Losing your hair might not be the most medically concerning symptom on its own, but its effects on mental health, social well-being, and personal identity can’t be understated. As Dr. Barbra Hanna, FACOG, NCMP, put it, “negative body image, poorer self-esteem, and feeling less control over their life” compound with other “menopause symptoms that can make one feel as if an alien has invaded their body” to make the time around menopause extremely difficult for many women. Many women suffer for years with thinning hair and widening parts before seeking help, sometimes only to have their concerns dismissed.
Menopause-related hair loss is normal. That being said, it is worth consulting a physician if it concerns you. It can sometimes be prevented or treated, and while it is an emotional subject, it should not cause embarrassment.
Androgenetic Alopecia, or Pattern Hair Loss
Depending on the study, the prevalence of alopecia in women is between 20 and 40%. It seems to affect white women more than those of Asian or Black descent. While it can occur at any point in life, it overwhelmingly occurs following menopause or 12 months of amenorrhea (absence of menstruation).
Most hair loss, in men or women, is androgenic alopecia. Also called androgenetic alopecia, pattern hair loss, or pattern alopecia, the term female pattern hair loss (FPHL) is often preferred specifically for women because the exact role of androgens isn’t completely understood.
Unfortunately, the research on female pattern hair loss is somewhat lacking, especially compared to male pattern hair loss (MPHL). That being said, while we don’t have as much information about FPHL, it does share a lot of commonalities with MPHL.
Human hair growth follows a three-phase cycle. First is anagen, the growth phase, during which the hair actively grows and lengthens. Next comes catagen, a transitional phase wherein the hair is cut off from the blood supply, and the follicle prepares to grow a new hair. Last is telogen, the loss phase, during which the hair is technically dead but still anchored to the scalp, and the follicle is focused on the next hair it will grow.
Every day, it’s normal to lose roughly 50-100 hairs. Most of them come from the last phase, telogen. Since the hair is no longer firmly attached to the scalp, it can be easily pulled free by brushing or friction, and as the follicle enters anagen again, the newly growing hair will push the dead one out, making it even easier to pull out.
Androgenetic alopecia, or pattern hair loss, occurs when testosterone is metabolized into dihydrotestosterone (DHT), which can interact with androgen receptors in hairs. As a result, follicles can be induced to miniaturize or produce thinner, more brittle hairs. Miniaturized follicles have a shorter anagen phase, grow slower, are anchored less securely, and are easily broken off, leading to shorter hairs overall.
Why do only some follicles miniaturize? That’s where the genetic part of androgenetic alopecia comes in. In men, hundreds of genetic loci are associated with hair loss, and many more are likely yet undiscovered. Research on women is lacking, but they’re believed to have many of the same genetic factors and some unique ones. Many—but not all—of them are located on the X chromosome. This can help explain the common observation that balding status seems to be passed down to you from your mother’s lineage. However, just because your mom has a full head of hair is not a guarantee that you’re in the clear.
How Female and Male Pattern Hair Loss Differ
Compared to MPHL, which tends to start around the temples and crown of the head, FPHL often presents as a diffuse loss of hair density or a widening part. Often, women first notice that their ponytail seems smaller. Some women experience sunburns on their scalps, as they have less hair to act as a protective cover.
The pattern of MPHL is due to regional differences in follicle sensitivity to DHT. The different pattern of FPHL is another clue that the two conditions are partially analogous. Women experiencing disorders of hyperandrogenism (overly sensitive responses to androgens), like polycystic ovarian syndrome, may develop FPHL as a symptom, implicating androgens. On the other hand, androgen levels are normal in most women with FPHL—in a study of 109 patients with moderate or severe FPHL, hyperandrogenism was found in only 39%. We do not yet have all the pieces of this puzzle.
FPHL tends to be noticed around menopause, not necessarily because it begins then, but because the sudden loss of hormones causes it to accelerate. Dr. Mary Wendel, the medical director of Medi Tresse, told me that “changes that start to occur in the early 40’s accelerate the [hair] loss and make it more noticeable. The decrease in estrogen and progesterone allows the testosterone to have a stronger effect.” In addition, Dr. Mel David-Hall, DFSRH, MRCGP, explained, “It is thought that estrogen may play a role in stimulating hair growth so the loss of estrogen during menopause may accelerate FPHL.”
Other changes typically occurring near perimenopause or menopause can also affect hair loss. Dr. Wendel wrote, “Circulation tends to decrease with aging, and that likely includes in the scalp. Without good circulation, nutrients that help maintain thick hair cannot get to the follicle where it is needed.” Dr. Hanna explained, “The perimenopause transition increases an individual’s risk of diabetes and high blood pressure, both of which have been associated with hair loss.” Midlife tends to be a busy and stressful time for many women. Not only can stress lead to hair loss (more on that later), but it can also lead to exercising less, eating a less balanced diet, and poor sleep, all of which are implicated in hair loss.
Treatments
For women experiencing hair loss around menopause, the good news is that there are treatment options with good evidence behind them. Daily application of Minoxidil, known by its trade names Rogaine (U.S./Canada) or Regaine (U.K.), in a 2% or 5% foam or liquid, has been shown to help reverse hair loss. Finasteride, marketed as Propecia or Proscar, has less evidence for FPHL but plenty for MPHL and is FDA-approved for women. While hormone replacement therapy has been shown to help with FPHL, evidence is insufficient to recommend it solely for that purpose.
Unfortunately, despite, as Dr. David-Hall put it, “the high level of unmet need,” the FDA has not approved any new treatments for pattern hair loss in men or women in decades. However, there are still plenty of non-FDA-approved treatments on the market. Some, like platelet-rich plasma, low-level laser therapy, and microneedling, have had mixed results in research studies. Many doctors I contacted recommended one or more of these interventions, but buyers beware when we don’t have robust clinical evidence to support a treatment.
There are countless vitamins, supplements, and natural health products marketed for hair health, and if you suffer from a nutritional deficiency, it can undoubtedly affect your hair. For example, iron deficiency has been implicated as contributing to hair loss. However, as Dr. Hanna put it, “unless you are suffering from a nutritional deficiency confirmed by lab testing,” supplements aren’t liable to help much, if at all.
Overall, it is much easier to keep the hair you have than it is to regrow lost hair. So, prevention is key! Be kind to your hair. Avoid excessive applications of heat and chemical products like dyes and perming solutions, which can compromise the cuticle of your hair. Condition your hair to keep it moisturized. Try not to wear tight hairstyles like braids, buns, or weaves for long periods, as these can lead to hair loss called traction alopecia, particularly for those with miniaturized hair follicles. If your hair is particularly long, the added weight could contribute to hair loss, so you may want to consider a cute pixie cut or bob.
Other Causes of Alopecia
Knowing about other non-genetic, non-menopause-related factors that could lead to hair loss is important—certain medications—famously chemotherapy agents—but also anticoagulants, amphetamines, antiretrovirals, and more. Smoking has been implicated as a contributing factor, as has physical trauma to the scalp and extreme stress.
A type of hair loss called telogen effluvium occurs when an abnormally high number of hairs enter the telogen phase at the same time. This can be triggered by an emotional shock like a death or a rapid change in hormones such as those accompanying the end of a pregnancy (whether it ends in birth, miscarriage, or abortion). As hairs typically spend 2-3 months in the telogen phase before falling out, hair loss might only occur a few months after the big event. Dr. Kathleen Jordan, the Chief Medical Officer at Midi Health, told me that they saw rates of telogen effluvium skyrocket during the pandemic.
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