Treating Female Pattern Hair Loss: Options for Women Over 60

Treatments for AGA in Women over 60

I'm often asked about treatment options for women over 60 who present with a diagnosis of androgenetic alopecia (female pattern hair loss). There is some degree of confusion as well as misconceptions which exist in this subject area.

My approach in this situation is to first confirm the diagnosis and then base treatment decisions according to the patient's medical history. The importance of the first step can not be overemphasized.

1: Confirming the Diagnosis

It is extremely important to confirm the diagnosis and ensure that a) another diagnosis is not more appropriate and b) to determine whether other diagnoses are also present. A patient need not have only one diagnosis.

A. Senescent Alopecia

Women who present with hair thinning in their 60s and 70s with no evidence whatsoever of thinning in the 30s, 40s or 50s may have senescent alopecia (age related hair loss) rather than true androgenetic alopecia. This distinction is important as senescent alopecia is less likely to be androgen-driven and therefore responds less to antiandrogens such as finasteride. The main treatment for senescent alopecia is minoxidil although agents such as low level laser and less commonly finasteride can be considered.

I typically ask patients if their hair density on their 50th birthday was more or less the same as their 30th birthday. If that answer is yes one should at least consider the possibility that senescent alopecia or even another diagnosis other than androgenetic alopecia is present.

B. Scarring Alopecia

Scarring alopecias are far more common than we currently diagnose. They range from subtle asymptomatic scarring alopecia to fibrosing alopecia in a pattern distribution to markedly symptomatic lichen planopilaris. Scarring alopecias are easy to miss but need to be considered in all patients with sudden onset of itchy hair loss or a more rapid decline in density from what they may have experienced in the past. A biopsy can help better evaluate these conditions. 

C. Hair shedding issues

Both acute and chronic telogen effluvium (CTE) need to be considered in women with hair concerns. Stress, thyroid problems, new illnesses and newly prescribed medications can all contribute to increased hair shedding and hair loss. Anyone with new shedding needs a very detailed examination and workup not only by the dermatologist but by the family physician. Blood tests are especially as is a full medical examination. One must also ensure that routine mammograms and colonoscopies are up to date.

Chronic telogen effluvium (CTE) is among the more challenging to diagnose conditions. Patients present with increased shedding that waxes and wanes. To an outsider it generally appears that the person has fairly good density. A hair collection or biopsy can help with the diagnosis.

Treatment Options

The main treatment options for patients with confirmed androgenetic alopecia is minoxidil, finasteride and low level laser. If the pattern of hair loss is localized frontal loss, and donor density in the occipital scalp is good, a hair transplant can be considered as well.

Minoxidil is formally approved for women 18-65. It may, of course, be used off label for women over 65 with proper evaluation by a physician.  Women with heart disease, heart failure or previous heart attacks for example may or may not be good candidates for minoxidil. One is not obligated to use the full recommended dose of minoxidil. Starting with one-quarter or one-half the recommended amount is often a good way to ease in to the treatment in patients with underlying medical issues.

Finasteride may also be a good option. Studies support the notion that higher doses of 2.5 mg and 5 mg are needed for post-menopausal women and doses of 1 mg are ineffective. Finasteride is relatively contraindicated in women with previous history of breast, ovarian or gynaecological cancer. Given the rare effects of finasteride on mood, this medication is also relatively contraindicated in women with depression.

Low level laser therapies are safe but may be less effective than minoxidil or finasteride.  A number of laser devices are available in the market for use by patients in their home. None have proven superior to another and so one must balance cost with ease of use. A helmet based device may be easier for some compared to the hand-held devices.

Scalp Inflammation. Scalp inflammation must be attended to fully when caring for patients with AGA. Many women with AGA have seborrheic dermatitis and this is best controlled with periodic use of an anti-dandruff shampoo. I frequently prescribe a trial of a mild cortisone lotion if there is scalp redness if the redness does not respond to anti-dandruff therapies.