Frontal Fibrosing Alopecia in Women Under 40: The Importance of Diagnosis

Frontal Fibrosing Alopecia and Early Menopause

Frontal fibrosing alopecia (FFA) is a scarring hair loss condition that affects often affects the frontal hairline and eyebrows first but can affect many regions of the scalp as well as eyelashes, and body hair. The condition was first termed “post-menopausal frontal fibrosing alopecia” but it is now recognized that pre menopausal women can develop this condition. Men can also develop the condition less commonly as well.

FFA in Younger Women: What are the important considerations?

In 2014, Dr Vano-Galvan and colleagues performed a retrospective study looking back at some 355 patients seen in spain. 14 % of women were reported to have premature menopause (early menopause). This is an important observation that it easily overlooked in a busy practice.

We have seen many younger women with FFA in our practice some of which do have early menopause. I feel strongly that screening for premature menopause is an important part of the work up of women under 40 with FFA even if they do not plan to become pregnant in the future. There are many health consequences of early menopause that simply can not be ignored.

What is Premature menopause?

Premature menopause is defined as menopause occurring in women under 40 years of age. Overall, about 1 % of women have premature menopause making the condition not really all that rare. A variety of genetic conditions, autoimmune conditions, infections, surgeries and medications (i.e. chemotherapies) can cause premature menopause. Without appropriate treatment, some of these women may be at increased risk of premature death, neurological diseases, psychosexual dysfunction, mood disorders, osteoporosis, ischemic heart disease and infertility. It is imperative to screen for possible early menopause in women with FFA who are less than 40 years of age.

Symptoms and signs of early menopause

The signs and symptoms of premature menopause are due in part to changing estrogen levels but other hormone levels are likely important as well.

Symptoms of early menopause may include changes in menstrual cycles but may not. Symptoms may also include

1. Hot flushes/night sweats

2. Vaginal dryness and painful intercourse

3. Urinary frequency, urgency and incontinence

4. Sexual dysfunction

5. Sleep problems

6. Headaches

7. Depression and anxiety and irritability

8. Joint pains

9. Poor concentration.

Screening for Early Menopause

Blood tests for estrogen (estradiol), FSH and LH, TSH, blood sugars, blood calcium levels are important tests to order in women who may be experiencing early menopause. Early menopause is associated with reductions in estradiol levels (E2 level <20 pg/ml) and a rise in FSH (FSH level >40 Miu/ml). Other screening tests may be considered depending on the results of estradiol and FSH including AMH (anti-Mullerian hormone) and ultrasounds of the ovaries. If premature menopause is considered a bone mineral density should be considered to evaluate for possible osteopenia/osteoporosis. Referral to specialists including endocrinology and gynecology is important.

Medical Issues in Women with Early Menopause:

Some of the medical issues that need to be reviewed with each patient have been outlined above and include hot flashes, night sweats, weight gain, sexual dysfunction, vaginal dryness, psychological issues like depression and anxiety, brain fog, irritability. The longer term consequences of osteoporosis, infertility, and cardiovascular disease/stork are essential to review with appropriate medical teams on a case by case basis.

Estrogen supplementation and hormone replacement type therapy may be appropriate for many women but not all women with premature menopause. The risks and benefits should be reviewed with the physician.

Conclusion

The management of FFA in women under 40 must include screening for early menopause. These guidelines have not been formally recognized but I feel that it is imperative. Tests for estradiol, FSH are a must and test for TSH, LH, blood sugars and calcium and important to consider as well. Other tests may be necessary as well but this is quite case specific. Women with FFA believed to have premature menopause should be referred to the appropriate medical teams for additional work up an evaluation.

Whether young women with FFA who do not show show evidence of entering menopause should be monitored more frequently or whether such women should consider egg retrieval (storage) if future pregnancy is desired is something that requires more investigation and study in our field.

For now, it is important the we all be aware of the possibility of early menopause in women under 40 with FFA.

References

Van Galvan et al. Original articleFrontal fibrosing alopecia: A multicenter review of 355 patients Journal of the American Academy of Dermatology. Volume 70, Issue 4, April 2014, Pages 670-678.

Okeke TC et al. Premature Menopause. Ann Med Health Sci Res. 2013 Jan-Mar; 3(1): 90–95.