There is so much to say on this subject that it is difficult to know exactly where to begin–and what age to begin with (see previous chapter).
It can begin at puberty, when pregnant, after childbirth, menopause, with taking oral contraceptives or HRT. The common denominator in all these is a change in hormones–oestrogens and androgens. But there is much more than just the involvement of hormones, as you will see later.
Those of you with thinning hair know only too well how much distress it causes, and not a day goes by in my practice without a distraught woman in despair because of her thinning hair.
Not long ago, a popular newspaper reported on ‘The plague of hair loss’ amongst women, arguing that because women have taken a more aggressive (and male) role, they must therefore suffer with male health disorders, of which hair loss is one.
But is there more female hair loss now than ever before? It is impossible to gauge whether there has been an increase. There is no doubt that more women are complaining of hair loss, but this doesn’t mean that there is more. Certainly there has been a progressive increase in press coverage, making women more aware and thus encouraging more of them to seek advice. The plethora of so-called ‘hair growing miracles’ adds to this awareness. With my practice, and that of colleagues, the incidence of women seeking advice has certainly increased, but we can’t compare it to ten or twenty or thirty years ago because there are no true statistics.
I have commented for many years that the incidence of hair loss in females is seriously underestimated and that hair thinning in women is as common as it is in men but without the extreme form of baldness. Indeed, although I have seen a few women with hair loss bordering on male baldness, it is rare.
There was a time, and it still exists to a great extent, when a woman wouldn’t mention hair thinning. It was, and still remains (perhaps less so), a taboo subject, with connotations of being unfeminine, unattractive, ageing and masculine. Gradually, it seems that women are thinking about it differently. And rightly so.
I would need to have my arm twisted quite hard to give my opinion on the purported extra occurrence of women’s hair loss. Assuming it has been twisted hard, I may give a ‘probably’ but not a definitely. It may well be connected to the extra stresses women are experiencing, which can cause hair loss, but also to the various hormone medications: oral contraceptives and hormone replacement therapies (HRT). But more about those later.
Hormones play a huge part and there has been one outstanding addition to our knowledge recently: PCOS.
I started my clinic in New York in 1977. Two or three years later, when I seemed to be successful, a woman was recommended to me by her doctor husband because of her thinning hair. After seeing her, I referred her back to her husband for specific blood tests to verify my suspicions. Consequently, I eventually met the doctor and began a relationship I consider to be one of the most important in my professional career–as well as making a true friend. His name is Dr Walter Futterweit, a Clinical Professor of Endocrinology.
We began cross-referring patients, and over time a pattern started to emerge in young women of reproductive age–women still having periods–all of them complaining of thinning or falling hair (or both, because they are not necessarily the same). We eventually became involved in a clinical study with two others: Dr Andrea Dunaif and Dr Hsu-Chong Yeh. In essence, of 109 women with an average age of thirty-two, about 30 per cent had PCOS–and the prevailing, if not the only, symptom was hair loss, which was the only reason the women had sought advice. At the time it was estimated that about 10 per cent of women suffered from PCOS. The original name was Polycystic Ovarian Disease (PCOD), but it’s not a disease as much as a syndrome, a combination of symptoms, with hair loss being one of them. Other symptoms include irregular menstrual cycles, difficulty in conceiving, extra hair on the face and body, acne, greasy skin, being overweight and having diabetes mellitis.
Another example of hair loss resulting from Polycystic Ovarian Syndrome
Since then, I and several other doctors have just completed another study that is almost ready for publication. However, the results are even more surprising than the first study. Of 89 women of similar ages to the first study, 67 per cent had PCOS–an enormously high percentage.
Although all women in both studies sought advice for thinning hair as the only symptom, the original estimate of 10–12 per cent of women suffering from PCOS is almost certainly underestimated (as, indeed, is the percentage of women suffering from hair loss). (See photographs p.35.)
PCOS is not dangerous or life-threatening, although the anxiety it causes can result in serious depression and ruin a person’s quality of life. And the name, polycystic ovaries, sounds worse than it really is. All ovaries have small undulations over their surface like small peaks and valleys, and these are called follicles. When the follicles become more pronounced they appear cyst-like–hence the name polycystic ovaries. It is actually an endocrine disorder and can produce more androgens (male hormones). Androgens affect the degree and frequency of bleeding in the menstrual cycle, cause oily skin and tendency to acne, grow hair where you don’t want it and diminish growth where you do. However, as with so many hair-related problems, it’s not that simple. Genetic susceptibility enters into the equation. Extra androgens have a greater detrimental effect on those with hair follicles that are more sensitive to their presence. For example, a woman with little or no hair follicle sensitivity could be affected very little by extra androgens, whereas one with high sensitivity could be affected by normal or even subnormal amounts.
Yet PCOS hair loss is predominately dependent on more androgens being produced–the term used being hyperandrogenism.
Treatment for PCOS can be complicated, depending on symptoms other than thinning hair. But if hair loss is the only or predominant symptom, it is relatively straightforward, treated by the ingestion of anti-androgens. The most common one used is Spironolactone (Aldactone) or Dianette, an oral contraceptive. Recent research indicates that women with PCOS may be more prone to heart disease and have a greater tendency to diabetes mellitis. Reduction of dietary fat and carbohydrates can improve symptoms. Metformin, a drug that decreases the body’s requirement for insulin, can also be effective. However, drugs taken orally are often insufficiently effective on the ‘target site’, in this case the hair follicle, and topical (externally applied) solutions are needed on the scalp itself. Containing anti-androgens, they can be extremely effective.
None of the treatments mentioned can be obtained over-the-counter. They need a qualified person to dispense them. It is also important to bear in mind that even if PCOS is a culprit in hair thinning, it may only be one of them. Do not overlook other aspects that may be causative, all of which you will read about later on.
One of the medications for PCOS is Dianette–an oral contraceptive. It’s an anti-androgen and contains the potent anti-androgen, cyproterone acetate. It is not available in the USA yet, but easily obtained in the UK, Europe and Canada (Dianne). For some types of hair shedding and thinning, it can be helpful–and so can many other oral contraceptives. However, others could be detrimental.
The Pill is no doubt the easiest and most reliable form of contraception. Most contain two hormones: oestrogen and progestin (some only a progestin). They inhibit ovulation, each of the two hormones able to do this job by themselves, although a combination is usually preferred.
As far as hair is concerned, there are many myths connected to oral contraceptives: I see many women aged twenty to forty who blame the Pill for their hair fall or hair thinning because it had been noticeable only since they started taking it. This type of self-diagnosis is very common, as it makes a person feel better if they can put the blame on something, stop what they think is the cause and all will be well again. Many women had done this: they had stopped taking the Pill and started again when they saw it made no difference or, indeed, led to increased hair fall (coming off the Pill can result in a type of post-partum shedding).
Some writers have blamed the Pill for the apparent increase in female hair loss. After all, the thinking goes that the Pill has been in existence for over forty years, so it must be one of the culprits!
To my knowledge there has been no published medical or scientific studies comparing pre-Pill to post-Pill days. There is an argument, though, for the assumption that the Pill increases the tendency to thinner hair. Some may do so but others would not and can even have a beneficial rather than detrimental effect.
A complication of comparison is the range of susceptibility of each person’s hair follicles, too. Some women have greater hair follicle sensitivity than others–and this is usually genetic.
There are some guidelines to consider if you are thinking of starting on the Pill, coming off it or changing to another brand of the type you are already on if you feel (or see) a potential hair thinning problem.
The past few years has seen an increase in ‘less androgenic’ combinations. A Pill with more androgens would be less desirable than one with a smaller percentage or a compound that in itself has a more androgenic effect.
The following is a guide that may influence your choice. Ones that may be considered more androgenic include those that contain Norethisterone, Levonorgestrel, Gestodene and Ethynodiol Diacetate. The better ones include those containing Medroxyprogesterone Acetate, Desorgestrol, Norgestimate, Ethinyloestradiol and Cyproterone Acetate (the last being unavailable in the USA, but available in Canada and most other countries). The Pills have different brand names but the active ingredients are on the package, so look at them carefully.
It goes without saying that you need to discuss your choice with your doctor or gynaecologist, and as these are guidelines, it is possible that the Pill best for your hair may not be suitable for your metabolism.
The misunderstandings and general mythology on the effects of pregnancy on your hair are countless.
Your hair is always important, but it will become even more so as soon as you know that you’re pregnant. It will take on a new meaning and, more than ever, you will want it to look wonderful and to use it as a sexual characteristic to enhance your appearance, particularly towards the end of your pregnancy.
A few years ago I helped in a study entitled ‘The effect of pregnancy on scalp hair and facial skin’. We studied 375 women for three years. It won’t come as a surprise to you to learn that the most frequently asked question was, ‘How will pregnancy affect my hair?’
The popular press has endorsed the theory that pregnancy is a terrific time for hair; it sometimes is and sometimes isn’t. Although skin changes are often noticeable within weeks of conception, changes in the hair are not. As hair has a growth rate of half an inch a month, it wouldn’t be possible to notice changes so rapidly (except that there may be changes in the amount of sebum produced by your sebaceous glands, and this can effect the hair’s appearance and feel).
We discovered that approximately 50 per cent of women had post-partum fall.
About a third of the pregnant women questioned in the study did see an improvement in their hair after four to five months, saying it fell out less and felt thicker. This lasted for the rest of the pregnancy. Hormonal changes during pregnancy, which include an increase in oestrogen levels and a diminishing of androgens, can cause a decrease in the production of sebum. An over-oily scalp can give the hair a heavy, limp and lanky feel, and it is the acidity of sebum that smoothes down the hair’s cuticle. When less sebum is produced, the hair appears to be drier and to have more body, so it feels thicker. Although the hair may look better, its condition has not really improved. However, oestrogens do extend the growth phase of hair, so it stays in the scalp and grows longer. This is certainly not an illusion.
On the other hand, a third of the women questioned stated the opposite! The remaining third did not notice any difference.
We also tried to connect poor hair conditions and post-partum fall with the incidence of morning sickness, but there was no correlation at all. So why some women have wonderful hair during pregnancy and others complain of it all the time is still puzzling. We know that hormonal changes during pregnancy vary and that the susceptibility of the hair follicles to these changes also varies. It is impossible to estimate in advance what the effects will be. We know that if your hair is wonderful during your first pregnancy, it could be quite the reverse during the second–or vice versa. What is certain is that women with two, three or more children tend to have less hair than women with one child. But don’t let that put you off! A woman with only one child is usually younger, so the age factor should be taken into account.
Many women also notice that their hair is terrible for the first three to four months of their pregnancy and then a miraculous change appears to occur. To make you feel better, and also because it’s true, I must say that it is rare for a woman to have problems with her hair all through the nine months. The last three months in particular should be very good for your hair.
So what can you do to ensure you get the best from your hair during these nine months? Firstly, without being told, you will automatically begin to take more care of yourself. You will eat better, do what your doctor tells you and take the supplements he gives you. You should also be less stressed, knowing you shouldn’t overexert yourself.
A growing foetus uses a huge amount of energy and, consequently, you will get tired more often, so you will need to rest whenever possible. You must follow the four-hour nutrition rule, i.e. snack on a piece of fruit if you leave more than four hours between meals. Your hair is not essential tissue like your growing baby, so it will suffer is you don’t eat regularly.
As previously mentioned, it is likely that your hair will feel progressively drier during your pregnancy. Give it an occasional drink with a moisturizing, pre-shampoo deep-conditioner. You may also need to change your shampoo or conditioner temporarily to one with a deeper moisturizing factor. Wash your hair every day, as it will look its best if clean. Go easy on the brush and don’t over-dry it with the hair dryer. Use whatever styling aids make you happy and have whatever style you want–pregnancy is rather a good time to experiment. You can perm, straighten, colour or bleach your hair if you wish.
Above all, don’t worry about your hair. Apart from a hiccup or two at the beginning, by the end of your pregnancy, the chances are that your hair will look great!
Continuing the subject of hair loss in women, there is a need to focus further on the hormonal aspect. The last two sections on PCOS and pregnancy are really examples of what hormone changes can do to hair growth. PCOS is a condition associated with younger women, since it can begin at puberty. Pregnancy is usually later and can continue into the mid-forties. But hormone changes causing the most distress are those that occur with menopause. The changes also almost always affect the hair.
The average age of menopause is around fifty but symptoms can begin long before. Apart from the more associated common symptoms of ‘hot flushes’ and discomfort, the skin begins to appear a little drier and not as elastic. This is quite easily countered by applying moisturizers, and I am sure that moisturizing cosmetics are used progressively more pre- and post-menopausally. The changes in the hair, though, are more difficult to counteract. They may begin with a heavier shedding rate or a noticed reduction in thickness (volume). Not straight away–it’s gradual. Reduction in hair volume, however, often begins long before menopause, with menopause being an extra and more accelerating cause. Not only that, from a psychological viewpoint more women begin to look even closer at themselves–they think they are now really ageing–and want to find more fault to prove their fears. The psychology of being unable to bear another child is an important aspect. However, a woman’s role does not diminish with menopause. At fifty she is still young and active and can be as attractive as she was a decade or more earlier.
Without delving further into other physiological changes, the change affecting a woman most is that which occurs with her hair. Hair is deeply psychologically sexual, and the feeling of insecurity in her sexuality with all the accompanying changes is further undermined with those in the hair.
The basis of all these changes is diminishing oestrogens.
Except for the time before puberty, oestrogens (and therefore androgens) become a greater issue throughout a woman’s life. They effect frequency of the menstrual cycle, the type of menstruation (heavy, light, long, short), sexual arousal and appetite, mood swings, skin and, of course, hair.
The diminishing oestrogens affect the cycle of hair growth–oestrogens prolong it. As the secretion of oestrogens slows down, so does the length to which the hair will grow. Additionally, androgens increase as a percentage. Androgens can cause extra facial and body hair and lessen scalp hair–not necessarily in numbers, but in diameter and length, resulting in a loss of volume or ‘body’. The hair fall could remain as it was but the replacement hairs become progressively weaker. This occurs slowly, not suddenly happen with menopause. The changes in oestrogen secretion do not occur overnight either–they are also gradual. It is inevitable that changes in hair volume begin long before the physical manifestations of menopause are noticed. But it is not unusual for women to blame the short time of, say, six months, when they first begin to realize that menopausal changes were occurring for their lack of hair.
I have for many years stated that nobody over forty has the same volume of hair they had in their twenties. So if the average age of menopause is fifty, changes would begin to occur in the early forties anyway.
The pattern of hair thinning tends to be similar to the early stages of male pattern hair loss–that is, a recession at the frontal hair line and temples. Not less hair in numbers, but smaller diameters and shorter growth. Sometimes a diffuse (generalized, overall) loss can occur, too. I can’t even attempt to guess at the number of women I have seen who have been in a state of near hysteria because of their diminishing hair. ‘I’m going to be bald like a man,’ is the cry I so often hear. Of course, they’re not; even with neglect, it is very rare for women to go bald. Yet the degree of anxiety the thought causes should not be underestimated.
You will no doubt be wondering how an apparently natural change such as menopause can be counteracted in your hair: it can, perhaps not wholly, but certainly considerably, an issue I will discuss later.
The dilemma of whether to have hormone replacement therapy continues. Studies have shown that there is the possibility of side effects such as breast cancer, heart problems, mood swings, greater tendency to cancer of the uterus and endometriosis. It all sounds frightening but the figures are rather misleading. The risks appear to be greater but the percentages are small. It is then a matter of choice–whether to alleviate the unpleasant symptoms that cause a lesser quality of life or to run the small extra risks associated with the side effects to enable you to lead a better and more comfortable existence. And often help your hair at the same time.
The choices of HRT can be confusing and complicated, and most women are guided by their doctor or gynaecologist, very few understanding or considering the effect of the medication on hair. Some can be detrimental whilst others can be beneficial. Another potential problem is that different women respond in different ways to the same HRT, and a few changes might be necessary before the correct combination is found, the result sometimes not being ultimately conducive to hair.
Basically, hormone replacement therapy is administered to restore circulating levels of oestrogen to average pre-menopausal levels in order to relieve menopausal symptoms and reduce the risk of osteoporosis.
A hysterectomy is the surgical removal of the womb, which may or may not include the removal of the ovaries. In either case, oestrogens may be administered alone. When a hysterectomy has not taken place, a progestogen must be added to the oestrogen therapy for ten to fourteen days at the end of each cycle to protect the endometrium (membrane lining the womb) against the greater cell reproduction that leads to cancer.
The oestrogen only HRTs for women without a uterus (womb) are numerous, and examples include Adgyn Estro, Climaval, Dermerstril, Elleste-Solo, Estraderm, Estradiol Implants, Evorel, Fimatrix, Femseven, Menorest, Oestrogel, Premarin, Progynova, Sandrena and Zumenon.
HRT preparations with oestrogens plus a progesterone derivative and that can be beneficial to hair include Premique, Indivina and Tridestra. All contain medroxyprogesterone acetate–usually a goodie as far as hair is concerned. Others, such as Femapak and Femoston, contain dydrogesterone–another goodie. Sometimes Premarin is given, which is oestrogen combined with Proveral as the progestogen. The combination may also be beneficial to hair.
As a further guideline, these are synthetic compounds with actions similar to those of natural progesterone. Both are hormones. There are two main groups of progestogens. All possess androgenic activity (you have already read that androgens can be detrimental to hair), however progesterone (and similar hormones) have less androgens than progestogens.
The choice of HRTs with progestogens that have a greater androgen effect is also quite large. In the main–and if possible–they should be avoided due to their possible deleterious effect on the hair. These include Adgyn Combi, Climagest, Climesse, Ellest-Duet, Estracombi, Estrapak 50, Evorel Pak, Kliofem, Kliovance and Trisequens. The progestrogen in these is Norethisterone. Another possible adverse progestogen is Levonorgestrol, which is contained in Cyclo-Progynova and Nuvelle. Livial, which contains Tibilone, a combined oestrogen and progestogen, is thought to have androgenic activity, too.
So, to sum up, the compounds to look for with regard to being hair-favourable are Dydrogesterone, Hydroxyprogesterone, Medroxyprogesterone and Natural Progesterone. Unfavourable to hair are Norgestrel, Desogestrel, Norgestinate and Gestodene. And the two most unfavourable are Norethisterone and Levonorgestral.
I hope this rather complicated list has been simplified sufficiently to enable you to make an easier choice. However, your doctor must be consulted, although a little knowledge of ‘hair adversaries’ in the choice of HRT could convince him or her in their recommendation.
Hair is not the only factor to be considered, although if you do have a hair thinning problem, you will no doubt be distressed and your doctor should be made aware of it to try to influence their choice.
