Millions of men are discovering that an enlarged prostate gland is negatively affecting the quality of their lives. But two popular prescription drugs designed to treat benign prostate hyperplasia (BPH), dustasteride (Avodart) and finasteride (Proscar), may throw a monkey wrench into the sexual machinery. That’s the report from a study in the journal PeerJ (March 9, 2017).
How Common is BPH?
BPH is a common consequence of adding birthdays. The feds (National Institute of Diabetes and Digestive and Kidney Diseases) estimated that 14 million American men suffer symptoms of BPH. That is probably an underestimate.
Aging baby boomers are starting to dominate the health stats. In the last seven years millions of men turned 60. More than half have symptoms of an an enlarged prostate. If they make it to 80 years of age, as many as 90 percent will experience prostate problems.
Symptoms of Benign Prostate Hyperplasia (BPH):
- Many men complain that they have to get up a couple of times at night to pee. That may make it hard to fall back asleep.
- Some men have trouble starting urination, especially if there has been a forced delay, such as at the movies or a ball game.
- While young men have a strong urine stream, older men with BPH often complain that it is a weak or interrupted stream. They may have incomplete bladder emptying.
- Many men have urinary frequency. That means they have to go several times a day.
- Lots of guys complain of dribbling at the end of urination.
- Urinary retention can be an emergency situation. It can occur if a man with BPH takes an oral decongestant (pseudoephedrine, phenylephrine) or another drug that affects the urinary tract. This can lead to an inability to pee. The resulting pain and bladder distention can be unbearable. This often leads to a trip to the ER and catheterization. Anticholinergic drugs are notoriously bad actors in this play. Here is a list of drugs with anticholinergic activity.
Treatment of Benign Prostate Hyperplasia (BPH):
The discovery of treatments for BPH reads a bit like a medical mystery. It dates back to the 1970s. There were reports that girls in a remote village in the Dominican Republic turned into young men when they reached adolescence. The people in the village had a name for this phenomenon. It was called “guevedoces.” In essence, balls or penis at age 12. Another name for the phenomenon was “machihembras.” In other words, first woman, then man.
An endocrinologist from Cornell University heard about this phenomenon and investigated it in the 1970s. What she found was that the young boys lacked adequate amounts of an enzyme called 5-alpha reductase. This enzyme converts testosterone to dihydrotestosterone (DHT). That’s why they looked like girls. They had very little DHT circulating in their bodies. At puberty, though, a surge in testosterone presumably overcame this enzyme deficiency. This in turn led to the development of testicles and a penis.
It is DHT that is thought to cause an enlarged prostate gland and male pattern baldness. The men in the remote village who were deficient in DHT had smaller prostate glands as they aged and did not lose their hair the way other men did.
Drug Company Involvement:
Roy Vagelos, MD, was then head of the huge drug company Merck Sharp & Dohme (aka Merck & Co.). He was fascinated by the notion that less DHT might lead to shrinkage of the prostate and possibly even a treatment for male pattern baldness. The company went full tilt at the challenge.
It received FDA approval for Proscar (finasteride) to treat BPH in 1992. The dose was 5 mg. In 1997 FDA granted approval for Propecia to treat male pattern baldness. It was the same oral medicine but in a 1 mg dosage form. A related drug, Avodart (dutasteride), was approved by the FDA to treat BPH in 2001.
How Popular are Finasteride and Dutasteride?
These drugs have gradually taken off. Many men would understandably prefer to avoid surgery to deal with symptoms of an enlarged prostate.
It is estimated that between 1993 and 2010 the use of such drugs in men with big prostates went from 3% to 15%. That means over two million men were taking either dutasteride or finasteride to control symptoms of benign prostate hypertrophy (BPH). That does not include the use of finasteride for male pattern baldness.
Complications of Dutasteride & Finasteride:
Many researchers thought DHT was just an unpleasant byproduct of testosterone metabolism. There was hope that the drugs that blocked formation of DHT would have few, if any, side effects. In other words, all gain, no pain. First, there would be reduced prostate problems. As a bonus, men would have a bushy head of hair as they aged.
Perhaps that is why President Donald Trump’s longtime physician Harold Bernstein, MD, proclaimed: “He has all his hair. I have all my hair.” He was acknowledging that he prescribed the drug finasteride for Mr. Trump.
The Unexpected Benefits of DHT:
Dihydrotestosterone (DHT) may not be a colossal mistake by Mother Nature after all. This byproduct of testosterone metabolism actually does a lot of things in the body. As already noted, it is critical for the development of testicles and a penis. It also plays a role in blood sugar regulation. DHT helps maintain insulin sensitivity and lowers blood glucose levels. It also seems to have a beneficial impact on brain tissue.
DHT seems especially important for human sexuality. It enhances libido. Animal research suggests that DHT is important in maintaining normal erectile function.
One other impact of DHT on men is its anti-estrogen effect. When levels of DHT are blocked with drugs like finasteride or dutasteride, estrogen may exert a feminizing effect. Many men who take these drugs complain of a condition called gynecomastia or male breast growth.
Sexual Side Effects of Finasteride & Dutasteride:
There has been tremendous controversy around the possible sexual side effects of drugs that block DHT formation. The official FDA prescribing information for Proscar states:
“PROSCAR is generally well tolerated; adverse reactions usually have been mild and transient….
“The most frequently reported adverse reactions were related to sexual function. 3.7% (57 patients) treated with PROSCAR and 2.1% (32 patients) treated with placebo discontinued therapy as a result of adverse reactions related to sexual function, which are the most frequently reported adverse reactions…
“In years 2-4 of the study, there was no significant difference between treatment groups in the incidences of impotence, decreased libido and ejaculation disorder…
“There is no evidence of increased sexual adverse experiences with increased duration of treatment with PROSCAR. New reports of drug-related sexual adverse experiences decreased with duration of therapy.”
The official prescribing information goes on to mention that sexual dysfunction that continued after discontinuation of treatment has been reported (“including erectile dysfunction, decreased libido and ejaculation disorders”). But that warning is toned down by the statement, “These events were reported rarely in men taking PROSCAR for the treatment of BPH.”
Dutasteride (Avodart) is reported to cause decreased libido, erectile dysfunction, decreased orgasmic sensation, abnormal orgasm, premature ejaculation, delayed ejaculation and ejaculation failure. The official literature states:
“These adverse reactions may persist after treatment discontinuation. The role of dutasteride in this persistence is unknown.”
Research On “Persistent Erectile Dysfunction”:
The latest research suggests that this may not be as rare a problem as the FDA has suggested in its official prescribing information. The study published in PeerJ (March 9, 2017) analyzed data from nearly 12,000 men between 16 and 89 years of age. Just over one percent of them developed long-lasting erectile dysfunction even after stopping the drugs.
Men under the age of 42 who took finasteride or dutasteride for more than 200 days were nearly 5 times more likely to report persistent erectile dysfunction than men who took the drugs for shorter periods of time.
Stories from Readers:
It is one thing to read official prescribing information from the FDA that makes everything seem remote and unrelated to the real world. It is quite another to read about real-life experiences. Here are just a few:
Chris in Virginia shared this:
“I have been taking Advodart for about 3 years or more.
“My side effects didn’t start right away but are exactly as described. When I stopped taking it for a few weeks, my urination problems returned. I am so upset at my urologist for not talking about the sexual side effects, but he did know that I would do anything to avoid surgery.”
Daniel in the UK reports:
“Around six weeks after starting Avodart, the volume of ejaculate began to decrease. After six months, there was nothing at all. In addition, there was a dramatic change in the sensation I felt at the time if ejaculating; the pleasure was gone.
“My BPH symptoms had improved and so I decided to stop taking the Avodart in the hope that normal sensations would resume. I’m sad to report that the side effects have continued nine years on. My sex life has been ruined!”
“I took Avodart for about 15 months before stopping on my own because of the sexual side effects. Although after a few months Avodart helped the trips to the bathroom at night, it caused my breasts to enlarge and literally destroyed everything related to my sex life. I thought I’d rather get up in the night than deal with the side effects. After 6 years of no Avodart, my breasts are normal, but the same sexual side effects described in the article are still there. Avodart is a very bad word in my vocabulary.”
Fonnie shares a woman’s perspective:
“What a shocker! My hubby started on Avodart in 1995, and he was only 55. Shortly afterwards, he had no interest in any sex at all. But he wasn’t going to the bathroom so many times at night.
“I thought it was me, and did everything I could to get him interested. But, it proved fruitless. I wish I had read this many years ago, as I wouldn’t have switched to flannel pajamas. I would have had a long talk with his doctor.”
Sexual Side Effects Frequently Overlooked:
Sex is a challenging topic for anyone. Doctors do not often ask about adverse sexual side effects. Men may not volunteer this kind of information. As a result, the official prescribing information for many medications lacks accurate information about this significant problem.
The idea that erectile dysfunction could persist long after a drug is stopped seems counterintuitive to many health professionals. And yet the latest research suggests that is precisely what can happen with 5-alpha reductase inhibitors like dutasteride and finasteride.
Learn more about finasteride side effects at this link.
Share your own experience with either dutasteride or finasteride in the comment section below.