Diagnosing and Treating Hair Loss Among Women

Diagnosing and Treating Hair Loss Among Women
Diagnosing and Treating Hair Loss Among Women

The real or perceived symptom of increased hair loss can be psychologically devastating for female patients. 

This article is intended as a brief review of the most common causes of adult female alopecia and a thorough introduction to the evaluation of this complaint in the primary-care setting. Bear in mind that many women who experience hair loss will still require referral to a dermatology practice.


Hair follicles constantly cycle through three phases: (1) anagen—the growth phase; (2) catagen—the phase transitioning between growth and resting; and (3) telogen—the resting phase. It is normal to lose as many as 100 hairs per day.

Women who present with excessive hair loss must undergo a detailed and extensive history and thorough examination of the hair, with the clinician paying special attention to the pattern of loss and how easily the hair pulls out. The clinician also must order blood tests and examine the scalp. In some cases, pathologic analysis of a scalp biopsy may be necessary. 



The Initial Examination



The following information should be obtained as part of the patient history of a woman who is experiencing hair loss:



  • Duration and pattern of hair loss

  • Whether the lost hair is broken or intact

  • Current diet and any change in weight within the past six months

  • Any surgeries in the past six months

  • All medications (current and taken within the past six months)

  • Any illnesses or infections within the past six months

  • Any other symptoms (a full review of systems)

  • Whether she has ever experienced similar hair loss before

  • A family history of hair loss and other medical conditions (e.g., metabolic disorders)

  • Date of most recent menstrual period

  • Normal hair and beauty routine. 



A thorough physical examination should discern the pattern and distribution of hair loss. Assess all areas of body hair, including eyebrows, eyelashes, arm hair and pubic hair. The scalp should be assessed for erythema, flaking, or scaring. Firmly grasp approximately 60 hairs and pull. If fewer than six hairs come out, this is considered normal shedding (or a negative pull test); six hairs or more is considered a positive pull test.

Special attention should be paid to how easily the hairs break. Easily breakable hair may suggest hair damage caused by overprocessing. 

Overprocessing can include heat damage from curling irons, straightening, perms, or hair coloring. The diagnosis for this type of hair loss is traumatic alopecia. Pulling from braids, tight hair buns, ponytails, or hair extensions can cause traction alopecia. 

The treatment for such hair loss is discontinuation of the beauty regimen, addition of biotin supplementation, and adoption of a healthy diet. Other forms of female hair loss to be considered in the differential are listed in Table 1.



Table 1. Differential diagnosis for female hair loss

Alopecia areata
Cicatricial alopecia (scarring alopecia)
Female pattern hair loss (androgenic alopecia)
Telogen effluvium
Traction alopecia
Traumatic alopecia
Trichotillomania
Underlying correctable skin condition (e.g., seborrheic dermatitis or psoriasis)
Underlying endocrine abnormality (e.g., hyperandrogenemia or thyroid dysfunction)


In searching for an underlying endocrine abnormality, such as hyperandrogenemia or thyroid dysfunction, blood work should include a complete blood count with differential, serum iron, serum ferritin, thyroid-stimulating hormone (TSH), free thyroxine (T4), antinuclear antibodies, free testosterone, prolactin, 17-hydroxy progesterone, cortisol level, and dehydroepiandrosterone sulfate.



Androgenic Alopecia



The terms androgenic alopecia and female pattern hair loss may be preferable to female pattern baldness. The word "baldness" may lead to unnecessary panic on the part of the patient. Androgenic alopecia describes hair loss caused by genetically determined sensitivity of hair follicles in the scalp to adult levels of androgens.

Androgenic alopecia is the most common cause of hair loss in adult women.1 The diagnosis is made by ruling out other possible diagnoses through lab work, recognition of the distinctive pattern of hair loss, and pathologic analysis of a punch biopsy. The biopsy should be full-thickness (at least 4 mm) sectioned horizontally.