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When Accelerated Male-Pattern Hair Loss on Testosterone Cypionate Becomes a Reason to Stop

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At a glance

  • Label entry / Male pattern of baldness listed among skin adverse reactions [1]
  • Label discontinuation statements / Suspected blood clot, or hypercalcemia in an immobilized patient [1]
  • Mechanism / DHT miniaturizes androgen-sensitive scalp follicles [3]
  • Background / Androgenetic alopecia affects up to 80% of men and tends to worsen [4]
  • Treatments with trial evidence / Minoxidil and finasteride beat placebo on hair measures [5]

Does the label make hair loss a reason to stop?

No. The Depo-Testosterone adverse reactions section lists male pattern of baldness with hirsutism, seborrhea and acne [1]. The label's discontinuation statements cover other events: it says to discontinue treatment if a venous thromboembolic event is suspected, and that the drug should be discontinued if hypercalcemia occurs in an immobilized patient [1]. Separately, it says testosterone products are not recommended in men with uncontrolled hypertension [1].

The Endocrine Society guideline lists near-term fertility plans, breast or prostate cancer, elevated hematocrit, untreated severe sleep apnea, uncontrolled heart failure, and a heart attack or stroke within 6 months as reasons not to start testosterone [2]. Hair loss is not one of them.

How testosterone relates to pattern hair loss

DHT is the androgen behind androgenetic alopecia. Up to 10% of testosterone is converted to DHT by 5-alpha reductase, and excess DHT miniaturizes hair follicles, shortening the growth phase and lengthening the resting phase [3]. The Depo-Testosterone label notes that in many tissues testosterone acts through its reduction to dihydrotestosterone [1].

Androgenetic alopecia affects up to 80% of men and is progressive [4]. A review in transgender men on testosterone lists alopecia among undesired effects and notes it continues to develop after the first year [6].

What has been measured

The label gives no dose, DHT level or progression rate for hair loss [1]. The link between cypionate and hair loss rests on the labeled adverse reaction [1] and on what is known about DHT and androgenetic alopecia [3][4].

Finasteride 1 mg and minoxidil 5% beat placebo on hair measures in a meta-analysis of randomized trials in men with androgenetic alopecia [5]. A 24-week phase III trial randomized 458 men with androgenetic alopecia to topical finasteride spray, oral finasteride or placebo: target-area hair count changed by 20.2 hairs with the spray versus 6.7 with placebo at week 24 (P<0.001), and mean serum DHT fell 34.5% with topical versus 55.6% with oral finasteride [7]. Those trials studied men with androgenetic alopecia and were not designed around testosterone therapy [7][5].

Frequently asked questions

Will my hair grow back if I stop testosterone cypionate?
The label does not report whether hair regrows after stopping [1]. Male-pattern hair loss tends to worsen over time [4], while minoxidil and finasteride have improved hair measures in men with the condition [5].
Can I use finasteride or minoxidil and stay on testosterone cypionate?
The Depo-Testosterone drug interaction section names oral anticoagulants, oxyphenbutazone and insulin in diabetic patients, and does not mention finasteride or minoxidil [1]. Finasteride 1 mg and minoxidil 5% beat placebo on hair measures in men with androgenetic alopecia [5]; those trials were not designed around testosterone therapy.
What does the label say to monitor?
The Depo-Testosterone label calls for hemoglobin and hematocrit checks periodically in long-term use, and for periodic blood pressure measurement [1]. It lists male pattern baldness as a skin adverse reaction without a monitoring threshold [1].

References

  1. U.S. National Library of Medicine, DailyMed. Depo-Testosterone (cypionate) intramuscular, Pharmacia & Upjohn/Pfizer (testosterone cypionate) prescribing information. Depo-Testosterone (cypionate) intramuscular, Pharmacia & Upjohn/Pfizer (testosterone cypionate) label
  2. Bhasin S, Brito JP, Cunningham GR, Hayes FJ, Hodis HN, Matsumoto AM, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(5):1715-1744. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline
  3. Dhariwala MY, Ravikumar P. An overview of herbal alternatives in androgenetic alopecia. J Cosmet Dermatol. 2019;18(4):966-975. An overview of herbal alternatives in androgenetic alopecia
  4. Piraccini BM, Alessandrini A. Androgenetic alopecia. G Ital Dermatol Venereol. 2014;149(1):15-24. Androgenetic alopecia
  5. Adil A, Godwin M. The effectiveness of treatments for androgenetic alopecia: A systematic review and meta-analysis. J Am Acad Dermatol. 2017;77(1):136-141.e5. The effectiveness of treatments for androgenetic alopecia: A systematic review and meta-analysis
  6. Irwig MS. Testosterone therapy for transgender men. Lancet Diabetes Endocrinol. 2017;5(4):301-311. Testosterone therapy for transgender men
  7. Piraccini BM, Blume-Peytavi U, Scarci F, Jansat JM, Falqués M, Otero R, et al. Efficacy and safety of topical finasteride spray solution for male androgenetic alopecia: a phase III, randomized, controlled clinical trial. J Eur Acad Dermatol Venereol. 2022;36(2):286-294. Efficacy and safety of topical finasteride spray solution for male androgenetic alopecia: a phase III, randomized, controlled clinical trial
Evidence overview for When Accelerated Male-Pattern Hair Loss on Testosterone Cypionate Becomes a Reason to Stop