Alessa Avec Fashion

I'd heard buzz about sexual side effects of Propecia (finasteride) and Avodart (both are Rx medications to treat male pattern hairloss), but now a study about the link is getting some serious news (see USAToday).

Reports USAToday: The drugs — prescribed to treat a common urological condition called benign prostatic hyperplasia (BPH) and baldness — work by blocking androgen. In the case of BPH, this helps reduce the enlarged prostate, making urination easier.

But there's a downside. "We need androgen for erectile function, libido and ejaculation, and for just feeling good," said Abdulmaged M. Traish, a professor of biochemistry and urology at Boston University School of Medicine.

No response from Merck (see Propecia FAQ or Merck news), but it takes a while to respond to studies like this. I wouldn't be surprised if there was no response, and GSK's Avodart isn't even indicated for male-pattern hairloss.

The prescribing information on Propecia indicates slightly increased sexual issues relative to placebo (see chart). But, says the PI, "Resolution occurred in men who discontinued therapy with
PROPECIA due to these side effects and in most of those who continued therapy."

Here's the study from "The Journal of Sexual Medicine" (via Wiley.com), and here's an abstract that seems less sensational than the news reports: "Although the adverse side effects of these agents are thought to be minimal, the magnitude of adverse effects on sexual function, gynecomastia, depression, and quality of life remains ill-defined."

The significant update is not the relationship between sexual adverse events, but the longer term impact (after people stop taking the medication). This also is addressed in Proscar's prescribing information (see link), which is finasteride in a 5mg dose to treat prostate.

"Prolonged adverse effects on sexual function such as erectile dysfunction and diminished libido are reported by a subset of men, raising the possibility of a causal relationship."

There's a guy who has devoted a website to this issue, and it's the first Google result if you search Propecia side effects: http://www.propeciasideeffects.com/

Bottom line: every approved drug has benefits that the FDA concludes (at launch) outweigh the risks (or they wouldn't approve it). Some guys care deeply about hair, and are willing to take a chance on the possibility of sexual side effects... which seems rare but possible.

So it's a personal decision of risk versus reward. Hopefully people realize that no hairloss medication radically grows back hair... Rogaine, Propecia and some of the lotions/potions can help hair grow slightly and maybe thicker. However a significant change in appearance is, today, only possible through a hair transplant (in my informed opinion).

Since hair transplant surgeons encourage using Propecia to preserve the patient's hair after a transplant (and it may even help the newly transplanted hair), this will be the group of physicians to watch. If they start shying away from the medications it will be an important cue.

That said, a hair transplant surgeon is not without bias... some sell Propecia and rely on it to cultivate longer term relationships with patients. And then there's this age-old debate: a patient losing more hair is a potential repeat customer. On the other hand, a transplant recipient untreated with Propecia may continue to lose hair. That could look silly: a fortified "front line" and continued male-pattern hairloss behind it) and reflect poorly on the physician. Dr. Rassman has some strong opinions on these matters, and is usually quick to play "devil's advocate" on his "Balding Blog."

Note that while I once marketed Propecia, I'm far from a medical professional... and have no dealings with Merck. These are just my observations reading the same information you can find online.

Greg Benson, the follicularly challenged brains behind MediocreFilms, has selected Earth's best hair-transplant doctor to update his Bosley transplant (see video). With more than 13,000 live viewers via the Internet, this would indeed make hair-transplant history.

Dr. Alan Bauman, who you may know as SurgeonOfNalts, did the work... and now it's a race to the finish. Will Nalts (me), the YouTube personality who once pitched Propecia, have the best hairline of 2010? Or will Greg? In a great moment of irony, Benson's sporting the old Propecia mirrors. Ah, the days that we pharmaceutical firms could give out tissue boxes, pens and mirrors. Those were the days.



Benson made me proud when he, like perhaps every male transplant candidate, made the obligatory joke when one of Bauman's peeps warned him about the loud, wet and cold cleansing-wash machine. It's funny because it's predictable, like his inclination to yell "bye MiniMi" before he runs over midgets.

Nearly 3500 new follicles (which represent a few hairs each) may be a record for a minimally invasive (no surgical slice) transplant. Dr. B uses a NeoGraft to do follicular unit extraction (FUE). Cutting edge that's so cutting edge, it doesn't require a cutting edge. Here's a photo of Benson, with wife Kim Evey (producer of TheGuild and star of Gorgeous Tiny Chicken Machine Show).



Go, Greg. As YouTube funnyman Mark Day exposed, there are some side effects as I well know. Here's some footage I just found that someone took of my live Internet broadcast during treatment, and here's my summary video called "Hair Transplant Fun."

Also worth watching are the educational videos we both did. Here's my conversation with Bauman (which summarizes the steps in 5 minutes), and here's Benson/Bauman talking about the entire procedure. Benson said he slept like a baby after his transplant, which is not what he experienced years before with the traditional surgery from Bosley. In a sequel to Alan's interview, the duo speak about how even a year ago this 3K plus process wouldn't have been possible, and about the recovery phase. After 6 months, you don't notice much, but by 10-12 months you'll see 90%.

Benson and I spoke recently, and are just gaga over this experience. In my Merck/Propecia capacity, I had lots of insights on the best hair-transplant surgeons. When I asked people who they'd chose, Bauman's name came up constantly. We both know why.

Benson did it for his acting career, and I did it because 3 years working on a medication that treats hairloss will make you somewhat self conscious.

With all of this buzz, one can only hope that hair-transplants don't need to be secrets. Some of the film and television actors and actresses you love have had these procedures, but you wouldn't know it. Why?

1. They don't talk about it because they feel it would hurt their image.


2. The doctors can't reference their celebrity patients... unless they're weblebrities who chose to take themselves a bit less seriously.

The Baltimore Sun did a piece Friday about hair loss and remedies, and ended with a nice quote:

Aside from the psychological implications, pattern hair loss has no negative health consequences. What you choose to do about it -- which may be absolutely nothing -- is a personal decision, best made after talking over the options with a dermatologist, family, and maybe some fairly objective friends.

The piece outlines the two FDA-approved remedies (Propecia and Rogaine), and offers some information about transplants. There's also some tips in regards to being "gentle" on hair, but I'm not sure I've seen enough reliable information about hairloss caused by scratching or towel drying. I think this is overstated because it's when we notice hair falling out.

I never paid much attention to the Dutasteride (Avodart) vs. Finasteride (Propecia) when I worked on Propecia. Avodart isn't approved by the FDA for hairloss treatment. But I do remember the conferences where some physician always seemed to have an agenda to prove Dutasteride was better (I assumed they were part of the Avodart studies, or trying to get selected as paid "thought leaders" by GSK, which markets Avodart).

Turns out there was a study on it, but I don't know much more than I've read here.

Seems .1 mg of dutasteride had similar hair improvement at 24 weeks to finasteride 5 mg. But I'm kinda perplexed as why they didn't use finasteride 1 mg (which is the dosage of Propecia) and why they jacked up the dutasteride in one group to friggin' 2.5 mg, which gave 9 of the poor study participants a lowered libido.

Why study the extreme, when most of the hairloss benefits (and lower side effects) is realized at lower dosages? The incremental benefit in hair growth (or reduced loss) seems to be offset by the side effects... of either drug. So I'm glad I'm taking Propecia not Proscar (5 mg).

That said, it would appear that too much of these medications can drop your libido, which is always something I thought preciously was overstated. But this generally resolves after you stop (and many side effects of pharma drugs resolve after your body adjusts to it).

The thing about sexual side effects is that if you're told you'll get them, your odds of getting them increase significantly. It shows the power of expectations. Remember that, in early clinical trials, Propecia saw one group of men who dropped treatment more often, citing adverse reactions. That group, it turns out, was the one taking the placebo (sugar pill). See the Propecia Q&A for more information. It took me months, but I finally promoted that little-known fact from its hiding-place in the PI (prescribing information) to the Q&A... because I found it charmingly interesting. Of course now I can't find it, but here's the Q&A.

Propecia, my former brand, is indeed one of the most counterfeited medications... perhaps rivaled only by the erectile dysfunction drugs. Via a recent post by TheBaldingBlog, here's a dated by interesting article by UKMedix that reveals the scam. Why does it work?

• It takes months before the effect (or lack of effect takes place), so that's plenty of time to cash in.
• Some men to feel embarrassed to go to a doctor to speak about their hair loss.

The article estimates that thousands of men around the world have stopped using Propecia believing that it doesn’t work for them... when in fact if they had used a real version of Propecia (made by Merck) they would have experienced good results and possibly hair regrowth.

Here's a discussion on HairlossTalk (a forum) with more information about counterfeit Propecia. Even better, check out this FDA warning on fake pharmaceuticals.

Now that I've watched a few hair loss videos, YouTube is constantly serving me more as a recommendation. Today I ran into this classic by Spencer Kobren (I was on his radio show last night). This is a fun game...



Look at this picture (or see it in the video) and tell me if you're impressed with the results. Before and after. Then watch the video, and you'll be amazed by the secret behind it.

I never cared much for before/after photos to promote Propecia, because the non-regulated drugs can pull these tricks, and Propecia couldn't. Instead I liked Terry and Perry's video in the bottom, left quadrant of this page (twins with one who took Propecia and one who didn't).

I'm always amazed by the myths of hairloss. Wear a hat, lose your hair? Please. Hair loss comes from the mother's side? Nope. Hair loss is inevitable? Not true.

Here's a site I inherited while at Merck, and it has some nice myths and facts. Probably my favorite regulatory/legal meeting ever was when an attorney asked for citation on a myth. How do you cite a myth?

Stress can cause hairloss, but it's not the same as male-pattern hairloss. It would typically be in patches in odd places, and that's also caused by other medical issues. Typically hair loss is simply genetics (from mom or dad's side) and treatable... with medication. There are a bunch of causes of hairloss, but if it's slow and progressive, it's usually genetically caused "male pattern hair loss." I haven't been wildly convinced of the efficacy of shampoos or products beyond minoxidil or finasteride. But maybe others have had better experiences with Nioxin or other lotions/potions. Some vouch for laser therapy, and that seems to be one of the few interesting innovations in an otherwise quiet marketplace.

Hats don't cause hairloss. Neither does rubbing the head. The hair follicles just die over time.

Best comment from a guy in our research:

"My mama said to use cayenne pepper on my head. It turned it red." Cayenne pepper might improve some blood flow, but I think mama got the last laugh.

Hi. I'm Kevin "Nalts" Nalty (one of the most-viewed people on YouTube, with 90 million views on 800 plus videos). I run a blog called WillVideoForFood.com, but I'm taking this hairloss information here because the content is so different.

I'm setting up this interim blog to document my hair transplant next week, and the experience before/during/after. If you discover this early enough, you can watch it yourself: Monday, Aug. 17, 2009... it's being done in Boca Raton, Florida by a leading physician in the field. If you'd like to watch part of it live, Alan (fallofautumndistro) will be MCing a 30-minute session from 12:30-1:00 at this blogv.com location. I'm writing my book about online-video marketing (likely publishing with Wiley) and Alan has written "YouTube: An Insider's Guide to Climbing the Chart." More importantly, Alan is savvy with the whole live-broadcast thing, and it intimidates me (unlike getting a hair transplant live for the world).

If anything changes regarding timing, look for this post, or check Twitter for updates.

Are you serious, dude? You're always pranking, so I don't know if this is real.

Yes! It's real. I broadcasted my anaphylactic fit via online video, and my doctor's visit when I thought I was pregnant (turns out, thanks to a comment from a viewer on this video, I discovered I really needed a spinal fusion. It's not a HIPAA violation if the when the patient consents, silly. So why not share a hair transplant with the world?

Which one are you? Vain or insecure?

A lot of people feel like treating hair loss (via Propecia, Rogaine, lotions & potions, or hair transplantation) is a sign of insecurity or vanity. Often they'll say "you don't need to treat your hair loss... you look fine the way you are." But that's little consolation to someone bothered by hair loss. In a recent online survey conducted by the International Society of Hair Restoration Surgery (ISHRS), 59.8 percent of people who were asked whether they would rather have more hair, more money or more friends chose more hair. By comparison, only 26.2 percent of respondents chose more money and 13.9 percent said they would rather have more friends! My research revealed that many guys would give up most of their favorite electronics for it.

Does this have anything to do with your former role as Propecia's Marketing Director?

Nope. This is completely unrelated to Merck. Not Merck sponsored, not compensated by Merck, not Merck reviewed, and not designed to annoy Merck. But darnit, it's the first time in 3 years I can talk freely about hairloss without worrying about attorneys or the FDA! Weeeeee. As a Propecia Marketing Director (a role I left this summer to pursue online-video marketing full time) I did learn a lot about hair loss, and met some of the best hair-transplant physicians in the country. One caught my interest. He's Dr. Alan Bauman (www.baumanmedical.com) and has his own YouTube channel, where he showcases his regular media appearances on NBC, ABC and CBS. I approached him because he came well recommended by colleagues at Merck, and I felt an instant rapport. He reminds me of Doogie Howser (Neil Patrick Harris). Other hair-transplant physicians turn me off because they're clearly in it for the money and gave me willies. Dr. Bauman is not paying me to promote this experience, but generously offered me a transplant for less than he normally charges. Had he not been interested, I might have approached Dr. William Rassman, who runs a really nice blog about hairloss, but I didn't know him as well. More likely, I'd rationalize my concern into submission. Hair Club for Men and Bosley are better known hair-transplant "brands," but I trust and like Bauman.

By getting a hair transplant, are you implying Propecia doesn't work?

Nope. Propecia worked for me, both helping me grow hair on my crown (top/vertex) and slow down hair-loss progression (see Norwood Hamilton scale for typical male-pattern hair loss progression). I believe I also grew some hair on my forehead, even though it's not "indicated" for that. If you're concerned about hair loss you really need to take Propecia before you start losing hair (talk to your doctor first, blah, blah, blah). So hopefully some of my video viewers who are 20 will learn the easy way. I would look dramatically different, I believe, had I started in my mid 20s or 30s and kept taking Propecia daily. Check out "Terry and Perry," identical twins from the Propecia television ads you may recall years ago (see video window at this page on Propecia.com). It's worth noting that Propecia's best advocates are, it might surprise you, hair transplant physicians. They typically urge their patients to treat with Propecia to help the new hairs and prevent additional hairloss (which would looks silly, since the donor hairs from the back of the head will otherwise outlive the forehead). A good hair-transplant physician helps the patient understand what to expect while taking Propecia, and how important it is not to stop. I tried Rogaine for a few months, but it made my hair sticky and rubbing it on my scalp was always a depressing reminder of my baldin head. I may go back on Rogaine after the transplant.

What? You want plugs?

Common reaction. Because we've all seen "hair plugs" that look like a doll, most people think that today's hair transplants are ridiculous looking. News flash. Plugs are the ancient method, and now individual hair follicles are extracted from the back of the head and placed individually on the forehead or other site (I'm getting an FUE- more on that later). So the people who have had recent hair transplants are invisible to you. A YouTube friend asked me if I'd know if I saw someone with a hair transplant, and I said no. He smiled and pointed to his head. And the actors, newscasters, athletes on television and film? It's a small industry... I know who they are, and I wish they'd just acknowledge it!

Why are you getting a hair transplant?

I have two agendas. First, duh, I would like to have hair and look younger. My brother (7 years older and 20 years wiser) has an xtreme receding hairline. But he's a priest dwelling higher on Maslow's Heirchy of Needs than I. Second, I'm hoping to help break the taboo around treating hairloss. My research while at Merck of men with "male pattern hair loss" (MPHL) gave me a deep appreciation for how a portion of the 40-million MPHL men are deeply bothered by hair loss. No kidding- some people see hair as their identity, and are very depressed losing it. The national hair loss society (ISHRS) has some nice statistics on hair loss transplantation (nearly 100K people had one in the US in 2008). But here's the amazing thing. I knew of many celebrities that have had transplants but don't discuss it. Now that's vanity.

Why is it okay for guys to talk about "erectile dysfunction" bot not hair loss?

That's a question that confounded me during my 3 years marketing Propecia. Pfizer and Bob Dole used big bucks and TV to create ED as a socially acceptable condition, but I also think people are okay "admitting" they're treating ED because it's code for "I'm still getting some action." But mention treating your hair loss and you're either vain or insecure. The cause of a flaccid wiener could be medical or psychological, but there's no disputing that hair loss is genetic (not caused by wearing hats, butthead) and can be medically treated.

So this is a public service effort?

Of course that's not my only goal. I wear the old "Nalts" hat because I'm bothered by my Burt-like forehead, and I wouldn't get a hair transplant just for fun or as a cause-marketing alone. But I do hope by treating my hairloss in public I might do -- albeit on a smaller scale (social media not television) -- what Bob Dole did for erectile dysfunction (ED). It became okay to treat, and I believe hair loss should be the same. It always confounded me that a celebrity wouldn't boast proudly about a hair transplant like many do when they treat with Botox. Are they afraid of ridicule?

Are bald people losers?

While it's true that society has a stigma about balding men (look no further than your choice of television or film), I have a lot of respect for people who age with dignity. They focus inward and don't worry about their appearance. "God made so many perfect heads, and the rest he covered with hair." In my marketing Propecia, I was very careful not to suggest people should be concerned about hair loss. Rather, IF YOU ALREADY ARE, then you shouldn't be embarrassed or afraid to treat it... right? I expect a lot of comments on my videos from men who are balding, and feel like me promoting treatment is an insult to their being "one with baldness." To each his own.

What does your wife think about this?

Oprah got a standing ovation on her show when she said "I'd love my man the way he is." That's admirable. But so is being supportive when a spouse wants to take reasonable means to improve his or her health or appearance. Jo (wifeofnalts) would never urge me to treat hairloss, and like many spouses felt obliged to "talk me out of it." I'd probably do the same thing if she considered plastic surgery, botox or a boob job. It would be my way of telling her (and I'm sincere on this) that her outward appearance is not as important to me as her inner happiness. But if it made her happy I would support it.

Dude- this is unnatural. Are you mental?

There was a part of me that considered how odd it is to combat the natural progression of aging. And when I saw Joan Rivers on her recent "Roast" or Michael Jackson's face in recent tributes, I was reminded how sad it is when people fight aging so hard they look unnatural and frightening. Anything in moderation. If you see me looking like Dick Clark in 30 years then I've gone off the deep end. In the meanwhile, however, hair loss is a pain. It's a sad but true reality (as evidenced in research you're welcome to Google) that people with hair are more likely to get a job, make friends, be a leader, and the list goes on. That's not something that will soon change.

How much does a hair transplant cost?

I probably would have gotten a hair transplant years ago, but when you're in debt and not saving enough for the kids' college, it doesn't seem fair to shell out $5,000-$20,000 for myself. Hair transplant prices vary, but ultimately the profession price competes on a "per graft" (unique hair) charge. Rassman (who wrote "Hairloss and Replacement for Dummies,") quotes $3,000-$10,000. It's not for everyone, and I certainly wouldn't shop by price. Many men get multiple transplants over time.


What's next?

This blog is an interim one. I'll post about the journey... answer questions. Try to keep from annoying those regular viewers and readers who don't give a hoot about hair. And hopefully reach, via this blog, some new people who do.