Hair Loss in Women

Hair loss in women is less common than in men, but can have a far greater effect on self-esteem and confidence. “Hair is sort of emotional for all women” states Fox News Anchor Megan Kelly May 2, 2016 People Magazine. Female hair loss is also more widespread than realized, because women will go to great lengths to disguise any bald patches or general thinning.

It is estimated that perhaps 40 percent of women will experience some degree of hair loss. The loss can be related to some underlying illness, hormonal changes before and after menopause or other conditions.

From ancient times up to the modern day, hair has always been a key aspect of female beauty and has often been described as a woman’s crowning glory. Look at the numerous advertisements promoting shampoos and conditioners. Who doesn’t remember the Farah Fawcett ads of the 1980s or the current Jennifer Lopez or Jennifer Aniston ads displaying a lush, gorgeous mane? If a balding man walks into a room full of people no one takes a second look, yet a woman with very thin hair walks in the same room, all turn around to gawk. Why? Unfortunately, society has placed tremendous pressure on women to live up to some Hollywood image of a sexy, desirable female.

Women are inundated with the images of long, flowing locks that seem impossible to achieve, but nevertheless a source of frustration to most women. To prove this point, look at the billion dollars a year hair extension business. Since hair loss in women is culturally unacceptable in the United States and most cultures of the world, it can cause considerable concern and fear. The fear factor is supported by research showing an increasing number of women losing their hair and experiencing thinning at an earlier age.

There are many similarities between body image dysfunction seen in young girls experiencing Anorexia Nervosa and poor self-esteem seen in women experiencing Female Pattern Hair Loss. Thomas Cash, PhD. published several research studies involving females suffering scalp hair thinning which revealed social anxiety, poor self-esteem, and sense of unattractiveness, helplessness, and self-consciousness. These women found their hair loss to be suffocating and insurmountable.

Embarrassment and shame also plays a role in how a woman perceives her hair loss. The loss of self-esteem continues to grow every time she looks in a mirror or sees a recent photograph. Remember, female pattern hair loss has no boundaries; it is an equal opportunity disease that affects all races and ages throughout the world.

Psychological effects and coping with hair loss
The psychological effects of hair loss in women should never be underestimated or disregarded. Due to social and cultural expectations, hair loss can be more distressing for a woman than for a man, in whom it is often considered normal or acceptable. Hair is seen as integral to a woman’s attractiveness and femininity. While hair loss is generally regarded as normal in men, women are more likely to be concerned how noticeable it is to other people, and the aging effect of thinning hair on their appearance. Women are also concerned with their attractiveness as it relates to social status and job security. Women experience deeper feelings of humiliation, anxiety, and disgrace than the typical balding man.

There are various different causes of hair loss in women, and they must be established before a suitable treatment can be recommended. Dr. Marty Sawaya, a dermatologist and specialist in hair loss explains, “The emotional impact for women with thinning hair is tremendous. One of the major roles of the doctor is to help women understand the various reasons why hair loss occurs, helping them to focus on realistic treatment options and expectations to optimize treatment outcomes.”
With women, hair loss is often seen as a generalized, diffuse thinning of hair, rather than losing hair over a specific region that is common in men. Unlike their male counterparts, females typically will preserve the hairline.

Although hair transplantation is less often performed in females, there is a need for this procedure in women who experience moderate to severe scalp hair thinning and who have an adequate donor region. Years ago, when all we had at our disposal were “plugs”, we would try to dissuade women from undergoing hair transplantation since we would be destroying some of the surrounding hair to make the recipient sites.

Today, women should consider hair transplantation where there is sufficient donor hair to cover the thinning areas. With follicular unit grafts and very tiny recipient sites, we can thicken the thinning areas without damaging or removing adjacent hair. The transplanted grafts give women the additional critical mass and hair density they need to achieve the maximum camouflage possible without sacrificing style.

At times, female hair loss can begin as early as the early twenties and remain at that same level of loss on the top of their head for the remainder of their life; while the hair on the back of the head maintains its original density. In these cases, the hair follicles in the back can be removed to create follicular unit grafts for placement throughout the areas of the head where there is marked thinning.

Societal expectation can run counter to reality, however. The fact is, many women experience hair loss at young to middle age and the incidence of the most common type of female hair loss (Female Androgenetic Alopecia) seems to be increasing.
“Many women today recognize the reality of hair loss and choose to do something about it by seeking hair restoration treatment or procedures. In the hands of a physician specialist in hair transplantation, most hair loss in women can be successfully treated.” — Note from International Society of Hair Restoration Surgeions (ISHRS).

How hair loss occurs in women
In males, pattern hair loss is almost 100% due to androgenetic alopecia, yet in females there are many other causes of hair loss that also gives a diffuse thinning presentation:

Poor nutrition, hormonal imbalance and trauma from hair styling are possible factors for hair loss in women. A crash diet or chronic protein deficiency in the diet can lead to hair loss, as can menopause and some oral contraceptives. Abnormalities in thyroid function both hypothyroid and hyperthyroid can contribute to hair loss, as well as some illnesses, high fevers, stress or a major operation. Iron Deficiency Anemia typically caused by heavy and frequent menstrual cycles can result in diffuse scalp hair thinning.

Recently, vegetarians who do not take protein supplementation have also seen an increase in hair loss due to a lack in protein intake. Pregnancy leads to hormonal changes, which can increase hair growth; when the body returns to normal after childbirth, a sudden loss of the extra hair may give the impression of excessive hair loss.

Medical evaluation by a hair transplant surgeon or dermatologist is advisable prior to exploring a hair transplant. Since there are several conditions that can mimic female pattern hair loss, a scalp biopsy and/or blood tests may be the only way to definitively diagnose the hair loss. Blood tests should include: A CBC (complete blood count) to rule out anemia and blood loss, T3, T4, TSH for thyroid disease, Serum Iron and Ferritin for anemia, ANA for ruling out Lupus, Total and Free Testosterone, DHEAS, Estradiol, Vitamin D, Vitamin B12, and RPR to rule out Syphilis.

Women can permanently lose hair from repeated use of tight braids, tight ponytail, or cornrow styles. The continual tension pulling on the hair leads to Traction Alopecia, where the hair is permanently lost from the affected follicles.

If someone compulsively pulls or plucks their hair, this can lead to irregular bald patches. This condition is called Trichotillomania. The compulsive behavior may be entirely unconscious, but can still lead to permanent hair loss.

As long as the individual has stopped the cause of the traction, hair restoration surgery can be performed successfully.

If excessive hair loss is seen during brushing, this could be due to Loose Anagen Syndrome, in which healthy, growing hairs are not held firmly within the follicles and are easily combed out. This condition is most often seen in blonde hair children. Diffuse shedding over the entire scalp is a condition called Telogen Effluvium. In this, an excessive number of hairs are shed simultaneously. This can be an acute or long term chronic condition. A stressful event such as a high fever, a severe dietary deficiency or severe blood loss can cause acute, diffuse shedding.

Irregular bald patches can also be a result of scarring from wounds, trauma, burns, or from medical treatments.

Alopecia Areata, an autoimmune disease is more common in women (affects approximately 2%) than men. Round or oval patches of hair loss can be found anywhere on the scalp or any hair-bearing area such as eyebrows, eyelashes or pubic region. The exact cause of this is unknown, but it is thought to be hereditary or an autoimmune condition. Although the cause of this recurrent disease is unknown, we know that stress and anxiety are frequently the initiator of the problem. In essence, the person’s own follicles are not being recognized by their anti-bodies and attack their hair follicles. The patches of baldness can be isolated or multiple and eventually coalesce to cover the entire scalp.

A less frequent form of alopecia areata can present as diffuse thinning which is indistinguishable from female pattern hair loss. This is another reason why a scalp tissue biopsy should be considered whenever there is no family history of similar hair loss. Active alopecia areata is not donor dominant; in fact, it is recipient dominant, which means that any healthy hair follicles from the donor region will be affected when transplanted into the diseased area. Frequently, alopecia areata reverses itself within a year of the loss, but sometimes the hair never grows back. If the area of baldness has not changed for at least 2 years, it may be inactive or quiescent and amenable to transplanting.

Any women affected by hair loss, whether short or long term, diffuse thinning or bald patches, should be assured that they are not alone, and treatment is often possible. Depending on the cause, a hair restoration specialist can recommend treatments to reverse the hair loss, and relieve the associated social anxiety. Hair loss is a medical condition, and a woman experiencing hair loss should seek a medical opinion and medical treatment. If left untreated, hair loss can progress.

Genetic Pattern Hair Loss in Women
Recent evidence suggests that female pattern hair loss is a different inherited disease from pattern hair loss seen in men. Fe-male pattern hair loss shows a complex inheritance, so the distribution and degree of hair loss among women in a family is not as predictable as that in men.

In women there is often generalized diffuse thinning over the entire scalp. Hair loss can also be localized, leading to a mosaic of patchy loss, or loss along the central parting on the top of the head. Dr. Elise Olsen described a common female pattern she labelled as a “Christmas Tree” pattern. The base or bottom of the tree is within the frontal region behind the hairline, and the top of the tree is located over the crown. Another common pattern following menopause is recession that is also common in men.

Ludwig developed a classification system for pattern hair loss in women, in which Stage I is described as thinning hair on the central scalp, Stage II is thinning hair and frontotemporal patches of scalp hair loss and Stage III shows male pattern hair loss at the frontal scalp to midscalp. Although it is rare, advanced hair loss in women is seen on occasion.
Women who have hair loss in the Ludwig’s pattern usually maintain a good hairline. The hair behind the hairline gets sparse. Hair loss due to hereditary causes can start to occur at any time from teenage to 40 years of age. It can also be triggered by events in a woman’s life, such as menopause, childbirth, a trauma or major operation.

Hair loss in women can occur with different patterns:

Gradual thinning throughout the top of the head behind the hairline (see Ludwig’s classification shown below).
Androgenetic alopecia, which follows the same patterns of male balding.
Angular alopecia in which hair is lost on the sides only.
Diffuse alopecia (DA) in which the hair thins throughout the entire scalp.

Ludwig Classification of Female Pattern Baldness

What Causes Hair Loss in Women?
Hereditary pattern hair loss, or androgenetic alopecia, is less common in women than in men. Early diagnosis of female pat-tern hair loss can be difficult because hair loss in women can be caused by many other factors, such as illness or hormonal changes. For this reason, a doctor or hair restoration specialist will ask for a medical history, possible contributing factors including pregnancies and onset of menopause and possibly a set of blood tests.

Female pattern hair loss is similar to male pattern hair loss in the fact that it is genetically inherited from either side of the family, not the old theory of blaming the mother’s side. It is more common to see a generalized diffuse type of female hair loss, but we also see a less common patterned distribution over the frontal and midscalp regions.

In female pattern hair loss, the cause of hair loss is similar to men with the major culprit involving hormones: The enzyme 5-α reductase reacts with testosterone producing dihydrotestosterone (DHT), which is the hormone that causes miniaturization (finer, shorter hairs) and ultimately the death of the follicle. Females produce testosterone (which belongs to a class of male hormones called androgens) in the ovaries and the adrenal glands.

Women also have the enzyme aromatase, which is responsible for the aromatization (formation) of androgens into estrogens. Estrogens (estrone and estradiol) compete with DHT at the follicle level. This action neutralizes or counteracts the deleterious action of DHT. Since women have higher levels of aromatase than men, especially at the hairline, this may explain why women typically retain an intact hairline.

Hair Texture: Diameter and Density
The texture of hair is a result of both the thickness of the individual strands and the density of hairs on the scalp. Scalp hair grows at about 0.6 – 1.25 cm per month, and will normally reduce in thickness and density with age. Hair in an individual person is at its thickest at the age of 20, and diminishes thereafter.

The thickness of hair ranges from fine to coarse, and varies between different ethnic groups and people. Fine hair has a diameter of about 50µm (microns) and because of its narrow size is most susceptible to breakage.
Medium hair has a thickness of 60-90µm and is the most common. Coarse hair is relatively strong with a thickness of 100µm or more.
The density of hair refers to the number of hairs on the scalp. As each follicle is in a continuous cycle of growth, degradation and resting, the number of hairs of a noticeable length will be less than the number of follicles. It must be remembered that 50-100 hairs are shed normally every day and 10%-15% of follicles will be in a resting stage at any one time.

On average there are 100,000 – 150,000 follicles on the scalp. If there are fewer than 90,000 hairs on the scalp, the hair density is considered thin. Closing your thumb and forefinger around your ponytail can make a rough estimate of hair thickness. If your fingers form a 1cm circle or smaller, your hair is thin. If they form a circle 2cm or larger, your hair is thick.

Ethnic hair types
There are three major types of ethnic hair: Asian, African and Caucasian. People of Asian descent will have a low density of hair, which remains straight along the length. The individual hairs are coarse and will give an appearance of thick hair. Ethnic African hair has a characteristic and irregular curling along the length, which gives high coverage and the appearance of high density, yet it is of fine diameter. Caucasian hair is between these two extremes and shows great variation. People with blonde hair have the highest number of follicles and those with red hair have the fewest, although they will have coarser individual hairs. Fine hair can be both a consequence and a predictor of thinning hair. Commonly hair will tend to become finer and finer before it is lost entirely.

Hair Transplantation for Women
One or more hair transplant procedures can result in considerable thickening of the hair. Women’s hair loss is less common than patterns of baldness in men. Most often women’s hair loss occurs either in the temple resulting in a “male shaped” hairline or the hair thins in a triangle pattern in the center of the frontal region. These hair loss conditions are most often repairable where there is sufficient donor supply on the back of the scalp. In addition, it is possible to create a feminine hairline, which is typically lower, straighter, and wider than a male’s hairline. Women’s hairlines seem to duplicate an adolescent or juvenile hairline seen in boys.

Hair Restoration Surgery for women is as successful as it is for men, although men uniformly have the opportunity to harvest more grafts over the donor region. Whereas men generally thin or bald over the frontal region, mid-scalp and crown. They maintain density over the occipital donor region (back of scalp over the neck) for their entire life. Many women will not only experience scalp hair thinning over the top of the scalp, but also experience thinning over the donor region.

Since hair transplantation is based on transplanting follicles that are scheduled to grow for the entire lifetime, we are limited in only harvesting follicles (grafts) we feel confident will not become sensitive to DHT and cease to grow in the future. For this reason, women may not have a sufficient number of donor grafts available to transplant the entire thinning area and achieve an acceptable cosmetic result. Most women whose hair loss falls in the Ludwig I or Ludwig II classification and have dense donor regions can expect a very good cosmetic result. Women who appear to resemble a Ludwig III are not good candidates for hair restoration surgery unless they are willing to concentrate on a smaller recipient area.

Since most women thin rather than bald, hair transplantation is more difficult than in men who are totally devoid of hair. Transplanting in thinning not balding areas raise the possibility of damaging adjacent follicles. Despite careful technique, there is the possibility of cutting or transecting surrounding hair, resulting in a less than optimal cosmetic result. Hair transplantation in women should only be performed by a very experienced hair restoration surgeon.

Above, before and after results FUT hair transplantation on woman in her late 50s with thinning hair.

Above, before and after left temple FUT hair transplantation in young, African-American Woman.

Above, same woman, before and after right temple.

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Hair Loss in Women

About Dr. Shelly A. Friedman