Violetta Tomaszewicz1, prof. of health, dr hab. n. med. Jacek J. Klawe1/, Maria Chrzanowska2/
1/ Department of Hygiene and Epidemiology, Collegium Medicum of the Nicolaus Copernicus University in Bydgoszcz
2/ Afrodita Cosmetics in Toruń
Abstract
Female pattern baldness is a common and disturbing phenomenon [1,2,4,6]. Ludwig first used the term in 1977 to describe diffuse hair loss in women [1,4]. In 2004, another researcher, Sinclair, expanded on this definition, adding that it is a decrease in hair density in the central part of the scalp in women after puberty [1,2,4]. Interest in this topic is growing due to the development of trichology in Poland. Hair is an important element of appearance, with particular psychosocial significance for women [15], therefore, excessive hair loss raises concern and contributes to the search for effective treatment from dermatologists and cosmetologists.
FPHL – English woman pattern hair loss, It is characterized by a diffuse reduction in hair growth, especially around the crown of the head [1,2,7,9] without scarring [9]. Female pattern baldness does not have any serious health consequences, but it may affect more than half of women over 50 years of age [1,14]. The incidence of this phenomenon is higher than initially thought, and the incidence of hair loss in women may be equal to that of hair loss in men. However, a significant increase in the incidence of FPHL is noted among postmenopausal women [1,7,9,14]. Many women first notice signs of this type of hair loss in their 50s [1,9,14].
Female pattern baldness (FPGA) has an as yet unclear etiology [1,2,13], but is likely caused by several factors. The literature frequently mentions so-called accelerated hair aging, which involves a change in the environment of hair follicles. This condition is likely influenced by genetic [1,2,6,13], inflammatory, hormonal, and blood circulation factors [1,2,13]. This process leads to changes in the hair cycle, with the anagen phase shortened and the latency phase prolonged [1,4]. Miniaturization of the papilla and hair shaft also occurs, transforming from a terminal hair into a vellus (primary) hair [1,2]. However, the vellus hair produced as a result of FPA has a well-developed hair-tightening muscle (unlike standard vellus hair) [9]. The duration of the anagen phase can be significantly shortened (from 3-6 years to even several weeks or months), while the duration of the telogen phase remains unchanged [2,4,9]. An imbalance between cytokines and various growth factors is also likely to occur, resulting in a shortened anagen phase [9]. FPHL can also be accelerated or exacerbated by factors that can induce telogen effluvium, including medications, stress, and weight loss [1]. The incidence of this condition increases with increasing age [2,9].
Alopecia is also common after childbirth [1,5]. During pregnancy, hair is typically shiny, thicker, and does not fall out. This is because the anagen phase is prolonged, and matrix cell division accelerates at the hair papilla. Increased estrogen and progesterone levels are responsible for this condition. However, this may reverse approximately 2-3 months after delivery. Increased prolactin levels during breastfeeding also further exacerbate hair loss. Alopecia areata also occurs. Hair thinning problems should resolve within a year (this is how long it takes for hormonal levels to stabilize). If the process lasts longer, a cause other than pregnancy and childbirth should be sought [5]. One cause of ongoing alopecia is postpartum thyroiditis, which usually appears between 3 and 12 months after delivery.To confirm this, it is necessary to check the levels of TSH, FT3, FT4, anti-TPO and anti-TG antibodies and thyroid ultrasound [5,15].
The effect of androgens is not yet clear [2,4,6,9]. Their key role in this type of alopecia has not been confirmed [2,4,13]. However, the significant incidence of female pattern baldness among postmenopausal women may indicate a hormonal influence [2]. The occurrence of this type of alopecia in women with elevated testosterone levels and hirsutism may also indicate hormonal factors [2]. This type of alopecia also frequently accompanies women with polycystic ovary syndrome [9]. Receptors and three important enzymes (5-alpha-reductase I, II, and aromatase) are expressed in the outer sheath of the hair and in the hair follicles in both women and men; however, a 40% lower content of androgen receptors in frontal hair is observed in women than in men. Hair in the anterior scalp has less (up to 3-3.5 times) 5-alpha-reductase I and II, but the aromatase content in this region is six times higher in women. Aromatase is an enzyme that converts androgens into estrogens (e.g., testosterone to 17-beta-estradiol and androstenedione to estrone). This may explain the clinical differences between the sexes [2].
There are also reports of this type of alopecia occurring in obese women [2].
FPHL takes place in 4 stages:
1. It is characterized by noticeable thinning of hair in the anterior "crown" of the head with minimal widening of the parting. Hair loss at this stage can be easily camouflaged [2]. This stage often manifests in young women along with seborrhea, acne, and hirsutism (so-called SAHA syndrome, of ovarian origin) [2,3], and may also accompany other manifestations of hyperandrogenism (seborrhea, acne, hirsutism, seborrheic dermatitis, menstrual irregularities), although hormone levels may be within the normal range [2].
2. Stage II progresses from stage I with increasing age, when the thinning of the "crown" of hair progresses and becomes much more pronounced. The number of sparse and shorter hairs also increases. Stage II female pattern baldness is no longer concealable. Excess free testosterone or androstenedione can be detected in blood tests [2,8]. A characteristic thinning of the hair part, known as a "Christmas tree pattern," also occurs [4].
3. Stage III does not usually occur in premenopausal women. The crown of the head becomes bald, with the remaining hair forming a fringe in the front. Stage III is usually accompanied by adrenal gland disease—nodular or not, with very high levels of androstenedione, DHEA-S, free testosterone, and sometimes prolactin [2].
The basic differences between FPHL and chronic telogen effluvium (TE) are illustrated in the table below [2].
| Differentiating feature | FPHL | Chronic TE |
| Location of baldness | Central part of the head, frontal hair preserved | Generalized |
| The beginning of baldness | Gradual | Sudden |
| Symptoms | Thinning hair with a wider parting (Christmas tree pattern) | Diffuse alopecia |
| Hair loss | Slightly higher than physiological | Significant |
| Hair Pull Test | Usually negative | Positive |
| Ratio of terminal to vellus hairs | Below 4 | Above 7 |
| Another possible cause | Positive family history | Illness, stress, medications |
Most women with female pattern baldness do not have elevated hormone levels in their blood [2,10]. However, women with symptoms of hirsutism, acne, or menstrual irregularities should be tested for elevated testosterone, DHEA-S, and prolactin levels. If testosterone levels are 2.5 times higher than normal or higher than >200 ng/dL, or DHEA-S is twice as high or >700 µg/dL before menopause and >400 µg/dL after menopause, cancer screening should also be performed [2].
Minoxidil has been shown to provide good therapeutic results in treating hair loss, but its mechanism of action is not fully understood [1,2,4,11]. Minoxidil prolongs the anagen phase, improving hair quality – hair appears thicker and denser. Women with FPHL also respond positively to antiandrogens and 5-alpha-reductase inhibitors [1]. However, there is no doubt that nutrition has a significant impact on hair condition and hair loss. This is confirmed by m.in. There have been reports of hair loss in severe malnutrition (e.g., anemia, kwashiorkor, anorexia, and bulimia). Vitamins, minerals, and other nutritional factors are very often recommended for hair loss [1,10,11,12]. However, the effectiveness of supplementation in FPHL is not yet fully documented. One study conducted on a group of 120 women (60 postmenopausal and 60 premenopausal) demonstrated significant effectiveness of omega-3 supplementation.&6 derived from fish, blackcurrant oil with antioxidants (lycopene, vitamins C and E). Over 88% of women noticed an increase in hair density after 6 months of use, compared to 51% in the control group.Most of them described this increase as moderate (45.6%), but 29% described it as significant. In both groups, a significant decrease in the number of telogen hairs was observed, as well as an improvement in hair condition (thickness, resistance) [1]. A positive effect of iron deficiency on hair loss was also demonstrated in a study on a large population of women aged 35-65. When iron levels fall below <40 mg/l moderate to severe hair loss was observed, especially in non-menopausal women [12].
Female pattern baldness is an intriguing issue, not yet fully understood and controversial. There is a significant need for research to elucidate the nature of this phenomenon and confirm the mechanism that initiates it. Only then will it be possible to find an effective remedy for female pattern baldness.
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Literature:
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