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Hair Loss Process : How
women lose their hair |
 Alopecia
is a general term and can refer to hair loss from any cause. Indeed many
diseases can cause hair loss but most are quite rare. Only two are common:
alopecia areata which is due to the immune system attacking the hair follicles
and androgenic alopecia, which is hormonal.
Androgenic alopecia is extremely common. A reasonable estimate is 20% of women.
In some it is so mild as to escape notice but most affected women are only too
aware that it is happening. A common abbreviation is AGA. Sometimes it is
referred to as “androgenetic alopecia” to emphasize the genetic component but I
do not like this term because some women with AGA do not have it in their
family.
As the name implies, androgenic alopecia is due to the effect of androgens, the
family of hormones which includes testosterone. One effect of testosterone is to
inactivate hair follicles on the scalp. Oddly, it makes follicles on the face
and body more active. It’s not fair that the same hormone takes hair away from
where it is wanted and puts it where it is not. But this is the unfortunate
truth about what testosterone does to hair follicles. This same effect of
testosterone is what gives men less hair on the scalp and more on the body than
women.
As if this were not enough, testosterone also makes the skin more oily, which in
turn can trigger acne. Many women with AGA have only the alopecia but some also
have other unwanted effects of testosterone -- increased facial and body hair
and oily skin or acne. Many women with AGA have only the alopecia without any
other hormonal changes.
While androgens are often the cause of female alopecia, there is another
hormonal factor – estrogen. This is hardly surprising, considering that abundant
hair is clearly a female characteristic. In contrast to testosterone, estrogen
helps hair. It does this by lengthening the hair cycle so that each hair stays
on the head longer – resulting in thicker hair. This is the reason women’s hair
gets fuller during pregnancy, then sheds several weeks after the baby is born.
Estrogen deficiency alopecia generally starts some months before and or just
after menopause. Because estrogen levels start to fall before periods stop, this
form of alopecia can be the first sign of approaching menopause. This varies
though; sometimes the hair loss does begin until some time after menstruation
has ended. Not all women get noticeable alopecia after menopause but most have
at least mild thinning.
The alopecia due to low estrogen has the same pattern of distribution as that
due to testosterone and dermatologists generally fail to make a distinction.
Estrogen deficiency as a cause of hair loss has not found its way into medical
textbooks but this does not stop it from happening.
What androgenic alopecia looks like AGA is distinguished from other forms of
alopecia primarily by the pattern of hair loss on the scalp. For this reason, it
usually needs to be diagnosed by a physician experienced with female hair loss,
of whom there are unfortunately very few.
There is some individual variation of course, but AGA tends to affect the
temples, the crown and the vertex; the sides are least affected. Sometimes AGA
is said to be the female equivalent of male pattern baldness but this is only
partially accurate. Though female AGA is caused by testosterone, unlike male
pattern baldness, the front hair line is usually preserved. Nor does the top of
the scalp lose all hair as often happens to men.
Female AGA tends to be much milder than male hair loss but this is not much
consolation for the women who experience it. Hair loss is expected for men,
though we don’t like it, but is not supposed to happen to women.
Telogen effluvium (TE) This elegant-sounding term simply refers to an increased
rate of hair shedding and implies that the hair will eventually grow back. Some
dermatologists make a distinction between telogen effluvium and androgenic
alopecia. However the only way to tell if the hair will grow back is to wait and
see. In my experience, it usually does not and waiting many months simply delays
treatment. There are some situations however in which hair loss is common and
regrowth usual. These include childbirth, substantial weight loss (typically 30
or more pounds over a few months) and illness with high fever (but not a mild
case of flu). In those cases it may be reasonable to wait some months to see if
the hair grows back. Be careful though: most of the women I see who have been
told they have TE actually have AGA.
Alopecia areata is less common than androgenic alopecia. It occurs when the
immune system attacks the hair follicle. As the name alopecia areata implies,
hair is lost in discrete areas. There will be a patch or patches of shiny scalp
with no hair at all but the rest of the hair is unaffected. However it can
spread to other areas or sometimes involve the entire scalp (alopecia totalis)
or all the hair on the body (alopecia universalis). When only a small area is
affected, the hair usually grows back but then may fall out again.
Unfortunately, we have no way to predict which way things will go with alopecia
areata.
Areata is not caused by hormones but can be associated with underactivity of the
thyroid, which can also be damaged by the immune system. When areata first
appears, thyroid testing should be done and then about every one to two years
after that. Though treatment of the thyroid condition is important for overall
well being, it does not help with the hair loss, unfortunately.
A usual treatment for alopecia areata is injection of cortisone-like medications
into the scalp. Taking similar medications orally does not help in the long term
and can cause weight gain and other undesirable side effects. (Similar
medications are sometimes used for adrenal conditions but in much lower doses
which do not cause these side effects. These conditions should be managed by an
endocrinologist.) Treatment of areata is not always effective, unfortunately.
The medications which help androgenic alopecia do not help areata. Sometimes
both forms can occur together and then treatment for androgenic alopecia may be
appropriate. |
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