The rise and fall of hair in women

Panic may be a necessary evil especially when you are young and at the prime of your career, and you suddenly experience severe hair fall.  EJ is no exception.   She was a graduating medical student when she first experienced hair fall.  Three months after giving birth to her first child, she noticed clusters of hair on her pillow everytime she woke up in the morning.  She would also notice that a ball of hair would accumulate everytime she shampooed her hair.  Before graduation, a yearbook photoshoot was conducted and she noticed her very thinned-out scalp.  Fortunately, after about several months, her hair started to grow again even without medical intervention.  Several years after, she again had her second child but luckily, she now had a classmate who was a resident in dermatology (that was me) and so, she asked my help.  This time, her hair fall was obviated.  Several years later, EJ, after experiencing menopause for almost two years, started to notice that her scalp hair was becoming noticeably thin again but this time, without increase in hair fall.  The skin on the top of her head was now showing.  She was really in distress at this point as even her hairdresser noticed the changes, too.   So she did not hesitate to call me and eventually, she now has a full-grown hair on her scalp just like in her younger days.  

The two episodes of hair fall experienced by EJ are not the same.  The first episode of hair fall is called telogen effluvium and the second episode is menopausal thinning. 

Scalp hairs complete the body self-image and patients with diffused alopecia suffer from overt disfiguration, leading to psycho-social embarrassment and significant lack of self-esteem.  Hair loss is, therefore, one of the most common complaints among all patients consulting a dermatologist and is usually associated with severe psychological disturbances, distress, and symptoms of depression.  It can be temporary or long lasting.  Diagnosis is based on detailed clinical history, physical exam, clinical diagnostic tests, laboratory testing, and scalp biopsy which may be necessary to confirm some diagnosis.  Such disorders may include infectious, nutritional, congenital, autoimmune or environmental causes.

Diffused balding is a non-scarring type of balding.  Telogen effluvium (TE) is the most common cause of diffused balding in females.  Abrupt, rapid, generalized shedding of club hairs, two to three months after a triggering event, like giving birth, high fever, major surgery etc., indicates telogen effluvium.  It may be associated with hypothyroidism, hyperthyroidism, lupus, intake of medicines such as retinoids, anticoagulants, carbamazine, and many others.  It can also be associated with chronic illnesses such as diabetes mellitus, hypertension, bronchial asthma, osteoarthritis, chronic hepatitis B infection, gastritis, migraine, and epilepsy.   Nutritional deficiency can also trigger TE (iron deficiency anemia, vitamin D deficiency, and iodine deficiency.  Heavy consumption of caffeine especially after meals inhibits absorption of iron so this adds to the deficiency.

On the other hand, gradual diffused hair loss with thinning or widening of central parting line indicates female pattern hair loss (FPHL), another common cause of diffused alopecia.   Facial hirsutism and FPHL are associated with an increase in androgen hormones.  Androgens stimulate body hair at specific sites such as axilla, chest, and pubic area.  In some cases, these changes may serve as clinical signs of an endocrine disease or malignancy.   FPHL leads to diffused alopecia over the mid-frontal scalp, which is the result of hair follicle miniaturization.  It represents a progressive reduction in diameter, pigmentation, and length of the hair shaft.  Most women with FPHL have normal menses and pregnancies.

One of the most common yet least-talked-about symptoms of menopause is hair loss which can be devastating for the millions of women who suffer from it.  Hair loss for menopausal women is a direct result of fluctuating hormone levels, namely estrogen and testosterone. To reverse the symptom, it is best to address the problem at the hormonal source.  Though it is popular to prescribe hormone replacement therapy (HRT) to treat this fundamental imbalance, persistent links to breast and ovarian cancer, along with heart disease and blood clots, have caused most healthcare professionals to rethink this drastic option.  Many agree that the most effective approach is to combine a few changes in lifestyle with treatment options, which are now very much available in our country.  Without an accurate knowledge of the normal range of hair changes associated with menopause, it is difficult to identify which changes may require further medical investigation.

 Excessive alarming diffused hair loss, from a normal-looking head without an obvious cause, is the hallmark of chronic telogen effluvium (CTE), which is a distinct entity different from telogen effluvium and FPHL.  CTE is characterized by hair shedding lasting longer than six months, with a fluctuating chronic course over many years.  It is idiopathic and usually a trigger cannot be identified.  The diagnosis of chronic telogen effluvium is made by the exclusion of causes of diffused telogen hair loss, including, FPHL.  Patients would often complain of scalp pain and reduced hair density.

Nutritional deficiency, on the other hand, is one of the most common causes of hair loss in premenopausal women. It is usually secondary to severe protein, caloric restriction in those who are undergoing a starvation diet.  It can also be secondary to zinc and a vitamin deficiency.   But the problem can really be complicated as more than one cause can lead to diffused hair thinning in women, so that treatments for one person may require multiple drugs, be it oral or topical.   Thus, advertisements with a cure-all logo are a hoax.  What is important in these hair balding problems is that a patient should not let this problem linger for a long time.   Delaying treatments can lead to a complete atrophy of the hair follicle or permanent loss of that part of the hair unit, leading to permanent baldness.  Hence, an early diagnosis and an aggressive treatment in the case of active hair loss are crucial in the management of diffused alopecia.

source: Philippine Star