Hair Loss In Women

The causes of hair loss in women are much more varied than in men. When a woman presents to a physician with alopecia (hair loss) for the first time, a careful history must be obtained. In other words, the pattern must first be determined.Is the thinning all over?, or is it a widening of the part, or a typical “male” pattern of hairline recession? This information suggests to the physician where to direct his physical exam, and if laboratory studies are indicated. 
The typical female pattern is the so-called Ludwig pattern, which retains the hairline, but sees the middle part become progressively wider over time; women, however, can also experience the typical Norwood pattern, so common in men. Then the progression must be determined. Did the loss begin suddenly, and was a “rapid “shedding” noted? Or has there been a slow, steady loss over time? Depending on the pattern and progression, the doctor may decide to do microscopic hair exams, together with hair pull or pluck tests, or to order various lab studies.

Ludwig Scale

Common systemic conditions which can cause hair loss include anemia, excess androgens, autoimmune disorders, and many, many causes of acute stress, such as surgery , childbirth, fever, severe illness, and extreme psychological stress. 
In men, the most common cause by far is male pattern baldness, or androgenetic alopecia. This is the common hair loss pattern that is dependent on genetic predisposition, androgens (male hormones), and the simple passage of time. This usually results in the common Norwood pattern of loss, consisting of hair line recession, with or without loss in the crown. It is quite uncommon to find other causes of hair loss in men. The most common treatments for men are medical treatment (Propecia, Rogaine) and surgical treatments (hair transplantation).

Hair Loss in Men

Hair loss occurs in both men and women, but the causes can be divergent. This is quite important, because treatment options depend closely on causative factors. 
It is normal to shed some hair each day as part of this cycle. However, some people may experience excessive (more than normal) hair loss. Hair loss of this type can affect men, women and children. Hair Loss as been the most common cause by far is male pattern baldness, or androgenetic alopecia. This is the common hair loss pattern that is dependent on genetic predisposition, androgens (male hormones), and the simple passage of time.
These men have increased levels of a hormone known as 5(alpha)-reductase, which transforms testosterone into dihydrotestosterone (DHT). The DHT, in turn, causes follicles to sprout shorter,

finer hairs, before eventually dying out. It also causes the growth phases of hair follicles to become shorter, and the other phases to be longer. This usually results in the common Norwood pattern of loss, consisting of hair line recession, with or without loss in the crown.
Sometimes, acute stress to the system (such as high fever, sudden weight loss, etc.) produces a sudden, rapid shedding of hair, where you find clumps of hair coming out all over the place. Although this syndrome (called telogen effluvium) is alarming, it actually is good news, because the body readjusts itself and most if not all the hair grows back. People whose loss of hair is inherited notice their hair is thinning but don't see very much hair actually coming out.
Most men will loose hair in some point during their lives. Seventy percent of adult males will experience some degree of balding, and advanced male pattern baldness affects well over one half of the adult male population.

Men who suffer from androgenetic alopecia will experience hair loss in a younger age and until age 60 will loose anywhere between 30-90% of their hair. While boys have a straight low hair line, adult men have more of an "M"-shape. 
Male pattern baldness is dependent on the interaction of three factors: age, a genetic pre- disposition, and male hormones, Once male pattern baldness begins, it does not stop.
The progression of male pattern baldness is generally classified on the Hamilton-Norwood scale, which ranges from stages I to VIII (see example)

Hair Loss Causes

There are many causes of hair loss in men and women, including disease, nutritional deficiency, hormone imbalance, and stress. However, by far the most common cause is what is called adrogenetic alopecia. Alopecia is simply the medical term for hair loss. Androgenetic refers to the fact that both a genetic predisposition to balding, and the influence of androgens, or male hormones, play a part in this type of hair loss. 
In fact, there is a third factor, which is the passage of time, or aging. In other words, in order for androgenetic alopecia to occur, there must be:

• A genetic propensity for balding
• The presence of androgens, or male hormones
• Enough aging time to allow the first two factors to exert their influence on the hair follicles genetics

Genetics is not always simple, and such is the case with balding. Just the presence or absence of balding in one’s parents or grandparents, on either the mother’s or father’s side, is not necessarily predictive of one’s likelihood of balding. Certainly, if a man’s father is completely bald, and this man begins to rapidly lose hair in his early twenties, it’s a safe bet that he will develop extensive balding at some point. In short, it’s very hard to accurately predict who will go bald and how rapidly.
This inherent uncertainly about the progression of balding is of utmost importance in planning surgical hair restoration, as we will see in later sections. We must always plan for a "worst case scenario" in order to give patients the best possible results in the long term, as well as in the short term. Anything less is irresponsible.

Androgenic Hormones

All normal men and women produce "male" hormones. The most common of these are testosterone, androsteinedione, and dihydrotestosterone (DHT). Androgens are produced by the testicles and adrenals in men, and by the ovaries and adrenal glands in women. These hormones are quite important in both sexes, but occur in different concentrations, being much more predominant in males than in females. This, in part, is responsible for the typical differences between the genders. 
It is the exposure of the hair follicles to DHT, in a genetically susceptible person, over a period of time, which leads to androgenetic alopecia, or male and female pattern baldness. How does this exposure to DHT occur?
In certain cells of the hair follicle, and in the sebaceous glands, there are high levels of an enzyme called 5-alpha-reductase. What this enzyme does is to convert testosterone, which is delivered to these areas by the blood, into DHT. This is important not only in understanding the mechanisms of balding, but also one medical treatment now available: Propecia (finasteride). What Propecia does is inhibit, or limit the activity of, this 5-alpha-reductase enzyme. Therefore, there is less conversion of testosterone to DHT, and lower levels of DHT are found in the follicle. In later sections, we will discuss this and other medical treatments in much greater detail.

Aging

There is no set age at which balding occurs. It is a process, and this is a simple, but oft-ignored fact. Like any process, it can be rapid or slow, it can begin toward the end of life or in the late teens, and it can progress in a predictably inexorable fashion, or it can stop and start, seemingly stabilize, and then begin again. Once we understand and accept this as a dynamic process, then we can better plan for the present and for the future in terms of how we treat it. This quest for understanding, which you have begun just by opening this book, will do more than all the despairing thoughts, hand-wringing, and self-pity, toward allowing a clear-eyed, rational, long term approach to the problem of hair loss.
So we now have looked at these three interdependent factors that play into the common types of balding. Again, they are: hormones, genetics, and Father Time. So what exactly does happen to the hair? Let’s take a look.
Assuming we have a genetically predisposed person, then as the follicles are continuously exposed to DHT, an interesting phenomenon occurs. Remember the anagen phase, or active growth phase of the hair? This phase becomes gradually briefer and briefer, and eventually the hair becomes finer and shorter, and less deeply colored. We call this "miniaturization" of hairs. This is also the point at which hair loss tends to first be noticed. It’s not that there are fewer hairs on the head, but that their caliber (cross-sectional area), color and length are so diminished that they no longer provide "coverage" for the scalp beneath. Light penetrates through to the shiny scalp, and this is perceived by the observer as "thinning" or balding.
Also, the ratio between hairs in the anagen phase and those in the telogen, or resting phase, is increased. This simply means that, at any given time, an increased number of hairs are in the telogen phase. These extra numbers of telogen hairs will be found in the susceptible zone for common balding, which is the front, top, and crown of the head. The so-called "permanent" zone, the familiar horseshoe-shaped wreath of hair around the back and sides, is unaffected by these changes. The telogen hairs are easily dislodged during washing, drying, or combing, and this is the second sign of balding: in addition to the apparent thinning seen with miniaturization, we begin to see larger numbers of hairs on the comb, the towel, the pillowcase, or in the bathroom drain. This can be quite traumatic, especially for the younger man or for women. In the next section, we will discuss the natural history of balding, that is, the way it first presents or appears, the different ways it progresses, and how it affects the different regions of the head. 
For the sake of completeness, let’s briefly mention some of the other patterns of hair loss, if only to distinguish them from androgenetic alopecia (male and female pattern baldness). There is alopecia areata, where discrete patches of scalp go bald; triangular alopecia, which tend to occur in a triangular pattern in the temporal area; alopecia universalis, in which the entire body may be affected; and various "toxic" alopecias, including those following a severe illness, sometimes with high fever, or following pregnancy. Toxic alopecias may also occur with low thyroid and/or pituitary gland function, or following chemotherapy. The cicatricial (scarring) alopecias occur following tissue destruction and inflammation.
Also seen are the so-called diffuse alopecias (patterned and unpatterned), in which there is widespread thinning that may affect the "permanent" zone as well as the areas vulnerable to balding. In any or all of these less common types of balding above, it may be necessary to have a complete physical and laboratory workup, possibly including scalp biopsy.
So again, the common types of balding are directly related to the presence of male hormones in a genetically predisposed person over time. This can occur in both men and women. The process involves progressive miniaturization of the terminal hairs, and diminished length of the active hair growth cycle. Now, let’s take a look at how this microscopic, cellular process is manifested on the head; we can call this the natural history of balding.

When tissues are deprived of their blood supply, even briefly, the damage to the cells comes not so much from the lost blood supply, but from the RE-PERFUSION! Perfusion is blood flow, so reperfusion means that the formerly oxygen-deprived tissues suddenly experience a flood of blood into their midst. This can cause tissue damage. On a biochemical level, what happens is this: free radicals are formed. What are free radicals? Well, they are usually highly charged, highly energetic oxygen species, like OH- (hydroxyl), H2O2 (peroxides), O- (superoxides), and others. These free radicals act as “little bullets”, if you will, and can damage cell membranes, and contents of the nuclei of cells. Of these, superoxide specifically is known to break down nitric oxide and to inhibit hair follicle cell growth. Interestingly, nitric oxide is also a “free radical”; however, in small amounts, it exerts a positive effect. Only when its production is out of control, such as in septic shock, is it damaging to the body.
Now, these free radicals are also part of normal metabolism, and are often used by certain white blood cells to destroy viruses, bacteria and other invaders. But as is often the case, it’s a matter of balance. Too many of them is bad, and in too concentrated an area. This is a major way that heart muscle is damaged after coronary occlusion (blockage), brain tissues killed after occlusive stroke and so on. 
These Hair Cycle products are physician-formulated, safe, and naturally-based, delivered in a vehicle that is gentle and effective, and leaves the hair soft and manageable. The products are ideal for those undergoing hair transplant surgery, and for the millions of men and women worldwide experiencing hair loss.
So, how is this pertinent to our field of hair transplant surgery? Well, our follicular unit grafts are tissues deprived of perfusion (they are ischemic). What ameliorates reperfusion injury and free radical formation? Cold for one thing (we use chilled saline as a storage solution, right?) and brevity of ischemic time (minimal time out of body). Certain substances like tetrahydrobiopterin (BH4), which we have yet to figure out how to apply to our work, can protect cells from ischemia-reperfusion injury. There are also fascinating studies which show that ischemic pre-conditioning (IPC) can protect tissues in remote locations from ischemia-reperfusion injury (IR). Thus, using IPC on a limb, like the forearm, may help protect tissues elsewhere in the body (possibly follicular unit grafts?)
One of the things that we can do is to use various antioxidants to shift the balance in the tissue’s favor. Our product line contains many antioxidants. Any antioxidant “quenches” free radicals, i.e., it allows itself to be oxidized rather than the cellular structures at risk. Our bodies have a very sophisticated antioxidant system; ascorbic acid (vitamin C), tocopherols (vitamin E), glutathione, glutathione synthetase, carotenoids (vitamin A-like substances), and many more. With our product line, we are placing these and others topically, that is, directly on the scalp and hair.

The products also are rich in anti-inflammatories, generally of the natural persuasion. Again, as with free radicals, it’s a matter of balance. Too much inflammation is deleterious to tissues and cells. Think rheumatoid arthritis, or atherosclerosis. These are basically inflammation out of control. It is well known that androgenetic alopecia (pattern baldness) is associated with markedly increased numbers of inflammatory cells around the follicles.
If we diminish inflammation in the scalp after transplant, there is less pain, less swelling, and possibly a higher likelihood of graft survival. And we have also included cell proliferants, anagen stimulators, and nitric oxide (NO) stimulators. A cell proliferant is any substance that stimulates an increase in cell division, and it is cell division at and around the hair’s bulb that drives growth of the hair shaft. Cell proliferation is also mandatory during the healing process.
An anagen stimulator is any substance which increases the amount of time the follicle is in the anagen, or active growth phase. Conversely, this would diminish the amount of time spent in telogen, or resting stage.
What about nitric oxide stimulators? Nitric oxide, or NO, is a small, gaseous molecule that plays an important role in an astounding number of metabolic processes. It is a signaling molecule and is produced by a number of enzymes collectively known as NO synthases. Among other things, NO is involved in immune system functioning, exerting an antimicrobial effect, decreasing inflammation in blood vessels, increasing blood flow (NO is intimately involved in mediating the effect of Viagra and other such drugs), and in stimulating hair cell growth. It has been proposed that deficient production of scalp nitric oxide is related to baldness. We also know NO is essential for proper wound healing such as after hair transplant surgery, and is an anagen stimulator.
Now, a quick word about androgens. It is well known that androgens (“male” hormones) are part of the hair loss equation in both men and women. Specifically, testosterone and other androgens may be converted, by an enzyme called 5-alpha-reductase, to a much more potent androgen called dihydrotestosterone (DHT). Propecia (finasteride) and Avodart (dutasteride) are 5-alpha-reductase inhibitors, and therefore decrease levels of DHT in the body and scalp. Pattern baldness, or androgenetic alopecia, as the name implies, depends on a combination of a genetic predisposition to hair loss, the presence of androgens, especially DHT, and the passage of time. The Hair Cycle product line contains topical inhibitors of 5-alpha-reductase and inhibitors of the action of DHT at the androgen receptor.
So, to reiterate, we have included: anti-inflammatories, antioxidants, cell proliferants, DHT inhibitors and androgen blockers, anagen stimulators and nitric oxide precursors. These Hair Cycle products are physician-formulated, safe, and naturally-based. All this and more, in a vehicle that is gentle and effective, and renders the hair soft and manageable. The products are ideal for those undergoing hair transplant surgery, and for the millions of men and women worldwide experiencing hair loss.