Female Hair Loss

Semin Cutan Med Surg. 2009 Mar;28(1):19-32.Click here to read Links

Hair loss in women.

Camacho-Martínez FM.

Department of Dermatology, School of Medicine, Hospital Universitario Virgen
Macarena, Seville, Spain.

Female pattern hair loss (FPHL) is a clinical problem that is becoming more
common in women.

Female alopecia with androgen increase is called female androgenetic alopecia
(FAGA) and without androgen increase is called female pattern hair loss.

The clinical picture of typical FAGA begins with a specific “diffuse loss of
hair from the parietal or frontovertical areas with an intact frontal hairline.”

Ludwig called this process “rarefaction.”

In Ludwig’s classification of hair loss in women, progressive type of FAGA, 3
patterns were described: grade I or minimal, grade II or moderate, and grade III
or severe. Ludwig also described female androgenetic alopecia with male pattern
(FAGA.M) that should be subclassified according to Ebling’s or
Hamilton-Norwood’s classification. FAGA.M may be present in 4 conditions:

persistent adrenarche syndrome, alopecia caused by an adrenal or an ovarian
tumor, posthysterectomy, and as an involutive alopecia.

A more recent classification (Olsen’s classification of FPHL) proposes 2 types:
early- and late-onset with or without excess of androgens in each.

The diagnosis of FPHL is made by clinical history, clinical examination, wash
test, dermoscopy, trichoscan, trichograms and laboratory test, especially
androgenic determinations.

Topical treatment of FPHL is with minoxidil, 2-5% twice daily.

When FPHL is associated with high levels of androgens, systemic antiandrogenic
therapy is needed.

Persistent adrenarche syndrome (adrenal SAHA) and alopecia of adrenal
hyperandrogenism is treated with adrenal suppression and antiandrogens.

Adrenal suppression is achieved with glucocorticosteroids.

Antiandrogens therapy includes cyproterone acetate, drospirenone,
spironolactone, flutamide, and finasteride.

Excess release of ovarian androgens (ovarian SAHA) and alopecia of ovarian
hyperandrogenism is treated with ovarian suppression and antiandrogens.

Ovarian suppression includes the use of contraceptives containing an estrogen,
ethinylestradiol, and a progestogen.

Antiandrogens such as cyproterone acetate, always accompanied by tricyclic
contraceptives, are the best choice of antiandrogens to use in patients with

Gonadotropin-releasing hormone agonists such as leuprolide acetate suppress
pituitary and gonadal function through a reduction in luteinizing hormone and
follicle-stimulating hormone levels.

Subsequently, ovarian steroid levels also will be reduced, especially in
patients with polycystic ovary syndrome.

When polycystic ovary syndrome is associated with insulin resistance, metformin
must be considered as treatment.

Hyperprolactinemic SAHA and alopecia of pituitary hyperandrogenism should be
treated with bromocriptine or cabergoline.

*** Postmenopausal alopecia, with previous high levels of androgens or with
prostatic-specific antigen greater than 0.04 ng/mL, improves with finasteride or

Although we do not know the reason, postmenopausal alopecia in normoandrogenic
women also improves with finasteride or dutasteride at a dose of 2.5 mg per day.
Dermatocosmetic concealment with a hairpiece, hair prosthesis as extensions, or
partial hairpieces can be useful.

Lastly, weight loss undoubtedly improves hair loss in hyperandrogenic women.

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