Although
a large percentage of the hair loss and thinning population
in this country are women, they are much less likely to
seek help from a hair transplant surgeon than are men.
True, women’s hair loss is less liable to benefit
from a hair transplant then are men, but large numbers
of female patients who could greatly benefit from surgical
hair restoration are unaware of this option.
Indeed, many women with hair loss are excellent candidates
for a hair transplant. The important understanding is
that women’s hair loss occurs in different patterns
than men’s, and therefore must be generally treated
in a different manner. Moreover, hair loss in women is
much more likely to reflect an underlying illness; we
must be sure a proper medical workup is done before recommending
any medical or surgical alternatives.
Psycho-emotional and Social Issues
As emotionally devastating as hair loss can be for some
men, the effect often pales compared to hair loss in women.
In men, hair loss is seen as a less than desirable, but
still sometimes expected and normal part of the male life
experience (although to the man who is balding, it may
seem like the end of the world). On the other hand, when
hair loss occurs in women, at any age, the resulting feelings
and emotions may be overwhelming. Hair loss is perceived
as a strictly male occurrence, and unacceptable in females.
For even the elderly woman, this can threaten her very
sense of self, of her femininity and sexuality, and of
her place in family and society.
Our culture strongly identifies femininity with a thick,
lustrous head of hair. From Rapunzel to the Breck Girl,
images of full bodied, shining hair are synonymous with
female attributes, sexuality, desirability and vigor.
Thinning, dry, lusterless hair is identified with illness,
old age, and poverty. In truth, there are a number of
systemic diseases that may cause hair loss in women, much
more so than is the case with men. It seems that the hair
follicles of women are more sensitive to certain stressors
(sources of stress) than are those of men; thus, we are
more likely to see widespread hair loss in females, rather
than the typical regional balding patterns of males. Let
us look for a moment at some of the causes and varieties
of female hair loss.
Causative Factors in Women’s Hair Loss
Just as in men, women’s hair loss may involve genetic
and hormonal factors. As we discussed in previous sections,
the three elements at play in androgenetic alopecia are
androgens (male hormones), genetics (a predisposition),
and the passage of time (aging). Although the loss patterns
we observe in women tend to be different than in men,
the mechanisms are similar. Because women have different
levels of certain enzymes in the follicles in various
areas of the scalp, they may lose hair in quite distinct
and different ways. For example, women very often will
retain the frontal hairline that is so commonly lost in
men, but have widespread miniaturization and thinning
on the top and vertex. This may in part be due to women’s
low hairline levels of 5-alpha-reductase, which is the
enzyme that converts testosterone into DHT.
Also, women have fewer androgen receptors on the frontal
hair follicles; therefore, they are less susceptible to
the effects of the DHT that is present. Finally, the enzyme
aromatase is found in much higher concentrations in women’s
hairlines; this important enzyme converts testosterone
to estrogens (just as 5-alpha-reductase converts it to
DHA), and estrogens are not likely to contribute to hair
loss.
Another distinguishing characteristic is that women have
a tendency to have more widespread hair loss than men.
In addition, females loss is often more gradual, whereas
men may begin to rapidly lose hair in their late ‘teens
or early twenties. Despite these statements, it is significant
that men may lose hair in a predominantly "female"
pattern, just as women may experience alopecia in what
is considered a typically "male" fashion. We
will examine these patterns more closely in the next section.
Systemic disease (affecting the entire system) and certain
medications can also lead to hair loss in women, and this
is notably more common than in men, probably in part due
to the aforementioned sensitivity of female follicles
to stress. Some of the disease states that may affect
female hair loss include: thyroid disease, anemia, endocrine
(hormonal) disorders leading to elevated levels of androgens
(ovarian cysts or tumors, adrenal or pituitary disease),
and connective tissue diseases (lupus, dermatomyositis).
In addition, various stressors, such as physical or emotional
trauma, surgery, childbirth, general anesthesia, or extreme
diets may precipitate differing degrees of hair loss.
In some cases, the hair loss is reversible when the disease
state is treated, or when the trauma or stress has resolved.
However, it may take a year or more for an acute effluvium
(hair shedding) to resolve to the point that the cosmetic
deficiency is overcome.
This last point deserves elaboration, in terms of the
actual process of hair transplantation. When women undergo
surgical hair restoration, they are more likely to experience
"shock loss" or telogen effluvium. Also, women’s
hairstyles tend to be longer than men’s, especially
today. Therefore, it may require more time for growth
of new grafts to "catch up" with existing hair,
so that a cosmetic difference can be appreciated. These
two factors make it crucial that the education process
of the patient is complete and well understood, so that
discouragement and dissatisfaction are less likely during
what may be a prolonged "interim period".
Medications known to cause alopecia include certain birth
control pills, the blood thinner Coumadin, thyroid hormone,
some blood pressure medicines, corticosteroids, high-dose
vitamin A, and many drugs of abuse (amphetamine, cocaine,
narcotics). It is vitally important for any woman experiencing
hair loss to discuss her medical history, in detail, and
any drugs or medications she is using. If there is a treatable
disease, or a medication that may be discontinued, hair
growth may resume. Although significant time may pass
after treating the illness or stopping the drug before
hair re-growth occurs, it is important to establish a
diagnosis before ever considering surgical hair restoration.
A third general cause of hair loss in women is known as
"traction alopecia". This name comes from the
precipitating factor of constant traction, or pulling,
tugging or mechanical stress on the hair. It is commonly
seen in this country among African-Americans due to the
fashion of wearing the hair in tight braids, pigtails,
or cornrows. This may also occur with the wearing of hair
weaves and other "hair systems". This variety
of hair loss is often permanent, yet very amenable to
treatment with transplantation. In addition, a specialized
type of traction alopecia is termed "trichotillomania",
which is a form of obsessive-compulsive disorder in which
hair loss is the result of constant hair twirling, tugging,
and actual pulling out of the hair. Hair transplantation
is also very effective in these cases, but only after
psychotherapy and antidepressant medications have the
condition under prolonged control. Otherwise, the transplanted
hair may be subject to the same fate as the hair it replaced!
Scarring from trauma (accidental, radiation, burns) or
surgery is another common cause of alopecia in women.
Burns or surgery to the head and scalp are treatable with
follicular unit transplantation in many cases. The residual
scarring after facelifts or brow lifts often leave women
with hairlines that are less than ideal, especially around
the temples and ears. These scars can be transplanted,
returning the soft, feathery hairline, and achieving a
more natural and aesthetically pleasing state.
Finally, some of the non-scarring localized alopecias
may occur. Alopecia areata is typical of these types.
It is characterized by sudden loss of hair in patches
on the scalp, in which the skin is normal. This type of
hair loss may be successfully treated with injections
of cortisone-like drugs.
Patterns of Women’s Hair Loss
Androgenetic hair loss occurs more frequently in women
than any other type of hair loss. However the pattern
is more often of the Ludwig variety (figure 1) than of
the typical male Norwood type. In the Ludwig classification,
the frontal hairline is preserved, and the thinning is
usually centrally located, running from front to back.
In the case of Grade I or II balding, transplantation
may be quite successful in adding density; women’s
styling options are more varied than men’s, and
they may obtain excellent coverage from artistically applied
grafting.
Figure 1
In more unusual cases, the pattern is similar to the Norwood
classifications (figure 2), with the frontal-temporal
recessions we are used to seeing in men. Bear in mind,
however, that either pattern may occur with either gender,
and is not absolutely identified with one or the other.
Figure 2
In either case, it is crucial that other medical problems
be ruled out, as was detailed in the section on causative
factors. Once this is accomplished, the donor area, as
well as the balding regions, must be checked for signs
of miniaturization. If there is evidence of widespread
or diffuse hair loss, the patient may not be a transplant
candidate.
In fact, diffuse hair loss has been classified into two
subcategories: Diffuse Patterned Alopecia (DPA) and Diffuse
Un-Patterned Alopecia (DUPA). These are both felt to be
variants on Androgenetic Alopecia, and may occur in males
as well. The difference between the two may have great
significance to the hair transplant surgeon.
DPA is quite similar to typical Norwood type "male"
pattern baldness, except that the affected areas become
very thin, but not completely bald. The donor area is
spared, and, because of this, the patient may be a candidate
for transplantation. On the other hand, DUPA essentially
affects the entire scalp, including, of course, the donor
area; this would preclude using unstable donor zone hair
for grafting. In circumstances such as these, the patient,
regrettably, must be counseled about hair systems, wigs,
camouflages, and other non-surgical methods of disguising
the alopecia. Transplanting a patient with an unstable
donor zone, regardless of their desires, amounts to the
unethical practice of medicine.
So we see now that a large percentage of the balding or
thinning population, that is, women, are unaware or ignorant
of some of the options that await them in their struggle
with hair loss. As we have shown, there are more possible
etiologies (causes) of balding in women than in men; the
reversible ones must be ruled out. Also, the hair, like
the skin as a whole, may be a "window" to the
internal health of many women, and deserves due attention.
Various laboratory and blood tests are available to help
with establishing a diagnosis, as are specialist consults
if necessary. When an identification of the cause is determined,
the patient and the hair restoration specialist may go
forward in deciding the best course of action for the
specific problem at hand
