Managing female pattern hair loss

Female pattern hair loss is common, and the onset is often before age 40. The incidence increases with age and affects over 50% of women over 70. Let's look at how this condition can be managed in the primary care setting.

Learn more about this topic in the HealthCert online Professional Diploma program in Women's Health.

Female pattern hair loss (FPHL), previously referred to as female androgenic alopecia, is characterised by a diffuse loss of hair density over the crown and frontal areas of the head, with preservation of the frontal hairline.

FPHL has a strong genetic component and is not linked to diet or hair styling processes. Risk factors include increased age, smoking, elevated fasting glucose levels and increased scalp sun exposure.

Presenting signs and symptoms typically include thinning and visible hair loss. Eyebrows and eyelashes may also be affected, and there may be associated symptoms, e.g., hypothyroidism, iron deficiency, or perimenopause.

A detailed history should be obtained, including symptom onset and progression and past medical history (including recent infection, autoimmune disorders, endocrine disorders, and medication changes).

Hair loss in women can cause significant psychosocial distress, and it is important to ask about symptoms of associated anxiety, depression, and low self-esteem.

FPHL is typically diagnosed clinically following a physical examination. The degree of hair loss can be assessed using the Ludwig scale. Hair loss typically affects most of the scalp, with widening of the parting and preservation of the frontal hairline. Examine for associated features of systemic disease such as hirsutism, iron deficiency and hypothyroidism.

Laboratory testing is not usually necessary to diagnose FPHL. However, if the presentation is suspected to be due to an underlying condition, laboratory testing such as a full blood count, ferritin, vitamin D, thyroid function, and endocrine testing may be indicated to delineate an underlying diagnosis.

Female pattern hair loss can be effectively managed within primary care. However, referral to an appropriate specialist should be considered where there is diagnostic uncertainty, extensive hair, abnormal laboratory tests or significant psychosocial effects.

When diagnosing female pattern hair loss, counselling patients on the natural course of hair loss, including its progressive nature, is important. It is important to reassure women that FPHL rarely results in baldness.

FPHL does not require medical treatment, and a decision to commence medical therapies should be made in conjunction with the patient. Topical minoxidil is a licenced medical therapy for female pattern hair loss and may be applied as a lotion or foam. It is important to counsel women that minoxidil may take up to 4 months to have a noticeable effect and should be continued indefinitely to maintain effects.

Hormone modulatory treatments such as spironolactone and cyproterone acetate may also be considered. Other management options include using hairpieces and wigs and exploring different hairstyles to maximise aesthetics. Surgical options such as hair transplanting are also available.

Female pattern hair loss (FPHL) is a common yet often distressing condition for women. For the primary care practitioner, assessing for underlying conditions and providing a diagnosis are important before initiating a holistic and patient-centred management plan.

Dr Samantha Miller, MBChB

Learn more about this topic in the HealthCert online Professional Diploma program in Women's Health.

Read another article like this one: Post-menopause urogenital issues

References

1.    Australian Journal of General Practice (2018). Female Pattern Hair Loss. https://www1.racgp.org.au/ajgp/2018/july/female-pattern-hair-loss 
2.    The Australasian College of Dermatologists (2019). Female Pattern Hair Loss (FPHL). https://www.dermcoll.edu.au/atoz/female-pattern-hair-loss-fphl/ 
3.    Health Direct (2022). Female Pattern Hair Loss. https://www.healthdirect.gov.au/female-pattern-hair-loss 
4.    BMJ (2017). Non-hormonal treatments for menopausal symptoms. https://doi.org/10.1136/bmj.j5101
5.    National Institute for Health and Care Excellence (NICE) (2021). Clinical Knowledge Summer (CKS): Female pattern hair loss (female androgenic alopecia). https://cks.nice.org.uk/topics/female-pattern-hair-loss-female-androgenetic-alopecia
6.    Enrico Carmina et al (2019). Female Pattern Hair Loss and Androgen Excess: A Report From the Multidisciplinary Androgen Excess and PCOS Committee, The Journal of Clinical Endocrinology & Metabolism https://doi.org/10.1210/jc.2018-02548
7.    Ludwig, E. (1977) Classification of the types of androgenetic alopecia (common baldness) occurring in the female sex. British Journal of Dermatology 97(3), 247-254. 
8.    British Association of Dermatologists (2012). Patient Information Leaflet: Hair Loss Female Pattern. https://www.bad.org.uk/pils/hair-loss-female-pattern-androgenetic-alopecia/ 
9.    NHS (2021). Hair Loss. https://www.nhs.uk/conditions/hair-loss/ 
10.    NHS (2021). Women and Hair Loss: Coping Tips. https://www.nhs.uk/conditions/hair-loss/coping-tips-for-women/ 
11.    Alopecia UK (2019). Androgenic Alopecia (Pattern Hair Loss). https://www.alopecia.org.uk/androgenetic-alopecia-pattern-hair-loss 
12.    British Hair and Nail Society. Female Pattern Hair Loss. https://www.drpaulfarrant.co.uk/wp-content/uploads/2013/11/Female-Pattern-Hair-Loss-vf.pdf