The two major concerns with women involve dermatological and more commonly hormonal problems that could be causing hair loss. Dermatological conditions include simple scalp conditions like temporary telogen effluvium that can follow delivery of a baby after pregnancy or more serious conditions like discoid lupus, etc. Typically, without any obvious skin lesions, etc., the surgeon who is contemplating surgical transplantation for a woman should recommend hormone evaluation to rule out metabolic conditions.
The most typical hormonal causes for female hair loss include a low iron level (which can be worsened owing to menstruation and with ferritin being the most sensitive blood marker for a treatably low iron level), low estrogen levels due to ongoing aging, etc. (which can be even more prevalent after menopause), low thyroid conditions, high androgen levels (the most common androgen in women is dihydroepiandesterone sulfate, or DHEAS), among other types of hormonal imbalances. A basic yet thorough chemistry panel may be a necessary first start before surgery should be contemplated.
Another important early intervention is managing the hair loss with minoxidil (marketed as Rogaine in the U.S. or Regaine in some countries). Minoxidil is a topical medication that is over the counter in the United States and comes in both 2% and 5% strengths. The 2% version is intended for women. However, for women who do not experience secondary facial or body hair growth, the 5% concentration can at times create a faster response than the 2% concentration but after one year the effects are nearly equal for women being treated with 2% and 5% minoxidil. Also, the 5% foam (which only comes as a brand Rogaine and there is no 2% foam) has eliminated the propylene glycol ingredient making the product less irritable on the skin.
A major drawback with minoxidil is that at 3 to 6 weeks patients may experience temporary further shedding, which is normal and indicative that the hair is entering what is known as anagen, or the growth phase of hair. In 3 to 6 months, hair is typically stabilized or reversed, as the investigation for the cause of the problem is discovered. In any case, if a woman is contemplating surgical hair transplant, the use of minoxidil can be very helpful in minimizing postoperative hair shedding following hair transplantation, as women are more susceptible to temporary shedding after surgery. Accordingly, ongoing minoxidil is a good idea for women considering upcoming surgical hair restoration.
Female pattern baldness presents in three distinct patterns. The most common type of hair loss is known as a "Christmas tree" pattern first described by Dr. Elise Olsen, who believes that it is the predominant pattern of hair loss in women. When a woman parts her hair in the middle and looks downward, the shape of a Christmas tree with the apex toward the back of the head is revealed. A second type of hair loss that could be a variant of Olsen's category has been described by Ludwig, which is a diffuse thinning throughout the scalp and which has classified according to the extent of thinning into Grades 1 through 3. Finally, the third type of hair loss mimics male pattern baldness with the exception that sometimes the hairline is spared. The purported reason for this variant is that women's higher serum aromatase level can maintain the hairline in some cases despite diffuse hair loss behind the hairline.
When a woman is ready to undergo surgical hair restoration by an experienced surgeon, she should review cases of female hair restoration that the surgeon has done because skills and design work for women differ radically than for men. First, the hairline is almost the exact opposite than that for a man. The fronto-temporal region is rounded and low versus open and triangular in a man losing hair. Second, the shape of the female hairline toward the center is also radically different with a cowlick that whorls and so-called lateral mounds that are positioned frequently on either side of the central cowlick. The surgeon creating recipient sites for the hair transplant must almost make these sites in an opposite fashion than for a male candidate, angling sites backward and obliquely, whereas for 95% of men this would lead to a bad outcome. Men's recipient sites that would accommodate the grafts are anterior, straight and low.
Secondly, when working with women, they may have compromised donor hair in the temple region in conditions of diffuse thinning. Surgeons must know how to harvest this hair to maximize yield and minimize the incisional scar. This involves avoiding the affected temple region and circumnavigating areas of loss that would otherwise create problems down the road for the surgically transplanted result.
Thirdly, women have been notoriously difficult patients regarding their satisfaction following hair restoration unlike men. We believe the most common reason for this outcome can be more likely due to the surgeon's fault on two accounts. First, unrealistic expectations were created for the patient, and poor communication of objectives was initiated. Secondly and just as important, the design to maximize a result requires judicious allocation of the grafts. We typically prefer to use two major patterns that we call an L-shape and a T-shape. For women who part their hair to the side, we use an L-shape with the longer limb of the L following along the part side and the bottom limb of the L across the central forelock and hairline. The T-shape is ideal for women who part their hair in the midline (or who have greatest density loss along the midline) with the long limb of the T being in the middle and the top horizontal limb of the T again being distributed along the frontal hairline and central forelock that in turn falls immediately behind the hairline. Of course, blending in the surrounding areas around these transplanted areas will yield the most natural result that is also targeted to the pattern of hair loss that a woman is suffering.
This primer on female hair loss and hair restoration clearly does not replace the consultation and relationship between a physician and patient but is intended as a general overview for a patient seeking basic information regarding female hair loss and what could be done for initial investigation, management, and/or surgical correction.
Samuel M. Lam, MD, FACS is a double board certified, Hair Restoration specialist. To learn more about Female Hair Loss Disorder and Female Hair Restoration procedures, please visit his extensive photo and video galleries.
