Female Pattern Hair Loss - Elise A. Olsen, M.D.

Female pattern hair loss presents as decreased hair density primarily on the top of the scalp. It has long been hearkened as the female counterpart of male pattern hair loss, hence the alternative terms male pattern alopecia, female baldness or androgenetic alopecia. Both men and women with pattern hair loss have less actively growing hairs and a progressive fineness and shorter growth of hair in affected areas but the hair loss in women never goes to the extreme baldness seen in men. Moreover, although male pattern hair loss has been conclusively shown to be related to the metabolism and binding of male hormones (androgens) to their target site in the hair follicle, it is not so clear cut in women. The majority of women with female pattern hair loss do not have increased levels of male hormones nor other signs of increased androgen effect and do not respond to anti-androgens with dramatic hair regrowth. Instead, only women with female pattern hair loss who also have hirsutism (ie hair growth in male areas such as the beard and/or moustache) or severe acne and/or irregular menses, typically have documented elevation of serum androgens. Unlike men with male pattern baldness, women may first present with female pattern hair loss in the 40 to 50 year old age range as well as in the teens and 20's, like affected males. Therefore, because of these different presentations of female pattern hair loss, it has recently been suggested that it should be classified as "early onset with and without androgen excess" and "late/postmenopausal onset with and without androgen excess". This new classification schema for female pattern hair loss will allow researchers to better evaluate potential causative factors and treatments in each group.

Unlike men with male pattern baldness in which the diagnosis seems self-evident, women experiencing hair loss should be evaluated by a physician to determine the cause. It is important that the distribution of the hair loss, presence or absence of increased shedding and condition of the underlying scalp be noted. This will help to eliminate the possible confusion with other types of hair loss including alopecia areata, telogen effluvium or a cicatricial (destructive) type of hair loss. Typically, blood work is also done at an evaluation including thyroid function tests, complete blood count and serum iron stores to screen for other conditions that may cause generalized hair loss. In the case of a woman with irregular menses and hirsutism, male hormones (testosterone, DHEAS) and prolactin may be drawn. A scalp biopsy may be very important to perform to discriminate between these various hair loss conditions if the diagnosis is in question: it is important that a pathologist familiar with hair disorders interprets the biopsy.

Once the diagnosis of female pattern hair loss is established, and the patient assigned to classification as having androgen excess or not, then treatment can be discussed rationally. Most women with female pattern hair loss will benefit from topical minoxidil (Rogaine). Topical minoxidil comes in two strengths, 2% and 5%, with only the 2% currently approved for women with this condition. Minoxidil encourages hair to move from the resting to actively growing stage and to grow longer and more vigorously. Some women may show visible regrowth while others note primarily a stabilization of loss. Side effects of topical minoxidil are primarily limited to irritation in £ 8% of patients and some "peach fuzz" growth on the sides of the face in approximately 5%: these are both readily reversible on stopping the drug.

Finasteride (Propecia) is a drug that inhibits the conversion of testosterone to dihydrotestosterone, the male hormone deemed most important in causing male pattern baldness. It has been shown to be highly effective in men with male pattern baldness and had long been assumed that Propecia would show similar efficacy in women. Since there can be genital abnormalities in male fetuses of mothers taking finasteride during pregnancy, only postmenopausal women with female pattern hair loss were initially studied. Surprisingly, finasteride was no better than placebo in effecting hair regrowth in these women. Finasteride and oral anti-androgens have been used to treat hirsutism and in this context, there have been reports of improvement in those women with concomitant female pattern hair loss. Large scale studies of younger women with female pattern hair loss who have excess androgens treated with eiher finasteride or oral anti-androgens are necessary to definitively decide their effectiveness in this condition.


References:

• Olsen EA. Female pattern hair loss. J Am Acad Dermatol 45:S70-80, 2001.
  

The following are frequently asked questions on female pattern hair loss. The information provided is not meant to be a substitute for the information obtained at an evaluation and by discussion with a physician but merely to encourage understanding of this condition. No questions regarding individual scenarios will be answered by the NAHRS. No changes in treatment should be undertaken by a patient without discussion first with the patient's physician.

• I've heard that Rogaine Extra Strength (5%) is not approved for women. Why is that?
• I'm a 41 years old woman, healthy and never had a problem with my hair before. Now my hair is all over my bathroom floor and every time I comb it, lots of hair comes out. What could be causing this hair loss?
• I was told by my beautician that Product X sold on the internet would help my hair. Is there anything to this?
• I was told by my health food store clerk that certain vitamins can make hair grow better. I'm now taking a hair pill that contains biotin, zinc, gingko biloba and echinacea. Are these vitamins that you'd recommend for my hair?
• I'm going through menopause now and having hair loss. Will hormone replacement therapy reverse the hair loss?
• Will Propecia work on my female pattern hair loss?

1. I've heard that Rogaine Extra Strength (5%) is not approved for women. Why is that?
   5% Rogaine has been studied in multicenter trials of women with female pattern hair loss and has been found to be safe and superior to placebo. However, the trials did not show statistically superior efficacy to 2% topical minoxidil in all endpoints tested so it is currently not FDA approved for this indication. Women and children with alopecia areata have also used 5% Rogaine off label and again safety has been maintained.
   
   
2. I'm a 41 years old woman, healthy and never had a problem with my hair before. Now my hair is all over my bathroom floor and every time I comb it, lots of hair comes out. What could be causing this hair loss?
   There is a gradual change in your blood hormones long before menopause (or its cousin adrenopause) raises its head. Whether this subtle decrease in estrogen/progesterone, which often lead to minor changes in the frequency, amount of flow or duration of menses, actually cause the hair loss needs to be further studied. This is certainly a common time of life for late onset female pattern hair loss to appear. You should see your primary care physician or dermatologist however, for an evaluation to get a definitive diagnosis and to rule out such medical problems as a thyroid disorder.
   
   
3. I was told by my beautician that Product X sold on the internet would help my hair. Is there anything to this?
   Product X, and many other products sold as hair cosmetics and not drugs, may make loose claims to effectiveness. They have not been held to the same standards as drugs either in providing documentation of effectiveness nor standardization of manufacture. If they did make the claim to reverse hair loss or actually effect hair growth, they must go through the FDA's rigorous testing for drugs, a path many such companies prefer not to do. Most of these products do little harm, have little positive effect, and are costly.
   
   
4. I was told by my health food store clerk that certain vitamins can make hair grow better. I'm now taking a hair pill that contains biotin, zinc, gingko biloba and echinacea. Are these vitamins that you'd recommend for my hair?
   Unless you are deficient in certain vitamins, taking a supplement is unlikely to change things. Zinc and/or biotin deficiency can cause hair loss but this usually is in childhood when a genetic problem in the absorption or use of these vitamins is first unmasked. There is no evidence that people can be deficient in ginko biloba or echinacea and because of similar unknown negative effects, these are probably best not taken.
   
   
5. I'm going through menopause now and having hair loss. Will hormone replacement therapy reverse the hair loss?
   We do not know enough about the relationship of human hair growth/loss in women to estrogens/progestins to warrant making treatment recommendations. Hormone replacement therapy is unlikely to reverse the hair loss and a decision on its use should be determined by other factors.
   
   
6. Will Propecia work on my female pattern hair loss?
   Propecia does not work in postmenopausal women with female pattern hair loss. It has not been tested in premenopausal women with female pattern hair loss