Hair Loss in Women

Female pattern hair loss (FPHL) is a clinical problem that is becoming more common in
women. Female alopecia with androgen increase is called female androgenetic alopecia
(FAGA) and without androgen increase is called female pattern hair loss. The clinical
picture of typical FAGA begins with a specific “diffuse loss of hair from the parietal or
frontovertical areas with an intact frontal hairline.” Ludwig called this process “rarefaction.”
In Ludwig’s classification of hair loss in women, progressive type of FAGA, 3 patterns
were described: grade I or minimal, grade II or moderate, and grade III or severe. Ludwig
also described female androgenetic alopecia with male pattern (FAGA.M) that should be
subclassified according to Ebling’s or Hamilton-Norwood’s classification. FAGA.M may be
present in 4 conditions: persistent adrenarche syndrome, alopecia caused by an adrenal or
an ovarian tumor, posthysterectomy, and as an involutive alopecia. A more recent classification
(Olsen’s classification of FPHL) proposes 2 types: early- and late-onset with or
without excess of androgens in each. The diagnosis of FPHL is made by clinical history,
clinical examination, wash test, dermoscopy, trichoscan, trichograms and laboratory test,
especially androgenic determinations. Topical treatment of FPHL is with minoxidil, 2-5%
twice daily. When FPHL is associated with high levels of androgens, systemic antiandrogenic
therapy is needed. Persistent adrenarche syndrome (adrenal SAHA) and alopecia of
adrenal hyperandrogenism is treated with adrenal suppression and antiandrogens. Adrenal
suppression is achieved with glucocorticosteroids. Antiandrogens therapy includes cyproterone
acetate, drospirenone, spironolactone, flutamide, and finasteride. Excess release of
ovarian androgens (ovarian SAHA) and alopecia of ovarian hyperandrogenism is treated
with ovarian suppression and antiandrogens. Ovarian suppression includes the use of
contraceptives containing an estrogen, ethinylestradiol, and a progestogen. Antiandrogens
such as cyproterone acetate, always accompanied by tricyclic contraceptives, are the best
choice of antiandrogens to use in patients with FPHL. Gonadotropin-releasing hormone
agonists such as leuprolide acetate suppress pituitary and gonadal function through a
reduction in luteinizing hormone and follicle-stimulating hormone levels. Subsequently,
ovarian steroid levels also will be reduced, especially in patients with polycystic ovary
syndrome. When polycystic ovary syndrome is associated with insulin resistance, metformin
must be considered as treatment. Hyperprolactinemic SAHA and alopecia of pituitary
hyperandrogenism should be treated with bromocriptine or cabergoline. Postmenopausal
alopecia, with previous high levels of androgens or with prostatic-specific antigen
greater than 0.04 ng/mL, improves with finasteride or dutasteride. Although we do not
know the reason, postmenopausal alopecia in normoandrogenic women also improves with
finasteride or dutasteride at a dose of 2.5 mg per day. Dermatocosmetic concealment with
a hairpiece, hair prosthesis as extensions, or partial hairpieces can be useful. Lastly, weight
loss undoubtedly improves hair loss in hyperandrogenic women.
Semin Cutan Med Surg 28:19-32 © 2009 Elsevier Inc. All rights reserved.

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