Part II:
With estrogens, you have estradiol, estrone and estriol. With androgens, you have testosterone, 5-DHT, androsterone and androstenedione, which was used by Mark McGwire and other steroid users in baseball, among others accused of using steroids.
Progesterone and DHEA are other types of steroids produced by and needed both sexes. They are all chemically similar to cholesterol. These steroidal hormones can often be converted by the body from one into another.
Aromatases are enzymes that can change testosterone into estrogen via a process known as aromatization. Estrogen and testosterone have similar chemical structures but estrogen can aromatize testosterone, i.e., change it to estrogen, while testosterone cannot turn estrogen into androgens.
So some of the various enzymes that end in "ase" can create both estrogens and androgens. Without reductase, DHT cannot be formed from testosterone. Testosterone, however, as mentioned, can be converted to estrogen via aromatization.
This mostly concerns people being prescribed testosterone, such as female to male transgender individuals or athletes with injuries prescribed androgen for treatment of injuries because just loading up on more and more T might have a limit as to achieving the primary goal of using the medication to increase circulating androgens. Also for athletes, DHT is likely to improve performance in terms of promoting muscle growth so some males may not want to decrease the levels of DHT created in the body even while knowing that it can cause baldness and acne and aggression, and other negative effects such as paraphilias which are all but unknown in cis-females.
This debilitating physical strength effect from 5-alpha reductase inhibitors is not so significant for male to female individuals except that it shows why some anti-androgens like dutasteride and finasteride have fairly weak feminization or effectively no feminization effects while others like spironolactone and flutamide, and compounds similar to flutamide, like bicalutamide can have far more significant effects on muscle, and can clearly decrease physical strength when taken by cis-males.
It helps to know at least a little about these different medications because transgender individuals might be able to have their treating practitioner switch from the weaker finasteride to flutamide if hair regrowth is a key concern. In my experiences, HRT physicians or their assistants might not titrate dosages or add things like flutamide or progesterone without being prompted and it helps to have a reason when you ask.
Some studies do, for instance, find positive effects from progesterone and its synthetics like depo-provera on both hair and breast and nipple size although this is vigorously debated.
Honestly, in my opinion, and according to the medical literature, none of the above non-hormonal treatments for cis-males, which I use here to include transgender females as well, and even those cocktails including the weak androgen inhibitors dutasteride and/or finasteride, are likely to result in significant hair regrowth, particularly for people over 30, without adding spironolactone or flutamide as part of the cocktail,
However, used in conjuction with estrogens or stronger anti-androgens, there could be a synergistic effect among 5-alpha reductase inhibitors, minoxidil or Nizoral. and I would encourage all cis-males, transgender or otherwise, unable to use or obtain estrogen or androgen-blockers to use all of these if possible.
From my reading of much of the most-recent literature, I am skeptical that any male to female transgender individual needs more than just estrogen plus flutamide or spironolactone for significant hair regrowth.
In fact there are current studies indicating that just estrogen alone is enough to regrow hair for transgender females provided high enough levels are prescribed. Many practitioners won't go this high up in terms of prescribing estrogen because they fear blood clotting becoming an issue, which is a legitimate concern but which may be well worth the risk for balding transgender females suffering from significant dysphoria.
This accounts for why most studies indicate that trans-females need both estrogen and either flutamide and spironolactone for significant hair regrowth. In Europe, they use Androcur, also known as cyproterone acetate exclusively instead of spironolactone.
Cyproterone acetate on its own may be more effective than spironolactone, also known as aldactone, for some but it isn't approved for the treatment of transgender females in the United States. It is available and fairly easy to get from overseas sites serving transgender individuals who don't have access to health insurance or a prescriber, which percentage might be half of our community. I will discuss this topic more fully in another post. I think that both cyproterone and spironolactone are roughly equal in their hair growth abilities.
For cis-males, regardless of future orientation, one needs to use all of the above non-feminizing baldness treatments daily for best resutls, except one only needs either finasteride or dutasteride, preferably the latter but not both.
When to start for cis-males? The very first second that you see a single hair fall be it at 18 or 30 or 50 years of age. All of the above combined with either finasteride or dutasteride seem to be quite effective to maintain a hairline but they won't regrow it fully the way that estrogen in combination with anti-androgens that bind to androgen receptors might.
For cis-females, it is recommended to avoid the 5-alpha reductase inhibitors if of child-bearing age. Doctors may take males off them too when males are attempting to start a family but this seems to be excessive and overkill. If a cis-male goes off them for 7-10 years, there's no getting that hair back after desisting. I did happen to go off them because of my physician's recommendation.
Why is it so difficult to regrow hair, even for people using estrogen? One theory is that balding scalp tissue is a sort of calcified scar which has lost its connection to most blood vessels and hence blood supply. Scarring is a very difficult thing to reverse anywhere on the body. Also, the male head tends to grow larger than the female head, further perhaps hampering blood flow by stretching out the affected tissue.
If someone wants to actually restore hair and is interested in even greater minutia, he or she might go to the site Perfect Hair Forever site, which is full of pertinent information for males and females. But I can summarize its findings pretty easily:
Intact transgender females supplementing with both estrogen, and one of the other among spironolactone or flutamide, or castrated males supplementing with estrogen alone are able to reverse baldness or shall we say have a significant probability of substantial regrowth in completely bald areas.
Castrated males and transsexual females no longer produce any significant amounts of testosterone or 5-DHT so only estrogen supplementation is necessary for them to theoretically regrow hair in balding areas.
We never used to think that massaging the scalp could restore hair from baldness and that it was instead an old husband's tale but it may be because it takes a massive amount of massage, say, 30 minutes per day, every day for a year, and then continuing onward, to break through the calcified tissue.
The author on that site tries to provide the total sum of minutes needed. I have verified that there are studies indicating positive effects on hair growth via sustained, rigorous massage but I am not sure this is really a likely path for most balding people. It requires too much effort, obviously much more than swallowing ten pills daily as do many female transgender individuals but for motivated people, it might improve their hair some.
A process called derma-rolling or micro-needling that he mentions seems to work as well, with several published papers indicative of its effectiveness and as to why this might work.
This treatment can be fairly painful, however and you have to keep at it for many months to a year, but essentially small pricks into the scalp "trick" the body into healing scalp tissue and re-establishing blood flow. It also seems to work well on non-ice pick facial scars and wrinkles but it can involve a bit of a bloody mess. Healing time is minimal since the skin really wasn't damaged deeply enough to cause more than say 12 hours of inflammation.
Finally, there is the estrogen factor. Research seems to indicate that estrogen greatly increases the length of the growth phase of hair and thus female hair might grow for three times as long as male hair before falling out and going into its resting phase. It is possibly for this reason that even the vast majority of men who essentially never lose any hair at all, still can't grow their hair long the way that women do, without achieving the mullet look.
Estrogen's affects on skin alone, in my experience are miraculous in terms of feminization and in terms of what transgender females are likely to view as improvement, meaning paler, less hairy and much softer, and these effects, unlike hair regrowth, begin immediately.
Heels of feet that were completely cross-linked before estrogen, meaning coarse and discolored, where even pumice might be useless but estrogen can immediately become much more supple.
So then, regardless of the efficacy of the medications above for males in maintaining or even subtly regrowing hair, males simply are never going to restore their mid-puberty locks from say ages 13-17 without hormonal manipulation via T-blockers that don't block androgen receptors.
Hair transplants don't improve hair quality generally unless the fringe hair remains very high on the sides and back of the scalp without any hint of the mullet-effect. I have seen this and such males with abundant fringe hair are able to get fantastic results from transplants but their hair is still inferior to that of most females.
I have anecdotal personal knowledge of this limiting quality factor for males regardless of treatment.
Both of my parents are in their 80's and they both have thick hair and maintain every follicle that they were born with, but still my father's hair can't match my mother's. She can still wear it down to her shoulders the way that she could when I was a child.
In the early 1970's when male hairstyles increased in length, my father's hair got curly and unruly and it simply was never going to look good worn long. It lacked the texture and sheen and was a bit mullety.
Most males don't care that much about the length of their hair. They just want the fullest coverage possible but there is nothing that I know of short of hormonal manipulation of the androgen receptors along with estrogen that will give a male long tresses that look and have the manageability of female locks.
Women's hair at its best has a consistency and sheen and smoothness when rubbed between the fingers that virtually no male, not even Jeff Bridges in Against All Odds, can match, as glorious as Mr. Bridge's hair was in that movie in his red Ferrari, hair blowing in the wind.
Most rock stars after 30 are wearing wigs or hair extensions. Mick Jagger had pretty great hair among front men and may have made it to 50 with great hair. George Harrison and his incredible long-growing hair is of note but it is apparent that some members of the Who and Zeppelin are "cheating" just like me and just like so many metal "hair" bands.
Rod Stewart? Pretty obvious, not that there is a thing wrong about anyone wearing wigs or hair extensions but there does seem to be a stigma, especially with respect to toupees which rarely seem to blend in or fit right compared to longer wigs that completely cover down to the neck or or further down.
So why do some men like my father or Ronald Reagan appear to have perfect hairlines into their 90's? In many cases, such men lack the ability to produce 5-alpha reductase at all and therefore have only testosterone and not any DHT at all, circulating in their systems. Dutasteride would be entirely superfluous for those males bearing this genetic trait and male pattern baldness is unknown among them.
One hears a lot about gender dysphoria but in my opinion, dysphoria about hair loss is probably just as brutal for many follicle-challenged males as is the gender dysphoria that many transgender females experience. For me, they are completely related and both started right after puberty at about the age of 19.
Anyone who goes to the male-oriented baldness sites can see this obsession. There is a willingness to try anything, be it onion juice or cod liver oil or inversion therapy or saw palmetto tablets or black cohosh or cayenne pepper or soy products, and on and on.
Many of these gentlemen however are unwilling to try even weak androgen blockers like finasteride and in my opinion, there is just not much hope for bald or balding males to keep their remaining hair without at least using such weak anti-androgens like dutasteride and finasteride sold by Keeps and other such companies.
Most of these packages advertised so frequently include minoxidil and finasteride, along with an online prescription that takes five minutes, and they can work very well to maintain hair but minoxidil by itself, even with say Nizoral 2 percent is unlikely to re-grow anything beyond fuzz. Yes, saw palmetto has some similar effects to finasteride but it is not cheap, there are very few studies and the effects are much weaker. It might actually cost more than finasteride.
