While hair loss in men is often a genetic condition, hence a lifelong process, it is unclear what predisposes a female toward hair loss. Some females may start exhibiting hair loss as early as after puberty, while others have no signs of any unusual hair shedding until later in life when they enter menopause. In women as in men, the most likely cause of scalp hair loss is AGA: an inherited sensitivity to the effects of androgens (male hormones) on the hair follicles of the scalp. Women with hair loss due to AGA tend to have miniaturizing hairs of variable diameter over all affected areas of the scalp. While miniaturizing hairs are a feature of AGA, in women, miniaturization may also be associated with other causes. In postmenopausal women, hair may begin to miniaturize over the entire head, thereby losing its original volume and becoming difficult to style.

Although in some cases, genetics can be the causative factor, health issues such as iron deficiency or hormonal imbalance that arise from pregnancy, menopause, withdrawal of oral contraceptives, or hysterectomy can also spur hair loss in women (telogen effluvium). Pregnancy can lead to a prolonged estrogen-rich state in which hairs remain in the anagen phase until delivery. Following childbirth, the hair is shed excessively for about 4–12 weeks afterward and most likely regrows within 3–6 months. Besides these acute states of telogen effluvium, women between 30 and 60 years of age are more likely to suffer an unexplained chronic telogen effluvium marked by recurrent hair shedding that does not lead to total baldness. It is important to note that female-pattern hair loss can begin as early as the late teens to early 20s in women who have experienced early puberty. If left untreated, this hair loss associated with early puberty can progress to more advanced hair loss. In the African-American female, several types of hair loss are observed, some of which are scarring alopecias that cannot be transplanted. Consequently, hair loss in a woman (even when there is a family history of AGA) should never be assumed to be due to AGA. Examination and diagnosis by a dermatologist is essential before any hair transplant is undertaken. Routinely, a battery of tests is suggested to female patients exhibiting hair loss, such as a full chemistry profile, sedimentation levels to check for inflammatory diseases, serum iron levels, male/female hormones (including T and dehydroepiandrosterone sulfate [DHEAS]), and thyroid levels to check for proper function and scalp biopsy.

For all of these reasons, hair loss in women can be more complicated than in men and should be more carefully explored for the cause so that a proper treatment plan can be instituted.

The most commonly used classification for female-pattern hair loss is the Ludwig classification (Type 1 to 3). Alternatively, for women who suffer from male-pattern baldness, the Norwood-Hamilton classification can be used. The Ludwig classification emphasizes the diffuse nature of much female-pattern hair loss with a frequently preserved hairline and thinning affecting the central top portion of the scalp, while the Norwood-Hamilton classification describes patterns of loss that are similar to male hair-loss patterns with affected hairline and/or thinning in the vertex area.

Hair loss in women is different than in men because the areas affected can thin significantly but rarely become totally bare of hair. There are various patterns of hair loss in women, and the following are the most common types:

  • A “Christmas tree” pattern of diffuse hair loss, with the “base” of the “tree” at the hairline and the “tip” of the “tree” at the center of the scalp. The women having this hair-loss pattern have difficulty parting their hair in the middle and often do a comb over to camouflage the thin area. This type is the most prevalent type of female hair loss and is easy to fix with hair transplantation because their donor area is oftentimes unaffected (Fig. 1.6A).
  • A “Diffuse” pattern of hair loss that expands throughout the top scalp. Some studies have indicated that a diffuse thinning of hair is experienced to some degree by a majority of premenopausal women and by a large majority of postmenopausal women. There is a visible pattern of thinning that affects the top scalp and often the temporal areas as well making these women less favorable candidates for hair transplant. The most common feature for female alopecia is that the involved areas can be camouflaged with coloring or “creative” styling until it reaches a certain point of decreased density (Fig. 1.6B).
  • A type of “Male-pattern baldness” with preserved central (midfrontal forelock) density. The regular female-shaped hairline is affected by the loss in both corners (i.e., frontotemporal triangles). These women often wear bangs to camouflage their bald area, which sometimes can be difficult to accomplish in cases of severe recession along the hairline. Though these women are great candidates for hair transplantation and the bald areas resemble the male- pattern hair loss of Norwood-Hamilton Types I-III, they should never be mistaken for an inflammatory scalp condition that would be unsuitable for hair transplant.
  • A hair loss found in women (and rarely in men) called diffuse unpatterned alopecia exhibits hair thinning throughout the entire scalp, oftentimes combined with global miniaturization, depriving these individuals from ever being candidates for hair transplant.
  • Traction alopecia is a hair loss caused by repeated pulling out of the hair from a specific area of the scalp. African-American women who wear their hair braided often exhibit hair loss in the hairline and/or in the front and above their ears. These women are good candidates for hair transplant as long as they have a good donor density.
  • It is important to mention that there is one more “model” seen in female hair transplantation, which is not a medical condition caused by hair loss but rather an aesthetic condition of being born with a high hairline.

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