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I agree with most of your critique, as stated many times before we need bigger and more thorough studies. But even studies with a small sample size are indicative and serve as a warning there's more going on. Also purely anecdotally but many men on finasteride experience "watery sperm" or reduced loads, it's a common side effect as far as I've read over the many years.Also, in the study you posted regarding infertility, just to make sure we're on the same page..
The summarized results section is poorly worded, but it states "There was no change in hormone parameters, sperm motility, or sperm morphology." It shouldn't be misinterpreted that these parameters were reduced and then did not change after finasteride was discontinued. They could only assess this if semen parameters were measured prior to finasteride administration, and they weren't. The correct interpretation, which is very clear in the results section, is that these parameters were not effected by finasteride. The only parameters that were effected is sperm concentration/counts which resolved in the majority of men that discontinued finasteride.
Another nitpick; "There were 14 men who had a semen analysis while taking and after discontinuation of finasteride. Twelve of 14 men had a single semen analysis after finasteride discontinuation. Two of 14 men had two semen analyses after discontinuation; for these men, the two analyses were averaged". So the sample size was effectively 14, which is very low.
Regardless, I think there's enough evidence floating around that you should discontinue finasteride when you're trying to conceive.
The shocking part is that the FDA actually admitted in their offical approval letter of 97 that they just do not know if finasteride is safe or not. It's quite crazy, I did not know this. Even more concerning then that some doctors (dermatologists) still prescribe this and tell patients it's "safe" when the official medical control organ of the USA admits not knowing if this is the case or not... Luckily it seems more doctors are aware now about the risks but this was not the case X years ago.Just playing devil's advocate here, but this tweet...
"1. Long-term benefits of finasteride 1 mg for baldness are uncertain.
2. LT risks in younger men are unknown, esp. effects on fertility.
3. Risk-benefit analysis for LT therapy cannot be made at this time.
Isn't this literally every medication that gets approved? Good luck getting funding and a statistically relevant sample size when you're trying to study a medication for 20+ years. I mean, what's the alternative to this statement? I guess it depends on what you consider "long-term". Are we talking 5 years, 10 years? More?
But you're right, if we want new medication we'll have to compromise on trial length but for some medication like finasteride that messes with hormones, neurosteroids, etc one can make the case we should have had much longer studies to assess safety.