic; perhaps when they inevitably experience some symptoms associated with hypogonadism they assume the worst and lament the choice between having hair and feeling youthful. This would also explain why many who get off finasteride don't notice their symptoms improve.
Personal bias: I've taken finasteride for years with no side effects.
This is exactly why people thought isotretinoin (brand name Accutane) caused suicides (and required huge hurdles to access for years). It turns out that people suffering from physical disfigurements, such as acne, are more prone to suicide than the general population. Not sure if this is also true of androgenetic alopecia but it would hardly be surprising.
I don't think we're saying different things. People who are distressed about their appearance are more likely to be depressed, and people who seek medicine and surgeries are probably more distressed still, and therefore more likely to be depressed, ..
It did jump out at me that the paper repeatedly cites studies that found a correlation between finasteride and psychological side effects, and then talks about them as though they're evidence of causation.
There's probably a difference in degree, however. Alopecia Areata is much more uncommon, while regular male pattern baldness is very common.
There's also the fact that Alopecia Areata is actually more common in women, which I imagine exaggerates the distress compared to the more run of the mill MPB.
I realize you didn't mean to use a study on Alopecia Areata, but the difference in degree could be quite large.
Does this research cover that? That was my first thought
If anything finasteride has improved my mental health. I've taken it for ~7 years with no negative side effects, and I'm certain it's the only reason I still have hair
> Concerns about depression from finasteride were raised in several studies as early as 2002.
It seems clear to me that anything which has depression as a side effect has an increased risk of suicide as well and the only remaining truth to find is the degree.
The executives and scientists should both be prosecuted.
Finasteride every year changes millions of lives globally, I take finasteride, and it’s the sole reason i have my hair.
Idk about you, but i know 10s of different friends who also went through hairloss and were struggling to stop it, who went through severe depression, loss of confidence, suicidal tendencies in extreme cases.
Just because you saw a study that X drug causes side effects/harms in 1-0.1% of patients, doesnt mean the med should be taken off sale especially for a drug as important as finasteride.
It’s easy for someone to say it’s just a cosmetic drug until they go through the full extent of social, mental, and even physical damage, hairloss at a young age causes.
I and almost everyone who takes finasteride take it knowing the risk of a whole range of side effects , often far more severe then just increasing risk of depression. like risk of reduction in fertility, libido in some patients often struggling with obesity.
Obesity creates a whole range of problems too, should we start prosecuting creators of tasty food too ? , fin 1mg is one of the most impactful drugs sold globally both under brand names and generic cheap drugs (i take a generic one) that is life changing for almost a quarter or more of men depending on the country who face male pattern baldness and its related issues.
More studies certainly should be done in link of depression and suicide in some patient cases, but bringing out the pitchfork like luddites and asking to prosecute executives and scientists for a non-opiod, non-addictive, drug that’s been used safely for decades across generations, and saved families thousands of dollars (including mine) in snake oil salesman products that claim to treat hairloss but dont. They should get awards, not pitchforks.
I take dutasteride (even stronger form of finasteride) and have been personally fortunate to not have any side effects in ~8 years.
My whole family on both sides is bald bald. Without it I would have been bald bald in my early 20s.
I knew there were risks of hormone disruption/mood swings/etc but I still prefer it over being bald. I took a calculated risk and I'm thankful that the drug exists. Please don't prosecute the people that gave me the only real, working treatment for my baldness.
> I take dutasteride (even stronger form of finasteride) and have been personally fortunate to not have any side effects in ~8 years.
Dutasteride is not a stronger version of finasteride. It's a more effective DHT blocker, but it works differently.
The side effects are also different and not easy to predict. Some people have terrible side effects from finasteride and none from dutasteride. Some people have the opposite. And some people can tolerate either one. We don't have a way at the moment to reliably predict which one will work better or be better tolerated for a given individual.
Anyway, I'm glad it has worked for you, and I also would not want to prosecute people who've created a medication that's one of the most effective and well-tolerated around.
> The executives and scientists should both be prosecuted.
For what? Many drugs have depression as a possible side effect, but that doesn’t mean they should be pulled from the market and executives prosecuted for simply the possibility of depression.
Negative reactions to drugs are always a possibility. Weighing the risks and tradeoffs and monitoring patients is important. This is why drugs like this are not OTC.
Thank you. If we prosecuted scientists for a drug as well tolerated as finasteride we would cease to develop new medication and all of humanity would be worse for it.
If there was some indication that the pharmaceutical company knew of and concealed evidence that finasteride caused depression/suicidality, then there could be grounds for criminal prosecution. But a non-consensus view in hindsight that a drug might increase depression looks more like a losing civil liability claim.
This is not a scientific paper. It is a "narrative review", which is another way of saying "editorial". It superficially looks like science, but doesn't do any of the methods, controls or (correct) statistics that you would expect in a legitimate meta-analysis. Do not take it seriously.
The "dedication" at the top should clue readers into what is going on -- it's not even trying particularly hard to look legitimate -- but alas.
Edit: this line, in particular, made me laugh. It is one of the more egregious examples of "pretending to do statistics" that I have seen recently:
> Table 1 summarizes the studies in the last decade examining a potential link between neuropsychiatric reactions and finasteride exposure. When prescribed mainly for AGA, all reports suggest that finasteride can cause depression, anxiety, suicide ideation, and suicides. Assuming a null hypothesis (finasteride does not affect mood) and a 50% chance of 1 result against this hypothesis, the probability of getting all 8 studies concluding against the null hypothesis by chance is 0.58 = 0.0039.
From your description it sounds like a review article? Which is common and normal. I haven't read it though because I'm not bald.
It isn't a review article, though the difference is more subtle, because a review article is also editorial in nature.
The difference here is that this article is someone with an axe to grind (again, see the "dedication", which is never done in a legitimate review; and the clownish application of statistics, which is so completely absurd that it implies incompetence, malice or both). I have no faith that this writer made a legitimate attempt to impartially weigh the evidence on this question.
Doesn’t mean this isn’t correct. These problems are definitely real.
> These problems are definitely real.
Maybe they are, maybe they aren't. Proof is required.
TFA cites eight peer-reviewed studies finding a link. Sounds like decent evidence to me.
> TFA cites eight peer-reviewed studies finding a link. Sounds like decent evidence to me.
There have been over 30 randomized controlled trials of this drug, and the author picked only eight papers, none of which were randomized, none of which were controlled, and all of which were based on mining self-reported data from patient databases.
Come now.
IMHO proof of safety of the drug should be required from the maker before they profit from selling it.
https://en.wikipedia.org/wiki/Precautionary_principle
Indeed. This is why the drug passed phase 1 (safety) trials when it was first approved in 1992 for treatment of prostate enlargement. Moreover, it subsequently passed additional rounds of clinical trials for the hair loss indication in 1998, and has been involved in more than 30 different clinical trials overall.
Now, I'm not going to argue that there can't be rare side effects that are only discovered with time. I'm also not going to claim that the original trials were perfect, or that research into the question isn't justified. But you're trying to assert that they didn't test for safety, and that's just factually incorrect.
"Misery loves company" the paper
Concerns about Finasteride are dramatically overblown. It’s one of the most extensively studied and commonly prescribed medications for men. Side effects like these are comparable to placebo. They also conveniently happen to be the same types of effects that can be produced psychosomatically.
Anecdotal, but I took Finasteride and I had suicidal thoughts until I stopped the drug. Not recommended.
I‘m 24 and bald now. I never even considered taking finasteride. A 1% of getting permanent erectile dysfunction without known cause (PFS) nukes the expected value for me
I started taking it when i noticed my hair going and ive had no problems while keeping the hair. I sorta think it’s worth a shot.
You rolled the dice and got out ok, perhaps just like any other drug technically. There is a small portion of people that will get irreversible damage from it and basically they have no real idea how to find them out first.
Tried finasteride and my sleep quality was altered ; vivid nightmares and tremors in my legs that would wake me up. I stopped taking it and those disappeared. Fwiw.
I took Finasteride (1mg) daily for 20 years, because both my GP and my wife had commented on my thinning hair. The pills worked, and I didn't have any side effects (that I can positively attribute).
Five years ago, I was diagnosed with CKD (3A), so I stopped taking Finasteride, which was the only prescription drug I was taking. I cannot claim any causal relationship, but I have been happier for these past five years. Of course, it could be because I'm now retired and financially secure. My hair seems to be thinning again, but it's still there.
Trying finasteride was the worst thing I ever did to myself. Traumatic and horrible experience if you are in that small % of people that it will permanently damage and alter your body.
What permanent damage and alterations have you noticed? I suspect these are all attributable to trauma, in which case psychotherapy might resolve them.
Can someone give us more context? Why is Finasteride of particular interest?
It's one of the most commonly used DTC prescription drugs and is used for a purely cosmetic purpose, so debates about it are common online and full of low-quality motivated reasoning.
Self-perception can have a profound effect on one's physical and mental wellbeing, so even drugs which are for cosmetic purposes can be important for health.
True, and, I'd posit that there are often better and safer alternatives that would be similarly or more beneficial with less potential for harmful side effects.
I have several anecdotes from my own life. When I was ~18 the doctor proposed to give me jaw surgery to fix my overbite by extending my lower jaw. I asked him what the reasons for this were and he said it was mainly cosmetic. I thought this was not a good enough reason for surgery - which while often safe does also often have harmful side effects - I now know way too many people who had surgery complications that often took a long time for them to become aware of. I think I feel better about myself now for having made that choice than I imagine I would if I had a better jaw line.
It's true that some people are going to have a story where they see the cosmetic medical intervention as having been beneficial for their mental wellbeing. I'd still suggest that in many such cases there might have been other ways to get a better outcome. It's for each of us to decide.
Still, burden of proof of the safety of a drug should be on the company profiting from it.
I think to just brush over surgery fixing a malloclusion as "cosmetic" as if it's kind of a trite thing just doesnt seem right. There's definitely risks since there's a lot of nerves that can get botched in jaw surgeries causing different problems.
I can tell you tho I would never consider it just so superficial. A lot of unconscious behavior happens based on facial symmetry that is hard wired into us. Malloclusions can effect breathing especially at night (some problems that will only surface later in life when options to fix limited by your age), the way other parts of your face look such as the nose, oral health, long term root problems, uneven wear etc etc
I had a doctor that just shrugged his shoulders and said the same thing to me. I wish id had a doctor that pressed me a little to really think about the long term picture when I had the chance.
If theres already problems like pain etc then obviously the justification is more than cosmetic.
I dont know if you are still young enough I would reconsider. I think in general overbites are still more bearable than under.
> ...is used for a purely cosmetic purpose
I know you probably didn't mean it this way, but Finasteride started as a treatment for prostate enlargement, and is still used for that.
Finasteride is also used (in higher dosage) to reduce the size of the prostate gland.
It decreases dihydroxytestosterone to treat hair loss.
This is the hormone that makes you bald (if you got bad cards in the genetic lottery) and also makes your prostate the size of an apple. Also causes acne as a bonus, again a bit dependent on genetics. Amazing.
A.k.a. Propecia.
I think it’s also for treating enlarged prostates.
The paper mentions that finasteride passes through the blood-brain barrier and affects the conversion of progesterone to allopregnanolone, where low levels of allopregnanolone are associated with depression. Together with the correlational evidence for depression and suicidality, this presents a reasonable picture for concern.
Since there is a known central activity, it also raises the question -- in fact the article explicitly mentions it -- of whether a brain-sparing analogue of finasteride might not show the same side effects.
The apparent connection to "masculinity" or "feminization" may be a red herring. Excessive concern about "sex" effects in biological systems kind of reminds me of the alchemical theory of the four elements. It's not a great way to analyze the complicated effects of medicines.
Exactly what finasteride does is not well understood. It effects the endocrine system, but not in consistent ways, and with some possibly serious side effects. It is being aggressively marketed as a way to stop hair loss, but may do various other things instead.
Hair loss drug. Commonly prescribed.
I assume it's a drug to treat hair loss, not a drug to cause hair loss?
Yeah - it's a selective testosterone blocker, kind of, and tries to target the part that causes male pattern baldness without lowering overall T Levels.
I assume it still blocks enough hormones to cause mood shifts or other effects?
It’s not a testosterone blocker at all. It blocks 5-alpha reductase, an enzyme that converts testosterone to DHT. It can actually increase serum testosterone by more than 10%.
As for DHT, that hormone doesn’t appear to have much significance for adult males. It’s critically important in puberty, though!
Blocking the conversion of testosterone to DHT (the effect of this medication) causes an indirect and minor increase in both testosterone and œstrogen levels, although DHT is more potent than testosterone for the receptors in many tissues.
> Yeah - it's a selective testosterone blocker, kind of, and tries to target the part that causes male pattern baldness without lowering overall T Levels.
> I assume it still blocks enough hormones to cause mood shifts or other effects?
Endocrinology is a lot more complicated than you're giving it credit for. DHT blockers don't necessarily lower testosterone levels; they can actually increase it (although even then, the mechanism isn't as direct as you might think).
It's neither established nor a given that any side effects of finasteride have anything to do with effects on testosterone or hormone levels at all. A lot of people make that assumption, and there's reason to suspect there's truth to that hypothesis, but it's completely possible it's an unknown side effect of the drug, and there hasn't been enough study into the mechanism to understand it (in part because the side effects are relatively rare and weakly established).
I'm shocked that this wasn't widely known in the US. Reports from trans people, way back in the 1940s, show clear links between sex hormones and depression: a priori, one would assume such a relationship would exist here. The article appears to allege a cover-up:
> It is difficult to imagine what data could justify hiding in a drug safety review.
I've been sceptical of any direct relationship between "post-finasteride syndrome" and sexual function, but I've never doubted the direct effect on mental health of suppressing dihydrotestosterone in cis men. (Even if the pharmacological effects end shortly after cessation, which I suspect, a sudden and unexplained strong feeling of constant wrongness can be traumatic.) The part I find interesting is that most men seem to be just fine with taking finasteride, even orally.
When I got it prescribed (in AU), my doctor told me he had many patients taking it with no side effects, and he also pointed out that the 1mg I was taking was much smaller than the 5mg some took for prostate enlargement. I also did some reading and never noted any links to depression. It just doesn't seem to always come up.
I think many men would also (naively) be happy to risk depression when confronted with impending hair loss. Ironically, maybe more happy chemicals are what's actually needed so we can feel like losing our hair is not the end of the world.
> Reports from trans people, way back in the 1940s, show clear links between sex hormones and depression: a priori, one would assume such a relationship.
We have a lot of data about trans women taking finasteride as part of HRT and depression, and the clear correlation runs in the exact opposite direction from what this article is talking about.
You might expect trans women to react differently to lower T levels than cis men for various reasons
Fin blocks the conversion of T to DHT, that rarely causes lower blood serum testosterone levels and can possibly even increase them depending on what else you've got going on hormonally.
indeed, finasteride raised my T levels slightly, from 18 ng/dL to 30 ng/dL. the same enzyme that converts T to DHT (5α reductase) can also to convert progesterone to DHT via the backdoor pathway, but i reckon that would have a very small effect for most cis men (where normal progesterone levels range from 0.0-0.5 ng/mL, compared to 2.0-24.0 ng/mL in cis women during the luteal phase, and much higher during pregnancy).
a sudden hormonal change can absolutely cause changes to mood and libido, but with finasteride these seem to be rare and generally mild. i would expect them to lessen or even disappear after some time of continued treatment. i wonder how often finasteride is discontinued before the body even has a chance to adjust to the new hormone levels. the claims that the side effects persist after discontinuation are particularly dubious, and they remind me of castration anxiety.
Right, but it's not the serum levels that matter: it's the agonistic effect on various receptors. (Most) hormones don't have direct chemical effects on the body. According to Wikipedia:
> Relative to testosterone, DHT is considerably more potent as an agonist of the androgen receptor (AR).
> Right, but it's not the serum levels that matter: it's the agonistic effect on various receptors. (Most) hormones don't have direct chemical effects on the body. According to Wikipedia:
>> Relative to testosterone, DHT is considerably more potent as an agonist of the androgen receptor (AR).
Judging from this and your other comments in the thread, I'm assuming you're not an endocrinologist.
You're pulling quotes from tertiary sources that at first glance seem to support the argument you're making, but you're missing the broader context, which is that pharmacokinetics and our endocrine systems are way more complicated than you're giving them credit for. It's not as simple as "drug A makes X go down, and X does Y, so A decreases Y".
It would make a lot of people's jobs much easier if that were the case, but the clinical reality is actually much more complicated.
> You might expect trans women to react differently to lower T levels than cis men for various reasons
Sure but that's besides the point. I was responding to - and refuting - the claom:
> Reports from trans people, way back in the 1940s, show clear links between sex hormones and depression: a priori, one would assume such a relationship would exist here.
There's no reason to believe that the effects of hormones on depression in trans people are predictive of hormones taken by cis people in completely different doses for different reasons, but it's especially fallacious to assume that it's not only predictive, but predictive of the the exact opposite effect.
It's possible there's a separate mechanism responsible for gender dysphoria in trans men, and the remarkably similar symptoms in hypoandrogenic cis men, but Occam's razor.
Many trans men who go on testosterone report reductions in suicidality. If the theory is that gender dysphoria related to hormonal incongruence causes depression, then the data from trans women taking the medication supports the theory that cis men might really struggle with it.
> Many trans men who go on testosterone report reductions in suicidality. If the theory is that gender dysphoria related to hormonal incongruence causes depression, then the data from trans women taking the medication supports the theory that cis men might really struggle with it.
This is a really weird argument because it gets so many basic facts wrong. The most fundamental of which is the idea that taking finasteride means lower testosterone levels - it doesn't!
And I'm not even going into the issues with all the other confounding variables at play here, such as the motivations and dosing schedules for HRT being substantially different from other uses of finasteride.
I really don't know why you're bringing up data about HRT for transgender people that's nearly a century old in an article that's not about HRT, when we have plenty of data that's not only far more recent but far more germane to the topic at hand.
A word of caution to anyone trying to take health advice from HN comments: don’t.
Want to debate javascript frameworks and linux distros? sure, there’s great knowledge here.
This is not the case for most topics outside of software.
If you followed the health advice here you’d be living in a shed in Antarctica to avoid microplastics, taking shrooms for your mental health and rejecting all pharmaceuticals when you get an infection.
Might be a good idea to switch to low-dose minoxidil? It seems to have very few side effects, and even then they are benign for most people (slightly lower blood pressure).
Min helps with growing back and strenghtening hairs, but it doesnt stop hair loss on its own.
the two drugs are complimentary and often prescribed together. finasteride is overwhelmingly well-tolerated, and i suspect that many reports of serious and lasting adverse reactions involve misattribution.
I took it and it was the absolute worst, with side effects that have lingered since and some changes in my body that probably now permanent. I can tell you for this drug if you were in the small unlucky camp it can absolutely ruin you. I can assure you it is NOT misattribution.
What's your basis for suspecting that?
topical or oral???
I would expect oral to have more of an impact on mood, but this article does not say. Good catch!
The studies listed are all about oral finasteride.
Correct.
Additionally, topical is not FDA approved. While not necessary for research it adds typically unwanted complications to studies.
Not kidding: What about suicides prevented from not going bald? To paint a fair image, this study should also compare suicide prevalence for bald people.
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Results: Compared with the controls, an increased risk of suicide attempts was observed in patients with AA, with an adjusted hazard ratio of 6.28 (95% confidence interval, 4.47-8.81). Suicide risk remained significantly elevated in AA patients when stratified by underlying psychiatric disorders. The mean age of initial suicidal behaviors was also lower in patients with AA.
Conclusions: Patients with AA had a significantly higher incidence of suicidal attempts than controls, regardless of concurrent psychiatric illness. Further studies are needed to elucidate the pathophysiology of the association between AA and suicidality. In addition, dermatologists should be aware of the increased suicidality of patients with AA.
https://pubmed.ncbi.nlm.nih.gov/36921592/
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Not enough time to size these in comparable numbers to this study, but would be really interesting.
Is it a net positive (reduced risk) over just going bald?
It's also possible that people taking Finasteride might be a more potent selection of people that are distressed about hair loss, and are therefore more likely to exhibit depression, etc. As in, if people with androgenetic alopecia are more likely to be depressed, people who take finasteride may be a sampling of those people who are distressed enough to seek and maintain treatments.
Additionally, the kind of person who would reach for prescription medication vs accepting hair loss may be predisposed to depression. I.e. this may be selecting for people who struggle with self-acceptance generally.
I also wonder whether there's some degree of placebo going on. Patients know finasteride is anti-androgenic; perhaps when they inevitably experience some symptoms associated with hypogonadism they assume the worst and lament the choice between having hair and feeling youthful. This would also explain why many who get off finasteride don't notice their symptoms improve.
Personal bias: I've taken finasteride for years with no side effects.
This is exactly why people thought isotretinoin (brand name Accutane) caused suicides (and required huge hurdles to access for years). It turns out that people suffering from physical disfigurements, such as acne, are more prone to suicide than the general population. Not sure if this is also true of androgenetic alopecia but it would hardly be surprising.
I don't think we're saying different things. People who are distressed about their appearance are more likely to be depressed, and people who seek medicine and surgeries are probably more distressed still, and therefore more likely to be depressed, ..
This is completely false; the psychiatric effects of isotretinoin are well studied and significant, with a plausible mechanism of action no less.
Many people supposed that it’s just the acne making people depressed because it’s a nice plausible explanation, but it’s verifiably wrong.
It did jump out at me that the paper repeatedly cites studies that found a correlation between finasteride and psychological side effects, and then talks about them as though they're evidence of causation.
The medicine has side-effects documented by users as well. There is PFS(post finesteride syndrome), I've never heard of Post Aspirine Syndrome.
Alopecia Areata ≠ Androgenetic Alopecia
Thanks, I googled "bald suicide risk pubmed" and it was the first article I found. I can't find any with as clear-cut statistics for AA.
I still think it applies though; the psychological effect of being bald probably doesn't care much about the underlying cause.
There's probably a difference in degree, however. Alopecia Areata is much more uncommon, while regular male pattern baldness is very common.
There's also the fact that Alopecia Areata is actually more common in women, which I imagine exaggerates the distress compared to the more run of the mill MPB.
I realize you didn't mean to use a study on Alopecia Areata, but the difference in degree could be quite large.
The amount of side-effects is correlated with how much people psyched themselves online before taking the medication.
I have been on it for 5 years but I didn't read stuff online about it before though so I didn't end up noceboing myself.
Does this research cover that? That was my first thought
If anything finasteride has improved my mental health. I've taken it for ~7 years with no negative side effects, and I'm certain it's the only reason I still have hair
> Concerns about depression from finasteride were raised in several studies as early as 2002.
It seems clear to me that anything which has depression as a side effect has an increased risk of suicide as well and the only remaining truth to find is the degree.
The executives and scientists should both be prosecuted.
Finasteride every year changes millions of lives globally, I take finasteride, and it’s the sole reason i have my hair.
Idk about you, but i know 10s of different friends who also went through hairloss and were struggling to stop it, who went through severe depression, loss of confidence, suicidal tendencies in extreme cases.
Just because you saw a study that X drug causes side effects/harms in 1-0.1% of patients, doesnt mean the med should be taken off sale especially for a drug as important as finasteride.
It’s easy for someone to say it’s just a cosmetic drug until they go through the full extent of social, mental, and even physical damage, hairloss at a young age causes.
I and almost everyone who takes finasteride take it knowing the risk of a whole range of side effects , often far more severe then just increasing risk of depression. like risk of reduction in fertility, libido in some patients often struggling with obesity.
Obesity creates a whole range of problems too, should we start prosecuting creators of tasty food too ? , fin 1mg is one of the most impactful drugs sold globally both under brand names and generic cheap drugs (i take a generic one) that is life changing for almost a quarter or more of men depending on the country who face male pattern baldness and its related issues.
More studies certainly should be done in link of depression and suicide in some patient cases, but bringing out the pitchfork like luddites and asking to prosecute executives and scientists for a non-opiod, non-addictive, drug that’s been used safely for decades across generations, and saved families thousands of dollars (including mine) in snake oil salesman products that claim to treat hairloss but dont. They should get awards, not pitchforks.
It's closer to 5%. It changes millions of lives negatively.
I have receding hairline and I am not touching fin with a 10-foot pole. It's basically chemical castration.
I take dutasteride (even stronger form of finasteride) and have been personally fortunate to not have any side effects in ~8 years.
My whole family on both sides is bald bald. Without it I would have been bald bald in my early 20s.
I knew there were risks of hormone disruption/mood swings/etc but I still prefer it over being bald. I took a calculated risk and I'm thankful that the drug exists. Please don't prosecute the people that gave me the only real, working treatment for my baldness.
> I take dutasteride (even stronger form of finasteride) and have been personally fortunate to not have any side effects in ~8 years.
Dutasteride is not a stronger version of finasteride. It's a more effective DHT blocker, but it works differently.
The side effects are also different and not easy to predict. Some people have terrible side effects from finasteride and none from dutasteride. Some people have the opposite. And some people can tolerate either one. We don't have a way at the moment to reliably predict which one will work better or be better tolerated for a given individual.
Anyway, I'm glad it has worked for you, and I also would not want to prosecute people who've created a medication that's one of the most effective and well-tolerated around.
> The executives and scientists should both be prosecuted.
For what? Many drugs have depression as a possible side effect, but that doesn’t mean they should be pulled from the market and executives prosecuted for simply the possibility of depression.
Negative reactions to drugs are always a possibility. Weighing the risks and tradeoffs and monitoring patients is important. This is why drugs like this are not OTC.
Thank you. If we prosecuted scientists for a drug as well tolerated as finasteride we would cease to develop new medication and all of humanity would be worse for it.
If there was some indication that the pharmaceutical company knew of and concealed evidence that finasteride caused depression/suicidality, then there could be grounds for criminal prosecution. But a non-consensus view in hindsight that a drug might increase depression looks more like a losing civil liability claim.
The only drugs without side effects are drugs that don't do anything
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