Overwiew

Hair loss is a common occurrence in women, more so than commonly realized. By the time women reach middle age, probably over 50% of them experience some degree of hair loss.  This is not properly recognized since women often conceal their hair loss using various methods such as styling, extensions, and cover-ups.  Hair loss can have a greater impact on women because it is less socially accepted than it is in men. When men experience hair loss, even though they may not like it, they appear like men who are experiencing normal hair loss.   When women’s hair starts thinning, they may start looking abnormal, almost as if they are unwell.

Women can be treated for hair loss…… but the approach   can be more involved than it is for men for a few reasons, including the following

• There are more causes of hair loss in women than men, and these causes need to be worked up.  Sometimes there are multiple factors contributing to hair loss, and they each must be addressed and treated to have the maximum benefit.
• Women’s hair is more “fragile” than men’s and very susceptible to shedding (telogen effluvium) after stressful physical and mental situations.  For example, after an operation, severe illness,  or even just a  high fever, many women will go through a phase of hair loss. The process is usually due to a process called Telogen effluvium.  In many, this hair loss will begin to resolve about 3-4 months after the stress is gone and can take up to a year to resolve totally.  In others who are less lucky, it may only partially resolve, or  does not resolve at all.   This is more commonly true if they have another associated cause of hair loss, such as female pattern hair loss for example.
• Until recently, the medical treatment options for women has been more limited and less effective than the medical treatment available for men.   However, recently this situation has improved.
• Hair transplant surgery is more difficult in women than in men. There is a higher risk of damaging existing native hairs due to the increased sensitivity of female hair. This could lead to post-surgical shedding and hair loss

All these issues need to be evaluated and addressed when treating a woman with hair loss.

The good news is that many women can be helped depending on the specifics of the situation and what is found.  In addition, newer medical treatments and improvements in surgical technique have made more women candidates.  The key is a thorough and systematic evaluation to determine what can be done.

THE MORE COMMON CAUSES OF HAIR LOSS IN WOMEN                  (This is not a complete list)

Metabolic & Nutritional Causes of Hair Loss in Women

• Vit D deficiency:  There is an epidemic of Vit D deficiency in the USA.  Over 40% of the population is felt to be Vit D deficient.  Vit D is now thought to be involved in many bodily functions.   Low Vit D not only causes hair loss but many other problems, including osteoporosis, depression, fatigue, poor wound healing, etc. Normal levels can range from are stated to be from 30-120 ng/ml, so many patients feel they are ok with a level of 30-40ng/ml     However, recently it has been felt that for proper hair health, it should be 50-70 ng/ml

• Iron deficiency:  Iron deficiency is also very common in women…especially during the childbearing years when they lose iron every month due to menstruation.  However, many women are iron deficient post-menopause because they never replaced the iron they lost when younger  Just like Vit D, it is sometimes misdiagnosed due to poor interpretation of tests like blood iron levels.  What needs to be measured is Iron storage levels which can be very low even while blood iron levels are normal.  In order to measure this, we need to measure Ferritin, which measures body storage levels of iron.  Just like Vit D, the “normal” range is said to be forum 30-100 but one needs levels of 50-70 for proper hair growth.

• Hypo or Hyper Thyroid disease:  Both can cause hair loss and are common in women.

• Folate and B12 Deficiency:  With vegetarian diets and extreme weight loss diets, this can occur not infrequently.

• Hyper-androgen states:   Androgens like testosterone, progesterone, and DHT can increase hair loss.  Testosterone and DHT are the most common causes of hair loss in men.   The most common cause of a hyper androgen state in women is Poly-Cystic-Ovaries (POC) which causes an increase in progesterone.    Another cause could be taking birth control pills that have a higher progesterone/ estrogen ratio.

• Medications with the side effect of hair loss:  This must be looked at

Primary Hair Disorders That Can Cause Hair Loss in Women

• Telogen Effluvium:  This is a situation where a patient’s hair is triggered to go into the “telogen phase” (resting phase)  of the normal hair life cycle and shed.  It is not an uncommon situation for women. It can cause by physical stress, emotional stress, illness, etc.   It is the common mechanism of action for many metabolic conditions  (Vit D, Iron deficiency, hypothyroidism)  and other fairly common stressful conditions (ie, after a major surgery, major illness, extreme diet, depression, etc.   Often if the underlying stress or condition is resolved, the hair can grow back…. however, not always.    Sometimes the Telogen Effluvium resolves but the process may unmask an underlying Female pattern of Alopecia (see below), resulting in the hair loss not resolving completely.
• Female Pattern Alopecia (Genetic):  This is the most common cause of hair loss in women.  It can be mild (Type 1) moderate (Type 2) or sever (Type 3) as seen in the photo below.

Female pattern hair loss can co-exist with some of the metabolic deficiencies and other stressors listed above.   These other co-existing factors can contribute to making the hair loss of female pattern alopecia more severe (as described above) This is why it is important to find and treat these other underlying disorders.  Otherwise, treatment for Female Pattern hair loss will be less effective.

• Alopecia Areata: This is an auto-immune disease where the body attacks its own hair. It can be triggered by many stresses …or just happen by itself.  It is usually temporary causing one or more localized, circular, smoothe patch’s of hair loss that will appear and then slowly return over 3-4 months.  It can also be diffuse rather than localized.  In this case, it is more difficult to diagnose clinically and  may require a biopsy to rule out. Most recover, but the patches can return intermittently over their life. Other less fortunate patients can progress to total hair loss called alopecia areata totalis

• Traction or Traumatic alopecia: Chronic pulling, touching or other physical stress to the hair can cause hair loss.  This can occur with hair extensions, tight braiding, constant touching, or a hair-pulling disorder called “trichotillomania.  Often the patient is not aware they are causing their hair loss

• Inflammatory scarring causes of hair loss (i.e, Lichen Planus Pilaris (LPP) and Frontal Fibrosing Alopecia (FFA)): These are two inflammatory disorders of hair loss that can be devastating to females. The cause is unknown.  These illnesses have become more common in recent years. Usually, the pattern and clinical presentation make it easy to diagnose, but sometimes it can mimic Female Pattern Hair loss.  If one is not certain of the diagnosis, a biopsy should be done where a small piece of tissue in the affected area is sent to a pathologist to look at.

APPROACH TO FEMALES WITH HAIR LOSS

1. WORK UP

• Physical Exam with dermoscopy and History
• Laboratory   tests:

        Required Laboratory  Tests

• Ferritin level

1. • Vit D level
   • B12 & Folate Level
   • Thyroid profile for hyper and hypothyroidism
   • Free and total testosterone level

       Optional Tests ( Depending on history)

• DHT levels ( if needed)

1. • Estradiol levels (if needed)
   • Prolactin level (if needed)
   • Syphilis titer (if needed)
   • Scalp Biopsy (if needed)

    

***Any underlying abnormalities found to need be addressed and corrected otherwise medical and/or surgical treatments for simple female pattern hair loss will not be effective.

 

MOST COMMON INITIAL NON-TREATMENTS FOR  FEMALE PATTERN ALOPECIA

1. Cosmetic Camaflouge and Coverups

• Dermatch or Toppix  Cosmetic cover-ups (See handout).  This can often be an easy fix by itself or in conjunction with other medical and surgical approaches. It is an adjunct that makes less hair look fuller.

1. Medical treatment for Female pattern hair loss ( See Handout)

• Topical Rogaine or Oral Rogaine (See handout)
• Finasteride in women past the childbearing years  or  if they cannot get pregnant (See handout)
• Spironolactone
• Low lever Laser Light therapy (See handout)

1. Regenerative/Cellular therapy ( See Handout)

• PRP
• Exosome  therapy
• Microneedling

1. Scalp Micro-pigmentation ( See Handout)

• Scalp Micro Pigmentations Procedure (See handout). This is a long-lasting cosmetic make-make procedure that makes less hair look fuller, similar to cover-ups. However, instead of having to use it daily,   you only have to touch it up once a year.

5.  Hair Transplant Surgery

• Hair transplant surgery can be very effective in the right patient.

However, most women should have a thorough evaluation and should also try non-surgical-medical therapy before jumping into surgery.   The reasons for this are many:

• • Medical Therapy will not  minoxidil, Finasteride, etc, will not be as effective if a person has an ongoing underlying metabolic issue
  • If a patient is a “responder”, and many are, they may improve to the point they no longer need surgery
  • And if they do have surgery, by having a year of treatment beforehand,  I believe their donor area improves and they are less likely to have the telogen effluvium that is more common in women.  Hence  the surgery is more likely to be  succesful