Following several emails and comments to my previous blog on hair growth (and *other* growth), I thought I would provide a few NSFAQS (not so frequently asked questions):
Q. If a trans guy goes on testosterone hormone replacement therapy, will he lose his hair and suffer some sort of male-pattern baldness?
A. Not necessarily. It depends on the genetics of the individual.
Q. If a trans guy goes on testosterone hormone replacement therapy and does start to lose his hair, will taking finasteride stop the hair loss?
A. It might. It could stop the hair loss completely, or it could stop hair loss somewhat, or it might not help at all. It depends on the genetics of the individual.
Q. If a trans guy goes on testosterone hormone replacement therapy and starts to lose his hair , will taking finasteride negatively affect the growth of his facial hair and penis?
A. It might. Or it might not. Or it might somewhat. It depends on the genetics of the individual.
I think you’re probably getting the drift: I like to give vague answers to NSFAQS…
Well, no, actually, the point is that all this beard growth and hair loss and penis growth and finasteride business depends on the genetics of each person.
I have been contacted by some guys who are so concerned about losing their hair that they hesitate to go on testosterone (T), even though they really want to medically transition, but without going on T, a guy won’t ever know whether his concern is grounded in the reality of his genetics.
I would point out that all of these events take time, so if a guy’s hair is going to fall out when he takes T, it won’t all happen at once. A guy will notice that it’s occurring and he will have time to do something about it. An example would be Matt Kailey, who described on his own experience with hair loss and finasteride in a comment to the first post on this subject.
Then there is the comment by Gender Outlaw regarding the use of topical saw palmetto — an excellent point. In my previous post, I was referring to ingested saw palmetto and had not considered a topical application. In addition, there are topical formulations of finasteride that are being tested as a treatment for male-pattern baldness.
The question there, as raised by Gender Outlaw, would enough of the compound get into the body through the scalp to negatively affect beard and genital growth? I touch on this when I talk about topical DHT (below).
More of What’s in Your Pants
To address the potential issue of topical hormones being absorbed and becoming systemic, let’s take a little side track and get back to genital growth. There are a number of methods that trans guys have used to increase the growth of their penis after starting T. I won’t discuss pumping, although it’s a popular topic, because I don’t know enough about it, but you can read about it here.
Another method is to put topical T directly on the genitals. I have heard guys say that their doctor told them to do it and some surgeons recommend it. The problem is, it’s never been properly tested. I’ve heard at least one surgeon say that he noticed no significant benefit to penis growth when guys put topical T directly on their genitals. All the data are anecdotal.
While on the topic of topical T, I will repeat one thing that I’ve heard multiple times, a warning that should probably be heeded: DO NOT PUT ANDROGEL ON YOUR GENITALS! Why? Because it has a high alcohol content, and it will burn your d**k! If a person absolutely must put T on their genitals, they should use the T cream.
Another method that guys use, mainly outside of the U.S., is to put topical DHT cream on their genitals in the hopes of enhancing penis growth. Considering the importance of DHT in genital growth in natal men (as mentioned in my previous post), some people might reason that more could be better. DHT formulated as a cream, however, is difficult to come by in the U.S.
Back in the fall, there was a significant discussion on one of the FTM lists about DHT cream to stimulate genital growth. I have reproduced here a summary of information that I wrote for that discussion, but for privacy reasons have removed the names of the other participants:
This thread has been about the use of topical Andractim/DHT cream to stimulate phallus growth in trans men either pre- or post-bottom surgery.
DHT stands for dihydrotestosterone, and is produced from testosterone by the action of the enzyme 5-alpha reductase. This is a one-way reaction, so DHT cannot be converted back into testosterone in the body, and unlike testosterone, DHT cannot be converted into estrogen. The 5-alpha reductase enzyme is located mainly in the skin, adrenal glands and prostate.
Because the androgen receptor binds DHT with higher affinity than it does testosterone, it is the DHT in skin and prostate that is responsible for male-pattern baldness (androgenic alopecia) and enlarged prostate (benign prostatic hyperplasia; BPH), respectively. One treatment for these conditions is oral finasteride which blocks the 5-alpha reductase enzyme, and is sold under the name Proscar for BPH and Propecia for baldness.
Use of DHT by Trans Men to Stimulate Phallus Growth
Female-bodied individuals who take testosterone treatments for masculinization of their bodies during transition usually experience clitoromegaly (growth of the clitoris) due to the action of androgen on the clitoris, which is an erectile organ with the same embryonic origins as the penis.
Because DHT is important in the growth of the penis and other external male genitalia during both fetal development and puberty, it stands to reason that DHT cream applied directly to the genitalia of female-bodied individuals could potentially stimulate growth of the clitoris/phallus.
There are no data in this area from studies with trans men so all the information in this area is anecdotal. However, there is one published paper, info provided by TransGuys.com that reports penis growth in 22 patients with microphallus.
This paper is not available in electronic form and I was not able to get a copy of it, so I can’t tell whether all of the patients were children or just some of them (i.e. still growing), how many of the patients experienced phallus growth (the abstract only reports an average) and I can’t tell what formulation of DHT was applied. Still, this is evidence that a potential exists for DHT to work to stimulate phallus growth of trans men – perhaps not all trans men, but maybe some trans men. That’s the potential benefit. What are the risks?
Risks of Topical DHT Administration
The risk of using DHT on the genitals to stimulate phallus growth has to do with testosterone levels.
First, let’s look at the information from Nick Gorton’s health guide on transgender men:
“Clitoromegaly occurs, and frequently reaches its apex within 1-3 years of therapy. Sizes generally range from 3-7 cm with 4-5 cm being about average.50 In a minority this may be sufficient to engage in penetrative intercourse with a partner.
This is genetically influenced, but some physicians advocate topical clitoral testosterone cream as an adjunct to growth before metaidioplasty (surgical reconstruction of the hypertrophied clitoris to more closely resemble in structure, location, and function a penis.) There is no definitive evidence for this practice, but anecdotally it seems to be effective for some patients.
However, this testosterone is absorbed and should be calculated into a patient’s total regimen. In addition, a greater proportion of testosterone absorbed through genital skin will be converted to DHT than if applied elsewhere. This may produce stronger masculinization as well as an increase in adverse effects. Patients should be counseled that higher parenteral dosages of testosterone have not been shown to significantly increase clitoral size in individual patients when compared to more normal dosing. Like other effects of androgens, time and genetics seem to be the primary determinants.”
As noted, application of testosterone gel/cream to the genitals has also been tried as a way to increase phallus growth, but there are problems associated with that. First, the testosterone applied this way is absorbed into the body and adds to the testosterone that is being administered as hormone replacement therapy for transitioning, which contributes to a risk of testosterone levels that are too high. In addition, the testosterone can be converted to both estrogen and to DHT. (One reason DHT is gaining popularity for this use is because it cannot be converted into estrogen.)
As stated above, a greater proportion of testosterone applied to the genitals than to other areas of the body will be converted to DHT, as mentioned by Nick Gorton: “The choice of the application site is quite important. When the gel is applied to the trunk or axillary area, the resulting balance of testosterone, DHT, and E2 will be very much in the normal physiologic range. However, when the gel is applied to the scrotum, the level of DHT becomes much higher because of the presence of a much higher level of the enzyme 5-alpha reductase.”
What are the ramifications when DHT (rather than testosterone) is applied to the genitals? The key passage from above is “In addition, a greater proportion of testosterone absorbed through genital skin will be converted to DHT than if applied elsewhere. This may produce stronger masculinization as well as an increase in adverse effects.”
In other words, DHT, whether metabolized from testosterone that has been applied to the genitals or applied to the genitals directly as Andractim or other topical cream, can cause the same adverse effects as too high of a testosterone dose – the problem is that because DHT is not converted to testosterone, you cannot monitor testosterone levels to determine whether your DHT levels are too high. And even if you did monitor your DHT levels, what would be “too high”? We don’t know in trans men what that would be. In addition, DHT is 3-10 times more potent than testosterone, so its effects in combination with those of testosterone could potentially cause adverse events (for example, on hematocrit levels).
These things are only a concern if the DHT becomes systemic rather than staying locally in the skin. On the TransGuys.com web site: “Topical DHT shouldn’t drastically affect blood pressure or testosterone levels, but it’s a good idea to get regular blood work done while you’re using DHT, and to observe your moods and adjust your testosterone dosage as required.”
So, for example, if you are combining topical DHT on the genitals with your regular testosterone and you see an increase in your hematocrit and hemoglobin (H&H), you might need to reduce your testosterone dose to get your blood work results back in line. This is a possibility considering that an increase in hematocrit and hemoglobin was seen in older men who were treated with transdermal DHT for hormone replacement therapy (reference from TransGuys.com).
The men in that study were treated daily with 70 mg of DHT and the dose mentioned on the TransGuys.com web site is almost the same : 20 mg at 3 times per day, which is 60 mg daily, so checking your blood work while on DHT cream would be prudent.
Effects of DHT on Testosterone Levels
One point of confusion in this discussion seems to stem from this particular publication (mentioned above), where DHT treatment of older men caused a decrease in total and free testosterone. In theory, treatment of cis-gendered men with DHT at a dose that results in measurable levels in blood *should* cause a decrease in the testosterone levels.
Under homeostasis in natal men, luteinizing hormone (LH) from the pituitary stimulates testosterone production by the testicles, and the testosterone feeds back to the pituitary to keep the LH production in check, which in turn keeps the testosterone levels in check – it’s a feedback loop.
So if testosterone production by the testicles were to decrease, then the pituitary would increase it’s production of LH to stimulate more synthesis of testosterone by the testicles, which would feed back again to the pituitary to get to homeostasis.
Conversely, if testosterone production by the testicles were to increase, then it would negatively feed back to the pituitary to cause a decrease in LH, which would reduce the stimulation of the testicles and less testosterone would be synthesized until homeostasis was reached again.
If you threw DHT into that loop by applying it to your genitals, the DHT would go to the brain and act like testosterone as negative feedback to reduce LH output by the pituitary. A decrease in LH from the pituitary would result in less stimulation of the testicles and that would result in a decrease in testosterone synthesis and lower overall testosterone levels in the blood. In fact, that was what was seen in the study – lower levels of both LH and testosterone in the blood of the men on DHT treatment.
In trans men, this feedback loop doesn’t exist because the testosterone is coming from outside of the body, which is all the more reason why guys on both genital DHT cream and testosterone HRT should keep a close eye on their blood work.
Unfortunately, it’s all a crap shoot because there isn’t enough research conducted with trans men. Hopefully, that will change with time. In the meantime, because there aren’t tried and true methods and data, it’s best to keep track of how your body reacts when trying to get the most out of, or should I say ‘into,’ beard growth and what’s in your pants.