There are a number of possible reasons for female hair loss. Causes of female hair loss can range from androgenetic alopecia (female pattern hair loss) to diffuse thinning caused by telogen effluvium which in turn can be nutritional, hormonal or stress induced. Mistakenly thought to be a strictly male disease, women actually make up significant percentage of hair loss sufferers. Hair loss in women can be absolutely devastating for the sufferer’s self-image and emotional wellbeing.
While hair loss itself can present psychological and emotional problems for a woman, failure of others to recognize the seriousness of these problems may contribute additionally to psychological and emotional effects that can range from decreased self-esteem to anxiety and depression.
Hair loss can be temporary or long lasting and progressive. Temporary hair loss can be treated when its cause is identified and dealt with, or difficult when it is not immediately clear what the cause is. Hair loss that could possibly have been temporary may become long lasting as a result of an incorrect diagnosis. The potential for such misdiagnoses is perhaps the most frustrating aspect of hair loss for women.Hair loss in a woman should never be considered “normal”, however. The cause should be pursued until a diagnosis is established. Usually extensive assessment is needed to ascertain the cause of hair fall/hair loss in women.
Of the many causes of hair loss in women, only a few such as aging, hormonal changes associated with pregnancy, and hereditary pattern hair loss may be considered “normal”. Treatment is available for hair loss due to these “normal” conditions, and treatment should be considered when hair loss influences the woman’s quality of life. Diffuse thinning in women in the fertile age group is usually caused by iron deficiency. The common scenario is that these women may have normal hemoglobin levels but still have some iron deficiency (non-anemic iron deficiency). Other potential causes of hair loss in women require medical treatment. These include cystic ovaries, hypothyroidism, autoimmune disease, chemotherapy, psychological or physical stress, and dietary deficiencies. Prescription drugs that commonly cause hair loss include beta-blockers, coumarin, anti-depressants and others. Medications may need to be changed or dosages adjusted due to hair loss. Damage to hair and scalp caused by tight braiding, corn-rowing, or chemicals used in hair styling are causes of hair loss that require change in life-style. Compulsive hair-pulling – a condition called trichotillomania that can cause unusual patterns of hair loss – may require psychological counseling.
Female Pattern Hair Loss (FPHL)
FPHL has been defined as non-scarring progressive miniaturization of the hair follicle, usually with characteristic pattern distribution that occurs in genetically predisposed women. Female pattern hair loss is the commonest cause of hair loss in women and prevalence increases with advancing age. FPHL may or may not have an androgenic basis. Generally it is sensitivity to androgens or androgen precursors that causes female androgenetic alopecia (FAGA). In these patients, clinical signs of increased androgen sensitivity (normal levels of male hormone) or hyperandrogenism (increased levels of male hormones) may be evident like – excessive facial or body hair, acne, irregular menses, weight gain etc. along with scalp hair loss. The inheritance
The hair loss is usually diffuse in naturewith progressive hair follicle miniaturization and conversion of terminal follicles into vellus-like follicles (producing fine/thin hair). These vellus-like follicles have a shortened hair cycle because their anagen phase is reduced and produce hair shafts that are short and fine. Unlike in men, the miniaturization is not uniform and intense, therefore, except for very rare cases; there are no complete areas of baldness.
The genetic inheritance of FPHL is still unclear. FPHL is possibly a multigenic disease, but the causative genes are not established and can come from either the mother’s or father’s side of the family.
Comparison of MPHL and FPHL
- Starts a little later than the males
- Often very gradual, Increases in severity with age
- Pattern differs from the male type as the hair line is maintained but there is diffuse thinning( less hair all over)
- More often cyclical than in men, with seasonal changes, and it is more easily affected by hormonal changes, medical conditions, and external factors
Factors impacting development of female hair loss
There are a number of medical conditions and factors that can cause temporary hair loss that are treatable without hair restoration surgery.
The following are a few of the common, underlying cause that may explain temporary hair loss.
Hypothyroidism: Another term for this is an underactive thyroid. Under normal circumstances, the thyroid gland regulates how your body uses energy and how sensitive your body is to other hormones. With hypothyroidsim, the thyroid gland doesn’t produce enough of certain hormones, which in turn upsets your normal chemical balance. One of the results can be thinning hair. Fortunately, when properly diagnosed, hypothyroidism can be controlled and any hair loss that has occurred can be reserved.
Pregnancy: Hormonal changes during and after pregnancy can lead to a number of changes in your body. Following pregnancy, women can experience an abnormal amount of hair loss when the hair follicles shift into a phase called shedding. This condition typically ends three to four months after pregnancy. However, if hair loss continues well after pregnancy, it may be a sign of a more significant hormonal imbalance that requires a consultation with your physician.
Stress: Extreme physical stress, such as crash dieting or a high fever, can shift the hair follicles into a premature shedding phase. The reasons for this connection are not well understood but your hair restoration surgeon or physician can provide treatment or therapy for your underlying condition. Once the stress is under control, your hair follicle cycle may return to the more normal phase.
Other list of factors which may impact hair loss in women
- Polycystic ovary syndrome
- Crash dieting,
- Traumatic emotional event.
- Thyroid disorders,
- Chronic illness or the
- Certain medications
Grading of female hair loss
Female-pattern hair loss has been classified by Hamilton using the Norwood-Hamilton classification, by Ludwig using a different classification of Grades 1 to 3 types of female-pattern hair and the Savin Scale. For all intents and purposes, they are identical except that the Savin Scale also measures overall thinning.
The Ludwig classification emphasizes the diffuse nature of much female-pattern hair loss.
The patterns of hair loss due to androgenetic alopecia tend to be less clearly defined than those in men. Hair loss due to causes other than androgenetic alopecia is also more frequent in women but often closely resemble hair loss due to androgenetic alopecia. Hair loss in a woman-even when there is a family history of androgenetic alopecia-should never be assumed to be due to androgenetic alopecia.
Three general patterns of female-pattern hair loss are:
- A “Christmas tree” pattern of diffuse hair loss, with the “base” of the “tree” at the hairline and the “tip” of the “tree” at the center of the scalp, was first described in the 1990s. Since that time, the “Christmas tree” pattern has been identified as perhaps the dominant diffuse pattern of female-pattern hair loss.
- Diffuse hair loss illustrated in the Ludwig classification. Some studies have indicated that a diffuse thinning of hair is experienced to some degree by a majority of premenopausal women and by a large majority of postmenopausal women. Whether postmenopausal hair loss is due to androgenetic alopecia may be difficult to determine as hair loss may also occur in association with aging in older women.
- Hair loss that resembles, in some degree, male-pattern hair loss of Norwood-Hamilton Types I to VII. Female-pattern hair loss rarely progresses to Type VI and VII severity. Studies have found that a mild Norwood-Hamilton Type II recession of the hairline is experienced by many women in young adulthood, but the recession is less prominent in women than in men and may go unnoticed unless hair loss progresses. Progression to Norwood-Hamilton Type IV by age 50 to 60 was seen in some of the women studied.
Hair loss due to androgenetic alopecia occurs at all ages after puberty in women. However, onset of female-pattern hair loss appears to be most frequent at ages 20 to 30 and 40 to 50.
How does one diagnose female pattern hair loss?
Female pattern baldness is usually diagnosed based on the appearance and pattern of the hair loss, along with a detailed medical history, menstrual history, dietetic history, including questions about the prevalence of hair loss in your family, .
At Hairrevive we try and arrive at a diagnosis of hair loss in every patient. The diagnosis depends on various steps:
- History: The onset of hair loss, pattern of hair loss and family history of pattern hair loss in close family members (both from paternal and maternal side). Detailed menstrual history, obstetric history, history of excessive facial and body hair, weight gain, difficulty in conception will help in pointing towards androgenic basis as well as ruling out Poly Cystic Ovarian Syndrome (PCOS)
- Examination: Scalp examination revealing a typical pattern of hair loss – fronto-temporal thinning/recession and/or thinning in the crown area
- The hair pull test is a simple diagnostic test in which the physician lightly pulls a small amount of hair (approx 50-60 simultaneously) in order to determine if there is excessive loss. Normal range is one or no hairs per pull.
- Trichoscopy: Revealing a variability of diameter of hair shafts in the affected area and no variability of diameter in the permanent zone of the scalp (the back and sides of the scalp)
- Biochemical tests: Women in the fertile age group (especially those on vegetarian diet) have non anemic iron deficiency and also suboptimal protein intake. These issues as well as the androgenic hormone and thyroid hormone levels can be checked with simple blood tests.
- Scalp biopsy: Sometimes accurate diagnosis is not possible due to unclear signs and in these patients it is best to confirm the diagnosis with a scalp biopsy. A small section of scalp usually 4mm in diameter is removed and examined under a microscope to help determine the cause of hair loss.