Hair Loss Women
Hair loss is relatively common in women with about 30% experiencing at least some degree of thinning in their lifetime. Because female hair loss tends to be diffuse (less hair all over), rather than showing the characteristic “patterned alopecia” of men, and the fact that the frontal hairline in women is often maintained, there is a misconception that hair loss in women is rare – but it is not.
The psychological effects of hair loss can be significant, and many women are emotionally affected even when thinning is in its very early stages. This is, in part, due to the assumption that few women lose their hair and that, in contrast to men, where it is “OK to be bald,” any hair loss in women is socially unacceptable. Both of these erroneous perceptions make dealing with hair loss particularly difficult for women.
Hair loss in women is generally very gradual, with the rate accelerating during pregnancy and at menopause. It is more often cyclical than in men, with seasonal changes that reverse themselves, and it is more easily affected by hormonal changes, medical conditions, and external factors.
Fortunately, since most of the time women’s hair loss is relatively mild and progresses very slowly, it is rare for women to lose so much hair that they can’t hide the thinning with creative styling techniques and it is extremely uncommon for women to develop an area that is totally devoid of hair.
The Ludwig Classification uses three stages to describe female pattern genetic hair loss: Type I (mild), Type II (moderate) and Type III (extensive). In all three Ludwig stages, there is hair loss on the front and top of the scalp with relative preservation of the frontal hairline. The back and sides may or may not be involved. Regardless of the extent of hair loss, only women with stable hair on the back and sides of the scalp are candidates for hair transplant surgery.
represents an adolescent or juvenile hairline and is not actually balding. The adolescent hairline generally rests on the upper brow crease.
Type II indicates a progression to the adult or mature hairline that sits a finger's breath (1.5cm) above the upper brow crease, with some temporal recession. This also does not represent balding.
Type III is the earliest stage of male hair loss. It is characterized by a deepening temporal recession.
The diagnosis of “female pattern” hair loss is relatively straightforward when there is a history of gradually thinning in the front and/or top of the scalp, relative preservation of the frontal hairline, a positive family history of hair loss, and the presence of miniaturization in the thinning areas.
Miniaturization is the progressive decrease of the hair shaft’s diameter and length in response to hormones. It can be observed using a densitometer, a hand-held instrument that magnifies a small area of the scalp where the hair has been clipped to about 1mm in length. With this instrument miniaturization is easily apparent.
Normally follicular units (natural hair groups) are made of predominately of full-thickness, healthy terminal hair. With miniaturization one or more hairs within each group begin to thin. Eventually these hairs are lost.
If the hair loss is diffuse (thin all over) rather than in the typical female pattern on the front and top, the diagnosis can be more difficult. The presence of miniaturization in the areas of thinning usually confirms the diagnosis of androgenetic alopecia, however, if the diagnosis is still unclear, a number of other conditions must be ruled out.
Besides densitometry, two other common diagnostic tests that can be performed in the physician’s office are the hair-pull and hair pluck. In the hair pull, the physician grabs on to 20-30 hairs with his fingers and gently pulls on them. If five or more come out in the pull then this is suggestive of the increased shedding associated with telogen effluvium, a reversible type of female hair loss seen with stress, pregnancy, drug reactions and a variety of other conditions. Telogen effluvium generally occurs 2-3 months after a stressful event and affects 35-50% of one’s hair. Over 300 club hairs (telogen hairs that have rounded ends) can be shed per day shed. In the hair pluck, 20 to 30 hairs are forcibly plucked from the scalp with a small clamp. The hair bulbs are then examined under a microscope to determine the ratio of anagen (growing) hairs to telogen (resting) hairs. Normally, at least 80% of the follicles should be in the anagen stage. A lower ratio would suggest telogen effluvium. With the hair pluck, various abnormalities of the hair shaft may be observed that can contribute to hair breakage and poor growth.