Two new publications centred on PFS have been published, and serve to highlight many of the urgent challenges faced clinically and scientifically in adequately addressing the condition.
Writing in Dermatology, Professor Irwig carefully reviewed the medical records of six patients who had committed suicide following the use of finasteride and subsequent development of multi-systemic symptoms. Apart from one patient with hyperlipidemia, the patients had no pre-existing medical or psychological conditions before the development of serious and persistent symptoms after taking finasteride. These patients experienced a range of symptoms including erectile dysfunction, ejaculate changes, genital shrinkage, loss of libido, anxiety, depression, memory and cognitive impairment, feelings of isolation, insomnia, fatigue and weight loss. Persistent insomnia and erectile dysfunction were common in the clinical records of all cases. Irwig concludes that rodent and human studies provide strong biological plausibility for finasteride to induce depression causative of suicide, and that patients under 40 who develop persistent sexual dysfunction and insomnia following use of finasteride are at risk of suicide.
Urging scientific and clinical action, Professor Traish reviews the current evidence for PFS and highlights the crucial role of steroids interrupted by finasteride in cellular function across the organism. A compelling basic hypothesis is suggested that finasteride may induce epigenetic changes in a susceptible subpopulation, differentiated by epigenetic phenotype. Traish forthrightly rebukes baseless psychosomatic dismissal of PFS patients by certain dermatologists, highlighting the significant contemporary evidence for the biological relevance of endocrine disruption with 5 alpha reductase inhibitors to the symptoms of PFS. Traish appropriately states that “to dismiss outright such obvious clinical symptoms in patients with PFS represents a new level of arrogance adopted by some in the clinical community due to scientific and clinical ignorance”. Finally, he concludes that it is of paramount importance to further investigate the underlying mechanisms leading to the onset and progression of PFS, as well as educating clinicians regarding the condition.
An untenable situation
With [humility] comes not only reverence for truth, but also proper estimation of the difficulties encountered in our search for it. …[T]his grace of humility is a precious gift. – William Osler, Aequanimitas: with other addresses to medical students, nurses and practitioners of medicine, 1849-1919
These two publications serve to highlight the exceptionally serious consequences of scientific and clinical failures that still leave consumers using a cosmetic product in the dark regarding a rare and remarkable disease. PFS has no known predictive factors, unpredictable severity between patients, a complete absence of dose-dependence, and no available therapeutic options. Both papers appropriately note the flawed and inadequate evidential basis for the apparent perception of finasteride as a safe drug for cosmetic use. The consequences – including suicide – are so profound that simply repeating that an arbitrary standard of evidence quality has not been met through placebo controlled trial is deeply inadequate at this point. A rarity of a supposed epigenetic predisposition in line with any number of rare genetic conditions would render any clinical trial aimed at determining the existence of PFS completely unfeasible owing to the required size of the arms and required duration of study. Indeed, Irwig notes that such a trial to establish causation would be unlikely to ever be funded or completed. Psychosomatic attribution, meanwhile, is in our view an inexcusable gaslighting of patients suffering a serious physiological condition. Frequent clinical ignorance has very real and devastating consequences considering that vulnerable young PFS patients – already in an invidious situation – are often reliant on the support of family members who understandably defer to the advice of clinicians.
PFS patients almost invariably express a profound shock at what has happened to them. Members of the public are not placed to imagine the potential consequences on their health and lives. Propeciahelp continues to do the best we can to support patients, but patient-operated platforms simply cannot continue to compensate for an ongoing clinical failure of this magnitude, particularly in an era in which social media marketing campaigns increasingly target young consumers with the offer of rapid online prescriptions.
Traish noted that there is a fundamental question as to why the existence of PFS has met with such clinical resistance. We believe the question of recognition of PFS as a novel disease mechanism is not a question of if but one of when, and that this question will only grow more urgent. We urge clinicians and scientists with the ability and expertise to undertake precision medicine investigation such as full-genome sequencing and epigenetic assay to contact us regarding the potential of basic science research aimed at determining the predisposition to and pathomechanisms of PFS.