Post Finasteride Syndrome

Irwin Goldstein, MD

Post Finasteride Syndrome (PFS) describes the persistent negative sexual, mood, cognitive and multiple other metabolic symptoms in patients who have taken 5 alpha reductase inhibitors, especially finasteride.

Concerning the sexual consequences, previous finasteride use is associated with such concerns as low libido, erectile dysfunction, reduced penile sensation, orgasm dysfunction, diminished ejaculatory volume and force, increased incidence of Peyronie’s disease and/or flaccid penile shrinkage.  Reports in the literature show the adverse side effects of Inhibition of 5 alpha dihydrotestosterone biosynthesis can persist despite discontinuation of finasteride.  In particular, we have shown the erectile dysfunction to be organic and related in part to erectile tissue fibrosis, likely induced by smooth muscle cell apoptosis secondary to the low levels of dihydrotestosterone.  Others have confirmed the organic nature of the erectile dysfunction to be in part related to cavernosal artery insufficiency.  Adverse effects pertaining to sexual dysfunction, are also reported to be associated with depression and suicidal ideation. In particular, 5 alpha reductases are the rate limiting step in the biosynthesis of neuroactive steroids which are critical for central nervous system function involved in mood and cognition.

5 alpha reductases play an important physiologic role in the regulation of cellular metabolism of androgens, glucocorticoids and other steroids. 5 alpha reductase isozymes are widely expressed in many tissues and organs. Metabolites produced by 5α-reductases enzymatic catalysis modulate multiple physiological functions in peripheral and central nervous tissues.   Specifically, there are concerns with 5 alpha reductase inhibitors use, especially on the metabolic adverse effects in liver, muscle, kidney and the ocular system.  Previous finasteride use induces a novel form of androgen deficiency independent of testosterone levels that can be associated with such metabolic concerns as insulin resistance, type 2 diabetes, lipid accumulation in liver, impairment of ocular function, dry eye disease, and/or impairment of kidney function.

Men with symptoms of PFS are evaluated at San Diego Sexual Medicine in a detailed biopsychosocial assessment by experts in sex therapy, pelvic floor physical therapy and biologic sexual medicine.  Other health care providers are engaged as needed for the wide diversity of PFS symptoms.  The organic sexual medicine investigation assesses a wide array of tests such as: hormonal blood testing, including dihydrotestosterone; neurologic testing; and erectile function testing, especially with Grayscale and color duplex Doppler ultrasound during pharmacologic erection.  Since opening in 2007, we have evaluated several 100 PFS patients at San Diego Sexual Medicine. In general, our multidisciplinary management algorithm has significantly helped more than 2/3 of patients improve life quality.