Finasteride was first approved for medical use in 1992 as a treatment for men with enlarged prostates. Photo / 123RF
The little orange pill looks unassuming enough. But taken every morning, finasteride is, for many men, nothing short of a miracle.
In the interests of full disclosure, I started taking finasteride almost a year ago, after I noticed my scalp in the mirror more than a few times. Though my boyfriend assured me it was just a bad haircut, paranoia consumed me.
Hair loss has always been likely for me. Though my paternal grandfather maintained a full head of hair until his death, and my dad didn’t start losing his until nearly 60, my uncles and grandfather on my mum’s side all lost theirs in their 20s.
Even so, I’m attached to my hair. Years ago, an expert told me that by the time you realise it’s going, you’ve already lost 50 per cent. I was hellbent on saving my hair while I still had it, consequences be damned. By the end of the week, after filling out an online form which was approved within the hour and paying £84 (NZ$173), I had a three-month supply of finasteride.
What soon became clear is that I am far from alone. A friend told me he’d started taking finasteride after his girlfriend noticed his receding hairline. Another revealed he’d been on it for two years. Before long, it became clear that practically every man in my life was either taking finasteride or thinking about it.
First approved for medical use in 1992 as a treatment for men with enlarged prostates, the drug, researchers soon noticed, produced an unexpected side-effect: their subjects’ hair was regrowing. By 1997, the drug was being sold as a treatment for male pattern hair loss.
For decades, finasteride was manufactured exclusively under the brand name Propecia by drug giant Merck. Generic options became available in the UK in 2014, but at high prices. It’s only in the past few years the 1mg pills have dipped under £1 per pill.
Meanwhile, the pressure on men to maintain their appearance has grown and grown. Though hair has been linked with virility and manliness since the Old Testament, footballers like Wayne Rooney have put hair loss treatment on the map, while a full head of hair is as much a prerequisite for Love Island and superhero films as a six-pack.
And yet, male pattern baldness affects the majority of men. By 70, between 96 and 100 per cent of men will have experienced noticeable hair loss. Around one in five start balding in their 20s, one in three in their 30s.
“The hair follicles begin miniaturising and over time the hair gets thinner until it is lost entirely,” explains consultant trichologist Eva Proudman, a fellow of the Institute of Trichologists. “It’s a genetic lottery, a sensitivity to testosterone. Testosterone combines with hair follicles and converts to dihydrotestosterone (DHT) which causes that miniaturisation.”
Though DHT isn’t the only cause of hair loss, millions of men around the world are reaching for finasteride to prevent and, in some cases, reverse hair loss because the drug stops the conversion of testosterone to DHT. When a man (or woman – though pattern hair loss is considerably more common in men, its causes and treatment are often similar in women) is taking it, his hair follicles should be protected from being miniaturised. Where treatment begins early, hair follicles that have been miniaturised can regenerate.
It sounds miraculous, but there is a dark side to these drugs. Finasteride affects testosterone, the hormone that regulates sexual function, and some men report loss of libido, erectile dysfunction, and premature ejaculation. In rare cases men can have skin reactions, discharge from the nipples, and one study has potentially linked finasteride and male breast cancer.
It has also been linked with increased anxiety, depression, and suicidal thoughts. In March, the Medicines and Healthcare products Regulatory Agency began examining a three-fold increase in people reporting mental health conditions on the drug and even after ceasing to use it.
And yet it is flying off the shelves or, rather, the internet. In 2020, finasteride was the 90th most-prescribed drug in the US, with more than 8 million prescriptions. It isn’t available on the NHS but private providers such as Hims, Manual, Boots and Lloyds Pharmacy sell the drug in the UK. Its popularity is growing on this side of the pond too – Hims says that between Q1 2022 and Q1 2023, subscriptions for finasteride are up by 87 per cent. Meanwhile, Google data show that searches for finasteride in the UK have consistently tracked upwards since 2004, peaking in March 2023.
“It’s really hard to get statistics on this, but anecdotally, I can tell you more people than ever are coming into my clinic having used a website to order finasteride, oral and topical minoxidil and are taking it without any diagnosis and it may or may not be appropriate,” says Proudman.
Not everyone is comfortable with the ease with which it is possible to access hair loss medication. “Hair loss makes people vulnerable,” says Proudman. “The internet providers who make it easy to get these drugs mean that you don’t see anybody. They don’t check whether you actually need the treatment. Some people are so desperate that they’re not asking where the medication is coming from or who made it.”
There is a world of things you can do before medicating, she adds. “Your hair reflects what you take in – you need a balanced diet, complete proteins, and a lot of vitamins and minerals. You might need a blood test to see if you’re deficient in any of those. You can also get thickening shampoos which plump up the hair.”
Dr Stefanie Williams, dermatologist and medical director of Eudelo Dermatology And Skin Wellbeing, is also wary of the drug being dispensed so freely. “Personally, I find it problematic,” she says. “You need a doctor to diagnose you properly, to decide which medicine is most appropriate, and then to monitor you. It’s vital people know the risks. Who knows if their hair loss is even hormonal hair loss? Maybe it’s telogen hair loss (stress-related), which is different – you can get it after having the flu – and needs different treatment.
“Any systemic medication [i.e. anything taken orally] comes with risks. Thankfully, most studies suggest it’s unlikely; roughly 2-8 per cent of men have side effects. But as a doctor I wouldn’t feel safe doing it all online.”
Hair treatment is not available on the NHS – and is expensive. An initial trichoscopy or dermatological assessment often costs over £200. Prices only increase from there. The consensus from several men I spoke to was “Why go to the expense when I could take the finasteride at home?”
The issue for some men is that they feel they are up against a ticking clock. If they don’t act fast, they could lose their hair entirely. “Each time you shed a hair, that hair follicle miniaturises before it regrows,” explains Proudman. “It’s a progressive condition which can be slow or quick. If you’ve got some hair in your follicles, we can work to stabilise those. If the follicle is empty, it can’t regenerate: it’s too late.”
The fear of acting too late is what motivated me to start taking finasteride even though I am not certain I need it. Perhaps seeing my scalp really was due to a bad haircut. But I’d rather not risk it. While I’m happy to report that I haven’t experienced any side effects, the financial cost isn’t inconsiderable, especially when you consider that the drug only works as long as you take it. But in my opinion it’s worth the expense for the peace of mind.
Perhaps the real solution is to break the baldness taboo, but as long as I’ve got hair on my head, I’ll leave that to someone else.
How it works: “Applied topically as a foam to the scalp, minoxidil increases blood flow to the hair and brings nutrients to the hair follicles, which helps to strengthen existing hairs and encourages them to grow,” says Rizvan Batha, an independent pharmacist and prescriber of hair loss treatments for Hims. “It is effective in around 70 per cent of men.”
Side effects: “Unlikely because only 1-2 per cent of the drug is absorbed through the skin. Some patients may experience skin conditions and sometimes it is mixed in an alcohol solution so it can dry the scalp out. You can get hypotension but it’s incredibly rare.”
How it works: “Effective in about 90 per cent of men, finasteride works by blocking the conversion of testosterone to DHT, preventing the hair loss from happening,” explains Batha. “In two-thirds of men, finasteride has been shown to regrow your hair. It comes in the form of 1mg tablets, taken every day for the rest of your life. If you stop taking it, hair loss resumes.”
Side-effects: Anxiety, depression, sexual dysfunction, discharge from the nipple. Side effects affect 2-8 per cent of patients.
Price: £5,000-£12,000 (based on UK treatment and how much hair needs to be grafted).
How it works: “They take healthy follicles, usually from the back and sides of the head and insert them into the front and top of the head,” says Proudman. “You need to show you’re on treatment like minoxidil and finasteride and responding to it. If not, you aren’t suitable for a transplant because the grafts won’t stay stable.”
Side effects: “There aren’t enough follicles on the head to transplant the whole of the head; you can only do so much. You have to be very careful with it, otherwise you can lose it all.”