Women are generally more attentive to the appearance of their hair and notice the see-through quality of thinning hair early on. Most women with thinning hair don’t lose enough all at once to clog the drain, so problems with styling may be the first sign of the female genetic balding process. This is fortunate because the slow onset of thinning allows women to adjust their styling to compensate for their hair loss.
Most women are able to conceal thinning with a new hairstyle, up to a point. Layering, a pulled-back style like a pony tail, or a bun can hide thinning hair fairly well. Or women can use hair extensions or other hair systems, which we discuss in Chapters 6 and 7. Regardless of how well they may be able to hide it , hair loss is a psychological challenge for women who fondly remember the luscious, thick hair of their youth and see it coming out in bunches on their hairbrushes. Thinning hair can make a woman feel older and less sexy.
This section looks at genetic female pattern hair loss and other causes of women’s hair loss.
Differentiating between possible causes
There are a number of types of identifiable hair loss in women, and they differ based on their causes. The cause of female hair loss is reflected in the pattern, so doctors look to the pattern of loss to get an idea of the cause and how to treat it.
About 10 percent of women experience the classic pattern of genetic hair loss, which is an intact frontal hairline for the first 2 / 3 inch or so and hair loss behind that persistent hairline. Another recognizable pattern of genetic hair loss in women is hair loss confined to the top of the head, sparing the leading frontal edge of the hair line. Some women with genetic hair loss experience a diffuse hair loss, which is a thinning of the hair all over the head (including the sides and back of the head) and isn’t confined to any particular area. This is more common in postmenopausal women, although it does show up in younger women as well.
Perimenopausal women frequently experience pattern thinning that’s usually worse in the front of the thinning area, about 2 to 3 inches behind the hairline. Over time, it progresses as far back as the swirl (the place in the crown where hair changes direction and produces a vortex); the thinning areas may spare the sides and back of the head. For perimenopausal women, thinning tends to be diagnosed in the 30s or 40s. It is present but less frequent with women in the 20s. The good news is that once the thinning is recognized in these women it is generally stable over time and does not show the progressive nature of the male balding patterns, at least until they reach menopause.
On the other hand, an advanced presentation of uniform hair loss, called diffuse unpatterned alopecia ( DUPA), leads doctors to narrow the type of hair loss down to a few distinct possibilities, including female genetic hair loss or senile alopecia.
Generalized thinning isn’t always genetic, and women should undergo a complete medical examination including a wide variety of laboratory tests. (We touch on these tests in this chapter in the section “Medical causes of female hair loss” and in detail in Chapter 5.)
Genetic hair loss in women
In women, there’s a distinct relationship between mother, sisters, aunts, and grandmothers when it comes to thinning hair patterns. When we take a careful history from women with thinning hair, far more than half of the women we interview with balding or thinning have female relatives with a similar problem. When one recognizes this in the family history , we generally ask these women to inquire on the course of the family balding patterns from a timeline perspective.
Genetic hair loss is relatively uncommon in women and is generally referred to as female pattern hair loss or female androgenetic alopecia. In women with this condition, the common pattern differs than that of men. Whereas the pattern in men follows the Norwood classification (refer to the earlier section, “Norwood classifications for measuring male pattern thinning”), the postmenopausal pattern in women is characterized by diffuse thinning starting just behind a normal hairline and extending to and beyond the swirl.
Unlike men, adult women with typical female postmenopausal androgenetic alopecia often have significant levels of miniaturization (decreased hair shaft thickness in some hairs and loss of hairs within the follicular unit) in the back and side of the scalp.
Miniaturization causes hair shafts to become thinner over time before falling out, and the higher degree of miniaturization present indicates an unstable hair loss process throughout the scalp.
In some women, the genetic pattern of hair loss is associated with an increase in male sex hormones ( androsterone, testosterone, and DHT), but in most cases of genetic hair loss, it occurs when the sex hormone levels are normal.
Compared to men, the mechanism of balding in women is less well understood because their hair loss isn’t as directly related to the presence of DHT. The enzyme aromatase appears to have a role in causing female hair loss and may partially explain the different pattern when compared to men. The loss of estrogens in postmenopausal women means that the protection against female genetic alopecia is withdrawn, bringing on the thinning.
Women who develop pattern balding later in life also have a genetic component to their hair loss, but the association is less strong. The changes in hormones that occur around menopause are an obvious contributing factor.
Because genetic hair loss presents itself differently in women than in men, a different classification system is used. Doctors use the Ludwig classification to describe the thinning that women experience. A Ludwig type I is associated with a mild widening of the part width. Patients who fall into type II have increased thinning with moderate widening of the part. Type III patients have significant widening of the part width. Figure 4-3 depicts types I through III.
A minority of women develop pattern balding in a distribution that’s similar to men. These patients are better classified using the Norwood classification system. Because these women have hair loss mainly limited to the front and top of the scalp that doesn’t affect the back and sides, they may be candidates for hair transplant surgery, which we discuss in Chapter 13. About 15 percent of women have this patterned balding.
Medical causes of female hair loss
Apart from genetics, female hair loss can stem from a variety of medical causes. This section looks at those causes, from the general to the more specific, including postpartum and menopausal hair loss .
Figure 4-3 The Ludwig classification system for genetic hair loss in women
Underlying medical conditions
In women, many medical conditions may cause hair loss, including the following:
Thyroid disease
Anemia
Iron deficiency
Weight loss induced by severe dieting or eating disorders
Medication use (particularly oral contraceptives, beta-blockers,vitamin A, thyroid drugs, tranquilizers and sedatives, Coumadin,and prednisone)
A variety of autoimmune diseases
See Chapter 5 for a full discussion of medical problems that cause hair loss.
ANA (antinuclear antibody): Used to test for lupus or other autoimmune diseases. This test is either positive or negative and further testing may be required if the initial screening tests are positive.Iron: Levels serum iron, TIBC (total iron binding capacity) , and ferritin deficiencies in iron.Estradiol: This sex hormone indicates the status of ovarian output.FSH (follicle-stimulating hormone): This sex hormone indicates the status of ovarian output. This hormone reflects the status of a woman’s ability to ovulate.LH (luteinizing hormone): This is a sex hormone indicates the status of ovarian outputa woman may be in her overall aging process. When she ovulates, this hormone stimulates the production of eggs.Free testosterone: May help the doctor understand a woman’s ability to convert testosterone into estrogen. Most testosterone is bound to proteins in the blood and the free testosterone is easily converted into estrogen.SHBG (sex hormone binding globulin): Level indicates the status of male hormones.TSH (thyroid-stimulating hormone): Level indicates the presence of hyperthyroidism or hypothyroidism.Total testosterone: Largely bound to proteins in the blood.
Baby blues: Postpartum hair loss
Pregnancy alters a woman’s overall hormone configuration in many different ways. When hormones change, hair becomes a target organ for change in some (but not all) women because the rapid growth of the hair cells reflects changes in the overall hormonal environment in the woman’s body.
When you’re pregnant, your production of the sex hormone estrogen increases, which prolongs the growth (anagen) phase of the hair cycle. During pregnancy, many women are delighted to discover that their hair is thicker and more lush. After the baby is born, however, estrogen levels drop and more hair lapses into the resting (telogen) phase. Consequently, your growing hair may fall out, and because the resting cycle lasts two to six months, it may take time to see the hair return to its growth phase.
Because hair grows at about 1 / 2 inch per month and doesn’t start growing again until the rest cycle is complete, it can take up to a year for you to get your “old” hair back. In that period, you may think you’re going bald; don’t worry, you aren’t. In nursing moms, the resting period can take longer than a year, and it may take more than a year for hair growth to return to previous levels.
Anemia and hypothyroidism also can contribute to postpartum hair loss. You can find out more about these medical conditions and others in Chapter 9.
Menopause-related hair loss
Over 50 percent of women going through the hormone fluctuations associated with menopause experience significant hair loss. The drop in estrogen levels in postmenopausal women may put the hair in a prolonged resting phase; this phase is particularly important for those women who have inherited female genetic hair loss. Unfortunately, doctors don’t really understand the mechanisms by which the withdrawal of estrogen causes hair loss in women, but they know that it occurs. Women who lose estrogen support have many changes in their bodies, of which hair is only one. There are books written on the use of hormone supplements for managing menopausal changes in the body, and this book is not meant to deal with these complex issues.
