Most of what I have written for male patients applies to women
also, but important differences do exist. For those reading this who
are primarily concerned with women’s hair loss and replacement,
reading what has been written in the prior sections will be imperative
to fully understanding what follows.
A significant number of women suffer from forms of hair
loss other than female pattern baldness. These other forms of hair
loss must be ruled out before a definitive diagnosis of female pattern
baldness can be made. Of these others, telogen effluvium is the
most common. Classically, telogen effluvium is that shedding of
hair that occurs several months after childbirth. Typically, the
woman will notice large amounts of hair suddenly coming out one
to six months after a significant stress in her life such as a surgery,
a serious illness, or a social or psychological stress. The bad
news is that there is no treatment for this type of hair loss. The
good news is that the patient does not require any treatment. The
hair should return on its own after a dormant phase.
Less commonly, I will see women with traction hair loss. This is
found most commonly in women who wear their hair tightly pulled
back or in tight braids for long periods of time. The slow, chronic
pull on the hair root eventually kills the follicular root system
so that no hair will grow in these areas. This form of hair loss
may be amenable to hair transplantation if the hairstyle is changed.
I frequently see patients who have had facelifts or other procedures
in the scalp that have left scars or, as in the case of brow lifts,
has left the hairline too high. In general, these types of hair
loss respond well to transplants.
True female pattern baldness is much more common than most people
realize. It tends to be underestimated because women go to great
lengths to hide it. In a study authored by O’Tar Norwood,
M.D. it was noted that the incidence increases from 3% of women
in their twenties to 30% of women in their eighties. By the time
women are in their fifties, approximately one quarter are affected.
(2)
Figure 10-1. Ludwig scale of balding for
women (3) |
The pattern of female pattern baldness tends to be different from
men’s. Typically, women will notice diffuse hair loss throughout
the mid scalp but retain the majority of their hairline. Although
this form of hair loss has been assumed
to be related to male pattern baldness, Dr. Norwood and I published
a paper, which brought this belief into question. If we are correct,
perhaps this should not be simply considered the same disease just
in different sexes. Some of the pertinent points of the paper include:
1. Male pattern baldness begins with the recession of the hairline
and results in complete hair loss across the top of the scalp. Female
pattern baldness causes diffuse thinning behind the hairline but
there is no recession of the hairline.
2. Male pattern baldness begins in the late teens and early twenties
when the testosterone levels are high. Female pattern hair loss
tends to begin in the late thirties and reaches its peak after fifty
when testosterone levels are falling.
3. Male pattern hair loss affects up to 70% of all males. Female
pattern hair loss affects up to 30% percent of women.
4. Females with a predisposition for male pattern hair loss rapidly
develop typical male pattern baldness if given high doses of testosterone.
5. There has been a report describing a young women with hypopituitarism
who presented with clinical and histological features of female
pattern baldness in the absence of detectable levels of circulating
androgens (testosterone and other male hormones) showing this pattern
of hair loss is not androgen dependent.
6. Treatment with Propecia, a medication that blocks the conversion
of testosterone to 5-DHT, certainly helps male pattern hair loss,
but has no effect on female
pattern hair loss. (4)
Figure 10-2. Woman with loss of hair in the
hairline, the temples, and the crown similar to male pattern
baldness. |
Other females do bald in more of a male pattern with recession
of their temples and loss of hair over the vertex of their scalps.
This form of hair loss has many similarities with standard male
pattern baldness and can be exacerbated by androgen (testosterone)
hormonal therapy.
As just mentioned, Propecia appears to be largely ineffective for
women’s hair loss. If a woman has more of a male pattern hair
loss and has elevated androgenetic hormones confirmed with a laboratory
evaluation, Propecia can be helpful. (5) I would stress, however,
that this is not a common occurrence. Rogaine is effective at halting
further loss, but if there is regrowth, it tends to only be short
and fuzzy hair. I urge my female patents to consider the use of
5% Rogaine labeled “For Men Only” rather than the 2%
for women. It is a more effective concentration and, in my opinion,
poses no serious threats. Side effects, specifically developing
an itchy red scalp, may be more common with the 5% formulation.
It is my understanding that the F.D.A. is considering approval of
the 5% Rogaine for women in the near future. In other countries,
various androgen blocking medications are available to women, but
in the U.S. we resort to spironolactone (Aldactone). This heart
medicine has been found to block some of the activity of the circulating
androgens. Since some forms of female pattern baldness do not seem
to be driven by androgens, this might be useful only in a percentage
of patients. Patients must not become pregnant while using spironolactone.
Side effects may include breast tenderness, irregular menses and
mood swings. Both Rogaine and spironolactone must be continued indefinitely
to remain effective.
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