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Female Pattern Hair Loss – Hormone Treatment Solutions

As many as 21 million women will experience hair loss at some point in their lives1. While hair loss is linked to genetic factors, so far, no GWAS have identified clear genetic mutations which contribute to hair loss 2. Although scalp hair is not biologically essential, the impacts of hair loss on how women feel about themselves is profound.  A 2002 study3 found that 55% of affected women displayed symptoms of depression. However, the effects of alopecia reach far beyond symptoms of depression and include anxiety, obsessions, dissatisfaction with one’s appearance, and low self-esteem4,5. There can be significant disturbance in a patient’s social life because they may change their hair style, clothing, or avoid social meetings. One study reported that 40% of surveyed women described marital problems and 63% had career-related issues that they ascribed to their hair loss6. 

There are a range of conditions and situations that contribute to Female Pattern Hair Loss (FPHL) including telogen effluvium, nutrition deficiencies, poor quality nutritional supplements, endocrine imbalances, drugs, infection, disease, and malignancy.7  Looking particularly at endocrine changes, an excellent article Hormonal Effects on Hair Follicles8 published this year is well worth a read. The article includes a comprehensive summary of hair growth phases, a review of androgenic, sex hormone, and stress hormone impacts on hair growth and resilience, and then looks at the hormonal effects on hair at different stages of a woman’s life.

A common thread of discussion of female pattern hair loss is the correlation of metabolic syndrome, with or without PCOS. When there are insufficient levels of estrogen and/or progesterone, as commonly occurs with PCOS, the hypothalamus will be triggered via negative feedback to produce Gonadotropin Releasing Hormone and stimulate the anterior pituitary to produce Follicle Stimulating Hormone which then triggers Luteinizing Hormone (LH) production. LH will, in turn, stimulate production of androgens. Androgens exert an inhibitory effect on the hair follicles in the region of the scalp9, in particular, through miniaturization of the hair follicle10. When saliva testing has established elevated testosterone levels in PCOS patients, maintaining adequate levels of progesterone goes a long way to ensuring that testosterone levels remain within range. 

The role of estrogen and progesterone in the treatment of hair loss and growth is still evolving. Estrogen is made when androstenedione or testosterone are modified by the enzyme aromatase. It is synthesized in the ovary and other peripheral tissues and then travels to its receptors, some of which are located in scalp hair follicles11. At the scalp follicle, estradiol has been reported to induce aromatase activity12. Estrogen has been hypothesized to have a protective role against hair loss on the basis of the observation that patients with lower estrogen levels during menopause, postpartum, or treatment with aromatase inhibitors or selective estrogen receptor modulators are more likely to develop FPHL13,14. Another supporting observation is that in the frontal hairline of women, which tends to be spared with FPHL, there is a higher level of aromatase enzyme when compared with the rest of the scalp15. This variation in hair loss could be the result of locally increased levels of estradiol or decreased levels of testosterone and DHT that is secondary to greater amounts of conversion.

In post-menopausal women when both progesterone and estrogen levels are significantly lower, there is the potential for imbalance between androgens and progesterone and estradiol.  While maintaining adequate testosterone and DHEA levels is vital for a range of functions, ensuring that androgens are balanced with adequate estrogen and progesterone is a treatment consideration for a range of symptoms, including FPHL.

  1. Amy McMichael, Hanh Pham, Erika von Grote, Matthew H Meckfessel. Efficacy and Safety of Minoxidil 2% Solution in Combination With a Botanical Hair Solution in Women With Female Pattern Hair Loss/Androgenic Alopecia. J Drugs Dermatol 2016 Apr;15(4):398-404.

  2. Silke Redler  Andrew G. Messenger  Regina C. Betz Genetics and other factors in the aetiology of female pattern hair loss Experimental Dermatology, 2017 Vol 25, Issue 6 pp 510-517

  3. Camacho F.M., Garcia-Hernandez M. Psychological features of androgenetic alopecia. J Eur Acad Dermatol Venereol. 2002;16:476–480

  4. N. Al-Mutairi, O.N. EldinClinical profile and impact on quality of life: Seven years experience with patients of alopecia areata, Indian J Dermatol Venereol Leprol, 77 (2011), pp. 489-493 

  5. N.C. Dlova, G. Fabbrocini, C. Lauro, M. Spano, A. Tosti, R.H. Hift Quality of life in South African Black women with alopecia: a pilot study Int J Dermatol, 55 (2016), pp. 875-881 (Al-Mutairi and Eldin, 2011).

  6. N. Hunt, S. McHale The psychological impact of alopecia BMJ, 331 (2005), pp. 951-953 

  7. Richard L. Lin,Lilit Garibyan,Alexandra B. Kimball &Lynn A. Drake Annals of Medicine Vol 48, 2016-Issue 6.  

  8. Monika Grymowicz et al Hormonal Effects on Hair Follicles. Int. J. Mol. Sci. 2020, 21(15), 5342

  9. Ceruti, J.M.; Leiros, G.J.; Balana, M.E. Androgens and androgen receptor action in skin and hair follicles. Mol. Cell. Endocrinol. 2018, 465, 122–133.  

  10. Rodney Sinclair, Niloufar Torkamani, Leslie Jones. Androgenetic alopecia: new insights into the pathogenesis and mechanism of hair loss. F1000Res 2015 Aug 19;4

  11. M.J. Thornton, A.H. Taylor, K. Mulligan, F. Al-Azzawi, C.C. Lyon, J. O’Driscoll, et al. Oestrogen receptor beta is the predominant oestrogen receptor in human scalp skin. Exp Dermatol, 12 (2003), pp. 181-190

  12. R. Hoffmann, S. Niiyama, A. Huth, S. Kissling, R. Happle 17alpha-estradiol induces aromatase activity in intact human anagen hair follicles ex vivo Exp Dermatol, 11 (2002), pp. 376-380.

  13. (N. Atanaskova Mesinkovska, W.F. Bergfeld Hair: What is new in diagnosis and management? Female pattern hair loss update: diagnosis and treatment Dermatol Clin, 31 (2013), pp. 119-127

  14. J. Park, J.I. Kim, S.K. Yun, H.U. Kim, C.W. Ihm Pattern alopecia during hormonal anticancer therapy in patients with breast cancer Ann Dermatol, 26 (2014), pp. 743-746 

  15. L.L. Levy, J.J. Emer. Female pattern alopecia: current perspectives Int J Women’s Health, 5 (2013), pp. 541-556

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