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FEMALE HAIR LOSS (ALOPECIA)
by
Geoffrey Redmond, MD
Quick Reference
What is Alopecia?
How I came to treat Alopecia
Why am I losing my hair?
Estrogen and
female alopecia
What androgenic alopecia looks
like
What is telogen
effluvium (TE)
The thyroid and
alopecia
What does it feel like to have
Alopecia?
The meaning of hair
Does it show?
What causes female Alopecia?
Hair care and Alopecia / Androgenic Alopecia
The workup for Androgenic Alopecia
Treatment
What to expect
Is there any hope?
Some final words
What is Alopecia?
Alopecia is simply the medical term for hair loss. Female alopecia is both
common and distressing.
How I Came to Treat Alopecia
In formal medical training, few physicians
hear a word about androgenic alopecia, yet it affects 20% of women up to the
forties and even more after that. I become interested in alopecia when I saw how
distressing it is to women who have it. Though many of my physician colleagues
do not think alopecia is worth medical attention, I disagree. Any bodily change
which causes so much unhappiness is worth the effort to diagnose and treat.
Alopecia falls in between specialties. Hair is part of the skin so is included
in dermatology. Yet the cause of the most common form, androgenic alopecia, is
internal: the actions of hormones which are the focus of a different specialty –
endocrinology. Yet few endocrinologists are trained to diagnose or treat hair
loss in women. This is unfortunately because bridging the gap between
specialties has made it possible to apply new knowledge about hormones to
understanding and treating androgenic alopecia.
The ignorance among health professionals about the all too common and
distressing condition of alopecia is truly astounding. Many doctors cannot even
recognize alopecia. This is terrible for the person seeking help. Being told
nothing can be done is bad enough, but not being believed is even worse. Often
when I see a woman for alopecia on her first visit, she is surprised when I
acknowledge that she has a problem, since so many doctors have told her nothing
is wrong. Yet I cannot remember ever seeing a woman worried about alopecia who
did not actually have it. With some the loss was very mild, but it was never
simply their imagination. After all, each of us knows our body better than
anyone else. So here are the first things that need to be said: female
hair loss is real, it is distressing to all women who have it, and it can be
treated!.
Why am I Losing
My Hair?
Alopecia is a general term and can refer to hair loss from any cause. Indeed
many diseases can cause hair loss but most are quite rare. Only two are common:
alopecia areata which is due to the immune system attacking the hair
follicles and androgenic alopecia, which is hormonal.
Androgenic alopecia is extremely common. A reasonable estimate is 20% of women
prior to menopause and up to 40% after that. In early stages it so mild as to
escape notice by others but most affected women are only too aware that it is
happening. A common abbreviation is AGA. Sometimes it is referred to as
“androgenetic alopecia” to emphasize the genetic component but I do not like
this term because some women with androgenic alopecia do not have it in their
family.
As the name implies, androgenic alopecia is due to the effect of androgens, the
family of hormones which includes testosterone. One effect of testosterone is to
inactivate hair follicles on the scalp. Oddly, it makes follicles on the face
and body more active. It’s not fair but the same hormone takes hair away from
where it is wanted and puts it where it is not wanted. Yet this is the
unfortunate truth about what testosterone does to hair follicles. These effects
are very obvious and familiar in men. The much higher testosterone levels give
us less hair on the scalp and more on the body than women.
As if this were not enough, testosterone also makes the skin more oily, which in
turn can trigger acne. Many women with AGA
have only the alopecia but some also have other unwanted effects of testosterone
– hirsutism, that is, increased facial and body hair (Hormones
and Unwanted Hair) and oily skin or acne. These can be part of
PCOS (polycystic ovary syndrome) (PCOSupport
The Polycystic Ovarian Syndrome Association Web Site)
but many women with AGA have only the alopecia without any other hormonal
changes.
In my practice I’ve seen women who have been told
they have
PCOS but only have androgenic alopecia. But then, I’ve seen some with
alopecia whose
PCOS had not been diagnosed. A woman with alopecia who is
overweight and/or has irregular periods, should get checked to see if she has
PCOS because then additional treatments may be helpful.
Estrogen and female alopecia
While androgens are often the cause of female alopecia, there is another
hormonal factor – estrogen. This is hardly surprising, considering that abundant
hair is clearly a female characteristic. In contrast to testosterone, estrogen
helps hair. It does this by helping the hair grow faster and stay on the head
longer – resulting in thicker hair. This is the reason women’s hair gets fuller
during pregnancy when estrogen levels are quite high, then sheds several weeks
after the baby is born.
Estrogen deficiency alopecia generally starts some months before menopause, that
is during perimenopause or shortly after menopause. Because estrogen levels
start to fall before periods stop, this form of alopecia can be the first sign
of approaching menopause. Women vary in this regard however. Sometimes the
alopecia does begin until a few months or even a few years after menstruation
has ended. Not all women get noticeable alopecia after menopause but most have
at least mild thinning.
The alopecia due to low estrogen has the same pattern of distribution as that
due to testosterone and dermatologists generally fail to make a distinction.
Estrogen deficiency as a cause of hair loss has not found its way into medical
textbooks but this does not stop it from happening.
What androgenic alopecia looks like
Androgenic alopecia is distinguished from other
forms of alopecia primarily by the pattern of hair loss on the scalp. For this
reason, it usually needs to be diagnosed by a physician experienced with female
hair loss, of whom there are unfortunately very few.
There is some individual variation of course, but androgenic alopecia tends to
affect the temples, the crown and the vertex; the sides are least affected.
Sometimes AGA is said to be the female equivalent of male pattern baldness but
this is only partially accurate. Though female androgenic alopecia is caused by
testosterone, unlike male pattern baldness, the front hair line is usually
preserved. Nor does the top of the scalp lose all hair as often happens to men.
Female AGA tends to be much milder than male hair loss but this is not much
consolation for the women who experience it. Hair loss is expected for men,
though we don’t like it, but is not supposed to happen to women.
What is telogen effluvium (TE)
This elegant-sounding term simply refers to an
increased rate of hair shedding and implies that the hair will eventually grow
back. Some dermatologists make a distinction between telogen effluvium and
androgenic alopecia. However the only way to tell if the hair will grow back is
to wait and see. In my experience, it usually does not and waiting many months
simply delays treatment.
There are some situations however in which hair loss
is common and regrowth usual. These include childbirth, substantial weight loss
(typically 30 or more pounds over a few months) and illness with high fever (but
not a mild case of flu). In those cases it may be reasonable to wait some months
to see if the hair grows back. Be careful though: most of the women I see who
have been told they have TE actually have AGA.
Alopecia areata is less common than androgenic alopecia. It occurs
when the immune system attacks the hair follicle. As the name alopecia areata
implies, hair is lost in discrete areas. There will be a patch or patches of
shiny scalp with no hair at all, but the rest of the hair is unaffected. However
it can spread to other areas or sometimes involve the entire scalp (alopecia
totalis) or all the hair on the body (alopecia universalis). When only a small
area is affected, the hair usually grows back but then may fall out again.
Unfortunately, we have no way to predict which way things will go with alopecia
areata.
A usual treatment for alopecia areata is injection of cortisone-like medications
into the scalp. Taking similar medications orally does not help in the long term
and can cause weight gain and other undesirable side effects. (Similar
medications are sometimes used for adrenal conditions but in much lower doses
which do not cause these side effects. These conditions should be managed by an
endocrinologist.) Treatment of areata is not always effective, unfortunately.
The medications which help androgenic alopecia do not help areata. Sometimes
both forms can occur together and then treatment for androgenic alopecia may be
appropriate.
The thyroid and alopecia
Alopecia areata is not caused by hormones but can be
associated with under activity of the thyroid, which can also be damaged by the
immune system. When areata first appears, thyroid testing should be done and
then about every one to two years after that. Though treatment of the thyroid
condition is important for overall well being, it does not help with the hair
loss, unfortunately.
Many women whom I see in my practice ask me whether
their alopecia may be due to a thyroid problem. This is rarely the case nowadays
because thyroid disorders are usually picked up at a very early, mild stage.
Still checking the thyroid with the very sensitive TSH test is an important part
of the workup. If you are on thyroid medication, too high a dose can make
alopecia worse so it is important to be sure that your TSH is normal on the dose
you are taking. If it is lower than normal, you should discuss the situation
with your physician.
What Does It Feel Like to Have Alopecia?
A renowned but unsympathetic dermatologist once said to me, chuckling, “We know
hair is totally unnecessary.” Some in my profession just cannot understand why
hair matters so much to women. While it’s true that hair is not necessary for
survival in the way the heart or kidney is, human life is more than survival.
Most take their hair for granted and have no particular reason to reflect on
what it means to them. When it starts to fall out however, everything is
different. Women with alopecia tell me that they are embarrassed and ashamed.
Though there is no reason for this -- alopecia is not the woman’s fault. --
these feelings seem nearly universal with AGA. Some women with alopecia are even
reluctant to go out of the house for fear that someone, even a stranger, might
notice her hair is thin. When women share these feelings with their doctors
some end up being told to see a psychiatrist – but psychotherapy or psych meds
will not make hair grow back. I am certainly not against these treatments for
people who need them but my view is that women with alopecia deserve to be
offered effective treatment, not simply be told to “learn to live with it.”
The meaning of hair
Hair represents youth, vitality, energy, even
fertility -- attributes no woman wants to be without. By youth I do not mean any
particular age but a sense of freshness and enthusiasm for life. My patients in
their seventies value their hair quite as much as do twenty-five year olds.
Hair is the only part of the body which can be altered and shaped. Styling and
coloring hair are forms of self-expression. Even the choice to do nothing with
one’s hair but wash and comb it is still a way of showing one’s individuality.
Does it show?
Women with androgenic alopecia live in fear that
others will notice I had a patient who would never go to the theater because she
feared everyone would stare at the back of her head. (Her alopecia responded
well, she started going out, got married, had children and now is quite content
with her life.)
Yet most of the time, no one notices. This is not always reassuring to women
with alopecia because they still worry that someone might notice. And if you
have alopecia, you notice. We tend to think of our appearance as
something for other people but it is oneself who first has to be pleased by how
one looks.
Men seem not to notice if their wives or girlfriends have alopecia and are not
much bothered by it if they do. On the other hand, many are sympathetic to the
distress it causes and try to aid in finding help. Often, it is the patient’s
partner who has heard of me and comes along for the first visit. This is not
because they mind the alopecia; rather, they want to ease their partner’s
distress by helping her find effective treatment.
Sexual orientation does not seem to affect how important hair is to a woman. Nor
does personal style have much to do with it. One of my less conventional
patients keeps her head shaved but is just as troubled by her alopecia. Even
though her hairs are very short, she still wants them all there.
What Causes Female Alopecia?
Androgenic alopecia is caused by testosterone which is carried by the
blood to the hair follicles of the scalp. There it is converted to a more active
form called DHT (dihydrotestosterone) which somehow inactivates the follicle.
Strictly speaking, the hair follicles still produce hairs but they are too tiny
to be visible. This process is called miniaturization. After many years, the
follicles disappear. For this reason, the sooner treatment can be started the
better, but even when alopecia has been present for years there can still be
some response to treatment.
Falling estrogen is the main cause of alopecia in menopause and beyond. If
alopecia begins in the forties or later, there is good chance that it is due to
lower estrogen levels, though occasionally the effect of androgens does not show
up until this age. Sometimes both are involved.
What happens at menopause both biochemically and personally is discussed in the
menopause article. (What's
Happening? What Do I Do? A Guide To Menopause)
Iron deficiency Some believe that subtle iron deficiency can contribute
to alopecia. I suggest taking a standard woman’s multiple vitamin with iron. Too
much iron can be harmful so larger doses should only be taken by women whose
tests have shown they are deficient.
Hair Care and Alopecia / Androgenic Alopecia
Many women wonder whether hair care products might be damaging their hair. With
products now available in North America and Europe, this is most unlikely. In
any case, they would only cause the hairs to break, not damage the follicle
itself. If hair breaks off due to a bad perm, it will eventually grow back.
Still, no one wants breakage so it is best to have your hair handled gently.
Hair Care with Androgenic Alopecia
Heat makes hair fragile. Use your blow dryer with the heat turned off.
Use a loose comb, not a brush. Don’t tug at your hair but separate tangles
gently with your fingers.
Don’t bleach unless you absolutely must make your hair color lighter. Bleaches
are hard on hair.
If your style requires pulling your hair back, as with a pony tail, braids or
corn rows, do so extremely gently. Most women with these styles pull out some
hairs inadvertently.
Many women with alopecia dread washing their hair because then they notice how
much has come out. Hair washing does not cause shedding but it does make you
more aware of it. Frequent washing keeps your hair in good condition.
The Workup for Androgenic Alopecia
For alopecia, the work-up starts with measuring total and free testosterone as
well as DHEA-S. It’s a good idea also to check your blood count and iron levels.
If you have other changes such as increased hair growth, oily skin and acne,
irregular periods, more extensive workup is often indicated. These are discussed
in the sections on hirsutism and on PCOS.
Most women with AGA have normal levels of testosterone and other androgens.
Their problems is that their follicles over-react to testosterone. If you want
to know more about this, check the section on unwanted hair. (Hormones
and Unwanted Hair). However, even if testosterone
and all other lab is normal, alopecia can still be successfully treated.
Don’t believe it if you are told, “All your tests are normal; there’s
nothing which can be done.”
Treatment
Oral contraceptives (OCs) These can lower free testosterone levels by about
half. Some OCs seem to be better than others for women with androgenic alopecia.
Though they sometimes help, OCs by themselves are not adequate treatment for AGA.
Additional therapy is necessary.
Medications to block testosterone Because androgenic alopecia is due to
the effects of testosterone, the logical treatment is to block testosterone.
Several prescription medications have this action, though they are approved by
the FDA for uses other than female alopecia. The most widely useful is
spironolactone (Aldactone®). Finasteride (Propecia® and Proscar®) also seems to
help androgenic alopecia but pregnancy must be absolutely avoided with this
medication – or with spironolactone. These are discussed in more detail in the
hirsutism and
PCOS sections. [Hormones
and Unwanted Hair]
Minoxidil (Rogaine®) is the one medication officially approved for alopecia in
women. Rogaine is non-prescription and comes in two strengths: 2% and 5%. The 5%
is not usually recommended for women because if it gets on other skin, such as
the forehead, it can cause hair to grow there. A more common problem is scalp
flaking and irritation. Still, some women benefit from this higher strength. To
tell if minoxidil is working takes three to nine months; not everyone sees a
benefit.
The main problem with minoxidil is that it must be applied to the entire scalp
twice a day. For men, this is not too difficult, but for women whose hair is
almost always longer, it is easier said than done. Also, whatever hair comes in
because of the minoxidil will fall out if it is discontinued. Minoxidil has its
place in treatment of female alopecia, but I do not usually recommend it as the
first choice unless nothing else is available for you.
Estrogen for alopecia If the problem is not testosterone but declining
levels of estrogen, then estrogen is the logical treatment. It is important to
point out that women under forty who are having normal cycles or who are on an
OC are not likely to be estrogen deficient. Estrogen begins to fall only as
menopause approaches, usually after age forty-five. Irregular or absent cycles
can be a sign of lower estrogen but can also be due to
PCOS or other conditions,
so evaluation is necessary to tell which is going on.
Whether to take estrogen is a serious decision for women. The menopause section
gives more information to help with this decision. as does my recent
newsletter. [What's
Happening? What Do I Do? A Guide To Menopause]
One of the oddities of estrogen replacement is
that different parts of the body require different amounts. The usual doses are
based on what the bones and blood vessels seem to need. More is sometimes needed
to fully control symptoms such as hot flashes, and hair follicles seem to need
even more. This means that the dose of estrogen needed to help alopecia is
sometimes more than the usual one. I frequently see women on low estrogen doses
who continue to have hair shedding and progression of their alopecia. An
increase in estrogen dose often stabilizes the hair and sometimes promotes
regrowth.
Hormone replacement needs to be individualized; there is no one dose or form
which is right for all women. It is important to work out what is right for you
with a physician experienced with the subtle changes of menopause. For this
reason, I do not here recommend specific forms or doses.
Women who have not had a hysterectomy also need to
take a form of progesterone. The natural form is probably better for hair than
some of the synthetics. If you want to know more about hormone replacement,
check the article on this website. (What's
Happening? What Do I Do? A Guide To Menopause)
Alternative treatments Saw palmetto is thought to inhibit 5 alpha
reductase, the enzyme which activates testosterone. It is mainly used by men for
prostate enlargement and sometimes for male alopecia. It may work to some degree
but experience in women is too limited to be sure. The problem with herbs is
that there is no assurance that the preparation you buy is actually active.
Herbs and supplements however are extremely valuable for certain other female
conditions such as PMS and menopause. (Escaping
The PMS Maze)
What not to take Anything with testosterone can make alopecia worse.
Testosterone is sometimes used to help restore sex drive. The most popular form
is a combination with estrogen called Estratest® and Estratest HS®. This
sometimes helps libido but it can cause hair loss. Testosterone creams obtained
from compounding pharmacies may produce very high blood levels and should be
avoided.
DHEA, popular as a supplement, is converted in the body to testosterone and so
should be avoided by women with androgenic alopecia.
What to Expect
There are no studies about overall effectiveness of treatment of alopecia since
it gets little research attention. I can only go by my personal experience
treating several thousand women in my practice over the past twenty years.
With proper
treatment, most women with androgenic alopecia or estrogen deficiency alopecia
have stabilization which means their hair stops thinning. Shedding slows but
does not stop because it’s normal to lose about 100 hairs a day. (New hairs are
always growing in to replace them but are hard to see.) With treatment, the
quality of the hair usually improves so that it looks brighter, fuller and
livelier and is easier to style. Regrowth can occur but may take a year or more
of treatment. Even a very good result does not bring the hair back to the
fullest it ever was but it can make a great difference -- many women who once
felt quite miserable about their alopecia now find that they no longer feel
embarrassed in public; they can go back to enjoying their lives.
Is There Any Hope?
Many of the women who come to the Hormone Center of New York for alopecia have
been told so often that nothing can be done that they are stunned when they find
out that alopecia, whether androgenic or due to estrogen decline, can be helped.
I’ve said this many times but it is so important that I must state it again:
female hair loss is treatable. There are several treatments and while no
medical treatment works for everybody, the odds are good that one will help. The
important thing is to search for a doctor knowledgeable about hair loss – there
are a few – have the necessary workup and then choose the treatment which makes
sense to you.
Some Final Words
Alopecia is one of the most disturbing and at the same time, most neglected of
female hormone problems. It is sad that so many women who desperately want help
are told that nothing can be done, that they must just learn to live with it.
However, the cause can usually be determined and there are treatments which
usually help. The knowledge exists; why the medical profession ignores it is a
mystery to me. If you have alopecia, do not let the common medical pessimism
demoralize you.
There is hope for alopecia.
