Treating female pattern hair loss

About one-third of women experience hair loss (alopecia) at some time in their lives; among postmenopausal women, as many as two-thirds suffer hair thinning or bald spots. Hair loss in women often has a greater impact than hair loss does on men, because it's less socially acceptable for them. Alopecia can severely affect a woman's emotional well-being and quality of life.

The main type of hair loss in women is the same as it is men. It's called androgenetic alopecia, or female (or male) pattern hair loss. In men, hair loss usually begins above the temples, and the receding hairline eventually forms a characteristic "M" shape; hair at the top of the head also thins, often progressing to baldness. In women, androgenetic alopecia begins with gradual thinning at the part line, followed by increasing diffuse hair loss radiating from the top of the head. A woman's hairline rarely recedes, and women rarely become bald.

There are many potential causes of hair loss in women, including medical conditions, medications, and physical or emotional stress. If you notice unusual hair loss of any kind, it's important to see your primary care provider or a dermatologist, to determine the cause and appropriate treatment. You may also want to ask your clinician for a referral to a therapist or support group to address emotional difficulties. Hair loss in women can be frustrating, but recent years have seen an increase in resources for coping with the problem.

What is androgenetic alopecia?

Almost every woman eventually develops some degree of female pattern hair loss. It can start any time after the onset of puberty, but women tend to first notice it around menopause, when hair loss typically increases. The risk rises with age, and it's higher for women with a history of hair loss on either side of the family.

As the name suggests, androgenetic alopecia involves the action of the hormones called androgens, which are essential for normal male sexual development and have other important functions in both sexes, including sex drive and regulation of hair growth. The condition may be inherited and involve several different genes. It can also result from an underlying endocrine condition, such as overproduction of androgen or an androgen-secreting tumor on the ovary, pituitary, or adrenal gland. In either case, the alopecia is likely related to increased androgen activity. But unlike androgenetic alopecia in men, in women the precise role of androgens is harder to determine.

In either sex, hair loss from androgenetic alopecia occurs because of a genetically determined shortening of anagen, a hair's growing phase, and a lengthening of the time between the shedding of a hair and the start of a new anagen phase. (See "Life cycle of a hair.") That means it takes longer for hair to start growing back after it is shed in the course of the normal growth cycle. The hair follicle itself also changes, shrinking and producing a shorter, thinner hair shaft — a process called "follicular miniaturization." As a result, thicker, pigmented, longer-lived "terminal" hairs are replaced by shorter, thinner, non-pigmented hairs called "vellus."

A clinician diagnoses female pattern hair loss by taking a medical history and examining the scalp. She or he will observe the pattern of hair loss, check for signs of inflammation or infection, and possibly order blood tests to investigate other possible causes of hair loss, including hyperthyroidism, hypothyroidism, and iron deficiency. Unless there are signs of excess androgen activity (such as menstrual irregularities, acne, and unwanted hair growth), a hormonal evaluation is usually unnecessary.

How to stop thinning hair: Hair loss treatment for women

Medications are the most common treatment for hair loss in women. They include the following:

Minoxidil (Rogaine, generic versions). This drug was initially introduced as a treatment for high blood pressure, but people who took it noticed that they were growing hair in places where they had lost it. Research studies confirmed that minoxidil applied directly to the scalp could stimulate hair growth. As a result of the studies, the FDA originally approved over-the-counter 2% minoxidil to treat hair loss in women. Since then a 5% solution has also become available when a stronger solution is need for a woman's hair loss.

Clearly, minoxidil is not a miracle drug. While it can produce some new growth of fine hair in some — not all — women, it can't restore the full density of the lost hair. It's not a quick fix, either for hair loss in women. You won't see results until you use the drug for at least two months. The effect often peaks at around four months, but it could take longer, so plan on a trial of six to 12 months. If minoxidil works for you, you'll need to keep using it to maintain those results. If you stop, you'll start to lose hair again.

How to use minoxidil: Be sure that your hair and scalp are dry. Using the dropper or spray pump that's provided with the over-the-counter solution, apply it twice daily to every area where your hair is thinning. Gently massage it into the scalp with your fingers so it can reach the hair follicles. Then air-dry your hair, wash your hands thoroughly, and wash off any solution that has dripped onto your forehead or face. Don't shampoo for at least four hours afterwards.

Some women find that the minoxidil solution leaves a deposit that dries and irritates their scalp. This irritation, called contact dermatitis, is probably caused not by the minoxidil itself, but rather by the alcohol that is included to facilitate drying.

Side effects and concerns: Minoxidil is safe, but it can have unpleasant side effects even apart from the alcohol-related skin irritation. Sometimes the new hair differs in color and texture from surrounding hair. Another risk is hypertrichosis — excessive hair growth in the wrong places, such as the cheeks or forehead. (This problem is more likely with the stronger 5% solution.)

Because the patent on Rogaine (the brand-name version of minoxidil) has expired, many generic products are available. They all contain the same amount of minoxidil, but some include additional ingredients, such as herbal extracts, which might trigger allergic reactions.

Anti-androgens. Androgens include testosterone and other "male" hormones, which can accelerate hair loss in women. Some women who don't respond to minoxidil may benefit from the addition of the diuretic drug spironolactone (Aldactone) for treatment of androgenic alopecia because this drug has anti-androgen properties. This medication is especially helpful for women with polycystic ovary syndrome (PCOS) because they tend to make excess androgens. Doctors will usually prescribe spironolactone together with an oral contraceptive for women of reproductive age. (A woman taking one of these drugs should not become pregnant because they can cause genital abnormalities in a male fetus.) Possible side effects include dizziness, excess thirst, loss of appetite, weight gain, loss of libido, and fatigue. If spirolactone is not effective, another medication with anti-androgen properties such as finasteride may help.

Iron supplements. Iron deficiency could be a cause of hair loss in some women. Your doctor may test your blood iron level, particularly if you're a vegetarian, have a history of anemia, or have heavy menstrual bleeding. If you do have iron deficiency, you will need to take a supplement and it may stop your hair loss. However, if your iron level is normal, taking extra iron will only cause side effects, such as stomach upset and constipation.

Other treatments. If other treatments are not effective, laser therapy or platelet-rich plasma injections may be recommended.

Hair transplantation

Hair transplantation, a procedure used in the United States since the 1950s to treat androgenic alopecia, involves removing a strip of scalp from the back of the head and using it to fill in a bald patch. Today, 90% of hair-transplant surgeons use a technique called follicular unit transplantation, which was introduced in the mid-1990s.

During this procedure, surgeons remove a narrow strip of scalp and divide it into hundreds of tiny grafts, each containing just a few hairs. Each graft is planted in a slit in the scalp created by a blade or needle in the area of missing hair. Hair grows naturally this way, in small clusters of one to four follicles, called follicular units. As a result, the graft looks better than the larger "plugs" associated with hair transplants of yesteryear.

Not everyone with female pattern hair loss is a good candidate for hair transplantation, especially if hair loss is widespread and severe. In addition, hair transplantation is expensive, can be time-intensive, and is not always successful.