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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.

 

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