Check out my paper on treating female pattern hair loss – just published in the December 2012 issue of “Naturopathic Doctor News and Reviews”, the leading Naturopathic Journal in North America:
Treating Female Pattern Hair Loss
What is Female Pattern Hair Loss?
Female pattern hair loss (FPHL) is a common condition characterized by a diffuse reduction in hair density over the crown and frontal scalp with retention of the frontal hairline.[i] As many as 10 percent of pre-menopausal women reportedly have some evidence of FPHL; however, the incidence increases greatly in menopausal women. As many as 50-75 percent of women 65 years or older may be affected by FPHL.[ii] The psychological implications of FPHL are profound; there is a significant association between perceptions of hair loss and rates of depression in women.[iii]
What Causes Female Pattern Hair Loss?
Unlike Male Pattern Hair Loss, which is clearly linked to increased androgen activity, the cause of FPHL is not as clear cut. In some cases, hyperandrogenism is connected with FPHL, but in many cases there is no evidence of increased androgenic activity. [iv]
Women with FPHL due to hyperandrogenism often exhibit other signs of increased androgens, such as hirsuitism, acne, and menstrual disturbances. If these symptoms exist, elevated serum androgens are not always necessary to attribute the FPHL to hyperandrogenism. [v] In women, most androgens are produced in either the adrenals or the ovary.
In cases where FPHL is observed, yet androgens are not elevated, the official cause is uncertain.
Regardless of whether the FPHL is androgen dependent or not, the follicular changes are the same; the anagen phase of the hair growth cycle appears to be shortened [vi] and follicular miniaturization occurs, which results in smaller and finer hairs being produced with each hair cycle. This causes the hair to become finer as time progresses, and can eventually result in scarring alopecia, where the hair follicle stops producing hair altogether.
Evaluating Female Pattern Hair Loss
Female pattern hair loss may mimic other conditions, and a proper evaluation should be done to rule out telogen effluvium, alopecia areata, and early cicatricial alopecia. The most common condition that can mimic female pattern hair loss is telogen effluvium, which is characterized by thinning/shedding of hair resulting from the early entry of hairs into the telogen phase.[vii] This pattern can be the result of emotional or physiological stress, such as eating disorders, fever, childbirth, chronic illness, surgery anemia, emotional disorders, crash diets, hypothyroidism, and drugs.[viii] Telogen effluvium is non-scarring, or reversible, and it does not result in the miniaturization of hair follicles.
A full naturopathic work-up includes the following tests:
- Complete Hormone Panel – Free testosterone, DHEAs, LH/FSH, Progesterone, Estradial, Estrone, Cortisol, DHT: A complete hormone panel is necessary to evaluate FPHL. Often there will be elevated levels of free testosterone or DHEAs, or the LH/FSH ratio will be elevated. This LH/FSH ratio is normally 1:1, but if it is elevated to 2:1 to 3:1, a diagnosis of polycystic ovarian syndrome may be considered. [ix] Androgens are converted to estrogens via the aromatase enzyme, so elevated levels of estrone and estradial may also indicate excess androgenic activity. Low levels of progesterone can also contribute to FPHL. Testosterone converts to DHT, or dihyroxytestosterone, with the aid of the enzyme Type II 5-alpha reductase, which is found in the hair follicles. DHT is the main perpetrator of androgenic hair loss,[x] and its levels can be high despite normal testosterone levels, due to the over activity of 5-alpha reductase. [xi] It must be noted that although DHT is a proven contributor to male pattern hair loss, its involvement in FPHL is not as well understood.
- CBC, TIBC, Iron, Ferritin: Iron deficiency is associated with hair loss. [xii] Hair follicles contain ferritin, and reduced stores of ferritin in the follicle can lead to the production of vellous (non-pigmented fine hair) which can mimic the hair miniaturization observed in female pattern hair loss. [xiii]
- TSH, free T3, free T4: Hair follicles are direct targets of the thyroid hormones T3 and T4, which modulate hair biology parameters from cycling to pigmentation. Specifically, T4 encourages hair growth and a combination of T3 and T4 down-regulate programmed cell death.[xiv]
- Vitamins and Trace Minerals – Zinc, Copper, RBC Mg, Manganese, Vitamin B12, Folic Acid, Vitamin D 25 Hydroxy, Vitamin C: Many nutrient deficiencies have been linked with hair loss. See Table 1 for more information.
- Heavy Metals: One study suggests that certain people with alopecia may have higher lead, cadmium and copper levels, which can potentially to displace zinc and contribute to alopecia. [xv] If heavy metals are detected, a heavy metal detox must be implemented so the body can rebalance itself.
Naturopathic Treatments for Female Pattern Hair Loss
Treating hair loss is not easy, and the results of treatment are often not observed for months. Patience is required for both the practitioner and the patient. However, fortifying the general health of the patient, including diet therapy, insulin regulation, adrenal health, and hormonal regulation will provide a strong foundation for success.
Optimal Nutrition, Vitamins and Minerals
As Hippocrates famously advised thousands of years ago: Let food be thy medicine. As with any naturopathic treatment, proper nourishment is required to firmly establish health and resolve illness. Treating any type of hair loss, including female pattern hair loss, is no exception. Proper gut health and food absorption should be established, and the diet should consist of lean, organic protein, vegetables, fruits, nuts and seeds. Refined, simple carbohydrates should be avoided completely to avoid insulin reactivity and adequate protein incorporated into the diet. Ensure that all the nutrients outlined in Table 1 are evaluated and corrected if necessary. A standard protocol of zinc, biotin, manganese and silica supplementation may be helpful in FPHL.
Balance Insulin Levels
Research has shown that high insulin levels have been linked to both female and male pattern hair loss, [xvi] and there have been significant positive associations between female pattern hair loss and metabolic syndrome. [xvii], [xviii] In addition to diet therapy, there are a variety of herbs and nutraceuticals that can be used to treat insulin resistance and metabolic syndrome. Inositol, which helps to establish healthy cell membranes and plays a role in fat metabolism, has been shown to reduce the symptoms of both insulin resistance and increased androgen levels,[xix] both hallmarks of polycystic ovarian syndrome. Gymnema sylvestre is another naturopathic remedy that can be used to manage insulin resistance and metabolic syndrome; the gymnemic acids in the plant curb the binding of carbohydrates to the receptors in the intestine, thus limiting glucose absorption and reducing the insulin response.[xx] In addition to inositol and gymnema, recent research has suggested that the plant-based compounds rho-iso-alpha acids (RIAA) from Humulus lupulus (hops) and proanthocyanidins (PAC) from Acacia nilotica have been shown to modulate insulin signaling. [xxi] This formulation has been particularly useful in my clinical practice.
Strengthen the Adrenals
Managing the effects of stress is a necessity in any successful naturopathic treatment, and hair loss is no exception. In fact, stress is directly related to alopecia areata, telogen effluvium and trichotillomania. [xxii] In the case of FPHL, stress can trigger increased production of the androgen DHEAs,[xxiii] which is produced exclusively in the adrenal glands. Stress reduction and management are critical, and the selection of adaptagens must be done carefully, as many adaptagens can actually increase androgens. Adaptagenic herbs that tend to be anti-androgenic include foeniculum vulgare, urtica dioca, ocimum sanctum, and trigonella foenum-graecum. [xxiv] Even in cases of FPHL where androgens are not elevated, a stress management and adrenal strengthening program is indicated, as reducing stress can only improve the body’s ability to strengthen itself and function optimally.
Balance Androgen Levels
If androgens are elevated, a protocol to reduce the androgens must be implemented. In addition to using the aforementioned anti-androgenic adaptogens, serenoa repens is an herb with a long history of reducing androgens through its DHT-blocking action. [xxv], [xxvi] Other herbs which have been shown to lower DHT activity include pygeum africanum and urtica dioica,[xxvii] and herbs that inhibit 5 alpha reductase activity include camellia sinesis and panax ginseng.[xxviii] Although the efficacy of anti-androgenic herbs has been studied mainly on male patients, many clinicians routinely prescribe these herbs for the symptoms of PCOS and FPHL.
Balance Progesterone Levels
In addition to evaluating and treating high androgen levels, it is imperative that estrogen and progesterone levels are examined. Estrogen dominance, which is a very common condition, can arise due to environmental estrogens, decreased nutrition, the oral birth control pill, and anovulatory periods. This situation results in elevated levels of estrogen and decreased levels of progesterone. Not only is progesterone an antagonist to DHT, the testosterone metabolite that wreaks havoc with hair follicles, but the body responds to low levels of progesterone by increasing it’s production of the adrenal cortical steroid, androstenedione. Androstenedione is an alternative precursor for the production of other adrenal cortical hormones and it conveys some androgenic activity. When progesterone levels are raised by progesterone supplements, the androstenedione level will gradually fall, and normal hair growth will eventually resume. Since hair growth is a slow process, it may take 4-6 months for the effects to become apparent.[xxix] The best known herb to increase progesterone levels is vitex agnus-castus ,[xxx] although its action of increasing lutenizing hormone levels may antagonize some symptoms of PCOS. Alternately, bio-identical progesterone cream can be used to successfully increase progesterone levels.
Topical solutions should not be overlooked when treating FPHL as the hair follicles are easily accessible with topical medications. Although topical applications may not completely resolve the problem, they can offer an effective solution while long-term, permanent solutions are being implemented. In fact, currently the only FDA-approved treatment for female pattern hair loss is topical minoxidil (2%).[xxxi] And a 2004 study reported that the topical application of 1% melatonin solution for 6 months in women with androgenic or diffuse hair loss resulted in a significantly increased anagen hair rate, resulting in reduced hair loss.[xxxii]
Essential oils have been anecdotally used to treat alopecia of all kinds for over 100 years. Cedarwood, lavender, thyme, and rosemary oils are purported to have hair growth-promoting properties, and a study conducted in 1998 found these oils successful in the treatment of alopecia areata.[xxxiii]
Using emu oil as a carrier for the above mentioned essential oils may be an excellent therapeutic option for FPHL. A study published by Dr. Michael Horlick of Boston University School of Medicine in the January 1996 issue of “Drug and Cosmetic Industry” Magazine claims that topical application of emu oil shifted 80% of hair follicles from resting to anagen phase. Emu oil contains oleic acid, which gives it the ability to penetrate deeply into the scalp. It is also anti-inflammatory and functions as a 5 alpha reductase inhibitor. [xxxiv]
Mesotherapy is technique that can also be beneficial for FPHL. Shallow injections deliver vitamins, minerals, and botanicals directly to the hair follicles, providing nutrition and anti-androgenic action. Although there are not any studies confirming its efficacy, mesotherapy is a common treatment for FPHL in Europe and South America.
Daily hair washing may also be used to treat FPHL as it can help to eliminate excess sebum from the hair follicle, [xxxv] which can contribute to clogging , congestion and impairment of the hair follicle function.
In conclusion, although the naturopathic treatment of FPHL is not always easy, it is imperative that we continue to research and share our experiences with this condition, as there are many women out there that need our help.
[i] Olsen EA. Female pattern hair loss. J Am Acad Dermatol 2001;45:570-80.
[ii] Norwood OT. Incidence of female androgenetic alopecia (female pattern alopecia). Dermatol Surg. 2001 Jan;27(1):53-4.
[iii] Schmitt JV, Ribeiro CF, Souza FH, Siqueira EB, Bebber FR. Hair loss perception and symptoms of depression in female outpatients attending a general dermatology clinic. An Bras Dermatol. 2012 Jun;87(3):412-7.
[iv] Futterweit MD, Dunaif A, Yeh H-C, Kingsley P. The prevalance of hyperandrogenism in 109 consecutive female patients with diffuse alopecia. J Am Acad Dermatol 1988;19:831-6.
[v] Elise A. Olsen, MD,a Andrew G. Messenger, MD,b Jerry Shapiro, MD,c Wilma F. Bergfeld, MD,d Maria K. Hordinsky, MD,e Janet L. Roberts, MD,f Dow Stough, MD,g Ken Washenik, MD, PhDh and David A. Whiting, MDi Evaluation and treatment of male and female Pattern hair loss. J Am Acad Dermatol. 2005 Feb;52(2):301-11.
[x] Andersson S, Berman DM, Jenkins EP, Russell DW. Deletion of steroid 5-alpha-reductase 2 gene in male pseudohermaphroditism. Nature 1991;354:159-61.
[xiv] Nina van Beek, Enikő Bodó, Arno Kromminga, Erzsébet Gáspár, Katja Meyer, Michal A. Zmijewski, Andrzej Slominski, Björn E. Wenzel, and Ralf Paus Thyroid Hormones Directly Alter Human Hair Follicle Functions: Anagen Prolongation and Stimulation of Both Hair Matrix Keratinocyte Proliferation and Hair Pigmentation. JCEM 2008 93: 4381-4388; doi:10.1210/jc.2008-0283
[xv] NAGINIENE R. (1) ; ABDRACHMANOVAS O. (1) ; KREGZDYTE R. (1) ; RYSELIS S. Investigation of heavy metals in people with alopecia. Trace elements and electrolytes 2002, vol. 19, no2, pp. 87-90 (8 ref.)
[xvi] Signorello LB et al. Hormones and hair patterning in men: A role for insulin-like growth factor-1. Journal of the American Academy of Dermatology February, 1999;40:200-203.
[xvii] Yi SM, Son SW, Lee KG, Kim SH, Lee SK, Cho ER, Kim IH, Shin C. Gender-specific association of androgenetic alopecia with metabolic syndrome in middle-aged Korean population. Br J Dermatol. 2012 Apr 5. doi: 10.1111/j.1365-2133.2012.10978.x. [Epub ahead of print]
[xviii] Matilainen V, Laakso M, Hirsso P, Koskela P, Rajala U, Keinänen-Kiukaanniemi S Hair loss, insulin resistance, and heredity in middle-aged women. A population-based study. J Cardiovasc Risk. 2003 Jun;10(3):227-31.
[xix] Iuorno MJ, Jakubowicz DJ, Baillargeon JP, Dillon P, Gunn RD, Allan G, Nestler JE. “Effects of d-chiro-inositol in lean women with the polycystic ovary syndrome.” Endocr Pract. 2002 Nov-Dec;8(6):417-23.
[xxi] Minich DM, Lerman RH, Darland G, Babish JG, Pacioretty LM, Bland JS, Tripp ML. Hop and Acacia Phytochemicals Decreased Lipotoxicity in 3T3-L1 Adipocytes, db/db Mice, and Individuals with Metabolic Syndrome. J Nutr Metab. 2010;2010. pii: 467316. Epub 2010 May 18.
Genetic variation in 11beta-hydroxysteroid dehydrogenase type 1 predicts adrenal hyperandrogenism among lean women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2006 Jun;91(6):2295-302. Epub 2006 Mar 21.
[xxv] Marks LS, Hess DL, Dorey FJ, Luz Macairan M, Cruz Santos PB and Tyler VE: Tissue effects of saw palmetto and finasteride: use of biopsy cores for in situ quantification of prostatic androgens Urology 2001 May; 57(5):999-1005
[xxvi] Chizick, et al.: Natural preparation for treatment of male pattern hair loss. October 26, 1999 United States patent 5,972,345
[xxviii] R. Kaushik, D. Gupta, R. Yadav: Alopecia: Herbal Remedies; International Journal of Pharmaceutical Sciences and Research, 2011; Vol. 2(7): 1631-1637
[xxix] Lee, John R. What Your Doctor May Not Tell You About Menopause. Warner Books Inc, 1996. Page 323
[xxx] Milewicz A, Gejdel E, Sworen H, Sienkiewicz K, Jedrzejak J, Teucher T, Schmitz H. Vitex agnus castus extract in the treatment of luteal phase defects due to latent hyperprolactinemia. Results of a randomized placebo-controlled double-blind study. Arzneimittelforschung. 1993 Jul;43(7):752-6. German.
[xxxi] Elise A. Olsen, MD, Andrew G. Messenger, MD,b Jerry Shapiro, MD,c Wilma F. Bergfeld, MD,d Maria K. Hordinsky, MD,e Janet L. Roberts, MD,f Dow Stough, MD,g Ken Washenik, MD, PhDh and David A. Whiting, MDi Evaluation and treatment of male and female Pattern hair loss. J Am Acad Dermatol. 2005 Feb;52(2):301-11.
[xxxii] Fischer TW; Burmeister G; Schmidt HW; Elser P. Melatonin increases anagen hair rate in women with androgenic alopecia or diffuse alopecia: results of a pilot randomized controlled trail. Br J Dermatol 2004 Feb;150(2):341-5
[xxxiii] Hay I; Jamieson M; Ormerod A; Randomized Trial of Aromatherapy – Successful Treatment for Alopecia Aereata. Arch Dermatol. 1998; 134(11):1349-1352