Androgenetic Alopecia in Women

Symptoms

Increasing diffuse thinning of the hair occurs in the area of the middle parting. In this case, unlike androgenetic alopecia in men, not all hair is lost, but the scalp becomes visible over time. Often, a densely hairy strip remains frontally above the forehead. Dense hair is also still found on the sides and back of the head. As a rule, there is no increased hair loss such as in telogen effluvium with many hairs in the comb. The changes begin insidiously between the ages of 12 and 40 and continue to worsen during menopause or become really visible. In some patients, hair density proximal to the scalp initially remains normal, but hair does not grow to the same length as before and is thinned distally. Hair must be cut shorter to maintain the same fullness. Full hair signals health, fertility and youthfulness. Therefore, loss can be a psychosocial and emotional problem and can decrease self-esteem.

Causes

Characteristic of androgenetic alopecia is the reduction in size (called miniaturization) of the hair follicles, which subsequently form greatly reduced, fine, and thin hairs. The growth phase (anagen phase) of the follicles becomes increasingly shorter. This reduction in size is caused by increased activity of the androgen dihydrotestosterone (DHT), which is formed in the follicle by 5α-reductase from testosterone. In women, the reduced activity of aromatase also appears to be important. This enzyme converts androgens into estrogens. If its activity is too low, androgen excess occurs. This elevation is peripheral and only a minority of affected individuals have concomitant elevated serum androgen levels and symptoms of masculinization. Risk factors:

  • Heredity: alopecia is inherited from father or mother to children. The mode of inheritance is polygenic, so several genes are involved.
  • Age: The symptoms worsen with age.
  • Local androgens: dihydrotestosterone.

Diagnosis

Important findings are already from the medical history and clinical findings. Hair loss can have numerous other causes that must be excluded in the diagnosis in medical treatment, for example, hypothyroidism, hair loss after pregnancy or iron deficiency (see under telogen effluvium). Androgenetic alopecia can also occur in women as part of androgenization. However, this masculinization manifests itself in accompanying symptoms such as hirsutism, acne, low voice, and menstrual disorders.

Nonpharmacologic measures

  • Hiding under existing hair
  • Wearing a head covering or wig
  • Hair transplant

Drug treatment

The course of treatment should be documented with photographs or another method so that individual effectiveness can be assessed. Minoxidil:

  • Minoxidil is used for the external treatment of androgenetic hair loss in women and men and is considered the 1st-line agent. It is applied topically twice daily and can inhibit excessive hair loss within weeks to months and even promote new hair growth in some patients. Its efficacy has been confirmed in large clinical studies. It should be applied to dry hair and scalp. The most common adverse effects include mild eczema of the scalp. Minoxidil is a vasodilator and was developed as a blood pressure lowering agent. Therefore, systemic adverse effects are possible. Another potential problem is adherence to therapy, as the agent must be applied twice daily for a longer period of time.

Antiandrogens:

Estrogens:

  • The estradiol hair alcohol is produced in many countries as a magistral formulation. The recipe can be found in the DMS: recipe DMS. We have no data on clinical efficacy.

In Germany, solutions with alfatradiol are commercially available (Ell-Cranell). This is not an estrogen, but a 5alpha-reductase inhibitor. For the treatment of hair loss various other agents on the market.