The mechanism of hair loss in postmenopausal women is largely genetic. Some women can lose up to 40% of their hair as they age! Yikes!
Bald sports or thinning areas may be a sign of a medical condition or nutritional deficiency. Having an evaluation with a medical doctor or dermatologist is a good first step.
Telogen effluvium (TE) is a non-scarring form of hair loss that often has an acute onset.
It is often a reaction to change in hormones, stress, or medication. Changes in hormones related to childbirth or menopause can be enough to cause TE. Stresses such as an injury, febrile illness, change in diet, or immunization can be implicated. The insult may have occurred 1-6 months previously. in TE, many hairs fall out all at once, instead of the usual asynchronous loss of hair. It is normal to lose about 150 hairs per day. TE can resolve in 6 months, but longer lasting episodes can occur. Patients should be reassured that time will correct this, but it is a slow process.
The most common cause of hair loss as we age is called androgenic alopecia. Androgenic alopecia is men is male-pattern baldness. In men, the hairline begins to recede, first at the temples, and then at the frontal hair line. Then balding occurs at the crown of the scalp.
In women, androgenic alopecia usually involves thinning of the entire scalp. It rarely leads to total baldness. In women, this form
of hair loss can be associated with polycystic ovarian disease, which causes irregular menses, increased hair growth on the body, weight gain and acne.
Factors for hair loss may include genetic factors and increased androgens, especially dihydrotestosterone. Androgens are important in women for sex drive and hair growth.
Each individual hair grows under the skin, and usually survives 2-6 years. Increased androgens in the hair follicle can cause shorter cycles of hair growth, as well as thinner and shorter individual hairs. Replacement of shed hairs may take longer.
There is a gene for the androgen receptor in the hair. This gene controls the activity of the androgens in the hair follicle.
So, what can you do?
First, an evaluation should be done. Taking a history includes noting changes in hormone levels, stress, family history (was your maternal grandfather bald?) and new medications. A physical exam can reveal skin changes in the scalp. Psoriasis and seborrheic dermatitis can cause hair loss. A “pull test” can be done to see if a gentle pull will remove several hairs easily. Nutritional factors should be evaluated. The diet should include adequate protein. Nutrients such as Vitamin D, zinc, and ferritin (iron) should be checked. Additionally, hormone levels should be evaluated including follicular stimulating hormone (FSH), estradiol, DHEAS, free and total testosterone. Labs should also include a CBC, CMP, and thyroid testing.
Drugs that can be implicated in hair loss include beta-blockers, anticoagulants, retinoids, propylthiouricil, carbamezapine, and immunizations.
In premenopausal women, the diagnosis of PCOS (polycystic ovarian syndrome) and congenital adrenal hyperplasia should be considered. Oral contraceptives using the progesterones drospirenone and desogestrol are better for skin and hair than levonorgestral and norethindrone which are more androgenic.
In menopausal women, estrogen is helpful. Oral estrogens, especially those using drospirenone, are most helpful. Oral estrogens increase sex hormone binding globulin which decreases the effect of androgens. Natural progesterone is also a mild inhibitor of testosterone at the hair follicle.
Nutritionally, adequate protein in the diet is recommended. Vitamin D supplementation, zinc, and adequate iron storage is also helpful. Biotin is also recommended, at doses of at least 2000 micrograms per day.
Decreasing stress is also an important consideration, and use of antidepressants may be considered in appropriate situations.
Use of Nizoral shampoo may decrease the loss of hair, and limiting the use of hair products and frequent washing can be helpful.
Other options include:
Minoxidil: This drug is independent of androgens, and works by making the the growing phase of the hair follicle more robust. It is applied topically to the scalp, and can be applied to the eyebrows with a q-tip. The high potency product will have better results, but it may take up to six months to see improvement.
Spironolactone: a diuretic that is widely used for androgenic alopecia. It blocks androgen receptors as well as decreasing production of androgens in the ovary. Side effects can include menstrual abnormalities and electrolyte disturbances, as well as low blood pressure.
Finasteride: an inhibitor of androgens in the circulation. Used more often in men, there is limited
data on the use in women, but can be considered for women with androgen excess.
Laser comb: may work by increasing heat in the scalp, increasing blood flow.
New treatments: Infusions of plasma rich protein are offered at some medical centers.
Cosmetic procedures include hair transplant and products that add fibers to the hair shafts or camouflage the visible scalp.
There is no doubt that loss of hair is troubling to women, and affects them psychologically.
As with many conditions, an evaluation with a physician is recommended to rule out treatable causes of hair loss. This evaluation includes blood work and an examination. Before taking any supplements or drugs, be fully informed about the risks and side effects.
NIH: Genetics Home Reference. Androgenic Alopecia
Clinical Interventions in Aging, 2007 June 2(20 189-199. Female Pattern Hair Loss: Current Treatment Options, Din and Sinclair
Managing Hair Thinning in Peri- and Postmenopausal Women: the Menopause Specialist’s
Perspective, Holly Thacker, MD, FACP, CCD, NCMP, NAMS Annual Meeting, October 4, 2018
Many women know that fibroids can make life miserable. Heavy bleeding and prolonged bleeding, pelvic pain and cramps, bladder pressure, anemia, and an abdominal mass can all result in making the menstrual cycle a dreaded monthly event.
The traditional treatment for uterine fibroids is surgery. Hundreds of thousands of hysterectomies are done per year, and the majority are for fibroids. We need to find alternative treatment modalities that are non-surgical, low risk, and improve quality of life for women.
Here are some of the topics discussed today at the North American Menopause Society Translational Science Symposium in San Diego.
If fibroids are not symptomatic, they do not need to be treated, unless you want to get pregnant.
Whether fibroids should be removed prior to attempting pregnancy depends on location and size. Fibroids do increase some adverse pregnancy outcomes including premature deliveries and miscarriage. It is complicated, but the message is that all fibroids do not have to be removed prior to attempting pregnancy. Before surgery is done for fertility reasons, other infertility factors should be considered.
African-American women have more fibroids and develop them younger than Caucasian women. Some studies show that fibroids grown from uterine muscle stem cells that may have a genetic mutation, and perhaps a hormonal event in utero, like DES, may be causative . African-Americans may have more hormonal sensitivity, and have been found to have more aggressive breast and uterine cancers. Learning about how to turn off this genetic change is an important area of research.
Physicians always believed that estrogen was the cause of fibroid growth, but it is now known that progesterone is also very important in fibroid development. That is why researchers are looking at drugs that can block progesterone receptors in the fibroids. SPERMS, selective progesterone receptor modulators, are being developed that can block fibroid growth.
So how do we manage fibroids in the peri-menopause. We know that fibroids are rarely a problem after menopause, as they shrink with the lower levels of estrogen and progesterone after menopause. But, those years prior to menopause can be very difficult, and there are many options
Birth control pills are very effective in reducing blood flow, without making the fibroids grow significantly. NSAID’s and can reduce bleeding about 20-40%. Tranexamic acid can reduce bleeding about 40%. A progesterone containing IUD can significantly reduce bleeding, but fibroids can increase the expulsion rate. Lupron, which creates a temporary menopause with lower estrogen, is very effective in reducing fibroid size. Fibroids in the cavity of the uterus, which are the ones that cause the most bleeding, can be removed by hysteroscopic resection. Endometrial ablation can significantly reduce bleeding. Uterine artery ablation is also
What is on the horizon?
In Europe, a procedure that uses ultrasound directed ablation of the fibroids, administered via laparoscopy is being developed. In Canada and the EU, a selective progesterone receptor modulator, ulipristal, is used that can stop heaving bleeding episodes. The FDA has failed to approve this in the US yet, due to concerns about side effects. It is expected that as more data is accumulated, this drug will be approved for use in the US. There are many other drugs in this category that are being developed.
Here are some other medications or supplements that show promise and are currently being studied that may reduce the size of fibroids: simvastatin, aromatase inhibitors, green tea extract,
retinoid acid, Vitamin D, and berberine (a Chinese herb).
The research on how fibroids grow and change is very interesting on a molecular level.
We look forward to additional treatments that will reduce surgery in the near future, while making quality of life much better for women with fibroids.
Marilyn Jerome, MD
2018 Wolf Utian Translational Science Symposium, Tuesday, October 2, 2018
New Therapies for Leiyomyomas: When Surgery May Not Be the Optimal Approach