Articles

Hair Restoration in Women

By Tiffany Spudich, R.Ph., Pharm. D.

Ever feel like you are pulling your hair out, literally? Everyone has some hair loss every day, but as we age, we grow less hair. It is also thinner and tends to break more easily. More than one third of women have clinically significant hair loss during their lifetime.¹

Hair is constantly cycling and regenerating on the scalp. Actively growing hairs are referred to as anagen hairs, and comprise more than 90% of the hair on the scalp. Anagen hairs are anchored deeply into the subcutaneous fat and cannot be pulled out easily. Each hair shaft may persist on the scalp for 3 to 7 years before falling out and being replaced by a new hair. The anagen phase, which lasts for most of this period, is followed by a 2-week phase of catagen, during which there is programmed death of the hair; the trigger factor for catagen is unknown.¹ After catagen, the hair goes into telogen, a resting phase that lasts 3 months. As compared with anagen hair, telogen hair is located higher in the skin and can be pulled out relatively easily. Normally, the scalp loses approximately 100 telogen hairs per day.

Some people lose a lot of hair early in life because it runs in their family or because of disease, chemotherapy, medications, stress, injury, or damage to the hair.
One most common cause of hair loss, female-pattern hair loss, is frequently referred to as androgenetic alopecia and is often inherited; however, the role of androgens such as testosterone in this type of hair loss remains uncertain.^2,3 Testosterone converts to dihydrotestosterone (DHT) with the aid of the enzyme 5-alpha reductase type 2, which is held in a hair follicle’s oil glands. Scientists speculate that it is not necessarily the amount of circulating testosterone that is the problem but the level of DHT binding to receptors in scalp follicles and shrinking the follicle, making it difficult for healthy hair to survive.⁴

Another common cause of alopecia is telogen effluvium. This condition results from an abrupt shift of large numbers of anagen hairs to telogen hairs on the scalp. This form of alopecia generally begins approximately three months after a major illness or other stress (e.g., surgery, rapid weight loss, nutritional deficiency, childbirth, high fever, or hemorrhage), hormonal imbalance, or medication usage. Tamoxifen, a medication often used in breast cancer therapy, has been reported in literature to be associated with hair loss. The anti-estrogen effect of tamoxifen may enhance androgen action on hair follicles, causing alopecia in genetically susceptible patients.^5,6 Some additional medications that can contribute to hair loss are included at the end of this article in Table 1, although note that this list is not comprehensive.

Hair loss is diagnosed through a medical history and physical examination. Your health professional will often ask you questions about your hair loss, such as whether your parents have hair loss, when your hair loss started, and how much hair you are losing. He or she will also look at the pattern of your hair loss, examine your scalp, and may tug gently on a few hairs or pull some out and perform a scalp biopsy. Certain testing parameters can be performed to help determine the underlying cause of hair loss, such as anemia, a thyroid condition, or syphilis. Clinicians may assess blood ferritin and iron levels to rule out iron deficiency, particularly in menstruating women, vegetarians, and women with a history of anemia.^7-9 A Venereal Disease Research Laboratory Test (VDRL) is recommended in patients who have risk factors for syphilis.

If patients have additional symptoms that correlate with a thyroid condition, clinicians may also perform lab tests to assess thyroid function including TSH, free T4, total T4, free T3, total T3, and thyroid antibodies. In women with female-pattern hair loss and other conditions suggesting androgen excess (e.g., hair growth on the body, acne, or irregular menses), assessment of free testosterone, total testosterone, and DHT is suggested. Although the role of estrogens in hair growth is not completely clear, estrogens are known to prolong the anagen state and counteract telogen effluvium and androgenetic alopecia, so practitioners may also assess the patient’s estradiol level.¹⁰

Therapies for female-pattern hair loss include topical minoxidil, antiandrogen medication, and hair transplantation in selected patients. Topical 2% minoxidil solution is approved by the Food and Drug Administration (FDA) for women with thinning hair due to female-pattern hair loss. In a double-blind, placebo-controlled trial, 2% minoxidil used twice daily results in minimal hair regrowth in 50% of women and moderate hair regrowth in 13% of women after 32 weeks of treatment, as compared with rates of 33% and 6%, respectively, in the placebo group.¹¹ The use of 5% minoxidil may be considered in women who do not have a response to the 2% formulation or who want more aggressive management.¹²

Antiandrogen agents including spironolactone and finasteride are not commonly used to treat female-pattern hair loss in North America, but they are used more commonly in Europe. Antiandrogens help to block the action of androgens such as DHT from binding to the hair receptors. Spironolactone 200mg daily in women with female-pattern hair loss has been shown to stabilize hair growth.¹³ In two small controlled studies, finasteride at a minimum dose of 2.5mg per day appeared to have a benefit for women with female-pattern hair loss.^14,15

Bellevue pharmacy frequently compounds agents such as finasteride and the similar drug dutasteride in a shampoo formulation, usually combined with bioidentical estradiol, which can be used directly on the hair and scalp daily for hair maintenance. Patient specific combinations of finasteride and spironolactone can also be compounded together in one oral capsule formulation. Additional supplementation with herbs such as Saw Palmetto can help prevent androgen activity on the hair follicles by helping to prevent the conversion of testosterone to DHT.

Therapy may also include thyroid treatment, if thyroid function is diagnosed as an underlying cause, or iron replacement therapy if iron deficiency anemia is a contributing factor. Restoring the body’s estrogen levels with supplementation such as bioidentical hormone therapy, may also have a role in counteracting hair loss if lab assessment demonstrates low or low normal estradiol levels. Bellevue Pharmacy is capable of compounding a variety of bioidentical estrogen formulations, as well as thyroid combinations to meet each patient’s specific dosing needs.

If hair loss is caused by medication, stress, or damage, hair often grows back after the cause is removed, although sometimes treatment may be needed. Six months to 1 year of treatment may be required before there is considerable improvement after most treatments and/or removal of determined causative factors.¹ However, in older women it is possible that the hair follicle may not completely recover.⁶

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4. American Hair Loss Association (2007). Retrieved November 19, 2007, from http://www.americanhairloss.org .
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16. Litt JZ. Litt’s drug eruption reference manual. 12th ed. Abdingdon, United Kingdom: Taylor&Francis, 2006.