Hair Loss in Women

The culture considers hair loss is a medical and surgical disorder only impacting men. The truth is women make up about forty (40) percent of hair loss patients. According to the American Academy of Dermatology, hair loss in women is a increasingly recognizable cosmetic disorder and concern. It impacts approximately thirty (30) million women in the United States. Female pattern hair loss is recognized as a chronic and progressive condition with multiple etiologies.

The thickness and youthfulness of hair is vitally important to all women. While most women don’t need medical or surgical treatments, for those women with hair loss the impact can be devastating. The visual density of hair is a essential physical attribute that defines character and personality. Hair loss negatively impacts self image and emotional well-being. It is a very real and serious aesthetic concern for many women.

But what exactly causes a woman to lose her hair? To understand that question, it’s important to know a basic understanding about hair growth.

Androgens Impact of the Hair Cycle

Hair grows at approxiamelty 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 degenerative phase for a few weeks and then into a resting phase for a period of time. It is during this hair cycling stage that the hair follicle falls out, and a new follicle starts the process all over again a few months later.

In some patients a genetic predisposition to hair loss, and perhaps 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. Nonetheless, it is unknown the exact role of androgens in female hair loss. In many women, hair loss can be due to the action of androgens on the hair follicles, or genetics.

In some 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 an exact diagnosis, while another term, “female pattern hair loss,” refers to a broad scope of etiologies for female hair loss. It is a broader term that encompasses many possible causes of hair loss in women. Androgenic alopecia can be 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 typically more distinct and can be described as varying stages of Norwood hair loss patterns. Whereas the hair loss patterns in women typically are a more diffuse thinning of 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 women, it is entirely different because men tend to lose it on the frontal hairline, midscalp, temples, and the crown, also known as the vertex.

The science of female balding is not entirely understood, and science is still defining and understanding 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

Medical Diseases

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 (AA). AA is a type of auto-immune, inflammatory condition that causes hair to come out in patches.

Accelerated hair loss, shedding, and thinning is common in women during menopause and perimenopuase. The exact causative mechanism is not known but may be secondary to changing hormone levels. When estrogen and testosterone levels change during this time period, the imbalance potentially causes increase hair shedding. Hair loss can also be from nutritional deficiency of vitamins A and D, iron and other essential nutrients.

Telogen Effluvium

Another type of hair loss in women is called Telogen Effluvium. This is described as a temporary hair loss that follows childbirth, sepsis, severe infections, 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 common for hair loss to come out in “large clumps” with profound visual loss of hair density.

Anagen Effluvium

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. This may also be a type of hair loss associated with hair surgery itself. This type of hair loss is consider temporary and the hair density returns after the hair cycling phases are completed.

Traction Alopecia

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. Treatment is avoiding this type of hair style. Sometimes the hair loss is permanent and hair transplant surgery is necessary.

Oral Contraceptives

Oral contraceptives may be a cause of hair loss in women who are predisposed to hormonal related hair loss. The hair loss can occur during or 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.

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:

  1. Progestin Implants such as Norplant release a continuous dose of progestin to prevent ovulation.
  2. Hormone Injections such as Depo-Provera prevents ovulation
  3. Skin Patch such as Ortho Evra continuously releases progestin and estrogen
  4. Vaginal Ring like the NuvaRing releases progestin and estrogen.

DIAGNOSIS

The most important rule in treating hair loss in women is obtaining the correct diagnosis. A good physician considers the underlying causes and problems. Diagnostic tests sometimes used in the evaluation of female hair loss are: Hormone levels- DHEA, testosterone, Androstenedione, Prolactin, Follicular Stimulating Hormone, and Luteinizing Hormone. Serum iron and ferritin, TIBC, Thyroid panel, VDRL, and CBC.

Sometimes to make an exact diagnosis of the causes of hair loss in women can be challenging. A scalp biopsy is often necessary to achieve a 100% diagnosis. A scalp biopsy is an office based procedure done under local anesthetic. The biopsy removes a small section of scalp, usually 4 mm in diameter. The scalp biopsy results performed by Dr. Williams at Orange County Hair Restoration facility is then sent to Boston University for detailed pathological diagnosis. The tissue is examined under a microscope to help determine the exact 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.

Dermatoscopy and Densitometry-The dermatoscopic evaluation and densitometer are a very important part of the female hair loss evaluation. The densitometer is a handheld magnification device which is used evaluate the scalp and hair for its density The dermatoscope is a thirty powered hand held type of microscope that evaluates the scalp and hair for certain anatomical characteristics.

Hair Mass Index (HMI)- This is an excellent and reliable test performed by our staff to determine baseline hair density. The HMI is used as a long term measurement of the efficacy of medical and surgical treatment protocols.

TREATMENT

The most important decision you can make is early medical intervention when you first notice or detect hair loss. Early medical intervention is a very important step to maintain and keep your existing hair density. If you delay treatment, hair loss can lead to permanent loss of your hair follicles.

There are topical medications and oral medications used to treat hair loss disorders. 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 5% Topical Treatment

Once you decide to have medical treatment, the most common medical product prescribed is Minoxidil. Currently, Minoxidil 5% 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 may be apparent as early as 12 weeks of starting treatment and generally peaks by six months.

Since Minoxidil does not appear to have either a hormonal or immunosuppressant effect, it believed Minoxidil induces cell division of the epidermal and hair cells. Minoxidil stimulates the hair follicle during the latent part of the telogen phase as the hair to enters the anagen or growth phase of the hair cycle. Theoretically, 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 FDA has approved for women the use of the 5% concentration.

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. The major side effect with this medication are the high doses of Spironolactone at 200 mg/daily required to have an impact upon women’s hair loss. The typically dose for this medication for the treatment of water retention and blood pressure is 50 mg daily. To achieve therapeutic doses of Spiroloactone, the patient’s electrolytes have to be routinely monitored and a larger than expected diuresis can be expected.

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. The efficacy of this medication varies form patient to patient.

Estrogen/Progesterone

Also known as hormone replacement therapy (HRT) and commonly prescribed at menopause, estrogen and progesterone pills and creams are a form of treatment for Androgenetic Alopecia for women in menopause or whose estrogen and/or progesterone are lacking for other reasons. Typically the patient will receive these hormones from their GYN physician after consultation with the hair loss specialist.

Oral Contraceptives

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

Finasteride is the generic name for Propecia/Proscar. This medication was original made to treat prostate disease in men. 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