ACOFP 54th Annual Convention & Scientific Seminars
Men's Health - Medical Concerns for the Aging Male
Igor Altman, DO
3/7/2017
The Aging Male
Primary Concerns in Men’s Health
Igor Altman, DO, MBA Assistant Professor of Clinical Family Medicine University of Illinois Hospital and Health System Chicago, Illinois
Objectives:
Recognize critical elements and formulate management plan for the following conditions: Benign Prostatic Hyperplasia Prostate Cancer Erectile Dysfunction Abdominal Aortic Aneurism Androgenetic Alopecia Practice provided material by successfully completing lecture questions.
1 3/7/2017
Urinary Retention – based on History and Physical Exam findings
History (LUTS) Physical Examination Possible Etiology Frequency, urgency, Enlarged, firm, non- Benign Prostatic straining to void, weak tender, non-nodular Hyperplasia stream, stopping & prostate on DRE; may (BPH) starting of a stream, etc. appear normal Fever; dysuria; back, Tender, warm, boggy Acute Prostatitis perineal, rectal pain prostate; possible penile discharge Weight loss; Enlarged nodular Prostate Cancer constitutional prostate; may appear signs/symptoms normal Pain; swelling of foreskin Edema of penis with non- Phimosis, paraphimosis or penis retractable skin
Pathophysiology of BPH
Testosterone Dihydro- testosterone (DHT) androgen receptors BLADDER ↑ GF’s primarily TZ PROSTATE (reduced apoptosis Central Zone with age) uniform, Transition Zone non-nodular Peripheral Zone enlargement (BPH)
Urethra Kirby RS, G.P., Fast Facts: Benign Prostatic Hyperplasia. 6th ed. 2010: Health Press Limited.
2 3/7/2017
Benign Prostatic Hypertrophy Risk Factors: age, ↑ BMI, DM, Dyslipidemia 88% of men in their 80s have BPH Myth: sexual activity, HTN, smoking, liver cirrhosis Protective effect: Alcohol (reduces testosterone, modulates sympathetic tone). No effect on LUTS. High physical activity; Higher vegetable intake.
Parsons KJ, I.R., Alcohol Consumption is Associated With a Decreased Risk of Benign Prostatic Hyperplasia. The Journal of Urology, 2009. 182: p. 1463-1468 Walsh, P.C., Anatomic radical retropubic prostatectomy, in Campbell's Urology. 1998, Elsevier: Philadelphia. p. 2565-2588. Rosen R, A.J., Boyle P, et al, Lower urinary tract symptoms and male sexual dysfunction: the multinational survey of the aging male. Europian Urology, 2003. 44(6): p. 637-649 Paolone, D.R., Benign Prostatic Hyperplasia. Clinical Geriatric Medicine, 2010(26): p. 223-239
BPH – Physical Exam Abdominal Exam – percussion and palpation of the bladder (might be palpable with >200 ml); External Genitalia – meatal stenosis or severe phimosis; Digital rectal exam – prostate size estimation, tenderness, nodularity, fecal impaction.
Selius, B., Subedi, R, Urinary Retention in Adults: Diagnosis and Initial Management. American Family Physician, 2008. 77(5): p. 643- 650. Paolone, D.R., Benign Prostatic Hyperplasia. Clinical Geriatric Medicine, 2010(26): p. 223-239
3 3/7/2017
BPH – LUTS Evaluation/Follow-Up
American Urological Association BPH Symptom Score Index Questionnaire Can be accessed on-line: http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/bph- management/chapt_1_appendix.pdf
1. Incomplete emptying (0-5) 2. Frequency (0-5) 3. Intermittency (0-5) 4. Urgency (0-5) 5. Weak stream (0-5) 6. Straining (0-5) 7. Nocturia (0-5)
Score < 7 8-19 20-35 Severity Mild BPH Moderate BPH Severe BPH
BPH – Work Up (revised AUA guidelines, 2010) URINALYSIS (infection, hematuria, proteinuria, glucosuria, etc.) SERUM PSA (When life expectancy is > 10 years and if the diagnosis of prostate cancer can modify the management. From the AUA PSA Best Practice Statement: 2009 Update)
AGE 50’s 60’s 70’s PSA Level ~ 1.6 ng/ml ~ 2.0 ng/ml ~ 2.3 ng/ml (prostate >40 ml)
FREQUENCY/VOLUME CHART (When significant nocturia is a predominant symptom) OPTIONAL TESTS: Flow rate recording & residual urine measurement. McVary KT, R.C., Avins AL, Barry MJ, et al, Guideline: Management of Benign Prostatic Hyperplasia (BPH). 2010, American Urological Association
4 3/7/2017
BPH – Treatment Options
Severity Score < 7 8-19 20-35 Severity Mild BPH Moderate BPH Severe BPH Treatment Watchful • Watchful • Medical Tx; Waiting waiting; • More invasive • If bothered – procedures consider medical Tx
Watchful waiting – behavioral modifications; severity scores (change by 3 points is acceptable improvement) Medical Therapy – ɑ-Adrenergic Receptors blockers, 5ɑ-Reductase Inhibitors, Combo is promising Minimally Invasive Therapy Transurethral Microwave Therapy (TUMT) Transurethral Needle Ablation (TUNA) Surgery (TURP, TUIP, open prostatectomy, & laser procedures) Paolone, D.R., Benign Prostatic Hyperplasia. Clinical Geriatric Medicine, 2010(26): p. 223-239 Edwards, J.L., Diagnosis and Management of Benign Prostatic Hyperplasia. American Family Physician, 2008. 77(10): p. 1403-1410.
Indications for Urologic Referral
Hematuria Recurrent UTIs Prior urologic surgery Urolithiasis Abnormal DRE Urinary retention LUTS refractory to medical menagement Elevated PSA
5 3/7/2017
Prostate Gland – Osteopathic Consideration
Dx: Viscero-Somatic Dysfunction Goal of therapy: improve circulation and lymphatic drainage Innervations: Parasympathetic: pelvic splanchnic nerves (S2-S4) Sympathetic: inferior hypogastric plexus (L1-L2) Chapman’s Points : Anterior: myofascial tissue along the posterior margin of the iliotibial (IT) band Posterior: sacral base (superior sacrum), bilaterally.
Modi RG, S.N., Urology, in Clinical Anatomy and Osteopathic Manipulative Medicine. 2006, Lippincott Williams & Wilkins. p. 249-250
Prostate Cancer (PCa) EPIDEMIOLOGY 2nd leading cause of cancer death in men During lifetime – 1 man in 6 (16%) will be Dx’d with Pca 1 in 35 ( ~3% ) will die from PCa 50% at 50 & 80% at 80 y/o RISK FACTORS One 1st degree relative – x2 fold Two or more 1st degree relatives – at least x4 fold African-American ethnicity Diet high in Omega-6 fatty acids (linoleic acid) from vegetable oils and red meats (Low level of evidence) Scher, H.I., Benign and Malignant Diseases of the Prostate, in Harrinson's Principles of Internal Medicine, K.D. Fauci AS, Longo DL, Braunwald E, Hauser SL, Jameson JL, Loscalzo J, Editor. 2008, McGraw Hill Medical. p. 594-600 U.S. Preventive Services Task Force Grade Definitions Hitzeman N, M.M., Screening for Prostate Cancer: Prostate-Specific Antigen Testing Is Not Effective. American Family Physician, 2011. 83(7): p. 802-804 What are the key statistics about prostate cancer?, American Cancer Society
6 3/7/2017
Prostate Cancer – where?
~ 70% of PCa begin in the peripheral zone ~ 15%-20% in the central BLADDER zone ~ 10%-15% of PCa cases develop in the PROSTATE transitional zone Central Zone Metastases – seminal Transition Zone vesicles, bladder, LN’s, Peripheral Zone BONES; less commonly – intestines, liver, lungs
Crawford, D.F., Understanding the Epidemiology, Urethra Natural History, and Key Pathways Involved in Prostate Cancer. J of Urol. 2009, 73: p. 4-10
Recommendations for screening USPSTF – against screening for all men (2012) (Grade D)
American Urologic Association (AUA) - strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man's values and preferences. (Evidence Strength Grade B)
American Cancer Society (ACS) -emphasizes informed decision making for prostate cancer screening: men at average risk should receive information beginning at age 50 years, and black men or men with a family history of prostate cancer should receive information at age 45 years American College of Preventive Medicine (ACPM) - recommends that clinicians discuss the potential benefits and harms of PSA screening with men aged 50 years or older, consider their patients' preferences, and individualize screening decisions-
7 3/7/2017
“Final Recommendation Statement - Prostate Cancer: Screening, Accessed on-line www.uspreventiveservicestaskforce.org, 2/25/17
8 3/7/2017
Prostate Cancer – Diagnosis DRE – digital rectal exam – enlarged, nodular or indurated gland (might be normal); Serum [PSA] – conventional screening cut-point is 4.0 ng/ml; Velocity of PSA rise >0.35 ng/ml in one year in patients with baseline PSA of < 4.0 ng/ml, or > 0.75 ng/ml in one year in patients with baseline PSA of 4.0 to 10.o ng/ml Transrectal ultrasound-guided biopsy 12-20 Bx cores is recommended (detects 31% more Ca than traditional 6 Bx cores) Heidenreich A, A.G., Bolla M, Joniau S, et al, EAU Guideline on Prostate Cancer. Europian Urology, 2007. 53: p. 68-80 Carter HB, F.L., Kettermann A, et al, Detection of life-threatening prostate cancer with prostate-specific antigen velocity during a window of curability. J of Natl Cancer Inst, 2006. 98(21): p. 1521-27. Eichler K, H.S., Wilby J, Myers L, Bachmann LM, Kleijnen J, Diagnostic value of systematic biopsy methods in the investigation of prostate cancer: a systematic review. J of Urol, 2006. 175(5): p. 1605-12
Prostate Cancer -- Types Pre-cancerous lesions PIN – prostate intraepithelial neoplasia; (low/high grade) ASAP – atypical small acinar proliferation; PIA – proliferative inflammatory atrophy ; Cancerous lesions THE MOST COMMON – adenocarcenoma RARE (4%) – sarcomas, small cell carcinomas, and transitional cell carcinomas
Crawford, D.F., Understanding the Epidemiology, Natural History, and Key Pathways Involved in Prostate Cancer. J of Urol. 73: p. 4-10
9 3/7/2017
Prostate Cancer -- Classification GLEASON SCORE = first + second most common pattern on biosies Grade 1 – well differentiated without infiltration Grade 2 – well differentiated with some infiltration Grade 3 – moderately differentiated Grade 4 – poorly differentiated Grade 5 – undifferenciated Score between 2 & 10 < 6 – indolent malignancy with good prognosis 7 – intermediate to high risk > 8 – aggressive with ↑ risk of systemic disease
Harnden P, S.M., Coles B, Staffurth J, Mason MD, Should the Gleason grading system for prostate cancer be modified to account for high-grade tertiary components? A systematic review and meta-analysis. The Lancet Oncology, 2007. 8(5): p. 411-419
Prostate Cancer – Treatment National Comprehensive Cancer Network Recommendations: Stage (by DRE, MRI, and metastases) Grade (histology – Gleason score) PSA level (predicts recurrence: 4 – 10 – low, 10 – 20 – intermediate, > 20 – high risk) Comorbidity-adjusted life expectancy (CALE) “10-year rule” – treat only if a comorbidity-adjusted life expectancy is at least 10 years Determination is based upon Charlson Comorbidity Index Table Treatment Options – Observation, RP, EBRT, Brachytharapy, Hormone Therapy, and combination.
10 3/7/2017
Prostate Cancer – Survival Rate
Localized Malignancy – 5-yr survival rate is ~ 95-99% Advanced Metastatic Disease – 5-yr survival rate is ~ 10 % with the median survival rate of 4 months.
Jemal A, S.R., Ward E, Hao Y, Xu J, Thun MJ, Cancer Statistics, 2009. A Cancer Journal for Clinicians, 2009. 59(4): p. 225-249
Prostate Cancer – Osteopathic Consideration CONTRAINDICATED Visceral Manipulation HVLA, if the proper diagnosis NOT established (i.e. mets?) May use soft tissue techniques for symptoms relief – fatigue, back pain S Sterrett, W., Disorders of the male genitourinary system, in Osteopathic Medicine, C.W. Hoag JM, Bradford SG, Editor. 1969, McGraw-Hill p. 657- 675
11 3/7/2017
Erectile Dysfunction (ED) – Definition “ ED is the persistent inability to achieve or maintain penile erection sufficient for satisfactory sexual performance. ED lasting for 3 months is considered a reasonable length of time to warrant evaluation and consideration of treatment.”
Qaseem A, S.V., Denberg TD, Casey DE, et al., Hormonal Testing and Pharmacologic Treatment of Erectile Dysfunction: a clinical practice guideline from the American College of Physicians. Ann Intern Med, 2009. 151(9): p. 639-649
Erectile Dysfunction (any degree) – Epidemiology ~ 18 % of the male population aged 20 years & older; ~ 27 % of current smokers ( 40 & older); ~ 38 % of men with treated HTN (40 & older); ~ 42 % among men with BPH; ~ 50 % among men with diabetes; ~ 50 % among men with CV disease; ~ 70 % in men aged 70 years & older; ~ 88 % with HTN, HLD, DM, & smoking (40 & older); ~ 93 % among men with PCa.
Selvin E, B.A., Platz EA, Prevalence and risk factors for erectile dysfunction in the US. The American Journal of Medicine, 2007. 120(2): p. 151-157
12 3/7/2017
Normal Sexual Response – Requires: 1. An intact LIBIDO (visual, olfactory, tactile, imaginative, & hormonal stimuli, i.e. testosterone) 2. The ability to achieve & maintain penile ERECTION, 3. EJACULATION, & 4. DETUMESCENCE
Parasympathetic NS (S2-S4 spinal segment) Erection Sympathetic NS (T12-L2 spinal segment) Ejaculation & Detumescence
Normal Sexual Response Vasc Endo Cell LIBIDO + Parasymp NS Nitric Oxide (S2-S4)
PDE-5 Vasodilation & ERECTION cGMP
GMP
EJACULATION Sympath NS (T12-L2)
DETUMESCENCE
13 3/7/2017
Erectile Dysfunction – Mechanisms 1. Failure to initiate Psychogenic (performance anxiety, depression, relationship conflict, loss of attraction, sexual abuse in childhood, etc.) Endocrinologic (hypogonadism – primary or secondary, hyperprolactinemia) Neurogenic (SCI, MS, peripheral neuropathy – DM or EtOH, surgical disruption – RP) 2. Failure to fill the lacunar spaces Arteriogenic (atherosclerosis or traumatic arterial disease) Vasoconstriction (tobacco, medications) 3. Failure to store adequate blood volume within the lacunar network Venooclusive dysfunction (aging, excessive glycosylation, hypoxia, hypercholesterolemia) Medication-related ED (thiazides, BB, estrogens, GnRH agonists, H2 blockers, spironoloctone, neuroleptics, tricyclics, & SSRI’s, etc.) IN MAJORITY OF CASES – MULTIFACTORIAL !!!
McVary, K.T., Sexual dysfunction, in Harrisonn's Principles of Internal Medicine. 2007. p. 296-300
Erectile Dysfunction – Treatment
1. Education, counseling, life-style modifications; 2. Manage comorbid conditions; 3. Initiate pharmacologic therapy with a PDE-5 inhibitor in men who seek Tx for ED and have no contraindications for its use; 4. ACP does not recommend for or against the routine hormone testing or treatment in the mngt of ED. 5. Hypogonadism – Testosterone Management
Qaseem A, S.V., Denberg TD, Casey DE, et al., Hormonal Testing and Pharmacologic Treatment of Erectile Dysfunction: a clinical practice guideline from the American College of Physicians. Ann Intern Med, 2009. 151(9): p. 639-649
14 3/7/2017
Erectile Dysfunction – Treatment
VCD – Vacuum Constriction Devices -- if PDE-5 is contraindicated ;
Intraurethral Alprostadil (PGE-1) – if PDE -5 inhibitor fails;
Intracavernosal Self-Injection of Alprostadil
Surgery – Semi-rigit or Inflatable Penile Prosthesis – for refractory ED
McVary, K.T., Sexual dysfunction, in Harrisonn's Principles of Internal Medicine. 2007. p. 296-300
Erectile Dysfunction – Osteopathic Consideration Dx: ED – NO Somatic Dysfunction (SD), since the Dx of SD is based on TART !!! Goal: 1. Address restrictions over the inferior mesenteric ganglion and facilitations at T12-L2 vertebral and paraspinal regions to enhance sympathetic innervation and treat somatic dysfunction; 2. Address sacroiliac somatic dysfunction to engage parasympathetic innervation via pelvic splanchnic nerves at the S2-S4 paraspinal region.
Simmons, S., The Neurologic System, in Osteopathic Manipulative Medicine: Review for the boards. 2001. p. 13-27 Modi RG, S.N., Urology, in Clinical Anatomy and Osteopathic Manipulative Medicine. 2006, Lippincott Williams & Wilkins. p. 249-250
15 3/7/2017
Abdominal Aortic Aneurism (AAA) AAA – infrarenal aortic diameter ≥ 3cm 4-9% in men and 1% in women ≈ 9K death annually in the US Almost all deaths from ruptured AAA – 65-80 y/o 1-year incidence rates of rupture: 9% -- 5.5-5.9cm 10% -- 6-6.9cm 33% -- ≥ 7cm
Johnston, K.W., et al., Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg, 1991. 13(3): p. 452-8. Gillum, R.F., Epidemiology of aortic aneurysm in the United States. J Clin Epidemiol, 1995. 48(11): p. 1289-98. Ashton, H.A., et al., The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet, 2002. 360(9345): p. 1531-9. Lederle, F.A., et al., Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA, 2002. 287(22): p. 2968-72.
AAA – Major Risk Factors
Male sex History of ever smoking (defined in surveys as 100 cigarettes in a person’s lifetime) Age 65 or older
Fleming, C., et al., Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force. Ann Intern Med, 2005. 142(3): p. 203-11.
16 3/7/2017
AAA Screening
USPSTF – rating B recommendation One-time screening by U/S in men aged 65 to 75 who have ever smoked (≥ 100 cigarettes in a person’s lifetime) CMS guidelines – will pay for one-time U/S if the beneficiary is included in AT LEAST ONE of the following risk categories: FHx of AAA Man age 65 – 75 who has smoked at least 100 cigarettes in his lifetime
CMS. Implementation of a One-Time Only Ultrasound screening for abdominal aortic aneurisms (AAA), resulting from a referral from an an initial preventive physical examination. 2006 11/6/12 [cited 2013 July 2]; Available from: http://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNMattersArticles/downloads/MM5235.pdf. USPSTF. Screening for Abdominal Aortic Aneurism: Recommendation Statement. 2005 [cited 2013 July 2]; Available from: http://www.uspreventiveservicestaskforce.org/uspstf05/aaascr/aaars.htm
Screening U/S
95% sensitive and 100% specific If negative at 65, 10-yr incidence rate of new AAAs is 0-4%; none exceeded 4cm Therefore, one-time negative U/S at the age of 65 virtually excludes the risk for future AAA rupture or death
Fleming, C., et al., Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force. Ann Intern Med, 2005. 142(3): p. 203-11. Crow, P., et al., A single normal ultrasonographic scan at age 65 years rules out significant aneurysm disease for life in men. Br J Surg, 2001. 88(7): p. 941-4.
17 3/7/2017
Recommendations of other groups
The Society for Vascular Surgery and the Society for Vascular Medicine and Biology: No further testing if aortic diameter is < 3cm; Yearly U/S – if 3 to 4 cm; Q 6 months – if 4-4.5cm; Referral to a vascular specialist if > 4.5cm Consider surgical repair if growth rate is ≥ 1cm/yr Surgical repair if > 5.5cm
Kent, K.C., et al., Screening for abdominal aortic aneurysm: a consensus statement. J Vasc Surg, 2004. 39(1): p. 267-9. Ferket, B.S., et al., Systematic review of guidelines on abdominal aortic aneurysm screening. J Vasc Surg. 55(5): p. 1296-1304.
AAA – Osteopathic Considerations
Dx: Viscero-Somatic Dysfunction Treatment: if back pain – gentle MFR Contraindicated: rotatory techniques, abdominal manipulation ( colonic stimulation, engagement of the inferior mesenteric ganglion, etc.)
18 3/7/2017
Male Pattern Hair Loss (MPHL) or Androgenetic Alopecia (AGA) Epidemiology: The highest prevalence is in Caucasian Men ~ 30 % -- by the age of 30 ~ 50 % -- by the age of 50 ~ 70 % -- by the age of 70
Messenger, A., Male Androgenetic Alopecia, in Hair Growth & Disorders. 2008, Springer. p. 159-170 Sinclair, R.D., Male Androgenetic Alopecia. The Journal of Men's Health & Gender, 2004. 1(4): p. 319-327
Male Pattern Hair Loss (MPHL) or Androgenetic Alopecia (AGA)
Norwood-Hamilton Scale of Male Pattern Baldness
On-line: Male Hair Loss & Pattern Baldness in Men. 2010, International Society of Hair Restoration Surgery, Assessed 9/5/11
19 3/7/2017
Androgenetic Alopecia -- Etiology
1. Genetic Predisposition – Polygenic Inheritance 2. Androgen (DHT) stimulation of the scalp dermal papilla cells ↑ TGF-β miniaturization of hair follicles shorter & finer hairs with less complete scalp coverage.
Androgen stimulation of beard dermal papilla cells ↑ IGF-2 enlargement of the entire hair follicle longer & thicker hair with more complete facial skin coverage.
Sinclair, R.D., Male Androgenetic Alopecia. The Journal of Men's Health & Gender, 2004. 1(4): p. 319-327
Androgenetic Alopecia – Diagnosis
Diffuse hair thinning; M pattern; Negative “Pull Test”
Mounsey AL, R.S., Diagnosing and Treating Hair Loss. American Family Physician, 2009. 80(4): p. 356-362
20 3/7/2017
Androgenetic Alopecia – Clinical Significance Little functional importance; Predominantly psychological (low self-esteem, depression, general dissatisfaction with body appearance) Negative effect is often trivialized or ignored by unaffected people; > 90 % of surveyed respondents (N=250) perceived balding men as less attractive!
Lee HJ, H.S., Kim D, Kim HO, Kim JW., Perception of men with androgenetic alopecia by women and nonbalding men in Korea, Inter J Dermatol, 2002. 41(12): p. 867-9 Sinclair, R.D., Male Androgenetic Alopecia. The Journal of Men's Health & Gender, 2004. 1(4): p. 319-327
Androgenetic Alopecia -- Treatment Minoxidil (aka Rogaine) MOA: vasodilation, angiogenic, antiandrogenic, immunosupressive 1 cc to scalp (NOT hair) BID ½ -life is 22 hrs with topical application – therefore, once a day application is reasonable for better compliance Duration: PRN, but at least for 6 months (discontinuation results in loss of any positive effects within 3-6 months) 2% vs 5% solution – efficacy data is not consistent Higher [solution] is associated more with side effects (ACD, dryness, & hypertrichosis) Mounsey AL, R.S., Diagnosing and Treating Hair Loss. American Family Physician, 2009. 80(4): p. 356-362 Rogers NE, A.M., Medical treatments for male and female pattern hair loss. J Am Acad Dermatol, 2008. 59: p. 547-66
21 3/7/2017
Androgenetic Alopecia -- Treatment FINASTERIDE (aka Propecia) MOA: 5-ɑ reductase inhibitor (↓ conversion of testosterone to dihydrotestosterone, DHT) 1 mg PO daily at least for 6 to 9 months Metabolized by liver Alone or in combo with topical minoxidil Comes as a “Propack” with 90 tabs 1 in 50 (2%) – decreased libido, ED, or ejaculation disorder May potentially ↓ PSA level by ~ 50% -- therefore adjust! Neither a promoter nor preventer of Pca Does not significantly affect sperm production Mounsey AL, R.S., Diagnosing and Treating Hair Loss. American Family Physician, 2009. 80(4): p. 356-362 Rogers NE, A.M., Medical treatments for male and female pattern hair loss. J Am Acad Dermatol, 2008. 59: p. 547-66
Androgenetic Alopecia -- Treatment • Saw palmetto (herbal extract) • Inhibits 5-ɑ reductase • One randomized, double-blind, placebo controlled trial -- ↑ hair growth in 6/10 men with mild to moderate AGA
Prager N, B.K., French N, Marcovici G, A randomized, double-blind, placebo controlled trial to determine the effectiveness of botanically derived inhibitors of 5-alpha-reductasein the treatment of androgenetic alopecia. J of Altern Complement Med, 2002. 8: p. 143-152
• Hair Transplantation • Wigs, hairpieces, and camouflages
22 3/7/2017
“Really Old” “When we are really old we will likely measure our lives by how well we loved, how well we were loved, and by what we created, whether that be family, work, art, or friendships” Joyce T. McFadden
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