Arachidonic acid is a compound that can be metabolized in several different ways. I will discuss two pathways. One of these pathways has a protective effect on the prostate (prostaglandin D2 pathway), while the other a malignant effect (prostaglandin E2 (PGE2) pathway). The intermediates in this pathway are prostaglandin G2 (PGG2), and prostaglandin H2 (PGH2). High levels of prostaglandin D2 synthase has been shown to inhibit prostate cancer and in the healthy production of “normal functioning prostate cells” [25]. Not only can prostaglandin D2 have beneficial effects in inhibiting prostate cancer but glioma and ovarian cancers as well [25] and [26]. It could have a protective effect through PGD2’s ability to prevent angiogenesis [27]. Creation of new vasculature helps stabilize and nourish growing tumors. The prostate is one of the few tissues in the body that has the same prostaglandin D2 synthase present in the scalp. Those with male pattern baldness have three times higher amounts of prostaglandin D synthase in the scalp and therefore a higher concentration of prostaglandin D2 [12]. Increased concentrations of this enzyme can encourage the metabolism of arachidonic acid away from harmful pathways and ultimately away from the harmful effects arachidonic acid can have on the prostate. Prostaglandin E2 (the harmful pathway product) can cause the genesis of prostate cancer and growth of prostate cancer cells [28]. Having the opposite effect as PGD2 on the prostate, it makes sense that this prostaglandin has been linked to promote cell proliferation, angiogenesis and inhibit apoptosis [29], [30] and [31]. If prostaglandin D2 synthase acts upon the arachidonic acid metabolite, more prostaglandin D2 could be created instead of PGE2, thereby indirectly inhibiting the deleterious PGE2 pathway. It has been shown that men who are balding have less PGE2 in their scalp than those who have no baldness due to the increased amount of the PGD2 synthase [12]. Therefore, an increase in androgen receptor or estrogen receptor activity in the scalp and elsewhere, like the prostate, could initiate more PGD2 synthase transcription. The increase in prostaglandin D2 synthase will prevent a large accumulation of PGE2 [12] and the resulting increased likelihood of prostate cancer. On a side note, PGE2 accumulation has shown to have a role in the progression of breast cancer [32]. For an overall picture, please see Fig. 1.
Discussion
Male pattern baldness is considered to result from an abundance of DHT and androgen receptor activity. It is conceivable that increased estrogen receptor activity plays a large role. Nevertheless, although higher amounts of DHT could activate more androgen receptors and estrogen receptors (beta), there are costs. Greater amounts of DHT and androgen receptors in the prostate results in increased prostate growth. Therefore, it is not surprising to learn that baldness is strongly associated with benign prostate hyperplasia, a condition characterized by a large prostate [38] and [39]. Nevertheless, the larger size of the prostate may be beneficial in the end, even though it can cause BPH. Smaller prostates have been linked with aggressive prostate cancer [40]. Furthermore, higher amounts of circulating androgens has been linked to less aggressive prostate cancer [41]. This information seems to suggest that larger prostates and a high amount of androgen circulation could therefore serve as a protective effect against aggressive prostate cancer.
Studies have shown that men diagnosed with male pattern baldness at younger ages (#8764;30–40) have a reduced risk of developing prostate cancer [22], [23] and [24]. This makes sense, since the protective effects I have outlined would be in effect. Patients with late onset male pattern baldness do not have as much of this protective effect. If hair loss at earlier ages is taken as an indication that the biochemical pathways I have delineated are occurring at higher frequencies, then it is clear how less prostate cancer would be observed. Late onset baldness could simply be reflective of earlier senescence or poorer health, and higher rates of prostate cancer and other health related issues would be more likely. The studies that studied the link between age of hair loss and prostate cancer are shown in Table 1.
One of these studies examined the link between aggressive and non-aggressive cancer and male pattern baldness. Younger ages of frontal baldness were associated with a decrease in both types of cancer. Unfortunately, the results were not significant due to the few number of patients with aggressive cancer [22].
Two different studies showed an increased rate of prostate cancer with early onset balding. Nevertheless, the populations studied were African American men and veterans [42] and [43]. African American men historically have low rates of baldness and hair loss at earlier ages could thus be from other reasons than the ones outlined above [44] and [45]. Specifically, I contend stress could be the major player in the hair loss among these African American and veteran men. As stress has also been strongly associated with cancer, it makes sense that the associations between cancer and hair loss among these African Americans and veterans can primarily be the result of stress [46] and [47].
An issue that crops up when thinking about AGA and prostate cancer is the particular type of baldness. The studies examining baldness and age show that vertex balding may be associated with an increased likelihood for cancer while other types of balding may be protective. Thus, it is not surprising to learn that vertex balding pattern (back of the head only) has been linked to increased risk for prostate cancer whereas frontal pattern balding has shown no increase of risk. Frontal pattern balding coupled with vertex balding also yields no increase of risk [48]. On a side note, differences in degrees of baldness result in no greater risk for developing prostate cancer [16]. The reason that frontal and frontal + vertex baldness patterns may be protective while vertex balding may be harmful could be explained through estrogen receptor beta. As stated in the hypothesis section, estrogen receptor beta could upregulate prostaglandin D2 synthase and influence hair growth as well as prostate health in tandem with the androgen receptor. The estrogen receptor beta has been shown to be the primary source of estrogen action on the hair follicle [49]. If frontal baldness is representative of estrogen receptor beta action from 3#946;-Diol binding, then the protective mechanisms resulting from estrogen receptor beta could also be occurring in the prostate. This explains why any type of frontal balding could be indicative of a protective effect, since this type of balding occurs from higher expression of 3#946;-Hydroxysteroid Dehydrogenase. For men undergoing vertex balding only, other reasons could be causing the hair loss (just androgen receptor activity instead of maybe a combination of estrogen receptor beta and androgen receptor activity).
Anti-androgen medication studies have shown that lowering DHT concentrations caused smaller prostates, less prostate cancer, but an increase in high-grade prostate cancer [50]. This could happen through less DHT accumulation in the prostate and less PGD2 formation. Older men who start balding may be at a higher risk of developing prostate cancer. If they take medications that slow prostate growth, it could slow carcinogenesis of the prostate. However, forgoing the protective effects of DHT could increase the rates of aggressive cancer if prostate cancer did form. One study has already hypothesized that Finasteride could inhibit 3#946;-Diol formation and therefore indirectly inhibit estrogen receptor beta, increasing the chance of high grade prostate cancer [51]. Also, as previously stated, men with vertex balding seem to have higher rates of prostate cancer. Finasteride can inhibit or counteract the mechanism behind vertex balding (androgen pathway) and effectively reduce the likelihood of prostate cancer in those men. If Finasteride were to be prescribed to reduce balding then estrogen receptor beta agonists should also be considered to protect against high grade prostate cancer [51].
It is very frequent for men to have (low grade) prostate cancer and not experience any noticeable effects. Autopsies after death reveal prostate cancers that showed no clinical evidence during life [52]. According to the Yale Cancer Center, by the age of 75–80, 75% of men will have developed prostate cancer. Furthermore, men often develop prostate cancer a long time before it becomes clinically significant and the development of cancer also seems to occur in a large proportion of young individuals [53]. It is very reasonable to believe that a protective mechanism could have evolved to protect against the cancer that forms at early ages and arises in almost every male. Not only is the fact that anti-DHT medications lower DHT levels and increase the frequencies of high-grade cancers an indication of the protective effects DHT can have, but a genetic variant that results in low alpha reductase and DHT levels is also strongly associated with high grade prostate cancer [54].
A previous study on male pattern baldness proposed that AGA could have been selected for in order to increase the amount of skin exposed to the sun. This would increase exposure to UV light and the creation of vitamin D [55]. Although greater vitamin D could certainly protect against prostate cancer, this hypothesis fails to explain the correlation between vertex balding and prostate cancer. The author suggests vertex balding exposes a large portion of skin directly towards the sun and would enhance vitamin D production. It is suggested that this would reduce prostate cancer. Unfortunately, this is contradicted by numerous studies that show clear correlations between vertex balding and higher incidence of prostate cancer.
We can take a sexual selection perspective to understand how male pattern baldness may have been selected for. Females would find balding males desirable if they were living longer and thus able to provide greater amounts of resources. If the same underlying gene that is present in male-pattern-bald men also reduces ovarian and glioma cancers, then females may gain added protection by having mothers choose such fathers. This could be the result of increased ER-Beta activity and PGD2. Furthermore, it has been hypothesized that men with balding heads can appear more mature, nonthreatening and perhaps better able to take care of children. Unfortunately, women seem to find balding males to be less attractive [56]. Nevertheless, men who have receding hairlines are also perceived as more dominant [57]. Sexual selection and natural selection for male pattern baldness could be possible if bald males were better able at combating prostate cancer as well as more successful in garnering mates.
All in all, my hypothesis outlined above can help explain why Finasteride has been linked to high-grade prostate cancers and why there is so much controversy in the literature regarding male pattern baldness and its relationship with prostate cancer. It also helps in understanding why male pattern baldness/androgenic alopecia could have been selected for.