Agreed. Let me throw in a question that I get over and over because years ago our group and other
groups pushed the use of Proscar and Avodart a lot, and back in the 1990's we didn't have
very many effective therapies, and when you look at the mechanism of action of blocking
dihydrotestosterone which is a more potent form of testosterone, it sounds so logical that we
would put people on Proscar and Avodart during intermittent therapy, and we actually showed
that it does kind of keep the PSA down—it has some activity—but there's been a whole literature—and
you're probably aware of this Mark—about the possibility of lingering suppression of the
libido with the use of Avodart and Proscar. In fact, there's a lot of litigation going on about
this now, and I personally, along with my partners in Marina del Rey, have sort of steered away from
using [them] because the goal of stopping Lupron and getting testosterone back is to
restore libido—that's one of the goals—and so even though the PSA rises more slowly with Proscar and
Avodart, we've shied away from it probably in the last five to ten years because we've frequently
seen this problem with suppressed desire, and have you have you encountered that as well?
That's interesting, I mean, again, if I look at the literature there has been more of a
scrutiny over who to use this with and I mean some some guys require and need it because of
BPH because they have large prostates and that's understandable, but you don't have to be a genius
to realize that when you're taking away the most potent form of testosterone and you're affecting,
for example, ejaculate volume, right? You're doing — clearly something is changing in the prostate,
in the area around the prostate, that when people are coming back and saying
that they have libido issues, those are relevant. Those are really relevant, and...
Whenever I prescribe this medicine I always warn them that about 1/3 of the men will experience
rather immediate and persistent loss of sex drive, loss of libido. Thankfully,
it is reversible if you get off it pretty quickly, but I think all the litigation is
about that for the men that stay on it for a couple years, some of them apparently,
I can't prove this, there's some of them are not recovering their libidos.
That's interesting.
There's a lot of anger and concern that maybe that this needs to be explained more. Now,
when you look at the package insert it talks about the loss of libido and I don't think — I
don't have any agenda against the companies; I'm very glad that we have this agent. Like you say,
it works well for men that have trouble — some large prostates, and maybe over half of the
men don't have libido problems, but you better be careful when you start it to be vigilant for that
loss of libido because it could and perhaps—it's not proven—but perhaps it could be long lasting.
Yeah because you also have to be careful what you ask for,
and there's also all these young men who are taking this exact same drug at a lower
dosage for hair loss because remember that these 5-alpha reductase inhibitors,
about a fifth of the dosage is the exact same drug approved for hair loss in men, like Propecia.
Yep
And we know that that can also bring PSAs down and some men have complained about libido there. So,
there are men who are taken off of it, but continue their hair loss drug,
right? And they wonder what's happening. So there has to be a discussion that they
the number one selling hair loss pill is just another form in less of a dosage of the exact
drugs you're talking about that you're concerned about. So both of those have to be brought up.
Yeah, what you mentioned briefly about how the PSA is lowered. Now
and then some less sophisticated family doctors are missing prostate cancers at
an early stage because they think the PSA looks fine, but they're taking Propecia.
Yeah.
Why don't you mention that?
Yeah they're taking propecia exactly, or they're taking or they're taking dutasteride or Avodart,
and that has a half-life that's much longer than Propecia,
and it takes longer to get rid of the drug out of your system. You know,
you're talking about weeks to months versus days, and I think the point is is that you they've got
to look at the entire list of what they're taking because there's some repeats there.
Yep, and plus with the PSA being lower sometimes they're not getting a biopsy or an MRI in a timely
fashion. Let's say your PSA is 3.9 on Propecia, we're supposed to double that number, right?
Right. That's right, but don't you think it's an amazing thought I have always
thought how ironic is it that a drug that's pushed to maintain youth there
have you look essentially younger—in a number of people—robs you of the drive that's also
supposed to make you feel younger, so there's a disconnect, right? You can't have both, right?
I've had some amusing conversations with patients about this, and you know,
where it's kind of like I warned them; I say, "okay you've been taking this Propecia,
it's working, but you've complained of a low sex drive, but if you stop it it's possible that
your hair is gonna start falling out again, and of course I figure, "Dang Dr. Scholz,
I didn't realize that I'm gonna stop it immediately" and I've had several patients
say, "Lose my hair? Lose my hair? yeah I think I'll pick the hair over my libido."
But people forget that the over-the-counter game is changing and that's where I become
so busy. The over-the-counter world is totally different from ten years ago,
and ten years to now be totally different. What that means is that, you know, there's
still 2% and 5% minoxidil over-the-counter. Yes, men gotta apply it every single day,
but there is absolutely no evidence that I'm aware of that applying minoxidil
over-the-counter to your hairline is gonna cause any testosterone or libido issues.
There you go.
Right?
It can dry your scalp
There's an alternative.
That's right, so it's not all or — isn't this the lesson of why we
have these conferences? It's not all or nothing.
Yeah.
There is a middle choice.