Female pattern hair loss cures… Does anything really work for women?
Many in our field would argue it’s not worth even treating women for female pattern hair loss, citing concerns about donor area, the scarcity of effective treatments, or how difficult it can be to achieve patient satisfaction. But these concerns should not prompt us to give up. Rather, women can be some of the most rewarding patients to treat, and using simple things like handouts, dermoscopy, and photography can help increase understanding, reduce confusion, increase compliance, and dramatically improve their response to treatment.
Women often undergo an extensive workup before arriving at a diagnosis of FPHL. They may start by seeing their internist, then their OB/GYN, their endocrinologist, and even a naturopath before seeing a dermatologist or hair loss specialist. Along the way, they may be told that the hair loss is due to stress, adrenal fatigue, or “low-normal” thyroid function, all of which when corrected fails to stop the hair loss. Then they find you. In a matter of seconds, you recognize the presence of miniaturized hairs either on clinical examination or with the use of dermoscopy. Finally, they get the diagnosis they have been dreading: female pattern hair loss. They believe nothing can be done for them…or can it?
Although there is only one FDA-approved medication for hair loss in women (topical minoxidil), there are other off-label options such as oral spironolactone, oral finasteride, and certain birth control pills that can be tried before, or in addition to hair transplantation. Women may also benefit from low-level light therapy (LLLT). Depending on how advanced their hair loss, they may benefit from one or more therapies. The physician should consider their lifestyle, family planning and personal preferences.
The only FDA-approved medication for hair loss in women is topical minoxidil or Rogaine®. There is new evidence that use of topical minoxidil can improve the quality of life for those with FPHL. The drug is recommended for twice daily usage as a 2% solution for women. The 2% solution has been shown to be effective at stopping hair loss in 60% of cases. Excellent results can be achieved with consistent usage. Recently, one study showed that a 5% foam worked just as well, used once daily in women, as the 2% worked twice daily. There also were fewer complaints about itching and dandruff. Many physicians already recommend using the 5% foam once daily at bedtime as a way to increase compliance and simplify the morning grooming routine. This has since prompted the FDA to approve a women’s 5% Rogaine foam formulation for once daily usage. The risk of hypertrichosis – hair growth in other areas of the body - should still be discussed as it has been reported in 8.9% of patients using this regimen.
Perhaps the most difficult thing about getting women to use topical minoxidil is helping them to understand that it works. They often believe that because it is over the counter, it can’t possibly work. Or, they believe that if they stop using it, all of their hair will fall out. These misconceptions can be addressed by drawing a simple diagram for your patients, using an x-y axis to demonstrate the natural progression of hair loss over time (Figure 2). By drawing a new (green) line, women can understand what will happen if they use medical therapy. And if they stop, they will just trend back to their natural course of thinning. By restarting, they will trend up again (purple line). They will not end up below this line (X), which is worse off than if they had never used the medication.
Minoxidil can still be a hard sell. Some women of Middle Eastern or Hispanic ancestry, or those with polycystic ovary syndrome, may already suffer from significant hirsutism – which is hair growth on the face - and do not want to worsen it with topical minoxidil. Other women in their 50s or 60s do not wash their hair more often than once a week, and dislike the idea of putting a product on the scalp every day and then not washing it out until they return to the salon. These women can benefit from off-label options like birth control pills, spironolactone, or finasteride.
Spironolactone is a diuretic with anti-androgen properties. It can be helpful to explain to women that they have both estrogens (girl hormones) and androgens (boy hormones). However, their follicles are genetically more sensitive to circulating levels of androgens, specifically in the frontal 1/3-2/3 of the scalp (or on the sides). Thus, spironolactone helps to block these androgen receptors and can help prevent the miniaturization process on the follicle.
Spironolactone can be an excellent choice for women with polycystic ovary syndrome, who already have signs of hirsutism or acne. The anti-androgen effects of spironolactone are already used widely in the field of dermatology to successfully treat both conditions. Women who are already other medicines may be switched to spironolactone as a single agent to treat both conditions. This should obviously be done with the involvement of their internist. With rising health care costs, and an already complex health care system, such women are usually grateful for a drug that addresses two or more conditions. The data supporting the link between hair thinning and heart disease might imply that we should place all our FPHL patients on spironolactone.
In order to slow down early thinning, patients may start at doses of 100mg/day. In order to achieve regrowth, higher doses of 200mg/day are generally required. The drug is a potassium-sparing aldosterone antagonist, so patients should avoid additional potassium supplements and make sure not to consume a lot of bananas.
Other side effects can include breast tenderness, mid-cycle spotting, a diminution or disappearance of the menses altogether, or light-headedness. These can be reasons to gradually escalate the dose over a 4-6 week period.
Due to the anti-androgen effect, women should not get pregnant on this drug. It is helpful to explain that the same anti-androgen effect that this has on the hair follicle, it may also have on a male fetus.
Early data investigating the use of 1mg daily finasteride in women failed to show any improvement. Subsequently, other studies done in the United States and around the world using higher daily doses of 2.5-5mg finasteride showed some significant results. The largest of these came from South Korea, showing that 70/86 (81.4%) of normoandrogenic women treated with 5mg finasteride for 12 months had improvement in global photographs
Widespread implementation for FPHL has been limited by concerns about breast changes or breast cancer. In the Propecia® post-marketing reports, there were reports of breast tenderness and enlargement in men. However, new data published in the Journal of Urology showed no statistically significant connection between breast cancer and the use. Although this study was limited to men, it can make us more comfortable prescribing the drug in women. Recommending annual mammograms can help protect us as prescribers. Women with a strong personal or family history of breast cancer may still choose not to use this drug. Ultimately, the patient and physician should make the decision together.
The physician should explain that the liver metabolizes it but that there are no real drug interactions. It should only be offered to women who are not able to or are planning to conceive in the near future. These women should have undergone a hysterectomy, had their tubes tied, or be on 1-2 forms of long-term and reliable birth control. They must stop the drug immediately if they get pregnant. They also should not donate blood while they are taking the drug.
Birth Control Pills and Other Anti-Androgens
Certain birth control pills may benefit women with hair loss. In particular, the brands Yaz® and Yasmin® appear to have the most efficacy.
A study was done to see if 2% ketoconazole shampoo could exert an effect on the thinning process. After 6 months in this small trial (39 patients total), the ketoconazole group demonstrated 18% improvement in hair density versus 11% improvement in the minoxidil + non-medicated shampoo group. It is still unclear whether the what hair growth effect was due to. Larger controlled studies are needed. In the meantime, it is an easy addition to the medical therapy since most patients have to shampoo anyway.
Topical Estrone Cream
There was a report in Greece using topical estrogen cream applied to the scalp of women with FPHL. In a study of 75 post-menopausal females, it demonstrated improvement in 60-65% of patients applying a lotion with estradiol valerate .03% over 12-24 weeks. The side effects included postmenopausal uterine bleeding in 2 patients and breast cancer in one patient. An important concern would be the development of an estrogen-dependent tumor, especially in a person with family history of breast or uterine cancer. Dr. Bobby Limmer reports recent use of this compound, and has been seeing quite impressive results. His data is forthcoming. In the meantime prescribers should balance the risks with the benefits for all possible patients.
Pregnancy and Lactation
If a patient is planning to get pregnant in the near future, she should not be prescribed either spironolactone or finasteride, given the risk of birth defects. Patients can continue with topical minoxidil right up until they get pregnant; however, they should stop when they get pregnant because there are isolated reports of birth defects. Patients can be reassured that the hair will thicken during the course of their pregnancy. The hairs won’t shed until 3-6 months after the baby is delivered.
Hair Thickening vs. Hair Growth Products
There are a large number of products on the market that claim to “instantly increase density” of hair. Such products are usually in the form of shampoos, conditioners, or serums applied to the hair. These products can be very effective at coating the hair shaft so that it feels thicker. However, the results will only last until the next hair washing. Patients should understand the difference between these products and those that actually can make the hair grow thicker.