Although a large percentage of the balding and thinning population in this country are women, they are much less likely to seek help from a hair transplant surgeon than are men. True, women’s hair loss is less liable to benefit from transplantation then is men’s, but large numbers of female patients who could greatly benefit from surgical hair restoration are unaware of this option.
Indeed, many women with hair loss are excellent candidates for hair transplantation. The important understanding is that women’s hair loss occurs in different patterns than men’s, and therefore must be generally treated in a different manner. Moreover, hair loss in women is much more likely to reflect an underlying illness; we must be sure a proper medical workup is done before recommending any medical or surgical alternatives.
Psycho-emotional and Social Issues
As emotionally devastating as hair loss can be for some men, the effect often pales compared to alopecia in women. In men, baldness is seen as a less than desirable, but still sometimes expected and normal part of the male life experience (although to the man who is balding, it may seem like the end of the world). On the other hand, when hair loss occurs in women, at any age, the resulting feelings and emotions may be overwhelming. Balding is perceived as a strictly male occurrence, and unacceptable in females. For even the elderly woman, this can threaten her very sense of self, of her femininity and sexuality, and of her place in family and society.
Our culture strongly identifies femininity with a thick, lustrous head of hair. From Rapunzel to the Breck Girl, images of full bodied, shining hair are synonymous with female attributes, sexuality, desirability and vigor. Thinning, dry, lusterless hair is identified with illness, old age, and poverty. In truth, there are a number of systemic diseases that may cause hair loss in women, much more so than is the case with men. It seems that the hair follicles of women are more sensitive to certain stressors (sources of stress) than are those of men; thus, we are more likely to see widespread hair loss in females, rather than the typical regional balding patterns of males. Let us look for a moment at some of the causes and varieties of female hair loss.
Causative Factors in Women’s Hair Loss
Just as in men, women’s hair loss may involve genetic and hormonal factors. As we discussed in previous sections, the three elements at play in androgenetic alopecia are androgens (male hormones), genetics (a predisposition), and the passage of time (aging). Although the loss patterns we observe in women tend to be different than in men, the mechanisms are similar. Because women have different levels of certain enzymes in the follicles in various areas of the scalp, they may lose hair in quite distinct and different ways. For example, women very often will retain the frontal hairline that is so commonly lost in men, but have widespread miniaturization and thinning on the top and vertex. This may in part be due to women’s low hairline levels of 5-alpha-reductase, which is the enzyme that converts testosterone into DHT.
Also, women have fewer androgen receptors on the frontal hair follicles; therefore, they are less susceptible to the effects of the DHT that is present. Finally, the enzyme aromatase is found in much higher concentrations in women’s hairlines; this important enzyme converts testosterone to estrogens (just as 5-alpha-reductase converts it to DHA), and estrogens are not likely to contribute to hair loss.
Another distinguishing characteristic is that women have a tendency to have more widespread hair loss than men. In addition, females loss is often more gradual, whereas men may begin to rapidly lose hair in their late ‘teens or early twenties. Despite these statements, it is significant that men may lose hair in a predominantly “female” pattern, just as women may experience alopecia in what is considered a typically “male” fashion. We will examine these patterns more closely in the next section.
Systemic disease (affecting the entire system) and certain medications can also lead to hair loss in women, and this is notably more common than in men, probably in part due to the aforementioned sensitivity of female follicles to stress. Some of the disease states that may affect female hair loss include: thyroid disease, anemia, endocrine (hormonal) disorders leading to elevated levels of androgens (ovarian cysts or tumors, adrenal or pituitary disease), and connective tissue diseases (lupus, dermatomyositis). In addition, various stressors, such as physical or emotional trauma, surgery, childbirth, general anesthesia, or extreme diets may precipitate differing degrees of hair loss. In some cases, the hair loss is reversible when the disease state is treated, or when the trauma or stress has resolved. However, it may take a year or more for an acute effluvium (hair shedding) to resolve to the point that the cosmetic deficiency is overcome.
This last point deserves elaboration, in terms of the actual process of hair transplantation. When women undergo surgical hair restoration, they are more likely to experience “shock loss” or telogen effluvium. Also, women’s hairstyles tend to be longer than men’s, especially today. Therefore, it may require more time for growth of new grafts to “catch up” with existing hair, so that a cosmetic difference can be appreciated. These two factors make it crucial that the education process of the patient is complete and well understood, so that discouragement and dissatisfaction are less likely during what may be a prolonged “interim period”.
Medications known to cause alopecia include certain birth control pills, the blood thinner Coumadin, thyroid hormone, some blood pressure medicines, corticosteroids, high-dose vitamin A, and many drugs of abuse (amphetamine, cocaine, narcotics). It is vitally important for any woman experiencing hair loss to discuss her medical history, in detail, and any drugs or medications she is using. If there is a treatable disease, or a medication that may be discontinued, hair growth may resume. Although significant time may pass after treating the illness or stopping the drug before hair re-growth occurs, it is important to establish a diagnosis before ever considering surgical hair restoration.
A third general cause of hair loss in women is known as “traction alopecia”. This name comes from the precipitating factor of constant traction, or pulling, tugging or mechanical stress on the hair. It is commonly seen in this country among African-Americans due to the fashion of wearing the hair in tight braids, pigtails, or cornrows. This may also occur with the wearing of hair weaves and other “hair systems”. This variety of hair loss is often permanent, yet very amenable to treatment with transplantation. In addition, a specialized type of traction alopecia is termed “trichotillomania”, which is a form of obsessive-compulsive disorder in which hair loss is the result of constant hair twirling, tugging, and actual pulling out of the hair. Hair transplantation is also very effective in these cases, but only after psychotherapy and antidepressant medications have the condition under prolonged control. Otherwise, the transplanted hair may be subject to the same fate as the hair it replaced!
Scarring from trauma (accidental, radiation, burns) or surgery is another common cause of alopecia in women. Burns or surgery to the head and scalp are treatable with follicular unit transplantation in many cases. The residual scarring after facelifts or brow lifts often leave women with hairlines that are less than ideal, especially around the temples and ears. These scars can be transplanted, returning the soft, feathery hairline, and achieving a more natural and aesthetically pleasing state.
Finally, some of the non-scarring localized alopecias may occur. Alopecia areata is typical of these types. It is characterized by sudden loss of hair in patches on the scalp, in which the skin is normal. This type of hair loss may be successfully treated with injections of cortisone-like drugs.
Patterns of Women’s Hair Loss
Androgenetic hair loss occurs more frequently in women than any other type of hair loss. However the pattern is more often of the Ludwig variety (figure 1) than of the typical male Norwood type. In the Ludwig classification, the frontal hairline is preserved, and the thinning is usually centrally located, running from front to back. In the case of Grade I or II balding, transplantation may be quite successful in adding density; women’s styling options are more varied than men’s, and they may obtain excellent coverage from artistically applied grafting.
In fact, diffuse hair loss has been classified into two subcategories: Diffuse Patterned Alopecia (DPA) and Diffuse Un-Patterned Alopecia (DUPA). These are both felt to be variants on Androgenetic Alopecia, and may occur in males as well. The difference between the two may have great significance to the hair transplant surgeon.
DPA is quite similar to typical Norwood type “male” pattern baldness, except that the affected areas become very thin, but not completely bald. The donor area is spared, and, because of this, the patient may be a candidate for transplantation. On the other hand, DUPA essentially affects the entire scalp, including, of course, the donor area; this would preclude using unstable donor zone hair for grafting. In circumstances such as these, the patient, regrettably, must be counseled about hair systems, wigs, camouflages, and other non-surgical methods of disguising the alopecia. Transplanting a patient with an unstable donor zone, regardless of their desires, amounts to the unethical practice of medicine.
So we see now that a large percentage of the balding or thinning population, that is, women, are unaware or ignorant of some of the options that await them in their struggle with hair loss. As we have shown, there are more possible etiologies (causes) of balding in women than in men; the reversible ones must be ruled out. Also, the hair, like the skin as a whole, may be a “window” to the internal health of many women, and deserves due attention. Various laboratory and blood tests are available to help with establishing a diagnosis, as are specialist consults if necessary. When an identification of the cause is determined, the patient and the hair restoration specialist may go forward in deciding the best course of action for the specific problem at hand.