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QUESTION OF THE WEEK

Dr. Donovan's Articles

QUESTION OF HAIR BLOGS

Filtering by Category: Women


Finasteride vs Spironolactone for Female Androgenetic Alopecia: How do side effects compare?

Comparison of Side Effects of Finasteride and Spironolactone For Women

Androgenetic alopecia (AGA), also called female pattern hair loss, is common among women. By age 50, about 40 % of women will have AGA. Treatments include minoxidil, anti androgens, oral contraceptives, laser, PRP, hair transplantation, as well as others. Minoxidil remains the only formally FDA approved treatment.

There are no FDA approved anti androgens for treating female AGA although many are used off label in treating this type of hair loss.  The evidence would suggest that anti-androgens are potentially the most consistently effective treatments. The antiandrogens finasteride and spironolactone are among the most commonly prescribed antiandrogens for treating female AGA. Dutasteride, bicalutamide, flutamide and cyproterone acetate are less commonly prescribed.

Finasteride vs Spironolactone: What are the side effects and how to they compare?

This article will focus on the side effects of spironolactone and finasteride. It is important for both prescribers as well as users of these medications to understand the risks and benefits of these medications before committing to use. The use of antiandrogens is lifelong when treating AGA. These medications can be helpful for treating AGA but are not appropriate for every female patent with AGA. The risks and benefits must be carefully reviewed. All anti androgens are contraindicated during pregnancy and also by any female patient who may become pregnant or is trying to conceive. Antiandrogens have the potential to cause serious harm to a developing fetus.

There have been studies of both finasteride in treating AGA and spironolactone in treating AGA. For Spironolactone, the vast majority of our understanding of side effects comes from understanding the side effects that this medication causes in women who use the medication for acne and hirsutism. There have been no good side by side comparative studies of finasteride and spironolactone in treating AGA.

Overall, studies would suggest that finasteride probably has fewer overall side effects which contributes to its discontinuation rate being lower. However, there are many reasons that physicians may choose spironolactone over finasteride, especially in premenopausal women.


1. Overall side effect rates, Discontinuation Rates and Effectiveness

General

2. Non specific Effects Spironolactone vs Finasteride among Female Users

general 2


3. Specific side Effects Spironolactone vs Finasteride among Female Users

spironolactone vs finasteride




4. Side Effects Related to Breast Health

breast health



5. Laboratory Changes among Female Finasteride and Spironolactone Users.

LABS




6. Dermatological Side Effects among Female Spironolactone and Finasteride Users.

derm



Summary and Conclusion

One must understand the risks and benefits of finasteride and spironolactone if use of these medications is being considered. These medications remain options for female patients with androgenetic alopecia. A careful review of side effects with one’s physician is essential in all individuals considering these medications. There are clearly certain situations where one medication might be preferred over the other. For example, given the effects on blood pressure, the use of finasteride is often preferred in patients with issues with problematic low blood pressure.

Many of the side effects listed above improve over time. Trueb and colleagues showed showed that finateride side effects decrease over time. This incluces side effects such as libido reduction, breast tenderness, or hypertrichosis/hirsutism decrease over time. Probably, there are some adaptative hormonal changes in brain-hormonal axis or in brain perception that lead to these side effects being less and less noticed.


References

Donovan J. Spironolactone in Female AGA

Donovan J. Bicalutamide for Female AGA

Donovan J. Finasteride Use in Women: Yes or No?

Donovan J. Flutamide in Women who Don’t Respond to Spironolactone

Goodfellow A. Oral Spironolactone Improves Acne Vulgaris and Reduces Sebum Excretion.Br J Dermatol 1984 Aug;111(2):209-14.

Helfer EL et al. Side-effects of spironolactone therapy in the hirsute woman.J Clin Endocrinol Metab. 1988 Jan;66(1):208-11. doi: 10.1210/jcem-66-1-208.PMID: 3335604

Hu et al. The Efficacy and Use of Finasteride in Women: A Systematic Review. Int J Dermatol. 2019 Jul;58(7):759-776.

Hughes BR, Cunliffe W. Tolerance of spironolactone. Br J Dermatol. 1988 May;118(5):687-91. doi: 10.1111/j.1365-2133.1988.tb02571.x.PMID: 2969259

Kohler C, Tschumi K, Bodmer C, et al. Effect of finasteride 5mg (Proscar) on acne and alopecia in female patients with 72. normal serum levels of free testosterone. Gynecol Endocrinol. 2007;23:142–145.

Oliveira-Soares R, et al.  5 mg/day for Patterned Hair Loss in Premenopausal Women.Int J Trichology. 2018 Jan-Feb;10(1):48-50. doi: 10.4103/ijt.ijt_73_15. 

Plovanich M et al.. Low Usefulness of Potassium Monitoring Among Healthy Young Women Taking Spironolactone for Acne. JAMA Dermatol. 2015 Sep;151(9):941-4. doi: 10.1001/jamadermatol.2015.34.

Seale LR, Eglini AN, McMichael AJ. Side Effects Related to 5 α-Reductase Inhibitor Treatment of Hair Loss in Women: A Review. J Drugs Dermatol  2016 Apr;15(4):414-9.

Shaw JC, White LE.  Long-term safety of spironolactone in acne: results of an 8-year followup study. J Cutan Med Surg. 2002 Nov-Dec;6(6):541-5. doi: 10.1007/s10227-001-0152-4. Epub 2002 Sep 12.PMID: 12219252

Townsend KA, Marlowe KF. Relative safety and efficacy of finasteride for treatment of hirsutism. Ann Pharmacother. 2004 Jun;38(6):1070-3.

Trüeb RM, Swiss Trichology Study Group. Finasteride treatment of patterned hair loss in normoandrogenic postmenopausal women. Dermatology 2004;209:202-7.  

Yemisci A et al. Effects and side-effects of spironolactone therapy in women with acne. J Eur Acad Dermatol Venereol. 2005 Mar;19(2):163-6. doi: 10.1111/j.1468-3083.2005.01072.x.PMID: 15752283








This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Bicalutamide for Female Pattern Hair Loss: Should we add it to the list of anti androgens ?

Bicalutamide (Casodex) is pure anti-androgen with Potential Benefit in Treating Female Androgenetic Alopecia

Bicalutamide is a non-steroidal pure anti androgen that was FDA approved for treating prostate cancer at a dose of 50 mg daily back in 1995. Recent studies have investigated its use in treating female androgenetic alopecia.

STUDY 1: Ismail and colleagues, 2020

Dr. Rodney Sinclair’s group from Australia (Ismail and colleagues, 2020) performed a retrospective review of 316 women treated with bicalutamide. The standard starting dose was 10 mg daily although starting doses ranged from 5 mg to 50 mg in the study. The average age of patients was 49 years with a range of 15-85 years. In the study bicalutamide was usually prescribed together with some other medication including oral minoxidil in 308 patients and spironolactone in 172 patients. Six patients received bicalutamide alone (i.e. monotherapy). The most common adverse effect was mild elevation of liver transaminases in 9 (2.85%) patients. This elevation was mild in all cases (less than twice the upper limit of normal) and asymptomatic in all cases as well.. Furthermore, the liver enzyme elevation resolved without needing to adjust the dose in 4 out of 9 patients. In 2 patients, the transaminitis resolved with further dose reduction. Other side effects bicalutamide in the study included peripheral edema in 2.5 % of patients and gastrointestinal complaints in 1.9 %. Use of bicalutamide provided benefit in the treatment of AGA in women.

STUDY 2: Fernandez-Nieto and colleagues, 2020

Dr. Sergio Vano Galvan’s group from Spain (Fernandez-Nieto et al. 2020) recently published their data of 44 women receiving bicalutamide at doses of 25-50 mg daily. The ages of patients in this study were 20-59 with an average age of 34.8 years. The authors chose higher doses than Sinclair’s group for the simple reason that higher doses of bicalutamide are already commonly used in treating hirsutism. Side effects in this particular study included transient elevation in liver enzymes with 5 of 44 (11.4%) patients having a mild increase liver enzymes - all of which self resolved without a need to stop the drug. In addition to elevated liver enzymes, other reported side effects including were shedding, amenorrhea, headaches and endometrial hyperplasia. None of the patients needed to stop treatment. Similar to the Ismail et al study mentioned above, use of bicalutamide in this study also provided benefit in the treatment of AGA in women.

COMMENTS

These are interesting studies and I suspect we’ll be hearing a lot more about bicalutamide in the years to come. I’ve been using it for a few years now and was encouraged to see some good data here with regard to side effect profile and generally good safety. Bicalutamide has fewer side effects than flutamide, another non stereoidal anti androgen (NSAA) and in general the side effects profile is acceptable when compared to the 2 other commonly used antiandrogens we use for treating androgenetic alopecia - spironolactone and finasteride. Further studies are needed to understand how bicalutamide compares to finasteride and spironolactone and what of side effects we might need to counsel our female patients.

Reference

Ismail et al. Safety of oral bicalutamide in female pattern hair loss: a retrospective review of 316 patients. Journal of the American Academy of Dermatology. Available online 19 April 2020

Fernadez-Nieto Et al. BICALUTAMIDE: A POTENTIAL NEW ORAL ANTIANDROGENIC DRUG FOR FEMALE PATTERN HAIR LOSS.J Am Acad Dermatol. 2020 Apr 19:S0190-9622(20)30667-8. doi: 10.1016/j.jaad.2020.04.054. Online ahead of print.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Hair loss in the Frontal Hairline.

Cause of Frontal Hairline Loss

I enjoyed giving a lecture yesterday to our brilliant University of British Columbia dermatology resident physicians. We discussed the common and uncommon scarring and non-scarring hair loss conditions that affect the frontal hairline of males and females.

frontal hairline

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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The Widow's Peak: How does it form?

Formation of the Widow’s Peak

The widow’s peak is a triangular area of hair in the middle of the hairline. It’s common and not associated with bad luck, bad omen or bad anything...of any kind.

The term is probably 200 years old. How did the name even get started? Well, the term probably comes from a type of headdress that a woman (widow) wore after the death of her husband in the 1500’s. The headdress had a triangular peak right in the middle of the frontal hairline. And so the term.

Studies by Dr Bernie Nusbaum suggested that up to 81 % of women have a widow’s peak. This information comes from his study of hairline characteristics of 360 female volunteers performed at an informal hair salon setting. A 2013 study from Spain involved examination of hairline patterns of 103 premenopausal women. 94.17 % had a widow’s peak.

Men have widow’s peaks. Small children (3-5) do not usually have much of a widow’s peak but the widow’s peak starts to be seen in some individuals in the teenage years. The widow’s peak is not actually “created” by the body - it’s due to the body removing hairs around it on either side. What’s left over is the new adult hairline - containing a widow’s peak in some. In case you were not aware, the hairline we get as adults is not the same as the one we get as children. This is normal. 

widow's peak


For some - the new adult hairline has a widow’s peak.

Reference 


Bernard P Nusbaum et al. Naturally Occurring Female Hairline Patterns. Dermatol Surg. 2009 Jun.

C Ceballos et al. Study of Frontal Hairline Patterns in Spanish Caucasian Women. Actas Dermosifiliogr. 2013 May.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Lecture on Hair Loss

55th Annual Post Graduate Review in Family Medicine

I was invited to speak this morning at the 55th Annual Post Graduate Review in Family Medicine at the Vancouver Marriott Pinnacle Downtown Hotel in Vancouver, BC. I spoke on “An Approach to Hair Loss in Women.”

UBC CME

This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Is Androgenetic Alopecia (AGA) Caused Only by the Effects of DHT ?

Despite the Myth, Androgenetic Alopecia is Not Simply a Story of DHT

Androgenetic alopecia is a type of hair loss that affects men and women. In males, this condition is also referred to as male balding or male pattern hair loss and eventually affects some 80 to 90 % of males. In females, the condition is referred to as female pattern hair loss or simply hair thinning and affects 40% of women by age 50. The purpose of this article is to deal with some misconceptions, wrong information, errors and myths that many people have about the role of DHT in the balding process. DHT is certainly important - but other factors must be considered too.

The Evolution of the DHT Theory of Male Balding

Some of the earliest observations about the role of hormones in male balding happened in the time of Aristotle back in 300 BC. Aristotle showed that castrated males (eunuchs) did not develop balding. JB Hamilton in 1942 did additional pioneering work to understand male balding. He showed that male hormones are relevant to the balding process. Specifically, he confirmed observations by Aristotle and others that males that were castrated before puberty did not go on to develop balding. Hamilton took this further and showed that if testosterone was given back to castrated males, the males proceeded to develop male balding. This showed that male balding was an “androgen-dependent” process.

Hamilton

Further key work in understanding male balding was done in the 1970s and ultimately published in the New England Journal of Medicine. These were studies that showed that male pseudohermaphrodite living in the Dominican Republic with a genetic deficiency known as 5 alpha reductase deficiency did not produce dihydrotestosterone (DHT) and did not develop male balding. These findings lead ultimately to the rational development of drugs such as finasteride and dutasteride which block 5 alpha reductase and lower DHT levels.

story of MPB

The Story of Male Pattern Balding has a DHT Chapter but Don't Forget to Read the Others

From 300 BC to the 1990’s, the story of male balding seemed pretty clear. Male hormones, particularly the infamous DHT, seemed to be what male balding was all about. Blocking DHT was what treatments were all about.

Many people incorrectly assume that male balding is just a DHT story. Many people incorrectly assume that this DHT chapter is the only chapter they need to read when trying to understand male balding. While it’s true that DHT has a whole lot to do with male balding - the correct way to state it is “male balding is due in part to the effects DHT on hair follicles that are genetically sensitive to this hormone.”


DHT not the only chapter in the balding story

DHT not the only chapter in the balding story. One only need to consider a few other treatments that are used for balding to very quickly realize that male balding must be much more complex than just a DHT story. Minoxidil (Rogaine), for example, has nothing to do with DHT - and yet it helps some people with male balding. Granted I agree that finasteride and dutasteride are much much better treatments than minoxidil - but if DHT was the only thing we need to think about when it comes to treating male balding then minoxidil would not be expected to have any sort of benefit. Well, it does. Low level laser therapy also has nothing to do with DHT hormone levels - and yet it helps some males with their male balding. Platelet rich plasma (PRP) also has very little to do with DHT- and yet it helps some males with their male balding.

Drug Companies are Investing Large Sums with the Knowledge that Male Balding is Far Far More than A Simply DHT Story.

At least 12 pharmaceutical companies are investing millions upon millions of dollars with the clear understanding that DHT is not the only chapter in the balding storybook. These companies are hoping to the first to market with brand new types of drugs - again drugs that have nothing really to do with DHT. A brief summary of the drugs is below.

companies in race



If Male AGA is Far More than A Simply DHT Story, Female AGA is Far Far Far More than A DHT Story

If you have now come to realize that male balding is a bit more complex than simply a story about DHT, I’d like to point out that female androgenetic alopecia (i.e. female pattern hair loss) is even more complex. If you think for even a moment that you’re going to apply the same DHT story that you used in males to explain balding to the mechanisms operating in females with androgenetic alopecia, you’re going to come up short in terms of your ability to explain hair thinning in women.

Androgenetic alopecia in females is a far more complex story - and we still don’t know all of the mechanisms that govern how hairs thin in women. Of course, there is some aspects of the DHT story that relevant to female thinning. But finasteride and spironolactone and anti-androgens are far less consistently helpful in females than in males. Other treatments such as minoxidil and laser may be far more helpful in some women than in males. In other words, there are likely several different mechanisms that are contributory to androgenetic alopecia in females besides simply a DHT story. As further information for reflection to readers who still doubt this information, one must consider that some women with a genetic condition that completely makes them insensitive to the effects of androgens (called androgen insensitivity syndrome) can still develop androgenetic alopecia. Even women with low testosterone and low DHT levels can develop androgenetic alopecia. There are even some androgen deficient women who do not develop any balding whatsoever when you give them back supplemental androgens through various means of testosterone replacement therapy.

Conclusion

Is androgenetic alopecia simply due to the sensitivity of hair follicles to DHT? Well, it’s a good story, but it’s only part of the story. The DHT chapter is an important chapter to read in the story of male balding and female thinning, but be sure to read the remaining chapters of the story book. The DHT story is not the only story - and many pharmaceutical companies are banking on this concept.





This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Children of Women with Polycystic Ovarian Syndrome:

What is the latest research ?

Polycystic ovarian syndrome (PCOS) is a hormonal disorder in women. It is not one condition but a constellation of symptoms. Patients with PCOS typically have evidence of hyperandrogegism (excess male type hormones and irregular periods. Women with PCOS typically have cysts present in the ovaries but some do not.  The exact cause of PCOS remains unknown although a genetic component is likely for many women. The ovaries of women with PCOS are known to secrete higher levels of male hormones which contributes to irregular periods and infertility. Women with PCOS may seek medical attention for a variety of reasons including insulin resistance, diabetes, high blood pressure, acne, increased hair growth on the face, irregular periods, infertility.  Women with PCOS may also present to a hair clinic with concerns about androgenetic alopecia. It is therefore extremely important that hair specialists understand this condition. 

 

New Research on Children born to Mothers with PCOS

A great deal of research is currently being conducted into the cause of PCOS and how it affects women. Research is also being conducted into the health of babies born to mothers with PCOS. Research has suggested that the hormonal changes in utero influence the development of the fetus. 

One issue that has been studied is the risk of attention-deficit/hyperactivity disorder (ADHD) in babies born to mothers with PCOS. ADHD is the most common childhood neurodevelopment disorder. Male hormones may play a role as boys are two to three times more likely to develop ADHD.

A study by Berni and colleagues of over 16,000 women showed that women with PCOS have a slight risk of giving birth to children with attention deficity hyperactivity disorder (ADHD) and Asperger syndrome. 

Kosidou and colleagues performed a matched case-control study using health and population data registers for all children born in Sweden from 1984 to 2008.  In their study, a total of 58,912 ADHD cases (68.8% male) were identified and matched to 499,998 unaffected controls by sex and birth month and year. The results indicated that Maternal PCOS increased the odds of offspring ADHD by 42% after adjustment for confounders (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.26-1.58). The risk for ADHD was even higher among obese mothers with PCOS and was highest among obese mothers with PCOS and other features of metabolic syndrome.

 

Conclusion

Recent research suggests that differences in maternal hormones during pregnancy in women with PCOS affect the chances of having children with ADHD and possible other neurodevelopmental issues. Overall the risk is low. 

 

 

 

REFERENCES

Berni TR, et al. Polycystic ovary syndrome is associated with adverse mental health and neurodevelopmental outcomes. J Clin Endocrinol Metab. 2018.

Kosidou K, et al. Maternal Polycystic Ovary Syndrome and Risk for Attention-Deficit/Hyperactivity Disorder in the Offspring.  Biol Psychiatry. 2017.

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Late onset Congenital adrenal hyperplasia (CAH)

Late onset CAH: A mimicker of PCOS and early balding in women

 

What is late onset CAH?

Late onset on non-classic congenital adrenal hyperplasia is an uncommon genetic disorder that is frequently due to mutations in 21-hydroxylase gene leading to reduced levels of the 21 hydroxyls enzyme.  Late onset CAH from deficiencies or mutations in other genes such as  11β-hydroxylase (CYP11B1) and 3β-hydroxysteroid dehydrogenase (HSD3B2) are extremely rare.

Late onset CAH should not be confused with the more serious and early onset condition of newborns called congenital adrenal hyperplasia (CAH). Women with late onset CAH develop signs and symptoms of the condition later in life as opposed to the first few weeks and months of life. 

 

What is the cause of Late onset CAH?

One of the most common causes of late onset CAH is so called 21-hydroxylase deficiency. This is caused by mutations in the CYP21A2 gene. To date, 127 mutations have been reported in CYP21A2. This particular gene provides instructions for making an enzyme called 21-hydroxylase (located in the hormone producing adrenal glands). Mutations in CYP21A2 lead to reduced or low levels of 21-hydroxylase enzyme activity (about 50-80% of normal) which then result in low levels of hormones such as cortisol and/or aldosterone and high levels of androgens (male hormones such as testosterone and androstenedione).

As a result of low cortisol, patients may experience changes in energy levels, blood pressure, blood sugar levels, as well as impaired ability of the body to respond to stress, illness, and injury. Aldosterone plays a key role in helping the body maintain the proper level of sodium and water and helps maintain blood pressure.  The amount of functional 21-hydroxylase enzyme determines the severity of the disorder. Patients with late onset CAH have CYP21A2 mutations that lead to reduce levels on the enzyme but not a complete absence. 

 

How is late onset CAH inherited?

Late onset CAH is usually inherited in an autosomal recessive (AR) manner. What this essentially means is that for a patient to be affected by the condition they need to have both copies of the affected gene - one gene  from mom and one gene from dad.  The parents of a person with late onset CAH are said to be 'carriers' and typically have only one mutated copy of the gene. The parents usually don't have any symptoms or signs of the disease themselves.   

 

How is late onset CAH diagnosed?

The patient's signs and symptoms may point to a possible diagnosis.  Generally speaking, the clinical features of late onset CAH reflect an excess of male hormones (androgens) rather than adrenal insufficiency.

Children with late onset CAH may present with premature pubarche (i.e. the development of pubic hair, axillary hair, and/or increased apocrine odor prior to age 8 years in girls and age 9 years in boys). Affected children may be tall and have accelerated linear growth velocity, and advanced skeletal maturation.

About 2-9 % of all women with hyperandrogenism may have late onset CAH. Women with  late onset CAH may develop a variety of symptoms including frontal baldness, hirsutism, acne,  irregular periods, a delay in the timing of the very first period, early onset of pubic hair, accelerated growth, reduced final height and infertility.  

In a multicenter study by Moran and colleagues, the most common symptoms among adolescent and adult women were hirsutism (59%), oligomenorrhea (54%), and acne (33%). Studies by Bidet and colleagues suggested that the initial presenting symptoms in 161 women with late onset CAH were hirsutism (78%), menstrual dysfunction (54.7%), and decreased fertility (12%). Therefore, presentation to a hair specialist regarding hair loss may not occur until later. 

 

Generally, additional testing is ordered to help confirm the diagnosis.  These tests may include a blood test to measure the concentration of 17-hydroxyprogesterone (17-OHP) on day 3-5 of the menstrual cycle. Levels of 170–300 ng/dL have been found to be useful as a screening tool. These should be obtained in the morning and during the follicular (preovulatory) phase of the menstrual cycle.

The clinical features of  late onset CAH in postpubertal adults may be difficult to differentiate from those of the polycystic ovary syndrome (PCOS). Even 17 OHP concentrations may be within the normal range for individuals with late onset CAH.  An adrenocorticotropic hormone (ACTH) stimulation test may also be ordered which involves measuring the concentration of 17-OHP in the blood before ACTH is administered and 60 min after ACTH is given. This test is typically conducted through an endocrinologist.  The acute ACTH stimulation test remains the gold standard to confirm decreased 21-hydroxylase activity.  

To perform the ACTH stimulation test, a blood sample is first collected to measure baseline hormone concentrations. Then, synthetic ACTH (Cortrosyn, 0.25 mg) is administered. A second blood sample is collected 30–60 minutes later.  When the ACTH-stimulated 17-OHP value exceeds 1500 ng/dL a mutation is likely. In few late onset CAH patients ACTH-stimulated 17-OHP levels will be between between 1000 and 1500 ng/dL.

A common error in investigating CAH is having the patient perform the blood test on any day of the menstrual cycle. 17-OHP levels normally rise in the second part of the menstruate cycle and if the test is done during this phase of the menstrual cycle falsely high levels will be recorded. the 17OHP test must be done on day 3-5. 

 

Other tests

In addition to 17 OHP, other tests may be recommended by the physician caring for the patient. These  are normally done in the MORNING and on day 3-5 of the menstrual cycle. They include cortisol, androstenedione, testosterone, free testosterone, DHEAS, progesterone, sodium, potassium, creatinine, glucose, hemoglobin A1C. LH and FSH may also be measured. Aldosterone may be tested. Blood pressure measurements will also be obtained. 

 

What is the treatment for late onset CAH?

For some patients affected with late onset CAH, treatment is not needed. Most endocrinologists agree that treatment is geared towards treating symptoms rather than simply helping bring lab tests into more normal ranges. 

Symptoms of late onset CAH may develop at various points in life, including puberty, after puberty, post part and during times of illness or increased stress.  If symptoms are present, a physician may prescribe a glucocorticoid, often dexamethasone. Dexamethasone is commonly used to treat irregular menstruation, acne, and excess body hair (hirsutism). Anti-androgens are also frequently used, especially by the hair specialist. Oral contraceptives are sometimes used as treatment for adult women or adolescents with irregular periods, acne or hirsutism who are not seeking to become pregnant

 

If identified early, treatment of children is geared towards helping with a normal linear growth velocity and a normal timing and progression of puberty. For adolescent and adult women, the goals of treatment goals are to help regulate menstrual periods, prevent excess hair growth on the face, and help with fertility. 

 

REFERENCE

Witchel et al. Nonclassic Congenital Adrenal Hyperplasia Int J Pediatr Endocrinol. 2010; 2010: 625105. 

Moran C, Azziz R, Carmina E, et al. 21-hydroxylase-deficient nonclassic adrenal hyperplasia is a progressive disorder: a multicenter study. American Journal of Obstetrics and Gynecology. 2000;183(6):1468–1474.

Bidet M, Bellanné-Chantelot C, Galand-Portier M-B, et al. Clinical and molecular characterization of a cohort of 161 unrelated women with nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency and 330 family members. Journal of Clinical Endocrinology and Metabolism. 2009;94(5):1570–1578.  

 

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Female Pattern Hair Loss

 

Major and Minor Criteria

fphl.png

Female androgenetic alopecia is common. By the age of 50, well over 1/3 of women will have androgenetic alopecia (AGA)- also known as female pattern hair loss (FPHL). This type of hair loss causes thinning in the frontal and mid scalp. The sides and back may also be affected but generally to lesser degrees than the front for most women. Traditionally, the diagnosis of androgenetic alopecia has been made based on the finding of reduced density in the frontal scalp compared to the back of the scalp and the clear demonstration via dermoscopy that there is a variation in the diameter if more than 20% of hair follicles. This is known as anisotrichosis.

In 2009, Dr Rudnicka and colleagues proposed a series of major and minor criteria for diagnosing FPHL.

 

FPHL MAJOR CRITERIA

(1) ratio of more than four empty follicles in four images (at 70-fold magnification) in the frontal area

(2) lower average thickness in the frontal area compared to the occiput

(3) more than 10% of thin hairs (<0.03 mm in diameter) in the frontal area.

 

FPHL MINOR CRITERIA

(1) increased frontal to occipital ratio of single-hair pilosebaceous units

(2) vellus hairs

(3) peripilar signs.

 

Remarkably, the presence of two major criteria or of one major and two minor criteria allow diagnosis FPHL with 98% specificity.

 

Reference

Rakowska A et al. Int J Trichol. 2009;1:123–30.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Trichoscopy of Central Centrifugal Cicatricial Alopecia

CCCA: Trichoscopy

ccca

Central centrifugal cicatricial alopecia (CCCA) is a scarring alopecia that commonly affects women with afrotextured hair.  It has a genetic basis in some women. The condition starts with central hair loss in most affected women and this is followed by expansion of the hair loss outwards. There may be symptoms such as itching, or pins and needles, but many women are asymptomatic. 

In an article earlier this year, I discussed some very interesting studies which showed a five fold increased risk of uterine fibroids among women diagnosed with CCCA.   

 

Dermatoscopic Features of CCCA
 

It is critically important to identify CCCA in the early stages in order to try to stop hair loss. Today I'd like to focus on the up close features of CCCA using a handheld dermatoscope.  We refer to this as trichoscopy. 

The trichoscopic features of CCCA are few. Miteva and Tosti in 2014 published the first real compressive overview of the trichoscopic features of CCCA. They retrospectively images obtained from 51 women with histologically proven CCCA and  compared to controls (which included 30 dermatoscopic images from histologically proven cases of scarring traction alopecia and discoid lupus erythematous).   

 

The Peripilar White Gray Halo

ccca

The so called "peripilar white gray halo" was found in 94% of patients and was highly specific and sensitive for CCCA. This halo was seen around the emergence of hair follicles.

The halo was shown to correspond on pathology to the lamellar fibrosis surrounding the hair follicle outer root sheath.

 

Reference

Miteva and Tosti. Dermatoscopic features of central centrifugal cicatricial alopecia. J Am Acad Dermatol. 2014.

 

  
 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Treatment of Androgenetic Alopecia During Pregnancy

Treating AGA in Pregnancy:

Most treatments for AGA are either not safe or not recommended during pregnancy. This includes minoxidil, anti androgens, various supplements, over the counter products and topical agents. The cardinal rule of treating any conditions during pregnancy or using any treatment during pregnancy is simple: ask a physician. 

 

Low Level Laser: Generally Safe for Most

 Low level laser treatments (LLLT) are the only safe treatments during pregnancy for women with AGA. This applies to most of the standard at home devices. Everything else needs stopping and some treatments need stopping well in advance. For some women, treatments during pregnancy are not necessary because it is possible due to hormonal surges during pregnancy stopping treatment may potentially not have a huge effect while pregnant and one can start many treatment again after giving birth. However, it should be noted that some women do experience hair loss during pregnancy as well.

 

WHICH HAIR LOSS MEDICATIONS ARE SAFE TO USE WHILE BREASTFEEDING?

Although I often ask my patients to discontinue most hair loss medications during pregnancy, the question frequently arises as to whether some medications can be restarted while moms are breastfeeding.  Breastfeeding has many benefits for babies.  For some drugs, the answer is yes. For others, the answer is no.

In 2001, the American Academy of Pediatrics published a helpful guide as to the safety of medications during breastfeeding. It's important to always check with your physician before starting any medication during breastfeeding. However, the following medications (used in hair loss) are felt to be safe for women who are breastfeeding.  For a full list of medications which are safe during breastfeeding, click here.

I generally do not recommend restarting treatments until month 1 after delivery if the baby is breastfed although many studies and reports show no harm in use if minoxidil and antiandrogens by women who are breastfeeding.

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Does one go bald in telogen effluvium?

TE can cause significant thinning 

Telogen effluvium is a hair shedding conditions whereby affected individuals lose more hair on a daily basis than they once did. It's important to understand that one's hair can go very thin but one NEVER loses all hair.

 

Why does one never lose all hair in TE?

Patients with telogen effluvium never go completely bald because not all the hairs on the scalp are converted to telogen hairs. A biopsy of TE will often show an increase in the proportion of telogen follicles above the typically expected level of 6-13 %. If the proportion of telogen follicles above 15% this suggests TE. However, if it's above 25%, this is a more definitive feature. One must keep in mind that a biopsy showed 25 % telogen hairs means that 75 % of hairs are anagen and growing well rooted in the scalp. There are never 100 % of the hairs in telogen phase in a patient with telogen effluvium and never 100 % of hairs in telogen phase in a biopsy from telogen effluvium. Therefore, one never loses all their hair.  However, that said, an individual with TE can have significant thinning and may even feel that they have lost 70 % or more of their hair. some telogen effluviums are mild but others are severe. In more severe cases, a wig or scarf may be used short term by the patient. 

 

What if a patient does bald in TE?

If one loses all hair and is absolutely certain they have a telogen effluvium, it is likely that is also something else going on as well. In other words, another diagnosis is present in addition to the TE. For example, if one ALREADY has genetic hair loss (or some other hair loss condition) to start with the thinning with a TE can be very, very noticeable sometimes.  In such a situation, it is both conditions that are contributing to thinning not just the TE.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Hair loss is not a guessing game.

Guessing is easiest for men's hair loss

If you had to "guess" the reason for someone's hair loss, you'd likely guess correctly if the patient was male and you chose male balding (androgenetic alopecia). By far that's the most common cause of balding in men.  Dozens of other causes are possible, but they are not common. 

 

Hair loss in women is more complex.

For women, there's a very good chance you'd be wrong if you guessed androgenetic alopecia as the sole cause. Female hair loss is far more complex - and hair shedding issues and even scarring conditions are not uncommon. Hair loss of course, is not a guessing game and a diagnosis can usually be made by the patient's history, examining the scalp and sometimes examining blood test results or (rarely) performing a scalp biopsy.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Do all women with hair loss really need blood tests?

Evaluating Hair Loss in Women: Are blood tests really needed?

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That answer, in my opinion, is a resounding - "yes." All women with concerns about hair loss need blood tests. The reason is simple: there are a great number of similar looking hair loss conditions in women and if one thinks they can confidently, with 100% certainty,  rule out any particular condition just by looking at the scalp they are wrong. One can not exclude a contribution from low iron or a thyroid disorder even in a woman presenting with classic androgenetic alopecia. Let's take a closer look why blood tests are needed.

For a review of blood tests typically recommend as part of a screening work up click on the following 

SCREENING BLOOD TESTS FOR WOMEN WITH HAIR LOSS.

 

1. Iron deficiency anemia is common

About 1 out of every 5 women age 18-45 have iron deficiency. It's common. Given that low iron levels may be associated with a variety of different hair loss conditions, it is important to test for it and supplement iron in women whose blood tests show low iron. Even if one were to argue that low iron levels are seldom really a true factor in hair loss, studies have also shown that supplementation with iron may allow other treatments to work better.

In 1992, Drs Rushton and Ramsay conducted a study looking at women with genetic hair loss who were being treated with an antiandrogen medication (called cyproterone acetate). The researchers showed that women with iron levels above 40 had much better results with the antiandrogen pill than women who had iron levels below 40.
 

2. Blood counts

Ordering a basic blood count (for levels of red cells, white cells) is important. It's not a very specific test, but when the levels come back abnormal, it signals something may be wrong. A common reason for low hemoglobin and a low number of red cells levels is iron deficiency. But a variety of internal illness also have as part of their presentations low blood counts. A basic screen is helpful.

My work up is very different when a female with hair loss has an abnormal blood count. A 31 year old female with low hemoglobin and low ferritin, may have this result from heavy menstrual cycles, but may also have this from celiac disease as well. Depending on the patient and specific details, I may order a so called 'celiac panel' as well. A  66 year old female with low hemoglobin and low ferritin who comes into my clinic for hair loss may need a comprehensive work up by her physician to rule out a cancer. 

 

3. Thyroid abnormalities are common

About 1 out of every 15-20 individuals will be diagnosed with a thyroid disorder in their lifetime. These thyroid conditions are 8 times more common among women. While it's true that many with thyroid disease will notice symptoms, about one half will not notice any problems at first. Hair loss is frequently part of the collection of symptoms that come with thyroid dysfunction. Testing for thyroid disease in women with hair loss is important.

 

4. Vitamin D deficiency is common

Vitamin D deficiency is common. Here in Canada, studies have shown that about two-thirds of the population is low in vitamin D and levels tend to be lower in winter than summer.  The exact role of vitamin D in hair loss is still being worked out but it's clear that individuals with alopecia areata and genetic hair loss have lower vitamin D levels than individuals without hair loss.  

 

5. Zinc deficiency

Zinc deficiency is not common in North America. Nevertheless, zinc deficiency does exist in a number of subgroups in the North American population and is likely more common than appreciated. About 12 % of the general population and up to 40-50 % of the elderly are at risk for zinc depletion in North America. In many parts of the world, zinc deficiency is extremely common. In North America, zinc deficiency is frequently asymptomatic - meaning that individuals with low zinc don't necessarily have symptoms. Zinc deficiency can be associated with hair loss as well as a variety of issues related to immune system function and infection. The recommended amount daily is 11 mg for men and 8 mg for women.

 

6. Hormone Testing

Most women with hair loss do not require complex and extensive hormonal work-ups that so often are seen. However women with irregular periods, acne, excessive hair growth on the face (hirsutism), difficulty conceiving/infertility, early menopause and abnormal or rapid hair loss do require hormone tests. 

 

Conclusion

Complete blood counts, along with tests for iron status (ferritin test) and thyroid status (TSH) are among the most important tests for all women with concerns about hair loss. Other tests may also be important for any particular individual but the exact test to order depends on the information obtained during the patient interview.  Too often I hear it said that a female patient does not need blood tests. For example, I often hear it said that a female presenting with classic androgenetic alopecia does not need blood tests because classic androgenetic alopecia is not associated with blood test abnormalities. Here, one needs to consider that classic androgenetic alopecia may be associated with low vitamin D and research has even shown that it may be associated with cholesterol abnormalities as well (low HDL, high LDL).  If one feels they can exclude with certainty that this patient does not have iron deficiency or a thyroid disorder, they are incorrect.

All women with hair loss need blood tests. 

 

REFERENCE

Rushton DH, et al. The importance of adequate serum ferritin levels during oral cyproterone acetate and ethinyl oestradiol treatment of diffuse androgen-dependent alopecia in women. Clinical Trial. Clin Endocrinol (Oxf). 1992.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Breast Implant Illness and Hair Loss

Hair Loss from Breast Implants: Any relationship?

BII.jpg

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I believe that there are countless numbers of hair loss conditions that exist in the world that have not yet been described in textbooks. The reason I believe this is quite simple - I see and hear them every day in my clinic.  There are stories of hair loss from certain medications,  various unusual patterns of hair loss in otherwise common conditions. Every once in a while a new scenario arises that again causes pause - one such example is a syndrome of medical conditions that arise in women who have had breast augmentation and breast reconstruction. Readers should note that this is a very different form of hair loss than the telogen effluvium that sometimes accompanies the surgery itself (or any surgery for that matter). This has been termed 'breast implant illness.' Whether or not hair loss occurs in a small proportion of women who have undergone breast augmentation continues to be studied.  It's an area of research that we follow closely given how often these scenarios arise in our clinic. 

 

Breast implants and human health

Anything that triggers a systemic reaction inside the body has the potential to cause hair loss. One therefore needs to look at the data on the effects of breast implants on human health. In the last 5 years new data has emerged that breast implants may be associated with cancer - specifically the development of a type of T cell lymphoma called anaplastic large cell lymphoma. The FDA continues to study this association and the risk may be in the order of 1 in 10,000 women to as great as 1 in 1000 women.

Breast Implant Illness has many similar names in the research and medical literature. ASIA syndrome (autoimmune/inflammatory syndrome induced by adjuvants) was a name given to a specific disease that can arise with exposure to silicone. To date, it is still controversial as to whether silicone implants increase the risk of true autoimmunity in the body.  However, some studies have shown increase incdience of autoantibodies in women with silicone breast implants. 

 

Breast Implant Illness

There is a subset of women with breast implants who feel that their health has changed in some way followed breast implant surgery. The term 'breast implant illness' is a term that has been given to the constellation of symptoms and signs that are proposed to be attributed to breast implants. The mechanism by which this would or could occur is not yet known. Women who report symptoms consistent with breast implant illness frequently mention chronic fatigue, chronic pain, anxiety, irregular heart rate, neurological problems, body odour, rashes, endocrine problems - and hair loss.  To date, it is hard to prove an association of these symptoms of these women to their breast implant surgery and many alternative explanations are frequently given.  Many symptoms are dismissed. Many women, but not all, experience some degree of improvement in symptoms after explanation (removal of the implant).

 

Breast Implant Illness and Hair Loss

As mentioned in the opening paragraphs, I strongly believe that there are countless numbers of  hair loss conditions and syndromes that are unrecognized and have not yet made their way into textbooks, and classrooms of learners.  (This concept forms Principle 9 of the 20 Principles that govern my practice).

There have been several studies examining breast implant illness and one some have addressed the issue of hair loss. One such study was a 1996 study by Brawer which reported illness in 300 women who had silicone breast implants. Most women (90 %) developed their illness within 6 years of the implants.  Although rupture of the implant was present in some affected, 97 % of women did not experience rupture prior to their symptoms.  Rupture however, did worsen symptoms. 

The table below shows the most common signs and symptoms in patients with breast implant illness according to the 1996 Brawer study. Fatigue tops the list followed by arthritis and chest pain. Hair loss is number 4 on the list and experienced by 59% of patients with breast implant illness.  

from Arthur Brawer.&nbsp;J. Clean Technol Environ. Toxic &amp; Occup Med Vol 5(3) 1996

from Arthur Brawer. J. Clean Technol Environ. Toxic & Occup Med Vol 5(3) 1996

Conclusion

Modern medicine is still in the early stages of understanding whether and to what degree breast implants affect health. There does appear to be an association with anapaestic large cell lymphoma and an increasing number of women are reporting concerns that can only be grouped together for now under a non specific term 'breast implant illness.'  Hair loss has been reported by many women with breast implant illness.  In my practice having seen at least a dozen cases, most end up being diagnosed with telogen effluvium, chronic telogen effluvium and/or androgenetic alopecia - which are extremely common in the population anyways. Pinpointing an exact cause is challenging. Explanation, or removal of the implant,  is helpful only in some.

For now, continued study of breast implant illness is warranted. 

 

 

 

Reference

1. https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239995.htm

2. Tang S et al. Breast implant illness: Symptoms, Patient Concerns, and the Power of Social Media.  Plast Reconstr Surg. 2017

3. Arthur Brawer.  Chronology of systemic disease development in 300 symptomatic recipients of silicone gel-filled breast implants. J. Clean Technol Environ. Toxic & Occup Med Vol 5(3) 1996

4. Bar-Meir E et al. Multiple autoantibodies in patients with silicone breast implants. J Autoimmune 1995

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Androgen Blockade For FPHL: Can I use more than I medication?

Androgen blockade has the potential to be help female pattern hair loss. Caution is needed with any hormone blocker due to significant harm that can come to a developing baby were a woman to become pregnant on any hormone blocker. For this reason they are frequently used with various strict contraceptive methods.

 

Hormone Blocking Medications for FPHL

Female Pattern Hair Loss (also called female androgenetic alopecia) affects 40 % of women by age 50. There are a variety of treatment options including minxodil, anti-androgens, laser and PRP. 

Anti-androgens can help some women with female pattern hair loss. A long list of anti-androgens exist including spironolactone, finasteride, cyproterone acetate, flutamide, dutasteride. The combination of anti-androgens can sometimes work even better than one alone provided the patient actually has a truly androgen responsive hair loss condition. Most men do. But not all women have a form of FPHL that is truly responsive to anti-androgens.

 

Anti-androgen Side Effects

The decision to use two or more anti-androgens must always be weighed against potential side effects. The combination of androgen blocking pills has the potential to be associated with side effects such as depression, worsening fatigue, breast tenderness, breast enlargement, weight gain, decreased libido.

 

 

 

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Hair Loss at the Nape of the Neck: What are the main causes?

Losing Hair at the Nape: What are the main Causes?

Hair loss can either be localized (meaning one area of the scalp) or diffuse (meaning all over the scalp). There are many causes of hair loss at nape of the neck and the back of the scalp. 

 

1. Traction alopecia (photo 1)

Traction alopecia refers to a type of hair loss due to the tight pulling of hair. The back of the scalp is particularly susceptible to loss of hair.  Hair styling practices can frequently lead to traction including braids and weaves and pony tail.  If traction alopecia is of recent onset, hair regrowth can occur even without treatment. If traction is longer standing, the hair loss can often be permanent.  Some women with hair loss that looks like traction actually have a scarring alopecia known as cicatricial marginal alopecia. 

PHOTO 1: Traction alopecia presenting as hair loss in the nape

PHOTO 1: Traction alopecia presenting as hair loss in the nape

 

2. Alopecia Areata (photo 2)

Alopecia areata is an autoimmune disease that affects about 2 % of the world. Hair loss can occur anywhere. Alopecia areata can frequently cause hair loss specifically at the nape in some patients. The particular form that causes loss at a the back of the scalp is the 'ophiasis' form. The ophiasis form is frequently resistant to standard treatments although topical steroids, steroid injections and diphencyprone are typically first line. 

PHOTO 2: Alopecia areata presenting as hair loss in the nape

PHOTO 2: Alopecia areata presenting as hair loss in the nape

 3. Androgenetic Alopecia (photo 3)

Androgenetic alopecia (male and female thinning) typically causes hair loss at the top of the scalp. In men, the temples and crown are most often affected. In women, the mid-scalp region is generally affect first. The back of the scalp can also be affected although this is not typically thought of. Hair thinking along the nape is not uncommon in advancing balding in men and women. 

PHOTO 3: Androgenetic alopecia (AGA) presenting as thinning in the nape

PHOTO 3: Androgenetic alopecia (AGA) presenting as thinning in the nape

 

 

4. Frontal Fibrosing Alopecia (photo 4)

Frontal fibrosing alopecia (FFA) is a type of scarring alopecia. FFA typically affects women between 45-70. Most often hair is lost along the frontal hairline and eyebrow. However the back of the scalp (at the nape) and frequently be affected. The hair loss in the nape typically starts at the sides (left side and right side) just behind the ears. Treatments for FFA include topical steroids steroid injections, topical calcineurin inhibitors. Oral drugs include finasteride, doxycycline and hydroxychloroquine at the top of the list.

 

PHOTO 4: Frontal fibrosing alopecia (FFA) presenting as hair loss in the nape

PHOTO 4: Frontal fibrosing alopecia (FFA) presenting as hair loss in the nape

5.  Heat and Chemicals

Heat and chemical treatments can lead to hair shaft damage and hair loss at the nape. Frequently, heat and chemical overuse leads to an increased tendency to develop traction alopecia which si discussed above. 

 

6. Acne keloidalis nuchae

Acne keloidalis nuchae (AKN) is a condition that can affect both men and women. Small papule or bumps develop along the posterior scalp and are accompanied by hair loss in the region as well.  The hair loss in AKN is often permanent and can lead to thicken and thicker scars some of which are disfiguring. 

 

7. Hair shaft disorders

Some individuals are born with abnormalities in how the hair shaft is produced. This frequently leads to hair breakage. Monilethrix is one of the hair shaft disorders that frequently leads to hair loss along the nape. 

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Finasteride Side Effects in Women

What are the side effects of finasteride in women?

First off, finasteride is not FDA approved for women. Any such use is therefore "off label" and any female considering finasteride will want to be guided by a knowledgeable and experienced physician if this is a route you wish to take. Depending in the patient's current age, type of hair loss and medical history and family history this may or may not be a good option.

Side effects

i'm often ask about the range of side effects that are possible for women who use finasteride. Side effects of finasteride in women include, but are not limited to: harm to a fetus (finasteride can not be used in pregnancy), fatigue, weight gain, depression, anxiety, decreased libido, sexual dysfunction, hair shedding, breast tenderness, breast enlargement.  Other side effects can occur but are less common. These include changes in platelet counts and muscle injury (myopathy).


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Androgenetic alopecia in women: Can I still have it if my hormones are low?

AGA in Women with Low Androgens

I'm often asked on various blogs and posts how it's possible to have androgenetic alopecia if a woman's androgen levels are normal or low. Many individuals have received a diagnosis of androgenetic alopecia and once their blood tests return normal, then have questions:

Is the diagnosis wrong?

How could I possibly have AGA if my androgens (testosterone, DHEAS, etc) is normal?

 

AGA in Women is best called FPHL

One must always keep in mind that androgenetic hair loss in women has much less to do with male hormones than it does in men. MOST women with AGA have normal hormone levels. In fact, about 90 % have normal hormone (androgen) levels. Treatments for AGA in women can still be helpful in many despite normal or low - normal levels. For this reason, many dermatologists choose to call female androgenetic alopecia "female pattern hair loss (FPHL)" rather than ANDROgenetic alopecia to de-emphasize the role of androgens.  

 

Summary

There are many complex mechanisms that lead to the development of AGA in women. For many women, androgenetic alopecia has little to do with androgens. For some it has a lot to do with androgens and for some it probably has nothing to do with androgens.  


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Lysine and Hair Loss

When Can Lysine be Helpful?

L-lysine is an amino acid, which are the building blocks of proteins. Lysine is one of the more difficult amino acids to get in foods but it is found in meat, fish and eggs.

L-lysine has an important role in iron and zinc absorption. In 2002 D.H. Rushton demonstrated the benefits of l-lysine to increase iron and zinc levels and to reduce hair shedding.

Ruston reported 14 women who were deficient in zinc and showed that 1000-1500 mg of Lysine daily led to an increase in zinc levels from 9.7 to 14.6 umol/L - even without these women consuming zinc pills.

Similarly with iron, Rushton showed that 100 mg per day of iron in 7 women with chronic telogen effluvium did not change ferritin levels at all. However, when combined with L-lysine (again at 1000-1500 mg per day), ferritin levels increased from 27.4 to 58.6 ug/L. This was associated with a decrease in the proportion of hairs in the telogen phase from 19.5 to 11.3.

L-lysine is an important amino acid and I often recommend it for my patients with chronic shedding abnormalities and those with deficiencies of iron and zinc that don't respond to routine supplementation. If I do recommend L-lysine, the dosing is typically 500 mg twice daily, and rarely three times daily for short periods.

Reference

DH Rushton. Nutritional factors in hair loss. Clin Exp Dermatol 2002

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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