This is a patient with Central centrifugal cicatricial alopecia (CCCA) which is the most common scarring alopecia among African American women

You mentioned that you were confused by the Reuters article so I thought it would be worthwhile to send you some of the highlights to break it down. These are all based on objective facts that can be verified in the documents.

When you look at the current Propecia label, Merck discusses the sexual side effects from their original clinical trials and reports that “Resolution occurred in men who discontinued therapy with Propecia”. Seems simple enough. You’d think from reading this text that Merck found no evidence of PFS in their clinical trials. This language has been in Merck’s label from 2002 onward.

However, if you go all the way back to their 2001 label, the label says “Resolution occurred in all men who discontinued therapy with Propecia”. If you read this one, you’d also assume that Merck did not have subjects develop PFS during the trials.

But why is this interesting? If you look closely, you’ll see Merck took the word ALL out of the label all the way back in 2002. But why did they change the language?

Fortunately, we have an accidentally unsealed deposition with Charlotte Merritt, the Merck woman who oversaw regulatory activity related to Propecia so we can see what her answer is on page 52.

Some paraphrasing to get to the point…

Q: So the word “all” has been removed in this label… why is that? A: Well, as you saw, there were some men in whom after some period of time the AEs did not resolve so this is — so the word “all” was no longer factual as it relates to the longer term data beyond the initial period of the trial.

Q: There was nothing that prevented Merck, which as we agreed is responsible at all times for its label, from putting into this 2002 label that it now had information for over a year, at least as early as November 2000, about the lack of resolution upon discontinuation in some patients in the clinical data, right? A: Merck didn’t feel at the time that that was something that needed to be put in the label. FDA apparently agreed. This is the label that was, you know, the results of that submission and we can’t comment any further.

Later on there is a reference to the “Ruane memo” that was sent to top Merck executives that discussed the details about what they knew about persisting adverse events and what they were going to do about it. This memo still remains under seal but Reuters has done some great investigative work and has filed to have it unsealed for the sake of public safety. The law says that these documents should never be filed under seal except for very narrow exceptions and public embarrassment to a company does not fall into that category.

If you look more deeply in the documents which I suggest you do, you’ll see they had gathered internal market research that showed 50% of potential customers who were aware of REVERSIBLE side effects, would be unwilling to take the drug due to that risk. One can only imagine how high that number would go if Merck properly warned about the data they found about irreversible side effects. There are also more detailed descriptions about the test subjects who developed persistent side effects and how they were excluded from what was reported.

I saw you refer to this as “speculative” on your blog today but this is all fact based and verifiable, much of it confirmed by Merck employees. It’s undeniable that Merck had clinical trial subjects that developed persisting sexual AEs since 2000 and never reported this to the public.

I have the link to the full court document below. Merck tried to file this under seal away from the public eye and this is very common feataure of how the legal system operates even though it isn’t supposed to be that way. The Reuters article says that this document was accidentally filed publicly so that is the only reason the public gets to see this information that would have been otherwise buried.

https://www.reuters.com/investigates/special-report/assets/usa-courts-secrecy-propecia/howes-deposition.pdf

A Second Reader posted this:

https://www.statnews.com/pharmalot/2019/09/12/merck-side-effects-opioids/

I just saw that StatNews reported on the same story last week too. Ed Silverman is another very credible journalist and in fact was a finalist for the Pulitzer for his work on explanatory reporting in the pharmaceutical industry.

If you still are confused, I suggest that you read the two primary source documents from the Reuters article which you may have missed. In fact I believe it is your moral responsibility to do so given many people look to your blog for medical advice about Propecia. The links are below.

https://www.reuters.com/investigates/special-report/assets/usa-courts-secrecy-propecia/howes-deposition.pdf

https://www.reuters.com/investigates/special-report/assets/usa-courts-secrecy-propecia/faulty-redaction-redacted.pdf

The document in the first link was meant to be filed under seal which would have made it hidden from the public. You will see why Merck wanted it sealed after you read it.

The document in the second link was filed publicly but with redactions. You can remove the redactions by copy and pasting those sections into word.

Happy reading :)

A Third Reader posted this:

Thomson Reuters is as authoritative and respected as they come. It is one of the two major global news agencies along with AP. They report on the facts and the facts support PFS. You can review the underlying documents that are publicly available on the article.

You can do a quick internet search to see how people rank Reuters and it is always among the most objective, often above agencies like NYTimes, WSJ, CNN, Fox which have some editorializing.

https://mediabiasfactcheck.com/reuters/

Hi Dr. Rassman. I’ve heard quite a few stories claiming that generic finasteride is not as effective as Propecia. Do you prescribe both, and if so have you noticed a difference in your patients responses?

Some patients have reported reduced effectiveness when they switch from propecia to the genetics but there are a few manufacturers of the generics and I have not kept a record of which is which.

I’ve been trying to get some sort of idea of about how much a hair transplant would cost to just fill in my temples. I’ve been on finasteride and minoxidil for over a year now with great results, but my temples are still thinner than i would like.

Anyone able to give a rough estimate of what the cost might be just to fill in thin temples? I think 500 grafts would be the absolute most I would need. And yes I am in the process of setting up a consultation but I would like to have an idea beforehand.

Hair transplant pricing is all over the place; however, think about what you are actually buying. If you needed a heart transplant or brain surgery, would you try to find the least expensive place to do it? I have seen many men find a cheap hair transplant and then, when either it failed or the doctor who performed it, didn’t bother to build a Master Plan for your future and then you find out that you lost a significant amount of your donor supply that is limited, the fee becomes ridiculously high regardless of how little that you think you paid for it. I have seen many hair transplant result where the doctor ruined the donor area or did it too soon just to get your money. Make sure that the doctor is reputable and if he employs a salesmen, don’t trust the consultation or possibly even the surgery. Try to find dirt on the doctor from Yelp, Realself, and Reddit. There are many potholes in selecting a doctor so don’t fall into one.

Here is a review sent into Realself for me this morning about the consultation I gave him yesterday and that I told him not to do a hair transplant, which is why he came in to see me:

As the years have gone by, I have started to notice some thinning up top. After doing some research, I decided to setup a hair loss consultation with Dr. Rassman.

I chose to setup my appointment via an online form, and was surprised when I received a phone call from Dr. Rassman himself within 15 minutes! Turns out, he happened to see my consultation request while relaxing on his deck, and decided to give me a call! He was very friendly and personable on the phone, which made me feel better about my upcoming in-person consultation.

I arrived on the day of my consultation and was seen very promptly. Dr. Rassman was as friendly and jovial in-person as he was on the phone. He did a quick visual examination, and then performed an inspection using a device called the Haircheck. This devices takes measurement of hair density per square inch at different sites on the scalp, using the back of the head as a baseline to compare with other locations on the scalp. I had never seen this type of device used before, and I was impressed by Dr. Rassman’s objective and data-based approach to evaluating hair loss.

After the Haircheck inspection, he informed me that there was some thinning, but not enough to recommend a hair transplant. He then gave me a thorough description of my options and talked through the potential side effects, while interjecting some lighthearted humor, which made me feel at ease. He was very knowledgeable, and was up to date on the latest research. In addition, he answered all of my questions and promised to email me additional info. I was surprised and delighted to find that Dr. Rassman followed-through on his promise quickly, emailing the additional info in about an hour.

I suspect that many other surgeons would have simply taken my money and performed a hair transplant, but I respect Dr. Rassman for his candor and honesty in recommending against a hair transplant. If you are thinking about seeing someone about your hair loss, I would definitely recommend seeing Dr. Rassman for a consultation!

I heard that hair falling is an autoimmune disease, with the body attacking its own hairs. Then, there is Wim Hof (google him), that has scientifically shown to control consciously so many processes in his body that were previously thought to be impossible.

Some forms of alopecia have an autoimmune cause. This is more common in women then men. 99% of men who are losing their hair find genetic causes inherited through various family lines.

Most of the stem cell treatment being offered are scams. A few doctors have built a reputation for delivering stem cell treatments and have made a fortune on men chasing the impossible. There are no stem cell treatment that are known to work.

Here are some considerations I’ve had before jumping into the HT route and wanted to share these with the community to get feedback and possibly provide some additional options for those in a similar position:

Background on me: 29M diffuse thinning throughout top of head. Finasteride/Minox for the last ~6 years that has slowed, but not stopped hair loss. When I first began noticing hair loss, I always considered a HT a possibility, but now my hair has progressed to where I think it may be appropriate to start considering it as an real option.

Everything you’ll read on the hairloss forums essentially boils down to the fact that getting a HT is a one way street. In almost all cases (especially if you are young) you will need a total of 2-4 surgeries. You will need to be financially and mentally ready for that. Even after that, you may not get the results you were really targeting.

The biggest hang-up for me, and undoubtedly for some of you, is that there’s not really any going back from the HT route. Regardless of if you go FUE or FUT, there will be scarring. If you get an unsatisfactory result, you will not be able to completely shave your head down without exposing those scars.

Here is the plan that I’m circling towards and may offer an avenue for some of you as well (I think this may be partiucularly suited for diffuse thinner like myself):

1. Go for an initial moderate-large size FUE procedure (2.5K-3.5 grafts). I’d really only go with this if you have the funds to go with a top surgeon

2. Enjoy your denser hair for 5-10 (hopefully!) years and then go for a second FUE procedure as age takes its toll and continues to take your native hair

3. At this point, in all honesty, you really won’t be able to shave your head with all the FUE scarring. If you still have areas that you’re not happy about, I think it’s wortwhile to look at SMP (maybe temporary at first) into both the FUE scars and in the transplanted recipient area. This helps boost the illusion of density even if you are out of available donor grafts.

I think having a plan for that 3rd step is crucial because there are so many results on here and the forums that end in regret and the person gets stuck because their result is sub-optimal AND they can no longer shave their head due to the scarring.

Hoping to discuss this plan with all you on here perhaps give me something else that I had not considered.

The Master Plan I always discuss with my patients is what happens now for the near and distant future. If hair transplants are in the future for you, you absolutely must know your donor density (a number) which will will deplete with each hair transplant. For FUE, the limit is half of the number as for a strip surgery and if you are not aware of this, then you could end up deformed as I often discuss on this site.