How Often Do You Treat Female Androgen-Induced Alopecia?

Premenopausal women who present with complaints of hair Loss require guidelines-based medical management for a condition that has a clinical basis meriting proper treatment.

with Enrico Carmina, MD, and Brad Anawalt, MD

Any woman who is experiencing female patterned hair loss that is related to androgen excess, and treating physicians have a new tool to help determine how best to address this problem. The Multidisciplinary Androgen Excess and PCOS Committee released guidelines to improve the clinical attention to central scalp hair loss, providing a path to improved well-being and quality of life for millions of women.1

A team of eight esteemed experts in polycystic ovary syndrome (PCOS) formed the research review task force who examined the available data to ascertain the various diagnoses and possible treatments for female pattern hair loss, according to first author, Enrico Carmina, MD, executive director and chief executive officer of the committee, and professor and chairman of endocrinology at the University of Palermo Medical School in Italy.

Patterns of female hair thinning differ from male-patterned baldness.I: Central hair thinning; II: Frontal Christimas tree formation hair loss; III: Thinning crown thinning. Source: Olsen EA. J Am Acad Derm. Female pattern hair loss. 2002;45:S70-S80.

“This is a carefully developed update of knowledge about pattern hair loss in women with a special focus on androgen-depending forms, providing clinicians with clear guidance in female patterned baldness drawing on the latest evidence,” says Dr. Carmina.

Basic studies have shown that the androgen excess in premenopausal women inducing hair loss that requires different diagnostic and treatment approaches from that experienced by men,2 he says. For one thing, inflammation may play a larger role in this condition for women than in male.

When a woman has excess androgen levels (primarily testosterone), a variety of signs may arise such as acne, weight gain, excessive facial and chest hair (hirsutism), irregular menstruation, and excessive loss of hair at the scalp. The physical presentation of hair loss is notably different between the sexes.

Female patterned hair loss usually occurs as a noticeable hair thinning in the central or midline region of the scalp with preservation of the front hair line—often described as a Christmas tree pattern, where the top of the head is the primary site of loss, often in a triangular pattern–and usually arising as a result of excess androgen production.

Some women with excessive androgenization may develop hair loss with different patterns that are more typical of male pattern baldness, such as hair thinning at both temples, but this is more rare, according to Dr. Carmina.

This task force report offers clear clinical guidance on the various presentations that commonly arise in women who experience hormone dysfunction, improved recommendations for proper diagnoses, and efficacious treatment targeted for a variety of different hair loss problems encountered in young women. There is a distinct difference in the androgen-excess related alopecia as opposed to the hair loss experienced during menopause, which is usually a more diffuse hair thinning more evenly across the scalp.2

Clincally Induced Causes of Alopecia, Diagnostic Methods, and Treatment Modalities

The guidelines committee identified multiple potential reasons for female pattern hair loss including possible molecular, inflammatory, genetic, and hormonal issues.1 Still, some women may present with hair loss that has no apparent or obvious reason; as such, age and ethnicity also play a role in who is more susceptible to excessive hormone-driven hair-thinning.1

In making a diagnosis, heed the concerns expressed by the patient as more than an issue of vanity. When making a diagnosis, there are two parameters to evaluate–the intensity and pattern of hair loss, paying particular attention to the degree of thinning and the location, as well as performing a hair strand test to access the integrity of the hair follicle. 

Other diagnostic tools that you may wish to employ include:

  • Referral for a dermatoscopic exam or scalp biopsy
  • Laboratory testing for serum levels of androgens, and potentially other hormones such as thyroid stimulating hormone and prolactin.
  • Further testing may include an assessment of vitamin or mineral deficiencies, like iron, vitamin D, and zinc.

Treatment Overview for Androgen-Induced Alopecia

Treatment for female pattern hair loss is presented in two forms: topical and systemic, most of which are directed to reduce production of excess androgens (and therefore are not recommended for any women in whom pregnancy is likely).(Olson)  In selecting a treatment, your doctor will first make a determination of whether or not the hair follicles remain open is necessary. If your hair follicles are still active, then hair regrowth is possible using one of several effective treatments, depending on the circumstances of the particular patient.1

Possible treatments include starting with topical minoxidil, anti-androgen medications, or finasteride (although this one has had mixed results. Other options which have proved successful include oral contraceptives and medications like spironolactone-a diuretic that has anti-androgen properties, and flutamide‑which while useful has the potential to cause liver toxicity.

Alternatively, there are treatments that have less evidence of success such as low-level laser therapy and microneedling which may be done to increase absorption of topical medications, platelet rich plasma therapy, and topical ketoconazole‑an antifungal medication often used in male pattern baldness. Even melatonin has been recommended for some women. Hair transplantation is also an option when the hair loss becomes significant and unresponsive to medical therapies. 

Steps to Take with Confirmed Androgen-Related Hair Loss

“We think that for first time we are giving doctors of different specialties— dermatologists and endocrinologists—the same message,” Dr. Carmina tells EndocrineWeb. “We are giving them the same terminology and the same ability to make clinical decisions such as a differential diagnosis. They will be able to interpret the laboratory data, order the right laboratory studies, and choose the drug therapies that are most effective for each specific patient.”

Brad Anawalt, MD, professor and vice chair of medicine at the University of Washington School of Medicine calls the guidelines “an excellent concise review of the latest science on the topic of a very vexing problem for many women.”

He concurs that the authors highlighted key elements necessary for determining when medical therapy is needed to block androgens. “Most of the information is not new, but the description of the approach is not well known to many clinicians so this report will likely lead to more effective management of female pattern hair loss,” Dr. Anawalt tells EndocrineWeb.

While this is good news for women who are experiencing noticeable hair thinning, those with other types of hair loss such diffuse hair loss across the whole scalp or patchy losses will require assessment for other diagnoses, says Dr. Anawalt. For example, systemic illnesses, side effects of medication, and inflammatory skin conditions may be at play.

Hair loss due to systemic illness or induced by medications often resolves when the illness abates or the causative agent is discontinued. On the other hand, dealing with skin problems is harder to treat, he says, but these too may respond to creams or injections of anti-inflammatories like cortisone, or immune-suppressing drugs.

The condition can be “mortifying” to women, leading many to reduce outside activities, even to become reclusive. “This report provides a commonsense approach that is very useful, and because it helps to distinguish hair loss due to androgen effect from other causes, women can better understand what medications might be useful and what benefit to expect or hope for,” Dr. Anawalt says.

One bit of advice that Dr. Anawalt was especially pleased to see:

Recommendation that women worried about hair loss try the hair pull test. “Try to pull gently on the end of a group of 50 hairs in multiple areas of the scalp,” he says. “It is normal to have 0-2 hairs come out per pull. More than that suggests telogen effluvium, which does not respond to anti-testosterone therapy but may reflect altered thyroid hormone or estrogen levels or a nutritional deficiency.”

There are also some caveats that clincians should share with their patients so they understand the reality of their hair loss, says Dr. Anawalt:

  • Hair loss due to aging isn’t reverseable.
  • Treatment with minoxidil results in only modest improvement of hair growth.
  • Anti-androgen treatment offers benefits only to women with either high levels of circulating blood testosterone or evidence of excess testosterone production.

“The guidelines nicely describe emerging evidence of the important growth factors for hair, and we might see effective treatments for hair loss for women and men based on further investigation and development of treatments related to these growth factors,” he says.

As a final note, clinicians should ask patients if they are taking biotin supplements—a common supplement taken for hair health—since it will result in a false result during hormone testing, and therefore preclude an inaccurate diagnosis and prohibit prescribing the right treatment.

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