Women Lose It, Too:
The Causes of Female-Pattern Hair Loss

• Common misperceptions about female hair loss
• Primary causes of hair loss in women
• How women can tell if they’re losing their hair

PARTICIPANTS Michael L. Reed, MD New York University School of Medicine Neil Sadick, MD Weill Cornell Medical College, New York Presbyterian Hospital

DAVID R. MARKS, MD: A lot of people who lose their hair feel embarrassed, especially women. For them, it can be a cosmetic disaster. But it's not just social factors that set male and female baldness apart. Causes and symptoms of hair loss can also be different in men and women.

Here to talk about these differences are two experts. First is Dr. Neil Sadick. He's a dermatologist and cosmetic surgeon at the Weill Cornell Medical College. Next to him, Dr. Michael Reed. He's a dermatologist and hair transplant surgeon at NYU here in New York City.

It really can be a cosmetic disaster for women, but it's something that we don't hear a lot about. Why is that?

MICHAEL REED, MD: I hear a lot about it all day long, because all women who have noticeable hair loss suffer from their hair loss. A man can choose to suffer or not to suffer, but all women suffer from hair loss. The problem is that initially they're not sure what to do, so they run off to their stylist, they talk about it with their female friends and relatives, and as you go down the list of places they go, finally, fourth or fifth down the list, they get to a dermatologist. But we see a lot of them, and we're seeing more and more of them, because now they're more aware that something can be done about it. In the past I think they were just afraid to ask because they thought there was no answer for their problem.

DAVID R. MARKS, MD: Talk to me a little more about the psychological impact on women. It's different than in men.

NEIL SADICK, MD: It's definitely devastating. It's been shown in studies that women who have hair loss have problems with interpersonal relationships, they have loss of self-esteem, and it really can have a tremendous psychosocial type of impact. They tend to be more introverted. And again, there are so many excellent treatments that are now available, and it's really not necessary for them to have to deal with this sort of emotional trauma.

DAVID R. MARKS, MD: How widespread is this problem in women?

NEIL SADICK, MD: It's interesting that the incidence of hair loss women is almost parallel to that in men. However, in women, usually the degree of hair loss is not as extensive as it is in the male population.

DAVID R. MARKS, MD: So are they hiding it better than men?

NEIL SADICK, MD: Luckily, their genes express the trait not to the same severe degree as men. They will notice the same amount, the same incidence of thinning or the same amount of thinning in terms of numbers of women compared to men, but the degree of hair loss is usually not as severe as it is in the male population.

DAVID R. MARKS, MD: What are the differences in the cause of hair loss in women, as opposed to men?

MICHAEL REED, MD: The orthodox view, meaning the correct thinking view at the present time, is that women lose their hair, most of them, for the same reason that men do -- from genetics. It's called female pattern -- as opposed to male pattern -- androgenetic alopecia, which means hair loss caused by a sensitivity to male type hormones, which men and women both have. It's just that women have lower levels and have an effect later than men. They're more protected by their estrogen for a period of time, but it's for the same reason. It's just that they have it happen later, it goes more slowly, and the pattern is such that it's easier to cover it up than it is for men.

If I lose half my hair and it's on the top of my head, I'm going to be bald. If I lose half my hair and I'm a woman, it's diffused all over my head, it's just going to be thin hair or see-through hair.

DAVID R. MARKS, MD: Are there some myths that women have about what could cause their hair loss? Washing their hair too vigorously?

NEIL SADICK, MD: People commonly feel that way when they begin losing their hair on a genetic basis. They feel that anything they do will cause the hair to accelerate, such as emotional trauma, washing their hair too often, poor diets, but those truly are myths. I mean, there is a new enzyme called aromatase that's felt to play a role in female pattern hair loss. 5 alpha reductase is felt to be the major enzyme in men. The pattern tends to be more diffuse, as has been mentioned, in women, but it truly is a great trauma, and we need to educate women more about hair loss, because there are some excellent treatments for them.

DAVID R. MARKS, MD: How can a woman tell if she's actually losing her hair, if it's so hard to detect?

MICHAEL REED, MD: First off, it's said that we have to lose 50% of our hair in any given area before it starts to be noticeably thin. A lot of women notice it long before then. In fact, they say that everyone thinks they're crazy, but they're not. Their hair doesn't grow as well. It doesn't have the mass and bulk it used to, so women notice it long before people looking at them will notice it, and it's not an illusion. It's real. There's very few people with delusions of hair loss. They can just tell by the texture, by the body, that it's not the hair it used to be.

Finally, though, it gets to the point where they begin to see scalp and not hair. Especially in women, right behind the hairline they tend to get a round or oval-shaped area that gets very, very thin, and those women, because of the location especially, come to the doctor and seek treatment.

DAVID R. MARKS, MD: There are some other causes we should talk about. There's telogen effluvium. What is that?

NEIL SADICK, MD: Telogen effluvium, David, is where the hair goes into a resting or shock phase after any type of insult. The major causes of this resting type of hair shedding is -- usually the most common cause is after pregnancy. Three to six months after delivering a child, commonly women will notice a great degree of hair loss as the hair cycles into a resting phase because of the physiologic insult of pregnancy.

This can also occur -- commonly we see it in women who are on crash diets and lose a great deal of weight over a short period of time, and also it can be seen after acute illnesses, such as an acute infectious illness. Anything that puts stress on the body can cause the body to recycle its hair into a resting phase and cause acute hair shedding, called telogen effluvium.

DAVID R. MARKS, MD: Does the body then recover into a normal growth cycle?

NEIL SADICK, MD: Yes, that usually does occur. Because the body is able to compensate for this insult, usually three to nine months after the insult, the hair will begin to regrow, and usually in most cases between 90 and 100% of hair regrowth can be expected in this case.

DAVID R. MARKS, MD: There are some other causes of hair loss that may be a little bit less common. There's an allergic type of hair loss.

MICHAEL REED, MD: The third most common cause that we see in clinical practice is a condition called alopecia areata. Areata is Latin for round or circumscribed, which means that people see suddenly bald spots here or there, or little, tiny short hairs that are broken off. Sometimes it's noticed by the person cutting their hair. It's often related to some stressful event, and it's believed to be some type of immunologic imbalance where the immune system goes after its own hair for some unknown reason and causes them to go into the resting phase and slow down their growth so they break off or come out. A lot of times it regrows by itself. In fact, probably most people who have it don't come to the doctor. It just goes away by itself.

But a small number of people have very severe problems. Some people will lose all the hair on their head, and some people all the hair on their body. You'll see these groups of women in support groups. There's the National Alopecia Areata Foundation for people with more severe conditions like this. It's quite a common condition.

DAVID R. MARKS, MD: Where can women go to find out more information about hair loss?

NEIL SADICK, MD: There are a number of different support groups and education groups that are available. One can consult the American Academy of Dermatology. There's the International Society of Hair Restoration Surgery. As has been mentioned, there is the Alopecia Areata Foundation, and there's also a National Hair Council. So these are common information areas that patients can look to for help and support in dealing with their particular problems.

DAVID R. MARKS, MD: But the first place to start may be a dermatologist?

MICHAEL REED, MD: If the hair loss has any unusual features -- suddenly a lot of hair is coming out, if hair is coming out in a bizarre or unusual pattern, even if it's very severe and premature general thinning of the scalp, see a dermatologist. Dermatologists are trained in medical -- and some of them also in surgical -- treatment of hair loss. They're the people to see first.

DAVID R. MARKS, MD: Thank you both for joining us. Thank you for joining our webcast. I'm Dr. David Marks. Goodbye.