There are many types of hair loss. In fact, when you add them all up, there are well over 100 causes of hair. Some of the causes impact another body system in addition to the hair and require additional focus and attention to ensure the patient's total health. For example, some of the causes are associated with an increased chance of having a thyroid disorder (alopecia areata and lichen planopilaris are example). Other causes are associated with a range of other issues including hearing issues, heart problems, kidney problems, cholesterol problems, bone abnormalities, etc.
Androgenetic alopecia is a form of hair loss that frequently affects women. It causes thinning in the central scalp area in early stages such that the scalp becomes much more "see through." Over time the hair loss pattern can be diffuse. Most women with androgenetic alopecia have no hormonal abnormalities but a small proportion do. Women with irregular periods, acne, hair growth on the face require blood tests to further evaluate for an underlying endocrine issues.
When should a referral to an endocrinologist be made?
I'm often asked by patients and physicians when I refer my patients to an endocrinologist. There are no hard and fast rules but referrals are generally made in the following situations:
1. Women with androgenetic alopecia and irregular periods, especially less than 9 menstrual cycles per year.
2. Women with androgenetic alopecia with possible evidence of late onset congenital adrenal hyperplasia evidenced by elevated day 3-4 17-hydroxyprogesterone.
3. Women with androgenetic alopecia with evidence of potential polcystic ovarian syndrome, especially elevated day 3-4 LH/FSH ratios, irregular periods and findings of acne and increased hair growth on the face.
4. Women with hair loss accompanied by regular menstrual cycles with a history of irregular cycles in the past who do not show normal surges of progesterone day 21.
5. Women with possible premature ovarian failure.
6. Women with irregular periods and elevated prolactin.
7. Women with markedly elevated DHEAS and testosterone regardless of age
8. Women with autoimmune mediated hair loss with low bone mass. Such women may require corticosteroid based therapies with the potential to further impact bone
9. Women with potential adrenal dysfunctional either concern for adrenal suppression from corticosteroid use or various causes of hyperadrenalism (especially when Cushing syndrome is a consideration).
10. Women with low TSH and elevated T4 and or T3
11. Women with high TSH above 7-10 that does not improve on repeat testing or does not improve with thyroid supplementation or is associated with symptoms such as low heart rate, mood changes, constipation and/or chronic shedding. A lower threshold for referral is made in my clinic if additional underlying health issues are present (ie heart disease) or thyroid autoantibodies are positive. For an elevated TSH 2.5 to 6, I handle these situations on a case by case basis.
Hair loss is associated with changes in several organ systems. There are several reasons why I might ask my endocrinology colleagues to evaluate my female patients and some are listed above. Other reasons may be possible too. It is not a routine referral meaning that not all patients need such referral. In fact, it is only a small minority.
Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887