Hair Loss in Women Different than in Men, Now Assured Better Treatment

with Enrico Carmina, MD, and Brad Anawalt, MD

There is good news for any woman who is experiencing female pattern hair loss and your health care practitioner—a new diagnostic tool is available to direct targeted treatment decisions to the specific reason causing this problem.

The Multidisciplinary Androgen Excess and PCOS Committee released guidelines to focus clinical attention on central scalp hair loss, providing a path to improved well-being and quality of life for millions of women.1

Alopecia in women shows up very differently than hair thinning in men.Women who experience hair thinning are assured better diagnosis and targeted treatment given release of new clinical guidelines. Photo: 123rf

Improved Guide for Better Treatment of Hair Loss in Women

A team of eight esteemed experts in polycystic ovary syndrome (PCOS) form the research review task force who examined the data.1 Their goal was to assess the various diagnoses and possible treatments for problematic hair thinning in women, according to first author, Enrico Carmina, MD, executive director and chief executive officer of the committee, and professor and chairman of endocrinology at the University of Palermo Medical School in Italy.

“This is a carefully developed update of knowledge about hair loss in women with a special focus on androgen-depending forms to provide clinicians with clear guidance in female pattern baldness drawing on the latest evidence,” Dr. Carmina tells EndocrineWeb.

Related topic: Symptoms of PCOS

Others causes of hair loss: Hyperthyroidism

There have been basic studies done showing that an androgen excess in premenopausal women induces hair loss that requires different diagnostic and treatment approaches than those effective in men,2 he says. For one thing, inflammation may play a larger role in this condition in women than for men.

When a woman has excess androgen levels (primarily testosterone), a variety of signs may arise such as acne, weight gain, excessive facial and chest hair (hirsutism), irregular menstruation, and excessive loss of hair at the scalp. However, the physical presentation of hair loss is notably different between the sexes.

While it is common to lose about 100 hairs a day, female pattern hair loss usually occurs as a noticeable hair thinning in the central or midline region of the scalp with preservation of the front hair line—commonly described as a Christmas tree pattern. With this pattern, the hair loss gets wider as the thinning spreads to the top of the head, creating a triangular shape–and usually arising as a result of excess androgen production.

Some women with excessive androgenization may develop hair loss with different patterns that appear more typical of male pattern baldness, such as hair thinning at both temples, but this is much rarer, according to Dr. Carmina.

Matching Patterns of Hair Loss to Appropriate Treatment  

The task force report offers clear clinical guidance covering various presentations of hair thinning (alopecia) that commonly arise in women who experience hormone dysfunction. The recommendations also address approaches to identify the cause of hair loss and lead to improved diagnoses and efficacious treatment that is more targeted to a variety of hair loss problems encountered in young women.

There is a distinct difference in the androgen-excess related alopecia in women who premenopausal as opposed to the hair loss experienced during menopause, which is usually a more diffuse hair thinning that occurs more evenly across the entire scalp.2

A Closer Look at the Causes, Diagnosis, and Treatment of Hair Thinning in Women

The guidelines committee identified multiple potential reasons for female pattern hair loss including possible molecular, inflammatory, genetic, and hormonal issues.1 Still, not everyone who is experiencing hair loss is facing other problems. Some women do present with hair loss that has no apparent or obvious reason; as such, age and ethnicity, all of which play a role in who is more susceptible to excessive hormone-driven hair-thinning.1

However, you will want your doctor to take a concern about hair loss seriously, and to rule out any treatable problem as early in the process as possible. So state your case strongly, insisting if necessary, that this isn’t an issue of vanity but a need to get to the root cause—literally!

What is the Process for Diagnosing Unusual Hair Loss?

In making a diagnosis, there are two parameters that your health care practitioner will evaluate—the intensity and pattern of hair loss. 

I: Central hair thinning; II: Frontal Christimas tree formation hair loss; III: Thinning crownFemale pattern hair thinning typically occurs in the middle of the scalp rather than in the front or evenly across the head as it does in men. Image: Olsen EA. J Am Acad Dermatol. 2002;45:S70–S80.

The clinician will want to pay particular attention to the degree of thinning and the location and will most likely perform a hair strand test to assess the integrity of the hair follicles. This will determine whether the hair can be encouraged to grow back or not.

Other diagnostic tools that your clinician may employ include:

  • Referring you to a dermatology specialist to have a dermatoscopic exam or scalp biopsy
  • Laboratory testing for serum levels of androgens, and potentially other hormones such as thyroid stimulating hormone and prolactin.
  • Further testing that may include an assessment of vitamin or mineral deficiencies, like iron, vitamin D, and zinc.

Expanding Treatments for Androgen-Induced Alopecia

Treatment for female pattern hair loss is presented in two forms: topical and systemic, most of which are directed to reduce production of excess androgens (and therefore are not recommended for any women in whom pregnancy is likely).2

In selecting a treatment, your doctor will first make a determination of whether or not the hair follicles remain open is necessary. If your hair follicles are still active, then hair regrowth is possible using one of several effective treatments, depending on the circumstances of the particular patient.1

Possible treatments include starting with topical minoxidil, anti-androgen medications, or finasteride (although this one has had mixed results. Other options which have proved successful include oral contraceptives and medications like spironolactone-a diuretic that has anti-androgen properties, and flutamide‑which while useful has the potential to cause liver toxicity.

Alternatively, there are treatments that have less evidence of success such as low-level laser therapy and microneedling, that may be done in an effort to increase absorption of topical medications, platelet rich plasma therapy, and topical ketoconazole‑an antifungal medication that is often used in male pattern baldness.

Even melatonin has been suggested for some women. Hair transplantation is also an option when the hair loss becomes significant and unresponsive to medical therapies. 

Steps to Take for Androgen-Related Hair Loss

“We think that for first time we are giving doctors of different specialties— dermatologists, endocrinologists, primary care specialists—the same message,” Dr. Carmina tells EndocrineWeb. “We are giving them the same terminology and the same ability to make clinical decisions such as a differential diagnosis. They will be able to interpret the laboratory data, order the right laboratory studies, and choose the drug therapies that are most effective for each specific patient.”

Brad Anawalt, MD, professor and vice chair of medicine at the University of Washington School of Medicine calls the guidelines “an excellent concise review of the latest science on the topic of a very vexing problem for many women.”

He concurs that key points have been highlighted to better guide healthcare practitioners in determining when medical therapy is needed to block androgens.

“Most of the information is not new, but the description of the approach needed is not well known to many clinicians so this report will likely lead to more effective management of female pattern hair loss in many more women,” Dr. Anawalt tells EndocrineWeb.

While this is good news for those of you who are experiencing noticeable hair thinning, for others experiencing non-hormonal types of hair loss such diffuse hair loss across the whole scalp or patchy losses, it will require looking for other causes, says Dr. Anawalt. For example, systemic illnesses, side effects of medication, and inflammatory skin conditions may be at play.

Hair loss due to systemic illness or induced by medications often resolves when the illness abates, or the causative agent is discontinued. On the other hand, dealing with hair loss related to skin problems (ie, psoriasis) is the hardest to treat, he says, but these too may respond to creams or anti-inflammatories injections with cortisone or immune-suppressing drugs.

While the condition can be “mortifying” to women, leading many to reduce outside activities, even to become reclusive, you can and should seek treatment.

Promise of Recognition that Hair Loss Is Often a Sign of a Medical Condition

“This report provides a commonsense approach that is very useful, and because it helps to distinguish hair loss due to androgen overproduction from other causes, women can better understand what medications might be useful and what benefit to expect or hope for,” Dr. Anawalt says.

One bit of advice that Dr. Anawalt was especially happy to see:

A recommendation that women worried about hair loss try the hair pull test. “Try to pull gently on the end of a group of 50 hairs in multiple areas of the scalp,” he says. “It is normal to have 0-2 hairs come out per pull. More than that suggests telogen effluvium, which does not respond to anti-testosterone therapy but may reflect altered thyroid hormone or estrogen levels or a nutritional deficiency.”

There are also some caveats that women must understand about hair loss, Dr. Anawalt notes.

  • Hair loss due to aging isn’t reversable.
  • Treatment with minoxidil results in only modest improvement of hair growth.
  • Anti-androgen treatment offers benefits only to women with either high levels of circulating blood testosterone or evidence of excess testosterone production.

“The guidelines nicely describe emerging evidence of the important growth factors for hair, and we might see effective treatments for hair loss for women and men based on further investigation and development of treatments related to these growth factors,” says Dr. Anawalt.

As a final note, be sure to tell your physician if you are taking biotin supplements for hair health since it will result in a false result of any hormone testing, and therefore preclude an accurate diagnosis and prohibit prescribing the right treatment.

Neither doctor has any financial conflicts with regard to this article.

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