Hair loss in women

Abstract

Hair loss is a common clinical problem in women. Female alopecia with androgen increase is called female androgenetic alopecia (FAGA) and without androgen increase is called female pattern hair loss (FPHL). The clinical picture of typical FAGA begins with a specific “diffuse loss of hair from the parietal or frontovertical areas with an intact frontal hair implantation line”. Ludwig called this process “rarefaction”. In Ludwig’s classification of hair loss in women, progressive type of FAGA, 3 patterns were described: grade I or minimal, grade II or moderate and grade III or severe. Ludwig also described female androgenetic alopecia of male pattern (FAGA.M) that should be subclassified according to Ebling’s or Hamilton-Norwood classification. A more recent classification (Olsen’s classification of FPHL) proposes 2 types: early- and late-onset with or without excess of androgens in each. The diagnosis of FPHL is made by clinical history, clinical examination with measurement of natural female hairline, wash test, trichograms and laboratory test, especially androgenic determinations. Topical treatment of FPHL is with minoxidil 2–5% twice daily. When FAGA is associated with high levels of androgens, systemic antiandrogenic therapy is needed. Persistent adrenarche syndrome (adrenal SAHA – seborrhea, acne, hirsutism, alopecia) and alopecia of adrenal hyperandrogenism is treated with adrenal suppression and antiandrogens. Adrenal suppression is achieved with glucocorticosteroids. Antiandrogens therapy includes cyproterone acetate, drospirenone, spironolactone, flutamide, finasteride and dutasteride. Excess release of ovarian androgens (ovarian SAHA) and alopecia of ovarian hyperandrogenism is treated with ovarian suppression and antiandrogens. Ovarian suppression includes the use of contraceptives containing an estrogen, ethinylestradiol, and a progestogen. Antiandrogens such as cyproterone acetate, always accompanied by tricyclic contraceptives, are the best choice of antiandrogens to use in patients with FAGA. Gonadotropin-releasing hormone agonists such as leuprolide acetate suppress pituitary and gonadal function through a reduction in luteinizing hormone and follicle stimulating hormone levels. Subsequently, ovarian steroids levels also will be reduced, especially in patients with polycystic ovary syndrome. When polycystic ovary syndrome is associated with insulin resistance, metformin must be considered as treatment. Hyperprolactinemic SAHA and alopecia of pituitary hyperandrogenism should be treated with bromocriptine or cabergoline. Postmenopausal alopecia, with previous high levels of androgens or with prostatic-specific antigen greater than 0.04 ng/ml, improves with finasteride or dutasteride. Postmenopausal alopecia in normoandrogenic women also improves with finasteride at a dose of 2.5 mg per day, or dutasteride at dose of 0.5 mg per day. Weight loss undoubtedly improves hair loss in hyperandrogenic women.