Post Finasteride Syndrome

from Wikipedia, the free encyclopedia

The post-finasteride syndrome ( PFS ) describes a term used by doctors, patients and the media for a symptom complex with persistent sexual, neurological, mental and physical side effects in patients taking finasteride , a 5α-reductase inhibitor, for the treatment of hair loss ( under the brand name Propecia or Generic ) or an enlarged prostate ( BPH ) (under the brand name Proscar or Generic). This probably rather rare disorder can last for months to years after stopping the drug; in many cases it remains permanent , although an intake of as little as 10 days can lead to this syndrome.

Classification according to ICD-10
Entry is missing Unwanted side effects ...
N48.4 Impotence of organic origin
F52.0 Lack or loss of sexual desire
F32.2 Severe depressive episode without psychotic symptoms
N62 Hypertrophy of the breast (mammary gland)
M62.5 Muscle wasting and atrophy, not elsewhere classified
... for therapeutic use of pharmaceuticals, drugs or biologically active substances
Y42.6 Antigonadotropins, antiestrogens and antiandrogens , not elsewhere classified
ICD-10 online (WHO version 2019)

Symptoms

The following symptoms are summarized under the so-called PFS:

Often the symptoms worsen after stopping or do not occur until after stopping.

frequency

The frequency of PFS is unclear, but these symptoms are very rare. However, a high number of unreported cases is assumed. On April 11, 2012, the FDA changed the package insert in the USA. a. indicates the number of reported cases in the United States. Further studies are required in science and on the patient side.

causes

The cause of the so-called PFS is not exactly known. Finasteride inhibits the conversion of testosterone to DHT , but it also changes testosterone, LH and FSH levels. The biosynthesis of DHT and various neurosteroids, such as allopregnanolone (ALLO) and tetrahydrodeoxycorticosterone (THDOC), depend on known isoforms of 5α-reductase . They are positive allosteric modulators of the GABA A -receptors , which the same place of action of euphoric and anti-anxiety drugs, such as z. B. Benzodiazepines own. Since finasteride has been shown to prevent their biosynthesis, and patients with PFS have decreased or increased levels of some neurosteroids, this effect is one of the possible causes of the emotional and sexual side effects, but some symptoms such as muscle wasting and loss of body hair and the persistent side effects long after stopping it, not fully explained.

Since many patients have both normal to high testosterone levels and normal to low estrogen levels , but the clinical picture of hypogonadism , it is believed that some type of androgen resistance is present.

Study results

In the fMRI, patients with the PFS showed an increased activity of the neural network for sexual arousal and a reduced activity of the brain regions, which are associated with the reaction to erotic stimuli. These conflicting findings may indicate a neurological change. In addition, other abnormal activities were identified in certain areas of the brain that are consistent with those of major depression .

In the investigation of the androgen receptor gene polymorphism , in which the CAG and GGN repeats of PFS patients were determined, a connection between the number of repeats and the PFS symptoms that occur, such as sensation of penile sensation and loss of scrotum sensitivity, was found to be reduced Pubic hair, regression of the perineum , involuntary muscle twitching, loss of muscle tone, weight gain, and dry skin. For example, in patients with short or long repeats, symptoms associated with dry skin are significantly more severe than in those with medium repeats, and penile sensations were more common in patients with medium and long repeats than in those with short repeats.

A team led by Steven M. Belknap found that men between the ages of 16 and 42 who took finasteride at a dose of up to 1.25 mg daily and had no previous sexual problems had an increased risk of erectile dysfunction and low libido . 1.19% of these men who took finasteride for more than 205 days developed persistent erectile dysfunction that lasted for more than 90 days. The risk of persistent erectile dysfunction increased the longer finasteride was taken, regardless of age.

In this Italian study, the neurosteroids of 16 PFS patients who showed no signs of erectile dysfunction or depression before taking finasteride and 25 control persons were determined in the blood plasma and CSF . The PFS patients showed significantly reduced levels of DHT, pregnenolone, progesterone, 17-beta estradiol and dihydroprogesterone (DHP) and increased levels of DHEA, testosterone and 3-alpha diol in the CSF. Significantly reduced levels of DHP and allopregnanolone and increased levels of pregnenolone, DHEA and testosterone were found in the blood plasma. Decreased levels of allopregnanolone in plasma and decreased progesterone levels in CSF are typical in depressive / anxious symptoms. Important functions of neurosteroids include controlling sexual behavior, synaptic plasticity , myelin maintenance, and neurogenesis in adulthood. In the PFS patients with severe erectile dysfunction (25% of those affected by PFS), abnormal somatosensitive evoked potentials of the pudendal nerve were found. Major depression was also diagnosed in 50% of patients with PFS on the basis of a questionnaire.

Scientific articles

In the 15th edition of the specialist journal Gynäkologische Endokrinologie (Springer Verlag), a 10-page article is dedicated to the post-finasteride syndrome for the first time in Germany. In addition to an exact pharmacological explanation of the mode of action of finasteride, one learns, for example, that the intake of just 0.04 mg finasteride per day reduces DHT almost as much as the recommended dose of 1 mg against AGA . In addition to the permanent side effects already mentioned in the leaflet, such as a decrease in libido, ejaculation disorders and impotence, the previously neglected permanent mental, cognitive and psychological disorders up to severe depression are listed. In addition to a tabular list of symptoms of patients with PFS who, in addition to the sexual symptoms, indicated muscle atrophy, increased anxiety, sleep disorders, suicidal thoughts, lethargy / fatigue, severe memory loss, slow thought processes, mental cloudiness, confusion and attention deficits, it is again pointed out that permanent Side effects can occur only after discontinuation of the drug. For the first time, the possible causes of the syndrome are discussed. It is assumed that an epigenetic change ( DNA methylation ) affects both the correct function of the 5-alpha reductase gene and the androgen receptor gene. These methylations are probably also related to the disorders in the central nervous system (CNS) listed . Finally, therapy options are weighed up. Treatment with testosterone and progesterone is not recommended based on the suspected causes. Due to the frequent side effects of various classes of antidepressants , we recommend treating depression with norepinephrine reuptake inhibitors , dopamine agonists and serotonin agonists.

Long-term consequences

In one study, the use of finasteride showed an overall decrease in the incidence of prostate cancer . However, among those patients who nevertheless developed prostate cancer, the more aggressive, poorly differentiated carcinoma occurred more frequently than in the placebo group.

On July 5, 2018, the Federal Institute for Drugs and Medical Devices published a so-called red hand letter to explain the persistent side effects of finasteride that can occur during or after taking the drug. This includes the risk of sexual dysfunction (including erectile dysfunction, ejaculation disorder and decreased libido), which - based on individual case reports on patients - can persist for more than 10 years even after treatment has been discontinued. It also warns of mental disorders such as mood changes (including depressed mood, depression and suicidal ideation). It should also be noted that, on the recommendation of the European Medicines Agency, “Anxiety” will be included as a new side effect in the product information for finasteride.

therapy

Nothing is currently known about a therapy for PFS, as the exact cause is still unclear. Some affected patients are hardly or not at all, or in some cases even negative effect on the substitution with different androgen - derivatives .

Public interest

Due to the high level of suffering of the patients and the growing number of lawsuits against the manufacturer in the USA , the interest of the media in this topic also grew there. Some of those affected and their parents dared to go public and, among other things , drew attention to themselves through a hunger strike in front of the manufacturer's headquarters .

Some scientists and doctors warn the public about the existing risks or publish on this topic. Mention should be made here:

Michael Irwig (George Washington University), AM Traish (Boston University), Irwin Goldstein (Editor-in-Chief of the Journal of Sexual Medicine ), Eugene Shippen (author of the book The Testosterone Syndrome ), Michael Zitzmann (Andrology, University Hospital Münster), A. Jacobs ( Neuroendocrinologist, New York), John Crisler, (Director, All Things Male - Center for Men's Health).

The post-finasteride syndrome has already been reported several times in the media in different countries. In Germany, the ZEIT, the Süddeutsche Zeitung, the Focus die Welt am Sonntag , Welt-Online, Spiegel Online , the Frankfurter Allgemeine Zeitung and the Huffington Post have already reported on this . In November 2016, the Vice Media health channel “Tonic” in the USA published a detailed report entitled “The medical mystery behind America's best-selling hair-loss drug”, in which the fate of several people affected is reported. Furthermore, the French broadcaster France 5 reported in November 2016 on the program “Le Magazine de la Santé” under the heading “Finasteride - un medicament sous surveillance” about the suicide of a 25-year-old PFS patient. In the same year, the Spanish broadcaster TV3 broadcast documentaries on the PFS under the title “Pills in Search of an Illness” and the Belgian broadcaster VRT under the title “The Wonderhair Pill”. Previously, in 2015, the American broadcaster WTVR-TV published the report “How One Man Said Hair-Loss Drug Ruined His Life”. In England, too, PFS has already been reported on iTV's This Morning show. In addition, intelligence services in the United States and Sweden have reported persistent side effects after stopping finasteride.

In early 2015, post-finasteride syndrome was added to the US National Institutes of Health's Information Center on Genetic and Rare Diseases.

In March 2016, New Zealand added Post-Finasteride Syndrome to its MedSafe division of the New Zealand Medicines and Medical Devices and Safety Authority.

Legal disputes

In the USA the number of lawsuits against the manufacturer is growing. This takes place, among other things, in the form of class actions. In Germany, too, several injured patients have come together to take action against Merck Sharp & Dohme with the newly created model declaratory action. There is also a group of other victims who are taking legal action against Merck and a generics manufacturer with the help of a litigation financer.

The Post-Finasteride Syndrome Foundation

In August 2012, the Post-Finasteride Syndrome Foundation (PFS Foundation) was established with its headquarters in the USA. Its goals are to: educate scientists, medical professionals, health organizations and the media about the existence and necessity of research into PFS, basic research and the search for a potentially effective therapy .

Since only very few doctors are aware of the post-finasteride syndrome and therefore often do not take those affected seriously who visit them, the PFS Foundation has a list of doctors around the world who are familiar with PFS and whom those affected can turn to.

Web links

Individual evidence

  1. ↑ Herbert Kuhl, Inka Wiegratz: The post-finasteride syndrome . In: Gynecological Endocrinology . tape 15 , no. 2 , May 2017, p. 153 , doi : 10.1007 / s10304-017-0126-2 .
  2. ↑ Abdulmaged M. Traish, Roberto Cosimo Melcangi, Marco Bortolato, Luis M. Garcia-Segura, Michael Zitzmann, in: Review of Endocrines & Metabolic Disorders (2015) 16: 177. doi: 10.1007 / s11154-015-9319-y .
  3. ↑ a b c Roberto Cosimo Melcangi, Donatella Caruso, Federico Abbiati, Silvia Giatti, Donato Calabrese, Fabrizio Piazza, and Guido Cavaletti: Neuroactive Steroid Levels are Modified in Cerebrospinal Fluid and Plasma of Post-Finasteride Patients Showing Persistent Sexual Side Effects and Anxious / Depressive Symptomatology . In: The Journal of Sexual Medicine 2013; 10, pp. 2598-2603. doi: 10.1111 / jsm.12269 .
  4. ↑ Carla Di Loreto, Francesco La Marra et al. a .: Immunohistochemical Evaluation of Androgen Receptor and Nerve Structure Density in Human Prepuce from Patients with Persistent Sexual Side Effects after Finasteride Use for Androgenetic Alopecia. (PDF) In: PLoS ONE. 9, 2014, p. E100237, doi: 10.1371 / journal.pone.0100237 .
  5. ↑ D. Caruso, F. Abbiati, S. Giatti, S. Romano, L. Fusco, G. Cavaletti, RC Melcangi: Patients treated for male pattern hair with finasteride show, after discontinuation of the drug, altered levels of neuroactive steroids in cerebrospinal fluid and plasma. In: The Journal of steroid biochemistry and molecular biology. Volume 146, February 2015, pp. 74-79, doi: 10.1016 / j.jsbmb.2014.03.012 , PMID 24717976 .
  6. ↑ a b c d e C. Trombetta, G. Mazzon u. a .: 698 Clinical analysis in young patient with persistent sexual dysfunctions after finasteride assumption to prevent male pattern hair loss. In: European Urology Supplements. 11, 2012, pp. E698 – e698a, doi: 10.1016 / S1569-9056 (12) 60695-2 .
  7. ^ A b F. La Marra, C. Di Loreto, G. Mazzon, G. Chiriacò, C. Trombetta, S. Cauci: Preliminary Evidence of a Peculiar Hormonal Profile in Men with Adverse Effects After Use of Finasteride Against Androgenetic Alopecia . In: AJP. September 2012, Vol. 181, Suppl.
  8. ↑ a b c d e f g h i j k l m n o p q r s t u v w x y z Irwin Goldstein: An Old Problem with a New Cause-5 Alpha Reductase Inhibitors and Persistent Sexual Dysfunction. In: The Journal of Sexual Medicine. 8, 2011, pp. 1829-1831, doi: 10.1111 / j.1743-6109.2011.02368.x .
  9. ↑ G. Chiriacò, S. Cauci, G. Mazzon, C. Trombetta: An observational retrospective evaluation of 79 young men with long-term adverse effects after use of finasteride against androgenetic alopecia . In: Andrology . tape 4 , no. 2 , March 1, 2016, p. 245–250 , doi : 10.1111 / andr.12147 .
  10. ↑ a b c d e f g h i j k Propecia leaflet (PDF; 210 kB) Merck (American package insert )
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  12. ↑ a b c Abdulmaged M. Traish: 5α-Reductases in Human Physiology: An Unfolding Story. In: Endocr Pract. 2012; 18, pp. 965-975. PMID 23246684 .
  13. ↑ a b M. S. Irwig: Depressive symptoms and suicidal thoughts among former users of finasteride with persistent sexual side effects. In: The Journal of clinical psychiatry. Volume 73, Number 9, September 2012, pp. 1220-1223, doi: 10.4088 / JCP.12m07887 , PMID 22939118 .
  14. ↑ a b c d e f g h i j k l m A. M. Traish, J. Hassani, AT Guay, M. Zitzmann, ML Hansen: Adverse side effects of 5α-reductase inhibitors therapy: persistent diminished libido and erectile dysfunction and depression in a subset of patients . (PDF) In: J Sex Med. 2011; 8, pp. 872-884. PMID 21176115 .
  15. ↑ a b c d e f g h i Rose Hartzell: Changes in Men's Sexual, Emotional, and Cognitive Functioning after taking Finasteride For Hair Loss. In: The Journal of Sexual Medicine. Special Issue, Proceedings of the World Meeting on Sexual Medicine, Chicago, USA, 26. – 30. August 2012, doi: 10.1111 / jsm.2012.9.issue-s4 .
  16. ↑ CV Oztekin, S. Gur, NA Abdulkadir, U. Lokman, A. Ö. Akdemir, M. Cetinkaya, WJ Hellstrom: Incomplete recovery of erectile function in rat after discontinuation of dual 5-alpha reductase inhibitor therapy. In: J Sex Med. 2012; 9, pp. 1773-1781. PMID 22568670 .
  17. ↑ Zhou-Jun Shen, Xie-Lai Zhou, Ying-Li Lu, Zhao-Dian Chen: Effect of androgen deprivation on penile infrastructure . In: Asian J Androl. 2003; 5, pp. 33-36.
  18. ↑ AM Traish, P. Toselli et al. a .: Adipocyte accumulation in penile corpus cavernosum of the orchiectomized rabbit: a potential mechanism for veno-occlusive dysfunction in androgen deficiency. In: Journal of andrology. Volume 26, Number 2, 2005 Mar-Apr, pp. 242-248. PMID 15713830 , ISSN  0196-3635 .
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  21. ↑ a b c d B Römer, P Gass: Finasteride-induced depression: new insights into possible pathomechanisms . In: Journal of Cosmetic Dermatology . tape 9 , no. 4 , December 2010, p. 331-332 , doi : 10.1111 / j.1473-2165.2010.00533.x , PMID 21122055 .
  22. ^ FDA Mandates New Safety Labeling Changes for Propecia, Proscar - April 2012.
  23. ↑ Michael R. Pinsky, Serap Gur, Anthony J. Tracey, Andrew Harbin, Wayne JG Hellstrom: The Effects of Chronic 5-Alpha-Reductase Inhibitor (Dutasteride) Treatment on Rat Erectile Function. In: J Sex Med. 2011; 8, pp. 3066-3074. doi: 10.1111 / j.1743-6109.2011.02425.x .
  24. ↑ MC Uygur, AI Arik, U. Altuğ, D. Erol: Effects of the 5 alpha-reductase inhibitor finasteride on serum levels of gonadal, adrenal, and hypophyseal hormones and its clinical significance: a prospective clinical study. In: Steroids. 1998; 63, pp. 208-213. PMID 9589555 .
  25. ↑ External identifiers or database links for allopregnanolone : CAS number: 516-54-1, PubChem : 92786 , ChemSpider : 17216124 , Wikidata : Q2482223 .
  26. ↑ External identifiers or database links for tetrahydrodeoxycorticosterone : CAS number: 567-03-3, EC number: 209-301-3, ECHA InfoCard: 100.008.457 , PubChem : 91475 , ChemSpider : 82600 , Wikidata : Q2058978 .
  27. ^ BG Gunn, AR Brown, JJ Lambert, D. Belelli: Neurosteroids and GABA (A) Receptor Interactions: A Focus on Stress . In: Frontiers in Neuroscience . tape 5 , 2011, p. 131 , doi : 10.3389 / fnins.2011.00131 , PMID 22164129 , PMC 3230140 (free full text).
  28. ↑ A. Vermeulen, VA Giagulli, P. De Schepper, A. Buntinx, E. Stoner: Hormonal effects of an orally active 4-azasteroid inhibitor of 5 alpha-reductase in humans . In: The Prostate . tape 14 , no. 1 , 1989, pp. 45-53 , PMID 2538808 .
  29. ↑ Neuroactive Steroid Levels are Modified in Cerebrospinal Fluid and Plasma of Post-Finasteride Patients Showing Persistent Sexual Side Effects and Anxious / Depressive Symptomatology. October 2013, accessed August 19, 2016 .
  30. ↑ Shehzad Basaria, Ravi Jasuja, Grace Huang, Whitney Wharton, Hong Pan: Characteristics of Men Who Report Persistent Sexual Symptoms after Finasteride Use for Hair Loss . In: The Journal of Clinical Endocrinology & Metabolism . September 23, 2016, ISSN  0021-972X , p. jc.2016–2726 , doi : 10.1210 / jc.2016-2726 ( press.endocrine.org [accessed October 20, 2016]).
  31. ↑ Sabina Cauci PhD, Giovanni Chiriacò MD Erika Cecchin MS, Giuseppe Toffoli, MD, Serena Xodo MD, Giuseppe Stinco MD, Carlo Trombetta MD: Androgen Receptor (AR) Gene (CAG) n and (GGN) n Length Polymorphisms and Symptoms in Young Males With Long-Lasting Adverse Effects After Finasteride Use Against Androgenic Alopecia. Retrieved January 19, 2017 .
  32. ↑ Tina Kiguradze, William H. Temps, Paul R. Yarnold, John Cashy, Robert E. Brannigan: Persistent erectile dysfunction in men exposed to the 5α-reductase inhibitors, finasteride, or dutasteride . In: PeerJ . tape 5 , March 9, 2017, ISSN  2167-8359 , doi : 10.7717 / peerj.3020 , PMID 28289563 , PMC 5346286 (free full text).
  33. ↑ Roberto Cosimo Melcangi, Daniele Santi, Roberto Spezzano, Maria Grimoldi, Tommaso Tabacchi: Neuro Active steroid levels and psychiatric and andrological features in post-finasteride patients . In: The Journal of Steroid Biochemistry and Molecular Biology . July 2017, doi : 10.1016 / j.jsbmb.2017.04.003 .
  34. ↑ Herbert Kuhl, Inka Wiegratz: The post-finasteride syndrome . In: Gynecological Endocrinology . tape 15 , no. 2 , May 1, 2017, ISSN  1610-2894 , p. 153-163 , doi : 10.1007 / s10304-017-0126-2 .
  35. ^ WR Pitts, Jr .: Finasteride (Propecia) and the Promotion of High-Grade Prostate Cancer . (PDF) In: Archives of Dermatology . 2004, 140, pp. 885-886.
  36. ↑ 5-alpha-reductase inhibitors (5-ARIs) may increase the risk of a more serious form of prostate cancer. FDA Drug Safety Communication, June 9, 2011.
  37. ↑ Rote-Hand-Brief on finasteride: Risk of sexual dysfunction and mental disorders. Federal Institute for Drugs and Medical Devices (BfArM), July 5, 2018, accessed on August 18, 2018 .
  38. ↑ a b Propecia Lawsuits Skyrocket as Sales of Merck's Risky Baldness Drug Decline . examiner.com
  39. ↑ Case Shaping Up for lawsuits targeting Merck's Baldness Drug Propecia . examiner.com
  40. ^ Matt O'Donnell: Merck Propecia Side Effects Class Action Lawsuit. ( Memento from April 15, 2011 in the Internet Archive )
  41. ↑ Hair-Raising Side Effect It's a common baldness remedy, but its side effects may be more than you - or your girlfriend - can handle . In: Men's Health
  42. ^ Looking at care with a critical eye . In: The Australian Financial Review. September 26, 2012.
  43. ^ Medication Can Cause Sexual Side-Effects, says study . In: FrenchTribune. September 28, 2012.
  44. ^ Hair-loss drug a downer in the bedroom . In: Sydney Morning Herald. Sept. 27th September 2012.
  45. ↑ Parents of Propecia suicide victim join in Kevin Malley's Merck protest . examiner.com
  46. ↑ Hair-loss therapy accused of link to impotence . In: The Australian Financial Review. September 26, 2012.
  47. ↑ Anne Kunze: Finasteride: "The pill the doctor gave me destroyed my life" . In: The time . February 23, 2018, ISSN  0044-2070 ( zeit.de [accessed March 13, 2018]).
  48. ↑ Christina Berndt: Full hair, broken life . In: sueddeutsche.de . 2018, ISSN  0174-4917 ( sueddeutsche.de [accessed on January 31, 2019]).
  49. ↑ FOCUS Online: Hair restorer: Men go to court because of depression and impotence . In: FOCUS Online . March 2, 2018 ( focus.de [accessed on March 13, 2018]).
  50. ↑ Anette Dowideit: Does this hair restorer destroy the lives of men. March 22, 2017. Retrieved May 5, 2017 .
  51. ↑ Anette Dowideit: How dangerous is the hair restorer finasteride? March 19, 2017. Retrieved May 5, 2017 .
  52. ↑ mli: Hair loss remedies make some men impotent for years. March 14, 2017. Retrieved June 9, 2017 .
  53. ↑ Nina Weber: Researchers warn of persistent impotence. March 14, 2017. Retrieved May 29, 2017 .
  54. ↑ Andreas Frey: Should the bald head be fate? April 3, 2017, Retrieved May 5, 2017 .
  55. ↑ Amelie Graen: 6 Troubling Facts About Propecia, Donald Trump's Hair Restorer. March 20, 2017. Retrieved May 5, 2017 .
  56. ^ The Medical Mystery Behind America's Best-Selling Hair-loss Drug - Tonic. In: Tonic. Retrieved January 16, 2017 (American English).
  57. ^ France 5 report on the suicide of PFS patient Romain Mathieu. pfsfoundation, November 30, 2016, accessed January 16, 2017 .
  58. ↑ a b Pills in Search of an Illness. Retrieved January 16, 2017 .
  59. ^ How one man said hair loss drug ruined his life. In: WTVR.com. May 1, 2015, accessed January 16, 2017 .
  60. ↑ 'Hair loss pills made my penis shrink' . June 24, 2014 ( itv.com [accessed January 16, 2017]).
  61. ↑ pfsfoundation: NBC Today - Report links hair loss drug with sexual dysfunction. August 27, 2012, accessed January 16, 2017 .
  62. ↑ Propecia (Finasteride) - 2009 Swedish TV News Report - Persistent Erectile Dysfunction Now Official. pfsfoundation, August 27, 2012, accessed January 16, 2017 .
  63. ^ Genetic and Rare Diseases Information Center (GARD) . US National Institutes of Health
  64. ^ Post-Finasteride Syndrome. In: medsafe.govt.nz. Retrieved August 19, 2016 .
  65. ↑ Model declaratory action against Merck Sharp & Dohme because of the drug Propecia (finasteride). Retrieved October 17, 2018 .
  66. ↑ http://www.medizinrecht-heynemann.de/en/aktuelles/finasterid-klagen/. Retrieved January 31, 2019 (UK English).
  67. ↑ Post Finansterid Syndrome. Accessed January 31, 2019 (German).
  68. ^ New Post-Finasteride Syndrome Foundation offers hope for Propecia victims . examiner.com.
  69. ^ Foundation Launches Website to Fund Research into the Post-Finasteride Syndrome . PFS Foundation, August 26, 2012.
  70. ^ Post-Finasteride Syndrome Patient Ressources The Post-Finasteride Syndrome Foundation. (No longer available online.) In: pfsfoundation.org. Archived from the original on January 16, 2017 ; accessed on January 16, 2017 .