Hair Loss in Women
Understanding the Root Causes of Hair Loss in Women
Thinning hair is generally thought of as a problem that men experience. To varying degrees, we tend to expect men to lose hair as they age. For women, however, it’s a different story. Women are often stereotyped as being hair-obsessed, whether it’s style, color, or simply using lots of tools and products. That makes the situation even more difficult for the women who make up an estimated 40% of Americans suffering from hair loss. While men might choose to just shave their heads or wear hats whenever possible, women don’t generally view these as options. For many women, hair loss takes an emotional toll.
There are many different causes of hair loss. People with a full head of hair have literally about a million strands, and normally shed 50-100 hairs per day. Each hair generally grows for 2-3 years, then will “rest” for 3-4 months. At the end of that period, the hair will fall out, and a new strand will start the cycle over again. When more hair falls out than grows back, you’ll start to see hair loss. In some cases, the amount of hair falling out becomes greater than the amount growing in because of a specific event (for example, pregnancy or taking certain medications). When that’s the issue, hair loss will resolve on its own. Other causes of hair loss can be much more difficult to deal with; while not all are progressive, the lost hair will not come back at a later point. Keep reading to learn more about some of the most common causes of hair loss in women, and how they can be treated.
Female Pattern Baldness
Androgenic alopecia—also referred to as male baldness—is the most common cause of hair loss. Though we’ve known for a long time that hormones cause this form of alopecia, it’s only relatively recently that physicians have come to understand that the problem is not testosterone but dihydrotestosterone (DHT). DHT is a derivative of testosterone, but it’s not exactly the same. Testosterone becomes DHT via an enzyme called 5-alpha reductase, which is found in the oil glands of your hair follicles. When it’s created, DHT turns on its creator, shrinking the hair follicles. This makes hair that does grow from that follicle finer and weaker, until the DHT shrinks the follicle so much that hair will no longer grow from it.
Men have higher testosterone levels than women, so it’s no surprise that they also have more DHT and thus hair loss is more common. But many women do experience hair loss. An estimated 20% of women experience hair loss prior to menopause. Due to the hormonal shifts that accompany menopause, that number doubles to 40% for older women. When levels of estrogen are lowered—as occurs during menopause—even though testosterone levels don’t rise, it still means that testosterone is now a greater proportion of your hormones. This hormonal imbalance can trigger hair loss, even when the change in hormone levels is relatively minor.
Female pattern baldness does tend to be different in appearance from male pattern baldness, even though both are androgenic alopecia. The hairline—which is often the first place where men notice hair loss—does not tend to change. Instead, women tend to experience thinning that begins at the crown of the head, with hair becoming sparser and the scalp growing more visible. Women who are experiencing androgenic alopecia may also notice other changes that are related to having a greater proportion of testosterone. This can include oily skin, acne, and hirsutism (increased hair on the face and body). It’s worth noting that all of these symptoms, including androgenic alopecia, can also be indicative of polycystic ovary syndrome (PCOS). Women who are premenopausal and experiencing these symptoms may want to be checked for PCOS.
Estrogen-related Hair Loss
Though it’s less common than androgenic alopecia, some women who experience hair loss following menopause are seeing the effects not of the increased proportion of testosterone but of the decreased proportion of estrogen. Estrogen is a hair-friendly hormone. It helps hair grow more quickly and stay in the resting phase longer (that’s why pregnant women often have thicker, fuller hair). When estrogen levels fall, hair growth slows and hair falls out more quickly. It’s been noted that this type of change in hair growth can be one of the first signs that menopause is approaching. Alopecia caused by estrogen deficiency tends to look different than androgenic alopecia, with hair loss starting at the center of the head and spreading outward. The Ludwig scale (shown in the image below) is often used to delineate the different severities of estrogen-related hair loss.
Given how strongly hormone levels are related to hair growth, it shouldn’t be too surprising that hormonal birth control (like the pill, the patch, or the ring) can impact your hair. This can happen sometimes when synthetic estrogen used in the OCP blocks our own natural estrogen. With less functioning estrogen, it creates a pseudomenopausal state that can cause hair to weaken. Birth control can also deplete certain B vitamins and other vitamins that are important for hair growth. Though hair loss related to birth control is less likely to be as noticeable as postmenopausal hair loss, women who have a family history of androgenic alopecia may want to consult their physician to choose a type of hormonal birth control with a low androgen index. Another option is to choose a form of birth control that’s non-hormonal to avoid altering levels of estrogen or testosterone.
Stress or Trauma
Different kinds of stressful events can cause hair loss that’s sudden and dramatic. Telogen effluvium is a type of hair loss that occurs when your body experiences a major change or stress, including childbirth, substantial weight loss, or a serious illness. This can cause as much as 90% of your hair that’s in the growing or resting faces to abruptly shift to the shedding phase. Women experiencing telogen effluvium can easily lose handfuls of hair at a time. The biggest difference between telogen effluvium and androgenic alopecia are its sudden, rather than gradual, onset and that when the stress has passed, the hair will grow back.
Telogen effluvium is similar to, but not the same as, the hair loss that cancer patients experience when they undergo chemotherapy. Chemo-related hair loss is caused by anagen effluvium, which impacts the cells in the hair follicle. Like cancer cells, the cells that create hair divide rapidly. This means that chemotherapy affects not only the cancer cells, but also hair follicle cells. Hair becomes narrower and thinner before falling out. That narrowing of the hair shaft is not seen with telogen effluvium.
Putting physical stress directly on the hair follicles can also cause hair loss. This is called traction alopecia, and because it’s generally related to styling, hair will generally regrow if it’s noticed quickly enough. Styles like tight ponytails, braids, cornrows, and hair extensions can pull at hair enough to damage the follicle and inhibit regrowth. Processes that weaken hair, like bleaching and heat styling, can also cause hair loss. If you’re worried about hair loss for other reasons, going easy on styling can give you one less worry. Opt for a wide-toothed comb rather than a brush, and avoid pulling on your hair. If you’ve got tangles or knots, use a leave-in conditioner or detangler to help sort out your strands.
Last, many women experience more hair loss than normal—though not enough to be considered telogen effluvium—due to day-to-day stress. When stress levels are high, your body stays in “fight or flight” mode. That means your levels of cortisol (aka the stress hormone) stay elevated, throwing off many of the body’s systems including hair growth. Elevated cortisol can block estrogen production and impede proper thyroid function; both of these hormones can impact hair growth.
In addition to shedding more hair than normal, women who have high levels of everyday stress can experience issues with glucose metabolism, blood pressure, immune function, and inflammation. Noticing that you are losing more hair than normal when you’re brushing or styling can be an early warning that your stress levels are too high.Last, many women experience more hair loss than normal—though not enough to be considered telogen effluvium—due to day-to-day stress. When stress levels are high, your body stays in “fight or flight” mode. That means your levels of cortisol (aka the stress hormone) stay elevated, throwing off many of the body’s systems including hair growth. Elevated cortisol can block estrogen production and impede proper thyroid function; both of these hormones can impact hair growth. In addition to shedding more hair than normal, women who have high levels of everyday stress can experience issues with glucose metabolism, blood pressure, immune function, and inflammation. Noticing that you are losing more hair than normal when you’re brushing or styling can be an early warning that your stress levels are too high.
It should be clear by now that your body’s different hormones can have a surprisingly large impact on your hair. There’s a natural decline in thyroid hormones as we age. It is not uncommon for this to cause thinning hair, because of the thyroid hormone’s important impact on blood flow throughout the body. Blood flow controls the amount of oxygen and nutrients that are delivered to the hair follicles. When the thyroid is not working properly, the flow of blood and oxygen to the follicles is impaired, and they’re also less able to utilize nutrients. That means that over time, hair growth will slow and hair will become thinner.
Problems with thyroid function can happen at any age. An unhealthy diet and poor nutrition can lead to the depletion of vitamins such as iodine, Vitamin B6, Vitamin 12, Vitamin D, magnesium, selenium, iron, and zinc (among others). This can affect how the body converts the predominant inactive stored thyroid hormone to the active thyroid hormone. This inefficiency represents a pseudo-hypo thyroid state. Unfortunately, when this occurs it is common for patients to get tested for thyroid issues and have normal lab values. Only additional testing beyond the traditional testing will help detect this subtle difference—since it will appear you have enough thyroid hormone, a basic test won’t show that too much of it is inactive. Some clinical signs can point to this problem. One particularly common symptom is the complaint of cold hands and/or feet, which is most often caused by either low thyroid levels or a dysfunctional thyroid and should prompt testing of the thyroid. In addition, unexplained high cholesterol, fatigue, or weight gain can be signs of a thyroid problem.
Hashimoto’s is another thyroid problem seen in pre-menopausal women. This autoimmune disease causes the body to attack the thyroid, causing a slow destruction of the thyroid gland and requiring an increasing amount of thyroid supplementation. This kind of self-destruction should never happen, but when it does it often signals an immune system gone mad. Based on his clinical experience, Dr. Tang truly believes that in most instances this type of autoimmune illness is caused by food intolerances that repeatedly trigger the immune system to the point where it starts to attack itself. More often than not, patients are unaware of their food intolerances or refuse to believe that the symptoms they experience are related to diet. However, without addressing food intolerances, the thyroid problem will continue to worsen, as will symptoms like hair loss.
Any patient who gets diagnosed with hypothyroidism at early age should be tested for Hashimoto’s. It is important to diagnose this particular autoimmune disease because the dietary habits have to be changed in order to prevent the body’s ongoing onslaught against the thyroid and the need to constantly supplement with thyroid hormones. There are thyroid antibodies that can be checked to look for this kind of illness, but unfortunately most doctors don’t check for them. It’s also important to note that a negative result does not rule out Hashimoto’s, because the tests give false negatives in about 30-40% of cases. The discovery of an autoimmune process such as Hashimoto’s should alert the patient that he or she has an increased risk of having or developing another autoimmune disease such as Lupus, Multiple Sclerosis, or Rheumatoid Arthritis. Fortunately, thyroid imbalances are often highly treatable, and can be diagnosed via hormonal testing.
People often say “you are what you eat,” and with your hair that’s literally true. Your hair is made up of protein, and a diet that’s lacking in protein can leave you with thinner, weaker hair. If you eat a vegetarian or vegan diet, it’s important to find sources of protein or to supplement properly to ensure that you are not experiencing any nutritional deficiencies.
It is very common for women to develop iron deficiency due to the menstrual cycle. It can be also seen in vegans and vegetarians who don’t eat meat or fish. Patients who have various food intolerances are also at risk of iron deficiency, because even if they do eat meat, their bodies do not efficiently absorb iron. When iron is low, it can directly affect the thyroid function (discussed above). Iron is found in organ meats, especially liver. It’s also found in oysters, mussels, and clams as well as spinach, spirulina, and lentils.
Biotin is another nutrient that can affect hair growth. Biotin is another name for the water-soluble B vitamin known as B7. Biotin helps cellular enzymes produce vital amino acids that are essential for daily function. It aids in producing keratin, a protein that is a key component of healthy hair and nails (brittle fingernails are one indicator of biotin deficiency). Biotin can be found in meat, fish such as salmon and tuna, nuts like almonds, brown rice, mushrooms, avocado, oats, whole grains, and dairy foods such as cheese and yogurt (though use caution if you have gluten or dairy sensitivity). When there is a true deficiency, patients who supplement with find that their hair grows in faster, stronger, and thicker, and that their nails grow more quickly and are less prone to breakage. Dr. Tang recommends supplementing with silica in addition to biotin, because silica can also boost keratin and collagen production.
Another nutrient that’s vital to hair growth is Vitamin D. We get Vitamin D from sunlight, and our bodies can also produce Vitamin D with cholesterol. (That’s why we’re often told that yes, you need “good cholesterol.”) Omega-3 fatty acids can be helpful on both counts. These produce good cholesterol and remove excess cholesterol, keeping cholesterol levels in check and allowing the body to produce Vitamin D. Keeping fish in your diet, or taking an omega-3 supplement like cod liver oil, good quality krill oil, or fish oil can help ensure you’re getting this vitamin.
Zinc gets much less attention, but it impacts over 200 functions in your body including hair growth because zinc is vital to cellular reproduction, growth, and repair. Zinc deficiency can cause excessive hair growth and causes the hair to look duller. It is found in oysters, pumpkin seeds, eggs, pecans, and cucumber. Zinc deficiency is often seen in patients who have problems with gut absorption that stem from food intolerances.
Treatments for Hair Loss
To determine what treatment will address your hair loss, it is important to know the cause. Everyone’s reason for hair loss is unique to the individual. That’s why when Dr. Tang talks with a patient about hair loss concerns, he covers many potential causes, including hormones, nutrients, stress, inflammation, auto-immune, and exposure to toxins and heavy metals. Checking your blood count and iron levels, along with a complete thyroid panel, different vitamin levels, measuring total testosterone, free testosterone, DHT, estrogen, progesterone, cortisol, and DHEA-S levels, also helps to unravel the possible causes.
If it looks like the cause could be PCOS or a thyroid issue, it’s important to do additional testing. Looking at estrogen and progesterone levels, inflammatory markers, and insulin as well as assessing other symptoms, can help determine whether hair loss is related to PCOS. A basic thyroid test may not provide enough information to determine whether your body is properly using thyroid hormones. A complete thyroid panel including tests for TSH, free T3, free T4, reverse T3, and thyroid antibodies can provide a better understanding on the impact of thyroid to your hair loss.
Hair loss caused by hormonal changes may be alleviated somewhat by treatment with bioidentical hormones. If patients are hormone deficient or imbalanced, Dr. Tang will go over which hormones are needed or will help balance the hormones naturally if possible.
Rejuvé also offers numerous other options for reducing hair loss and for encouraging the growth of strong, healthy hair. We offer medical grade products that include higher strength Minoxidil (more potent that OTC Rogaine) to maximize blood flow to the scalp and other products that have vitamins like Biotin, Vitamin E, and DHT blockers like Saw Palmetto to help grow the hair topically. Other available treatments that you can use at home include Viviscal Professional products, Nutrafol, Collagen, Alpha Varin, and Formula 82M.
Hair loss can also be addressed with minimally invasive treatments. Regenerative therapies including ACell and PRP (platelet-rich plasma) encourage the body to generate new cells. Injected into the scalp, these can help restore hair follicles that had become miniaturized due to hormonal shifts. A different option is the Laser Hat, which uses a nondescript black baseball-style hat to deliver low-level laser light energy directly to the scalp. The laser helps encourage circulation, support cell metabolism, and increase ATP production, which is the energy needed to keep hair follicles healthy.
If you are experiencing thinning hair or hair loss, you don’t have to simply “live with it.” To understand hair loss in women and want to know your treatment options near you please call Rejuvé at 408-740-5320 to set up a one-on-one consultation with Dr. Tang or you can contact the office here. Dr. Tang is a hair loss MD who specializes in alopecia or hair loss and will individualize a treatment plan to help you. He is the medical director of Rejuvé, an Anti-aging and hair loss clinic, which serves the San Jose Bay Area as far as San Francisco, Oakland, Santa Cruz, Palo Alto, Monterrey, and the local communities of Saratoga, Los Gatos, Campbell, Cupertino, Los Altos, Mountain View, and Morgan Hill.