Although it is not generally appreciated, discount hair loss occurs as just as frequently in women as it does in men. Half of all women experience some degree of hair loss by age 50, levitra and this figure increases to about 75% of women at age sixty five. In affected individuals, cialis sale the process begins between the ages of twelve and forty. As some women experience an acceleration of their hair loss as they approach menopause, it has been postulated, that this is attributable to the alteration in the ratio of estrogen to testosterone during the menopausal transition.
While some men who are balding may find it somewhat distressing, the psychological burden carried by women experiencing hair loss is a different story. Contemporary society seems to suggest, that male baldness is an indication of increased virility and sexiness. This is definitely not how balding women are perceived. Society appears to dictate, that a full head of attractively styled hair is an essential component of the complete woman’s persona.
Accordingly, most of the women who come to my office with a concern about hair loss are absolutely devastated. They suffer from both a diminished body image and loss of self esteem, which affects their psychological adjustment, relationships, and quality of life.
What causes hair loss?
Hair loss appears to be genetically determined, and in susceptible women, is an inherited alteration in the way individual hair follicles metabolize the sex hormone testosterone. This type of hair loss is referred to as genetic balding or androgenic alopecia. Most of these women have normal hormonal function, including, normal testosterone levels, normal menstrual function, and fertility. Those affected are believed to undergo a higher rate of conversion of testosterone to dihydrotestosterone, or DHT. It is the effect of DHT on the hair follicles that is thought to be the mechanism responsible for the hair loss.
Fortunately, the hair loss experienced by women is usually milder, and although the pattern is generally more diffuse, it is less intense. It is concentrated on the top, or crown of the scalp. The frontal hairline is usually spared, and if there is thinning of the temple areas, it is typically more subtle. This difference is attributed to differences in (1) the level of 5 alpha-reductase and cytochrome P-450 aromatase, the enzymes responsible for the conversion of testosterone to dihydrotestosterone, DHT and (2) the number of testosterone receptors in the individual hair follicles of the scalp.
What role does menopause play in hair loss?
There is no question that the variations in hormone levels associated with menopause are influential factors in female hair loss. If an adequate estrogen level is present, it will compete with, and to some extent block, the affect of DHT, on the testosterone receptors of individual hair follicles. In contrast, as hormone levels decline during the menopausal transition, the protective affect estrogen exerts on the hair follicle is lost, and the potential of hair loss increases. Two biological models of this scenario are: first the hair loss that occurs subsequent to the dramatic fall in estrogen levels in a susceptible woman after having a baby, and second the loss of hair following removal of a woman’s ovaries when she is not given adequate hormone replacement. Typically, the actual hair thinning does not occur until three, or four months following the fall in hormone levels, and accordingly, any benefit of treatment takes that length of time or longer to be noticed.
Are there are other conditions unrelated to the menopausal transition that have been associated with hair loss in women?
Yes. These include anemia, thyroid disorders, syphilis, fungal infections, infection with the human immunodeficiency virus, and connective tissue diseases, such as lupus, hormone secreting tumors, significant weight loss and stressful life events. Alopecia areata, a condition of localized balding is considered by many to be an autoimmune disease. Traction alopecia is a form of hair loss associated with excess traction, or pulling, on the hair, either during styling, or by habitual tugging, or twirling the hair, a condition known as trichotilomania.
Women, who have abnormally high levels of male sex hormones, or androgens, may also experience thinning of scalp hair. Other signs of androgen excess include an increase in body or facial hair, especially if it appears in a masculine distribution, severe cystic acne, abnormal menstruation, breast secretions and clitoral enlargement. Women, who exhibit these characteristics, should see a physician who is experienced in the diagnosis and treatment of these disorders.
What about poor scalp circulation and clogged hair follicles?
Commonly used explanations for hair loss put forth by those selling over-the-counter remedies for hair loss, such as poor scalp circulation, and clogged hair follicles, have been found to have no role in hair loss. To my knowledge the products they sell are of no benefit.
Can medication cause hair loss?
Treatment with cancer chemotherapy is well known to be associated with hair loss. Medication-related hair loss is not fully understood, but thought to be due to a disruption of the normal phases of hair growth. The hair loss may be reversible after the medication is discontinued. Medication-induced hair loss is an occasional side effect of antidepressants and other psychoactive drugs, cholesterol lowering medication, oral contraceptives and anticoagulants.
Testosterone replacement at levels appropriate to enhance mood, sexual function, and quality of life, is rarely associated with hair loss, but, may be a factor in some susceptible women. Adding spironolactone[i] to the patients regimen, and if necessary, a reduction in the dose will usually alleviate the problem.
What about treatment?
Rogaine, a topical treatment, is available in two strengths, 2% and 5% and is applied to affected areas twice daily. The 5% dose is marketed for only men as there is a concern that this dose may cause facial hair in some women. Concentrations of minoxidil as strong as 13% are available for purchase on the internet.
Propecia is presently the most effective medical treatment for men. At prescribed doses it promotes hair growth and prevents further hair loss in a significant proportion of men with genetic balding. It is thought to work by inhibiting the conversion of testosterone to DHT. Although some research suggests it is effective for this type of hair loss in women it is not FDA approved for this use because of a known risk of fetal malformations. Regardless, some physicians, including myself, currently use it in women who are not at risk of pregnancy.
Spironolactone is an orally administered mild diuretic, which is believed to diminish the affect of androgens. I prescribe it in doses up to 200 mg daily in postmenopausal women. I use lower doses in women who are still menstruating as doses in this range may cause menstrual irregularities. The rationale for its use is based on the belief that it interferes with the ability of androgens to bind to the receptors in the hair follicle thereby not allowing DHT to exert its effect.
When estrogen replacement is either used alone or in combination the above strategies it will increase the possibility of stopping, or slowing the hair loss. Plus, it has the added benefit of alleviating menopausal symptoms, sustaining hormone dependent tissues and increasing quality of life. In some women I also prescribe a compounded shampoo containing a low concentration of estrogen and dutasteride a medication similar to finasteride. I usually suggest that the patient shampoo their hair with it three times a week or combine a small amount with their regular shampoo and use it daily.
None of these treatments are FDA approved for women and are designated “off label.”
As a practical matter, I almost always suggest combination therapy to my patients.
Treatment should be initiated at the earliest sign of hair thinning, as in almost all instances, even the most optimum therapy can only stop, or slow, the process. In women with a strong family history of genetic baldness, early intervention should be considered.
If a form of treatment is found to be effective it should be continued indefinitely assuming there are no negative side effects, as stopping the treatment results in a return of hair loss.
Hair replacement surgery is an option for some women. The best candidates for this type of treatment should have areas of dense hair growth at the back or sides of the head available for transplantation. Women, in whom a medical or surgical approach is not effective, not feasible, or not desired, may choose to use a wig, or hair extensions.
Hair loss in menopausal women is perceived uniquely by the individual woman experiencing it. Nonetheless, it is capable of negatively impacting self-esteem and quality of life. Some of the women I see who suffer from this problem, are among the most distressed and desperate patients who come to my office. Every woman who experiences this dilemma should address it in the manner she feels is most appropriate for her. It is important for women with undiagnosed hair loss to be appropriately evaluated by a physician for causes of hair loss other than genetic balding, as there are a number of underlying medical conditions that may mimic this condition.
[i] Spironolactone is a mild diuretic with antiandrogenic properties.