Male or female pattern baldness

Male-pattern baldness also called ‘androgenetic alopecia’ typically appears first at the hairline or top of the head. The typical pattern of male pattern baldness begins at the hairline. The hairline gradually moves backward (recedes) and forms an “M” shape. Eventually the hair becomes finer, shorter, and thinner, and creates a U-shaped (or horseshoe) pattern of hair around the sides of the head. It can progress to partial or complete baldness. Male-pattern baldness is the most common type of hair loss. Male-pattern baldness affects all men to some degree as they get older. For a few men, this process starts as early as the late teens. By the age of 60, most men have some degree of hair loss. Each strand of hair sits in a tiny hole in the skin called a hair follicle. In general, baldness occurs when the hair follicle shrinks over time, resulting in shorter and finer hair. Eventually, the hair follicle does not grow new hair. The hair follicles remain alive, which suggests that it is still possible to grow new hair. Significant balding affects about one in five men (20%) in their 20s, about one in three men (30%) in their 30s and nearly half of men (40%) in their 40s.

Male-pattern baldness is caused when hair follicles are oversensitive to the hormone dihydrotestosterone (DHT), produced by the male hormone, testosterone. Dihydrotestosterone (DHT) causes the follicles to shrink and eventually stop functioning. Both men and women produce this hormone in different amounts.

The involvement of testosterone in balding has led to the myth that going bald is a sign of virility. But men with male-pattern baldness don’t have more male hormones than other men. Their hair follicles are simply more sensitive to the hormones.

Male pattern baldness is usually not a sign of an underlying medical disorder. Hair loss is usually permanent.

While hair loss is a normal part of the ageing process, for some men it can be distressing, particularly if it happens at an early age. Men losing their hair can feel less confident, less attractive and may think it makes them look older; some may feel depressed.

Some men find talking to a counselor helpful if they are feeling worried about their hair loss.

Male-pattern baldness is so called because it tends to follow a set pattern. The first stage is usually a receding hairline, followed by thinning of the hair on the crown and temples. When these two areas meet in the middle, it leaves a horseshoe shape of hair around the back and sides of the head. Eventually, some men go completely bald.

If you have inherited the genes responsible for male-pattern or female-pattern baldness there’s little you can do to prevent it from happening.

Treatments can slow down the process, but there’s no cure. The two most effective treatments for male-pattern baldness are medicines called minoxidil and finasteride. Side-effects are uncommon, but minoxidil can cause skin irritation or a rash in some men.

Current male-pattern baldness treatment options include:

• Hair replacement / transplantation
• Cosmetics
• Micropigmentation (tattoo) to resemble shaven scalp
• Hairpieces
• Minoxidil solution
• Finasteride tablets (type II 5-alpha reductase inhibitor)
• Dutasteride.

There is some evidence that ketoconazole shampoo may also be of benefit, perhaps because it is effective in seborrheic dermatitis and dandruff.

Low level laser therapy is of unproven benefit in pattern balding; one device has been approved by the FDA for marketing. Further studies are required to determine the magnitude of the benefit, if any.

Other treatments for hair loss include wigs, hair transplants and plastic surgery procedures, such as scalp reduction.

As a general rule, it’s easier to maintain existing hair than to regrow it, and once the hair follicle has stopped working it cannot be revived.

Figure 1. Male-pattern baldness

Female-pattern baldness presents as generalized thinning of hair and widening of the scalp parting. Female-pattern baldness typically starts with scalp hairs becoming progressively finer and shorter as you age. Many women first experience hair thinning and hair loss where they part their hair and on the top-central portion of the head. Some affected women also experience thinning at the frontal hairline or temples. There may be an increase in hair shedding. These changes usually lead to a reduction of the hair volume that may be evident by a shrinking hair ponytail. Some women get episodic bursts of accelerated hair shedding for a few months in between longer stable periods of little activity.

In female pattern baldness:

• the hair tends to thin all over the scalp;
• the hair on the top of the head thins and the hair part line (parting) becomes wider; and
• the hairline at the front of the head becomes more sparse.

The reason for female pattern baldness is not well understood, but may be related to:

• Aging
• Changes in the levels of androgens (hormones that can stimulate male features)
• Family history of male or female pattern baldness

Untreated, hair loss in female pattern baldness is permanent. In most cases, hair loss is mild to moderate. You do not need treatment if you are comfortable with your appearance.

Your doctor might prescribe minoxidil, or a cream containing minoxidil. This active ingredient is found in lotions like Hair Revive Extra Strength, Hair Retreva, and Hair A-Gain. It’s important to discuss the potential side effects of these treatments with your doctor. If minoxidil does not work, your doctor may recommend oral tablets such as spironolactone and cyproterone acetate or Androcur®.

Many women find that hair loss can impact on their confidence and self-esteem. Some women may even develop depression. Counseling can help, as can joining a support group where you can share experiences with other people experiencing hair loss. Talk to your doctor if your hair loss is causing you distress.

Figure 2. Female-pattern baldness

Hair Production

Hair follicles extend deep into the dermis, often projecting into the underlying subcutaneous layer. The epithelium at the follicle base surrounds a small hair papilla, a peg of connective tissue containing capillaries and nerves. The hair bulb consists of epithelial cells that surround the papilla.

Hair production involves a specialized keratinization process. The hair matrix is the epithelial layer involved in hair production. When the superficial basal cells divide, they produce daughter cells that are pushed toward the surface as part of the developing hair. Most hairs have an inner medulla and an outer cortex. The medulla contains relatively soft and flexible soft keratin. Matrix cells closer to the edge of the developing hair form the relatively hard cortex. The cortex contains
hard keratin, which gives hair its stiffness. A single layer of dead, keratinized cells at the outer surface of the hair overlap and form the cuticle that coats the hair.

The hair root anchors the hair into the skin. The root begins at the hair bulb and extends distally to the point where the internal organization of the hair is complete, about halfway to the skin surface. The hair shaft extends from this halfway point to the skin surface, where we see the exposed hair tip.

The size, shape, and color of the hair shaft are highly variable.

Growth and Replacement of Hair

The human scalp contains about 100,000 hair follicles. These anchor the hair to the skin and contain the cells that produce new hairs. A hair in the scalp grows for two to five years, at a rate of around 0.33 mm/day (about 1/64 inch). Variations in hair growth rate and the duration of the hair growth cycle account for individual differences in uncut hair length. Hair grows in 3 developmental stages (see Figure 5):

1. Anagen. The anagen or follicle growing phase starts growing the new hair. This phase is genetically determined and can vary from 2 to 6 years (the average is just under 3 years). Most hair follicles on the scalp are in the anagen phase.
2. Catagen. The catagen phase is a transition stage between the growing and resting phases and lasts 1-2 weeks.
3. Telogen. The telogen or resting phase is a mature hair with a root, which is held very loosely in the follicle. The telogen phase generally lasts about 4-5 months. About 100 telogen hairs are lost from the human scalp each day.

Figure 3. Hair structure

Figure 4. Hair follicle

Figure 5. Hair growth cycle

At any given time, about 90% of the scalp follicles are in the Anagen stage. In this stage, stem cells from the bulge in the hair follicle multiply and travel downward, pushing the dermal papilla deeper into the skin and forming the epithelial root sheath. Root sheath cells directly above the papilla form the hair matrix. Here, sheath cells transform into hair cells, which synthesize keratin and then die as they are pushed upward away from the papilla. The new hair grows up the follicle, often alongside an old club hair left from the previous cycle.

In the Catagen stage, mitosis in the hair matrix ceases and sheath cells below the bulge die. The follicle shrinks and the dermal papilla draws up toward the bulge. The base of the hair keratinizes into a hard club and the hair, now known as a club hair, loses its anchorage. Club hairs are easily pulled out by brushing the hair, and the hard club can be felt at the hair’s end. When the papilla reaches the bulge, the hair goes into a resting period called the Telogen stage. Eventually, anagen begins anew and the cycle repeats itself. A club hair may fall out during catagen or telogen, or as it is pushed out by the new hair in the next anagen phase.

You lose about 50 to 100 scalp hairs daily. In a young adult, scalp follicles typically spend 6 to 8 years in anagen, 2 to 3 weeks in catagen, and 1 to 3 months in telogen. Scalp hairs grow at a rate of about 1 mm per 3 days (10–18 cm/yr) in the anagen phase.

Hair grows fastest from adolescence until the 40s. After that, an increasing percentage of follicles are in the catagen and telogen phases rather than the growing anagen phase. Hair follicles also shrink and begin producing wispy vellus hairs instead of thicker terminal hairs. Thinning of the hair or baldness, is called alopecia. It occurs to some degree in both sexes and may be worsened by disease, poor nutrition, fever, emotional stress, radiation, or chemotherapy. In the great majority of cases, however, it is simply a matter of aging.

Pattern baldness is the condition in which hair is lost unevenly across the scalp rather than thinning uniformly. It results from a combination of genetic and hormonal influences. The relevant gene has two alleles: one for uniform hair growth and a baldness allele for patchy hair growth. The baldness allele is dominant in males and is expressed only in the presence of the high level of testosterone characteristic of men. In men who are either heterozygous or homozygous for the baldness allele, testosterone causes terminal hair to be replaced by vellus hair, beginning on top of the head and later the sides. In women, the baldness allele is recessive. Homozygous dominant and heterozygous women show normal hair distribution; only homozygous recessive women are at risk of pattern baldness. Even then, they exhibit the trait only if their testosterone levels are abnormally high for a woman (for example, because of a tumor of the adrenal gland, a woman’s principal source of testosterone). Such characteristics in which an allele is dominant in one sex and recessive in the other are called sex-influenced traits.

Excessive or undesirable hairiness in areas that are not usually hairy, especially in women and children, is called hirsutism. It tends to run in families and usually results from either masculinizing ovarian tumors or hypersecretion of testosterone by the adrenal cortex. It is often associated with menopause.

Contrary to popular misconceptions, hair and nails do not continue to grow after a person dies, cutting hair does not make it grow faster or thicker, and emotional stress cannot make the hair turn white overnight.

Different causes of hair loss affect the hair follicles in different phases of growth. See below for the different types of hair loss.

What is male pattern baldness

Male pattern baldness is also known as androgenetic alopecia affects all men to some degree as they grow older. Progressive thinning of the hair on the head eventually leads to baldness. The hair loss usually begins at the temples, with the hairline gradually receding. Subsequently, hair at the crown (back) of the head also starts to get thinner.

Male pattern hair loss affects nearly all men at some point in their lives. It affects different populations at different rates, probably because of genetics. Up to half of male Caucasians will experience some degree of hair loss by age 50, and possibly as many as 80% by the age of 70 years, while other population groups such as Japanese and Chinese men are far less affected.

The severity of male pattern baldness can be classified in several ways. Norwood and Sinclair systems are shown below.

Figure 6. Types of male pattern baldness (Norwood Classification)

Figure 7. Male pattern baldness stages

Male pattern baldness causes

Male pattern baldness is related to your genes and male sex hormones. Testosterone is the most important androgen (male sex hormone) in men and is needed for normal reproductive and sexual function. Testosterone is important for the physical changes that happen during male puberty, such as development of the penis and testes, and for the features typical of adult men such as facial and body hair. In the body, testosterone is converted to dihydrotestosterone (DHT) by an enzyme (5-alpha reductase). Dihydrotestosterone (DHT) acts on different organs in the body including the hair follicles and cells in the prostate.

Normally, in the hair cycle, 90 per cent of the hairs on a man’s scalp are in a growth phase (anagen). The other 10 per cent are mostly in a resting phase (telogen). Up to 100 telogen hairs fall out each day, and are replaced by the growth of new hairs.

Dihydrotestosterone (DHT) is the main hormone responsible for male pattern baldness in genetically susceptible individuals. Dihydrotestosterone (DHT) causes hair loss by inducing a change in the hair follicles. The hairs produced by the follicles affected by dihydrotestosterone (DHT) become progressively smaller until eventually the follicles shrink completely and stop producing hair entirely.

In some families there are genes passed on through the family that make men more likely to have androgenetic alopecia. In men with these genes, the hair follicles are more sensitive to dihydrotestosterone (DHT). This leads to hair follicle miniaturization (where the hairs growing from the follicles become thinner and shorter with each cycle of growth) at a younger age.

Scientists are still investigating why men with male pattern baldness inherit this sensitivity to dihydrotestosterone (DHT), but it causes changes in the hair follicle (called miniaturisation), which results in:

• fewer hairs emerging from each follicle;
• each hair becoming finer;
• the anagen growth phase of each hair gradually becoming shorter, so that each hair exists for a shorter time;
• the telogen hairs are shed faster; and
• the lag time between the end of the resting phase and the next growth phase increases.

Each strand of hair sits in a tiny hole (cavity) in the skin called a follicle. Generally, baldness occurs when the hair follicle shrinks over time, resulting in shorter and finer hair. Eventually, the follicle does not grow new hair.

So the hair becomes progressively shorter and finer, and can eventually stop growing altogether, resulting in baldness. The balding process is gradual and only hair on the scalp is affected. The follicles remain alive, which suggests that it is still possible to grow new hair.

It is your genes that will determine whether or not you will develop this type of hair loss and at what age it starts, as well as how extensive it will be and the pattern that the hair loss will follow. You can inherit male pattern hair loss from your mother or your father (or both).

Male pattern baldness genetics

Male pattern hair loss occurs in men who are genetically predisposed to be more sensitive to the effects of dihydrotestosterone (DHT). Researchers now believe that the condition can be inherited from either side of the family. There is a myth that hair loss is a genetic trait passed down from the mother’s side of the family. Genetics is the cause of male pattern hair loss, but a number of genes are responsible and they probably come from both parents. If there is a close relative with male pattern hair loss there is a higher risk of the condition.

Male pattern baldness prevention

There is no known prevention for male pattern baldness.

Male pattern baldness signs and symptoms

The typical sequence of hair loss in men with male pattern hair loss is loss of hair from the temples (sides of the head), which progresses to loss of hair from the front of the head. The hair loss is gradual and referred to as a receding hairline.

Over time, a bald spot may develop at the back or crown of the head, and, in some men, the entire top of the head may become bald over time, leaving a horseshoe-shaped rim of hair. And even that can be lost in some men.

Hair loss can start as early as puberty, although this is uncommon. Many men start to notice thinning of their hair in their late 20s or early 30s, and about 80 per cent of men are affected to some degree by the age of 70.

Some men find that their hair loss progresses quickly, losing much of their hair within 5 years. However, it is more common for hair loss to progress more slowly, usually over 15 to 25 years.

Male pattern baldness diagnosis

Classic male pattern baldness is usually diagnosed based on the appearance and pattern of the hair loss.

Hair loss may be due to other conditions. This may be true if hair loss occurs in patches, you shed a lot of hair, your hair breaks, or you have hair loss along with redness, scaling, pus, or pain.

A skin biopsy, blood tests, or other procedures may be needed to diagnose other disorders that cause hair loss.

Hair analysis is not accurate for diagnosing hair loss due to nutritional or similar disorders. But it may reveal substances such as arsenic or lead.

Male pattern baldness treatment

Treatment is not necessary if you are comfortable with your appearance. Hair weaving, hairpieces, or change of hairstyle may disguise the hair loss. This is usually the least expensive and safest approach for male baldness.

Medicines that treat male pattern baldness include:

• Minoxidil (Rogaine), a solution that is applied directly to the scalp to stimulate the hair follicles. It slows hair loss for many men, and some men grow new hair. Hair loss returns when you stop using this medicine.
• Finasteride (Propecia, Proscar), a pill that interferes with the production of a highly active form of testosterone that is linked to baldness. It slows hair loss. It works slightly better than minoxidil. Hair loss returns when you stop using this medicine.
• Dutasteride is similar to finasteride, but may be more effective.

Hair transplants consist of removing tiny plugs of hair from areas where the hair is continuing to grow and placing them in areas that are balding. This can cause minor scarring and possibly, infection. The procedure usually requires multiple sessions and may be expensive.

Suturing hair pieces to the scalp is not recommended. It can result in scars, infections, and abscess of the scalp. The use of hair implants made of artificial fibers was banned by the FDA because of the high rate of infection.

Finasteride

Finasteride (also known as Propecia®) is taken as a tablet and works by blocking the conversion of testosterone to DHT. The hair follicles are then not affected by DHT and can grow normally. About two in three men who take finasteride every day get some hair regrowth. One in three men may have no hair regrowth but most of these don’t have any further hair loss. Finasteride has no effect in about one in 100 men.

The usual dose of finasteride is one tablet daily, with regrowth or reduction of further hair loss visible after about 4 months. However, it may take 2 or more years before a noticeable effect is seen. Hair growth is usually greater over the crown than over the front areas of the scalp. Also, the effect of finasteride is only maintained while you continue to take the medicine – if you stop taking the tablets hair loss will resume, so ongoing treatment is needed for long-term benefit. Side-effects are uncommon, but about two in 100 men taking finasteride experience a lower libido (sex drive).

Finasteride (marketed as Proscar®) is taken in higher doses as a treatment for benign prostate enlargement.

Finasteride taken at these higher doses may raise a man’s chance of getting certain types of prostate cancer. However, the much lower dose used for hair loss is not known to have any effect on a man’s chance of developing prostate cancer.

If you have any concerns, speak to your doctor.

Be aware that finasteride does not lead to hair regrowth in all men who try it, although it does stop further hair loss in most men. In order to decide how effective the treatment is for you, it may be a good idea to photograph your scalp before treatment and again after 6-12 months. Finasteride is only available on prescription from your doctor.

Side effects of finasteride

Side effects of finasteride are uncommon and usually mild.

A small number of men report a decreased libido (sex drive) and problems with their erections (erectile dysfunction), which may be related to the medication.

In rare cases, gynecomastia (male breast enlargement) has occurred in men taking finasteride.

Minoxidil

Minoxidil (also known as Rogaine®, Hair a-gain®, Hair Retreva®) is a lotion that is rubbed onto the head. About half of the men using minoxidil have a delay in further balding. About 15 in 100 men have hair regrowth, while hair loss continues in about one in three users. Minoxidil needs to be rubbed onto the scalp twice daily, and used for four months before results can be seen. There may actually be some hair loss at the beginning of treatment, as hair follicles in the resting phase are stimulated to move to the growth phase. Treatment needs to be ongoing for hair growth to continue; any hair that has regrown may fall out two months after treatment is stopped.

Be aware that minoxidil is not effective for all men, and the amount of hair regrowth will vary among people. Some men experience hair regrowth while in others hair loss is just slowed down. If there is no noticeable effect after 6 months, it’s recommended that treatment is stopped.

Side effects associated with minoxidil

The most common side effects of minoxidil include a dry, red and itchy scalp. Higher-strength solutions are more likely to cause scalp irritation.

Bear in mind that minoxidil is also used in tablet form as a prescription medicine to treat high blood pressure, and there is a small chance that minoxidil solution could possibly affect your blood pressure and heart function. For this reason, minoxidil is generally only recommended for people who do not have heart or blood pressure problems.

Always follow the directions on the product, making sure you use minoxidil only when your scalp and hair are completely dry. Wash your hands after use.

Hair transplantation

Hair transplant surgery is an option for men with hair loss that has not responded to other treatments. Hair transplantation involves taking tiny clusters, or plugs of hair (each containing up to 4 hairs) from areas where it continues to grow (usually the back of the head) and inserting them in bald or thinning areas. The procedures used to transplant hair are called micrografting or follicular unit transplantation. They can be expensive and painful and transplant sessions may be needed to achieve the desired effect and this can be expensive. Side effects such as skin infection and minor scarring are possible. However, results are usually good and are permanent. Choosing a surgeon with experience in this operation is recommended.

Procedures that involve transplanting body hair to the scalp or implanting artificial hair fibers may be used in some cases, although there is a higher rate of complications with artificial hair implants.

Talk to your doctor about whether these procedures would be suitable for you and about the risks and benefits of these treatments. Your doctor should be able to refer you to a dermatologist or hair transplant surgeon if hair transplant surgery is likely to be a suitable treatment for you.

Cosmetic treatments

Cosmetic treatment options include the following.

• Wearing a wig, hairpiece or toupee. Synthetic and real hair wigs are available.
• A special type of tattooing called scalp micropigmentation or dermatography can give the appearance of a shaved head of hair or thicker hair.
• Coloring the scalp with a camouflage dye may be recommended in some cases where the hair is thinning.
• The use of hair thickening fibers, such as natural keratin fiber, is a treatment that is inexpensive. It involves applying tiny, microfiber ‘hairs’ that bond to existing hair through static electricity to give the appearance of thicker hair.

Talk to your doctor about these options before deciding which, if any, may be suitable for you.

Unproven treatments for hair loss

Remedies for hair loss which have not been shown or proven to be effective include:

• nutritional supplements;
• platelet-rich plasma injections – sometimes known as PRP rejuvenation;
• acupuncture;
• scalp massage; and
• laser treatment.

Discuss with your doctor any treatments that you are interested in trying. It’s important to discuss the risks and benefits before opting for any hair loss treatment options.

If you consult a hair loss clinic or alternative medicine practitioner about treatments for hair loss, make sure you understand exactly what treatments they offer and whether there is any proven scientific evidence for their effectiveness.

It’s always a good idea to check with your doctor before using any treatment, to avoid unwanted effects and spending time or money on a treatment that is unlikely to help.

What is female pattern baldness

Female pattern baldness is also called female pattern hair loss or androgenetic alopecia in women, is a term used to describe hair loss and thinning in women. Female pattern baldness is a term used to describe genetic hair thinning in females. Female pattern baldness can affect women of any age but is more common after menopause. Around 40% of women show signs of female pattern baldness by age 50.

Female pattern baldness can develop at any age. It usually progresses slowly, but can also come in bursts.

Female pattern baldness is a similar condition to male pattern baldness, but the hair loss and thinning follow a different pattern. Unlike with male pattern baldness, which starts with a receding hair line, hair loss in women occurs across the top of the head. The hair usually thins across the whole scalp. A receding hairline or a bald patch on the top of the head is rare, although this can happen.

Figure 8. Female pattern baldness stages

Female pattern baldness causes

Genetics usually plays a part in the development of female pattern baldness. You can inherit the genes that cause female pattern baldness from one or both of your parents. However, some women with female pattern baldness do not have any paternal or maternal family history of baldness. It’s also possible that hormones contribute to female pattern hair loss, although the exact role that androgens play in women is uncertain.

Female pattern baldness is more common after menopause, suggesting that changes in the levels of female hormones (estrogens) may also be involved.

Female pattern baldness is different from alopecia areata, which is an auto-immune disease resulting in hair loss from the scalp and other parts of the body.

At the scalp level, hair follicles are more sensitive to the effects of androgen hormones that are required to drive female pattern baldness. This does not imply any underlying hormonal abnormalities. In fact, the vast majority of women with female pattern baldness have normal hormonal profiles. Routine hormonal testing is not required but may be recommended by your doctor if you have other signs of androgen excess such as acne, irregular periods, excessive body hair, etc.

Female pattern baldness is not caused by changes to your diet, infections or hair styling practices.

In a small number of women with female pattern hair loss have a higher than normal concentration of male hormones in their bodies. These women may lose hair in a similar pattern to men with male pattern hair loss and often have additional symptoms related to this excess of androgens, such as:

• hirsuitism (too much hair on the face or body);
• severe acne; or
• irregular periods.

If you have hair loss plus these additional features, your doctor may want to rule out the possibility that a condition such as polycystic ovary syndrome (PCOS) may be causing (or contributing to) your hair loss. Rarely, this combination of symptoms may indicate a tumor that is secreting male hormones.

Female pattern baldness prevention

There is no known prevention for female pattern baldness.

Female pattern baldness signs and symptoms

Hair thinning is different from that of male pattern baldness. In female pattern baldness:

• Hair thins mainly on the top and crown of the scalp. It usually starts with a widening through the center hair part.
• The front hairline remains unaffected except for normal recession, which happens to everyone as time passes.
• The hair loss rarely progresses to total or near total baldness, as it may in men.
• If the cause is increased androgens, hair on the head is thinner while hair on the face is coarser.

Itching or skin sores on the scalp are generally not seen.

Female pattern baldness diagnosis

Talk to your doctor if your hair is thinning. Your doctor will examine your hair and scalp, and might refer you to a dermatologist, a doctor who specializes in skin problems. Your doctor can often diagnose female pattern baldness on clinical grounds without a scalp biopsy. However, your doctor may suggest a biopsy to rule out other hair loss conditions that can mimic female pattern baldness.

Female pattern baldness is usually diagnosed based on:

• Ruling out other causes of hair loss.
• The appearance and pattern of hair loss.
• Your medical history.

If you have acne, irregular periods or a lot of body hair, your doctor might recommend a test to check your hormones, or to rule out polycystic ovarian syndrome (PCOS).

They might also recommend removing a tiny piece of skin from your scalp (skin biopsy) to test for hair loss conditions such as alopecia areata.

Your health care provider will examine you for other signs of too much male hormone (androgen), such as:

• Abnormal new hair growth, such as on the face or between the belly button and pubic area
• Changes in menstrual periods and enlargement of the clitoris
• New acne

A skin biopsy of the scalp or blood tests may be used to diagnose skin disorders that cause hair loss.

Looking at the hair with a dermoscope or under a microscope may be done to check for problems with the structure of the hair shaft itself.

Female pattern baldness treatment

The main aim of treatment is to slow down or stop your hair loss. Treatment might also stimulate hair growth, but this kind of treatment works better for some women than others.

Medicines

The only medicine approved by the United States Food and Drug Administration (FDA) to treat female pattern baldness is minoxidil:

• It is applied to the scalp.
• For women, the 2% solution or 5% foam is recommended.
• Minoxidil may help hair grow in about 1 in 4 or 5 of women. In most women, it may slow or stop hair loss.
• You must continue to use this medicine for a long time. Hair loss starts again when you stop using it. Also, the hair that it helps grow will fall out.

If minoxidil does not work, your provider may recommend other medicines, such as spironolactone, cimetidine, birth control pills, ketoconazole, among others. Your doctor can tell you more about these if needed.

There is not enough evidence to show that laser treatments, platelet-rich plasma injections, ‘hair tonics’ and nutritional supplements will stimulate hair growth. The true value of commercially available hair tonics and nutritional supplements claiming to treat female pattern baldness is also dubious.

Minoxidil

Minoxidil is a medicated solution you apply to the scalp to help stop hair loss. It may also stimulate hair regrowth in some women. Brand names include Regaine for Women and Hair A-Gain. Minoxidil for hair loss is available over-the-counter from pharmacies – you don’t need a prescription.

It takes about 4 months of using minoxidil to see any obvious effect. You might have some hair loss for the first couple of weeks as hair follicles in the resting phase are stimulated to move to the growth phase.

You need to keep using minoxidil to maintain its effect – once you stop treatment the scalp will return to its previous state of hair loss within 3 to 4 months. Also, be aware that minoxidil is not effective for all women, and the amount of hair regrowth will vary among women. Some women experience hair regrowth while in others hair loss is just slowed down. If there is no noticeable effect after 6 months, it’s recommended that treatment is stopped.

Always carefully follow the directions for use, making sure you use minoxidil only when your scalp and hair are completely dry. Take care when applying minoxidil near the forehead and temples to avoid unwanted excessive hair growth. Wash your hands after use.

Side effects associated with minoxidil

The most common side effects of minoxidil include a dry, red and itchy scalp. Higher-strength solutions are more likely to cause scalp irritation.

Bear in mind that minoxidil is also used in tablet form as a prescription medicine to treat high blood pressure, and there is a small chance that minoxidil solution could possibly affect your blood pressure and heart function. For this reason, minoxidil is generally only recommended for people who do not have heart or blood pressure problems.

Minoxidil should not be used if you are pregnant or breast feeding.

Anti-androgen medicines

Spironolactone and cyproterone acetate (brand names include Androcur, Cyprone and Cyprostat) are anti-androgen medicines that may be prescribed to treat female pattern hair loss.

These medicines help stop hair loss and may also stimulate hair regrowth. Spironolactone has been shown to stop the loss of hair in 90 per cent women with androgenetic alopecia. In addition, partial hair regrowth occurs in almost half of treated women.

The effects of treatment generally only last while you continue to take the medicine – stopping the medicine will mean that your hair loss will return.

Spironolactone and cyproterone acetate should not be taken during pregnancy. Effective contraception must be used while you are being treated with these medicines, as it can affect a developing baby. These medicines should also not be taken if you are breast feeding.

Side effects of anti-androgen medicines

Side effects of spironolactone can include:

• irregular periods and spotting;
• breast tenderness or lumpiness; and
• tiredness.

Side effects of cyproterone acetate can include:

• spotting and irregular periods;
• tiredness;
• weight gain;
• reduced libido; and
• depressed mood.

Hair transplant

Your doctor can refer you to a dermatologist or hair transplant surgeon to assess whether hair transplant surgery may be a suitable option for you.

Hair transplant surgery involves follicular unit transplantation, where tiny clusters of hair-producing tissue (each containing up to 4 hairs) are taken from areas of the scalp where hair is growing well and surgically attached (grafted) onto thinning areas. However, if your hair is very thin all over your scalp, you may not have enough healthy hair to transplant.

Hair transplant surgery can be expensive and painful, and multiple procedures are sometimes needed, which can be expensive. Side effects may include skin infection and scarring. However, the results are often excellent and permanent.

Talk to your doctor about the risks and benefits of this treatment.

Other solutions

The following cosmetic treatments for hair loss are available for women with female pattern baldness.

• Hair bulking fibre powder, such as natural keratin fiber, is an inexpensive treatment that involves applying tiny, microfiber ‘hairs’ that bond to existing hair through static electricity to give the appearance of thicker hair.
• Coloring the scalp with a camouflage dye, or coloured hair spray.
• A special type of tattooing called scalp micropigmentation or dermatography may be recommended in some cases where the hair is thinning to give the appearance of thicker hair.
• Synthetic and real hair wigs are available for those with severe hair loss.

Unproven treatments

Hair loss remedies that have not yet been shown or proven to be effective include:

• laser treatment;
• nutritional supplements;
• platelet-rich plasma injections (also referred to as PRP rejuvenation);
• scalp massage; and
• acupuncture.

Some hair loss clinics and alternative medicine practitioners offer unproven treatments for hair loss. Make sure you understand exactly what is involved with any hair loss treatment and whether there is any proven scientific evidence for its effectiveness.

Discuss with your doctor the risks and benefits of any treatments that you are interested in before trying them. This will help you avoid spending money on a treatment that is unlikely to help and may involve side effects.

Your doctor can refer you to a specialist dermatologist for an expert opinion on current treatments that have been shown to be safe and effective.

Living with hair loss

For some women, hair loss can be incredibly distressing and can affect their self-esteem. Others might accept their hair loss a little more easily.

Some women find that scarves, hats and wigs can help. Scarves and hats, whilst useful as cosmetic camouflages, also provide good sun protection to the scalp. Others find that synthetic ‘spray-on hair’ products are a clever way to disguise thinning hair.