Written by Aimee Paik, MD
As a practicing dermatologist, I treat a lot of patients with various skin concerns—rashes, growths, etc. But, I also see many patients, both men and women, with hair loss, known as alopecia.
Male hair loss or male pattern baldness is well-known, as are its treatments (think RogaineⓇ)). Female hair loss or female pattern hair loss is much less talked about but is in fact very common. Two out of 5 women will experience hair loss by age 60, but female hair loss can start as early as in your 20s. We just don’t hear a lot about it. That’s unfortunate for several reasons, including the fact that it can have a profound impact on mental health.
Alopecia has been linked to both anxiety and depression. A recent systematic review of 17 studies found that hair loss undeniably impacts one’s quality of life, and it showed that alopecia is heavily associated with major depression and anxiety (Note: stress and other mental health factors are also linked to hair loss).
I have a few female patients with hair loss whose mental health symptoms are very severe. They’re incredibly preoccupied and distressed with their hair loss, so much so that they feel it’s ruining their lives. But there are things that can be done to help.
Many women with hair loss do not end up in my office at all. While thinning hair can be distressing, many women don’t know that female pattern hair loss is common nor that there are safe and effective treatments available. Many end up suffering alone. Even my hairdresser was unaware of medical treatments for female hair loss, yet clients often come to her seeking hairstyles to camouflage thinning hair or advice about supplements.
When women with hair loss do make it to my practice, they may have already tried over-the-counter products unsuccessfully, stopping when they didn’t see immediate results. Many of them have experimented with various unproven treatments that just don’t work. Some are desperate for help. I also commonly see women struggling with anxiety or depression or both as a result of their hair loss. Their hair loss may even be wreaking havoc on their mental health.
I had one recent patient who appeared to have fairly normal hair density but who reported she had lost over half of her hair volume in the last year. She had an overwhelming sense of loss of self and identity because she no longer had her previously very thick hair, and she had terrible anxiety about losing even more hair.
I had another patient with a history of breast cancer who had hair loss induced by chemotherapy. But she had continued severe thinning over a year after her chemotherapy treatment. Chemotherapy can cause total hair loss, but it can also unmask an underlying genetic predisposition to female pattern hair loss and hair may not grow back to its previous density.
This hair loss was very distressing to her, and in a lot of ways was more salient to her than her breast cancer diagnosis. I started her on hair loss medications and she was absolutely thrilled with her improvement, even though her regrowth was somewhat subtle. Her experience is not unique. For some women with a cancer diagnosis and scheduled chemotherapy, the possibility of chemotherapy-induced alopecia is their greatest concern. Women with breast cancer reported the loss of hair associated with chemo as more psychologically difficult than losing a breast to surgical treatment.
In a 2004 book called Rapunzel's Daughters: What Women's Hair Tells Us About Women's Lives, the author wrote “There is an important link between hair and identity, especially for women.”
Current developments in women’s hair emphasize this connection. There’s the natural hair movement, which encouraged black women to embrace their hair; pandemic gray hair, where many women stopped dyeing their hair; and changing hair trends, where a new style might be tied to significant life events.
Because hair is closely tied to women’s identity, hair loss can have a profound effect on self-esteem and body image. Furthermore, hair loss can affect how women cope with their surrounding world.
One study found about 4 out of 10 women with alopecia reported relationship issues and over 6 out of 10 had work-related problems. In another study of women seeking treatment for alopecia, almost 9 out of 10 reported a negative impact on their day-to-day lives and half of them were worried or fearful in social situations.
As with many of my patients, treatment can improve satisfaction and quality of life. There are safe and effective treatments for alopecia in women. I use several medications, including topical and oral minoxidil in my practice. Many patients are initially wary of side effects. I reassure them that these medications are actually quite safe and I find most of my patients tolerate them well.
But for my highly anxious female hair loss patients, they often need something more than just medications. Some do not give treatments enough time to work and switch gears too soon; they are impatient or fearful of worsening hair loss.
I tell them, they need to trust the process—it’s a marathon, not a sprint. While hair growth can occur sooner, improvement is often only appreciated in about 6 months, with continued improvement over the next 1-2 years.
Women have one disadvantage compared to men when it comes to identifying improvement. Men may have a bald spot that fills in after several months of treatment. Since men typically have short hair and get haircuts frequently, this improvement is often easily noticed. For women with longer hair, improvement may be harder to appreciate as hair grows at the roots but the ends still feel thin.
I communicate the idea of the slow progress of treatments with follow-up visits every 6 to 12 months. I often suggest that they focus on a special event—a holiday or vacation 6 or 12 months in the future—at which point they can gauge whether hair loss has improved. It gives them a more realistic and positive way to think about hair regrowth.
Since improvement is so distant, I encourage women to focus on things outside of their hair loss to help them cope with challenging emotions. I encourage them to focus on their sense of self outside of their hair identity—their strengths, what makes them happy and so on—while trusting the process and their treatment.
What’s most important here? Hair loss in women is real and there is help for it.
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