Indian J Sex Transm Dis Indian J Sex Transm Dis
Official Publication of the Indian Association for the Study of Sexually Transmitted Diseases
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ABSTRACTS
Year : 2017  |  Volume : 38  |  Issue : 2  |  Page : 200-202
 

Abstracts from the current global literature: Finasteride and sexual dysfunction


Department of Skin and V. D., Baroda Medical College, Vadodara, Gujarat, India

Date of Web Publication23-Oct-2017

Correspondence Address:
Avani M Modi
Department of Skin and V. D., Baroda Medical College, OPD 1, Vadodara, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijstd.IJSTD_25_17

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How to cite this article:
Modi AM, Menon DS, Marfatia YS. Abstracts from the current global literature: Finasteride and sexual dysfunction. Indian J Sex Transm Dis 2017;38:200-2

How to cite this URL:
Modi AM, Menon DS, Marfatia YS. Abstracts from the current global literature: Finasteride and sexual dysfunction. Indian J Sex Transm Dis [serial online] 2017 [cited 2019 Jul 23];38:200-2. Available from: http://www.ijstd.org/text.asp?2017/38/2/200/216987




Finasteride and sexual side effects

1.Mysore V. Finasteride and sexual side effects. Indian Dermatol Online J 2012;3:62-5.

This article critically examines the evidence available and makes recommendations as to how a physician should counsel a patient while prescribing the drug.

The androgens testosterone and dihydrotestosterone (DHT) have somewhat different actions. The enzyme 5-alpha reductase inhibitor (5ARI) converts testosterone into DHT. It exists in two isoenzyme forms. While type I is predominant in liver, type II is predominant in prostate, seminal vesicles, epididymis, hair follicles, and liver. Finasteride is a specific and competitive inhibitor of Type II 5ARI (has a more significant role in pattern hair loss) and has therefore a selective action on hair follicles. Studies reveal that sexual adverse effects occur at the rates of 2.1%–3.8%, erectile dysfunction being the most common followed by ejaculatory dysfunction and loss of libido which occur early in the therapy and return to normal on stopping or over a time on continuous usage of the drug.

A comprehensive review of a total of 73 papers on medical therapies for benign prostatic hyperplasia revealed that finasteride is infrequently associated with problems of ejaculation (2.1%–7.7%), erection (4.9%–15.8%), and libido (3.1%–5.4%). The nocebo effect has an influence in the causation of side effects and suggesting the role of psychological factors.

A large prospective study in as many as 17,313 patients was conducted to look into the effects of finasteride on sexual dysfunction as part of the analysis. The Prostate Cancer Prevention Trial concluded that the effect of finasteride on sexual functioning is minimal for most men and should not impact the decision to prescribe or take finasteride, but it is recommended that physicians treating male pattern hair loss should discuss the potential risk levels with patients while prescribing the drug.

The evidence available about the safety of the drug can be considered as questionable, but cannot certainly be ignored. Losing potency for gaining hair is not an attractive proposition, however remote that possibility is. In addition, the author also feels that, in patients who are apprehensive about the side effects, it is worthwhile considering administration of lower daily doses or staggered pulse doses of the drug, to enhance patient compliance. While 0.2 mg caused 55% DHT suppression, 5 mg/day achieved 69% DHT suppression.

Guidelines on the use of finasteride in androgenetic alopecia

2.Mysore V, Shashikumar BM. Guidelines on the use of finasteride in androgenetic alopecia. Indian J Dermatol Venereol Leprol 2016;82:128-34.

Finasteride is a widely used drug in dermatology for the treatment of androgenetic alopecia. There are many reports of associated sexual side effects. Finasteride has been tried in several doses ranging from 0.2 mg to 5 mg. There is no difference in efficacy between doses of 1 mg and 5 mg. A literature search was performed to collect data on the use of finasteride in male pattern baldness. Relevant literature published till March 2014 was obtained from Medline, EMBASE, CINAHL, Cochrane registers, and LILACS. All systematic reviews, meta-analyses, national guidelines, randomized controlled trials, prospective open-label studies, and retrospective case series in the English literature were reviewed. The methodology of each study selected was assessed as per the National Institute of Clinical Excellence Technical Manual. Two hundred and sixty-two studies were evaluated, 12 of which fulfilled the inclusion criteria. An Indian study of 100 patients suggested that finasteride alone, or in combination with minoxidil or ketoconazole, showed statistically significant improvement (P < 0.05) over minoxidil only recipients (evidence level 1+). The study concluded that a combination of drugs enhanced the efficacy. Evidence for topical formulations of finasteride is scanty. Many studies have concluded that the side effects are not significant. The nocebo effect may explain side effects in some patients. Erectile dysfunction is the most common side effect followed by ejaculatory dysfunction and loss of libido. These findings suggest that a subset of patients receiving finasteride may develop sexual side effects which may not be entirely reversible. They suggest that this deserves serious consideration and it needs to be discussed with patients. On April 11, 2012, the U.S. Food and Drug Administration (FDA) announced changes to the professional labels for Propecia (finasteride 1 mg) and Proscar (finasteride 5 mg) to include libido disorders, ejaculation disorders, and orgasm disorders that continued after discontinuation of the drug. The FDA advised patients to consult their health-care provider to discuss the risks and benefits of finasteride. There is limited evidence (level C) for the use of finasteride at higher dosages for the treatment of female pattern hair loss in postmenopausal women. The drug is a useful option for treatment failure cases. Informed consent and adequate contraceptive measures should be taken. Current evidence on the safety of finasteride indicates that it is safe, but there is growing concern about its sexual side effects. In view of this, proper information should be provided to patients before starting treatment. Researchers are yet to find safer and proven alternatives to finasteride.

5-alpha reductase inhibitors and erectile dysfunction: The connection

3. Erdemir F, Harbin A, Hellstrom WJ. 5-alpha reductase inhibitors and erectile dysfunction: The connection. J Sex Med 2008;5:2917-24.

The first-line medical therapy for benign prostatic hyperplasia includes alpha 1 blockers and 5 alpha-reductase inhibitors (5ARIs), such as finasteride and dutasteride.

The aim of this study was to clarify the association between sexual adverse effects (AEs) and 5ARIs through a review of literature concerning 5ARIs and to review the proposed mechanisms of these effects.

A comprehensive literature review, using Medline and PubMed search engines, was conducted for all publications concerning 5ARIs and sexual AEs.

Sexual AEs, such as ED, ejaculatory dysfunction (EjD), and decreased libido, were the measured outcomes of this literature review.

Sexual AEs are reported in clinical trials at rates of 2.1%–38%. The most common sexual AE is ED, followed by EjD and decreased libido. These effects occur early in therapy and attenuate over time. A proposed mechanism for sexual dysfunction involves decreased nitric oxide synthase activity due to decreased dihydrotestosterone.

The connection between 5ARIs and sexual dysfunction is apparent upon review of the literature. Though theories have been proposed, little is known about the exact mechanisms behind 5ARI-related sexual dysfunction.

Side effects of 5-alpha reductase inhibitors: A comprehensive review

4. Trost L, Saitz TR, Hellstrom WJ. Side effects of 5-alpha reductase inhibitors: A comprehensive review. Sex Med Rev 2013;1:24-41.

Aim: The primary aim of this study was to review and summarize findings from published literature detailing adverse effects (AEs) associated with the usage of 5 alpha-reductase inhibitors (5ARI). A secondary aim was to review the potential mechanisms of action, which may account for these observed and reported AEs. Methods: A PubMed search was conducted on articles published from 1992 to 2012, which reported AEs with 5ARIs. Priority was given to randomized, placebo-controlled trials. Studies investigating potential mechanisms of action for 5ARIs were included for review. Discussion: A pooled summary of all randomized, placebo-controlled trials evaluating 5ARIs (n = 62,827) revealed slightly increased rates over placebo for decreased libido (1.5%), erectile dysfunction (ED) (1.6%), ejaculatory dysfunction (EjD) (3.4%), and gynecomastia (1.3%). The limited data available on the impact of 5ARIs on mood disorders demonstrate statistically significant (although clinically minimal) differences in the rates of depression and/or anxiety. Similarly, there are limited reports of reversible, diminished fertility among susceptible individuals. Postmarketing surveillance reports have questioned the actual prevalence of AEs associated with 5ARI's use and suggested the possibility of persistent symptoms after drug discontinuation. Conclusion: 5ARIs are associated with slightly increased rates of decreased libido, ED, EjD, gynecomastia, depression, and/or anxiety. Further studies directed at identifying prevalence rates and persistence of symptoms beyond drug discontinuation are required to assess causality.

Effects of 5-alpha reductase inhibitors on erectile function, sexual desire, and ejaculation

5. Gur S, Kadowitz PJ, Hellstrom WJ. Effects of 5-alpha reductase inhibitors on erectile function, sexual desire, and ejaculation. Expert Opin Drug Saf 2013;12:81-90.

The true prevalence of sexual side effects with 5-alpha reductase inhibitors (5ARI) treatment is currently unknown.

This article reviews the reported adverse effects (AEs) of 5ARI in regard to erectile function, sexual desire, and ejaculation. A PubMed search was performed of all articles from 1990 to present, which reported any sexual side effects with finasteride or dutasteride. Preference was given to more recent and human studies where available. Clinical trials with 5ARI report prevalence rates of de novo erectile dysfunction to be 5%–9%. Decreased circulating dihydrotestosterone resulting from 5ARI use is associated with diminished sexual desire and/or orgasm. The presence of adverse sexual effects is associated with decreased self-esteem, quality of life, and an ability to maintain an intimate relationship. Inhibition of 5ARI additionally influences progesterone and deoxycorticosterone levels and may alter psychological functions, including increased depression, melancholy, and loss of general well-being. Ejaculatory dysfunction has not been well studied in patients using 5ARI. Patients receiving therapy with 5ARI should be counseled as to potential sexual and psychological AEs.

Finasteride: Its impact on sexual function and prostate cancer

6. Anitha B, Inamadar AC, Ragunatha S. Finasteride: Its impact on sexual function and prostate cancer. J Cutan Aesthet Surg 2009;2:12-6.

Finasteride, a specific and competitive inhibitor of 5α-reductase enzyme Type 2, inhibits the conversion of testosterone into dihydrotestosterone (DHT). In adults, DHT acts as primary androgen in prostate and hair follicles. The only Food and Drug Administration-approved dermatological indication of finasteride is androgenetic alopecia. However, apprehension regarding sexual dysfunction associated with finasteride deters dermatologists from prescribing the drug and patients from taking the drug for androgenetic alopecia. Testosterone, through its humoral endocrine and local paracrine effects, is relevant in central and peripheral modulation of sexual function than locally acting DHT. Several large population-based, long-term, placebo-controlled studies, using the International Index of Erectile Function-5 questionnaire and objective method (Nocturnal Penile Tumescence) to assess the erectile function, have demonstrated no clear evidence of the negative effect of finasteride on erectile function. Reduction in ejaculatory volume is the only established causal relationship between finasteride and sexual dysfunction. Although finasteride causes significant reduction in all the semen parameters except sperm morphology, they did not fall below the threshold levels to interfere with fertility. Therefore, the sexual adverse effects associated with finasteride should be viewed in relation to normal prevalence and natural history of erectile dysfunction in the population, age of the patient, other confounding factors, and also nocebo effect. The impact of finasteride on the prevention of prostate cancer has been discussed extensively. Finasteride is found to be effective in significantly reducing the incidence of low-grade prostate cancer. However, the paradoxical increase in high-grade cancer in the finasteride group has been attributed to increased sensitivity and improved performance of prostate-specific antigen levels to detect all grades of prostate cancer. The effects of both doses of finasteride (5 mg and 1 mg/day) on prostate and PSA levels are almost similar. Hence, as dermatologists, we should be aware of the potential risks and benefits while treating baldness in young men with long-term finasteride.






 

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