Safe to say finasteride isn't to blame?

[Bryan]

I can say though that the change is minor enough that, had I not read about finasteride side effects, I would never have noticed it. (But it still would have been there).

Exactly!! This is a very good time to review that other important study about the "nocebo" effect from finasteride studies:

"Finasteride 5 mg and sexual side effects: how many of these are related to a nocebo phenomenon?"

J Sex Med. 2007 Nov;4(6):1708-12

INTRODUCTION:
Sexual adverse experiences such as erectile dysfunction (ED), loss of libido, and ejaculation disorders have been consistent side effects of finasteride in a maximum percentage of 15% after 1 year of therapy. Such data could be seen as far from reality, if compared to a higher percentage that may be found in any common clinical practice.

AIM: This study aims to explain the dichotomy between literature's data and clinical practice data.

METHODS:
One hundred twenty patients with a clinical diagnosis of benign prostatic hyperplasia (BPH), sexually active and with an International Index of Erectile Function-erectile function (IIEF-EF) domain >/=25 were randomized to receive finasteride 5 mg concealed as an "X compound of proven efficacy for the treatment of BPH" for 1 year with (group 2) or without (group 1) counseling on the drug sexual side effect. The phrase used to inform group 2 patients was ". . . it may cause erectile dysfunction, decreased libido, problems of ejaculation but these are uncommon".

MAIN OUTCOME MEASURES: The estimation of side effect was conducted at 6 and 12 months using the male sexual function-4 (MSF-4 item) questionnaire and a self-administered questionnaire.

RESULTS: One hundred seven patients completed the study. Group 2 patients (N = 55) reported a significant higher proportion of one or more sexual side effects as compared to group 1 (N = 52) (43.6% vs. 15.3%) (P = 0.03). The incidence of ED, decreased libido, and ejaculation disorders were 9.6, 7.7, and 5.7% for group 1, and 30.9, 23.6, and 16.3% for group 2, respectively (P = 0.02, P = 0.04, and P = 0.06).

CONCLUSION: In the current study, blinded administration of finasteride was associated with a significantly higher proportion of sexual dysfunction in patients informed on sexual side effects (group 2) as compared to those in which the same information was omitted (group 1) (P = 0.03).

A scenario similar to group 2 of the current study is likely to occur in clinical practice, where the patient is counseled by the physician and has access to the drug information sheet.

The burden of this nocebo effect (an adverse side effect that is not a direct result of the specific pharmacological action of the drug) has to be taken into account when managing finasteride sexual side effects.

 

[Nevis]

[but if you're going in ignorant and you come out wrecked, then there's something wrong.

but you're not going in ignorant...you know you're taking a/the drug. Or, in a stricter sense of "nocebo response", you know you are taking any pill, which could be a sham pill, which you associated with negative responses. That is the "nocebo" responses; the increase in intensity of negative symptoms when you're undergoing treatment--sham or active.

Keep your eyes on the word "intensity" too. The decision to report side effects, as in the study Bryan posted, is often mistakenly viewed as "evidence of no side effects occurred with the people who voted no side effects." It's still possible they had some side effects. But, the limited information they had about the possiblity of those side effects changes their threshold for reporting side effects relative to the "knowledgeable" group.

Think of the stylized story: You have a bad day, come home from work, have no desire for sex, or even try and have a bad erection. You know the pill you took this morning has this side effect. Do you report "adverse reaction" to your doctor? It's more likely you do than the case of the person who has the same bad day but does not know about the possible side effect.

In the same vein, we're clearly not claiming that side effects are therefore all in one's head! There very well can be a pharmacological connection between the pill and the side effects. You can still "go in ignorant and come out wrecked." (as barcafan says) It's only that the degree of "wrecked" is not uncorrelated with the knowledge that you're taking the pill. The pharmacological aspects might make you "tweaked" or "off" while the knowledge of taking a pill with side effects then takes you from there up to "wrecked". And the possibility exists that on the level of "tweaked" or "off" you would not have reported the side-effect in the absence of information on the pill.

That is why the burden of the nocebo effect (as Bryan stated) has to be taken into account when managing sexual side effects of finasteride. How many of those 30.9% reporting ED would not have reported that same level of ED if they had not known of the side effect? (Just as Fundi said, the change was so minor that had he not known he would not have reported it). They still might have had ED, but it might not have mattered enough to report, or set off alarm bells for them. In the same sense, how many of the 9.6% in the uninformed group would not reported side effects if they weren't taking any pill...if somehow someone secretly administered a medication with no knowledge on their part?

The problems of nocebo/placebo are manifest in all drug studies, all the more so in the realm of sexual side effects. Libido and performance are so tied up in mental processes and emotions already. Would one have "overcome" their pharmacologically-caused problem if they had not been worrying that it was causing a problem?

Who knows. The study isn't claiming that you personally are or aren't getting side effects from your finasteride. And in a true sense, it doesn't matter where they are coming from, as they are real and manifest. The study only showing that above the general knowledge of a nocebo effect, we have measured nocebo evidence specifically regarding finasteride, and it's appreciably large with respect to sexual function side effects. The only action that suggests is that you should exercise caution in ascribing the intensity of finasteride sides all to the finasteride itself. Bryan's test is a nice way of accomplishing a personal-breakdown between the pharmacological experience, and the nocebo experience.

And I say this all as a person who has taken finasteride (for a long time, over 9 years) and so am sensitive to both sides of the issue.

 

[3pm]

You'll get the guys here telling you it's in your head and to continue finasteride until it wears off. Then you'll get the guys over at propeciahelp.com to tell you to get off it immediately or you'll be stuck with a floppy sausage and tits.

The latter is prudent advice when the subject is responding negatively to the drug. Common sense suggests a bad responder should stop if they don't like the drug's effects, not act on a hunch.

The guys at propeciahelp.com think the guys here are crazy for taking this "poison" and in fact ,hate any hair related issue arising in their forum

PH.com is not for discussing hair loss, it's for curing unresolved health complications acquired by Propecia. So it's not hate; it's simply not the proper venue. I don't think anyone is "crazy" to take Propecia, as the odds appear in their favor and most professional physicians dispense it with little concern. We just want the consumer to know the possibility of unresolved side effects, and the other inhibitions of finasteride undisclosed by the manufacturer. We're no one's parents.

The fact is everyone reacts differently. Nobody on either forum seems to understand this.

I'm on both boards, and this is blatantly obvious to me and many more. But when the risk is a long-lasting health hazard...

You are going to have to experiment yourself.

...using this drug may irreparably jeopardize one's health, which is why we aim to determine the truth about finasteride, and would rather see healthy men avoid the gamble.

I would have loved to have known that so many consumers had unresolved side effects, and the severity of them. I would have not tried it. It comes down to individual sensibility. We can only provide the valid data. Anything else just isn't my problem.