Female Pattern Hair Loss – Part 1

Dr Shahram Sadeghi | North Brisbane Cosmetic Clinic | Elinay Cosmetic Surgery Centre

Female Pattern Hair Loss: Epidemiology, Mechanism, Classification, Diagnosis and Treatment Options

Dr Shahram Sadeghi M.D,FRACGP, Ph.D, Registrar Australasian College of Cosmetic Surgery, Dr Russell Knudsen MBBS, FFMACCS


Hair loss is a frequent and stressful event for women(1). Despite being prevalent in up to 50% among women as they age, its’ severity is underestimated by women. In addition, due to complexity of treatment, it is undertreated or even ignored by doctors(2, 3). Among many different causes of hair loss in women, female pattern hair loss (FPHL) is the most common cause of hair loss. FPHL is most often described as reduced hair density in crown and frontal scalp while the frontal hairline remains intact(2, 4). Affected women may experience psychological distress and it can deteriorate their quality of life by affecting their appearance.

Hyperandrogenism and the role of these hormones on hair follicles has been well explained and related to MPHL, however its’ role in FPHL is less certain. Probably the best way to describe FPHL is that anagen phase of scalp hair reduces and activation of local androgens in scalp skin accelerates this process (5).Furthermore, unlike male pattern hair loss, family history is not always a easily identified risk factor. Due to this ambiguity in aetiology, there hasn’t been a worldwide accepted algorithm for the treatment of FPHL.

Diagnosis should be made based on history, close clinical examination, biochemical and hormonal tests and scalp biopsy to rule out other causes including acute telogen effluvium and chronic telogen effluvium. Pharmacological interventions, including topical minoxidil, 5α reductase inhibitors (finasteride and dutasteride), anti-androgenic medications (including spironolactone and cyproterone) have all been suggested. Furthermore, low energy laser treatment also has been used successfully in some institutions. In some suitable candidates, surgical interventions, such as hair transplants have also been employed. There hasn’t, however, been a clear comprehensive publication to present these interventions in a practical order.

We used “Embase”, “Medline” and “Cochrane” databases to search for latest publications about FPHL, including all identified studies and systematic reviews with interest in diagnosis, classification and treatment of this condition. They were critically reviewed and their findings were summarised in a practical format. This review aims to provide a sound knowledge about prevalence and incidence and classification of FPHL, its’ patterns, possible causes, diagnosis and treatment options. In this summary we will try to provide a practical algorithm about how to approach and manage FPHL.

Hair is a major factor of the self-esteem and the feeling of attractiveness among women(1). Interestingly, women tend to underestimate the severity of their hair loss more than their treating doctors and therefore there are potentially more patients with hair loss than those already seeking treatment (2).

Hair loss can be classified as scarring (rare) and non-scarring hair loss. Discoid lupus erythematosus is an examples for scarring hair loss. The main causes of non-scarring hair loss are alopecia areata or alopecia totalis, telogen effluvium, anagen effluvium and female pattern hair loss (FPHL). Differentiation of these types of hair loss is crucial as each of them needs a different approach. Appropriate history, physical examination, and biochemical and histological investigations are the key to the right diagnosis (6). Alopecia areata represents itself as distinct patches of hair loss on hair bearing areas of the scalp while alopecia totalis involves the whole scalp. In both of these conditions hair loss is complete and is characterised by presence of hair loss and hair breakage (7). Telogen effluvium is categorised as acute or chronic. Acute telogen effluvium can be seen among patients with previous history of severe physical or psychological illness, prolonged surgery or anaesthesia, pregnancy, blood loss, or crash dieting. Chronic telogen effluvium is seen in patients with underactive thyroid, SLE, iron deficiency anaemia or history of taking certain medications (8, 9). Sometimes there seems to be no initiating cause. The history of these medical conditions can go back as much as 6 to 8 months (9). The most commonly reported drugs that can cause hair loss include chemotherapy agents, amphetamines, allopurinol, aspirin, carbamazepine, beta blockers, warfarin, heparin, isotretinoin, levodopa, lithium, propylthiouracil and Vitamine A (10-12). There has also been case reports of hair loss by bromocriptine, an ergot derivate used for the treatment of hyperprolactinemia(13) and Paroxetine a Selective Serotonin Reuptake Inhibitor (SSRI) (14).

Female pattern hair loss (FPHL) is the most common cause of hair loss among women(2). In this type of hair loss, terminal hair follicles transform to small and unpigmented vellus hair follicles and there is also reduction in the number of pilosebaceous units of scalp.Clinically it is generally described as reduced hair density in the crown and frontal scalp while frontal hairline remains intact (4). In severe cases it can extend variably into the lower scalp. Affected women may experience psychological distress and it can deteriorate their quality of life as women pay more attention to their looks than men. Prevalence and the intensity of FPHL increases with age from 12% among women younger than 30 to 25%-32% among women aged 65 to 80 and more than 50% in women 80 years or older(3).

Olsen has categorised FPHL occurrence into two peaks: early onset in teen age with more severe hair loss if left untreated, and late onset in the 40s or later in life with less severe presentation of hair loss but with a higher incidence (15). Despite being a common problem, our knowledge about FPHL is limited and there is not a general agreement on how to treat it.