Hormone Replacement and Hair Loss - BaumanAJ a4m 2012

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Androgenetic Alopecia or hereditary hair loss, considered by many as an outward and undesirable sign of premature aging that can be ‘seen from across the room,’ currently affects an estimated 50 Million men and 30 Million women in the U.S. Approximately 40% of men in their 40’s are experiencing hair loss and 50% of men in their 50’s with over a billion dollars spent in the U.S. annually on medical treatments, hair transplants, non-medical ‘cures’ and cover-ups to address the condition.
Hormone replacement therapy (HRT) that includes androgens/testosterone may accelerate the progression of unwanted androgenetic alopecia, especially in those patients whose hair follicles are highly androgen sensitive.

OBJECTIVE: Patients who undergo testosterone replacement may be at risk for hair loss related side effects. It is our goal to present an overview of the mechanisms of Androgenetic Alopecia, new diagnostic and monitoring methods, prevention/treatments options and management stratagems specifically for patients who are undergoing an Hormone replacement therapy regimen that includes testosterone.

MATERIALS/METHODS:
Chief Complaint & Goals
Medical History
Family history
Medical Conditions
Medications
Surgical History
Hair/Scalp Care
Lab Testing / Measurements
Genetic Testing
Cross Sectional Bundle Trichometry Measurements with Hair Check(TM)
Photography
Standardized Global Photos
Scalp Microscopic Photos
Treatment Plan
Recommended Tracking & Follow-Up Schedule

DISCUSSION
Identifying patients at risk for hereditary hair loss as well as being able to offer guidance and treatment options holds significant benefit for the Age Management (Anti-Aging) Physician and their Hormone Replacement patients because it:
1) enhances the risk/benefit discussion with the testosterone patient.
2) Identifies and addresses a possible side-effect and potential barrier to HRT compliance.
3) Adds a beneficial service to the Age Management Physician’s repertoire that may enhance patient retention and compliance.
4) Successful hair loss management adds a psychological boost to a Androgen Replacement patient’s outlook.
References:

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Hormone Replacement and Hair Loss - BaumanAJ a4m 2012

  1. 1. Male Hair Loss &Hormone ReplacementStratagems for Managing Androgenetic Alopecia During Androgen Replacement Therapy Alan J. Bauman, M.D. American Academy of Anti-Aging Medicine 20th World Congress on Anti-Aging and Regenerative Medicine Las Vegas - December 2012 © 2012 Alan J. Bauman, M.D. All Rights Rese
  2. 2. Disclosures• The following conflicts of interest are germane to my presentation: None• The use of off-label treatments will be © 2012 Alan J. Bauman, M.D. All Rights Reserved. discussed.
  3. 3. “It’s better to look good than to feel good.” © 2012 Alan J. Bauman, M.D. All Rights Reserved. --Fernando Lamas (via Billy Crystal)
  4. 4. Learning ObjectivesParticipants will be able to... • remove a major compliance barrier for male androgen replacement therapy. • ethically prepare androgen replacement patients for a very common side effect. • understand the basic methods of medical © 2012 Alan J. Bauman, M.D. All Rights Reserved. hair loss evaluations, treatment and tracking. • help male anti-aging patients achieve their best possible results physiologically, aesthetically and psychologically.
  5. 5. Overview• background/bio• androgen replacement• androgenetic alopecia © 2012 Alan J. Bauman, M.D. All Rights Reserved.• stratagems for treatment & tracking
  6. 6. Alan J. Bauman, M.D. • M.D. - New York Medical College • Surgery - Mt Sinai Medical Ctr & Beth Israel Medical Ctr NY • Hair Transplant Fellowship - Eastwood Medical, NY • American & International Board of Hair Restoration Surgery • American Academy of Anti-Aging Medicine • International Society of Hair Restoration Surgery • American Academy of Cosmetic Surgery • © 2012 Alan J. Bauman, M.D. All Rights Reserved. Bauman Medical Group - 15,000 hair loss patients since 1997 • 1000 hair loss patients/yr ~250 hair transplants/yr • 50:50 male/female; 4-94 y/o; ave 45 • multi-therapy approach: diagnosis, treatments & tracking
  7. 7. tug o‟ war?© 2012 Alan J. Bauman, M.D. All Rights Reserved.
  8. 8. “Have it ALL..?” Can our patients© 2012 Alan J. Bauman, M.D. All Rights Reserved.
  9. 9. Testosterone & Age• fetal sexual dev‟mt Text• pubertal dev‟mt & growth © 2012 Alan J. Bauman, M.D. All Rights Reserved.• adult vitality Plasma testosterone levels through the male lifecycle. From Ewing, Int Rev Physiol., 1980.
  10. 10. Function Testosterone© 2012 Alan J. Bauman, M.D. All Rights Reserved.
  11. 11. Androgens - Reproductive Functions• spermatogenesis• maintenance of secondary sex characteristics (facial hair growth, larynx enlargement, vocal chord growth) © 2012 Alan J. Bauman, M.D. All Rights Reserved.• functional competence of accessory sex organs (seminal vesicles, prostate)• libido
  12. 12. Adult Testosterone Decline• decreased libido and/or sexual performance• infertility• fewer spontaneous erections• insomnia, sleep disturbances• increased body fat• reduced muscle bulk, © 2012 Alan J. Bauman, M.D. All Rights Reserved. strength• gynecomastia• hot flashes• less energy, concentration• decreased motivation • links to metabolic syndrome / diabetes• (Gould 2007, Makhsida 2005, Svartberg 2006) decreased self-confidence
  13. 13. Testosterone ReplacementBenefits reproductive function muscle strength, erythropoiesis, bone strength, energy © 2012 Alan J. Bauman, M.D. All Rights Reserved. bone strength, epiphyseal closure libido quality of life Mechanisms of action of testosterone, tissues affected by testosterone, and potential effects of testosterone replacement therapy. From Snyder, N Engl J Med., 2004.
  14. 14. Testosterone ReplacementRisks erythrocytosis sleep apnea prostate(?) hair loss © 2012 Alan J. Bauman, M.D. All Rights Reserved. Mechanisms of action of testosterone, tissues affected by testosterone, and potential effects of testosterone replacement therapy. From Snyder, N Engl J Med., 2004.
  15. 15. © 2012 Alan J. Bauman, M.D. All Rights Reserved.
  16. 16. Testosterone ➔Dihydrotestosterone via 5α-Reductase © 2012 Alan J. Bauman, M.D. All Rights Reserved.
  17. 17. Androgen Hair Effects Stimulate growth of chest, axillary, facial hair Androgenetic Alopecia (due to DHT) • temporal recession, crown thinning • © 2012 Alan J. Bauman, M.D. All Rights Reserved. baldness
  18. 18. “end organ” DHT© 2012 Alan J. Bauman, M.D. All Rights Reserved.
  19. 19. DHT is the primary trigger for androgenetic alopecia © 2012 Alan J. Bauman, M.D. All Rights Reserved. smaller, thinner, wispier, less pigmented hair decreased time in anagen (growth)increased time in catagen/telogen (resting)
  20. 20. Testosterone & Hair © 2012 Alan J. Bauman, M.D. All Rights Reserved. What are your patients‟ goals?
  21. 21. Why is hair important? Self-image Self-esteem Body-image satisfaction Well-being moderate stress/distress © 2012 Alan J. Bauman, M.D. All Rights Reserved. coping mechanisms “Look as good as you feel”Cash, T.F. (2001). The psychology of hair loss and its implications for patient care. Clinics in Dermatology, 19(2), 161-166.Cash, T.F., & Pruzinsky, T. (1996). The psychosocial effects of androgenic alopecia and their implications for patientcare. In D.B. Stough & R.S. Haber (Eds.), Hair Replacement: Surgical and Medical (pp. 1-8). St. Louis: Mosby.
  22. 22. Hair & Age “Aged? But he does not appear aged, just look, his hair has remained young!” © 2012 Alan J. Bauman, M.D. All Rights Reserved. --Marcel Proust In Search of Lost Time (1913- 1927)Trüeb RM. Aging of hair. J Cosmet Dermatol. 2005 Jun;4(2):60-72.
  23. 23. Androgenic AlopeciaHereditary Male Pattern Hair Loss © 2012 Alan J. Bauman, M.D. All Rights Reserved.
  24. 24. Androgenetic Alopecia• Incidence 20% men in their 20s• 38% men in their 30s• 45% men in their 40s• © 2012 Alan J. Bauman, M.D. All Rights Reserved. 50% men in their 50s• 65% men in their 60s• 70% men in their 80s
  25. 25. peripheral tissue metabolism © 2012 Alan J. Bauman, M.D. All Rights Reserved.Exogenous testosterone will convert toDHT
  26. 26. DHT-mediated Miniaturization ➧ © 2012 Alan J. Bauman, M.D. All Rights Reserved.Decreased Hair Density, Caliber & Length results in loss of
  27. 27. “Crown Balding”© 2012 Alan J. Bauman, M.D. All Rights Reserved.
  28. 28. Patient Goalsmaintain benefits of testosteronereplacement: libido, energy level, lean muscle mass, © 2012 Alan J. Bauman, M.D. All Rights Reserved.etc.reduce undesired consequences: male pattern hair loss
  29. 29. Side-Effects• Patients with unexpected or unwanted side effects are more likely to discontinue treatment.• Hair loss can be a reason patients may © 2012 Alan J. Bauman, M.D. All Rights Reserved. choose to discontinue testosterone replacement.
  30. 30. What is the answer? • Patient Education • Risk Assessment • Treatment Options • Tracking • Follow-up © 2012 Alan J. Bauman, M.D. All Rights Reserved.
  31. 31. Stratagems for Hair Loss Preventionduring Androgen Replacementeliminate/reduce triggers • medical conditions, meds, social habits, stress, etc.block androgen effects: 5αR inhibition • finasteride, dutasteride, herbal © 2012 Alan J. Bauman, M.D. All Rights Reserved.stimulate hair follicles • minoxidil, bimatoprost, low level laser therapy, PRP (platelet rich plasma)redistribute (transplant) permanent follicles • no scalpel/no-stitch harvesting w/ NeoGraft FUE
  32. 32. Hair Loss Risk Assessment• Family History (mother‟s or father‟s side)• Signs of hair loss (hairline/temple © 2012 Alan J. Bauman, M.D. All Rights Reserved. recession, thinning crown, etc.)• Dermoscopy (miniaturization)• Genetic Testing (androgen sensitivity)
  33. 33. Untreated Male Pattern Hair Loss75% of patients withuntreated MPHL get„much worse‟ in five © 2012 Alan J. Bauman, M.D. All Rights Reserved.years. Kaufman KD et.al., Eur J Dermatol 2002, 12:38-49.
  34. 34. Androgen MetabolismTestosterone ➔ Dihydrotestosterone5-alpha-reductase • high activity in the skin, prostate, seminal vesicles, epididymis, liver. © 2012 Alan J. Bauman, M.D. All Rights Reserved. (end organs) • produced in testes, secreted
  35. 35. 5-αR inhibitors Testosterone ⇏ Dihydrotestosterone • Finasteride - 1mg/day • FDA-approved • increases hair counts • stops the loss • reverses miniaturization © 2012 Alan J. Bauman, M.D. All Rights Reserved.Kaufman, et. al. Finasteride in the treatment of men with androgenetic alopecia. Finasteride Male Pattern Hair Loss Study Group. J Am Acad Dermatol. 1998 Oct;39(4 Pt 1):578 89.
  36. 36. Finasteride & 5αR• Competitive, specific, preferential inhibitor of Type II 5α- reductase.• Two isozymes (Type I and Type II)• Type I - sebaceous glands of skin and scalp, liver. Responsible for 1/3 of circulating DHT• Type II - prostate, seminal vesicles, epididymus, hair © 2012 Alan J. Bauman, M.D. All Rights Reserved. follicles, liver. Responsible for 2/3 circulating DHT.• finasteride has a 100-fold selectivity for Type II over Type I, blocking resulting in significant decrease in serum and tissue DHT concentrations.
  37. 37. Finasteride Facts• no affinity for androgen receptor• no androgenic, antiandrogenic, estrogenic, antiestrogentic, progestational effects.• no changes to LH, FSH, prolactin• no effect on the hypothalamic-pituitary-testicular axis• © 2012 Alan J. Bauman, M.D. All Rights Reserved. no effect on circulating cortisol, thyroid-stimulating hormone, thyroxine• no effect on plasma lipid profile• no effect on bone mineral density http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/020788s018lbl.pdf (Accessed
  38. 38. Finasteride Results © 2012 Alan J. Bauman, M.D. All Rights Reserved.• Kaufman, et. al. Finasteride in the treatment of men with androgenetic alopecia. Finasteride Male Pattern Hair Loss Study Group. J Am Acad Dermatol. 1998 Oct;39(4 Pt 1):578-89.
  39. 39. Finasteride Results “yes it can”• before and after 10 months on finasteride © 2012 Alan J. Bauman, M.D. All Rights Reserved. *Results NOT typical!
  40. 40. Finasteride Concerns • Propecia $477M (2011), Proscar $223M (2011) • Sexual side effects: • 3.8% of 945 ♂ on Propecia vs. 2.1% of 934 ♂ on placebo • “Reversible” vs. “Persistent” side effects • FDA request label changes based on 421 post- © 2012 Alan J. Bauman, M.D. All Rights Reserved. marketing reports, 59 cases of sexual dysfunction > 3mos after stopping medication. • “Clear and causal link” between finasteride and sexual adverse events “have NOT been established.” --FDAhttp://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm299754.htm (Accessed 12/1/2012)
  41. 41. Finasteride Concerns “Persistent Sexual Side-Effects” - M. Irwig • n=71, 18-40 y/o c/o side effects >3mos after d/c‟g finasteride, retrospective study • Recruited via word-of-mouth or propeciahelp.com (where „guidelines‟ for answering questions were posted) • phone or skype survey, no bloodwork, no physical exams performed • 17 of 92 of initial respondents excluded due to baseline sexual dysfunction, psych disorders or psych medications, systemic prescription medications. © 2012 Alan J. Bauman, M.D. All Rights Reserved. • 4 of 75 excluded b/c scores on Arizona Sexual Experience Scale didn‟t meet criteria for sexual dysfunction. • M. Irwig rec‟d compensation from class-action lawsuit attorneys* • Irwig “Limitations include post-hoc approach, selection bias, recall bias, no serum hormone levels.” * Elizabeth Cohen, CNN, July 13th, 2012 [**12:49:29 PM ET**]Irwig MS, Kolukula S. Persistend Sexual Side Effects of Finasteride for Male Pattern Hair Loss, J Sex Med. 2011 Jun;8(6):1747-53. doi: 10.1111/j.1743- 6109.2011.02255.x
  42. 42. Finasteride Risks Common Side Effects • decrease in serum Prostate Specific Antigen (PSA) • decreased libido © 2012 Alan J. Bauman, M.D. All Rights Reserved. • difficulty maintaining erection • decreased ejaculate volumehttp://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm299754.htm (Accessed 12/1/2012)
  43. 43. Finasteride Risks Other Reported Side Effects • breast tenderness, gynecomastia • depression • decreased libido after stopping the medication • allergic reactions: rash, itching, hives, swelling of lips and face • © 2012 Alan J. Bauman, M.D. All Rights Reserved. testicular pain • difficulty maintaining erection after stopping the medication • male infertilityhttp://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm299754.htm (Accessed 12/1/2012)
  44. 44. Other options… Dutasteride Suppression of Serum DHT: Dutasteride 0.5mg vs. Finasteride 5.0 mg vs. placebo • 5-αR type I & II inhibitor • faster onset than finasteride • greater decrease in DHT • side effects similar to © 2012 Alan J. Bauman, M.D. All Rights Reserved. finasteride, slightly higher% • longer 1/2-lifeClark RV, et.al. Marked suppression of dihydrotestosterone in men with benign prostatic hyperplasia by dutasteride, a dual 5alpha-reductase inhibitor. J Clin Endocrinol Metab. 2004 May;89(5):2179-84.
  45. 45. Dutasteride Finasteride 5.0 mg © 2012 Alan J. Bauman, M.D. All Rights Reserved.RV Clark, et. al. Marked Suppression of DHT in Men with Benign Prostatic Hyperplasia byDutasteride, a Dual 5-aR Inhibitor, Journal of Clinical Endocrinology & Metabolism May 1, 2004 vol89, no 5, 2179-2184.
  46. 46. Strategems for Hair Loss Preventionduring Androgen Replacement• eliminate/reduce triggers medical conditions, meds, social habits, stress, etc.• block androgen effects: 5α-R inhibition © 2012 Alan J. Bauman, M.D. All Rights Reserved. finasteride, dutasteride, herbal• stimulate hair follicles minoxidil, bimatoprost, laser therapy, PRP (platelet rich plasma)• redistribute (transplant) permanent follicles no scalpel/no-stitch harvesting w/ NeoGraft FUE
  47. 47. Compounded Formula 82M Minoxidil Less greasy, dries fast, less dermatitis Synergistic Components: • retinoic acid • oleanolic acid (anti- © 2012 Alan J. Bauman, M.D. All Rights Reserved. androgen) • fluocinolone 0.01% • minoxidil 5% • propylene glycol-free Formula 82M is compounded by MasterPharm Compounding Pharmacy, NY under a license from Hair Science, LLC.http://www.scribd.com/doc/109423398/Bauman-Medical-Formula-82M-Minoxidil-v-100512-AJBauman
  48. 48. Formula 82M minoxidil • mild to moderate39 y/o ♂ before & after 6 mos androgenetic alopecia • 15 drops (1ml) © 2012 Alan J. Bauman, M.D. All Rights Reserved. to the scalp twice daily28 y/o ♂ before & after 6 mos http://www.scribd.com/doc/109423398/Bauman-Medical-Formula-82M-Minoxidil-v-100512-AJBaum
  49. 49. Other Topicals• Bimatoprost (Latisse)• Prostaglandin Analog• FDA-app‟d for eyelash growth (2008)• lengthening, darkening, © 2012 Alan J. Bauman, M.D. All Rights Reserved. thickening• Allergan Phase II trials on hair growth... pending. Bauman Patient, before and 6 months after use of Latisse/bimatoprost QD on the lids for eyelash hair growth http://clinicaltrials.gov/show/NCT01325337 Safety and Efficacy Study of Bimatoprost in the Treatment of Men With Androgenic Alopecia
  50. 50. Low Level Laser Therapy growth factor production extracellular matrix deposition cell proliferation & motility anti-apoptosis and pro-survival• Cytochrome-C- Oxidase• ATP production Gene Transcription• non-ionizing• non-thermal• non-mutagenic © 2012 Alan J. Bauman, M.D. All Rights Reserved.• no side-effects Illustration Credit: M Hamblin PhD, Wellman Center for Photomedicine, Harvard/MIT, Massachusetts General Hospital. http://www.slideshare.net/DrBauman/mechanisms-of-llltantiaginghamblina4morlando2011
  51. 51. LaserCapLow Level Laser Therapy • 650 nm • 5mW x 224 diodes • 80% duty cycle • 30 min. qod • hands-free • rechargeable © 2012 Alan J. Bauman, M.D. All Rights Reserved. • cordless • ~600 cm2 coverage • high compliance www.lasercap.info
  52. 52. Male LLLT Results © 2012 Alan J. Bauman, M.D. All Rights Reserved.43 y/o ♂ before & after 6 mos 25 y/o ♂ before & after 6 mos Bauman patients before and after low level laser therapy (LLLT)
  53. 53. Strategems for Hair Loss Prevention during Androgen Replacement• eliminate/reduce triggers • medical conditions, meds, social habits, stress, etc.• block androgen effects: 5α-r inhibition © 2012 Alan J. Bauman, M.D. All Rights Reserved. • finasteride, dutasteride, herbal• stimulate hair follicles • minoxidil, bimatoprost, laser therapy, PRP (platelet rich plasma)• redistribute (transplant) permanent follicles • no scalpel/no-stitch harvesting w/ NeoGraft “FUE”
  54. 54. Hair Transplantation• NeoGraft „FUE‟ = Follicular Unit Extraction• minimally-invasive donor harvesting• no strip removal © 2012 Alan J. Bauman, M.D. All Rights Reserved.• redistribute permanent donor follicles into thinning/balding areas
  55. 55. Hair TransplantationDonor Area © 2012 Alan J. Bauman, M.D. All Rights Reserved. Recipient Area Bauman Patients before and after NeoGraft FUE hair transplant procedures
  56. 56. Hair Growth Tracking• HairCheck™ aka “Cross-Section Bundle Trichometry”• Hair Mass Index (HMI)• Combined measurement of hair caliber and density• Fast, accurate, repeatable © 2012 Alan J. Bauman, M.D. All Rights Reserved.• Diagnosis and Results-Tracking• HMI is measured every 90 daysAJ Bauman, “The use of Cross-Section Bundle Trichometry in the Medical Management of Androgenetic Alopecia,” ISHRS 20th Annual Scientific Meeting, Nassau Bahamas, October 2012
  57. 57. Find the balance© 2012 Alan J. Bauman, M.D. All Rights Reserved.
  58. 58. Conclusion• Candidly & confidently discuss hair loss with your androgen-replacement patients.• Present treatment options to patients.• Continue to educate yourself on the © 2012 Alan J. Bauman, M.D. All Rights Reserved. new methods of prevention and treatment.• Refer or ask for assistance (we‟re here to help via phone, skype or email).
  59. 59. References• National Institutes of Health: National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS): Q&A Alopecia Areata• Al-Mutairi N. (2007): 308-nm Excimer laser for the treatment of alopecia areata. Dermatologic Surgery 33(12):1483-1487.• Avram M.R., Leonard R.T.Jr., Epstein E.S., Williams J.L., Bauman A.J. (2007): The current role of laser/light sources in the treatment of male and female pattern hair loss. Journal of Cosmetic and Laser Therapy 9(1):27-28.• Bernstein E.F. (2005): Hair growth induced by diode laser treatment. Dermatologic Surgery 31(5):584-586.• Chung P.S., Kim Y.C., Chung M.S., Jung S.O., Ree C.K. (2005): The effect of low-power laser on the murine hair growth. Journal of the Korean Society of Plastic & Reconstructive Surgeons.• Satino J.L., Markou M. (2003): Hair regrowth and increased hair tensile strength using the HairMax LaserComb for low-level laser therapy. International Journal of Cosmetic Surgery and Aesthetic Dermatology 5(2):113-117.• Vlachos S.P., Kontoes P.P. (2002): Development of terminal hair following skin lesion treatments with an intense pulsed light source. Aesthetic Plastic Surgery 26(4):303-307. © 2012 Alan J. Bauman, M.D. All Rights Reserved.• Waiz M., Saleh A.S., Hayani R., Jubory S.O. (2006): Use of the pulsed infrared diode laser (904 nm) in the treatment of alopecia areata. Journal of Cosmetic and Laser Therapy 8(1):27-30.• Pontinen, PJ; et.al. Comparative effects of exposure to different light sources (He-Ne laser, InGaAl Diode laser, non-coherent LED) on skin blood flow of the head, Int J Acupuncture & Electro-therapeutics Research 1996 21(105-118). 670nm• Weiss R., McDaniel D.H., Geronemus R.G., Weiss M., LED Photomodulation induced hair growth stimulations, presented at ASLMS Annual Meeting – Orlando FL (April 2005), www.interscience.wiley,.com DOI.1002/lsm.20164.
  60. 60. Thank You! © 2012 Alan J. Bauman, M.D. All Rights Reserved. Alan J. Bauman, M.D. www.baumanmedical.comdoctorb@baumanmedical.co m

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