From Thinning to Winning: Tackling Menopause Hair Loss
Menopause is hard! Amid the daily challenges of working, managing the house, helping the kids, walking the dog, exercising (if there’s time), cooking, AND surviving menopause or perimenopause, there is also hair loss. 40-70% of women experience hair loss in midlife. This can, of course, affect women psychologically and emotionally. After all, we want to remain smart, strong, and beautiful inside and out.
An informed woman is a powerful one and can advocate for her care. Let's arm you with information so you can revive your roots!
WHY IS THIS HAPPENING?
First, we need to acknowledge that mild hair loss is normal. However, if you are noticing a significant increase from your baseline, then this is something to be concerned about.
Second, we cannot assume that all hair loss is due to menopause.
Culprits can be hypothyroidism, vitamin deficiency, anemia, stress, autoimmune, and medication-induced. However, in midlife, by far the most common reason is hormonal. This form of hair loss is coined “androgenic alopecia” or “female pattern hair loss (FPHL).”
It is not exactly clear why FPHL occurs. It is postulated that during perimenopause or menopause, estrogen levels drop, and the androgen-to-estrogen ratio is increased. This, in turn, contributes to hair loss.
CLINICAL EVALUATION WITH YOUR DOCTOR
In female pattern hair loss (FPHL), one would see a widening central hair part and overall thinning hair. Your doctor will need to do a careful physical exam and order blood work to exclude the less common causes of hair loss. Lab work should include thyroid function, blood count to assess for anemia, complete metabolic profile, iron level, zinc, androgen levels, including testosterone and DHEA.
TREATMENTS THAT DO NOT WORK
The market is rampant with products intended to quickly treat hair loss. If they promise a result in a month, do not buy it! The hair cycle involves a growth phase, a transitional phase, and a resting phase. When stimulating hair growth with treatments, hair follicles need time to transition from a resting phase to an active growth phase, which normally takes several months. Therefore, it is impossible to see an effect in a month.
Some products have minimal efficacy but come at a big price. Furthermore, once the product is stopped, the benefits stop, and you go back to hair loss. So let’s discuss a few below:
Biotin. There is no evidence to support its efficacy. It is not recommended by reputable dermatologists. Furthermore, it will interfere with thyroid lab results, making it appear as if you have hyperthyroidism. It also interferes with troponin levels, which are markers for a myocardial infarction. May you never have to go to the ED, but biotin will prevent doctors from being able to rely on these useful markers.
Multivitamins. Unless you have malabsorption, i.e., have irritable bowel disease or had a gastric bypass or celiac disease, then multivitamins are unlikely to help. For instance, vitamin A deficiency can cause hair loss, so supplementation would help. However, if you are eating a well-balanced diet and do not have a condition that would cause you to have vitamin deficiencies, then taking more may not help. In the worst-case scenario, it can be harmful. Particularly with vitamin A, increased amounts can be harmful to hair growth. I would not rely on this to save your locks.
TREATMENTS THAT DO WORK AND HAVE A GOOD SAFETY PROFILE
There are several treatments available for hair loss that are effective. I will exclude the ones that have an unacceptable safety profile, such as oral finasteride, which can cause loss of libido or depression. In my opinion, my mental health and sex life are far more important than my lock, but others might not agree. Let’s focus on the commonly used options that are effective and reasonably safe. Note, almost no medication has “zero” cons, but the benefits must outweigh the risks.
Topical Minoxidil.
This medication is FDA-approved for FPHL. It prolongs the hair growth phase of the hair cycle and increases follicular size.
Pros:
It is effective and safe
Inexpensive
Cons:
Daily application is required.
Some patients find the solutions to be greasy.
“Dread shed” is normal. This is hair loss that occurs for 1-2 months and later allows for new hair to grow. It is an unpleasant side effect to be expected. It can take 4-6 months to see improvement, but this is standard.
Some people can notice some hair on their face. This can be annoying but manageable with tweezers. Some skin irritation may occur. These side effects resolve after discontinuing use.
Impression: Overall, if you are okay with daily hair application, this is an effective approach. However, it may be annoying to apply this every day.
Oral Minoxidil
Oral minoxidil is approved for hypertension, but it is not FDA-approved for FPHL. However, it is very common and appropriate to use non-FDA-approved medications. Since the generic version is available, it does not make sense for the pharmaceutical company to spend millions of dollars to get it approved for hair loss. We know that it is safe and effective. You can search on PubMed the hundreds of articles on the safety of oral minoxidil for androgenic alopecia.
The tablets come at a dose of 2.5mg. You would need a pill cutter to take approximately 1mg daily.
It takes 4-6 months to see results.
Pros:
It is very effective.
Inexpensive (as low as $10/month)
Cons:
An initial “dread shed” period of hair loss will occur before hair starts growing.
Some facial hair growth may occur.
Impression: This is a very effective, low-cost medication. You would need to be patient to see results and accept the “dread shed” period, knowing hair will grow. A nuisance is some hair growth on the face so you would need to pluck the hairs. This is reversible if you discontinue the medication.
Spironolactone
Spironolactone is an androgen receptor blocker and suppresses ovarian androgen production. It is not FDA approved for hair loss, but is effective and safe. See discussion above about FDA-approved treatments (under oral minoxidil).
Pros: Effective
Cons: can cause fatigue, low blood pressure (if on other medications that cause low blood pressure), changes in liver function tests (this is extremely rare). Need to monitor for a rise in potassium more common if taking other medications that can contribute to this or if kidney disease is present.
Impression: This is an effective medication. There is a topical and an oral form. The topical form will have a lower side effect profile but needs to be applied twice a day, which may be bothersome. This is an affordable, low-cost medication.
Platelet rich plasma injections
Blood is drawn, and platelets are extracted. These platelets are injected under the skin. This promotes blood supply and causes cells to divide. Local anesthetic cream is used. Usually, 3-5 rounds of this are necessary, and after two years, a yearly maintenance therapy is needed.
Pros: Effective and clinically safe
Cons:
Costly-can cost $1000s
Impression: This is an effective but expensive approach. However, this is less expensive than Nutrafol or other supplements that cost close to $100 monthly, so over several years, one ends up spending much more.
ADDITIONAL APPROACHES TO CONSIDER
If you have dandruff this may exacerbate hair loss. Consider treating with 1% zinc pyrithione.
Low-energy laser light showed a minor but statistically significant benefit. I do not think that it is worth the cost.
You may want to consider a topical spray, powders, or keratin fibers. Your hairstylist might be better than me to suggest specific brands.
Brushing your hair for a few minutes twice a day can be effective. It brings blood flow to your roots and can promote growth. You may want to invest in a head massager.
WHAT ABOUT ESTROGEN?
I know what you’re thinking. If FPHL occurs in midlife more commonly when estrogen drops and the androgen to estrogen ratio rises, then won’t replacing estrogen fix the problem? Well, it’s complicated. Yes and no. In some women, estrogen can support hair growth. It is not consistently effective. There is no harm in using hormone therapy for menopause/ perimenopause if you have other reasons to take i,t but hair loss would not be my only reason.
THE BOTTOM LINE: YOU CAN OVERCOME HAIR LOSS
As you can see, you do have an option! You can tackle life with a beautiful head of hair. Remember, while female pattern hair loss is likely the cause of your hair loss, your doctor needs to do a careful physical exam and rule out other secondary causes.
Please be careful with not subscribing to costly and minimally effective treatment options. Some companies spend a lot on excellent marketing. I do not want you to be a victim of this.
The treatment options I mentioned are effective and overall safe. Yes, they are not “natural” but arsenic is also natural but its certainly not safe. Antibiotics are not “natural” but allow us to survive those urinary tract infections. Hair dye isn’t natural either. What should really be “natural” is your food.
TAKING IT HOME
In conclusion, while hair loss during menopause/ perimenopause can be frustrating, there are effective treatment options. Menopause is not the end of vitality or beauty. It is a normal chapter of our lives. With the right support, women can continue to thrive and feel confident, inside and out. You’ve got this, and there’s always support to help you along the way!