Hair Loss in Women: A Crisis of Vanity and Sanity

You’ve seen the infomercials. You’ve seen the ads with before and after photos. Rogaine (minoxidil) and Propecia (finasteride) are two treatments for hair loss. Before I tell you why I don’t think you should be in a rush to slime your hair follicles every day or remove every molecule of testosterone in your body, let’s first consider why women are doing so poorly with hair loss.

Thirty percent of women report serious hair loss by age thirty. By age fifty, that statistic climbs to 50 percent. This is a major problem, of both vanity and sanity. It’s demoralizing, and conventional medicine often pats you on the back, murmuring, “You’re getting older; you need to get used to it.” As someone who has struggled personally with hair loss and heard that same message from my primary care doctor, I find that answer completely unsatisfying and more important, unnecessary. So if you have hair loss, take heart, help is on the way.

Before my patients start looking for a solution to their hair loss in a box from the drugstore or a pill bottle from a dermatologist, I encourage them to look inside their bodies.

Getting to the Root: Causes of Hair Loss

Sometimes hair loss is associated with a simple root cause. Most of the time, there are hormonal imbalances such as thyroid, insulin, or testosterone. Occasionally, hair loss is linked to physical and emotional trauma, and probably dysregulation of cortisol. Even more rare, I find underlying health conditions such as autoimmunity as the root cause.

To find a patient’s particular reason for hair loss, I order a blood panel (listed at the end of the blog) to test several hormones and conditions. Correcting hair loss is all about sussing out the cause. For example, some women make too little thyroid hormone to grow their hair – it’s a matter of rationing and in your body’s triage system, hair growth is lower priority than, say, keeping your body warm. Other women make too much of the male hormone testosterone and that causes balding, although the main culprit is a metabolite (daughter) of testosterone called dihydrotestosterone (DHT)

Here are the most common causes of hair loss:

1. Low thyroid

Rapid hair loss can be an early sign of a thyroid problem, often first diagnosed in the beauty salon. In addition to thinning and shedding, your hair can become coarse, dry, and easily tangled.

This kind of general hair loss will slow and eventually stop once your hormone levels are stabilized. But sometimes the problem continues even after treatment, especially if you’re taking levothyroxine, a synthetic hormone often used to treat hypothyroidism. Excessive or prolonged hair loss is a known side effect of this drug. Look into this if you’re still losing hair despite what your doctor calls sufficient treatment.

Do this: Work with a functional medicine practitioner with experience treating thyroid conditions. Get a full thyroid blood panel (see below). Sometimes micronutrient deficiencies such as low selenium or zinc are a reason for faulty thyroid function, or you may have autoimmune thyroiditis (Hashimoto’s thyroiditis), which needs to be addressed with a full functional medicine protocol. Because changes in dose can trigger hair loss, low and slow is the goal with any medication. Some people find their hair loss diminishes if they take Thyrolar, a synthetic combination of both thyroid hormones, T4 and T3.

2. Low iron, low lysine

In one study, 90 percent of women with thinning hair were deficient in iron and the amino acid lysine.¹Rushton DH. Dover R, Sainsbury AW, et al. “Iron deficiency is neglected in women’s health.” British Medical Journal 325 (7373) (2002): 1176. Lysine helps transport iron, which is essential for many metabolic processes.

Do this: Measure your ferritin levels, the most sensitive indicator of iron in the body. You need a minimum of 40 to grow new hair, and a healthy range is 70–80. Make sure you get your daily dose of iron from grass-fed red meat and greens. Good sources of lysine are foods rich in protein. Add lysine to your diet with foods rich in protein, such as meat and poultry, soy, eggs, cheese (especially Parmesan), and some fish (cod, sardines). If you need additional doses of an iron supplement, be sure to have a functional medicine practitioner track your ferritin so you don’t get too much and trigger iron overload.

3. Androgenic alopecia

This is the most common type of hair loss and affects 30 percent of women.²http://www.ncbi.nlm.nih.gov/pubmed/22171680) The typical pattern for hereditary female-pattern hair loss, or androgenic alopecia, is a widening part or noticeable thinning of hair, particularly over the mid-frontal portion of the scalp.

Sometimes women with androgenic alopecia have polycystic ovary syndrome (PCOS). Typical signs and symptoms are ovarian cysts, irregular periods, weight gain, blood sugar problems, infertility and hair loss. The problem may be exacerbated in some patients taking drugs for thyroid problems. Approximately 22 percent of women with PCOS have androgenic alopecia.³http://www.ncbi.nlm.nih.gov/pubmed/24534277

The good news is that you can often stop and even reverse the symptoms of hair loss once you balance your hormones.

Do this: Run the full blood panel (see below). This is where evening primrose oil can help. Besides inhibiting DHT, the main culprit behind androgenic alopecia, evening primrose oil is a good source of essential fatty acids, and the symptoms of hypothyroidism are quite similar to those for insufficient essential fatty acids. See The Hormone Cure, chapter 9, for the full protocol. Berberine and inositol may be helpful to reset hormones. As always, I advocate a “food first” strategy along with taking targeted supplements. If changing your food and supplement plan doesn’t result in more hair on your head, then discuss with your functional medicine practitioner if minoxidil might be a good idea. (Minoxidil or Rogaine is approved for women for this type of hair loss and available over the counter.)

4. Not enough protein

If you don’t get enough protein in your diet, your body may enter famine mode and shut down your hair growth. This may occur about two to three months after a drop in protein intake.

Do this: Eat clean protein from fish, grass-fed meat, eggs, and quinoa. Read The Hormone Reset Diet, page 232, for a more complete list.

5. Excess vitamin A

Maybe you just started taking a new multivitamin, or started on a supplement containing vitamin A. You may have driven your vitamin A levels too high, which may trigger hair loss.

Do this: Total intake of vitamin A should be no more than 5,000 International Units (IU) per day. When you remove excess vitamin A, your hair should grow normally again.

6. Stress hormones—from physical or emotional stress

Any kind of physical or emotional trauma can trigger telogen effluvium: surgery, weight loss, eating disorder, car accident, illness, troubled marriage, sick kid. Hair grows on a programmed cycle that involves a growth phase, rest phase, and shedding phase. Big emotional and/or physical stressors can cause the hair to lock down in the shedding phase.

Do this: If you clear the stress, the telogen effluvium usually clears in three to six months as your body recovers.

7. Fluctuating female hormones of pregnancy, perimenopause, going on/off birth control pills

This may also cause telogen effluvium, especially if you have a family history of hair loss.

Do this: Keep hormones as stable as possible by mitigating stress. In pregnancy, if you lose more hair post partum than before you got pregnant, see your healthcare professional and run the blood panel (see below) to see if there’s an underlying thyroid and/or autoimmune condition.

8. Menopause

Sadly, hair follicles can shrink in menopause, making hair finer and more likely to shed. It’s called “miniaturization,” and it’s totally unfair. One study suggests that the ratio of estradiol-to-testosterone may influence in hair loss in women and that low ratios may be the culprit in some cases.⁴http://www.ncbi.nlm.nih.gov/pubmed/18333699

This ratio typically decreases during menopause. Not surprisingly, another study showed that women treated with bioidentical estradiol had less hair loss. ⁵http://www.ncbi.nlm.nih.gov/pubmed/22879713

Do this: If you’re over forty, talk to your functional medicine practitioner about whether bioidentical estrogen may be right for you. You need to be followed by a gynecologist to make sure you stay safe and don’t develop side effects and adverse events, such as blood clots, endometrial cancer, stroke, breast cancer, heart disease.

9. Vitamin B deficiency

This can be exacerbated by stress or taking birth control pills, both of which deplete B vitamins in the body.

Do this: Between food intake and supplementation, you should be able to correct the problem. Rich sources of vitamin B include meat, fish, starchy vegetables, and some fruits.

10. Lack of fat

If you go low-fat in your food plan, you may consume fewer calories, nutrients, and more carbohydrates than your body requires. Most importantly, you may miss out on essential fatty acids, omega 3 and 6, which nourish the scalp and stabilize hair growth. The stress of restricting a macronutrient such as fat (or carbs or protein) may force more hair follicles to enter the telogen phase. Similar to the low thyroid state, your body gets the message to ration; there isn’t enough fuel to support the growth phase.

Do this: Maintain a balanced diet rich in “good” fats such as from coconut, avocado, and nuts—good for your hair and your health. Don’t skip out on macronutrients, but find the matching diet for your locks.

11. Autoimmunity

Sometimes the problem is alopecia areata, which appears as hair loss in round patches on the head, and sometimes the problem is autoimmune thyroiditis. Either way the cause is an overactive immune system. The body misidentifies the hair as foreign and attacks it.

Do this: Work with a functional medicine clinician to reverse autoimmune thyroiditis. Consider starting an autoimmune protocol for food. In some cases, you may need to see a dermatologist for steroid injections.

12. Medications

Some medications such as beta blockers, antidepressants, lithium, blood thinners, methotrexate, NSAIDs (such as ibuprofen) can cause hair loss.

Do this: If you’re taking one of these medications, talk to your medical professional about alternatives.

13. Overdoing hair care and products

Hair dye, frequent shampooing, other treatments, products, and vigorous styling can traumatize your hair follicles and lead to hair loss.

Do this: Wash your hair less often. The American Academy of Dermatology suggests that you let your hair air dry and limit hot devices (like flat irons and curling irons) to once per week or less. I know, I know, I love blowouts, too. Once per week, max!

14. Insulin resistance and blood sugar problems

Insulin, that helper hormone in charge of regulating blood sugar levels, also affects hair growth. Half of female patients and 60 percent of male patients with androgenic alopecia have a constellation of signs and symptoms related to insulin resistance, blood sugar abnormalities, hypertension, and abnormal cholesterol.⁶http://www.ncbi.nlm.nih.gov/pubmed/20619491 Another study found that androgenic alopecia may be an early marker of insulin resistance, metabolic syndrome, and cardiovascular disease in men.⁷http://www.ncbi.nlm.nih.gov/pubmed/26585114 So it could be for women as well.

Do this: The good news is that cutting sugar and artificial sweeteners, being active, and losing weight can reverse insulin resistance and lower your chances of hair loss.

15. Aging

While the aging-related cause isn’t totally clear, it probably has to do with the hair follicle slowing down and getting depleted.

Do this: Well, we are all getting older. The key is your biological age as opposed to your chronological age. Slow down your aging and lengthen your healthspan in Dr. Sara’s Aging Reset Program

The blood panel I order

My advice is to try therapies aimed at the root cause of your hair loss first. Ask your doctor for my top blood tests, including these:

• Complete blood count (a measure of whether you are anemic and your immune system is functioning)
• Ferritin (the most sensitive test for iron stores in your body) – you may want to run a full iron panel
• Thyroid-stimulating hormone (TSH), free T3, free T4, and possibly, reverse T3, thyroid peroxidase antibodies, anti-thyroglobulin antibodies
• Cortisol, ideally free and metabolized in a 4-point measurement in the urine
• Fasting insulin and glucose
• Testosterone (I prefer total and free testosterone in women with hair loss)
• Antinuclear antibody (tells you whether the hair loss is related to an autoimmune condition)

Treatments

I have a food-first strategy when it comes to hair loss. You can help hair loss with your fork. Start by dialing in your macronutrients and micronutrients. If you’ve been low-carb for a while, add a ½ sweet potato to dinner. Make sure you get adequate fat from avocado, hemp seeds, and nuts. Add 5 to 7 Brazil nuts to your green smoothie to get the selenium your thyroid needs.

Grains contain small quantities of lysine, but legumes contain even more; therefore, meals that combine the two—Indian dal with brown or black rice, beans with black rice and tortilla, falafel and hummus with gluten-free crackers—are a good way to get complete protein in your diet and keep hair on your head.

When it comes to filling micronutrient gaps, you may want to take a multivitamin while you perform testing to see what nutrients may be missing. This will ensure that you get the B vitamins, copper, zinc, and selenium that you need.

Another natural treatment strategy includes a 1,000-mg daily supplement of evening primrose oil, which as I mentioned, blocks the conversion of testosterone to dihydrotestosterone (DHT). Sometimes you have more than one cause of your hair loss, and these are simple and natural strategies that won’t harm you.

If you are wigging out because of hair loss and need to do something while investigating root causes, the only drug approved for women by the Federal Drug Administration is minoxidil.⁸http://www.ncbi.nlm.nih.gov/pubmed/26411201; http://www.ncbi.nlm.nih.gov/pubmed/22592723 You can buy minoxidil without a prescription. It’s actually a drug for lowering blood pressure, but when applied topically, it slows hair loss and promotes regrowth. It dilates blood vessels, allowing more oxygen, blood, and nutrients to reach the hair follicles, resulting in new, thicker, and better hairs. Minoxidil comes in two doses: 2 percent (for women) and 5 percent (for men). There’s some debate about which strength is better for women. According to the research, 5 percent appears superior to 2 percent in women, although some women report greater adverse scalp reactions with 5 percent.⁹http://www.ncbi.nlm.nih.gov/pubmed/15034503

How to Use Minoxidil

Once you decide to commit to daily minoxidil, I recommend parting your hair down the middle, snapping a few photos to document the width of your part and your hairline. Make sure your hair is dry when you start.

• Apply the dose to your scalp (2 percent or 5 percent).
• Wash your hands immediately after application as it can stain clothing and bedding.
• Allow to dry for 2 to 4 hours. Don’t shampoo, apply hair products, or blow dry for four hours.
• Apply twice per day or as recommended by your health professional.

Then wait patiently for four months and watch your hair grow. Unfortunately, this is not a cure—when you stop using minoxidil, hair loss will return unless you’ve corrected the cause.

Taken orally, finasteride acts systemically to reduce androgens by inhibiting the enzyme that converts testosterone to DHT. While most people take these treatments to hang on to their hair, they are actually treating the downstream symptoms of high testosterone and DHT.

Both these treatments for hair loss have been studied primarily in men. Are they safe for women? Minoxidil has been used for more than thirty years, so it’s got a longer track record. But the real answer is this: we don’t know.

Bottom line: When it comes to your hair loss and prescription therapies, we want to reproportion your hormones, not search and destroy. So I highly recommend that you get to the root of your hair loss by finding the cause. Work with a collaborative health professional. View hair loss as an important message from your body that needs to be decoded. Often when you heal your hair loss, you heal other systems in your body, such as your gut, immune system, and endocrine system.