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Hair Loss in Women: Irregular periods = Blood tests

Irregular periods = Blood tests

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When speaking with patients about their hair loss, there are many pieces of information that a patient may share that should trigger the clinician to look deeper into the particular issue.

Irregular menstrual cycles in women are one such example especially when they occur in females age 16 to 43. Of course, there are many reasons for irregular periods and some of these reasons may have nothing to do with hair loss.

However, a variety of medical issues associated with hair loss may cause irregular periods. These include polycystic ovarian syndrome, congenital adrenal hyperplasia, hyperprolactinemia, Cushings, adrenal and ovarian tumors and cysts, stress, excessive dieting, thyroid disease.

The evaluation of women with irregular periods is best done on a case by case basis after review of all the facts. Blood tests shown here are frequently helpful especially in the third to fifth day of the menstrual cycle and especially in the morning. Patients with abnormalities may sometimes undergo further testing or referral, depending on the suspected cause.

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
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Biotin Deficiency in Pregnancy

Biotin Deficiency in Pregnancy


Most people are not deficient in biotin. However, that said, biotin deficiency is difficult to measure. Deficiencies known to exist in a variety of situations including pregnancy, inflammatory bowel disease, Advanced age, oral antibiotics, alcoholism and certain medications (like isotretinoin, valproic acid and carbamazepine). Unlike many blood tests for testing “deficiencies”, there is no simple “biotin” blood test.

One way to determine if someone is biotin deficient or not is to evaluate for increased urinary excretion of 3-hydroxyisovaleric acid (3HIA), which likely reflects decreased activity of the biotin-dependent enzyme beta-methylcrotonyl-CoA carboxylase. A second way is to search for decreased activity of the biotin-dependent enzyme propionyl-CoA carboxylase (PCC) in peripheral blood lymphocytes.

A 2009 study by Mock and colleagues provided evidence that biotin deficiency may actually be quite common during pregnancy. In their pilot study, activity of PCC in peripheral blood lymphocytes (as a measure of biotin deficiency) was decreased in 18 of 22 (81%) pregnant women.

These studies are interesting. While they draw attention to the issue of biotin deficiency in pregnancy, it also draws attention to whether such deficiency impacts the hair during or after pregnancy. This is not known at present but deserves further study. Biotin deficiency may be more common during pregnancy than most realize.


Marginal biotin deficiency is common in normal human pregnancy and is highly teratogenic in mice. Mock DM. J Nutr. 2009.

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
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Preparing for Pregnancy: Considerations for Women with Androgenetic Alopecia

Planning a Pregnancy with Female Pattern Hair Loss

Many women with genetic hair loss are worried about getting pregnant and how the pregnancy and delivery will affect their hair. It's an area that really isn't talked about very much. Some women feel it's difficult to talk opening with their partner or family about their hair when all the focus is on the pregnancy, the baby and the new or expanding family.  But these issues are important and issues that I help patients with on frequent basis. 


Preparing for the Pregnancy

For women who are planning when to become pregnant, there are a number of considerations that are related to the hair. I encourage all patients with hair loss who are considering pregnancy to have a good discussion with the dermatologist and of course the physician caring for the pregnancy as well.  

Most of the time, hair improves in pregnancy.  However, some women do experience hair loss during the pregnancy. A significant proportion of women experience some degree of hair shedding after delivery. Hair regrowth occurs 6-7 months later but may or may not return to pre-pregnancy densities.  


1. Deciding to Stop Medications

Many of the medication used for treating female pattern hair loss (androgenetic alopecia) can't be used during pregnancy. This includes minoxidil, Rogaine, platelet rich plasma, anti-androgens. The only treatment that can be used are vitamins and low level laser therapies. 

Minoxidil should ideally be stopped two weeks before the time that a women decides to start trying. However, there are many women world-wide who become pregnant while using minoxidil and simply stop minoxidil once they miss their period. There is no evidence that this method has any harm for the pregnancy or the baby.  However, minoxidil must not be used during the pregnancy and anytime after the first period is missed. Many physicians will strictly recommend that their patients stop minoxidil if they are trying to conceive. However, there is no good evidence to support this recommendation. 

Anti androgens, however, need to be stopped several months before the pregnancy. The most common anti-androgen used in women of child bearing age is Spironolactone (Aldactone) and this must be stopped ideally 2 months before any planned pregnancy. Spironolactone can not be used during pregnancy as it could cause harm to a developing baby. Other anti-androgens, including saw palmetto, and finasteride need to be stopped long before as well. Dutasteride is not typically be used in women of child bearing ages. However due to it's very long half life, any woman who is using dutasteride and considering pregnancy should speak to their physician and dermatologist about how long they need to be off the medication before trying to get pregnant. 


2. Blood tests

For some women, pregnancy can lead to changes in the levels of many key mineral and vitamins relevant to hair growth. Blood tests can help identify these deficiencies. Deficiencies of vitamin D and iron are among the most common during pregnancy and levels may need to be followed during the pregnancy. Other deficiencies are less common but can include biotin and zinc. If there are concerns about thyroid stratus or diabetes these will also need to be monitored.


3. Supplements

All women considering pregnancy should speak to their physicians about appropriate supplements. These will generally include appropriate folic acid. However, other supplements may be very relevant depending on the patient's history. As mentioned above, these may include vitamin D, iron, biotin and zinc.


4. Scalp Inflammation

I am a strong believer that scalp inflammation needs to be addressed at any time during the course of hair loss. This is also true during pregnancy. Prolonged scalp inflammation from various sources has the potential to accelerate androgenetic alopecia (AGA). Inflammation can come from many potential sources including seborrheic dermatitis, psoriasis and various eczemas. 

We don't have much information on the safety of anti-dandruff shampoos in pregnancy. The data would suggest that periodic use of zinc pyrithione and ciclospirox have reasonable safety and these are frequently my top choices for many of my own patients.  If dandruff (or seborrheic dermatitis) is troublesome, I generally advise use once every 2 weeks and to be left on the scalp for 60 seconds before rinsing off. Small amounts of betamethasone valerate scalp lotion can be used once weekly if itching persists.  

Ketoconazole shampoos don't have much in the way of data. Patients interested in using should check with their OB or the physician caring for the pregnancy. There is no good data to really suggest a problem with periodic use of topical shampoos containing ketoconazole. It's not the top choice for my practice as they have the potential to affect testosterone synthesis.  Oral ketoconaole is certainly not advised. It increased the risk of cardiovascular, skeletal, craniofacial and neurological problems in many studies.  I don't recommend coal tar shampoos during pregnancy. Animal studies show that high doses are associated with perinatal mortality, cleft palate, small lungs and other developmental issues. I avoid them in my practice. 



Patients with androgenetic alopecia (female pattern hair loss) who are considering pregnancy should review their general health and scalp heath with their physicians. Blood tests may be recommended and periodic monitoring of the scalp may be appropriate during the pregnancy.



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
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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.



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. 





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.


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
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Finasteride Use in Women: Yes or No?

Finasteride & Women

Finasteride is FDA and Health Canada approved for men with hair loss. Although it's not formally FDA approved for use in women, the medication has been prescribed to women with androgenetic alopecia for nearly two decades.  When a physician prescribes finasteride for androgenetic alopecia in women, they are said to be using these medications in an 'off label' manner.  The following is the key point about using finasterde for women : it's only prescribed on a case by case basis. 


Polar Views on Finasteride Use

The public needs to understand there are many views among physicians  on finasteride. There are some physicians that will never prescribe this medication to women -  period.  There are some physicians who will prescribe it only to post-menopausal women. There are some who will prescribe to some pre-menopausal and some post-menopausal women - but only on a case by case basis - and only with full counselling of risks and benefits.   

Much of the concern around use of finasteride in pre-menopausal women stems from the significant harm that would come to any fetus that was born to to a mother who used finasteride during pregnancy. These risks and real - and serious. Finasteride is given the highest category of risk during pregnancy - so called "category X." Women who are pregnant or who could become pregnant must never use finasteride.

The other concern that some physicians have pertains to cancer risk. To date, we actually don't have any good evidence to suggest that finasteride increases a woman's risk of cancer. In fact, reasonably well conducted studies in men would suggest that breast cancer risk is not increased. Good studies have not been done in women. However, women with strong histories of estrogen dependent cancers (breast, ovarian, gynaecological cancers) should also review use of finasteride with their doctors.  In some cases, use may not be appropriate.  I'll discuss other side effects below. 


Does Finasteride Help Genetic Hair Loss in Women?

So does it help women with genetic hair loss? Studies from nearly two decades ago said no. A study by Dr vera Price and colleagues in 2000 suggested a 1 mg dose in post menopausal women did not help androgenetic alopecia.  But just 2 years later, in 2002, Shum and colleagues presented 4 women (2 pre and 2 post menopausal) who did respond to a higher dose of finasteride - this time 2.5 mg finasteride. All 4 women had hyperandrogenism (one or more of elevated hormones, hair on the face, infertility issues). This refueled interest in the role of finasteride for women. 

In 2006, Dr Iorizzo and colleagues from Bologna, Italy published a study which further renewed interest in the use of finasteride for the treatment of female pattern hair loss. Iorizzo and colleagues looked at the benefit of finasteride at a dose of 2.5 mg in 37 women diagnosed with female pattern hair loss. All women in the study were also using a birth control pill to prevent pregnancy.  After 12 months of follow up, 62 % of women using finasteride had an improvement in hair density. 13 patients (30 %) hair loss had stabilized -   it did not get worse but  did not improve. Only 1 of 37 patients experienced a worsening of their hair density.

What are the side effects of finasteride in women?

I'm often asked 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).



Iorizzo M1, Vincenzi C, Voudouris S, Piraccini BM, Tosti A. Finasteride treatment of female pattern hair loss. Arch Dermatol. 2006.

Shum et al. Hair loss in women with hyperandrogenism: Four cases responding to finasteride. Journal of the American Academy of Dermatology 2002; 47: 733-9

Bird ST et al. Male breast cancer and 5 alpha reductase inhibitors finasteride and dustasteride. J Urology; 190:1811-4


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
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Preventing Androgenetic Alopecia: Is it possible?

Preventing AGA in Men and Women

I'm often asked if one can prevent genetic hair loss. The typical scenario is a patient whose parent or sibling is bald or balding and wants to know if they can reduce their chances of developing a similar pattern of hair loss. Can one prevent balding outright? In the present day, that answer is no. However, there are things that can be done to reduce the magnitude and speed of progression of the hair loss.

Genetic Hair Loss is strongly ... genetic. It's the genes inside the hair follicles that influence how the hair loss will or will not unfold. We'll take a look at factors that can affect genetic hair loss to a slight degree in a moment, but first let's turn our attention to studies of identical twins. 

Studies of identical twins are very important in answering questions like "does what I eat affect my rate of balding?" or ,,,, "does being stressed affect how fast I bald?"

Identical twins carry the same genetic profile. By studying the appearance of identical twins at various points throughout their lives, we can get a better sense of how important factors like genetics and the environment actually are. If genes are the "key factor" in how balding progresses then, identical twins should look ‘identical’ in terms of their hair density at various points in their lives. In contrast, if environmental factors like smoking, drinking, stress, weight loss and ultraviolet radiation are important, identical twins might not have the same hair density because their environment is different. 


The 1992 Hayakawa Study

Interesting research studies in 1992 showed that genetics is by far the most important factor and the environment only has a minor role. 92 % of identical twins were found to have "no significant" differences in their hair density at later points in their lives. However,  8% of identical twins had a slight difference. Interestingly, no twin had a striking difference! In other words, there was never a situation where one identical twin was bald and another had full hair. These studies support the notion that one’s genetics is by far the most important factor in the balding process - but there is a slight role for how outside 'environmental factors' shape genetic hair loss.


Limiting Genetic Hair Loss: Optimizing Environmental Factors  

The Hayakawa studies taught us that there is a bit of room to optimize how fast genetic hair loss occurs. Overall, these factors have a minor role but still have some role. These factors include the following.


1) Be a non smoker.

It's clear that smoking can influence genetic hair loss by speeding up how fast it progresses. An important study examing the relationship between smoking and hair loss was a 2007 study by the Taiwanese group of Dr. Su and Dr Chen.  These researchers examined 740 patients between the ages of 40 and 91 over a 2 month period.  They found that smokers generally had worse androgenetic alopecia compared to non-smokers. In fact, smokers had nearly a two-fold increased risk of having moderate or severe genetic hair loss compared to non-smokers. In addition, the early development of male balding was more likely in smokers. The exact reasons is not clear but it has been proposed that smoking is damaging to the tiny blood vessels and the there are toxic substances in cigarette smoke that damage the cells in the hair follicles. It's also possible that smoking causes inflammation which speeds up the process of genetic hair loss. 


2) Keep a healthy weight. 

It does appear that obesity increases one's risk of developing worsening androgenetic alopecia. A 2011 study looked at the risk factors for male balding in policeman in Taiwan. Interestingly, young male policemen who were obese had much higher rates of male balding than thinner policemen. In 2014, researchers from Taiwan explored whether there was a relationship between obesity the severity of male balding. They studied 142 men (average at 31 years) with male balding who were not using hair loss medications.   The study showed that men with more severe  hair loss tended to be more overweight than men with less severe hair loss.  In fact, men who were overweight or obese had an approximately 3.5 fold greater risk for severe hair loss than men with more normal weights. In addition, young overweight or obese men had a nearly 5 fold increased risk of severe hair loss. The exact reasons are unclear. However, obesity leads to altered metabolism, insulin resistance and worsening inflammation that could affect balding. 


3) Limit excess triggers that cause shedding (weight loss, stress, some medications).

Individuals with genetic hair loss are well advised to limit triggers of shedding. This is not always easy to do, but shedding can trigger worsening of hair loss in some people. Repeated cycles of shedding speeds up the arrival of genetic hair loss in patients who are genetically predisposed to develop genetic hair loss. In my hair clinic, I use the term AFMPS - or Accelerated Follicular Miniaturization from Prolonged Shedding. It's a phenomenon that happens only in those who are predisposed to develop androgenetic alopecia.  It's a phenomenon that is frequently seen but rarely is it fully appreciated.

The concept of AFMPS is very important. It is critically important to limit hair shedding in those predisposed to genetic hair loss.  Everything that causes shedding - iron, thyroid issues, dieting, medications, stress, seborrheic dermatitis - must be properly managed. 


4) Limit anabolic steroid use.

Anabolic steroids can worsen genetic hair loss in those that are predisposed. These steroids increase the pool of androgens that all act to facilitate miniaturization.


5) Reduce ultraviolet radiation to the scalp.

An interesting study from researchers in Taiwan offers further clues that sunlight just 'might' contribute in some way to male balding.  The researchers compared balding patterns in 758 policemen  and 740 men in the general polulation.  Interestingly, policemen aged 40 to 59 had a two fold increased risk of having male balding. In addition, there was a statistically significant association between male balding and sunlight exposure. More research is needed understand if and how ultraviolet radiation affects the process of male balding. Reference



It's not always possible to prevent genetic hair loss. However, it may be possible to reduce the speed of its progression by limiting hair shedding and limiting toxic (i.e. smoking, obesity, UV radiation) and hormonal effects (i.e. anabolic steroids) on the hair follicle.



Hayakawa K, et al. Intrapair differences of physical aging and longevity in identical twins. Acta Genet Med Gemellol (Roma). 1992.

Su LH and Chen T H-H. Association of Androgenetic Alopecia with Smoking and Its Prevalance Among Asian Men. Archives of Dermatology 2007 143; 1401-1406.

Mosley JG and Gibbs AC. Premature grey hair and hair loss among smokers: a new opportunity for heatlh education? British Medical Journal 1996; 313: 1616.

Severi G et al Androgenetic alopecia in men 40-69 years: prevalence and risk factors.British Journal of Dermatology 2003; 149: 1207-1213

Chao-Chun Y et al. Higher body mass index is associated with greater severity of alopecia in men with male-pattern androgenetic alopecia in Taiwan: A cross-sectional study.  J Am Acad Dermatol 2014; 70; 297-302.

Su LH et al. Androgenetic alopecia in policemen: higher prevalence and different risk factors relative to the general population (KCIS no. 23). Arch Dermatol Res. 2011 Dec;303(10):753-61



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
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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. 



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.  



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
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Spironolactone for Female Androgenetic Alopecia (AGA)

Spironolactone for Female Genetic Hair Loss

Spironolactone has been used off label in the treatment of androgenetic alopecia (also known as female pattern hair loss, FPHL) for approximately two decades.  The medication acts to reduce the effects of androgens in several ways.   It reduces adrenal androgen production and exerts competitive blockade on androgen receptors. 

Although there are yet to be any randomized placebo controlled trials examining the benefits of Spironolactone in FPHL,  case reports, series, and an open-label trial support its benefit. In a small case study, 200 mg spironolactone reduced hair loss by 50%–62.9% and also increased the total number of anagen hairs.  Perhaps the most important study to date was an an open-label study of 80 women with biopsy-proven FPHL who either received spironolactone (200 mg daily) or cyproterone acetate (either 50 mg daily or 100 mg for 10 days per month if premeno- pausal) for at least 12 months. This study showed that 44% of patients experienced visible hair growth (improvement), 44 % had their hair loss stopped. Only 12 % had reduced hair density. Another key finding of this particular study was that benefits did not depend on whether women had high androgens or normal androgens.  Other studies have shown that adding minoxidil to a spironolactone based treatment plan can be additive and some patients will achieve even further benefits. 


Readers may find these links helpful. The pertain to other articles written by Dr. Donovan on Spironolactone:

Spironolactone for FPHL - A UCLA Study

Irregular Periods from Spironolactone

Spironolactone for FPHL

Hormone Levels and Spironolactone Use: Does it matter?

Should one start Spironolactone with Minoxidil?



Sinclair R et al. Treatment of female pattern hair loss with oral anti androgens. Br J Dermatol 2005



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
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Birth Control Pills, Hormones and Hair Loss: Important Considerations

Birth Control Pills affect Androgens

Oral contraceptives have many effects on the hair.  For some  women, oral contraceptives can cause hair shedding when started or stopped by triggering a telogen effluvium. Fortunately for most, this shedding is temporary.  Oral contraceptives can also benefit the hair in many women with androgenetic alopecia by reducing the levels of androgens (male type hormones) in the blood.


Where do androgens come from? 

There are three important sources of androgens in women.  About 50 % of testosterone in the blood comes from the conversion of hormones such as androstenedione and dehydroepiandrosterone (DHEA) and its sulphate dehydroepiandrosterone sulphate (DHEA-S). About 25 % of testosterone comes form the adrenal gland and 25 % from the ovary. 

About 65 % of testosterone that circulates in the blood stream gets bound and inactivated by sex-hormone-binding globulin (SHBG). Most of the remaining 30–35% is bound by albumin. Only 0.5–3% represents freely circulating T ("free T"). Despite the low amount, free T is important as it is active and able to cause a range of clinical phenomena such as hair loss acne and increased hair growth on the face (hirsutism).


Effects of Oral Contraceptives Pills on Androgens

Oral contraceptives (birth control pills), particular the combined oral contraceptives (COCs) are known the levels of androgens in the blood including testosterone, androstenedione and DHEAS. For example, blood levels of testosterone decrease by as much as 50 %. This occurs from the ability of oral contraceptive pills to a) reduce androgen synthesis in the ovary b) reduce androgen synthesis in the adrenal gland and c) increase sex hormone binding globulin in the liver. 

Because of their effects on androgens, birth control pills are options for women with certain types of hair loss, including androgenetic alopecia associated with normal hormone levels, and androgenetic alopecia associated with polycystic ovarian syndrome (PCOS).  Birth control pills are not appropriate for everyone with these hair loss conditions and anyone considering these medications should carefully review risks and benefits with a physician.





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
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Female Pattern Hair Loss


Major and Minor Criteria


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.



(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.



(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.



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

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
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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.



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.


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
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Does Finasteride Help All Causes of Hair Loss?

Finasteride: FDA approved for Male Balding

Finasteride is FDA approved for androgenetic alopecia in males but may also help hair loss from other conditions.

Finasteride for Male Balding

Finasteride was approved in 1997 for male balding at a dose of 1 mg. This approval came 5 years after finasteride was approved for treating prostate enlargement at a dose of 5 mg. Although generics are now available, the finasteride pills was initially marketed only as Propecia. For males with balding, it helps all areas that are thinning with the crown helped somewhat more than the front. Young males under 40 seems to get more benefit in the frontal areas of hair loss than men over 40.  Side effects of finasteride should always be reviewed before starting. 

Finasteride Side Effects - Donovan Hair Clinic


What conditions does finasteride help?

Finasteride is approve for male balding but may help several other conditions. These conditions include frontal fibrosing alopecia, some types of female patterned hair loss and very rare cases of lichen planopilaris including fibrosing alopecia in a pattern distribution (FAPD). Such uses are "off-label" and prescribed only in select cases.


What conditions does finasteride not help?

Finasteride does not help other types of hair loss. It does not appear to have benefit in alopecia areata, trichotillomania, telogen effluvium,  infectious causes of hair loss, and scarring alopecias such as folliculitis decalvans.  


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
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Permanent Chemotherapy Induced Alopecia (PCIA)

A New type of Hair loss in Patients Undergoing Chemotherapy: PCIA

Every year about 650,000 patients undergo chemotherapy in the United States. Hair loss is a common side effect of chemotherapy and occurs in about 65 % of patients who receive chemotherapy. There are two main types of hair loss that can occur in patients undergoing chemotherapy. The first is hair loss that happens within weeks of starting the chemotherapy and then lasts several months before growing back.  This is known as temporary chemotherapy induced alopecia ("TCIA"). The second type is uncommon and occurs when patients fail to regroth their hair back to the level it was before undergoing chemotherapy. If hair has not grown back after chemotherapy by the 6 month after chemotherapy, we call this permanent chemotherapy induced alopecia (PCIA) and it is sometimes also called Chemotherapy Induced Permanent Alopecia (CIPAL).


Permanent Chemotherapy Induced Alopecia (PCIA) 

The failure of the hair to grow back fully 6 months post chemotherapy raises concerns about a phenomenon known as permanent chemotherapy induced alopecia (PCIA).     In recent years a number of studies have highlighted the possibility of PCIA in women with breast cancer treated with various chemotherapeutic agents, especially drugs known as taxanes. Docetaxel and paclitaxel are part of this group of drugs. The exact mechanisms are unclear although injury to the bulb as well as follicular stem cells are thought to be relevant. Adjuvant anti-estrogen hormonal therapy may be an important cofactor in many women with PCIA. A similar PCIA presentation has been reported in patients undergoing bone marrow transplantation. The scalp is predominantly affected in women with PCIA although a minority may have eyebrow, eyelash and body hair loss as well.


Different Clinical Presentations of PCIA

PCIA doesn't appear similar in all patients. In fact, three main types appear to exist including a diffuse type, a diffuse type with vertex accentuation (mimicking androgenetic alopecia) and a patchy type mimicking alopecia areata.   


Examination under the Microscope: Biopsies of PCIA

Histopathology of biopsy specimens shows a non-scarring alopecia with preservation of sebaceous glands, miniaturization, decreased anagen hairs, increased telogen hairs and end stage avascular fibrous tracts. There may be several histological presentations and the exact features remains to be defined although a high proportion show dysmorphic telogen germinal units. Some biopsies show peribulbar type inflammation.


How do we treat PCIA?

We don't really know yet how to best treat PCIA. The most common treatments described in the medical literature are oral and topical minoxidil. Both seem to provide benefit to at least a proportion of patients.  Other treatments are not known to provide benefit. 


Dr. Donovan's Articles for Further Reading

Preventing Hair Loss from Chemotherapy

Does hair always grow back after chemotherapy?





Miteva M, Misciali C, Fanti PA et al. Permanent alopecia after systemic chemotherapy: a clinicopathological study of 10 cases. Am J Dermatopathol. 2011 Jun;33(4):345-50.  

Fonia A, Cota C, Setterfield JF et al. Permanent alopecia in patients with breast cancer after taxane chemotherapy and adjuvant hormonal therapy: Clinicopathologic findings in a cohort of 10 patients. J Am Acad Dermatol. 2017 May;76(5):948-957.

Rugo HS.  Real-world use of scalp cooling to reduce chemotherapy-related hair loss.  Clin Adv Hematol Oncol. 2017


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
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Risk of Fibroids Increased in Women with CCCA

Five Fold increased Risk of Fibroids in Women with CCCA  


A new study, published in JAMA Dermatology, has given evidence that women with central centrifugal cicatricial alopecia (CCCA) are at increased risk of developing benign uterine tumors known as fibroids.  The medical terms for these are uterine leiomyomas.

CCCA is a type of scarring alopecia that occurs predominantly in women with afro-textured hairs. This new data suggests that a genetic predisposition to develop excessive scar tissue in other area of the body may be central to the underlying mechanisms that cause these two diseases.  

The researchers analyzed data from over 487,000 black women and examined the incidence of fibroids in women with CCCA and those without CCCA. Out of 486,000 women in the general population,  3.3 % had fibroids. However, 13.9 % of women with CCCA were found to have fibroids. Taken together, this works out to a five fold increased risk of fibroids in women with CCCA.



There is an increased risk of uterine fibroids in women with CCCA.  Whether there is an increased risk of other scarring related diseases of the body warrants further study.



Dina et al. Association of Uterine Leiomyomas With Central Centrifugal Cicatricial Alopecia. JAMA Dermatology, 2017; DOI: 10.1001/jamadermatol.2017.5163

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
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Do all women with hair loss really need blood tests?

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

Click here for PDF of Article

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 



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. 



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. 



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.

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
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Breast Implant Illness and Hair Loss

Hair Loss from Breast Implants: Any relationship?


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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


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. 






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


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
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Is Low Level Laser Therapy (LLLT) Helpful For Treating Hair Loss?

Is LLLT Helpful For Treating Hair Loss?


Is low level laser therapy (LLLT) helpful for treating hair loss? To date there has been a number of studies that suggest LLLT is helpful including 5 randomized double blind studies - 2 studies with so called "laser brush/comb" devices and 3 studies with helmet/cap devices.

The photo here shows a LaserCap. This LLLT device consists of 224 ‘pure’ laser diodes (no LEDs) of 650nm/5mW each. The device is worn every second day for 30 minutes. Several hemet/cap devices now exist and are marketed as FDA cleared LLLT devices.

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
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Does stress accelerate balding?

There is not a lot of great medical evidence to support the notion that stress directly impacts MPB.  However, it probably has a minor role and only in some men and women with the right genetic background. Of course, we don't understand yet what that genetic background is at present.

When one examines studies of identical twins, one sees that 92% actually still look identical (same level of hair loss) years and years down the road. If stress, diet, and environmental factors played a huge role, one would not expect this number to be so high.

But for some males and females, it is likely that stress accelerates balding to a minor degree. A study by Gatherwright in 2013 suggested that higher stress could lead to worsening hair loss in the crown in men.  For women, a 2012 study suggested that higher stress was correlated with worse hair loss in the frontal area and divorce and separation were correlated with worsening hair loss in the temples.


Stress probably accelerates the rate of progression of balding in some individuals who have the right genetic predisposition.   We know that stress can cause an increased amount of daily shedding and such shedding can accelerate follicular miniaturization. It makes sense that stress can accelerate the balding process in some individuals. However, it's not likely to be a consistent phenomenon amongst all individuals.  


The contribution of endogenous and exogenous factors to male alopecia: a study of identical twins.

Gatherwright J, et al. Plast Reconstr Surg. 2013.

The contribution of endogenous and exogenous factors to female alopecia: a study of identical twins.

Gatherwright J, et al. Plast Reconstr Surg. 2012.

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
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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.





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
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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.


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
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