The cause of hair loss in women is not as straight forward as it is in men, who usually follow a specific male pattern balding. Male pattern balding involves hair loss only on the front, top, and crown of the scalp. Male pattern balding spares the hair in the back and sides of the scalp, which is often referred to as permanent hair. This is the area where hair is harvested for hair transplantation.
Unlike men, adult women with typical female androgenic alopecia often have significant levels of miniaturization in the donor area (back of the scalp). Miniaturization is part of the balding process where hair shafts become thinner over time before falling out. The mere presence of miniaturization is not necessarily a contraindication to surgery. However, miniaturization does indicate an unstable donor supply and one has to make a judgment regarding the risk/reward of the procedure. One needs to consider the absolute number of full terminal hairs that are available for the hair transplant, the risk of further miniaturization, the area that needs to be covered, and the risk of the surgery accelerating the hair loss (since in women, hair is often transplanted into an area that has a considerable amount of existing hair –- some of which is at risk of being shed from the surgery).
Before further discussing the phenomenon of clinical (“socially” visible) hair loss, here are a few basic facts for your general knowledge. It is normal to lose 100 to even 150 hairs a day. As hair falls out there are hairs that are also starting to grow. Hair may also grow in cycles and you may notice more hair falling out at different phases and seasons of the year. Hair follicle cells have three phases of growth:
- Growth phase (Anagen phase) which lasts anywhere from 2 to 6 years. This is the phase where your hair is actively growing at approximately 10cm per year. 85% of hair is at this phase at any given time.
- Transitional phase (Catagen phase) which lasts about 2 weeks. This is the phase where the hair follicle shrinks and prepares to enter the resting phase.
- Resting phase (Telogen phase) which lasts about 1-6 months. This is the phase where hair does not grow, but stays attached to the follicle. Some hairs are shed at this phase, but at the end the hair follicle re-enters the growth phase to start the cycle over again. 10-15% of hairs are at this phase at any given time.
The first step in evaluating hair loss in women, after a detailed history and physical exam, is to rule out any underlying medical causes of hair loss which can be treated. If clinically appropriate, the following disease processes should be considered: anemia, thyroid disease, connective tissue disease, gynecological conditions and emotional stress. Furthermore, over 50% of women going through change of life hormone fluctuations (menopause) experience significant hair loss. It is also important to review the use of medications that may cause hair loss, such as (but not limited to) oral contraceptives, beta-blockers, Vitamin A, thyroid drugs, coumadin, and prednisone. The following laboratory tests have been recommended to rule out the aforementioned medical conditions:
Some common blood tests for female hair loss:
- Sex Hormone tests
- SHBG (Sex Hormone Binding Globulin) used to test status of male hormones
- Estradiol is a sex hormone
- FSH (Follicle Stimulating Hormone) *not hair follicle but follicle in the ovary*
- LH (Luteinizing Hormone) is a sex hormone
- Free Testosterone
- Total Testosterone
- ANA (Anti Nuclear Antibody) used to test for Lupus or other autoimmune diseases
- TSH (Thyroid Stimulating Hormone) used to test for hyper or hypo-thyroid disease
- Test Iron status
- TIBC (Total Iron Binding Capacity)
These laboratory tests are a good starting point to medically rule out underlying medical conditions. If there is an abnormality in your test results, we can proceed to address these medical issues. It is important to note that even after a medical condition has been corrected, your hair loss may still persist to some degree. It is thought that this is due to a “switch” in your genetic makeup that has been turned on when the medical insult had occurred. Once the hair loss starts, it is difficult to turn off this “switch”. At the very least, your hair loss may slow down and your medical condition addressed.
The only medicine that seems to work for women (who do not have a medical cause of the thinning or hair loss) is minoxidil.
Now with all of what I said above, there is a small subset of women who have what appears to be the ‘male’ form of alopecia with front to back balding and no miniaturization in the donor area. These women may be helped by Propecia and certainly get the types of excellent results from frontal hair transplants.