Beards, Baldness and What’s in Your Pants

I flipped on the TV the other day and was greeted with a view of the top of a middle-aged man’s head.  In high definition.  I think I was supposed to be paying attention to the guy’s bald spot, because an authoritative voice posed this question:

If you had a choice between baldness and a full head of hair, which would you choose?

Uh, is this a trick question?

Of course, this was a commercial for some sort of hair restoration method, but where I’m headed (no pun intended) is that I often see questions on the lists from guys who want to know how to stem the tide of male-pattern baldness that they experience after going on testosterone.

I also have heard trans guys question themselves about their concerns over losing their hair while on testosterone.  Does that make them shallow?  Does them make them vain?  Don’t they have more important things to worry about than baldness?  Does worrying about it make them less of a man?

Although hair loss doesn’t happen to all trans guys, it happens to some, just like it happens to some non-trans guys.  The spot I saw on TV was just one of a gajillion commercials and ads for products that are designed to combat hair loss — obviously there are lots of men who are concerned about hair loss, or these products wouldn’t be out there.  In other words, if some trans men are wanting to do something about male-pattern baldness, then aren’t they’re just being…  men?

So you might be wondering, what causes male-pattern baldness and how can it be stopped?   Well, okay, you might not really be wondering, but I’ll tell you anyway, because it’s interesting.  (No, honest, it is.)

Hair Growth

Explaining hair loss is easier when starting from the point of hair growth.

Hair shafts are manufactured in the hair follicles, which are considered “skin appendages” (as are bird feathers and fish scales).  Hair follicles cycle through phases of growth (anagen), transition (catagen) and rest (telogen).  In humans, hair follicles are asynchronous in their cycles, with about 85% of the follicles in anagen and 10-15% in telogen at any given time. (Some animals, like mice and rabbits, have waves of hair growth during which the hair follicle cycles are synchronized.)

The longer the duration of the follicular cycle, the longer the hair shaft; follicles in the scalp have a cycle that lasts two-to-five years and so have longer hair shafts than the vellus follicles which are located on the body and have much shorter cycles.

[On a side note, each human hair follicle sports a single shaft, whereas the hair follicle of the chinchilla manufactures 50 to 100 shafts, which explains the incredibly dense nature of, and the market for, chinchilla fur coats.]


Male-Pattern Baldness

In natal men and in trans men who undergo testosterone hormone replacement therapy (I will leave women out of the discussion – they can experience hair loss too but with a slightly different scalp pattern) , the testosterone (T) is converted in the skin to dihydrotestosterone (DHT) by the action of an enzyme called 5-alpha-reductase.

Actually, there are two forms of 5α-reductase, Type 1 and Type 2.  Type 1 is mainly found in skin whereas Type 2 is predominant in the prostate and external genitalia – more on that later.

DHT is a more powerful androgen than T because it binds to the androgen receptor with higher affinity than T and thereby causes more significant effects.  And although T can be converted to estrogen by an enzyme called aromatase (a chemical reaction called aromatization), DHT cannot.


In the case of male-pattern baldness, the hair follicles in the top and front center part of the scalp have a genetically-based sensitivity to DHT, which is why male-pattern baldness is also called “androgenetic alopecia” or “androgenic alopecia.”

Current dogma says that the genes that underlie male-pattern baldness are linked to the X-chromosome and are inherited from a person’s mother.  In fact, the genetics behind androgenic alopecia are more complex than that, involving multiple genes that can be inherited from both or either parent.

So how does this hair loss business come about?  Over time, the DHT causes a reduction the duration of the hair growth cycle, and as the cycle of the hair follicle becomes shorter and shorter, the hair shaft has less and less time to grow, so it becomes shorter and shorter, and thinner and thinner, and wee and tiny (called “miniaturization”), until the follicle finally burns out — more with a whimper than with a bang — as a “terminal follicle.”

And then what are you left with?  Pure, unadulterated scalp.

There is hope, though, for the guy who is on T and wants to stem the migration of hair from his scalp to the shower drain.  Finasteride, a drug that is available in tablet form, inhibits the Type 2 form of the 5α-reductase enzyme and is a treatment for androgenic alopecia.   Now I know that I said that Type 1 is the predominant 5α-reductase in skin, but the Type 2 isoenzyme is present in skin as well and appears to be the form that is mainly responsible for male-pattern baldness, presumably because of its specific location within the hair follicle.

Finasteride comes in two doses — the more-expensive 1 mg Propecia tablet for treatment of hair loss and the less-expensive 5 mg Proscar tablet prescribed for benign prostatic hyperplasia (BPH), a.k.a. enlarged prostate.  [DHT in prostate, converted from T by Type 2 5α-reductase, is one culprit behind BPH.]

To stop hair loss, I know some guys who get a script for Proscar, because it’s the cheaper of the two finasteride drugs, and then they use a pill-cutter to break it into quarters to arrive at a dose similar to the single tablets of Propecia.  [I’m not giving advice that anyone should or should not do that – I’m just saying that I know guys who do.  That’s something to discuss when asking a doctor for the prescription.  Although many people take finasteride without any issues, there are side effects associated with the drug that, as with any drug, should be considered  before taking it.]

 


The Paradox

Problem solved, right?  Take a little pill and stop hair loss.  Well, hold off on that trip to the pharmacy, because there is a paradox about this whole DHT/finasteride/hair growth business.

The trouble is, while DHT is pushing scalp hair follicles to their doom, it is also stimulating facial hair follicles in the beard area to produce heavier, longer shafts.  So if a trans guy takes finasteride to arrest the loss of scalp hair, he might also be stopping or slowing new facial hair growth.  I have a friend who experienced this.

If that is an issue, a guy might have to hold off on the finasteride and take a hit on the male-pattern hair loss until his beard grows in completely.  In the meantime, he could use Rogaine (minoxidil) to try to stop the hair loss.   Other than finasteride, minoxidil is the only other drug that has been approved by the FDA for the treatment of androgenic alopecia.

Originally developed as a drug to treat high blood pressure, one of minoxidil’s side effects was hair growth!  But no one knows how it works.  An increase in blood flow to the hair follicles is presumed to be part of the mechanism of action.  Results from minoxidil vary from person to person, but some people can slow or stop hair loss with this product.  The down side — it ain’t cheap.

What about saw palmetto?  A member of the traditional medicine arsenal, saw palmetto is an extract of the Serenoa reppens plant and is used to treat enlarged prostate and androgenic alopecia.   In case you’re thinking of using it, here’s a word about saw palmetto:

Finasteride (sort of).

Okay, so that was more than one word, but my point is that one of the ways that saw palmetto works to (supposedly) stop or slow male-pattern baldness (and treat enlarged prostate) is the same way that finasteride works — by inhibiting 5α-reductase.  So if a guy is avoiding finasteride so that it doesn’t interfere with his whisker development, he should avoid saw palmetto as well for the same reason.

What’s in Your Pants

Lastly, and certainly not leastly, we come to the genitals, so to speak.  Believe it or not, hair growth, male-pattern baldness and genital growth all have something in common:  5α-reductase and DHT.  While testosterone is responsible for development of the internal male reproductive organs (including the testicles because they develop inside the body), DHT directs development of the male external genitalia.

This role of DHT becomes evident in cases of the intersex condition 5α-reductase deficiency which is due to mutation of the gene for the Type 2 form of the enzyme.  These individuals are genetically male (XY chromosomes), usually with female or ambiguous genitalia, although some can have male genitalia with a micropenis.  At puberty, the internal testes in these individuals produce testosterone and often descend, and some virilization of the body occurs.

Why does the external genitalia of genetic males with this condition fail to develop completely?  No 5α-reductase –> no DHT.  No DHT –> no “traditional” external male genitalia.   What does that mean for a trans guy on T?  Well, with DHT’s importance in growth and development of external genitalia in natal men, it stands to reason that it is involved in growth of the genitalia of trans men who are on testosterone.

Bottom line?  If you’re in your first couple of years of testosterone hormone therapy and you want to do something about your thinning scalp hair, but you also want your beard to come in better and your penis to grow, it might be a good idea to stay off the finasteride and saw palmetto and go with Rogaine.  Or nothing at all.

If all goes well, you’ll be doubly endowed (if that’s what you want) with facial hair and what’s growing on your head.  I will post another time about potential ways to improve endowment of what’s in your pants, but in the meantime, here is some informative reading material regarding DHT for transgender men that was written by another trans guy.

— ATM

Reference:  Controls of hair follicle cycling, K.S. Stenn & R. Paus, Physiological Reviews 81:449-494, 2001

The Straight Dope:  Is Male Pattern Baldness Inherited?  Who’s to Blame?  (August 19, 2005)
USNLM Genetics Home Reference:  Androgenetic Alopecia

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20 Responses to Beards, Baldness and What’s in Your Pants

  1. genderoutlaw says:

    Wow, great article! Very in depth and well-researched!! I’ve experimented with topical saw palmetto extract, applied directly to the scalp. It immediately stopped hair loss. I was only on it for a few months, and once I stopped the hair loss returned. My pharmacist didn’t think that 3 months of use would block DHT systemically, but presumably long term topical use would seep into the bloodstream, causing DHT inhibition. I’m thinking that used on and off though, it could be helpful in slowing hair loss.

    There are other herbs with similar properties that can also be used topically: This Japanese study indicates that licorice, clove and peppermint also inhibit DHT. Apparently spearmint and green tea have similar properties. I’m going to talk with my pharmacist about formulating a custom shampoo that I could use on and off. I’d love to get DHT testing while I’m using it, but that test is $180 in Canada (they have to ship the sample on dry ice to Utah.)

    From the world of TCM, there’s also Glycyrrhiza Glabra root extract, Paeonia Albiflora root extract, Polygonum Multiforum extract and Prunus Persica (peach) seed extract. I have yet to speak with my TCM doc though to find out how these work.

  2. americantransman says:

    Oh you are so right! I completely forgot about topical applications of saw palmetto, which is probably an okay route to use it. I was speaking more of ingesting saw palmetto.
    Thanks!

  3. Matt Kailey says:

    I use Finasteride now, but I had no idea about the beard growth thing. I’m glad to learn that, because my doc didn’t mention it. I was on T for about 8 or 9 years before I started losing my hair. I thought I was in the clear–I figured, after that long, I didn’t have the male pattern baldness gene.

    Then all of a sudden, it started falling out–hair everywhere but on my head! I went off T for a few months to mitigate a health problem, and to my surprise, my hair grew back! I don’t think this would happen for someone who is completely or almost completely bald, but the bald circle that was forming in back grew back, and my receding hairline came forward again.

    When I went back on T, I also started Finasteride. I get the one that you have to cut into fourths. So far, so good, although my hair is still falling out, but at a reduced rate. I didn’t think about beard growth, but after 12+ years on T, I think I have everything I’m going to get. I have never had a thick beard and it grew in sparsely even before the Finasteride. I think it’s just genetics. But the topical application makes sense.

    Thanks for the great and informative article.

  4. Michael says:

    Fantastic Blog and thoroughly entertaining and informative article. I like the way you have combined science with some humor to make it accessible and an enjoyable read. I look forward to reading your next blog entry!

  5. Jason says:

    I was curious as to whether hair would grow back in if someone stopped T. Matt, about how many months did it take for your hairline to fill back in? Did you use Rogaine when you were off T to encourage growth and did the new growth continue to fill in when you resumed T and started Finesteride? My HDL and LDL levels could use an adjustment off T, they’re not doing so well.

    • Matt Kailey says:

      Sorry, I didn’t see this question, Jason. I don’t know why it grew back. I didn’t expect it to, and I don’t think it would for guys who are really bald. I had a receding hairline and a circle in the back of my head (you know the kind) that was slowly getting larger. When I went off T, within a month, my hair stopped falling out and I would say that I noticed that it was growing back within about three months. I think I was off T for about 6 months, maybe 9 months. It was a while back, so I can’t remember for sure. But I would say that, within about 3 months, I noticed that it was growing back.

      I still have a slightly receding hairline, but my hair in front thickened back up and it really doesn’t appear as much of a receding hairline. And I still have a thinning spot in back, but it was getting large, and it basically grew almost all the way back in.

      I did not use anything while I was off T to grow the hair back in. I didn’t even think about it, because I was not expecting the hair to grow back. Then when I realized it was, I thought, “Wow, this is great,” and when I went back on, I asked for the Finasteride to try to maintain the hair that grew back. I had some Rogaine, too, but I didn’t use it. My doc said I didn’t need the Rogaine, because the Finasteride would keep the new hair from falling out. So far, it has done a pretty good job. Since I went back on (a while back), I have noticed that my hair is continuing to fall out, but at a much slower rate, and even though I see hair in the sink, etc., I’m not seeing any real change on my head (my hairline and the back don’t seem to be changing at all–the regrowth seems to be staying put).

      I don’t know if this would happen with every guy. I don’t know why it happened to me. I’ve had some health problems with T–high cholesterol, thick blood, liver inflammation. So I have adjusted my dose, and I think going off for a while helped those things, and the hair regrowth was an added bonus for me.

      I do know trans women who used Rogaine in the beginning of transition to grow hair back, and I think this was successful for some of them until they were able to have surgery or get a testosterone blocker and start estrogen. One woman I know says that she used Rogaine until she had surgery, which stopped the massive testosterone production in her body, and then she didn’t have to use it anymore, and she has a full head of hair now. So obviously it helped her.

      In my case, no Rogaine, but I do think it works for a lot of people. I can’t guarantee that hair will grow back if a person goes off T. I think it depends. But you could try Rogaine to grow hair back in, and Finasteride to keep that new hair from falling out.

      This is a rambling answer. I don’t know if I answered your question or not!

  6. Jason says:

    Thanks Matt, you did answer my questions. I started taking Finasteride early in transition when I noticed a rapidly receding hairline and excessive hair loss in the shower. It worked well to slow down the hair loss, I even had some new growth. I stopped taking it thinking it might be a factor in my slow facial hair development. After 9-12 months without it I still don’t have much facial hair so I’m leaning towards genetics. I wouldn’t be opposed to stopping or reducing T for a few months to fill in part of the receding hair line, a “do-over” of sorts, and my lipid profile would get a break too. I wore my hair in a crew cut for years before I transitioned and was surprised it bothered me when it started to fall out.

  7. jas says:

    These wrk: boil green tea leaves in water. Till the water turns brown. Spray the water on your scalp when it cools.
    Go to an Asian Indian store. Buy yourself Bhringraj hair oil. rub a little on your scalp. Do it every day. Should help. Bhringraj has a herbal aroma. Evry guyI know worries abt hair loss whether he’s a natal man or trans man. when ppl have reported that when they go off rogaine they loose more hair.

  8. Gabe says:

    There’s at least one study (from Merck, strangely enough) that says that individual effective dosage for Propecia has a range of .2 – 1.0 mg per day, even though all the literature recommends a minimum dosage of 1.0 mg per day.

    Personally, I started taking 1 pill per day (1.0 mg) as directed and after about a month it definitely made my hair thicker in front. But I also started getting terrible stomach pains – the beginning of pancreatitis – so I stopped and the stomach problems went away immediately. After another month off of Propecia I noticed the hair getting thinner again and started to panic a little – if I had a bad reaction to Propecia then I figured I had to deal with going bald pretty fast (I started transitioning in my 30s, an age by which most of my male relatives had already lost a lot of their hair, so I worried it would happen more or less overnight).

    I did a little research and found the Merck study, so I decided to test out a quarter dosage. Unfortunately I can’t remember where I read the actual study but it’s referenced in a few hair loss forums. The pills are small and difficult to cut accurately but I’m getting around .2 – .3 mg per day instead. The good news is the quartered dose seems to be both working and not causing any stomach problems. Another nice “side effect” is that it cuts the cost by a quarter as well.

    It probably won’t work for everyone – which is probably the reason for the 1.0mg prescribed dose – but I thought it was worth mentioning.

  9. 65mm says:

    Hey, great articles. It’s shocking how many trans guys have little to no scientific understanding of their medical transition. This is a very helpful blog. Also I think there’s an extra hydrogen at carbon-3 of testosterone in that diagram.

    • Hey 65mm, good catch on the extra hydrogen on the testosterone molecule. I don’t even remember where I pulled that image but I certainly missed it. I’ll have to fix it. Thanks for the heads-up.

      As for guys not having scientific understanding of their medical transition, I guess it’s all relative, with some guys knowing more than others.

      Thanks for the comments.

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  11. Ian Maxwell says:

    The men on my Mom’s side are bald, my brother is bald and I’m starting to see significant hair loss on top of my head at almost 10 months on T. So my suspicions are that I will also end up bald. I’d rather have a beard and maximum growth in my pants than worry that those will stop. If my hair thins to much I will look into a hair transplant. I have thick hair in the parking strip, so there should be plenty for a transplant. One good thing, a bald dude will never be called, “Mam”! Always got to look to the bright side. May see if Rogaine will slow the inevitable though. Thanks for the great article and resources

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  13. TomCat says:

    This is great information, thanks for sharing. I discuss finasteride on my blog and refer readers to your post for a more detailed description: https://thomasingenderland.com/2016/04/26/zero-dollar-haircut/

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