Posts Tagged ‘Finasteride’

Male Fountain of Youth in a Pill

July 14, 2018

Andrew Siegel MD 7/14/2018

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Thank you http://www.goodfreephotos.com for the image above

I only believe in prescribing (and taking) medications when absolutely necessary,  after simpler measures have been tried (usually lifestyle modification) and have failed to improve the issue and when advantages outweigh disadvantages.  That stated, there is one medication in particular that can lop off a number of years in terms of its positive effect on male form and function.  Requirements for any medication are twofold—safety and effectiveness.  Recent studies conducted over the course of twenty years confirm the safety and effectiveness of this medication. The chief investigator presented his long-term findings at the 2018 American Urological meeting in San Francisco and called the findings of the study “transformational.”

Aging can be unkind and Father Time is responsible for a host of changes that occur with the aging process. The aging male often suffers with an enlarging prostate gland that can cause annoying urinary symptoms as the enlargement crimps the flow of urine. Aging is also a key risk factor for the occurrence of prostate cancer. As we know all too well, aging also often causes the loss of one’s youthful full head of hair, leaving a balding and shiny scalp subject to sunburn and often managed by combovers or shaving one’s head.

What if I told you that there is a drug that can shrink the prostate and often alleviate the symptoms of prostate enlargement?  That would be considered a good drug.  What if I told you that it could also reduce the risk of prostate cancer?  Now we’re talking excellent drug.  Finally, what if I told you that it could reverse male pattern baldness?  Now we are talking exceptional drug.  This drug not only exists, but also is generic, inexpensive and yours truly is proof of its success!

Prostate Cancer Prevention Trial

The Prostate Cancer Prevention Trial was a clinical experiment that tested whether the drug finasteride (brand name Proscar) could prevent prostate cancer. The medicine works by blocking the activation of testosterone to DHT (dihydrotestosterone).

This trial was based on two facts:

  1. Prostate cancer does not occur in the absence of testosterone
  2. Men born without the enzyme that converts testosterone to its activated form DHT do not develop benign or malignant prostate growth (nor hair loss, for that matter).

This 7-year study enrolled almost 20,000 men who were randomly assigned to finasteride or placebo. The study was terminated early because men in the finasteride arm of the study were found to have a 25% risk reduction for prostate cancer.  The original study in the 1990s also demonstrated a slight increase in aggressive prostate cancer in the finasteride arm.  This negative finding resulted in a “black box” warning from the FDA, as a result of which many men were frightened about the prospect of using the drug.

Recent follow-up on the original clinical trial (median follow-up > 18 years) presented at the 2018 American Urological Association meeting found 42 deaths from prostate cancer in the finasteride arm and 56 in the placebo arm. The study concluded that finasteride clearly reduces the occurrence of prostate cancer and that the initial concerns regarding high grade prostate cancer were unfounded.

Prostates in those treated with finasteride were 25% smaller at the end of the study as opposed to the prostates in the placebo group. Finasteride (and other medications in its class) lower prostate specific antigen (PSA) by 50%, so any man on this class of medications will need to have his PSA doubled to estimate what the PSA would be if not taking the medication.

proscar-tablet.jpg

When my thinning hair progressed to the point that I had a sunburn on my crown, I started using Propecia (a.k.a. finasteride). In a matter of a few years I had a full regrowth of hair. After the Prostate Cancer Prevention Trial report revealed a 25% risk reduction for prostate cancer with finasteride use, I was strongly motivated to continue using the drug, particularly since my father had been diagnosed with prostate cancer at age 65 (he is thriving over two decades later).

The 2 photos are proof of my fine head of hair, thank you finasteride

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 The bottom line is that finasteride (Proscar and Propecia) and dutasteride (Avodart) can help prevent prostate cancer, shrink the prostate gland, improve lower urinary tract symptoms due to prostate enlargement, help prevent the need for prostate surgery and grow hair on one’s scalp… a fountain of youth dispensed in a pill form if ever there was one!

For more information on the fascinating tale of how this drug was developed–one of the most interesting backstories on drug development–see my entry: Girl at Birth, Boy At Puberty…and A Blockbuster Drug.

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.

Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:

MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health 

PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food

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These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.

Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD (female version is in the works): PelvicRx

New video on female pelvic floor exercises:  Learn about your pelvic floor

On the topic of “fountain of youth,” my first foray into writing was Finding Your Own Fountain of Youth: The Essential Guide to Health, Wellness, Fitness & Longevity.  If you see me as a patient and ask for a copy, it’s yours for free.  Alternatively, if you would like to download a free copy in PDF format, visit www.AndrewSiegelMD.com and click on “books.”

 

 

 

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The Guevedoces: How An Intersex Genetic Defect Led To A Blockbuster Class Of Medicines

February 18, 2012


Blog #46   Andrew Siegel, M.D.

In the early 1970’s, a Cornell endocrinologist by the name of Julianne Imperato conducted an expedition to the Dominican Republic to investigate reports of a community where children who were thought to be “girls” at birth turned into “boys” at puberty.  In this remote area, these intersex children—biological males with a normal male chromosomal make-up (46 XY) who have female-appearing genitals—surprisingly develop male genital anatomy at the time of puberty. The very interesting tale of the guevedoces (literally, “penis at 12 years”) and how an understanding of their genetic defect led to the development of a commonly used medication is the subject of this week’s blog.

In Salinas, an isolated village of the southwestern Dominican Republic, 2% of the live births in the 1970’s were guevedoces.  These children who appeared to be girls at birth, developed a penis, testicles and all of the typical male physical characteristics at the time of puberty.  Most guevedoces were found to be descendants of a single common ancestor, Altagracia Carrusco.  Their underlying pathology was shown to be deficiency of an enzyme known as 5- alpha reductase (5AR).  This enzyme is responsible for converting the male hormone testosterone into dihydrotestosterone (DHT), the more potent, active form of testosterone.

During uterine gestation, DHT is essential for the development of normal male external genitals.  In the absence of DHT in utero, the external genitals develop as female.  However, internally the gonadal tissue is that of the male.  The guevedoces have feminized external genitals, a short “vagina,” undescended testicles and an absent uterus.  With the testosterone surge at puberty, the tiny penis– that was thought to be a clitoris–develops into a normal-size, functional penis; at the same time, the testicles, previously not within the scrotal sac, descend into the scrotum, and other usual male characteristics develop in terms of libido, musculature, voice change, etc.  For the duration of their lives, the guevedoces resemble other Dominican men in all respects except that they have scanty beard growth, never develop acne, their prostate glands remain small and they never develop baldness.

The discovery of this congenital 5-alpha reductase (5AR) deficiency in this small enclave of the Dominican Republic helped transform my field of urology from a largely surgical specialty into a discipline that became enabled to offer effective drug treatments and minimally invasive procedures for prostate and urinary conditions.  The clinical findings of the guevedoces led Merck researchers in the 1970’s to work on the development of a drug that would replicate the effects that the 5AR deficiency had on the adult guevedoces population. Pharmaceutical scientists reasoned that if 5AR could be inhibited after the external genitalia were fully formed and mature, then a medication to shrink the prostate, relieve urinary symptoms and treat baldness and acne might be developed.  The legacy of the guevedoces became a class of drugs known as 5 alpha-reductase inhibitors (5ARIs), the “prostate pills.”  Finasteride, the original 5ARI, was approved in 1992.  Dutasteride followed, and the treatment approach to prostatic obstruction was forevermore changed.  Aside from prostate shrinkage and symptomatic relief of urinary symptoms, this class of drugs is an effective treatment for male pattern baldness.

I do not believe in medications unless there is a compelling reason to use them and the benefits outweigh the potential side effects. The 5ARIs are genuine winners with a terrific reward/risk ratio and not only do I endorse them and prescribe them liberally, but I personally start my mornings with a dose of Finasteride.   The 5ARIs cause prostate atrophy and alter the natural history of benign prostate hyperplasia, BPH (prostate enlargement), improving the typical urinary symptoms that the aging male is prone to.  They help prevent a situation where a male cannot urinate (acute urinary retention) and requires emergency placement of a catheter and also help prevent the need for prostate surgery.  The 5ARIs are very useful to control blood in the urine that is of prostatic origin, a not uncommon manifestation of BPH.  Studies have shown that these medications confer a risk reduction for prostate cancer, so urologists often employ the 5ARIs for men at high risk: those with a family history; those with very elevated PSA levels; and those with prior prostate biopsies showing pre-malignant findings.   Men on 5ARIs will have a decrease in prostate specific antigen (PSA) to about 50% of baseline and this is factored into ongoing PSA testing.  Another utility is that if the PSA does not drop to 50% of baseline, it is suspicious that an underlying prostate cancer may be an issue.  Additionally, the shrinkage of the BPH as a result of these medications will make the digital rectal exam more sensitive to finding abnormalities that can help make an early diagnosis of prostate cancer.  Most recently, the 5ARIs have been shown to delay prostate cancer progression in men with low-risk, localized prostate cancer. Finally, the 5ARIs promote hair growth, particularly for men with hair loss at the crown of their heads.

The safety record of the 5ARIs deserves mention, as they are intended for long-term use. Aside from a relatively low incidence of sexual dysfunction—difficult to distinguish from the declining erectile capabilities that occur with aging—the 5ARIs are among the most benign treatments for any chronic condition.  Another rather inconsequential result of 5ARIs is that they cause a decrease in ejaculate volume as a result of the prostate atrophy.  5ARIs do not cause major side effects while still depriving the prostate of stimulation because inhibiting 5AR results only in lowering the concentration of DHT within the prostate gland, leaving serum testosterone levels normal or even slightly elevated.

My own tale:

A number of years ago, within a few day period of time, both my wife and father independently noticed and related to me that I had sunburn on the crown of my head.  This did not appeal to my sense of vanity!   I tried topical Minoxidil (Rogaine) but it was ineffective, so I started Propecia (Finasteride 1mg) every morning.  Lo and behold, about six months later, I was startled to find that my exposed scalp was not so exposed any more. It worked slowly, but within a couple of years after starting the Propecia, the vertex of my head had a full regrowth of hair.  No kidding!

When the Veterans Administration report came out demonstrating that the risk of prostate cancer diminished 25% with Finasteride use, this cinched it—particularly insofar as my father had been diagnosed with prostate cancer at age 65.  This is a drug that fixes my bald spot, shrinks my prostate, and helps prevent prostate cancer for which I have a positive family history. This was truly a win-win situation, a real no- brainer.  I will share with you a little insider information—a significant number of urologists and other physicians avail themselves of this class of medications for all of the reasons just stated.  It is truly a medication worth taking.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food

Now available on Amazon Kindle

www.PromiscuousEating.com

Prostate Cancer: Can Diet And Lifestyle Make A Difference?

September 30, 2011

September is National Prostate Cancer Awareness Month, so I thought that a discussion of prostate cancer and preventative measures would be an appropriate topic to write about as the month approaches its end.  As a urologist and a wellness advocate, this subject is very dear to my heart.

Prostate cancer is the second leading cause of cancer-related deaths among men in the USA.  The burden of this disease is felt not only by those men diagnosed with this disease, but also by their partners, relatives and friends who are key elements in their emotional support system.

Prostate cancer is the most common non-skin malignancy among men in most Western populations (240,000 estimated new cases in 2011 in the U.S.), and is the second leading cause of cancer death among U.S. men (34,000 estimated deaths in 2011). To put this in perspective, heart disease causes more than 800,000 deaths per year in American men and is the leading cause of death in men with prostate cancer.  Many more men die of heart disease than of prostate cancer, and even in the population of men with prostate cancer, many more men die with it than of it.

The three major risk factors for prostate cancer are age, race, and family history. The likelihood of developing prostate cancer increases with the aging process, thought to be on the basis of gradual accumulation of DNA mutations due to incremental oxidative damage (literally “rusting”) of prostate cells. With each decade of aging, the incidence of prostate cancer increases appreciably.

In terms of race, African-American men have the highest reported incidence of prostate cancer in the world, with an incidence of 1.6 times that of Caucasian men in the United States; additionally, mortality is 2.4 times higher for African American men. On a worldwide basis, the highest incidence is in North America and Scandinavia and the lowest incidence is in Asia.

Prostate cancer tends to run in families, so it is prudent for male children of those with prostate cancer to be checked on an annual basis starting at age 40 (with a PSA blood test and digital rectal exam). With respect to familial prostate cancer, risk increases according to the number of affected family members (the more affected, the higher the risk), their degree of relatedness (brother and/or father affected confer a higher risk than cousin and/or uncle), and the age at which they were diagnosed (relatives of patients diagnosed younger than 55 years old are at highest risk). Generally speaking, if you have a brother or a father with prostate cancer, your risk of developing it is doubled. If you have three family members with prostate cancer, or if the disease occurs in three generations in your family, or if two of your first-degree relatives have been diagnosed at an age younger than 55 years, then you have a good likelihood for hereditary prostate cancer, which confers a 50% risk of developing the disease.

My father, a retired urologist, was diagnosed with prostate cancer at age 65 and underwent curative surgery and is currently 80 years old and thriving. For this reason, I have been very diligent in seeing my internist annually for a prostate examination and a PSA blood test. Additionally, I have been proactive in taking a medication to decrease my risk of prostate cancer.

Prostate cancer is unique among solid tumors in that it exists in two forms: a latent form (evident on autopsy studies, but not causing an abnormal digital rectal exam or PSA), which is present in 60-70% of men older than 80; and a clinically evident form (causing an abnormal rectal exam or elevated PSA), which affects approximately 1 in 6 men in the United States. Overall, men have an approximately 17% chance of being diagnosed with prostate cancer and a 3% chance of dying from it. This high ratio of prostate cancer incidence to mortality suggests that a portion of the cancers are minimal or indolent, non life-threatening conditions.

Currently, most prostate cancers are detected on the basis of a PSA elevation ranging from 2.5-10 ng/ml. Widespread PSA testing has resulted in the increased diagnosis of prostate cancer and a downward stage migration to non-palpable, organ-confined cancer with a parallel reduction in deaths—as opposed to the pre-PSA era, when most cancers were detected on the basis of a palpably abnormal digital rectal exam and were at a more advanced stage at presentation.

It is very important to know that when detected early, prostate cancer is highly curable. In the USA, more than 90% of men diagnosed with prostate cancer survive at least 10 years after the diagnosis is made. Even when not discovered early, it is a very manageable condition. In general terms, prostate cancer is a relatively slow-growing process.   Although most prostate cancers diagnosed at an early stage often have an indolent course, local tumor progression and metastases may certainly develop in the long term; therefore, early treatment is an important consideration for men with a general life expectancy exceeding 10 years.

Localized prostate cancer typically causes no symptoms and is typically diagnosed by a biopsy done because of a PSA elevation, an accelerated increase in the PSA over time, or an abnormal digital rectal examination. Non-palpable cancers, i.e., those picked up by virtue of a PSA elevation or accelerated PSA velocity, now account for 75% of all newly diagnosed prostate cancers. Although screening for prostate cancer remains somewhat controversial because of a lack of studies demonstrating a decrease in mortality in screened populations, the observed trends in PSA-driven detection of prostate cancer at earlier stages and declining mortality where screening is common provide strong inferential evidence that screening is beneficial.

Wouldn’t it be wonderful if we could prevent the occurrence of prostate cancer? It certainly would make my job a whole lot easier. Unfortunately, we are not there yet—but we do know a thing or two about lifestyle measures that can be pursued to maintain health and wellness in general and to help mitigate the chances of developing prostate cancer.

When Asian men (the ethnic group that has the lowest incidence of prostate cancer) migrate to Western countries, their risk of prostate cancer increases substantially over time.  So it is clear that environment plays a strong role in the genesis of prostate cancer and it is not just a simple matter of genetics.

Unquestionably, a coronary artery-clogging Western diet high in animal fat and highly processed foods and low in fruits, vegetables, legumes and whole grains is associated with a higher incidence of many preventable chronic health problems including cancer.  A heart-healthy, colon-healthy diet is a prostate-healthy and life-healthy diet.  A healthy diet combined with a healthy lifestyle, will afford us our best opportunity at minimizing heart disease, diabetes, and a host of cancers. This means weight management; the avoidance of obesity; healthy eating with abundant fruits and vegetables (chock full of antioxidants, vitamins, minerals and fiber) and real food as opposed to processed foods; consumption of animal fats and dairy in moderation; avoidance of tobacco and excessive alcohol; and plenty of exercise. And if we do develop prostate cancer, we will be in stellar physical shape and will heal that much better from any intervention necessary to treat the prostate cancer. Good nutrition and exercise helps in part by inhibiting oxidation and inflammation, factors that contribute not only to prostate cancer but also to conditions such as heart disease and osteoarthritis.

Michael Pollan, a journalism professor at the University of California, Berkeley and author of The Omnivore’s Dilemma, summarized in a most succinct way the answer to the question of what humans should eat, in his seven words: “Eat food. Not too much. Mostly plants.” By food, he means a nutritional substance that your grandmother would recognize as food, not a food-like highly processed substitute. Not too much is pretty obvious. A mostly plants-based diet will result in the consumption of a moderate amount of calories and plenty of fiber and anti-oxidants.

In addition to recommending a regimen of healthy eating and regular participation in exercise, there are medications that can help prevent the occurrence of prostate cancer. The presence of precursor lesions such as high grade prostate intraepithelial neoplasia (HGPIN) many years before the onset of prostate cancer, coupled with the increasing prevalence of prostate cancer with the aging process, suggest that the process of developing cancer takes place over a protracted interval of time. In fact, it is estimated that it takes many years—often more than a decade—from the initiation of the initial mutation to the time when prostate cancer becomes clinically manifest with either a PSA elevation or an abnormal digital rectal examination. In theory, this provides the opportunity for intervention before the establishment of a cancer.

The Prostate Cancer Prevention Trial was a clinical trial that tested whether Finasteride, which induces a deficiency of the enzyme 5-alpha reductase, would prevent prostate cancer. This trial was based upon the fact that prostate cancer does not occur in the absence of testosterone and that men with a congenital absence of 5-alpha reductase (that functions to convert testosterone to the activated form, dihydro-testosterone) do not develop benign or malignant prostate growth. This 7-year study involved almost 20,000 men who were randomly assigned to Finasteride or placebo. The study was terminated 15 months early because a 25% risk reduction for prostate cancer was achieved on Finasteride. The other finding was that the prevalence of higher-grade cancers was slightly higher in the Finasteride group (6.4% vs. 5.1%); however, Finasteride is known to change the pathological appearance of the prostate in such a way as to make determination of an accurate grade difficult.

A number of years ago, I was given the disheartening news that I had sunburn on my crown!  A balding pate frankly did not appeal to my sense of vanity!   After topical Minoxidil (Rogaine) proved ineffective, I started taking Propecia (a.k.a. Finasteride) every morning. Lo and behold, my thinning crown filled in and ultimately I had a full re-growth of hair.  When the Prostate Cancer Prevention Trial report came out revealing a 25% risk reduction for prostate cancer associated with the use of Finasteride, this cinched it—particularly insofar as my father had been diagnosed with prostate cancer.  Finasteride is a drug that fixes my bald spot, shrinks my prostate, and helps prevent prostate cancer, for which I have a family history. It seemed like a win-win situation, a no-brainer!

Bottom line:  Prostate cancer is very prevalent in men, involving one in six men in the USA.   When picked up on a timely basis via screening with the digital rectal exam and blood PSA test, it is eminently treatable and has an excellent prognosis, with only 3% of deaths in the USA attributable to prostate cancer.  There are both genetic and environmental factors at work in the genesis of prostate cancer.  We are not in control of our genetics, but we are in command of our lifestyle.  Maintaining a healthy lifestyle—including rational food choices—can help mitigate our chances of developing prostate cancer.

Andrew Siegel, M.D.

September 30, 2011

www.PromiscuousEating.com

For more information on prostate cancer:

American Cancer Society: http://www.cancer.org

American Urological Association Foundation: http://www.auafoundation.org

Cancer Care: http://www.cancercare.org

National Cancer Institute: http://www.cancer.gov

National Prostate Cancer Coalition: http://www.pcacoalition.org

Prostate Cancer Foundation: http://www.prostatecancerfoundation.org

Prostate Cancer Research and Education Foundation: http://www.pcref.org

Us TOO Prostate Cancer Education and Support Network: http://www.ustoo.org