Before I discuss treatment, I will briefly comment on hair physiology and health.
There are 4 hair phases per cycle:
- Anagen: the growth phase, lasting 2-8 years, about 90% of hair follicles are in anagen
- Catagen: an intermediate phase, lasting 3 weeks
- Telogen: the resting phase, lasting 3-4 months
- Exogen: the hair shedding phase, it is normal to lose up to 100 hairs daily
Hair loss naturally occurs with age. However, some people lose hair earlier and more dramatically. In this group of people, various factors might be causative.
One of the most important factors is genetic sensitivity of the scalp hair follicles to a normal level of dHT. Testosterone is converted to DHT (dihydrotestosterone, which is 10 times more potent than testosterone) by an enzyme called 5- alpha reductase within the hair follicle, and in a genetically sensitive person, activates gene(s) to cause a shortening of the growth cycle of the hair follicle, with subsequent miniaturization, and ultimately, a dormant follicle, with hair loss. In balding people, activity of the enzyme 5-alpha reductase and the number of DHT receptors are increased.
Both estrogen and progesterone promote an increase in the anagen phase of hair growth, causing thicker hair. In pregnancy, hair tends to be denser and thicker, and this may be due to other factors aside from estrogen and progesterone, including increases in hormones such as hCG and prolactin, and other growth factors.
With menopause, hair thins and becomes brittle. This is due to multiple changes occurring at the same time:
The estrogen level abruptly decreases.
The progesterone level, which decreases the conversion of testosterone to DHT, also decreases, causing increased DHT.
Sex hormone binding globulin (SHBG), a blood protein increased by estrogen, normally binds up free testosterone (the active form of testosterone). However, with menopause, SHBG drops, causing an increase in free testosterone, ready to be converted to DHT.
Other causes of hair loss:
- Stress
- Nutrient deficiencies
- Thyroid and other endocrine disorders
The following recommendations are for men and post-menopausal women only.
For the treatment of hair loss, I employ a multi-faceted approach. It may take 2-4 months from the onset of treatments before you notice increased hair fullness.
Pharmacotherapy
Finasteride 1 mg daily. Finasteride decreases the activity of 5-alpha reductase, dropping DHT within the hair follicle. While finasteride may cause unwanted side effects such as growth of breast tissue in men, reduced libido, or erectile dysfunction, I usually don’t hear those complaints. You should monitor for symptoms.
I also prescribe minoxidil 2.5 mg daily. The mechanism by which minoxidil improves hair growth is unclear, but purported mechanisms include lengthening the anagen phase of the hair cycle, and by improving blood flow to the hair follicle.
For post-menopausal women, hormone replacement therapy may be a good compliment to the other therapies.
Non-pharmacotherapy measures
PRP (platelet rich plasma) injection
For this procedure, your blood is harvested, placed in a test tube, and centrifuged. PRP, which is rich in growth factors, is extracted from the tube and injected into your scalp. Each procedure costs $500-1,000, and you will be asked to have one procedure monthly for 3 months. If you have a good response, the procedure should be repeated every 6-12 months for maintenance.
Stress reduction
Assess for and correct any micronutrient deficiencies, including iron, zinc, selenium, vitamins A, E, B3 (niacin), B7 (folate), and vitamin B12. Over-supplementation is not helpful and may be harmful. Biotin increases the strength of hair, not the density or thickness.
Correct for macronutrient deficiency, such as protein deficiency
Assess for endocrine problems that might be contributing to hair loss.