Hair loss is more common in women than we might imagine, with over 40% of women experiencing it in some form during their lives. It manifests differently than in men, requiring significant expertise in diagnosis and treatment.
Generally, women experience diffuse thinning in contrast to men, often with a “pattern” of hair loss affecting the back and sides. There is a decrease in follicular units with more than one hair, replaced by single-hair units. Women typically maintain hair at their frontal line, unlike men where loss typically starts with the recession of the first line.
It’s rare for women to lose all their hair, resulting in completely bald areas, as seen in men.
Androgenetic alopecia can be a symptom of hormonal disorders such as polycystic ovary syndrome (PCOS) and may be associated with conditions like insulin resistance or metabolic syndrome. Androgenetic alopecia may be accompanied by seborrhea.
Hair loss in women is often more gradual, accelerating after childbirth and during menopause. The shedding is more cyclical (periods of loss or stability) than in men, exacerbated by seasonal changes and more easily affected by hormonal changes, specific medical conditions, certain medications, and external factors.
To understand the different types of hair loss in women and their proper management, it is useful to categorize them into different groups:
Androgenetic Hair Loss
Similar to hair loss in men, androgenetic hair loss in women is a non-scarring alopecia primarily stemming from a combination of factors: genetics, hormones, and age. However, in women, in addition to 5-alpha reductase, testosterone, and dihydrotestosterone (DHT), which are also involved in male hair loss, the enzyme aromatase and the female hormones estrone and estradiol come into play.
Let’s delve into the process leading to the most common hair loss in women.
In both men and women, 5-alpha reductase reacts with testosterone to produce DHT, the hormone responsible for the miniaturization and gradual disappearance of affected hair follicles. This explains why both men and women experience hair loss. However, one reason women rarely lose all their hair as men do is that, naturally, women only have half the 5-alpha reductase compared to men.
Furthermore, in women, the enzyme aromatase is responsible for the formation of the female hormones, estrone, and estradiol, countering the action of DHT. Women have higher levels of aromatase than men, especially at the frontal hairline, allowing them to typically retain this line.
All of the above helps clarify why women generally have a poor response to 5-alpha reductase inhibitors (Finasteride and Dutasteride), which work by blocking the formation of DHT and are widely used to treat hair loss in men.
Androgenetic alopecia in women primarily manifests in three forms:
- Diffuse (generalized)
- Patterned (localized)
- Male pattern
Diffuse Hair Loss (Generalized)
This is the most common type of hair loss in women. It presents as a generalized thinning affecting all areas of the scalp. In this situation, a significant portion of the hair still exists but is finer than normal hair. The medical term for this type of thinning is “diffuse pattern alopecia.” These women have hair miniaturization that also affects the “donor area” and are generally not good candidates for a transplant.
This condition can be identified with trichoscopy, a diagnostic technique that analyzes the population of miniaturized hair in different areas of the scalp. Miniaturization is the process by which hairs lose length and thickness due to hormonal effects.
Hormonal evaluation is only necessary if the patient is also experiencing symptoms of hyperandrogenism: irregular menstrual periods, infertility, hirsutism, cystic acne, virilization, or galactorrhea.
Because diffuse hair loss can also be caused by conditions other than “hereditary baldness,” such as Telogen Effluvium, women experiencing hair loss should be evaluated by a physician with solid expertise in the field to avoid incorrect treatment, as diagnosis becomes more challenging.
Patterned Hair Loss (Localized)
Women with this type of alopecia have a pattern similar to that in men. In other words, they experience thinning on the top of their scalp with little or no hair loss on the sides and back, accentuating the frontal area, forming a triangular or “Christmas tree” shape with triangular hair loss in the fronto-vertical area.
Therefore, this baldness has a “pattern” characteristic (affects a specific area) and is not generalized.
Women with patterned hair loss can be excellent candidates for transplant surgery and experience the same benefits as seen in men. Unfortunately, this type of loss is the least common.
Female androgenetic alopecia is classified into three evolutionary stages corresponding to earlier manifestations according to the Ludwig Scale.
Male Pattern Hair Loss in Women
A third manifestation is a deep recession of the fronto-temporal hairline and true crown baldness, typically observed in men but occasionally occurring in women, although it is uncommon.
Localized Hair Loss
(Non-Androgenetic)
Localized hair loss can be subdivided into scarring and non-scarring.
Alopecia Areata is a genetic autoimmune disease characterized by non-scarring hair loss. It manifests with the sudden appearance of round patches of hair loss associated with normal skin and can be treated with local injections of corticosteroids and/or immunomodulators.
Scarring alopecias can be caused by various medical or dermatological conditions, such as lupus and lichen planus, or local radiation therapy, in addition to traumatic injuries, caustic substances, and burns. Hair loss from injuries and resolved medical issues is generally amenable to hair transplantation. Localized loss occurring around the hairline after facelift surgery can be permanent due to traction. Both conditions can be treated with hair transplantation. (see other types of alopecia)
MEDICAL CONDITIONS THAT CAN CAUSE DIFFUSE ALOPECIA IN WOMEN
MEDICATIONS THAT CAN CAUSE DIFFUSE HAIR LOSS IN WOMEN
Many times, we encounter patients experiencing hair shaft pathology, such as Trichorrhexis, leading to hair breakage. This condition is not related to follicular dysfunction but can cause a significant loss of hair mass, often confusing these women, and even some professionals, with an indeterminate type of alopecia. Correct diagnosis and treatment of this issue usually resolve the problem in a short time.
The lack of information often prompts many women suffering from alopecia to attempt self-treatment. Only after trying several unsuccessful treatments do they give up and seek professional help.
Since hair loss may not seem life-threatening, many doctors pay little attention to women’s complaints about hair loss, essentially telling their patients that “it’s not a big deal” and that “you’ll have to live with it.” These professionals may not realize that the psychological damage caused by hair loss and feeling unattractive can be as devastating as a severe illness, and, in fact, can take an emotional toll that directly affects physical health.
Hundreds of cosmetic products and “miracle treatments” are offered in the market, claiming to stop hair loss or regenerate hair. While some may help improve overall hair quality or provide a livelier appearance, it does not mean they address the root cause of the problem.
Hair loss that could have been temporary may become long-lasting or permanent as a result of misdiagnosis. The potential for such inaccurate diagnoses is perhaps the most frustrating aspect of hair loss in women.
