Finasteride: What I Tell My Male Patients (And What I Don't)
"Doc, just give it to me straight. Will finasteride kill my dick?"
I get this question at least three times a week. Usually from guys who've spent hours on forums reading horror stories about permanent sexual dysfunction, growing breasts, and brain fog.
After prescribing finasteride to over 500 men in the past 15 years, here's the conversation I have behind closed doors – the one without the medical journal speak or pharmaceutical company talking points.
The Numbers I Share (And the Ones I Don't)
What the studies say:
- 1-2% experience sexual side effects
- Most resolve when stopping the medication
- Highly effective for hair retention (90% keep their hair)
What I've actually seen in my practice:
- ~8-10% report some sexual changes
- ~5% stop due to sides
- ~2% have persistent concerns after stopping
- 100% were terrified before starting
That discrepancy between published data and real-world experience? It keeps me up at night.
The Consultation That Changed My Approach
Three years ago, James, 26, came in. Classic male pattern baldness, Norwood 3. Textbook finasteride candidate. I gave him my standard spiel about how rare side effects were.
He started the medication. Within two weeks:
- Weak erections
- Watery semen
- Zero morning wood
- Panic attacks about his dick not working
I told him what I'd been trained to say: "It's probably anxiety. The studies show..."
He looked me dead in the eye: "Doc, I know my dick. This isn't anxiety."
He was right. And I was being a dismissive asshole.
What Actually Happens (The Real Talk Version)
Finasteride blocks 5-alpha reductase, which converts testosterone to DHT. Less DHT = less hair loss. But DHT does other things:
- Sexual function (for some men)
- Mood regulation
- Cognitive function
- Muscle development
When you nuke 70% of your DHT, most guys are fine. But some aren't. And we can't predict who.
The sides I see most:
- Decreased libido (most common)
- Erectile issues (less common)
- Brain fog (surprisingly common)
- Mood changes (under-reported)
- Gynecomastia (rare but real)
The Nocebo Effect Problem
Here's where it gets complicated. The mind is powerful. I've seen guys read about sides and develop them before the medication could even build up in their system.
But I've also seen guys with zero anxiety, no forum reading, who had legitimate sexual dysfunction within days of starting.
Both realities can exist. Dismissing either is medical malpractice.
My Current Informed Consent Speech
"Finasteride works. Really well. About 90% of men will keep their hair, and many will regrow some.
Most guys have zero issues. But about 1 in 10 in my practice notice some sexual changes – usually decreased libido or weaker erections. Most of the time, these resolve if you stop.
Very rarely – and I mean maybe 1-2% – guys have issues that persist after stopping. We don't fully understand why. Post-finasteride syndrome is controversial, but I've seen it enough to believe it's real for some men.
You need to decide: is keeping your hair worth a small but real risk of sexual sides? There's no wrong answer."
Why I Respect Guys Who Say No
After that speech, about 30% of guys say "thanks, but no thanks."
Good for them.
Seriously. Making an informed decision about your body, weighing risks and benefits, and choosing what matters to you? That's adulting at its finest.
Hair loss sucks. But you know what sucks more? Taking a medication you're terrified of every single day.
The Alternatives I Offer
For guys who pass on finasteride:
Topical finasteride:
- Lower systemic absorption
- Fewer sides (in theory)
- Still works (but maybe less)
- More expensive
Minoxidil:
- No hormonal effects
- Decent results
- Twice daily forever
- Can cause its own issues
Microneedling + topicals:
- No systemic medication
- Solid evidence
- More work
- Still helps
Accept it:
- Shave it off
- Own it
- Jason Statham that shit
- Honestly? Respectable choice
The Success Stories I Don't Post on Instagram
Most of my finasteride patients are happy. They keep their hair, their dicks work fine, life goes on. But you won't see me posting their before/afters with "ZERO SIDES!" captions.
Why? Because that dismisses the guys who had real problems. It creates pressure to not report sides. It makes the 8-10% feel like failures.
Medicine isn't marketing. Every patient matters, including the ones with bad outcomes.
What I Watch For (Red Flags)
I'm more cautious prescribing to:
- Guys under 25 (brain still developing)
- History of depression/anxiety
- Sexual dysfunction already present
- Extremely fearful (nocebo risk)
- Perfectionist personality types
Not saying I won't prescribe, but we have longer conversations.
The Elephant in the Room: Post-Finasteride Syndrome
PFS is controversial. Many doctors think it's psychological. The studies are mixed.
But I've had three patients with persistent sexual dysfunction years after stopping. Three out of 500+ isn't many, but tell that to those three guys.
I don't know if it's receptor changes, epigenetic modifications, or something else. But I believe them. Their suffering is real, regardless of the mechanism.
My Protocol for Guys Who Want to Try
- Baseline assessment:
- Sexual function questionnaire
- Mood assessment
- Sometimes hormone levels
- Start low:
- 0.5mg daily or 1mg every other day
- Can increase if tolerated
- Check-ins:
- 2 weeks (sides usually appear fast)
- 1 month
- 3 months
- Then every 6 months
- Permission to stop:
- Any time
- For any reason
- No judgment
The Bottom Line Truth
Finasteride is simultaneously:
- The most effective hair loss drug we have
- Generally safe for most men
- Capable of causing real sexual sides
- Worth trying for many
- Worth avoiding for others
There's no universal answer. There's only YOUR answer.
What I Wish Every Guy Knew
- Your mental health matters more than your hairline
- Sexual function matters (whoever says otherwise is lying)
- You can always stop the medication
- There are other options
- Bald can be attractive
- Fear of sides can cause sides
- Real sides aren't "in your head"
- Doctors who dismiss your concerns suck
- Forums aren't medical advice
- Your choice is valid, whatever it is
Some guys pop finasteride for decades with zero issues. Some get sides from looking at the bottle. Most fall somewhere in between.
Know the risks. Make your choice. Live with it.
And if your doctor dismisses your concerns or pressures you either way?
Find a better doctor.
Note: James stopped finasteride, sides resolved in 3 months, now uses topical solutions with good results. He taught me to listen better. Every patient since has benefited from that lesson.