The Other Baldness: Hair Loss in Women

Approximately 21 million American women experience a slowly progressive pattern of hair thinning that may or may not be associated with increased shedding. Female pattern hair loss (FPHL) is a distressing and overwhelming affliction that eludes diagnosis, and as time marches on, it is less likely to be remediable.

The condition usually presents in one of 3 patterns:

1. A diffuse thinning of the crown region with preservation of the frontal hairline
2. Wide thinning in the frontal scalp, creating a triangular-shaped area resembling a Christmas tree
3. Thinning associated with bitemporal recession

Researchers from the University of Miami in Florida recently assembled a review addressing the problem of FPHL in its various presentations.

As FPHL is usually diagnosed by observation in a clinical setting, it is not usually associated with elevated androgens, and biopsy is rarely necessary. Women with FPHL may occasionally have other skin or general signs of hyperandrogenism such as hirsutism, acne, irregular menses, infertility, galactorrhea, and insulin resistance. If a patient does have an endocrinological abnormality, it is most often polycystic ovarian syndrome (PCOS).

According to the authors, some important diseases to consider in the differential diagnosis of FPHL include chronic telogen effluvium (CTE), permanent post-chemotherapy alopecia, alopecia areata incognito (AAI), and frontal fibrosing alopecia (FFA). These conditions differ from FPHL in many respects, and the researchers describe the key predisposing factors, tests, and clinical symptoms to look for when making a diagnosis.

Even though the US Food and Drug Administration (FDA) has only approved one treatment for FPHL known as 2% topical Minoxidil, the review authors extensively discuss off-label alternatives like 5-alfa reductase inhibitors, antiandrogens, estrogens, and prostaglandin analogs. They also discuss lasers, light treatments, and hair transplantation, as well as the lack of evidence for the use of these treatments in women with FPHL.