Comprehensive Clinical Guidance to Address Hair Loss in Women

Female pattern hair loss is a bonafide quality of life issue that deserves clinical action based on recently introduced evidence-based recommendations that may or may not arise from androgen excess.

With Enrico Carmina, MD, and Kathleen Hoeger, MD, MPH

A vexing but rarely discussed medical issue for many women arises with the occurrence of dramatic and noticeable hair thinning. While not a life-threatening condition, noticeable hair thinning—known as female pattern baldness may seriously impact a woman’s quality of life and emotional well-being,

Quite different in its presentation from a receding hairline typically recognized as male pattern baldness, none the less,  symptoms of depression or mood changes have been commonly reported among women experiencing significant hair loss.1

Noticeable hair thinning can be a signficant quality of life issue, leading to depression if not treated.

Do you address this vexing issue, affecting upwards of 60% of your female patients?

After all, there is a clinical component to conspicuous hair loss—at least some of these women may be experiencing hyperandrogenism, which is also a common symptom in the majority of women with polycystic ovary syndrome (PCOS).1

Given the distress faced by many women who face this dramatic unanticipated female pattern hair loss, a multidisciplinary expert task force was appointed by the Androgen Excess PCOS Society to determine the current state of knowledge concerning the relationship of female hair thinning to hyperandrogenism.2

However, many affected women have normal circulating androgen levels.  Enrico Carmina, MD, professor of endocrinology at the University of Palermo, Italy, and lead author of this expert panel, said: “Female hair loss may present in different ways but the most common form presents very differently from male hair loss and is characterized by hair loss starting along the central scalp line."

A comprehensive report on the findings drawn from peer-reviewed studies evaluating alopecia in women published through December 2017, was used as the basis for evidence-based guidance,2 available in the Journal of Clinical Endocrinology & Metabolism.

These clinical recommendations were developed to provide clinicians with the most current thinking about  the probable causes of female pattern hair loss as well as the evaluation, diagnosis, and treatment of significant hair thinning in women.2

The Multidisciplinary Androgen Excess and PCOS Committee also suggested a classification of female patterned hair loss based on age-related incidence; four categories of female pattern hair loss were designated:2

  • Early onset (adolescence and young adulthood) with androgen excess
  • Early onset (adolescence and young adulthood) without androgen excess
  • Late onset (peri- and post-menopausal) with androgen excess
  • Late onset (peri- and post-menopausal) with and without androgen excess

Female Pattern Hair Loss Is a Treatable Condition

Until quite recently, it was assumed that all female patterns of hair loss were directly attributable to hyperandrogenism and the term “androgenic alopecia” was applied to this condition.  However, we now know that many women who experience significant hair loss have normal circulating androgen levels,Dr. Carmina said.

“Female hair loss may present in different ways but the most common form emerges very differently from male pattern hair loss and is characterized by hair loss starting along the central scalp line. Thirty percent of young women have some female pattern hair loss. Although this common form of female hair loss may be associated with hyperandrogenism, it may also present independently and more commonly without excess androgen levels,” he told EndocrineWeb.

More commonly, women experience bitemporal hair changes in which hair is shorter, less dense, and thinner. “Because of this, we prefer to avoid the term ‘alopecia’  when referring to this condition, using  ‘female pattern hair loss,' instead," Dr. Carmina said.  

The guidelines on the diagnosis of PCOS consider the comorbidity of hair loss to be indicative of hyperandrogenism and have continued to use the term “alopecia”.1 In contrast, the task force recommended using only female pattern hair loss to distinguish noticeable hair loss in women without obvious signs of androgen excess, and is the terminology used in the dermatological literature to more aptly describe this condition.2

Factors to Inform a Diagnosis of Female Pattern Hair Loss

A differential diagnosis should be conducted to rule out other common causes of hair loss such as chronic telogen effluvium, central centrifugal cicatricial alopecia, frontal fibrosing alopecia, and patterned fibrosing alopecia.  

In evaluating a patient for female pattern hair loss, Dr. Carmina mentioned a few key recommendations:2

  • Assessment of female pattern hair loss is clinical so healthcare providers should look for two common patterns:
  1. Centrifugal expansion in the mid-scalp (Ludwig pattern)
  2. Frontal accentuation, also termed Christmas tree pattern (Olsen pattern)
  • Isolated hair loss with androgen levels at 4 ng/dl would not be considered a form of hyperandrogenism.
  • Seek a dermatoscopic exam and/or dermatologic biopsy (4 mm punch of scalp) to assess hair density that will vary by ethnicity
  • Evaluation for possible androgen excess should be done routinely (ie, mandatory) while assessing for vitamin D, iron, zinc, thyroid panel, and prolactin is recommended.
  • First-line treatment with minoxidil (5%) with adjunctive therapy as needed

Treatment Options Expand for Female Pattern Hair Loss

The task force, with specialists from dermatology, endocrinology, and reproductive endocrinology, examined multiple databases including MEDLINE, EMBASE, Cochrane, ERIC, and EBSCO.

The most common treatment to date for female pattern hair loss in women has been topical minoxidil,3 which promotes hair growth by stimulating the dermal papilla and inducing proliferation and differentiation of bulge stem cells, the epithelial cells near the follicle base.

Recent evidence suggests that minoxidil may also achieve hair growth by promoting growth factor release of adipose-derived stem cells.3 Researchers have suggested that the mechanisms of hair growth from minoxidil occurred by promoting the telogen (quiescent) to anagen (active growth phase) transition of hair follicles that have long been considered as the most effective treatment for female pattern hair loss.

Dr. Carmina agreed, saying, “Independent of the presence of hyperandrogenism, topical minoxidil by solution or gel (5%) should be the first line treatment for female pattern hair loss.” However, treatment of hair loss in women when excess androgens levels have been found requires additional anti-androgen therapy.

The effect of androgens on the hair follicle has been well documented and have been extensively studied in both men and women.4,5  Free testosterone binds to intracellular androgen receptors in the hair bulb and dermal papilla, resulting in the miniaturization of the hair follicle. Free testosterone is also metabolized into dihydrotestosterone (DHT), which binds to the same receptors as testosterone, but with much higher affinity.

The enzyme 5-alpha-reductase is responsible for the conversion of free testosterone to DHT. The therapeutic effects of minoxidil may be enhanced with the addition of 5-alpha-reductase inhibitors, which blocks this metabolism.

One such 5-alpha-reductase inhibitor is finasteride, which had been approved by the U.S. Food and Drug Administration (FDA) for the treatment of male androgenetic alopecia.6 However, as of 2017, finasteride had not been granted use for widespread treatment of alopecia because it was found to have strong teratogenicity and was linked to the feminization of male fetuses, and is classified as pregnancy category X drug.

In clinical trials, however, finasteride has proven effective in both pre- and postmenopausal women at doses of both 2.5-mg and 5-mg per day.4 In women of reproductive age, finasteride should be used in conjunction with an oral contraceptive, to minimize the teratogenic risks.  

Spironolactone is another commonly prescribed anti-androgen therapy that works by blocking the interaction of testosterone and DHT at the androgen receptors in target tissues.7 This has been used successfully to treat female pattern hair loss at 100- to 200-mg daily doses and its effects are enhanced with the concomitant use of minoxidil; however, it was considered to have teratogenic properties and so ought not be prescribed to any woman planning a pregnancy.

Another still experimental treatment–the use of laser therapy–has gained in preference among patients looking to avoid medications, which may be of modest benefit in lessening hair loss in women.2

Dr. Carmina summarized the use of non-pharmaceutical therapies for the treatment of female pattern hair loss: “Additional forms of treatment, including the application of low-level laser or platelet-enriched plasma, are gaining in popularity but more data are needed. Hair transplantation may sometimes be effective, but maintenance of transplanted hair requires ongoing topical and medical treatments.”

Assessing the Strength of the Task Force Guidance for Hair Loss in Women

Overall, the evidence-based recommendations for the treatment of female pattern hair loss remain limited, and treatment options may often result in only minor improvements. “We found only a few studies dedicated to female hair loss, and most of the treatment options lacked strong clinical evidence,” Dr. Carmina said. 

“Yet, this is a comprehensive look at the available literature and its recommendations are evidenced based to the degree that we have adequate trials available,” said Kathleen Hoeger, MD, MPH, professor of obstetrics and gynecology and chief of the Division of Reproductive Endocrinology and Infertility at the University of Rochester School of Medicine. 

“The [task force report] looked at all aspects of alopecia including assessment, prevalence, psychological impact, and treatment options,” she told EndocrineWeb. “Furthermore, the report provides a sound evidence-based roadmap for patients to get concrete answers from their physicians—from the best approach to manage hair loss in women to acknowledging that there is not a single most effective treatment but modestly beneficial medical treatments are available.”

Dr. Hoeger valued having the benefit of a multidisciplinary analysis of existing findings. “This review has pulled together the best literature on female pattern hair loss to provide an opportunity for physicians to both improve the assessment of hair loss in female patients and to recognize the impact on the patient’s well-being as well as providing some guidance for currently available treatment options,” she said.

“I consider this [meta-analysis] an important summary of the state of treatment of hair loss in women and provides data-driven direction for clinicians to recognize, evaluate, and more actively treat this condition,” she said.

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