Hair loss is relatively common in women, more common than one would imagine. Half of women over the age of 50, have some degree of cosmetic hair loss. The presentation, however, is much different than in men and the management of women with hair loss requires significant expertise in both diagnosis and treatment. For those women in whom surgical hair restoration is indicated, special surgical skills are required to achieve the best results. It is a mistake for a surgeon to assume that hair loss in women can be treated the same way as in men and hair transplants in over 90% of women is the wrong decision.
Women generally have a diffuse thinning (hair loss all over the head including the back and sides of the head), in contrast to men who more frequently have a “patterned” type (hair loss that spares the back and sides). Women often maintain their frontal hairline, whereas men characteristically lose a significant amount of hair in the front part of their scalp from the very beginning including the very frontal part of the hair line. Hair loss in women is most often very gradual, with the rate accelerating during pregnancy and at menopause. In family lines where mother, aunt, grandmother or sisters have it, it may start gradually in their 20s and plateau quickly or continue to progress. It is more often cyclical than in men, with seasonal changes that reverse themselves, and it is more easily affected by hormonal changes, medical conditions, and external factors such as emotional stress.
There are two simple “bedside” tests that a doctor can use to help support a diagnosis of hair loss. The first is the “hair pull” in which a fingerling of hair is gently pulled and the hairs that easily pull out are counted. The second is test is “densitometry” in which a small area of the scalp is clipped short and examined under magnification (usually 30x). The hair density (number of hairs per cm) can then be measured and the approximate percentage of hairs that are in a miniaturized state (and subject to being lost) can be assessed. Women also have many skin disease causes of hair loss that cover an entire gamut of disease entities that are genetic or autoimmune.
To understand the different types of hair loss in women, and their management, it is helpful to divide the patterns into three broad categories:
Localized Hair Loss
Localized hair loss may be sub-divided into scarring and non-scarring types. Alopecia Areata is a genetic, auto-immune disease that typifies the non-scarring type. It manifests itself with the sudden onset of round patches of hair loss associated with normal skin and can be treated with local injections of Cortico-steroids. Scarring Alopecia can be caused by a variety of medical or dermatologic conditions such as Lupus and Lichen Planus, or local radiation therapy. Baldness from injuries, or from local medical problems that have been cured, are usually amenable to hair transplantation.Localized hair loss that occurs around the hairline after face-lift surgery may be permanent as can Traction Alopecia, the hair loss that occurs with constant tugging on the hair. Both of these conditions can be treated with hair transplantation.
Patterned Hair Loss
Women with this type of hair loss have a pattern but this pattern differs from the classic male patterns shown in the Norwood Scale for men’s hair loss. There are two types of patterns seen in women. One pattern is similar to the ‘A’ variants where the male looses only frontal hair which can progress to the swirl. This frontal pattern is often stronger in the front similar to what we observe in men. In other words, they have thinning in front progressively to the top of their scalp with little hair loss in the permanent zone around the sides and in the back.
The second type of patterned female hair loss reflects thinning behind the hairline from the front to the vertex (swirl area) and this thinning is often uniform and progressive. This second type is more common than the first type discussed above. Thus, the balding process occurs in a characteristic “pattern” rather than generalized thinning throughout the scalp. Depending upon the degree of hair loss and its distribution, women with patterned hair loss may be excellent candidates for surgical restoration provided that the donor hair (around the sides and back of the head) remain normal without significant miniaturization.
Diffuse Hair Loss
A third category of hair loss in women is a generalized thinning that affects all parts of the scalp. This is the most common type of hair loss seen in females. In this situation, much of the hair remains, but the thickness of the hair shaft is smaller than normal hair. The medical term for this type of thinning is “Diffuse Un-patterned Alopecia”. These women have thinning that involves the donor area so that women with this type of hair loss are generally not good candidates for surgery. This condition may be identified with a Densitometer, an instrument developed by the New Hair Institute, which assesses the population of miniaturized hair in different parts of the scalp. (Miniaturization is the process by which hairs shrink in length and diameter from the effects of hormones.) Because diffuse hair loss can be caused by a variety of conditions other than “hereditary balding” women who are losing their hair should be evaluated by a physician who is experienced with these problems. Most important, they should know when a medical evaluation is appropriate and whether medical or surgical treatments will offer the greatest benefit.The physicians at the New Hair Institute have extensive experience treating women with hair loss problems. They have developed instrumentation that is used to determine which women may be helped by hair transplantation and those whose hair loss would be better managed by non-surgical means. NHI physicians are dedicated to seeing that women who are not candidates for transplantation receive the proper care and are not inappropriately treated with surgery.
As is men, the genes that cause hair loss can be inherited from either your mother or father. The expression of these genes is dependent on hormones called androgens, so common hair loss in women is called “Androgenetic Alopecia” (the same term is used for common balding in men).
There are a number of reasons to explain why hair loss in women presents differently than in men (although all of the factors are still not completely understood). Probably the most important reason is that men have a much higher level of the androgen testosterone. This is the hormone that is responsible for male sexual characteristics and, when the body converts it to DHT, it becomes the main culprit in causing baldness. Fortunately, the much lower levels of testosterone in women spare them from the extensive hair loss that is often seen in men.
Testosterone is converted to DHT by the enzyme 5-alpha reductase that is present in higher concentrations in the balding areas of the scalp. Women have only ½ the amount of this enzyme overall as men and have even less in the crown. In addition, women have higher levels of an enzyme called aromatase in all areas of the scalp that may block the formation of DHT. This enzyme is present in especially high concentration in the frontal hairline in women, possibly explaining why this area is fortunately resistant to balding in most females.
With age some normal degree of hair loss occurs in everyone so that total hair volume will decrease over time in both sexes. The hair loss associated with genetic balding is also dependent upon time to express itself. Hair loss tends to occur at different rates at different periods in one’s life with increased loss often occurring during periods of hormonal change, such as pregnancy and menopause.
Among the many medical conditions that can cause hair loss, the most common ones are:
- thyroid disease
- other endocrine problems (especially those that produce excess androgens)
- gynecological conditions – such as ovarian tumors
- connective tissue disease (such as Lupus)
- surgical procedures and general anesthesia
- rapid weight loss or crash diets that are not nutritionally balanced
- severe emotional stress
It is also important to review the use of medications that can cause hair loss. The more common ones are:
- oral contraceptives
- thyroid medication
- blood pressure medication (such as beta-blockers or water pills)
- “mood” medication such as lithium, Prozac, or tri-cyclic antidepressants
- blood thinners such as heparin or coumadin
- cholesterol lowering medication
- medication for gout, such as Zyloprim
- anti-inflammatory drugs such as cortisone
- vitamin A or tryptophan in high doses
- street drugs (such as cocaine)
The following signs and symptoms suggest that specific blood tests might be appropriate to rule out underlying sources of excess androgen:
- Irregular periods – for an extended period of time
- Cystic acne – severe acne which usually leaves scars
- Hirsuitism – increased body hair that doesn’t normally run in your family
- Virilization – appearance of secondary male sex characteristics such as a deepened voice
- Infertility – inability to become pregnant
- Galactorrahea – breast secretions when not pregnant (this is due to prolactin which is not actually an androgen)
Some of the tests that your doctor might order in these situations include the following:
- Total and Free Testosterone – the hormone that is mainly responsible for male secondary sex characteristics
- DHEA-Sulfate – a precursor to testosterone
- Prolactin – the hormone that enables the breast to secrete milk
Other test that are commonly ordered for underlying medical conditions include:
- CBC (complete blood count) – for Anemia
- Serum iron (and TIBC) – for Anemia
- T3, T4, TSH – for Thyroid disease
- ANA – for Lupus
- STS – for Syphilis