Alopecia in Women: New Condition, Same old Cracks
A complex, often perplexing condition, but help is available.
Alopecia in Women?
New Condition - Same old Cracks?
Androgenic Alopecia
Estrogen Deficiency and Alopecia
Alopecia and PCOS
Workup and Diagnosis
Treatments for Alopecia
Points to Remember
Related conditions
Alpecia in Women
Alopecia is simply Latin for “hair loss” - perhaps too simply, for such a complex and subtle condition. Sadly, Alopecia is one of those subjects that medical schools tend to breeze past. Since the condition imposes no threat to health or life, MDs often dismiss the problem as being “untreatable”, and even “insignificant.” If the patient seems “overly distressed”, she’s likely to receive a referral to a mental health provider. In our opinion, the importance of hair to a woman seems entirely natural - and the best course of action would be to treat the problem - not simply bring in a specialist to convince the woman that it’s “OK.”
New Condition - Same Old “Cracks" TOP
Alopecia is yet another example of problems that “fall between the cracks” of medical specializations. As a component of the skin - it falls in the domain of dermatology. As a female problem, your ObGyn might take an interest. However the real causes of Alopecia are internal, based on hormone activity, and therefore the domain of endocrinology. Unfortunately many MDs don’t understand alopecia - regardless of specialization - but there are some that do. As a patient, it’s your right (and responsibility) to keep looking until you find that special MD that cares enough about your disorder, then see it through together.
The most common form of alopecia in women is Androgenic Alopecia, (also called “AGA") affecting about 20% of women before age 40 - and about twice as many thereafter. The two major culprits in androgenic alopecia are Androgen: a male hormone related to testosterone, and declining estrogens. Their mischief centers around the shrinking and deactivation of hair follicles in the scalp - resulting in “miniaturization” of the follicle,and eventual loss of the hair.
Ironically, androgens can also stimulate the hair follicles of the face and neck, which can result in unwanted facial hair (hirsutism) in some women. Note: hirsutism, acne, and significant weight gain are not symptoms of alopecia, but may indicate PCOS, with differing treatment options.
Estrogen Deficiency and Alopecia TOP
Estrogen arrests the onset of alopecia by countering testosterone - however it also exerts very positive effects on women’s hair-growth! These effects can be seen in the fast-growing, full head-of-hair women experience during pregnancy, which inevitably thins some time after child birth. Just how much thinning occurs depends on the rate of decreasing estrogen levels.
While the onset of alopecia during perimenopause is generally associated with increasing androgen levels; during and after menopause it is generally attributed to declining estrogen levels.
Androgenic alopecia can be compared with male pattern baldness, since both are caused by testosterones (androgen) and happen somewhat predictably in time, as well as spatially on the scalp. In women, the impact is generally less severe, with the front hairline being preserved. Most affected are the crown, vertex and temples, with the least effect around the perimeter - front, sides and back.
Both Alopecia and PCOS can result in hair loss or thinning, however it is important to make the distinction, because the indicated treatments differ.
In practice we have seen women diagnosed with PCOS when their problem was androgenic alopecia - as well as cases when PCOS mistakenly diagnosed as being alopecia. Hirsutism, (unwanted facial and other hair), adult acne, and significant weight gain are symptoms typically associated with PCOS.
- (Blood) testing for total and free testosterone and estrogens, dhea-s, blood counts and iron.
- Interview / questionnaire: If symptoms include increased hair growth (hirsutism), acne, oily skin, or irregular periods; additional testing is indicated, per discussions on hirsutism and on PCOS.
- Oral contraceptives are a good start. They can lower free testosterone levels by about half. However they care generally supplemented with additional treatment/medications, such as:
- Testosterone-blocking medications. The most frequently used is spironolactone (aldactone®). finasteride (propecia®, proscar®) also shows promise with androgenic alopecia—however pregnancy absolutely cannot occur with either this medication or spironolactone. (The action associated with them could interfere with male genitalia development in the fetus.)
- Minoxidil (rogaine®) has been officially approved for alopecia in women. Now available without prescription, rogaine is available in 2% and 5% strengths, however the 5% strength is rarely recommended for women because it works too well. If spilt on the forehead (for example) it could cause hair to grow there. Scalp flaking and irritation are also frequent problems at this strength. minoxidil must be applied twice per day to the entire scalp - a challenge for long haired women. Furthermore, it requires three to nine months to produce a noticeable effect, and doesn’t work for everyone. Finally, discontinuing the drug will cause any new minoxidil-hairs to fall out. Having said the above, Minoxidil has a definite place in treatment of alopecia - particularly when other treatment options are not available or have failed.
- Estrogen When alopecia results primarily from declining levels of estrogen, then estrogen replacement therapy makes sense. Pre-menopausal women with normal cycles or using OC would not likely be estrogen deficient. Again, irregular cycles in pre-menopausal women may be due to PCOS or other problems, and further evaluation is required. If the decision for estrogen replacement is made, we would estimate your more “youthful” pre-menopausal estrogen level as a baseline, then gradually increase the amount while monitoring your reactions. Women’s bodies not require estrogens uniformly, rather need it in varying amounts for different purposes. Experience has shown us that reducing hair follicle sensitivity usually requires a higher estrogen level than does resolving hot flashes or other PMS symptoms. However we have found that increasing the dose often stabilizes the follicle, and even promotes regrowth for alopecia patients.
- Alternative: Saw Palmetto is thought to inhibit the testosterone activating enzyme 5 alpha reductase. Used mainly by men to reduce prostate enlargement, it may also provide a degree of benefit to women with alopecia. However experience in women is too limited to recommend Saw Palmetto as a first-line treatment. A problem with herbal treatments in general is the lack of regulation means you have no assurances of potency. That said, Herbs and supplements have proven themselves to be quite useful for certain female conditions, including PMS and the relief of menopause symptoms.
- Avoid products that contain testosterone, such as the popular libdo enhancers such as Estratest® and Estratest HS®. They can result in hair loss, as can the popular supplement DHEA, since it is converted in testosterone in the body.
- Some women have hair folicles that over-react to normal levels of testosterone. This means you can have alopecia even though your hormones are “normal."
- Perhaps because it is not a disabling or life-threatening disease Alopecia receives little formal research attention. However a growing number of women’s health specialists such as ourselves are citing successes in their own practices.
While not every treatment listed above will be successful; we have a selection of treatment options. The key is identifying the treatment - or combination - best suited for the individual patient. Hence, we are able to achieve stabilization in most cases of androgenic or estrogen deficiency alopecia. Stabilization means decreasing the rate of shedding, so that the hair stops thinning. (note: some hair loss is normal, and new replacement hair is always growing) Continued treatment will improve both the quality and quantity of hair, usually increasing lustre and strength as well. (for easier combing, styling)
We cannot (and don’t) promise to restore hair to it’s original condition. However we can usually make a genuine improvement - and that’s usually more than enough. When women, who have felt the sting of shame and embarassment, can venture out in public with confidence - they can begin to enjoy their lives once more.
- The most disturbing aspect of androgenic alopecia is the attitude of many “conventional” medical practitioners toward it. Why any physician would tell a patient “it can’t be helped” when effective treatment options exist, is beyond our comprehension. Furthermore, even if your hormones and other blood tests are “normal,” your alopecia can still be successfully treated. We urge you to ignore any doctor that tells you “you have to live with it.”
- If you suffer from alopecia, there is hope and help for you.
Related (but rare) conditions TOP
- Telogen effluvium - diffuse hair loss that results in decreased hair density but does not progress to complete baldness
- Anagen effluvium - diffuse shedding of hairs, including growing hairs, that may progress to complete baldness
- Alopecia areata - patchy, non-scarring hair loss