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Hair Loss In Women
Most people think hair loss is a medical problem only impacting men. The truth is women make up about forty (40) percent of hair loss patients. According to the American Academy of Dermatology, it's a increasingly recognizable aesthetic concern, affecting thirty (30) million women in the United States. More importantly, female pattern hair loss needs to be recognized as a chronic and progressive condition. All treatments need to be continued to maintain the effect.
For many women their hair is a defining physical attribute that defines character and personality. Hair loss affects one’s self image and emotional well-being. It is a very real and serious aesthetic concern for many women, and in 2008 over 15 percent of patients having hair restoration surgical procedures were women.
But what exactly causes a woman to lose her hair? To understand that, it's important to know a basic understanding about hair growth.
Androgens Impact of the Hair Cycle
Hair grows at one-half inch per month and the growth phase lasts two to six years. With yet-to-be discovered physiologic signals, the hair goes into a resting phase for a period of time, then the hair follicle falls out and a new follicle starts the process all over again.
In some patients with a genetic predisposition to hair loss, a group of hormones called androgens interferes with the growth cycle of the hair. These androgen hormones-testosterone, Androsteinedione, and Dihydrotestosterone (DHT)- are dominant hormones in men, but are present in women to a lesser degree. In many women, hair loss is due to the action of androgens on the hair follicles.
In women who are genetically susceptible, when the testosterone comes in contact with enzymes residing in the hair cell, it is converted into the more potent androgen DHT, which then binds with receptors deep within the hair follicle. Over time, DHT in the hair follicle alters the natural resting and growth phases of the hair. Some of the hair follicles eventually die, while others stop continuing healthy hair growth.
The term 'androgenic alopecia' in women is often referred to “female pattern hair loss.” It is a broader term that encompasses many possible causes of hair loss in women. Androgenic alopecia is caused by factors related to the actions of hormones, e.g., ovarian cysts, use of high androgen index birth control pills, pregnancy, and menopause. Just like in men, DHT and heredity plays a major factor in this disease.
In men, the pattern of hair loss is distinct whereas, women have a diffuse thinning of their hair. Female pattern balding affects circumferentially the whole top of the head. Men rarely have diffuse thinning and compared to the hair loss pattern of men, it is entirely different because men tend to lose it on the temple, the crown, and the bald spot in the back.
The science of female balding remains misunderstood and we don’t understand all the genetic codes and other factors that plays a role in hair loss in women. There are most likely other types of enzymes, as well as hormone receptors and blockers that have yet to be discovered.
Causes of Hair Loss in Women
Other medical conditions such thyroid disorders, polycystic ovary syndrome, anemia, chronic illness, or the use of certain medications can cause hair loss in women. Certain types of autoimmune disorders result in a slightly different and often less dramatic hair loss problem known as alopecia areata -- an inflammatory condition that causes hair to come out in clumps or patches.
Accelerated hair loss and thinning is common in women during menopause and perimenopuase secondary to changing hormone levels. When estrogen and testosterone levels change during this time period, the imbalance causes hair thinning. Hair loss can be from nutritional deficiency of vitamins A and D, iron and other essential nutrients.
Another type of hair loss in women is called Telogen Effluvium. This is described as a temporary hair loss that follows childbirth, crash dieting, surgery, or a traumatic emotional event. Telogen Effluvium can begin about six (6) weeks to three (3) months after a stressful or traumatic event. It is not uncommon for hair to come out in “large clumps”
Anagen Effluvium is another type of hair loss caused by factors impairing the metabolic activity of the hair follicle. This type of hair loss is associated with chemotherapy because the toxic effect of the chemotherapy that is designed to stop the cancer cells from growing and dividing. Unfortunately, chemotherapy is not selective and it negatively impacts all cells-healthy and cancerous- including hair follicles in the body.
Traction Alopecia is a type of hair loss that occurs when the hair follicles are traumatized by hair being pulled tight by hairstyles. Braiding, cornrows, tight ponytails, and hair extensions often cause this type of alopecia.
Oral contraceptives can be a cause of hair loss in women who are predisposed to hormonal related hair loss. The hair loss can occur during of after the use of the oral contraceptive. It is important to note that any medication or therapy that alters a woman's hormones, including but not limited to, contraceptives, can trigger hair loss.
This is why women who have a genetic or family history of hair loss need to be aware that the use of oral contraceptives can negatively impact the hair growth cycle resulting in hair loss. If there is a family history of hair loss it is recommended that you use birth control pills that have the lowest androgen index.
Below is a list of birth control pills ranging from lowest androgen index to highest:
Desogen, Ortho-Cept, Ortho-Cyclen, Ortho Tri-Cyclen, Micronor, Nor-Q D, Ovcon-35, Brevicon/Modicon, Ortho Norvum 7/7/7, Ortho Novum 10-11, Tri-Norinyl, Norinyl and Ortho 1/35, Demulen 1/35, Triphasil/Tri-Levien, Nordette, Lo/Ovral, Ovrette, Ovral, Loestrin1/20, Loestrin 1.5/30
The following hormonal contraceptives have a significant potential of causing or exacerbating hair loss:
- Progestin Implants such as Norplant release a continuous dose of progestin to prevent ovulation.
- Hormone Injections such as Depo-Provera prevents ovulation
- Skin Patch such as Ortho Evra continuously releases progestin and estrogen
- Vaginal Ring like the NuvaRing releases progestin and estrogen.
The most important rule in treating hair loss in women is obtaining the correct diagnosis. A good physician is always evaluating and looking the underlying physical problem. Diagnostic Tests to consider in the evaluation are: Hormone levels- DHEA, testosterone, Androstenedione, Prolactin, Follicular Stimulating Hormone, and Luteinizing Hormone. Serum iron and ferritin, TIBC, Thyroid panel, VDRL, and CBC.
Scalp biopsy A small section of scalp usually 2-3 mm in diameter is removed and examined under a microscope to help determine the cause of hair loss.
Hair pull- The hair pull test is a simple diagnostic test in which the physician lightly pulls a small amount of hair (approx 100 simultaneously) in order to determine if there is excessive loss. Normal range is one to three hairs per pull.
Densitometry-The densitometer is a handheld magnification device which is used check for miniaturization of the hair shaft.
The most important decision you can make is early medical intervention when you first detect hair loss. Early medical intervention is a very important step you make in order to maintain and keep your existing hair. If you delay treatment, Female Balding Pattern hair loss can lead to permanent loss of your hair follicles.
The use of anti-androgen medication after prolonged hair loss will help prevent further hair loss and encourage some hair regrowth from dormant hair follicles. Common sense and healthy lifestyles are also important like diet, weight loss, and exercise that are required to keep your body in good health. Maintaining your nutritional support and monitoring your vitamin and mineral levels helps while you're on anti-androgen medications.
Minoxidil 2% Topical Treatment
Once you decide to have medical treatment, the most common medical product prescribed is Minoxidil. Currently, Minoxidil 2% is the only FDA approved treatment for female pattern hair loss. The effectiveness of these medicines varies from person to person, but most women have found using these treatments have made a positive difference in their hair and their self-esteem.
Minoxidil was first used in tablet form as a medicine to treat hypertension. It was noticed that patients treated with oral Minoxidil experienced excessive hair growth (hypertrichosis) as a side effect. Further research showed that applying a solution of Minoxidil directly to the scalp could also stimulate hair growth. The amount of Minoxidil absorbed through the skin into the bloodstream is insignificant to cause internal side effects.
Minoxidil does not appear to have any anti-androgen effect. In animal studies, the drug does not stimulate testosterone secretion or adrenal androgen secretion. In humans, serum testosterone levels remain unchanged after topical application of Minoxidil. Clinical trials of topical Minoxidil in male and female hair loss show an increase in hair growth, measured by hair counts or hair weight. This increase is apparent within 6–8 weeks of starting treatment and generally peaks by 12–16 weeks.
Since Minoxidil does not appear to have either a hormonal or immunosuppressant effect, it believed Minoxidil induces cell division on epidermal and hair cells. Minoxidil stimulates the hair follicle during the latent part of the Telogen phase to enter the Anagen or growth phase of the hair cycle sooner than normal. This the hair cell spends less time in the resting phase and more time in the growth phase.
In medical studies, it has been shown that women with diffuse Androgenetic Alopecia can use Minoxidil, and it appears to be more effective for women than men. The manufacturers of Minoxidil recommend women only use the 2% concentration. Minoxidil 5% has not bee approved for use by women, but many physicians prescribe Minoxidil 5% for women with Androgenetic Alopecia. Early clinical trials have been conducted on 5% Minoxidil for Androgenetic Alopecia in women showing that indeed the 5% solution is effective in both retaining and growing hair follicles than the 2% solution.
ANDROGEN RECEPTOR INHIBITORS
Aldactone / Spironolactone
Spironolactone or Aldactone is in a class of drugs called potassium-sparing diuretics (water pill). It is used to reduce the amount of fluid in your body without causing the loss of potassium. It is also used to treat hypertension (high blood pressure) and edema (swelling) and used to treat potassium deficiency and hyperaldosteronism (a hormonal disorder).
Spironolactone is an anti-androgen that works by primarily decreasing the production of androgens in the adrenal glands and ovaries. Secondly it blocks the action of androgens in part by preventing Dihydrotestosterone (DHT) from binding to its Androgenetic receptor.
Tagamet / Cimetidine
Cimetidine or Tagamet belongs to a class of H2 blockers used to treat gastrointestinal ulcers. The histamine blocking action prevents the stomach from producing excess acid, allowing the body to heal the ulcer. Cimetidine also has a fairly powerful anti-androgenic effect and has shown to block DHT form binding the follicle receptor sites.
Cimetidine has been used to treat hyperandrogenic conditions like Hirsuitism in women (excess facial hair growth), and has been studied in women with Androgenic Alopecia showing promising results. Because of the high doses needed to achieve it’s hair raising results, men should not take Cimetidine to treat their hair loss due to possible feminizing effects including adverse sexual side effects.
Also known as hormone replacement therapy (HRT) and commonly prescribed at menopause, estrogen and progesterone pills and creams are probably the most common systemic form of treatment for Androgenetic Alopecia for women in menopause or whose estrogen and/or progesterone are lacking for other reasons.
If necessary, Dr. Williams is capable of performing the necessary hormonal evaluation and prescribed Bioidentical Hormone Replacement (BHR) if indicated. Our BHR program is a separate evaluation and done after the initial consultation. If you are interested to learn more details about insurance coverage and fees please feel free to talk to one of our office representatives.
As described above oral contraceptives (OC) can be used to treat hair loss in women. It is important to remember, though, precautions must be followed by female patients because contraceptive pills solely to treat female pattern baldness does carry a risk. For example, smokers over thirty-five who take OC’s are at higher risk for blood clots and other serious conditions. This is the reason why a thorough physical evaluation and hormone evaluation is important before you begin treatment.
If you use OC’s, only use low androgen index birth control pills. High androgen index birth control pills contribute to hair loss by triggering it or enabling it.
Nizoral or Ketoconazole
Available as a topical treatment by prescription, Nizoral or it generic form Ketoconazole, is used as an antifungal agent but its anti-androgenic effects reduce the production of testosterone and other androgens by the adrenal gland and by the male and female reproductive organs.
Ketoconazole has been seen to cause 5 -reductase inhibition. Additionally, in humans Ketoconazole has also been shown to inhibit the binding of 5 -reductase to sex hormone globulins. Clinical studies suggest that Ketoconazole may inhibit the production of DHT thus reducing the pathway that leads to the characteristic miniaturization of hair follicles in Androgenetic Alopecia.
In the case of Androgenetic Alopecia treatment, the only tissue that requires a relative high concentration of Ketoconazole is the hair follicles, and local application of Ketoconazole in the form of a shampoo is the best way to administer treatment. Topical administration avoids systemic toxicity and the agent can be directly delivered to the affected area.
Finasteride is the generic name for Propecia/Proscar. This medication was original made to treat prostate disease. It works primary by inhibiting an enzyme that harms the hair follicle. This enzyme is called 5-alpha reductase. It is well known that testosterone is converted to Dihydrotestosterone (DHT) in the Dermal Papillae region of the hair follicle. It is the DHT that inhibits the normal growth cycles of the hair follicle.
Finasteride is a prescription medication often used for men, but it can be used in women who have Polycystic Ovarian Disease and Hirsuitism caused by elevated androgen levels. Finasteride is not recommended for women primarily because it is often associated some birth defects if the patient is in their child bearing years. For women in child bearing years two forms of contraception is necessary if this medication is going to be used.
Recent studies have shown Oral Finasteride at a dosage of 2.5 mg may be effective in treating women