What Works to Restore Hairloss for Cis-Males? Not Much
It has been interesting to me to experience how different types of estrogen can have different temporal effects in terms of how soon they begin and how they can affect different areas unevenly.
I started off wanting just to get my feet wet. I had monitored the undergraduate microfiche and then as the internet became ubiquitous, the various online hair sites as that was my main concern, if not obsession, when I was younger and it fascinated me how basically forever there had been no baldness cures for males ever except for estrogen and testosterone blockers, or other such types of medications or treatments altering hormonal levels of estrogen and testosterone.
Castration plus estrogen is something that historically has been noted in medical literature to regrow scalp hair from completely bald areas but not many people are willing to go that far who are not transgender females. So as will be mentioned later, bottom surgery might significantly increase hair regrowth for transgender females because many treating practitioners are wary of prescribing enough estrogen for this hair regrowth effect to take effect without adding much stronger anti-androgens than those prescribed for cis-males.
Thus either an anti-androgen like flutimide or spironlactone, or castration may be needed to get testosterone down to the low levels needed for significant hair regrowth.
But what follows is more geared to cis-males or transgender females not receiving HRT.
By the way, any "transgender" females seeking to maintain full erectile capability, only the parts that follow regarding cis-males apply. I do know something about the subject but I consider it a non-binary topic.
Minoxidil was the first non-hormonal baldness treatment to come out that had actually been double-blind tested. I would say that I first became aware of it in 1986 after at least three years of thinning on top already but back then you needed a prescription so it wasn't easy to get. It was also pretty expensive; it still is. For me and probably others, there was the verification factor. Did it really work?
Eh. I still generally use it but at best it probably helps prevent hair loss. It might "regrow" some hair that just recently went out of cycle. I would often look in the mirror hoping to see little hairs growing but I never did. It was supposed to work slightly better in the crown but once again, eh. When I get lazy or don't want to spend, minoxidil is the hair treatment that I am willing to forego. I have seen very little to indicate that minoxidil works very well for anybody, male or female. You don't tend to see pictures that are impressive without it being combined with another treatment.
What did perhaps, work, however were off-label concoctions of minoxidil sold online, if you can still find them. The FDA tends to shut them down. These concoctions would have between 12 percent and 15 percent minoxidil but usually mixed with potentiators. Off the top of my head, no pun intended, the two main additional growth factors were azelaic acid and then spironolactone. They tended to smell bad.
Now, conceptually that seemed like something that might work and I think that it did work for many, especially younger males and females. Topical spiro does not appear to go systemic the way that estrogen does, and oral spiro does. This meant that one could rub these formulas on his or her scalp and it wouldn't promote breast growth. Interesting, I thought.
So, yeah I tried it. It wasn't that expensive. I was maybe 35 and I used it for a couple of years and I still just didn't see a lot of difference. I was only thinning in front and s little on top just to provide a backdrop. Nothing works for males who are completely bald except for female hormones and anti-androgens, but those thinning in the crown often did see improvements from these non-hormonal treatments combining minoxidil with different factors, and there were credible photos of thickening hair, if not regrowth.
Then came Proscar or Propecia. One was prescribed for hair and the other for prostate issues but they were exactly the same pharmaceutical. Once these went out of patent protection, they became referred to as finasteride and are featured on Keeps.com, which advertises them a lot during sports.
Now this one seemed to help a lot of people but once again, it mostly stopped hair loss and it stopped it cold for many younger people. Finasteride is a DHT suppressor and its specs indicated how it worked. The medication "mopped" up the enzymes that are needed for the body to produce DHT. It can be prescribed by doctors for baldness and prostate issues. It is a type of anti-androgen like Spiro but it tends not to have any feminizing effects since the DHT not converted remains as testosterone, and is not blocked from the androgen receptors as happens with flutamide and spiro.
Then came dutasteride or Avodart. Dutasteride was very similar to finasteride but it can only be prescribed by doctors for prostate issues and not for hair loss currently. I would go on to learn that baldness and prostate issues are highly linked because DHT is the culprit for problems in both areas.
Many doctors prescribe dutasteride off-label for hair loss. It has far better specs than finasteride in terms of the enzymes that it mops up as it mops up three different types of 5a-reductase and higher percentages of reductase as well, as both both finasteride and dutasteride are 5a-reductase inhibitors. Although dutasteride seems likely to be more effective than finasteride, some HRT practitioners still seem to prescribe solely finasteride and I don't believe that there are many studies with dutasteride.
Sometimes such prescription preferences have to do with what insurance is willing to pay for, if for example, a certain medication is still under patent protection and therefore more costly but many HRT practitioners don't seem to keep themselves exactly up to date with the latest research and studies as to what medications are most efficacious, and they might just keep prescribing what they have prescribed in the past.
There is also a shampoo that might be somewhat effective for males, known as Ketoconazole or Nizoral. Over the counter Nizoral has one percent, and prescription Ketoconazole two percent of the active ingredient, but you need a prescription for the latter. Nizoral is a type of anti-fungal medication which is somewhat effective against those DHT-related afflictions above the neck but also against things fomented by fungi like ringworm. The shampoo is very red and staining to clothing, and quite viscous, and it doesn't foam much, which is good, according to what I know about shampoos, but don't spill it on your light-colored clothing.
Again pops up our "friend" DHT which I have mentioned several times previously as a villain of people born as cis-males who suffer with imbalances of DHT and testosterone.
DHT seems to provide an environment where the skin can become excessively oily or sebaceous,
Because the yeasts that are present in all of us, consume the sebum, it seems to create an environment where malassezia furfur, a type of fungus or yeast thrives. As the colony of said yeasts expands, it can cause a multitude of skin afflictions. It has been associated with numerous dermatological conditions, including acne, dermatitis, dandruff, and apparently hair loss, and can create scaly sores underneath the hair on the scalp.
It can be very difficult to treat such sores so many of the afflicted have to just wait for a particular infection to run its course on its own. Sebaceous glands are particularly prominent in areas covered by hair, where they are connected to beard or scalp hair.
I don't claim to know the exact mechanisms but this seems likely to account for beard hair possibly seeming to continue to cause these oppressive facial and scalp issues in male to female transgender individuals such as it seems to have done with me.
It was only after I started the beard removal process that I was able to tame the dermatitis accompanying the growth of my beard hair. It was only after I began using topical estrogen on my scalp, and then began oral estrogen that the painful sores went away, seemingly permanently.
Remember that estrogen even with spironolactone seems unable to stop or really even significantly lessen beard growth or beard thickness so beard removal might be the only treatment that would have stopped my break-outs. Regardless, it worked seemingly at least concomitantly for me.
My thought is that the beard itself is pulling up whatever DHT remains in the body up to the skin's surface causing an eruption of dermatitis even after the 5-alpha reductase inhibitors have prevented the production of DHT in other tissues.
Once the beard follicles are gone or completely miniaturized, the dermatitis might go away as well. At least, this is what seems to have happened in my case. My skin cleared up immediately, which is also likely due to increasing my titrated doses of oral estrogen as well.
So ketoconazole, then seems to provide a scalp environment less susceptible for the hostile yeasts, which yeasts we all have and need for nice shiny hair but issues arrive when too much sebum is made because the yeasts "love" sebum. That's what they "eat".
We can see then that an imbalance of DHT is likely to promote an excess of sebum. The excess of sebum causes the malassezia furfur to over-populate, leading to inflammation and dermatitis and possible hair loss. Androgens like DHT stimulate the secretion of sebum while estrogens help decrease sebum production.
That being said, I have used keto for several years and I haven't noticed that it did a lot for either my face or hair. But the shampoo is not expensive and it may work for some or act in a synergistic way, so I use it. Leave it on for several minutes when possible. I have a monthly prescription for it. You can find it usually for sale near the dandruff shampoos for the one percent type.
It may help further to gain some understanding of the process by which steroid hormones are converted back and forth into different metabolites.
I am no chemist or biologist but I will try a greatly simplified explication. Reductases are enzymes that can change sex hormones into different versions by changing the molecular structure.
With estrogens, you have estradiol, estrone and estriol. With androgens, you have testosterone, 5-DHT, androsterone and androstenedione, which was used by Mark McGwire and other steroid users in baseball, among others accused of using steroids.
Progesterone and DHEA are other types of steroids produced by and needed both sexes. They are all chemically similar to cholesterol. These steroidal hormones can often be converted by the body from one into another.
Aromatases are enzymes that can change testosterone into estrogen via a process known as aromatization. Estrogen and testosterone have similar chemical structures but estrogen can aromatize testosterone, i.e., change it to estrogen, while testosterone cannot turn estrogen into androgens.
So some of the various enzymes that end in "ase" can create both estrogens and androgens. Without reductase, DHT cannot be formed from testosterone. Testosterone, however, as mentioned, can be converted to estrogen via aromatization.
This mostly concerns people being prescribed testosterone, such as female to male transgender individuals or athletes with injuries prescribed androgen for treatment of injuries because just loading up on more and more T might have a limit as to achieving the primary goal of using the medication to increase circulating androgens. Also for athletes, DHT is likely to improve performance in terms of promoting muscle growth so some males may not want to decrease the levels of DHT created in the body even while knowing that it can cause baldness and acne and aggression, and other negative effects such as paraphilias where are all but unknown in cis-females.
This debilitating physical strength effect from 5-alpha reductase inhibitors is not so significant for male to female individuals except that it shows why some anti-androgens like dutasteride and finasteride have fairly weak feminization or effectively no feminization effects while others like spironolactone and flutamide, and compounds similar to flutamide, like bicalutamide can have far more significant effects on muscle, and can clearly decrease physical strength when taken by cis-males.
It helps to know at least a little about these different medications because transgender individuals might be able to have their treating practitioner switch from the weaker finasteride to flutamide if hair regrowth is a key concern. In my experiences, HRT physicians or their assistants might not titrate dosages or add things like flutamide or progesterone without being prompted and it helps to have a reason when you ask.
Some studies do, for instance, find positive effects from progesterone and its synthetics like depo-provera on both hair and breast and nipple size although this is vigorously debated.
Honestly, in my opinion, and according to the medical literature, none of the above non-hormonal treatments for cis-males, which I use here to include transgender females as well, and even those cocktails including the weak androgen inhibitors dutasteride and/or finasteride, are likely to result in significant hair regrowth, particularly for people over 30, without adding spironolactone or flutamide as part of the cocktail,
However, used in conjuction with estrogens or stronger anti-androgens, there could be a synergistic effect among 5-alpha reductase inhibitors, minoxidil or Nizoral. and I would encourage all cis-males, transgender or otherwise, unable to use or obtain estrogen or androgen-blockers to use all of these if possible.
From my reading of much of the most-recent literature, I am skeptical that any male to female transgender individual needs more than just estrogen plus flutamide or spiro for significant hair regrowth.
In fact there are current studies indicating that just estrogen alone is enough to regrow hair for transgender females provided high enough levels are prescribed. Many practitioners won't go this high up in terms of prescribing estrogen because they fear blood clotting becoming an issue, which is a legitimate concern but which may be well worth the risk for balding transgender females suffering from significant dysphoria.
This accounts for why most studies indicate that trans-females need both estrogen and either flutamide and spiro for significant hair regrowth. In Europe, they use Androcur, also known as cyproterone acetate exclusively instead of spironolactone.
Cyproterone acetate on its own may be more effective than spiro, also known as aldactone, for some but it isn't approved for the treatment of transgender females in the United States. It is available and fairly easy to get from overseas sites serving transgender individuals who don't have access to health insurance or a prescriber, which percentage might be half of our community. I will discuss this topic more fully in another post. I think that both cyproterone and spiro are roughly equal in their hair growth abilities.
For cis-males, regardless of future orientation, one needs to use all of the above non-feminizing baldness treatments daily for best resutls, except one only needs either finasteride or dutasteride, preferably the latter but not both.
When to start for cis-males? The very first second that you see a single hair fall be it at 18 or 30 or 50 years of age. All of the above combined with either finasteride or dutasteride seem to be quite effective to maintain a hairline but they won't regrow it fully the way that estrogen in combination with anti-androgens that bind to androgen receptors might.
For cis-females, it is recommended to avoid the 5-alpha reductase inhibitors if of child-bearing age. Doctors may take males off them too when males are attempting to start a family but this seems to be excessive and overkill. If a cis-male goes off them for 7-10 years, there's no getting that hair back after desisting. I did happen to go off them because of my physician's recommendation.
Why is it so difficult to regrow hair, even for people using estrogen? One theory is that balding scalp tissue is a sort of calcified scar which has lost its connection to most blood vessels and hence blood supply. Scarring is a very difficult thing to reverse anywhere on the body. Also, the male head tends to grow larger than the female head, further perhaps hampering blood flow by stretching out the affected tissue.
If someone wants to actually restore hair and is interested in even greater minutia, he or she might go to the site Perfect Hair Forever site, which is full of pertinent information for males and females. But I can summarize its findings pretty easily:
Intact transgender cis-females supplementing with both estrogen, and one of the other among spiro or flutamide, or castrated males supplementing with estrogen alone are able to reverse baldness or shall we say have a significant probability of substantial regrowth in completely bald areas.
Castrated males and transsexual females no longer produce any significant amounts of testosterone or 5-HT so only estrogen supplementation is necessary for them to theoretically regrow hair in balding areas.
We never used to think that massaging the scalp could restore hair from baldness and that it was instead an old husband's tale but it may be because it takes a massive amount of massage, say, 30 minutes per day, every day for a year, and then continuing onward, to break through the calcified tissue.
The author on that site tries to provide the total sum of minutes needed. I have verified that there are studies indicating positive effects on hair growth via sustained, rigorous massage but I am not sure this is really a likely path for most balding people. It requires too much effort, obviously much more than swallowing ten pills daily as do many female transgender individuals but for motivated people, it might improve their hair some.
A process called derma-rolling or micro-needling that he mentions seems to work as well, with several published papers indicative of its effectiveness and as to why this might work.
This treatment can be fairly painful, however and you have to keep at it for many months to a year, but essentially small pricks into the scalp "trick" the body into healing scalp tissue and re-establishing blood flow. It also seems to work well on non-ice pick facial scars and wrinkles but it can involve a bit of a bloody mess. Healing time is minimal since the skin really wasn't damaged deeply enough to cause more than say 12 hours of inflammation.
Finally, there is the estrogen factor. Research seems to indicate that estrogen greatly increases the length of the growth phase of hair and thus female hair might grow for three times as long as male hair before falling out and going into its resting phase. It is possibly for this reason that even the vast majority of men who essentially never lose any hair at all, still can't grow their hair long the way that women do, without achieving the mullet look.
Estrogen's affects on skin alone, in my experience are miraculous in terms of feminization and in terms of what transgender females are likely to view as improvement, meaning paler, less hairy and much softer, and these effects, unlike hair regrowth, begin immediately.
Heels of feet that were completely cross-linked before estrogen, meaning coarse and discolored, where even pumice might be useless but estrogen can immediately become much more supple.
So then, regardless of the efficacy of the medications above for males in maintaining or even subtly regrowing hair, males simply are never going to restore their mid-puberty locks from say ages 13-17 without hormonal manipulation via T-blockers that don't block androgen receptors.
Hair transplants don't improve hair quality generally unless the fringe hair remains very high on the sides and back of the scalp without any hint of the mullet-effect. I have seen this and such males with abundant fringe hair are able to get fantastic results from transplants but their hair is still inferior to that of most females.
I have anecdotal personal knowledge of this limiting quality factor for males regardless of treatment.
Both of my parents are in their 80's and they both have thick hair and maintain every follicle that they were born with, but still my father's hair can't match my mother's. She can still wear it down to her shoulders the way that she could when I was a child.
In the early 1970's when male hairstyles increased in length, my father's hair got curly and unruly and it simply was never going to look good worn long. It lacked the texture and sheen and was a bit mullety.
Most males don't care that much about the length of their hair. They just want the fullest coverage possible but there is nothing that I know of short of hormonal manipulation of the androgen receptors along with estrogen that will give a male long tresses that look and have the manageability of female locks.
Women's hair at its best has a consistency and sheen and smoothness when rubbed between the fingers that virtually no male, not even Jeff Bridges in Against All Odds, can match, as glorious as Mr. Bridge's hair was in that movie in his red Ferrari, hair blowing in the wind.
Most rock stars after 30 are wearing wigs or hair extensions. Mick Jagger had pretty great hair among front men and may have made it to 50 with great hair. George Harrison and his incredible long-growing hair is of note but it is apparent that some members of the Who and Zeppelin are "cheating" just like me and just like so many metal "hair" bands.
Rod Stewart? Pretty obvious, not that there is a thing wrong about anyone wearing wigs or hair extensions but there does seem to be a stigma, especially with respect to toupees which rarely seem to blend in or fit right compared to longer wigs that completely cover down to the neck or or further down.
So why do some men like my father or Ronald Reagan appear to have perfect hairlines into their 90's? In many cases, such men lack the ability to produce 5-alpha reductase at all and therefore have only testosterone and not any DHT at all, circulating in their systems. Dutasteride would be entirely superfluous for those males bearing this genetic trait and male pattern baldness is unknown among them.
One hears a lot about gender dysphoria but in my opinion, dysphoria about hair loss is probably just as brutal for many follicle-challenged males as is the gender dysphoria that many transgender females experience. For me, they are completely related and both started right after puberty at about the age of 19.
Anyone who goes to the male-oriented baldness sites can see this obsession. There is a willingness to try anything, be it onion juice or cod liver oil or inversion therapy or saw palmetto tablets or black cohosh or cayenne pepper or soy products, and on and on.
Many of these gentlemen however are unwilling to try even weak androgen blockers like finasteride and in my opinion, there is just not much hope for bald or balding males to keep their remaining hair without at least using such weak androgens like dutasteride and finasteride sold by Keeps and other such companies.
Most of these packages advertised so frequently include minoxidil and finasteride, along with an online prescription that takes five minutes, and they can work very well to maintain hair but minoxidil by itself, even with say Nizoral 2 percent is unlikely to re-grow anything beyond fuzz. Yes, saw palmetto has some similar effects to finasteride but it is not cheap, there are very few studies and the effects are much weaker. It might actually cost more than finasteride.
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