Female Pattern Hair Loss
 
Susan Kingsley, MBA, PhD (Susan Kingsley, a professional medical writer and President of BioPharma Solutions in Vancouver, BC, Canada, is an independent consultant to the ISHRS and assisted the Forum in covering several keynote talks at the ISHRS Annual Meeting in Vancouver.)
 
Based on Dr. Elise A, Olsen's "Female Pattern Hair loss: Androgenetic vs. Age-Related." presented Friday, August 13, 2004, at the 12th Annual Meeting of the ISHRS in Vancouver, British Columbia.
 
Hair Transplant Forum International. Volume 15, Number 2. March/April 2005.

"Female pattern hair loss is not a specific diagnosis but a clinical phenotype," declared Dr, Elise A, Olsen, MD, of Duke University Medical Center in Durham, North Carolina, USA, at the 12th Annual Meeting of the ISHRS (August 2004, Vancouver, BC). The patterns of hair loss in women are not as easily defined as those in men. In fact, female hair loss may present as one of three major patterns: male pattern baldness; a diffuse loss across the entire top of the scalp; or with frontal accentuation, "Frontal accentuation is found in approximately 70% of women with obvious hair loss," advised Dr, Olsen.
 
Furthermore, unlike men, the definitive cause of hair loss in women is often difficult to determine, Thus, naming all female hair loss "androgenetic alopecia," the term given to androgen-dependent genetically determined male pattern baldness, may be misleading. Dr. Olsen recommended instead that the term "female pattern hair loss" be used to describe the type of hair loss in women that is primarily central and characterized by miniaturization of hairs.
 
Dr. Olsen identified three important potential etiologic factors for female pattern hair loss: androgen irregularities, age, and inflammation. In part, these different causes can be distinguished by determining hormone levels, particularly free testosterone.
 
She then described how various types of hair loss can be distinguished and diagnosed. Such differential diagnosis is important as it will influence treatment choices. Dr. Olsen advised that "scalp biopsy data can offer supportive information to the clinical clues," such as the presence of fine hair, frontal accentuation, central scalp thinning, or the microscopic results of hairs extracted by the hair pull technique. For example, miniaturization of the follicles is seen both clinically and histologically. Scalp biopsy is also critical for diagnosing cicatricial alopecia, and female and male pattern hair loss may, in some cases, have a component of this.
 
Dr. Olsen continued her presentation by identifying and describing the two different subgroups of women with hair loss, a classification based on age. The early onset group first exhibits hair loss, with or without hyperandrogenemia, between puberty and 30 years of age; the hair loss of the late onset or postmenopausal group starts from the age of 40 years or later and, again, includes women with or without excess androgen. Fewer women in the older group have obvious hyperandrogenemia. Although hyperandrogenemia may present as irregular menstruation and/or hirsutism, and is frequently related to polycystic ovary syndrome in younger patients. Dr. Olsen stressed that most women with female pattern hair loss do not have any signs or symptoms of androgen abnormalities. So what other factors may be behind female pattern hair loss?
 
Dr. Olsen identified three important potential etiologic factors for female pattern hair loss: androgen irregularities, age, and inflammation. In part, these different causes can be distinguished by determining hormone levels, particularly free testosterone. For example, hyperandrogenemia is found in more than 85% of women with both hirsutism and female pattern hair loss. However, hormonal changes may also be age related, rather than pathologic, particularly in menopausal women. Dr. Olsen concluded that androgen abnormalities in younger women almost certainly indicates a subtype of androgen dependant alopecia, i.e., androgenetic alopecia," but in older women the diagnosis is not as clear. Additional testing may be needed in the latter group to determine etiology.
 
"Inflammation may have a role in alopecia, acting as a primary or secondary etiological factor," emphasized Dr. Olsen. Although histological evidence of inflammation is found in patients without hair loss, its presence is far greater in women with female pattern hair loss and can lead to scarring. Clinically, inflammation can be seen surrounding the hair follicle (peripilar) or in focal atrichia (so named by Dr. Olsen to describe small areas of absent hairs in female pattern hair loss). Microscopically, in female pattern hair loss inflammation typically involves the upper follicle, including the bulge area.
 
Dr. Olsen concluded that the reason for female pattern hair loss may be different in the two age groups identified above. In women with female pattern hair loss who have the onset of hair loss between puberty and the age of 30 years, the cause is frequently androgen dependent. In those whose hair loss starts in their 40s or 50s, the cause is likely multifactorial and may involve changes in estrogens, androgens, and/or other hormones. "Finally," she acknowledged, "the role of inflammation in female pattern hair loss is still unexplored and needs further evaluation."

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