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Chapter: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 |17 | 18
PATIENT GUIDE TO SURGICAL & MEDICAL HAIR
RESTORATION
PAGE 16 |
Hair Loss and Restoration in Women |
Although a large percentage of the balding
and thinning population in this country are women, they are much less likely to
seek help from a hair transplant surgeon than are men. True, women’s hair loss
is less liable to benefit from transplantation then is men’s, but large numbers
of female patients who could greatly benefit from surgical hair restoration are
unaware of this option.
Indeed, many women with hair loss are excellent
candidates for hair transplantation. The important understanding is that women’s
hair loss occurs in different patterns than men’s, and therefore must be
generally treated in a different manner. Moreover, hair loss in women is much
more likely to reflect an underlying illness; we must be sure a proper medical
workup is done before recommending any medical or surgical alternatives.
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Psycho-emotional and Social Issues |
As emotionally devastating as hair loss
can be for some men, the effect often pales compared to alopecia in women. In
men, baldness is seen as a less than desirable, but still sometimes expected and
normal part of the male life experience (although to the man who is balding, it
may seem like the end of the world). On the other hand, when hair loss occurs in
women, at any age, the resulting feelings and emotions may be overwhelming.
Balding is perceived as a strictly male occurrence, and unacceptable in females.
For even the elderly woman, this can threaten her very sense of self, of her
femininity and sexuality, and of her place in family and society.
Our culture
strongly identifies femininity with a thick, lustrous head of hair. From
Rapunzel to the Breck Girl, images of full bodied, shining hair are synonymous
with female attributes, sexuality, desirability and vigor. Thinning, dry,
lusterless hair is identified with illness, old age, and poverty. In truth,
there are a number of systemic diseases that may cause hair loss in women, much
more so than is the case with men. It seems that the hair follicles of women are
more sensitive to certain stressors (sources of stress) than are those of men;
thus, we are more likely to see widespread hair loss in females, rather than the
typical regional balding patterns of males. Let us look for a moment at some of
the causes and varieties of female hair loss. |
Causative Factors in Women’s Hair Loss |
Just as in men, women’s hair loss may
involve genetic and hormonal factors. As we discussed in previous sections, the
three elements at play in androgenetic alopecia are androgens (male hormones),
genetics (a predisposition), and the passage of time (aging). Although the loss
patterns we observe in women tend to be different than in men, the mechanisms
are similar. Because women have different levels of certain enzymes in the
follicles in various areas of the scalp, they may lose hair in quite distinct
and different ways. For example, women very often will retain the frontal
hairline that is so commonly lost in men, but have widespread miniaturization
and thinning on the top and vertex. This may in part be due to women’s low
hairline levels of 5-alpha-reductase, which is the enzyme that converts
testosterone into DHT.
Also, women have fewer androgen receptors on the
frontal hair follicles; therefore, they are less susceptible to the effects of
the DHT that is present. Finally, the enzyme aromatase is found in much higher
concentrations in women’s hairlines; this important enzyme converts testosterone
to estrogens (just as 5-alpha-reductase converts it to DHA), and estrogens are
not likely to contribute to hair loss.
Another distinguishing characteristic
is that women have a tendency to have more widespread hair loss than men. In
addition, females loss is often more gradual, whereas men may begin to rapidly
lose hair in their late ‘teens or early twenties. Despite these statements, it
is significant that men may lose hair in a predominantly "female" pattern, just
as women may experience alopecia in what is considered a typically "male"
fashion. We will examine these patterns more closely in the next
section.
Systemic disease (affecting the entire system) and certain
medications can also lead to hair loss in women, and this is notably more common
than in men, probably in part due to the aforementioned sensitivity of female
follicles to stress. Some of the disease states that may affect female hair loss
include: thyroid disease, anemia, endocrine (hormonal) disorders leading to
elevated levels of androgens (ovarian cysts or tumors, adrenal or pituitary
disease), and connective tissue diseases (lupus, dermatomyositis). In addition,
various stressors, such as physical or emotional trauma, surgery, childbirth,
general anesthesia, or extreme diets may precipitate differing degrees of hair
loss. In some cases, the hair loss is reversible when the disease state is
treated, or when the trauma or stress has resolved. However, it may take a year
or more for an acute effluvium (hair shedding) to resolve to the point that the
cosmetic deficiency is overcome.
This last point deserves elaboration, in
terms of the actual process of hair transplantation. When women undergo surgical
hair restoration, they are more likely to experience "shock loss" or telogen
effluvium. Also, women’s hairstyles tend to be longer than men’s, especially
today. Therefore, it may require more time for growth of new grafts to "catch
up" with existing hair, so that a cosmetic difference can be appreciated. These
two factors make it crucial that the education process of the patient is
complete and well understood, so that discouragement and dissatisfaction are
less likely during what may be a prolonged "interim period".
Medications
known to cause alopecia include certain birth control pills, the blood thinner
Coumadin, thyroid hormone, some blood pressure medicines, corticosteroids,
high-dose vitamin A, and many drugs of abuse (amphetamine, cocaine, narcotics).
It is vitally important for any woman experiencing hair loss to discuss her
medical history, in detail, and any drugs or medications she is using. If there
is a treatable disease, or a medication that may be discontinued, hair growth
may resume. Although significant time may pass after treating the illness or
stopping the drug before hair re-growth occurs, it is important to establish a
diagnosis before ever considering surgical hair restoration.
A third general
cause of hair loss in women is known as "traction alopecia". This name comes
from the precipitating factor of constant traction, or pulling, tugging or
mechanical stress on the hair. It is commonly seen in this country among
African-Americans due to the fashion of wearing the hair in tight braids,
pigtails, or cornrows. This may also occur with the wearing of hair weaves and
other "hair systems". This variety of hair loss is often permanent, yet very
amenable to treatment with transplantation. In addition, a specialized type of
traction alopecia is termed "trichotillomania", which is a form of
obsessive-compulsive disorder in which hair loss is the result of constant hair
twirling, tugging, and actual pulling out of the hair. Hair transplantation is
also very effective in these cases, but only after psychotherapy and
antidepressant medications have the condition under prolonged control.
Otherwise, the transplanted hair may be subject to the same fate as the hair it
replaced!
Scarring from trauma (accidental, radiation, burns) or surgery is
another common cause of alopecia in women. Burns or surgery to the head and
scalp are treatable with follicular unit transplantation in many cases. The
residual scarring after facelifts or brow lifts often leave women with hairlines
that are less than ideal, especially around the temples and ears. These scars
can be transplanted, returning the soft, feathery hairline, and achieving a more
natural and aesthetically pleasing state.
Finally, some of the non-scarring
localized alopecias may occur. Alopecia areata is typical of these types. It is
characterized by sudden loss of hair in patches on the scalp, in which the skin
is normal. This type of hair loss may be successfully treated with injections of
cortisone-like drugs. |
Patterns of Women's Hair Loss |
| Androgenetic hair loss occurs more
frequently in women than any other type of hair loss. However the pattern is
more often of the Ludwig variety (figure 1) than of the typical male Norwood
type. In the Ludwig classification, the frontal hairline is preserved, and the
thinning is usually centrally located, running from front to back. In the case
of Grade I or II balding, transplantation may be quite successful in adding
density; women’s styling options are more varied than men’s, and they may obtain
excellent coverage from artistically applied grafting. |
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Figure 1
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| In more unusual cases, the pattern is
similar to the Norwood classifications (figure 2), with the frontal-temporal
recessions we are used to seeing in men. Bear in mind, however, that either
pattern may occur with either gender, and is not absolutely identified with one
or the other. |
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Figure 2
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In either case, it is crucial that other
medical problems be ruled out, as was detailed in the section on causative
factors. Once this is accomplished, the donor area, as well as the balding
regions, must be checked for signs of miniaturization. If there is evidence of
widespread or diffuse hair loss, the patient may not be a transplant
candidate.
In fact, diffuse hair loss has been classified into two
subcategories: Diffuse Patterned Alopecia (DPA) and Diffuse Un-Patterned
Alopecia (DUPA). These are both felt to be variants on Androgenetic Alopecia,
and may occur in males as well. The difference between the two may have great
significance to the hair transplant surgeon.
DPA is quite similar to typical
Norwood type "male" pattern baldness, except that the affected areas become very
thin, but not completely bald. The donor area is spared, and, because of this,
the patient may be a candidate for transplantation. On the other hand, DUPA
essentially affects the entire scalp, including, of course, the donor area; this
would preclude using unstable donor zone hair for grafting. In circumstances
such as these, the patient, regrettably, must be counseled about hair systems,
wigs, camouflages, and other non-surgical methods of disguising the alopecia.
Transplanting a patient with an unstable donor zone, regardless of their
desires, amounts to the unethical practice of medicine.
So we see now that a
large percentage of the balding or thinning population, that is, women, are
unaware or ignorant of some of the options that await them in their struggle
with hair loss. As we have shown, there are more possible etiologies (causes) of
balding in women than in men; the reversible ones must be ruled out. Also, the
hair, like the skin as a whole, may be a "window" to the internal health of many
women, and deserves due attention. Various laboratory and blood tests are
available to help with establishing a diagnosis, as are specialist consults if
necessary. When an identification of the cause is determined, the patient and
the hair restoration specialist may go forward in deciding the best course of
action for the specific problem at hand. |
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