Post finasteride syndrome & The importance of DHT

Intro

This article will discuss post finasteride syndrome, its cause and how to best go about reversing it and restoring normal functionality.

Finasteride is a 5a-reductase inhibitor and therefore can be classified as an anti-androgen.

It works by inhibiting the conversion of Testosterone to Dihydrotestosterone (DHT) by about 70%.

Some individuals that take finasteride suffer lasting side effects, even after they stop taking it! This is referred to as Post finasteride syndrome (PFS).

It’s estimated that 1 in 8 men will experience some side effect from taking finasteride.

What is post finasteride syndrome (PFS)?

Post finasteride syndrome is an umbrella term for the insidious sexual, physical and neurological side effects as a result of taking the commonly prescribed hair loss medication finasteride.

Men suffering from PFS often describe feeling that they no longer feel like men. Which makes sense considering finasteride is inhibiting the most powerful androgen in the body.

How does finasteride work

Finasteride works by inhibiting an enzyme called 5 alpha reductase. Which is responsible for converting a percentage of a mans Testosterone to DHT.

DHT is much more powerful and androgenic than Testosterone. It binds to multiple receptor sites in the body.

Men use finasteride to systemically reduce the amount of circulating DHT to lower the total amount binding to hair follicles – where it is reponsible for progressing male pattern baldness (MPB) in those with a genetic predisposition.

If the receptor sites for DHT were limited to only the hair follicles, that would be great. But unfortunately DHT is a double edged sword and it’s needed to maintain and regulate other key processes in the body including but not limited to… maintaining proper sexual function, libido, and it also has anxiolytic properties that positively impact mood.

Another important thing to consider here is that the portion of Testosterone that would normally be converted to DHT via 5AR is left to convert to estrogen via Aromatase instead, creating a more estrogen-dominant hormonal profile and possibily leading to estrogenic side effects.

Normal Testosterone metabolism.

Testosterone metabolism after adding finasteride and blocking 5AR.

Yes, my MS paint artwork is amazing!

Symptoms of PFS

Men often report an array of side effects including…

• A mild to drastic reduction of libido
• Varying degrees of decreased penile sensitivity from minor changes, to total loss of tactile sensation
• Depression
• Increased anxiety
• Shrunken genitals – The penis takes on a shrivelled state and testicles are pulled tight to the body
• Testicle pain/aching
• Tinitus
• Insomnia
• Impaired motor function
• Brain fog
• Dry skin
• Memory loss

There’s also several reports of suicide attributed to the devastating side effects of finasteride.

In the interview below, Daniels mother details the devastating effects her son was experiencing as a result of PFS before his suicide.

My experience with finasteride

I have my own personal account of finasteride and did experience some of the side effects often associated with it.

In 2022 I used 1mg of finasteride a day in combination with minoxadil and derma-rolling for about 4 months to try and combat hair loss due to genetic MPB.

Although it didn’t really effect my mood initially, I did notice that I became less interested in sex and even experienced some numbing of the genitals after about 2 months on the drug. My penis would often appear smaller and took on a shrunken state while being flaccid. If you’ve ever taken a cold shower or been in a cold pool, you’ll know exactly what I mean, although it would do this at normal tempuratures.

I thought that was acceptable, and as long as it didn’t get any worst then I would continue using finasteride.

However things did progressively get worse, I noticed more severe numbing of the genitals and it was even starting to effect my mood. The mood changes could well have been placebo, because at that point I’d started doing research into the side effects of finasteride.

At the 4 month mark I decided to pull the plug and discontinue using finasteride and just accept the hair loss.

As much as balding sucks, I’d much rather have a nice clean shaved head and a functioning penis and libido, than hold onto an inevitably receeding hairline and have a limp sausage and no sex drive.

Fortunately for me, when I discontinued finasteride things slowly but surely returned to normal, and after 2 months I had made a full recovery.

However some men are not so lucky and symptoms persist for many years afterwards and based on the accounts of some individuals – may be permanent… SCARY!

The importance of DHT

Upon conducting further research I discovered how critical DHT was to male libido and sexual function.

As well as providing an array of health benefits such as reducing visceral fat around organs and lowering the risk of heart disease.

It also plays a key role in general mood, sense of well being and lowering anxiety.

I’ll discuss each of these in more depth in the following sections.

Sexual function

DHT is the key hormone that is responsible for carrying adolescent boys through puberty and developing male characteristics. It even plays a key role in the development and growth of the penis and men that lack DHT during puberty often develop a micropenis.

With this knowledge, and men suffering from PFS often reporting shrunken/shrivelled genitals, I speculate that it’s very possible that this would lead to atrophying of the penis over time as the shrunken state is direct evidence of a lack of blood flow and therefore nutrients and key growth factors like VEGF (vascular endothelial growth factor) – chronic lack of blood flow to any tissue in the body will lead to tissue death and atrophy over time.

On the other hand men that have used a drug called proviron, which is basically oral DHT report a drastic increase in libido and penile sensitivity.

Accounts of men using Proviron.

Health benefits

Higher levels of DHT have also been associated with lower amounts of visceral fat around organs and in this study, it was found that elderly men with higher levels of DHT have lower death rates from heart disease.

Anxiety & depression

This study was done on 128 men who were taking 1mg of finasteride a day. They were asked to fill out two questionnaires, one before treatment and another two months into treatment with finasteride.

They concluded that finasteride might induce depressive symptoms and as a result – may be of high risk for those with prior mental health conditions.

A common side effect of low Testosterone (therefore low DHT) is anxiety and depression. These are listed symptoms of low Testosterone, notice how closely they overlap with symptoms of PFS.

There was a study done on male rats who were given an intrahippocampal adminstration of an androgen receptor antagonist called flutamide which was shown to increase anxiety-like behaviours.

‘Testosterone (T) and its 5alpha-reduced metabolite, dihydrotestosterone (DHT), can decrease anxiety-like behavior; however, the mechanisms underlying these effects have not been established. First, we hypothesized that if T reduces anxiety-like behavior through actions of its 5alpha-reduced metabolite, DHT, then gonadectomy (GDX) would increase anxiety-like behavior, an effect which would be reversed by systemic administration of DHT.

Second, we hypothesized that if T and DHT reduce anxiety-like behavior in part through actions at intracellular androgen receptors in the hippocampus, then administration of an androgen receptor antagonist, flutamide, directly to the hippocampus should increase anxiety-like behavior of intact and DHT-replaced, but not GDX, male rats.

Inserts that were empty or contained flutamide were applied directly to the dorsal hippocampus of intact, GDX, or GDX and DHT-replaced rats 2h prior to testing in the open field, elevated plus maze, or defensive freezing tasks. GDX rats exhibited significantly more anxiety-like behaviors than intact or DHT-replaced rats. Intact and DHT-replaced rats administered flutamide to the hippocampus showed significantly more anxiety-like behavior than did intact and DHT-replaced controls.

However, flutamide alone did not increase anxiety-like behavior of GDX rats. Together, these findings suggest that androgens can decrease anxiety-like behavior of male rats in part through DHT’s actions at androgen receptors in the hippocampus.’

How to cure PFS

I strongly believe that a normalisation and upregulation of androgens and androgen receptors hold the key to curing PFS.

Obviously androgens are not very friendly to your hair, but unfortunately if you are suffering with PFS and are genetically prone to MPB, then it’s one or the other – hair loss or loss of sexual function, depression, anxiety etc.

I believe that a three pronged attack is nesessary to restoring sexual function and reversing PFS. These include;

1. Upregulation of androgen receptors & dopamine
2. Added exogenous androgens to bind to upregulated receptors
3. Increasing nitric oxide and blood flow capacities of the penis

Upregulation of androgen receptors

There are many things you can do to upregulate your androgen receptors and dopamine. These include resistance training, abstaining from porn and ejaculation, and L-carnitine supplementation.

Weight training

Weight training has been proven to increase Testosterone levels and androgen receptor density in those over untrained individuals.

Lifting weights is something you should be doing as a man anyway and for someone trying to recover from PFS, this is of even more importance.

Abstainance from porn & ejaculation

Porn is a supernormal stimuli and makes the brain produce far more dopamine than it can handle – as a response your brain downregulates dopamine receptors. Check out the porn section of my dopamine detox guide for more information.

Ejaculation spikes a hormone called prolactin, which has an inverse relationship with dopamine. When prolactin is high, dopamine is low and vice versa. After ejaculation prolactin levels can take up to 2 weeks to return to baseline.

Porn that downregulates dopamine receptors and excessive ejaculation that spikes prolactin and supresses dopamine is a recipe for brain fog, lack of motivation and sex drive.

Androgens and DHT derivatives

Many men report that taking synthetic DHT derived androgens like Masteron (Drostanolone), Primobolan (Methenolone) and Proviron (Mesterolone) have a huge impact on their sex drives, sexual function and sense of wellbeing.

It’s important to note that using these DHT derivatives will have suppressive effects on your own hormones and shut down your HTPA.

Nitric oxide and blood flow

Due to the chronic lack of blood flow to the genitals as a result of PFS. Supplements and practices can be leveraged to boost nitric oxide and promote the normalisation of blood flow to allow growth factors to the genitals.

Cardio

Cardiovascular exercise has been shown to improve endothelial health within blood vessels, lower blood pressure and improve nitric oxide levels.

L-citrulline

L-citrulline is a supplement that can easily found online. It is an amino acid and pre-cursor to nitric oxide that improves blood flow, lowers blood pressure and aids with erectile dysfunction by increasing nitric oxide levels.

Alternatively you can eat more foods that are naturally rich in nitrates. It can be found in leafly greens and other vegetables, which include:

• Spinach
• Beetroot
• Celery
• Arugula

PDE5 inhibitors Sildenafil (Viagra) and Tadalafil (Cialis)

PDE5 inhibitors work by increasing nitric oxide levels and relaxing the smooth muscles of the penis enabling strong erections.

The best way to use PDE5 inhibitors when trying to restore sexual function is to use a low dose before bed so that they can enhance and prolong nocturnal erections. 25mg of viagra before bed with 2-3g of L-citrulline would be ideal.

Noctural erections occur during REM sleep and are critical to maintaining the vasculature and health of the penis. Men suffering from PFS often report insomnia (therefore reduced REM sleep), shrivelled genitals and the dissapearance of morning wood, all indicating poor blood flow and potential damage to the blood vessels of the penis – PDE5 inhibitors can help to mitigate some of the damage in the short term while the longer processes on this list can take effect (cardio, androgen receptor upregulation etc).

Penis pumping

Penis pumps are another way to increase blood flow to the penis, these work by creating a vacuum that artificially engorges the penis with large amounts of oxygenated blood, creating a controllable stressor on the vasculature which leads to adaptations to occur and angiogenesis (growth of existing and creation of new blood vessels)

PFS recovery protocol

If I was to put a protocol together to cure PFS it would be the following:

Lifestyle changes

• Reduction of saturated fats and sugars – Improves cardiovascular health

• 15-20 minutes of zone 2 cardio daily – Improves cardiovascular health

• Abstainance of porn and ejaculation – Normalises dopamine sensitivity

• Resistance/weight training 3x a week – Upregulates existing, and increases the number of androgen receptors

• 20 minutes of penis pumping 3x a week to promote penile health, blood flow and trigger angiogenesis

Supplementation

• 6-9g of L-citrulline split 3x per day, 2/3g AM, 2/3g PM, 2/3g before bed

• 25mg Sildenafil before bed to promote, extend and enhance noctural erections

Hormones

(I AM NOT A DOCTOR AND THEREFORE IN GOOD CONSCIENCE, CANNOT RECOMMEND THAT YOU USE THE FOLLOWING COMPOUNDS)

• High ‘replacement’ dose of Testosterone, typically 120-200mg per week*

• An additional DHT derivative like Masteron at a 2:1 ratio with the Testosterone*

• Proviron (oral DHT) 12.5-25mg daily*

• 500-750iu HCG weekly to maintain HTPA function while using exogenous hormones

*Note that these hormones will shutdown your current endogenous production, so careful consideration and research is needed before proceeding to use the above compounds.

Overview

PFS is certainly no joke and can be devastating for many men. There’s a channel called ‘PFS network’ on youtube that documents mens experiences and symptoms of PFS. If you think you have PFS it’s worth checking out to see if what you’re going through mirrors the experiences of these men.

I have a good understanding of androgens and I believe that they, in combination with lifestyle changes and proper supplementation, hold the key to reversing post finasteride syndrome.