DEFINITION

It is a diffuse capillary rarefaction in the temporal, parietal and occipital areas, starting in the mid section of hair partition. There is the transformation of a terminal thick hair into velus (fuzzy hair). It is also known as Feminine Androgenic Alopecia, or Female Hair Loss Pattern.

ETIOLOGY (CAUSES)

Female baldness is as common as male baldness; however, it is less severe and it has a totally different clinical presentation.

The beginning is gradual and it starts after the puberty period, but with peaks of appearances between the ages of 30 and 50 years old. Around 25% of women between the ages of 25 and 40, and 50% of women over 40, present some degree of baldness. Just as male baldness, there is also a dominant autosome genetic predisposition, inherited from both parents, not only from the mother’s side. Only 20% of the cases present positive family history.

The cause is considered multi-factorial, and it is believed that it might occur in women the conversion of testosterone (masculine hormone that also circulates in women, but in less amounts than in men) into DHT (dihydrotestosterone), through the 5-alfa-redutase enzyme, which in women is produced by the suprarenal gland or in the ovaries.

Women have 3,5 times less 5-alfa-redutase than men, but this enzyme is also found in larger concentration in the frontal region. That explains the beginning of capillary rarefaction in the area.

Most of the time there is no increase of masculine hormones in the bloodstream. What happens is that there is a sensibility of cellular receivers to normal amounts of hormones, triggering a hair miniaturization process (a decrease in the diameter and in the size of the stems of hairs and the reduction of their growth phase).

The triggering factors can be: hormonal disorder, considering either the beginning or interruption in the use of contraceptives, post-childbirth and peri- and post-menopause periods.

DIAGNOSIS

In order to have a precise diagnosis of female baldness, we should always eliminate any other cause of abrupt hair loss. The most common are: anemia caused by lack of iron, restrictive diet, thyroid diseases, hormonal changes with the increase of masculine hormones, beginning or interruption in the use of oral contraceptives, post-childbirth period, the use of some medications as well as post-surgery or post-stress states. So the patient should undergo a detailed clinical history, physical exams, and laboratorial exams.

During the clinical exam, we do not find a totally bald area or advances on the forehead, like in men. The anterior line of the hair remains in its original place. This is due to the presence of an enzyme called aromatase, which turns the testosterone into estradiol (female hormone) and the androstenedione, androgen presented in higher concentration in women, into estrone (female hormone), protecting the hairs in this region from suffering miniaturization. Women possess a concentration of aromatase 6 times higher than men. The female hormones protec women from baldness, and it´s because of the presence of these hormones that the clinical apperance in women is so different than in men.

The main complaint by female patients is that they are able to see the scalp through the hairs, when they look at themself frontly in the mirror.

Female baldness is classified into three main groups according to Ludwig, and into eight groups, according to Savin. The classification is based on capillary rarefaction that begins at the line of hair partition, and that evolves laterally, taking over the entire upper surface of the scalp.

TREATMENT

Once the diagnosis is ready, there are three possible treatments that can be indicated the medical expert according to each case: the clinical, the surgical, or an association of both.

The clinical treatment consists of continuous use of hair lotions, specific vitamin capsules, anti-male hormones medications (if necessary), fortifying shampoo, and, more recently, Low Potency Laser. Due to the phases of hair growth cycles, we are able to assess if the treatment is being effective only after a minimum period of 6 to 8 months.The surgical treatment is the megassession (the highest number of hairs transplanted in a single surgery, depending on the density and elasticity of each patient’s donor area). This procedure is the one with the highest qualification at the Muricy Clinic.

Since decreased capillary density might occur also in the occipital region, not always female patients are possible candidates for hair transplant, once this region (occipital) is the main donating area for a transplant.  When there is surgical indication, density and elasticity of this posterior area should always be analyzed, in order for a good surgical plan. In most female cases, the quantity of donor hairs is insufficient to cover the entire rarefied area. For this reason, it is very important to establish a priority area for placement of follicular units, according to each patient’s hair style. Thus, a cosmetic effect is achieved by hiding the other areas when hairs are superimposed.

WE SHOULD EMPHASIZE THAT EVEN IF THE PATIENT DECIDES FOR GOING UNDER THE SURGERY, SHE SHOULD ALWAYS FOLLOW A CLINICAL POST-SURGERY TREATMENT GUIDED BY OUR TEAM. This will allow the cosmetic result obtained from the surgery to last longer. In case there is no clinical follow-up, the tendency is that the patient presents capillary rarefaction again as time goes by, because the non-transplanted hair tend to undergo baldness process.

During the post-surgery period, there might be a slight loss of non-transplanted hair. This is due to the fact that the patient underwent surgery, that thousands of incisions were done in between the hairs, that there are micro traumas in blood circulation, and the healing process itself. THERE IS NO LESION ON PRE-EXISTING ROOTS. These hairs grow again along with transplanted hair. For this reason, female patients may need psychological support under medical supervision in order to do this type of procedure. There is a need of post-surgery follow-up in order to ensure these patients of the natural evolution of this type of surgery.