Understanding Female Pattern Hair Loss: Stages, Causes, and Treatments

Hair loss is a common concern for many, but it can be particularly distressing for women. Female pattern hair loss (FPHL), also known as female androgenetic alopecia, affects millions of women worldwide. It's essential to understand the stages, causes, and available treatments for this condition to manage it effectively.

The Hair Growth Cycle: A Foundation for Understanding Hair Loss

Like all biological entities, hair follows a cycle. Human hair grows in a continuous cyclic pattern of growth and rest, known as the hair growth cycle. This cycle consists of three phases:

1. Anagen (Growth Phase): This is the active growth phase, lasting between two and eight years, during which hair grows approximately one centimeter per month.
2. Catagen (Degradation Phase): A brief transition phase lasting two to four weeks, where the hair follicle degrades. During this phase, the hair shaft moves upward toward the skin's surface, and the dermal papilla begins to separate from the follicle.
3. Telogen (Resting Phase): This phase lasts for two to four months. During the telogen phase, the follicle rests for two or three months, and then the hair falls out. Shedding of the hair occurs only after the next growth cycle (anagen) begins and a new hair shaft begins to emerge. On average, 50-100 telogen hairs are shed every day. Not more than 10 percent of the follicles are in the resting phase (telogen) at any time.

A variety of factors can affect the hair growth cycle and cause temporary or permanent hair loss (alopecia) including medication, radiation, chemotherapy, exposure to chemicals, hormonal and nutritional factors, thyroid disease, generalized or local skin disease, and stress.

What is Female Pattern Baldness?

Female pattern baldness is a type of hair loss that affects women, causing hair loss on the scalp, and without treatment, the hair doesn’t grow back. Healthcare providers may refer to it as female pattern hair loss or androgenic alopecia.

Female pattern baldness causes the hair follicles to shrink gradually, leading to thinner and shorter hairs. Over time, these hairs stop growing. It doesn’t affect physical health but can impact psychosocial and psychological well-being. Studies show that over 65% of women experience some type of female hair loss, which can lead to decreased self-confidence and affect social interactions.

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Causes of Female Pattern Hair Loss

While there are various causes of female hair loss, the most common is androgenetic alopecia or female pattern hair loss. Similar to male pattern hair loss, both heredity and hormones seem to play major roles in female pattern hair loss. However, patterns of hair loss appear differently in women than in men.

Androgenetic alopecia (AGA) or “female pattern” hair loss is a type of hair loss manifested by diffuse thinning on all areas of the scalp. AGA results from male hormones that are typically present in small amounts in women called androgens. The male hormone dihydrotestosterone (DHT) causes certain hair follicles on the scalp to become shorter and shorter, eventually disappearing. Although heredity is involved in AGA, hormone activity can also play a role.

The essential feature of FPHL is the pattern of the hair loss. Women develop diffuse thinning over the mid-frontal scalp with relative sparing of the anterior hairline. Hair loss may begin at any age after the onset of adrenarche and may precede pubarche and menarche.

Role of Androgens

Androgens (testosterone, dihydrotestosterone) are the most important control factors of human hair growth. Androgens must be present for the growth of beard, axillary (underarm), and pubic hair. Growth of scalp hair is NOT androgen-dependent, but androgens are necessary for the development of male and female pattern hair loss.

The pathogenesis of MPHL involves activation of hair follicle cytoplasmic androgen receptors (AR). Both testosterone and dihydrotestosterone (DHT) activate the AR; however, DHT binds five times more avidly than testosterone and is thought to be the principle androgen involved in MPHL. Testosterone is converted into DHT by 5α-reductase, and DHT in turn is converted into estrogen by the cytochrome P450 enzyme aromatase.

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Other Potential Factors

While the role of androgens in the pathogenesis of MPHL has been clearly established, the role of androgens in FPHL is less clear. There are some women with FPHL who do not have elevated androgen levels, and other androgen-independent mechanisms are likely to be involved in the development of FPHL. This may explain why post-menopausal women respond to finasteride less well than men.

Increased hair shedding is common in the early stages of FPHL. When women present with increased hair shedding, but little or no reduction in hair volume over the mid-frontal scalp, various differential diagnoses should be considered, in particular acute and chronic telogen effluvium.

Stages of Female Pattern Hair Loss

Once the cause of the hair loss is determined, the next step in figuring out the best course of treatment is to evaluate the extent of the hair loss. Several scales measure the extent of female hair loss, but the two most common standards are the Ludwig Scale and the Savin Scale. Traditionally, FPHL severity has been graded using the Ludwig scale which divides the severity of hair density reduction over the crown into three grades. The Savin scale measures overall thinning of the crown scalp and consists of 8 crown density images reflecting a range from no hair loss to severe hair loss (Stages I-1, I-2, I-3, I-4, II-1, II-2, III, advanced).

Ludwig Classification

Clinicians use the Ludwig Classification to describe female pattern hair loss. This scale, developed by Dr. Erich Ludwig in 1977, categorizes hair loss into three main stages, each with subcategories:

• Type I (Early Hair Thinning): Minimal thinning that can be camouflaged with hair styling techniques. The first stage (I-1) shows a woman with a central part in her hair with no hair loss. This stage is characterised by a widening of the hair part along the central scalp. You might notice slightly less hair volume overall, but the hairline remains unaffected.
• Type II (Progressive Thinning): Characterized by decreased volume and noticeable widening of the mid-line part. During this stage, hair loss becomes more noticeable. The part widens further, and thinning progresses towards the crown of the head. The hair might feel thinner to the touch.
• Type III (Advanced Hair Loss): Full baldness (total denudation) within the area seen in Grades I and II. This stage represents the most severe level of hair loss. Significant thinning occurs across the scalp, with a noticeable reduction in overall hair density.

Sinclair Scale

More recently, a 5-point visual analogue scale (the Sinclair Scale) was developed, which assesses the degree of hair loss using the midline part.

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Savin Scale

The Savin scale measures overall thinning of the crown scalp and consists of 8 crown density images reflecting a range from no hair loss to severe hair loss (Stages I-1, I-2, I-3, I-4, II-1, II-2, III, advanced).

Other Stages

There are also five stages of female pattern baldness according to the Sinclair scale:

• Stage 1: Little or no hair loss.
• Stage 2: A slight gap appears in your center hair part.
• Stage 3: A wider gap is present in your center hair part, and there’s hair loss on either side of your part line.
• Stage 4: Bald spots appear toward the front of your hairline.
• Stage 5: Advanced hair loss.

Importance of Staging

The clinical assessment of the woman with hair loss should incorporate a thorough history including a detailed drug history as well as a general examination for features of hyperandrogenism. It is also useful to enquire whether the patient intends to become pregnant in the near future as antiandrogen drugs are potentially teratogenic. Not all patients need screening blood tests.

Diagnosis of Female Pattern Hair Loss

A clinician diagnoses female pattern hair loss by taking a medical history and examining the scalp. They will observe the pattern of hair loss, check for signs of inflammation or infection, and possibly order blood tests to investigate other possible causes of hair loss, including hyperthyroidism, hypothyroidism, and iron deficiency. Scalp biopsy is the best way to distinguish between CTE and FPHL. If a biopsy is required, the most information is gained from horizontal sectioning of the tissue and calculation of the terminal to vellus hair ratio. A ratio of <4:1 is considered diagnostic of FPHL while a ratio of >8:1 is considered diagnostic of CTE. Ratios of 5:1, 6:1, and 7:1 are considered indeterminate. Multiple scalp biopsies reduce the risk of an indeterminate result or of underestimating FPHL.

Treatment Options for Female Pattern Hair Loss

While there’s no guaranteed way to prevent hair loss entirely, maintaining a healthy lifestyle with a balanced diet, managing stress, and using gentle hair care practices can all contribute to overall hair health.

Without treatment, FPHL is a progressive condition; however, the rate of its progression is highly variable. All treatments need to be continued to maintain the effect. An initial therapeutic response often takes 12 or even 24 months.

Current management options are limited, and even in positive responders, there is a significant time delay before improvement becomes apparent. Regardless of which option is chosen, sufficient time should be spent counseling the patient.

Medications

Medications are the most common treatment for hair loss in women. The two main pharmacological options are antiandrogens and minoxidil. Both treatments need to be continued indefinitely to maintain a response.

• Minoxidil (Rogaine, generic versions): This drug was initially introduced as a treatment for high blood pressure, but people who took it noticed that they were growing hair in places where they had lost it. Research studies confirmed that minoxidil applied directly to the scalp could stimulate hair growth. As a result of the studies, the FDA originally approved over-the-counter 2% minoxidil to treat hair loss in women. While it can produce some new growth of fine hair in some - not all - women, it can't restore the full density of the lost hair. Usually 1 ml of minoxidil is applied twice daily to dry scalp with a dropper. This is left for 1 hour before shampooing or wetting of the hair is allowed to maximize medication absorption. Patients should be warned that in the initial 2-8 weeks, a temporary telogen effluvium may occur, which is self-limiting and subsides when subsequent anagen regrowth begins, and should not be a cause for treatment cessation. Common adverse effects of minoxidil include scalp irritation including dryness, scaling, itching, and/or redness. Specific to its use in FPHL, hypertrichosis may occur, primarily on the cheeks and forehead. If this occurs, it generally disappears within 4 months of ceasing the medication. Recently, it has been found that most cases (82%) of scalp irritation after use of topical minoxidil results from a contact dermatitis to propylene glycol, one of the vehicles of the solution, rather than the minoxidil itself.
• Anti-androgens: Androgens include testosterone and other "male" hormones, which can accelerate hair loss in women. Some women who don't respond to minoxidil may benefit from the addition of the diuretic drug spironolactone (Aldactone) for treatment of androgenic alopecia because this drug has anti-androgen properties. This medication is especially helpful for women with polycystic ovary syndrome (PCOS) because they tend to make excess androgens. Doctors will usually prescribe spironolactone together with an oral contraceptive for women of reproductive age. Possible side effects include dizziness, excess thirst, loss of appetite, weight gain, loss of libido, and fatigue. The use of all androgen-dependent medications to treat FPHL carries a risk of causing abnormalities in the genitalia of the male fetus. Thus, these medications are contraindicated in women who are pregnant, which leads many physicians to recommend that women start and remain on an oral contraceptive pill throughout their course of treatment with these medications. Finasteride works by inhibiting 5α-reductase II enzyme, which is responsible for catalyzing the conversion of testosterone to the much more active chemical 5 DHT. Thus, finasteride suppresses overall androgen activity by restricting total circulating androgen activity. Large scale studies on its efficacy are currently limited, with one large multicenter randomized placebo-controlled trial failing to find any change in hair growth or progression of hair loss with finasteride 1 mg/day in postmenopausal women with FPHL over a 1 year follow-up period. Finasteride is generally well tolerated. Cyproterone acetate inhibits gonadotropin-releasing hormone (GnRH) and blocks androgen receptors. Other uses include prostate cancer, hirsutism, and severe acne.

Other Treatments

• Iron supplements: Iron deficiency could be a cause of hair loss in some women. If you do have iron deficiency, you will need to take a supplement, and it may stop your hair loss.
• Hair transplantation: A procedure used to treat androgenic alopecia involves removing a strip of scalp from the back of the head and using it to fill in a bald patch. During this procedure, surgeons remove a narrow strip of scalp and divide it into hundreds of tiny grafts, each containing just a few hairs. Each graft is planted in a slit in the scalp created by a blade or needle in the area of missing hair. Hair grows naturally this way, in small clusters of one to four follicles, called follicular units. Not everyone with female pattern hair loss is a good candidate for hair transplantation, especially if hair loss is widespread and severe.
• PRP hair treatment: PRP hair treatment involves the use of nutrient-rich plasma drawn from your blood. Platelet-rich plasma is separated from the blood through centrifugation and injected into the trouble areas to promote hair growth and decrease hair loss. PRP treatment is found to be exceptionally effective on female pattern baldness and has been increasingly used as a treatment.
• Cosmetic camouflages: Cosmetic camouflages include colored hair sprays to cover thinning areas on the scalp, hair bulking fiber powder, and hair wigs.

Lifestyle Adjustments

• Diet: Lack of essential nutrients, especially iron (due to anaemia) and vitamin D and B (including B5, B6, and B7 or biotin), can affect hair health. Maintaining a healthy diet for your hair that is rich in vitamin A, vitamin D, omega-3 fatty acids, and zinc is extremely important.
• Stress Management: Telogen Effluvium is a condition where a sudden, temporary loss of hair occurs due to situational stress (illness, hormonal changes, physical or mental stress), causing a large number of hair follicles to enter the telogen (resting) phase of the hair growth cycle. This means the follicle is dormant and the hair shaft is not actively growing, resulting in diffuse thinning across the scalp.
• Hair Care: Women are generally more likely than men to frequently style and change their hair, which often involves the increased use of hair products and heat styling tools. Additionally, tight hairstyles such as braids, cornrows, or ponytails can contribute to a condition known as traction alopecia. This occurs when constant tension and pulling on the hair cause damage to the hair follicles, leading to hair loss, particularly in areas under the most strain.

Other Types of Hair Loss in Women

While androgenetic alopecia is the most common, women can experience other types of hair loss:

• Telogen Effluvium (TE): Typically catalyzed when the body goes through a traumatic event such as major surgery, childbirth, or suffers from malnutrition. Experience of trauma can cause hair follicles to transition from the “rest” phase (telogen) to a shedding phase resulting in hair loss. Other stressors include certain types of medication or environmental exposures.
• Anagen Effluvium: A form of hair loss that occurs when something inhibits the hair follicle’s metabolic activity. Commonly associated with chemotherapy, this type of effluvium hair loss affects hairs in the active or anagen phase.
• Traction Alopecia: Caused by hairstyles inflicting trauma on the hair follicles.
• Alopecia Areata: An autoimmune condition where the body’s immune system attacks healthy hair follicles, causing hair to fall out and preventing new hair from growing.
• Tinea Capitis: A fungal infection of the scalp that’s a common cause of hair loss in children.
• Cicatricial Alopecia: A rare type of hair loss in which inflammation destroys hair follicles and causes scar tissue to form in their place.

The Psychological Impact of Hair Loss

Hair loss in women often has a greater impact than hair loss does on men because it's less socially acceptable for them. Hair loss in women produces greater psychological distress than in men. In a 1993 Glamour magazine survey, over half of the women stated “if my hair looks good, I look attractive no matter what I’m wearing or how I look otherwise,” and “if my hair isn’t right, nothing else can make me feel that I look good”.

Women are more likely than men to have a lowered quality of life and to restrict social contacts as a result of hair loss. After the initial shock of diagnosis, most women adopt a variety of coping mechanisms. “Compensation” refers to efforts to offset the hair loss with other physical improvements such as greater attention to dress in order to create positive body images. “Concealment” of hair loss aims to avoid associated negative body-image feelings. Women may want to avoid the negative reactions from family, friends, and even strangers, and may wear hats or wigs to achieve this.

Seeking Help

If you notice unusual hair loss of any kind, it's important to see your primary care provider or a dermatologist to determine the cause and appropriate treatment. You may also want to ask your clinician for a referral to a therapist or support group to address emotional difficulties. Your first stop would be to see your general practitioner (GP) who can perform a medical workup to exclude other reasons for hair loss. Your GP can refer you to a dermatologist for further management of FPHL.

tags: #female #pattern #hair #loss #stages

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