Hormone Replacement and Hair Loss - BaumanAJ a4m 2012

Male Hair Loss &
Hormone Replacement
Stratagems 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

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.

“It’s better to look
good than to feel
good.”

--Fernando Lamas
(via Billy Crystal)

Learning Objectives
Participants 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

hair loss evaluations, treatment and tracking.
• help male anti-aging patients achieve their
best possible results physiologically,
aesthetically and psychologically.

Overview

• background/bio
• androgen replacement
• androgenetic alopecia

• stratagems for treatment & tracking

• 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

•

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

tug o‟ war?


“Have it ALL..?”
Can our patients


Testosterone & Age

• fetal sexual
dev‟mt Text
• pubertal dev‟mt
& growth

• adult vitality
Plasma testosterone levels through the male lifecycle. From Ewing, Int Rev Physiol., 1980.

Function
Testosterone


Androgens -
Reproductive
Functions
• spermatogenesis
• maintenance of secondary sex
characteristics (facial hair growth,
larynx enlargement, vocal chord
growth)

• functional competence of accessory sex
organs (seminal vesicles, prostate)
• libido

Adult Testosterone Decline
• decreased libido and/or
sexual performance
• infertility
• fewer spontaneous
erections
• insomnia, sleep
disturbances
• increased body fat
• reduced muscle bulk,

strength
• gynecomastia
• hot flashes
• less energy, concentration
• decreased motivation • links to metabolic syndrome /
diabetes
•
(Gould 2007, Makhsida 2005, Svartberg 2006)
decreased self-confidence

Testosterone
Replacement
Benefits
reproductive function
muscle strength,
erythropoiesis, bone
strength, energy

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.

Testosterone
Replacement
Risks
erythrocytosis
sleep apnea
prostate(?)
hair loss

Mechanisms of action of testosterone, tissues affected by testosterone, and potential effects of testosterone replacement therapy. From Snyder, N Engl J Med., 2004.

Testosterone ➔
Dihydrotestosterone
via 5α-Reductase


Androgen Hair
Effects
Stimulate growth of chest, axillary, facial
hair
Androgenetic Alopecia (due to DHT)
• temporal recession, crown thinning
•

baldness

“end organ” DHT


DHT is the primary trigger
for androgenetic alopecia

smaller, thinner, wispier, less pigmented
hair
decreased time in anagen (growth)
increased time in catagen/telogen (resting)

Testosterone & Hair

What are your patients‟ goals?

Why is hair
important?
Self-image
Self-esteem
Body-image satisfaction
Well-being

moderate stress/distress

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 patient
care. In D.B. Stough & R.S. Haber (Eds.), Hair Replacement: Surgical and Medical (pp. 1-8). St. Louis: Mosby.

Hair & Age
“Aged? But he does
not appear aged, just
look, his hair has
remained young!”

--Marcel Proust

In Search of Lost Time (1913-
1927)

Trüeb RM. Aging of hair. J Cosmet Dermatol. 2005 Jun;4(2):60-72.

Androgenic Alopecia
Hereditary Male Pattern Hair Loss


Androgenetic
Alopecia
• Incidence
20% men in their
20s
• 38% men in their
30s
40s
•

50% men in their
50s
60s
80s

peripheral tissue
metabolism

Exogenous testosterone will convert to
DHT

DHT-mediated
Miniaturization

➧

Decreased Hair Density, Caliber & Length results in loss of

“Crown Balding”


Patient Goals

maintain benefits of testosterone
replacement:
libido, energy level, lean muscle mass,

etc.

reduce undesired consequences:
male pattern hair loss

Side-Effects

• Patients with unexpected or unwanted
side effects are more likely to
discontinue treatment.
• Hair loss can be a reason patients may

choose to discontinue testosterone
replacement.

What is the answer?
• Patient Education
• Risk Assessment
• Treatment
Options
• Tracking
• Follow-up


Stratagems for Hair
Loss Prevention
during Androgen Replacement
eliminate/reduce triggers
• medical conditions, meds, social habits, stress, etc.
block androgen effects: 5αR inhibition
• finasteride, dutasteride, herbal

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

Hair Loss
Risk
Assessment
• Family History (mother‟s or father‟s
side)
• Signs of hair loss (hairline/temple

recession, thinning crown, etc.)
• Dermoscopy (miniaturization)
• Genetic Testing (androgen sensitivity)

Untreated Male
Pattern Hair Loss

75% of patients with
untreated MPHL get
„much worse‟ in five

years.

Kaufman KD et.al., Eur J Dermatol 2002, 12:38-49.

Androgen
Metabolism
Testosterone ➔ Dihydrotestosterone
5-alpha-reductase
• high activity in the skin, prostate,
seminal vesicles, epididymis, liver.

(end organs)
• produced in testes, secreted

5-αR inhibitors
Testosterone ⇏ Dihydrotestosterone

• Finasteride - 1mg/day
• FDA-approved
• increases hair counts
• stops the loss
• reverses miniaturization

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.

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

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.

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

•

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

Finasteride Results

• 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.

Finasteride Results
“yes it can”

• before and after 10 months on
finasteride

*Results NOT typical!

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-

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.” --FDA

http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm299754.htm (Accessed 12/1/2012)

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.

• 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

Finasteride Risks

Common Side Effects
•
decrease in serum Prostate Specific
Antigen (PSA)
•
decreased libido

•
difficulty maintaining erection
•
decreased ejaculate volume


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
•

testicular pain
•
difficulty maintaining erection after stopping the
medication
•
male infertility


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

finasteride, slightly
higher%
• longer 1/2-life

Clark 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.

Dutasteride

Finasteride 5.0 mg

RV Clark, et. al. Marked Suppression of DHT in Men with Benign Prostatic Hyperplasia by
Dutasteride, a Dual 5-aR Inhibitor, Journal of Clinical Endocrinology & Metabolism May 1, 2004 vol
89, no 5, 2179-2184.

Strategems for Hair
Loss Prevention

• eliminate/reduce triggers
medical conditions, meds, social habits, stress, etc.
• block androgen effects: 5α-R inhibition

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

Compounded
Formula 82M Minoxidil
Less greasy, dries fast, less
dermatitis
Synergistic Components:
•
retinoic acid
•
oleanolic acid (anti-

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

Formula 82M
minoxidil
• mild to
moderate
39 y/o ♂ before & after 6 mos androgenetic
alopecia
• 15 drops (1ml)

to the scalp
twice daily

28 y/o ♂ before & after 6 mos http://www.scribd.com/doc/109423398/Bauman-Medical-Formula-82M-Minoxidil-v-100512-AJBaum

Other Topicals
• Bimatoprost (Latisse)

• Prostaglandin Analog
• FDA-app‟d for eyelash
growth (2008)
• lengthening, darkening,

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

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

• 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

LaserCap
Low Level Laser Therapy
• 650 nm
• 5mW x 224 diodes
• 80% duty cycle
• 30 min. qod
• hands-free
• rechargeable

• cordless
• ~600 cm2 coverage
• high compliance

www.lasercap.info

Male LLLT Results

43 y/o ♂ before & after 6 mos
25 y/o ♂ before & after 6 mos

Bauman patients before and after low level laser therapy (LLLT)

Strategems for Hair
Loss Prevention

• eliminate/reduce triggers
• medical conditions, meds, social habits, stress, etc.
• block androgen effects: 5α-r inhibition

• 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”

Hair Transplantation

• NeoGraft „FUE‟ =
Follicular Unit Extraction
• minimally-invasive
donor harvesting
• no strip removal

• redistribute permanent
donor follicles into
thinning/balding areas

Hair Transplantation

Donor Area

Recipient Area

Bauman Patients before and after NeoGraft FUE hair transplant procedures

Hair Growth Tracking
• HairCheck™ aka “Cross-Section
Bundle Trichometry”

• Hair Mass Index (HMI)

• Combined measurement of hair
caliber and density

• Fast, accurate, repeatable

• Diagnosis and Results-Tracking

• HMI is measured every 90 days

AJ Bauman, “The use of Cross-Section Bundle Trichometry in the Medical Management of Androgenetic Alopecia,”
ISHRS 20th Annual Scientific Meeting, Nassau Bahamas, October 2012

Find the balance


Conclusion
• Candidly & confidently discuss hair loss
with your androgen-replacement
patients.
• Present treatment options to patients.
• Continue to educate yourself on the

new methods of prevention and
treatment.
• Refer or ask for assistance (we‟re here
to help via phone, skype or email).

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.

• 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.

Thank You!

www.baumanmedical.com
doctorb@baumanmedical.co
m

Hormone Replacement and Hair Loss - BaumanAJ a4m 2012

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