Introduction to Hair Loss (alopecia) in Women
Women constitute 40 percent of hair loss sufferers in the United States. It can be devastating to a woman’s self-image and her emotional well-being. Society accepts hair loss in men, but rejects hair loss in women. Even much of the medical establishment ignores the demoralizing condition in women. It isn’t life-threatening, is considered cosmetic, and is usually not discussed by primary care providers.
Mayoral Dermatology physicians and care providers understand the psychological damage associated with hair loss in women. The damage can lead to the deterioration of physical health. Their pledge to their patients is to treat not just the cause of hair loss, but its effects on psychological and emotional well-being, also. A major source of frustration is an incorrect diagnosis – which can lead to worsening of hair loss, or create permanent loss of hair which might have been temporary if properly diagnosed.
Alopecia is the medical term for excessive or abnormal hair loss. It’s a symptom of some underlying condition. That condition may be a gene that predisposes a woman to have female pattern hair loss (FPHL), or a complex medley of disorders.
A short-term event, particular or extreme stressors, such as pregnancy, or infections, or some medications can cause temporary hair loss. The hair often grows back when the stressor is removed. Some substances such as hormones and medications can alter hair growth, shedding and resting phases, as well as their duration.
Causes/Types of Hair Loss
Dihydrotestosterone (DHT), derived from the hormone testosterone, can have adverse effects on hair follicles. It’s the root cause of numerous types of hair loss. In normal conditions, women have trace amounts of testosterone. It can be converted to DHT by an enzyme in hair follicle oil glands. Research has demonstrated that it is not circulating testosterone which is responsible for the hair loss called androgenic alopecia, but the level of DHT. It shrinks hair follicles, rendering them useless for healthy hair growth.
The conversion to DHT happens in both men and women. Even low levels of DHT can cause hair loss in women. The level can even be in the normal range, but high enough to damage hair follicles in someone who is very sensitive to the hormones.
Hormones are usually in a delicate balance. Androgens, male hormones, can cause hair loss in a woman whose estrogen level drops.
Hormones function in cycles. A woman’s female hormone levels wane as she approaches menopause, drop sharply during menopause, and remain low throughout post-menopausal life.
Androgenic alopecia causes diffuse thinning on the entire scalp. Women have androgens in very small amounts. Some of the conditions associated with androgenic alopecia are ovarian cysts, use of oral contraceptives, pregnancy and menopause. Heredity is a significant factor in this type of hair loss.
Telogen effluvium can occur when there is extreme stress on the body, such as malnutrition, severe infection, and major surgery. Hair follicles have a life cycle. About 90 percent of a hair follicle’s life is in the growing phase (anagen), and the resting phase (catagen). Extreme stress can suddenly shift the hair into the shedding phase (telogen). It often occurs at 6 weeks to 3 months after the stressful condition. There is usually complete remission if the extreme stress can be avoided. For some women, however, it becomes a chronic condition that lasts months or years. The stressor may not always be identifiable.
Anagen effluvium occurs in response to damage to hair follicles that interferes with the growth process (metabolism). This is the type of hair loss that occurs with chemotherapy, which destroys rapidly dividing cells. Hair growth in follicles is a process characterized by rapidly dividing cells. Soon after starting chemotherapy, 90 percent or more of the hair will be lost; the hair shafts narrow and break.
Traction alopecia is caused by localized trauma to the hair follicles from tight hairstyles that pull on the hair shaft over time. The hair will regrow if the traction is eliminated.
Oral contraceptives, since they were introduced in 1960, have become known as “the pill.” It is one of the most popular forms of contraception. Few women are aware that oral contraceptives are common triggers of hair loss. Most oral contraceptives contain both estrogen and progestin, although some contain progestin only. Some women seem more sensitive to hormonal hair loss. Usually the excessive hair loss weeks to months after stopping the pills. Hair loss can be so emotionally traumatic that any woman should be informed of the potential for loss of hair before starting an oral contraceptive. The loss may be more severe in women who have hair loss running in the family.
Progestin implants are small rods surgically implanted beneath the skin, usually the upper are. Continuous progestin exposure prevents ovulation.
Progestin injections have a similar mechanism of action.
Skin patches are formulated with both estrogen and progestin.
Vaginal rings also contain both estrogen and progestin.
All of the contraceptives listed here have the potential to trigger hair loss. Responses are widely variable for different women, in their ability to tolerate the method and the severity of the hair loss. There is no way to predict how an individual woman will respond.
The specific condition causing hair loss in women can be much more difficult to determine than in men. Men will usually have hereditary male pattern baldness, but there are many diseases and conditions which cause hair loss in women.
Blood tests usually rule out a number of causes of hair loss. Basic blood tests to evaluate for hair loss include:
Serum Fe, Serum ferritin, TIBC (total iron binding capacity) – to evaluate for anemia
Hormone levels – estrogen, testosterone, FSH, and others
T3, T4, TSH (thyroid stimulating hormone) – to evaluate for thyroid disorders
Scalp biopsy is done with a punch instrument of 4mm diameter or less, for microscopic examination of hair follicles.
Densitometry is performed with a hand-held magnifying glass, checking the scalp for miniature follicles.
Drug treatment for androgenic alopecia is either systemic, topical, or a combination of the two. Most physicians are reluctant to treat systemically unless it has been confirmed that hair loss is the result of excess androgens, or that a woman is oversensitive to normal levels of androgens.
It is best to start treatment as early in the course of disease as possible, before hair follicles are destroyed. For women who have had prolonged hair loss, the use of antiandrogens may at least prevent further loss, and encourage growth in hair follicles which are still viable.
Stopping therapy may allow the hair loss to resume, if androgen levels aren’t kept low.
The treatment should be geared to the specific cause of the alopecia, as well as stimulating hair growth. Only one drug has been approved for alopecia by the United States Food and Drug Administration (FDA), but there are other drugs to use. The drugs described here are all approved by the FDA for other conditions, but are prescribed to be used “off label.” The effects vary widely, but many women have found that some drugs do stimulate hair growth, with favorable effects on self-esteem.
Minoxidil 2 percent
Minoxidil 2 percent for topical therapy was initially marketed as a pill for the treatment of hypertension (high blood pressure). It was noted that a side effect of the pills was excessive hair growth. Further research demonstrated that applying a solution of minoxidil to the scalp could stimulate hair growth. The amount of minoxidil absorbed through the scalp into the bloodstream is clinically insignificant.
Minoxidil used for androgenic alopecia seems to be more effective in women than in men. It’s available in solutions of 2 percent and 5 percent. The manufacturer does not have FDA approval to promote the 5 percent solution for women with androgenic alopecia, although many dermatologists prescribe it, to be used under close supervision. Some clinical trials show that the 5 percent solution is significantly more effective in retaining and regrowing hair in women than the 2 percent solution.
In studies of women 18 to 45 years of age, with mild to moderate degrees of hair loss, 19 percent of women reported moderate hair growth after using minoxidil. Forty percent had minimal hair growth. Seven percent of women reported moderate hair growth in response to placebo; 33 percent of women reported minimal hair growth in response to placebo.
Androgen Receptor Inhibitors
- Spironolactone (brand name Aldactone) is in a class of drugs called potassium-sparing diabetics (water pills). It was originally used to treat high blood pressure and swelling.
- Cimetidine (brand name Tagamet) belongs to a class of drugs used to treat gastrointestinal ulcers. It has an antiandrogen effect and prevents DHT from affected hair follicles. It has been used to treat hirsutism in women and studied in androgenic alopecia.
Ketoconazole is an antifungal medication used to treat fungal infections, available as a topical medication. It has antiandrogenic effects, but is not sufficient alone to significantly improve androgenic alopecia. Shampoos are available by prescription, with 2 percent ketoconazole, used in combination with other treatments for androgenic alopecia. A one percent version is now available over the counter, but may be less effective than two percent products.
Finasteride (also known as Propecia or Proscar) inhibits the conversion of testosterone to the follicle-destroying DHT. It was first marketed as Proscar in 5 milligram pills. Starting in 1998, a one milligram pill named Propecia was released. It was the first pill approved by the FDA for hair loss in men. It has significant favorable action on retaining hair and stimulating regrowth. It may work for some women, but must not be used in women who are pregnant or trying to become pregnant, due to the high risk of birth defects in a male fetus.
If you are a woman concerned about distressing hair loss, please make an appointment with one of the cosmetic dermatologists at Mayoral Dermatology. Remember – the sooner in the course of the condition effective treatment is initiated, the better the potential response to treatment. Improvement is not guaranteed. For patients who experience a favorable response to treatment, the effect may not be permanent; continuous therapy may be necessary to maintain the response.
American Hair Loss Association, 23679 Calabasas Road #682, Calabasas, California 91301-1502; http://www.americanhairloss.org; [email protected]