Hair Loss in Women

by Susan Goto | May 8, 2020 | Article, Feature, Uncategorized, Women's Health

For women, hair has always been considered as one of the most important outward signs of beauty.  Billions of dollars are spent each year on styling, colouring, and nourishing those luscious locks.  A good or bad hair day can make or break our mood and few things cause more distress than the thought of losing our hair. However, more than 50% of women will experience significant hair loss by the age of 50. Female pattern hair loss (FPHL) is characterized by diffuse hair thinning, typically over the crown of the head and temporal regions, with retention of the frontal hairline, though variations of this pattern do occur.  Unlike male pattern hair loss, which is predominantly due to increased androgen activity and genetically determined, FPHL is more complex and multi-faceted.  

Life Cycle of Hair:

All of our hair follicles are formed before birth—by about week 22 of fetal development.  At this stage, there are roughly 1 million hair follicles on the scalp, representing the maximum number we will ever have, as we unfortunately do not regenerate follicles at any point during our lives. 

There are three phases of hair growth.  Anagen is the active phase, where a new hair is formed and grows about 1cm every month. Follicles typically stay in this phase for anywhere from 2-7 years. Catagen is a transitional phase in which the hair stops growing and its outer sheath attaches to the root of the hair to form a ‘club hair’.  Telogen is the resting phase of the follicle, which lasts for about 3 months for scalp hair. Shedding is normal during the telogen phase, averaging up to around 100 hairs per day.  This number can increase greatly during telogen effluvium, a type of temporary hair loss brought on by a shock to the system such as stress, surgery, or other traumatic event. At any given time, around 85% of follicles are in the anagen phase.  Anything that shortens the anagen phase will affect the thickness and length of hair, and premature entry and prolongation of telogen leads to increased hair loss.  Permanent hair loss results when follicles transition from producing thick, pigmented terminal hairs to short, fine, unpigmented vellus hair—a phenomenon known as miniaturization.

Causes of Hair Loss:

Genetics:

Upwards of 200 genes affect the characteristics of human hair, including its colour, texture, curl, and susceptibility to hair loss, androgenetic or otherwise.  Thus, hair loss is almost always multifactorial, especially for women, and must be addressed as such.  

Medications:

Hair loss is a very common but often overlooked side effect of a number of commonly prescribed medications. The most likely culprits are blood pressure medications such as beta-blockers and ACE inhibitors, cholesterol-lowering drugs such as statins, and antidepressants including bupropion (Wellbutrin) and SSRIs such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).  These medications typically cause the type of hair loss known as telogen effluvium, which can take 2-4 months to become noticeable.  The good news is that this type of hair loss is reversible. Oral contraceptives can also affect hair growth.

Scalp health:

The overall health of the scalp also affects the health of the hair follicles.  Dandruff, a common problem, can indicate simple dryness of the skin, fungal infections, or other skin disorders that affect hair growth.  Autoimmune diseases such as psoriasis can also lead to significant hair loss. 

Nutrient deficiencies:

The rapidly dividing cells of the active follicle require many nutrients to produce healthy hair and many nutrient deficiencies have been linked with hair loss.  These include minerals such as iron, zinc, copper, manganese, and magnesium, as well as various B vitamins, Vitamin D, and Vitamin C. Conversely, excess levels of heavy metals like lead and cadmium can have a detrimental effect.

Underlying medical conditions:

Hair health is a good indicator of overall health, thus hair loss is often a signal of an underlying medical condition.  Both hypo- and hyperthyroid states can cause hair loss, particularly in the case of Hashimoto’s disease, an autoimmune condition.  Other autoimmune diseases that can affect the hair follicles include alopecia areata, psoriasis, lupus, and Crohn’s disease.  

Various hormonal changes can also affect hair growth.  In women, this is particularly evident with pregnancy, where many women notice a marked increase in hair growth, only to have it fall out post-partum, sometimes to below pre-pregnancy levels.   Estrogen and progesterone levels decline significantly after menopause, corresponding with an increase in the frequency and severity of hair loss. The most common hormonal cause of hair loss, in both women and men, is excess androgen activity due to a form of testosterone known as dihydrotestosterone (DHT).  Testosterone is converted to DHT by the enzyme 5-alpha-reductase, which is present in the hair follicles.  Overactivity of this enzyme can lead to high levels of DHT, even when testosterone levels are normal.  Thus, many treatments are aimed at inhibiting the activity of 5-alpha-reductase.  Women with polycystic ovarian syndrome (PCOS) often experience hair loss, along with other symptoms of hyperandrogenism such as hirsutism, acne, and irregular periods. 

Treatment of FPHL:

The basic principles of naturopathic medicine emphasize finding the root cause of a condition and treating the whole person.  Hair loss is often a symptom of an underlying problem which must be addressed.  Lab testing can identify simple nutrient deficiencies, anemia, or thyroid issues.  With FPHL, complete hormone panels are often necessary to identify imbalances.  These can include testosterone, DHT, DHEA, estradiol, progesterone, cortisol, and thyroid hormones, to name a few.  Treatments can include diet and lifestyle modifications, nutritional supplements, topical treatments, prescription medications, and more.  

Nutrition:

Robust hair growth requires many nutrients, thus a nutritious, well-balanced diet is essential, as is a healthy gut capable of digesting and absorbing those nutrients.  Any deficiencies identified through testing must be corrected.  Common supplements to promote keratin formation and follicle health in FPHL include zinc, biotin, manganese, and silica. 

Hormone balancing:

• Androgens: elevated DHT levels are often addressed by inhibiting the 5-alpha-reductase enzyme.  Finasteride is the standard prescription medication for men, but its use is contraindicated for women of child-bearing age due to its potential effects on development of a male fetus.  In post-menopausal women, finasteride has been used off-label for FPHL with a success rate of roughly 50%.  Many herbs can also be used to lower DHT activity.  These include Serenoa repens (saw palmetto), Urtica dioica (nettle), Trifolium pretense (red clover), Pygeum africanum, and Polygonum multiflorum, to name just a few.  
• Insulin: high insulin levels have been associated with both male and female pattern hair loss, due at least partly to its influence on androgen levels. Diet modifications to manage blood sugar levels and insulin resistance are therefore very important.  Supplementation with inositol has been shown to decrease symptoms of insulin resistance and androgen excess and is a common treatment for PCOS. Herbs such as Humulus (hops) and Gymnema can also be helpful. 
• Progesterone: progesterone acts as an antagonist to DHT, therefore low levels can exacerbate the effects of DHT.  Low progesterone levels can also stimulate production of the adrenal hormone androstenedione which itself has some androgenic activity. The best-known herb for increasing progesterone is Vitex agnus-castus.  Bioidentical progesterone may also be prescribed, particularly peri- or postmenopausally, to increase progesterone levels.

Topical treatments:

Because the hair outside the follicle is dead, any treatment of the shaft itself (i.e. shampoos, conditioners) is purely cosmetic. Topical treatments must reach the follicle in order to be effective.  

• Minoxidil: The most common prescription medication is minoxidil (best known as Rogaine).  Initially introduced as a blood pressure medication, minoxidil acts primarily by increasing circulation in the scalp.  It helps to both activate resting follicles and to keep follicles in the active phase longer.  It can be difficult to apply and requires twice a day dosing to be effective. Newer formulations of minoxidil include tretinoin (a form of Vitamin A) which acts synergistically, and a small amount of an anti-inflammatory corticosteroid such as fluocinolone.  This underscores the role inflammation can play in promoting hair loss, both at the follicular and systemic levels.  
• Melatonin: topical application of melatonin (1% solution) has been used in the treatment of FPHL and appears to decrease hair loss by increasing anagen rates.
• Essential oils: numerous essential oils have been used traditionally to treat hair loss for centuries.  A combination of thyme, rosemary, lavender, and cedarwood massaged into the scalp daily has been shown to be effective in the treatment of alopecia areata.

Non-chemical treatments:

• Low level laser therapy: also known as photobiomodulation or photobiostimulation, these treatments are thought to stimulate hair follicles by improving mitochondrial oxidative metabolism and activating transcription factors to promote transition from telogen to anagen.
• Platelet-Rich Plasma (PRP): in this treatment, the patient’s own blood is drawn then spun in a centrifuge to isolate a serum fraction rich in platelets, which contain abundant growth factors and cytokines responsible for regeneration and repair.  This PRP is injected into the scalp to help stimulate hair regrowth.

Dr. Susan Goto, ND

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