The Many Sizes and Shapes of Baldness in Women
Posted Mon, May 17, 2010

Baldness comes in various shapes and sizes, but when it appears on a woman’s head it is always bad. The problem is of such magnitude that doctors vacillate between dismissing female hair loss complaints and ordering a battery of tests they have little idea what to do with. An organized approach to the problem is necessary. In many cases hair loss can be slowed or stopped and in some cases it can be reversed.
Compounding the problem is that baldness now affects women from age 20 to death. Clearly, younger women are losing hair and losing it in greater quantities than in the past, and this has led to more cosmeceuticals and outright irrational remedies for a vexing problem. In addition dermatologists are making diagnoses of hair loss that do not hold up to rational examination.
Perhaps over simplistic, the most common examples of female pattern baldness can be understood in 3 categories, of which there are several subcategories. The most common cause of hair loss is called female pattern baldness or Ludwig’s female patterned hair loss. Most commonly women aged 50-80 present with these complaints however it is more and more commonly presenting in younger women. The hallmark of the process is the maintenance of the frontal hairline, although it may thin. In male pattern baldness the frontal hairline disappears or shrinks. Not so with women. Hair loss tends to be diffuse although most noticeable on the top of the head. Initial complaints range from “my part is getting wider” to “I can see my scalp” to “I am shedding hair everywhere”. Traditionally this is considered a form of genetic hair loss, a pre-programmed event in which cell death of the hair follicle precedes death of the individual. It is often called androgenetic alopecia even though blood tests for androgens, male hormones, are universally normal and the hair loss pattern is completely different from men. In questioning some of the leading authorities in the country I cannot get them to explain why they use this term.
The second most common form of female hair loss is called telogen effluvium. Hair growth goes through cycles: growing, regressing, and resting. The resting part of the cycle is called telogen and typically up to 20% of the scalp hair is resting at any one time. However, when a greater percentage of hair goes into a resting phase at the same time the hair begins to shed more than the normal 100-200 hairs per day and scalp hair appears less dense. Most often this occurs after pregnancy but other causes such as general anesthesia, trauma, infection, and medicines can cause this. The prognosis is excellent and hair growth normally resumes in 9 months as most of the hair will be restored.
The third category involves nutritional deficiency or hormonal abnormalities. Iron deficiency is known to cause hair loss and since many women have heavy menstrual periods with borderline or frank anemia and low iron levels it is one of the first tests ordered by dermatologists. Disease states characterized by hormone abnormalities are unusual but a known cause of female pattern baldness. Polycystic ovary disease (PCOS) and adrenogenital hyperplasia are diseases of the ovaries and adrenal glands respectively and are characterized by associations with masculine changes such as deeper voice, bearded face, and acne. Not uncommonly patients with over or underactive thyroid glands lose hair but often doctors know about their thyroid disease before the hair loss becomes a problem.
I have purposely left out diseases of the scalp since these patients complain of changes in their scalp as well as problems of hair loss. These patients also tend not to present with diffuse hair loss and maintenance of their frontal hairline.
While not an article on remedies, this blog is an attempt to make some sense of the frustration many women experience as they go from doctor to doctor in search of answers for their hair loss. As with all medical problems a history, physical examination, and sometimes a biopsy is necessary to make a diagnosis and from this rational treatments can be prescribed. A rational understanding as well as a realistic approach to hair loss are necessary if treatment is to be effective and if patients are to avoid the plethora of fake treatments available to grow hair.

Edward Lack
Edward Lack MD is a board certified dermatologist and a board certified dermatologic cosmetic surgeon. He is President and Medical Director of MetropolitanMD, a multispecialty cosmetic surgery center in Chicago,which is unique in having a double board certified cosmetic dermatologic surgeon, a double board certified facial plastic surgeon, and a double board certified cosmetic plastic surgeon. Dr. Lack is also the Past President of The American Academy of Cosmetic Surgery.

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