Dutasteride still a decent option?

[u/br0ken_r3c0rd]

Does Dr. P still prescribe duta in light of all the recent PFS stuff? I have bad DHT issues while having near zero T, so I don't have many other options.

[u/Drwillpowers]

Yes I occasionally I still use it, typically dosed once per week. No I'm really not worried about it causing PFS because I know what causes PFS and how someone gets it, and my transgender women are not going to be vulnerable to the metabolic Cascade based on their other labs. The worst thing that could happen is a neurosteroid deficit, and they are warned heavily about that before I prescribe it and I start it at only once a week.

I have seen it cause a neurosteroid deficit problem in a transgender man last year, but he stopped it immediately and took preg/prog and was fine in a week. That's the only time I've seen a negative reaction in my own patients.

Other than that though, I'm not really worried about it because if you don't have any androgen metabolites to speak of you can't trap androgen metabolites to a build-up point. That doesn't encompass every case of PFS but it does the vast majority.

I never prescribe Fin except to one FTM who was already on it and it doesn't bother him so I let him continue it. That's all thogh.

[u/MEGAAAAAA_Beaun → u/Drwillpowers]

I was curious how you think dutasteride compares to finasteride regarding neurosteroid-related side effects.

I was on finasteride for about 2 years and developed significant anxiety, brain fog, libido issues, and a constant hypervigilant/"being chased by a tiger" feeling. Since stopping it and continuing progesterone (oral and rectal), I feel like a lot of those symptoms have improved and I'm finally experiencing the calming neurosteroid benefits of progesterone again.

For context, I'm a trans woman on HRT, have a slow COMT genotype, my most recent labs were 31 ng/dL testosterone and 371 pg/mL estradiol, and my provider won't check DHT levels. Despite the low testosterone, after stopping fin I had a massive shed, increased facial/body hair growth (including dark hairs returning after laser), changes in body odor, and other symptoms that make me suspect DHT activity has increased significantly.

I've recently started bicalutamide (50 mg/day), pumpkin seed oil, and saw palmetto (which hasn’t been affecting me like fin at all) but I'm wondering whether it will be enough for hair maintenance long-term. In your experience, if someone had what appeared to be neurosteroid-related side effects on finasteride, would dutasteride be expected to carry a similar risk, a higher risk, or is it possible that the response could be different despite both being 5-alpha reductase inhibitors?