Essays

July 3, 2024

What You Need To Know About Hormones and Hair Loss

Photo by Juan Moyano

By Elizabeth Kiefer

When men start losing their hair, they have the option to bite the bullet, buzz it all off, and, at least in theory, join the “bald hottie” ranks populated by the likes of Tyrese Gibson, Stanley Tucci, and Jason Statham.

But let’s be real. For women, thinning hair can be a psychological blow with no such silver lining.  Even admitting that it’s happening to you is often traumatic, explains endocrinologist Gillian Goddard. “I think there’s a lot of shame surrounding hair loss that women don’t necessarily want to talk about,” she says.

For more than a decade, Goddard — a practicing endocrinologist and adjunct professor of medicine at both NYU Langone and Hofstra School of Medicine in New York City — has treated patients experiencing hormonal issues during their reproductive and post-reproductive years. She also pens a weekly newsletter, Hot Flash, for Emily Oster’s acclaimed ParentData platform.

Alopecia is a broad medical category with a range of complex causes, manifestations, outcomes, and treatments. But in female pattern hair loss, arising from hormonal changes, often coincides with menopause and perimenopause, and is among the top symptoms women bring up when they come into her office.

I spoke with Dr. Goddard about what’s happening at a follicular level, what you can (and can’t) do about it, and why Gen X women deserve credit for moving the conversation about it into the mainstream.

Hair loss can be such a touchy subject, even among friends — I feel like the only neutral conversations I’ve had on the subject were postpartum, when the assumption among us was that it might be a little funky for a while, but would eventually grow back. 

Yep. When men have thinning hair or go bald, we say it’s distinguished and sexy. But for women, a full head of hair is a benchmark of what we consider to be attractive.

What’s typically happening when women in their late 30s and 40s start noticing that their hair is thinner than it used to be? 

The most common thing is female pattern hair loss, a.k.a. androgenic hair loss. It’s the same way testosterone and some related hormones impact men’s hair follicles, and why men have more hair loss earlier in life.

Women have about a tenth of the testosterone and androgen that men have. During our reproductive era, estrogen levels are high, which is great for hair. It’s why women have such great hair during pregnancy and why [some] notice their hair improves on birth control. But in the perimenopausal years, the balance between estrogen and androgen changes. Estrogen levels drop after menopause, but many women’s androgen levels don’t shift that much; without the estrogen to balance things out, androgen has more of an opportunity to act on the hair follicles. This is why hair loss is a phenomenon women see in this phase of life and beyond.

Oh boy. Is there anything we can do about that? 

Some things are beneficial, like topical minoxidil, i.e. topical Rogaine. They also started making a high-percentage Rogaine for women that’s a foam mousse instead of a serum, which can create a greasy, crunchy texture [for some hair types].

Since the pandemic, there’s been a lot of interest in oral minoxidil for hair loss. The challenge is that it’s not focused on the hair follicle in the scalp — it’s circulating in your bloodstream — so more women complain of hair growth where they don’t want it.

There are also oral medicines: Spironolactone is an old medicine that’s been around for years and actually blocks testosterone at its receptors, which can help many women. The challenge is to get a good response for hair loss, it’s quite a high dose, which not everyone can tolerate because of the side effects.

Microneedling has been shown to be beneficial; PRP (platelet-rich plasma injections); certain types of laser treatments. A lot of the data looks at combining different modalities, like topical minoxidil plus laser, or microneedling and then minoxidil. Basically, what you’re really trying to do with all those therapies (except spironolactone) is bring growth factors to the hair follicle. That’s kind of the theory behind all of those things.

How and when would you advise people to start exploring the options? 

It depends on what you’re seeing. The dermatologist is a good place to begin because they can do things like a scalp biopsy, look at the hair under the microscope, or see if the bulb is attached, and that can all give you information about the cause of hair loss. They’re also the ones who do more intensive interventions.

Both endocrinologists and dermatologists are pretty good about doing a workup to ensure we’re only talking about one thing. There are so many factors that can be at play. I always look for iron and vitamin deficiencies, because if you don’t look for those things you’re not going to find them, and they’re easy enough to fix. For example: Women in perimenopause whose periods have gotten really heavy could be iron deficient on top of experiencing female pattern hair loss and when you’re stimulating regrowth with growth factor treatments, you need iron to see results.

If your hair loss is in an unusual pattern — like patches or punched-out spots, not the typical “horseshoe” temples and top of the head — that deserves a workup. There are a few situations where you should expect to have some hair loss and it may pass: If you’re someone who is both postpartum and perimenopausal, which happens more and more these days, you should probably give that postpartum shed a chance to run its course before you start getting too concerned.

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“The current generation of women going through menopause — Gen X — are over the idea that we should grin and bear it. But also, women have money to spend on these things now in a way that they didn’t have in the past. ”

What should someone undergoing treatment for hair loss know about the projected results? 

Well, one of the challenges with hair is that you have to give an intervention a full six months to see if it’s been helpful. All of the studies of treatments for hair loss are 24 weeks, and it’s just not an area where you’re going to see a quick response. Which, when you think about it, makes sense because hair just doesn’t grow that quickly.

Six months feels like a long time when you’re worried about whether something is working, but there’s no way around it. Knowing it’s going to take a while to recognize any real improvement can help.

Hair is tied up in our psyche and identity, and experiencing hair loss can be so emotionally charged. How do you help comfort patients in your practice?

It’s hard. Really hard. Especially when someone comes in and says “my mom is completely bald,” because genetics are definitely a factor and their fears are very reasonable. Many women get dismissed by doctors. My biggest thing is just validation. Any time you can take a minute, listen to someone, tell them you hear what they’re saying and their concerns are real … It goes a long way.

Outside of a clinical setting, I think women often respond to other women by playing things down — telling them it’s not noticeable to anyone else or whatever seems comforting. It’s hard to find the right words sometimes. 

You know, it’s funny: I have terrible hair, always have. It’s just something that I got in the genetic lottery. So people will come in with thick ponytails like, “I’m losing all my hair!’ and sometimes my knee-jerk instinct is to be like: Really? Because I would die to have as much hair as you do. But they are seeing something real and they deserve validation as much as the next person.

You mentioned that Rogaine foam for women is a newer innovation … but there have been treatments for men for so long. What’s driving, or impeding, innovation at this moment? 

We just have different standards now for what we expect mid-life to look like. There have been so many things that have happened before now that have enabled people to age better.  I think one thing that’s happening is the current generation of women going through menopause — Gen X — are over the idea that we should grin and bear it. But also, women have money to spend on these things now in a way that they didn’t have in the past.

Women are [often] at the peak of their career and earning potential in mid-life, and because they’re at the peak of all these things, they have disposable income. Which matters, of course, because the vast majority of these things aren’t covered by insurance.

I love the Instagram account Toupee Queen, a stylist who does custom semi-permanent hair pieces and cuts for men. It reminds me of how my Italian great aunties would save the hair they shed to make their own hair pieces back in the day. Do you think there are more non-invasive treatments for women breaking through? 

We’re going to see more women dabbling in things like that. A lot of women already wear extensions to have not just long hair, but thicker hair. In New York, I think there are more people doing interesting and better things with wigs made and styled with real hair, partially because of the community of ultra Orthodox women here. Things like that are going to continue expanding, and the technology will continue to get better. I mean, toupees didn’t used to be that good, either!

This interview has been lightly edited for length and clarity. 

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