Women’s Hair Loss is a condition that occurs in more than 50% of women over the age of 50 and is often emotionally “leveling”.
There are many possible causes for female hair loss. They vary from Female Androgenetic Alopecia (about 70% of women with hair loss) scalp’s ailment, anxiety, malnutrition and some diseases. In addition, female hair loss might be due to iron deficiency (from the period or pregnancy), certain thyroid disorders (such as hypothyroidism), menopause, polycystic ovarian syndrome (POS), some medicines and, of course, chemotherapy.
In all cases, it is best to consult a Dermatologist or a Physician specialized in Hair Transplantation to identify the causes and decide on an effective treatment for hair loss.
The rates of Female Androgenetic Alopecia (FAA)
Female Androgenetic Alopecia is by far the most common cause of hair loss in women. 70 out of 100 women with hair loss suffer from FAA.
The ratio of Female Androgenetic Alopecia is increasing with age. Epidemiological studies show that 13% of pre-menopausal women (19-49 years) suffer from FAa, and the rate reaches up to 37% after menopause.
Other than frequency and severity of FAA, increases with age.
How Female Androgenetic Alopecia (FAA) work?
Compared to men, the Mechanism of Female Androgenetic Alopecia (FAA) is a bit vague because it is not directly related to the DHT hormone as in male Androgenetic Alopecia, except from some cases of women with polycystic ovarian syndrome, where there is a connection with hormone DHT.
The aromatase enzyme appears to have an important role in the FAA and may partly explain the differences between men and women with FAA regarding the hair appearance.
In addition, the normal reduction of estrogens in postmenopausal women also reduces the natural protection that estrogens provides to hair follicles causing the thinning of hair in many postmenopausal women.
However, comparing FAA in woman to AA in men, there are three significant differences:
- The degree of hair loss is neither localized nor so spread, as it is typically seen in men who finally become bald in the androgen-sensitive regions. Women, on the other hand, develop an extend hair loss throughout the scalp and almost never get completely bald in one region.
- Whilst in men with AA all hair follicles in the androgen-sensitive areas, get thinner and fall off, in woman with FAA some of the hair diminish and fall, while others remain normal, presenting a “mosaic” pattern. This gives the impression of an extend hair loss to all the head but without any “empty” areas.
- In women with FAA, although we see a decrease in hair diameter (thinning), particularly in the androgen-sensitive areas of the scalp, they rarely show the widespread hair loss (shedding) often seen in men.
The Standards of Female Androgenetic Alopecia
Hair loss due to Female Androgenetic Alopecia is more difficult to diagnose than male Androgenetic Alopecia.
Hair loss due to other causes, than Female Androgenetic Alopecia, is quite common and closely resembles its clinical picture. Therefore, it is difficult to have a diagnose just by examining the scalp, as we do in men.
Hair loss in a woman, even if there is a family history of Female Androgenetic Alopecia in 1st degree relatives, should never be considered immediately responsible for FAA without a thorough clinical examination and additional laboratory tests.
Examination and diagnosis by a physician specialized in hair loss and hair transplantation is necessary before taking an efficient treatment or proceed to Hair Transplantation.
Female Androgenetic Alopecia has a different classification than Male Androgenetic Alopecia, due to its different pattern.
Usually there are three patterns of female hair loss
The model of Female Androgenetic Alopecia was originally categorized by Ludwig using a different classification from that of Male Androgenetic Alopecia, with grades from I to III and severeness 1-3.
Ludwig’s classification emphasizes at the diffused character of female hair loss patterns.
According to the categorization of Ludwig:
- The hairline remains intact.
- There are almost never completely bald areas.
- The hair loss on the vertex is extended and more noticeable from the rest of the scalp.
Diagnosis of FAA is, however, more difficult than Male AA because of these hair loss patterns. The most common FAA standards are the following:
- The “Christmas tree” model. An extended hair loss, with the “base” of the “tree” at the hairline) and its “top” at the vertex. This pattern was first described in the 1990s by the Dr. Olsen. Since then, the “Christmas Tree” pattern has been defined probably as the most common pattern of hair loss in the FAA.
- The diffused FAA is best manifested in Ludwig’s classification. In these cases we notice an extended hair loss throughout the scalp and it is not defined to any particular area. Women who fall in Ludwig l category show a slight enlargement at the part. Women who fall in Ludwig lI category show a significant enlargement at the part. In Ludwig III category, patients show a remarkable enlargement of the part and intense hair loss. Some research show that the vast majority of postmenopausal women manifest this kind of extend hair loss. Whether postmenopausal hair loss is due to Female Androgenetic Alopecia or just aging, is very difficult to be determine.
- Approximately 10% of women have the type of hair loss that resembles, to some extent, the male Androgenetic Alopecia model of Norwood-Hamilton. The Female-Androgenic Alopecia model rarely extends to the Norwood-Hamilton 6 and 7 stages. Many women after adulthood show limited hair loss, i.e. hairline retreat, without further hair loss (Norwood-Hamilton stage 2). This pattern of hair loss in women is less obvious than men and may go unnoticed unless hair loss goes to any of the above distinct patterns.
Common elements in all FAA standards
Women almost always maintain the hairline, even in cases of extensive FAA. In the rare cases of hair loss at the hairline, this is most often accompanied by acne, hirsutism, menstrual disorders and requires further laboratory testing.
Some women may develop thinning and hair loss on the temples, as in the Hamilton II-III Men’s Stage. This is usually mild, begins after puberty, and its course may be independent and more often, it does not proceed in other scalp’s areas. Women with FAA do not become completely bald, in scalp areas, except for minor exceptions.
Woman must be reassured that despite the amount of hair they lose this will not result in total alopecia. However, without taking any medication, the hair diameter will gradually become smaller, the hair will become thinner, smaller and more discolored, leaving some parts of the scalp exposed.
Due to the extended hair loss on the entire head, even the posterior area, of the permanent hair growth area (small total number of hair in the donor area), many women are not suitable candidates for Hair Transplantation.
Heredity and hair loss in women
In women, there is a distinct association between the appearance of FAA in a patient and the FAA that may be inherited by mother, sisters, aunts and grandmothers. This is proven by the fact that in the Medical Report (Medical History) more than 50% of woman with hair loss have a woman relative (1st or 2nd degree) with similar problem. Though, in many women, Female Androgenetic Alopecia is associated with an increase of male sex hormones (Testosterone and DHT), in the vast majority laboratory tests show normal hormonal levels in both male and female hormones.
It is unanimously accepted that the androgen-dependent nature of Female Androgenetic Alopecia has not yet been clearly confirmed. FAA should be differentiated from other causes of hair loss in women because they resemble each other and often coexist. It is sensible to require tests that exclude high androgen levels, especially from women who have the clinical picture of high level of androgen, such as hypertrichosis and acne in association with hair loss.
However, because of the fact that, the clinical signs of high androgen do not appear all together, it is up to the physician to decide which test he will require from a woman patient.
Last but not least, women with FAA should be reassured that they would not lose all their hair but it must be made clear that without the proper medication, FAA is an evolving “disease” with an extremely erratic rate of progression and for this reason it must be aggressively treated by a Dermatologist or a Surgeon specialized in Hair Transplantation.