Hair Loss & Restoration in Women

Courtesy of International Society of Hair Restoration Surgery

A man may expect to lose hair as he gets older, especially if his father, uncles, or other near relatives had male-pattern baldness. A woman does not generally expect to lose hair even if there is a history of hair loss in male or female relatives. In the United States, at least, there has been a general belief that thinning hair and baldness is a “male thing.”

A woman also usually feels she must have a full head of hair to meet societal expectations. Thinning hair is acceptable only when a woman is very old.

Societal expectation run counter to reality, however. The fact is, many women do experience hair loss at young to middle age and the incidence of the most common type of female hair loss (female androgenetic alopecia) seems to be increasing [Norwood OT. Incidence of female androgenetic alopecia (female pattern baldness). Dermatol Surg 2001; 27:53-54.].

Many women today recognize the reality of hair loss and choose to do something about it by seeking hair restoration treatment or procedures. In the hands of a physician specialist in hair transplantation, most hair loss in women can be successfully treated.

What Causes Hair Loss in Women?

The most common type of hair loss in women is female androgenetic alopecia (female pattern baldness). It occurs in about 20% of American women overall. In one study of 1,008 Caucasian women, female androgenetic alopecia was found in 3% of women aged 20-29 years, 16-17% of women aged 30-49 years, 23-25% of women aged 50-69 years, 28% of women aged 70-79 years, and 32% of women aged 80-89 years. [Norwood OT. Incidence of female androgenetic alopecia (female pattern baldness). Dermatol Surg 2001; 27:53-54.]. The statistics reflect the increased incidence of female androgenetic alopecia during and after menopause. See About hair loss for more information.

The underlying cause of female androgenetic alopecia is believed to be related to production of androgenetic (male) hormones and the effect of androgenetic hormones on the hair follicle—the same underlying cause responsible for male androgenetic alopecia (male pattern baldness). The pattern of hair loss in female androgenetic alopecia has some distinctive features that differentiate it from male-pattern hair loss. In general, there are three patterns of hair loss in female androgenetic alopecia:

• Grade I: Thinning hair on the central scalp (top of the head).
• Grade II: Thinning hair and patches of greater scalp hair loss.
• Grade III: Male-pattern alopecia with hair loss at the front of the scalp to mid-scalp. However, it is very rare to see complete male-pattern “cue-ball” baldness in a woman.

Other causes of hair loss in women include scalp scarring from injury or an underlying disease, traction alopecia due to injury from tight braiding or corn-rowing of hair, and trichotillomania (compulsive hair plucking). See About hair loss for detailed information on these causes of hair loss.

Consultation with a Hair Restoration Doctor

A woman who is experiencing hair loss should consider consulting a hair restoration doctor. The consultation has both medical and esthetic aspects.

Medical

The focus of the medical examination is the reason for hair loss. In a healthy woman the most common reason for hair loss is female androgenetic alopecia in a Grade I, II or III pattern as described earlier. If the patient’s medical history and physical examination indicate no underlying medical conditions, and the hair-loss pattern is clearly that of female androgenetic alopecia, no further tests may be necessary. However, if the hair-loss pattern (1) is not clearly that of female androgenetic alopecia, or (2) suggests the possibility of an underlying medical condition, further medical tests and inquiry into personal and family medical history may be indicated. A scalp biopsy can be helpful in establishing a reason for hair loss when the reason is not immediately apparent.

While the primary reason for the medical examination is to determine the reason for hair loss, the examination may occasionally result in diagnosis of a previously unsuspected underlying disease. Hair loss can be a symptom of certain autoimmune diseases and diseases that cause overproduction of androgenic (male) hormones. An underlying disease does not necessarily preclude hair restoration. However, it may be necessary to treat the underlying condition before hair restoration can proceed.

Esthetic

The rationale for hair restoration is primarily esthetic—how a woman feels about her appearance and how she wants others to perceive her. The esthetic consultation with the physician hair restoration specialist is every bit as important as determining the reason for hair loss. The patient has esthetic goals that she hopes hair restoration can achieve. The physician helps the patient refine her goals within the context of what surgical and/or nonsurgical hair restoration can accomplish. Many questions can be raised and discussed in the esthetic consultation:

• What hair styles has the patient been using to minimize the appearance of thinning hair?
• What hair styles would the patient hope to use after hair restoration?
• Would the patient change her hair style, curl, color, etc., to get the most out of hair restoration?
• Does the patient want a “luxurious head of hair” that might require procedures such as hair weaving or hair extenders? Does the patient want to be able to swim and/or exercise heavily without worrying about her hair?
• What can hair transplantation accomplish and is transplantation an option for the patient?
• If transplantation is not an option because of scalp scarring or underlying disease, what options for hair restoration can be considered?

Results of the medical and esthetic consultation are the primary considerations that guide the selection of a surgical or non-surgical hair restoration treatment appropriate to the patient’s needs.

Treatment of Female Hair Loss

Hair restoration treatments for women are primarily surgical, or treatments such as hair weaving or extending. Medical treatments for hair loss are largely directed at male androgenetic alopecia (See Nonsurgical hair loss treatment options for more information). A surgical treatment for female androgenetic alopecia may occasionally be combined with finasteride or minoxidil, the two products approved by the Food and Drug Administration (FDA) for non-surgical treatment of androgenetic alopecia. The physician hair restoration specialist may be able to determine whether the patient’s alopecia would be responsive to one of the FDA-approved drugs.

Hair Transplantation in Women

Hair loss occurs in women as well as in men, and increasing numbers of women seek medical or surgical treatment for thinning hair. The time is long past when women were unwilling to recognize their hair loss, or accept it as an inevitable consequence of aging.

Hair transplantation is a hair-loss treatment option chosen by many women whose loss of hair has a hereditary basis-the type known as female pattern hair loss. Like male pattern hair loss, female pattern hair loss is genetic in origin and “runs in the family”. It is the most common form of permanent hair loss in women. See female hair loss to read more about reasons for hair loss in women).

Be Certain About the Cause of Hair Loss

No treatment for a woman\’s hair loss should be undertaken until the cause and permanence of her hair loss is diagnosed with certainty. While hereditary female pattern hair loss is the most common cause of permanent loss of hair in women, there are other causes of both permanent and temporary hair loss that should be ruled out before hair transplantation is undertaken.

Hair transplantation is not an option for treatment of temporary hair loss. Temporary hair loss should never be treated by hair transplantation or other surgical intervention.

Hair transplantation may be a treatment option for some non-pattern causes of permanent hair loss such as physical trauma to the scalp, but female pattern hair loss is the most frequent indication for hair transplantation in women. No treatment should be undertaken until the patient thoroughly understands the rationale for treatment.

What Causes Hair Loss in Women?

Androgenetic alopecia-inherited pattern hair loss-is the most common cause of permanent hair loss in women as it is in men. Female pattern androgenetic alopecia usually occurs as diffuse thinning of hair rather than the frank baldness often seen in men. However, patterns in hair loss vary greatly in women and every case of hair loss in women should be considered for individual diagnosis. Correctly diagnosed hair loss can usually be treated medically or surgically.

Other common causes of hair loss in women include:

• Alopecia areata-patchy loss of hair from the scalp and sometimes eyebrows or other hair-bearing areas of the body; thought to be due to an autoimmune disorder. Hair loss can be episodic and recurrent.
• Traction alopecia-hair loss associated with consistent traction pressure on hair follicles, as may occur with tight braiding or corn-rowing of hair.
• Trichotillomania-compulsive hair plucking, believed sometimes associated with emotional stress or a psychological disorder.
• Telogen effluvium-unusually accelerated hair loss that may have hormonal, nutritional, drug-associated or stress-associated causes.
• Loose-anagen syndrome-a condition in which scalp hair is easily pulled out by normal combing or brushing; more common in fair-haired individuals.
• Triangular alopecia-due to unknown cause, hair is lost from areas around the temples.
• Scarring alopecia-caused when physical trauma or burns damage scalp hair follicles. Traction alopecia can lead to scarring alopecia.

Remember that most female hair loss can be treated medically or surgically, but successful treatment requires correct diagnosis by a physician hair restoration specialist.

For more detailed information on causes of female hair loss, see female hair loss.

As noted in the discussion in female hair loss, hair loss in women can sometimes have an underlying hormonal or dermatologic cause, or be associated with severe emotional or physical stress. When such an underlying cause is suspected, a physician hair restoration specialist will refer the woman to an appropriate medical specialist for further examination and diagnosis. Hair loss can be a first sign or symptom of an underlying medical condition.

Appropriate treatment of an underlying medical condition may resolve the problem of hair loss, and no treatment for hair loss will be indicated. Some causes of temporary hair loss-such as hormonal changes during pregnancy-will resolve spontaneously. When a prolonged period of temporary hair loss seems likely-for example, while a woman undergoes prolonged treatment for a medical condition such as cancer-the patient may consult a physician hair restoration specialist regarding a full or partial temporary hair prosthesis.

When is a Woman with Female Pattern Hair Loss a Good Candidate for Hair Transplantation?

After it is determined that a woman\’s thinning hair is due to female pattern hair loss and no other cause, hair transplantation can be considered as a treatment.

When is a woman a good candidate for hair transplantation? The criteria for candidacy are largely the same for both women and men, with some specific considerations that apply more often to women than to men. The best approach to the question is open and honest discussion between the woman and the physician hair restoration specialist.

A woman should not be “sold” hair transplantation as a hair-loss treatment; she should choose it as a treatment only if she fully understands the reasons for the physician\’s recommendation. Neither should a woman “push” for hair transplantation that the physician is unwilling to recommend. The decision to undergo hair transplantation should be made on the basis of the physician\’s professional judgment after complete examination of the patient, and full and honest discussion between patient and physician regarding cost, time, details of the procedure, potential side effects and complications, and anticipated result.

Hereditary hair loss patterns differ in women as compared to patterns in men. Hereditary hair loss in women tends to be more diffuse than in men, presenting as areas of patchy thinning rather than the areas of total hair loss more common in men.

The extent and rapidity of patchy hair loss are considerations in determining whether a woman is a good candidate for hair transplantation.

The physician hair restoration specialist will use scalp examination as well as the patient\’s personal and family history to determine (1) whether there will be enough donor hair currently and in the future to make transplantation a viable treatment option, and (2) if hair transplantation is undertaken, will the result meet the patient\’s expectations for cosmetic improvement? Inadequate donor hair could rule out hair transplantation as a viable option for hair loss treatment. In some women, for example, the diffuse pattern of hair loss is widespread and rapidly advancing, and this may make it difficult for the physician hair restoration specialist to find scalp hair that is dense enough to provide adequate donor hair (the hair that is taken from one site on the scalp and transplanted to a balding recipient site).

Other scalp and hair characteristics that the physician may consider include hair color, hair texture, degree of hair curl, and skin-to-scalp hair color contrast-all characteristics that the physician hair restoration specialist may be able to use to achieve maximum cosmetic improvement. For example, the physician hair restoration specialist may creatively use color, texture and curl of transplanted hair to complement existing hair and recreate an appearance of density in an area of diffuse hair loss.

If donor hair is limited by overall hair thinning, hair transplantation may be able to offer an improvement in recipient areas by creative use of hair characteristics, but may not be able to offer full density that returns the patient to complete pre-hair loss appearance. Another consideration-applicable to both women and men-is the rapidity and extent of hair thinning. Rapid and extensive hair loss may deplete the amount of donor hair available for future use in keeping pace with continued loss of hair. If this appears to be a possibility, the patient and physician hair restoration specialist should discuss realistic expectations for hair transplantation over a period of years. The patient must determine whether the anticipated result justifies the time, cost and discomfort of hair transplantation.

Women more than men are bombarded with advertising images of models with luxuriously dense hair-images that establish a standard which women are challenged to emulate. These unrealistic images may be in the background when a woman discusses realistic expectations for hair transplantation with her physician hair restoration specialist. Unrealistic images promoted by hair-product advertising should not cloud judgments regarding realistic expectations for cosmetic improvement from hair transplantation.

In the great majority of cases, women who have hair transplantation performed by a skilled, experienced physician hair restoration specialist are highly satisfied with the result. While satisfaction is due in large part to the physician\’s technical skill and expertise, it also reflects the feeling of patients who find that their realistic expectations were achieved.

Hair Transplantation Technique

Hair transplantation techniques are adapted to the necessity for placing grafts in multiple areas of patchy hair loss. The types of grafts used and the number of transplantation sessions scheduled for the patient are decisions influenced by the patient\’s objectives for hair density in the final result.

Combination Treatments

The topically-applied hair loss remedy minoxidil (Rogaine®) is sometimes used in selected female patients (1) to complement hair transplantation by stimulating new hair growth, or (2) to prevent the temporary postoperative loss of transplanted hair that occurs in a percentage of transplant patients.

When donor hair is limited and hair loss areas are relatively extensive, the patient and physician hair restoration specialist may agree on a treatment plan that combines hair transplantation and hair styling. If all hair loss areas cannot be effectively treated by transplantation, the transplanted areas may be configured to maximize the future use of hair styling to achieve maximum cosmetic improvement.

Scalp Reductions and Scalp Flaps

A scalp problem such as traumatic scarring may make a patient unsuitable for hair transplantation. A reconstructive procedure such as scalp reduction or a scalp flap may be necessary to restore a suitable hair pattern (See Surgical Treatments and Hair Transplantation for a discussion of these procedures).

Advances in hair transplantation have made transplants in a scarred scalp possible in some patients. The possibility of hair transplantation should be discussed with the hair restoration doctor.

Summary

Perhaps because “baldness” was long believed to be a male characteristic, hair loss in women was often ignored or dismissed as a socially unacceptable topic. Hair loss in women is now fully recognized as a medical problem and esthetic concern that can be treated by a physician hair restoration specialist.

References

Cotterill PC. Hair transplantation in females. In: Unger WP (Ed..) Hair Transplantation, 3rd ed.. New York: Marcel Dekker, Inc.; 1995:287-292.

Griffin EI. The treatment of female pattern alopecia by hair transplantation. In: Stough DB, Haber RS (Eds.) Hair Replacement. Surgical and Medical. St. Louis: Mosby; 1996:210-216.