While most of what I have written for male patients, stands true for female patients as well, however a difference does exist. For those who are reading this to understand hair loss and replacement in women, reading the prior sections is very important to grasp the concept thoroughly.Many women suffer from different forms of hair loss, over and above female pattern baldness. It is important to rule out other forms of hair loss before one can be diagnosed for female pattern baldness. Telogen Effluvian of these is the most common. This condition often takes place several months after childbirth when one’s hair starts shedding. This will usually happen about 1 – 6 months after a woman has undergone significant stress in her life such as surgery, a serious illness and psychological or social stress, and cause women to shed chunks of hair. There is both good and bad news here. The bad news is that this type of hair fall cannot be treated and the good news is that it does not need any treatment as the hair fall will stop after a dormant phase.
In some cases I have seen women suffer from traction hair loss. Here, most women who wear their hair tightly pulled up or in very tight braids for long periods of time, the chronic pull on the hair root will eventually work towards killing the follicular system and hair will stop growing in these areas. This kind of hair loss is treatable through hair transplantation, if the woman changes her hairstyle.
Other cases that I have noted are when women have had facelifts or other procedures that have left scars behind, in case of a brow lift would have left the hairline too high. These cases are good for transplants.
Figure 10-1. Ludwig scale of balding for women (3)
True Female pattern baldness is very common in women. It is highly underestimated though, simply because women do many things to hide it. A study by O’Tar Norwood, M.D suggests that the incidence of hair loss in women increases from 3% in women in their twenties to 30%to women in their eighties. One quarter women in their fifties are affected.
The pattern of baldness though is different for men and women. Most women will notice a diffused hair loss pattern in their mid scalp, but they will retain their hairline. While this pattern is more applicable to men, the paper that Dr. Norwood and I published together, questions this altogether. If we are right, then this condition cannot be considered as the same condition but in different genders. The paper included some important points.
1) Male pattern baldness starts with recession of the hairline and can result in complete hair loss all across the top of the scalp. While in women, there is diffused thinning behind the hairline, but there is no recession.
2) Male pattern baldness begins in the late teens or early twenties when testosterone levels are very high in men. On the other hand, female pattern baldness usually begins in the late thirties and reaches its highest point in the fifties when testosterone levels are diminishing.
3) While male pattern baldness affects up to 70% of all men, female pattern baldness affects only up to 30% of all women.
4) Women with a predisposition to male pattern hair loss will quickly develop typical male pattern baldness if they are given very high doses of testosterone.
5) A young woman with hypopituitarism when presented with histological and clinical features of the female pattern baldness in the absence of circulating androgens (testosterone and other male hormones) suggested that this pattern is not dependent on androgens.
6) When treated with propecia, a drug that does not allow the conversion testosterone to 5-DHT, helps the male pattern hair loss but has zero affect on female pattern hair loss.
Figure 10-2. Woman with loss of hair in the hairline, the temples, and the crown similar to male pattern baldness.
Some women do bald in a male baldness pattern as well, where there is recession over their temples and there is loss of hair all over the vortex of their scalp.This kind of hair loss has a number of similarities with male pattern baldness and can be treated with androgen (testosterone) hormonal therapy.
Propecia does not work well with women’s hair loss. If a woman has hair loss which is more like male pattern hair loss and also has high levels of androgenetic hormones, Propecia can be helpful. However, this is not very common.
While Rogaine can help halt any further hair loss, when regrowth happens, it will tend to be short and fuzzy. I advice most of my patients to use 5% Rogaine labeled for men as apposed to 2% for women.It is a more effective solution and does not pose any serious threats. The only side effect may be developing an itchy red scalp. The FDA may be considering approval of the 5% Rogaine formula for women as well in the near future. In the US we use Spironolactone (Aldactone), while in other countries there are a host of androgen blocking medications used. This heart medicine tends to block activity of the circulating androgens.Not all forms of female pattern baldness are driven by androgens, it is useful only to a small percentage of patients. Patients should ideally not conceive while using spironolactone, as the side effects may include breast tenderness, mood swings and irregular menses. In order for the medication to be effective, both spironolactone and Rogaine should be used indefinitely.
Figure 10-3. If a woman now has, or potentially will have significant hair loss, the transplant will possibly need to be concentrated in specific areas and combined with specific hair styles. In most cases the transplant is concentrated in the front behind the hairline and the patient will then let the hair in front grow long and use it pulled back over the thinning area.
There are a number of differences that exist when transplanting hair for men and women. Men are happy with whatever hair you give them, they would want full, thick hair, but are also understanding as they know that even getting some hair back in the balding areas is good. A woman on the other hand is difficult to please as she will not be satisfied, till she has the appearance of full thick hair.Most women will not be happy with just some hair back is not enough. In the case of a woman if hair loss is even moderately advanced, hair transplants will not be able to provide the thickness that is desired. This is the reason why I have turned more female patients away as apposed to male patients. If a woman’s hair loss problem is not too advanced and she may be willing to use Rogaine regularly, we could reach an amicable understanding. If a woman also agrees to maintain a certain hairstyle, I may be able to help her better. An example for this would be for Ludwig Type I and Type II patients. For instance if I could convince patients not to grow bangs, but instead let the hair that is in the hair line to continue growing, and then pull that hair back, will be a style that will keep it in place. This will help me focus on the follicular units in a particular zone mainly behind the hairline so that it can give that particular area more fullness. For men I would suggest coloring their hair to a color that helps decrease the contrast between their scalp and hair, so that their hair loss is not as noticeable. If men are open to maintain the remaining hair in a particular style to cover the areas that are experiencing hair loss, then maybe increasing the length and curl of the hair can add volume. Women in general have the ability to style the hair that they have remaining in a way so that the hair loss is concealed. When these women are given even little more hair, they are indeed happy.
Another difference between men and women lies in telogen hair loss – loss which happens after shock of surgery, in transplanted areas. In men this kind of hair loss is limited to just 5 – 10 %, whereas for women it can be up to 25 – 50%. I always make sure to tell my patients that this hair loss if happened to healthy hair will return in four to eight months, however, if it is miniaturized hair that is lost, it may not return at all. If hair has indeed been lost due to Telegen loss, the scalp will look more bald three to five months before the operation. It is only after those months pass, that the transplanted hair will start to grow.All the other hair that has fallen out slowly will start growing back soon thereafter. However, there is no way one can know, who is susceptible to this condition. I have worked with some women, who have experienced it once, but not again. It is a risk that women have to be willing to take. It is important that patients are warned about the occurrence, in order to ensure that they are more understanding of the condition and the way forward. This is the reason why; I often use 2 – 3 follicular unit grafts in women. I believe that using larger multi unit follicular grafts and reduced number of needle sticks by 50%, the chances of telegon occurring is reduced. I also do let my patients know that there will be a slight show of plugginess if hair loss is continued. Most women will agree, as they know that they would lose their hair anyway and then they wouldn’t mind wearing a wig. Even if they choose for me to use multi-unit follicular grafts, I choose to use single follicular units for work on the hairline.
One last disadvantage that women have is that they have a fairly limited donor area. Men in most cases have a good amount of hair remaining above their ears around their balding scalp. The only sad part is that women will have hair in this area that is thinning and is not suitable for transplantation. Over and above that women too are great candidates for hair transplantation. Though the ultimate result depends on quality of remaining hair, degree of hair loss and patient expectations.
I found the experience, on the whole, to be good. I truly appreciated Dr. Cole's candor, kindness, and integrity. And I found his staff to be professional and considerate. Should I have any future needs, I have no doubt that Dr. Cole is my guy.