Female pattern hair loss (androgenetic alopecia) is the most common type of hair loss experienced by women. It affects women of all races and ethnic groups as early as puberty, although most with the condition first experience hair loss around the time of menopause (end of menstruation). Rates of incidence increase with age, with female pattern hair loss to some degree affecting a majority of women aged 65 and older.
The condition is genetically predetermined and incurable, though factors such as age and levels of androgens (male sex hormones) may help determine when it occurs and how extensive it may become. Female pattern hair loss differs from male pattern hair loss in that women typically experience an overall thinning of the hair across the top of the scalp as opposed to a “bald spot” or receding hairline. A widening of the part or a decrease in pony tail width is usually the most noticeable sign that hair loss is occurring.
A physician diagnoses female pattern hair loss by taking the patient’s medical history and performing a physical examination, during which time the scalp will be closely examined for other signs of hair disease (e.g., scarring, plugging of hair follicles). Additional testing may be done (e.g., skin biopsy, blood tests) if other conditions that cause similar hair loss patterns (e.g., telogen effluvium, alopecia areata) are suspected.
The only treatment approved by the U.S. Food and Drug Administration (FDA) to specifically treat female patten hair loss is minoxidil 2 percent solution. Some women may also benefit from treatment with antiandrogens that can reduce levels of hormones (e.g., dihydrotestosterone) that contribute to hair loss. Hair transplantation surgery can restore hair growth by moving healthy follicles from an unaffected area to an area with extensive thinning or balding. However, no treatment is effective all of the time and some patients may not benefit regardless of the method used.
About female pattern hair loss
Female pattern hair loss (androgenetic alopecia) is the most common type of permanent hair loss in women. It affects approximately 30 million women in the United States, according to the American Academy of Dermatology. It occurs in women of all races and ethnic groups, but is especially common among Caucasian women. Although the condition can develop as early as puberty, most women affected by the condition first experience hair loss around the time of menopause (end of menstruation). The rate of incidence tends to increase with age, affecting a majority of women aged 65 and older in varying degrees.
Hair plays a significant role in a woman’s self-image. The cultural and social importance placed on women’s hair and hair styling makes female pattern hair loss a debilitating condition for millions of women in the United States. Hair loss tends to have a greater psychological impact on women than on men.
Hair is composed of a protein called keratin and is produced in follicles located in the outer layer of the skin (epidermis). Each person is born with a pre-determined amount of follicles. The follicle holds the lower part of the hair shaft in place and contains blood vessels that stimulate new hair growth. The growth of hair from these follicles is cyclical and happens in three stages:
Growth (anagen) phase. May last two to three years for any given hair. On a normal scalp, about 80 to 90 percent of hair follicles are in the growth phase at any given time.
Involutional (catagen) phase. Reduction in size of the hair. Approximately 1 to 3 percent of hair on the scalp is undergoing involution at any given moment. The involutional phase is a transitional period the hair undergoes before being shed. Typically, it lasts about two or three weeks.
Resting (telogen) phase. Shedding of hair from the scalp. Following involution, hairs go through a resting phase for about two to three months. At the end of this time, the hairs are shed and the growth cycle is reinitiated. On a normal scalp, approximately 5 to 10 percent of hairs on the scalp are in the resting phase at any given time, with about 75 hairs shed every day.
A full head of hair has about 100,000 hairs, with the exception of redheads, who have fewer hairs, and blondes, who have more. Up to 30 percent of hair may be lost by middle age as a normal part of the aging process.
Female pattern hair loss usually occurs around the time of menopause due to a combination of inherited factors, increased follicle sensitivity to the male sex hormone (androgen) dihydrotestosterone (DHT) and other systemic hormonal changes happening throughout the body. All of these factors combine to progressively shrink affected hair follicles around the hair part, decreasing the length of the growth phase and causing new hairs to be finer, thinner and to shed more rapidly. When the affected hair is shed, the root grows a new one that is finer and shorter. Over time, thick, colored terminal hairs become colorless vellus hairs (“peach fuzz”).
Female pattern hair loss is not the only cause of hair loss in women. For instance, hair loss can occur after pregnancy, due to the shift from an active growth phase during pregnancy to the usual pattern of growth, reduction and resting after childbirth. Hair loss may also result from physical or emotional stress or the discontinuation of birth control pills. Known as telogen effluvium, these forms of hair loss are characterized by an increased loss of hair over the entire scalp. Female pattern hair loss, on the other hand, is characterized by increased shedding of hair from only the top of the scalp. Telogen effluvium is usually a temporary condition, whereas female pattern hair loss is permanent.
Women experience hair loss nearly as frequently as men do. However, they tend not to lose as much hair due to hormonal differences and to have different balding patterns. Female pattern hair loss differs from male pattern hair loss in that women typically experience an overall thinning of the hair across the scalp as opposed to a “bald spot” or receding hairline. Women may also be able to disguise their hair loss more effectively than men because of differences in hair length and styling.
Potential causes of female pattern hair loss
Female pattern hair loss is the most common type of hair loss in women. The condition is genetically predetermined, though factors such as age and androgen (male sex hormones) levels are commonly associated with the timing of its onset and how far it progresses. It most often begins during menopause (end of menstruation) but may begin as soon as puberty in very rare cases.
Dihydrotestosterone (DHT) and an enzyme (a complex protein found in body cells) known as 5-alpha reductase are involved in the androgenic alopecia process. Women with large amounts of this enzyme produce excess amounts of DHT, the hormone primarily responsible for hair loss. This subsequently reduces levels of estrogen, a hormone that naturally counteracts the affects of DHT. Over time, this excess DHT causes the hair follicle to shrink or even stops hair growth.
Women who experience hair loss early in life typically have a family history of androgenetic alopecia on both sides of the family, though this occurs rarely. Female pattern hair loss that begins around the time of menopause generally occurs due to a combination of heredity, an increased sensitivity to androgens and other hormonal changes occurring normally throughout the body.
Unusually high androgen levels can also cause hair loss to occur and may be confused with female pattern hair loss in some patients. An androgen imbalance may be present if hair loss occurs around the temples (more of a male pattern) or in conjunction with any of the following conditions:
Galactorrhea (discharge of milk from the nipples without pregnancy or childbirth)
Infertility
Abnormal development of male characteristics (e.g., low voice, hirsutism [excess hair in areas where hair growth usually does not appear in females], increased muscle mass)
Signs and symptoms of female pattern hair loss
In most cases of female pattern hair loss, the hairlines at the front and back of the head remain intact. As opposed to the “bald spot” or receding hairline that commonly distinguishes men with hereditary hair loss, women typically experience an overall thinning of the hair just behind the frontal hairline or middle scalp area and extending back to the crown (top of the head).
A widening of the part or a decrease in pony tail width is usually the most noticeable sign that hair loss is occurring. Hairs tend to be miniaturized or of various lengths and diameters in the affected area. An abnormally high number of hairs found on brushes or combs, pillows or in the shower drain may be the first noticeable indicators of the condition. However, female pattern hair loss may not be visually identifiable in an affected area until significant thinning or hair loss has occurred.
Hair loss is not usually a cause for concern. However, it can be an early sign of certain diseases (e.g., diabetes, lupus, hypothyroidism, hyperthyroidism). Hair loss may also develop as the result of poor nutrition (e.g., iron deficiency), skin damage or as a side effect of certain medications. Women who are troubled by their hair loss should consult a dermatologist, especially if the condition is accompanied by other symptoms such as itching or skin irritation.
Diagnosis methods for female pattern hair loss
To diagnose female pattern hair loss, a physician will take the patient’s medical history and perform a physical examination, during which time the scalp will be closely examined for signs of disease (e.g., scarring, plugging of hair follicles).
Other causes of diffuse hair loss may be considered (e.g., illness, medications, trauma) before diagnosing female pattern hair loss. Diagnosis may be slightly more challenging in women than in men, as female pattern hair loss is less defined and tends to consist of broad thinning over large areas of the scalp. A skin biopsy or other procedures (e.g., blood tests) may be used to diagnose medical disorders that can cause balding (e.g., hyperthyroidism, iron deficiency) or that may be confused with female pattern hair loss (e.g., telogen effluvium, alopecia areata).
In most cases, extensive hormonal testing is not needed unless additional signs or symptoms of a hormonal imbalance are present (e.g., hirsutism). In most cases, hairs observed with different degrees of thickness or length are often sufficient to diagnose the disease. An increase in vellus (nonpigmented) hairs may also be noted. Extensive balding for an extended period of time may cause connective tissue (scar tissue) to replace follicles.
Women with female pattern hair loss may be generally classified as having early- or late-onset alopecia, with or without excessive androgen (male sex hormones) levels. These categories may require alternate treatments or result in variable responses to treatment.
The Ludwig classification system may also be used to describe the extent of a patient’s hair loss. However, it is insufficient to diagnose the cause of hair loss. The Ludwig system organizes levels of hair loss in the following manner:
Grade I. A minimal widening of the part width.
Grade II. Moderate thinning or widening of the part.
Grade III. Extensive thinning and widening of the part width.
Treatment and prevention of female hair loss
Female pattern hair loss is not a serious medical condition. Therefore, treatment is not necessary. Patients who are emotionally impacted by the condition, however, may benefit from seeking treatment.
The only treatment approved by the U.S. Food and Drug Administration (FDA) to specifically treat female patten hair loss is minoxidil 2 percent solution. Minoxidil is sold without a prescription and is applied either by spray or in liquid drop form. It must be applied to the scalp twice daily for at least four months in order for it to be effective, though it does not work for everyone. Furthermore, using more of the product or applying it more often does not improve results.
Persistent use of minoxidil is necessary to maintain and increase new hair growth or hair loss will resume. Limited evidence suggests that the stronger minoxidil 5 percent solution used twice daily may be more effective than minoxidil 2 percent in treating women with female pattern hair loss. However, it may cause excessive facial hair growth as a side effect and is only specifically approved for treatment of pattern hair loss in men.
Minoxidil should not be used if any of the following circumstances apply to a patient’s hair loss:
No family history of hair loss exists
Hair loss is sudden or patchy (alopecia areata)
Hair loss occurs because of childbirth
The cause of hair loss is undetermined
The patient is under 18 years of age
The scalp is red, inflamed, infected, irritated or painful
In addition, minoxidil should not be used by women who use other scalp medication. Women with heart disease, and those who are pregnant or breastfeeding, should consult a physician before using the drug.
Treatment with antiandrogens may be effective for some cases of female pattern hair loss. These medications perform a variety of functions that make them effective in treating female pattern hair loss in some patients, including:
Reducing the quantity of androgens produced
Blocking the transformation of androgens into dihydrotestosterone (DHT)
Limiting the interaction of androgens with the hair follicle.
Some women who experience female pattern hair loss after menopause (end of menstruation) may benefit from hormone replacement therapy (HRT). HRT uses medications to replace the hormones lost during menopause.
Other medications that are used to treat male pattern hair loss have not been proven to work in women (e.g., finasteride).
An increasingly popular treatment option for female pattern hair loss is hair transplantation surgery. Originally developed to treat men, newer techniques are better suited to effectively treat female pattern hair loss safely and with results that appear natural. Hair transplantation surgery involves the removal of small pieces of hair-growing scalp (grafts) from a “donor site” (usually the lower back or sides of the scalp) and moving them to a bald or thinning area. This may cause minor scarring in the donor area and carries with it a minor risk for skin infection. Once transplanted, the hair retains the characteristics from where it is taken and continues to grow.
Additional treatments for female pattern hair loss, such as hair weaving, hairpieces, or changes in styling may effectively hide hair loss and improve appearance in some patients. Methods such as these are often less expensive than the alternatives and pose virtually no risk of side effects.
Female pattern hair loss can not be prevented or predicted, though individuals with a family history of hair loss are more likely to be affected. Minoxidil and/or antiandrogen therapy may be effective at slowing, stopping or regrowing hair in some patients once hair loss has begun, but it is not considered effective prevention from the onset of the disease.
Questions for your doctor
Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctors the following questions about female pattern hair loss:
Is my hair loss a cause for concern?
What may be causing me to lose my hair?
Should I be tested for an underlying condition that may be causing hair loss?
Could my hair loss be in response to a medication I’m taking?
What methods will you use to determine the cause of my hair loss?
How likely is my hair loss to continue?
What are my treatment options?
How much hair regrowth should I expect?
Some of my female family members have experienced hair loss. Does that make me more likely to lose my hair?
Are there any steps I can take to prevent female pattern hair loss?
