Most of what I have written for male patients applies to women also, but important differences do exist. For those reading this who are primarily concerned with women's hair loss and replacement, reading what has been written in the prior sections will be imperative to fully understanding what follows.

A significant number of women suffer from forms of hair loss other than female pattern baldness. These other forms of hair loss must be ruled out before a definitive diagnosis of female pattern baldness can be made. Of these others, telogen effluvium is the most common. Classically, telogen effluvium is that shedding of hair that occurs several months after childbirth. Typically, the woman will notice large amounts of hair suddenly coming out one to six months after a significant stress in her life such as a surgery, a serious illness, or a social or psychological stress. The bad news is that there is no treatment for this type of hair loss. The good news is that the patient does not require any treatment. The hair should return on its own after a dormant phase.

Less commonly, I will see women with traction hair loss. This is found most commonly in women who wear their hair tightly pulled back or in tight braids for long periods of time. The slow, chronic pull on the hair root eventually kills the follicular root system so that no hair will grow in these areas. This form of hair loss may be amenable to hair transplantation if the hairstyle is changed.

I frequently see patients who have had facelifts or other procedures in the scalp that have left scars or, as in the case of brow lifts, has left the hairline too high. In general, these types of hair loss respond well to transplants.

True female pattern baldness is much more common than most people realize. It tends to be underestimated because women go to great lengths to hide it. In a study authored by O'Tar Norwood, M.D. it was noted that the incidence increases from 3% of women in their twenties to 30% of women in their eighties. By the time women are in their fifties, approximately one quarter are affected.

The pattern of female pattern baldness tends to be different from men's. Typically, women will notice diffuse hair loss throughout the mid scalp but retain the majority of their hairline. Although this form of hair loss has been assumed to be related to male pattern baldness, Dr. Norwood and I published a paper, which brought this belief into question. If we are correct, perhaps this should not be simply considered the same disease just in different sexes.

Some of the pertinent points of the paper include:

  • Male pattern baldness begins with the recession of the hairline and results in complete hair loss across the top of the scalp. Female pattern baldness causes diffuse thinning behind the hairline but there is no recession of the hairline.
  • Male pattern baldness begins in the late teens and early twenties when the testosterone levels are high. Female pattern hair loss tends to begin in the late thirties and reaches its peak after fifty when testosterone levels are falling.
  • Male pattern hair loss affects up to 70% of all males. Female pattern hair loss affects up to 30% percent of women.
  • Females with a predisposition for male pattern hair loss rapidly develop typical male pattern baldness if given high doses of testosterone.
  • There has been a report describing a young women with hypopituitarism who presented with clinical and histological features of female pattern baldness in the absence of detectable levels of circulating androgens (testosterone and other male hormones) showing this pattern of hair loss is not androgen dependent.
  • Treatment with Propecia, a medication that blocks the conversion of testosterone to 5-DHT, certainly helps male pattern hair loss, but has no effect on female pattern hair loss.

Woman with loss of hair in the hairline, the temples, and the crown similar to male pattern baldness. Other females do bald in more of a male pattern with recession of their temples and loss of hair over the vertex of their scalps. This form of hair loss has many similarities with standard male pattern baldness and can be exacerbated by androgen (testosterone) hormonal therapy.

As just mentioned, Propecia appears to be largely ineffective for women's hair loss. If a woman has more of a male pattern hair loss and has elevated androgenetic hormones confirmed with a laboratory evaluation, Propecia can be helpful. I would stress, however, that this is not a common occurrence. Rogaine is effective at halting further loss, but if there is regrowth, it tends to only be short and fuzzy hair. I urge my female patents to consider the use of 5% Rogaine labeled "For Men Only" rather than the 2% for women. It is a more effective concentration and, in my opinion, poses no serious threats. Side effects, specifically developing an itchy red scalp, may be more common with the 5% formulation. It is my understanding that the F.D.A. is considering approval of the 5% Rogaine for women in the near future. In other countries, various androgen blocking medications are available to women, but in the U.S. we resort to spironolactone (Aldactone). This heart medicine has been found to block some of the activity of the circulating androgens. Since some forms of female pattern baldness do not seem to be driven by androgens, this might be useful only in a percentage of patients. Patients must not become pregnant while using spironolactone. Side effects may include breast tenderness, irregular menses and mood swings. Both Rogaine and spironolactone must be continued indefinitely to remain effective.

Important differences do exist between transplantations in men and women. If I give a man any hair, he is happy. He may wish for full thickness, but he understands that most men have some hair loss and anything he can get back into the balding areas helps. A woman, on the other hand, frequently will not be happy unless she has the appearance of full thickness after a transplant. To most women, getting some hair back to give a thinning look is still unacceptable. If a woman's hair loss is even moderately advanced, hair transplants may not be able to deliver the thickness she desires. I turn many more female than male patients away after consultation for this very reason.

If a woman's hair loss is not too advanced, and she is willing to use Rogaine indefinitely, frequently we can come to a compromise. If the patient will settle on a particular hairstyle, often I will be able to concentrate the follicular units in the area where they are most needed. The most common example of this occurs with Ludwig type I and II patients. If I can convince the patient not to wear bangs, but instead let the hair remaining in the hairline grow long and then use that hair pulled back over the balding area in a style that keeps it in place, I will then concentrate the follicular units in a zone directly behind the hairline to give the hair being pulled back more fullness. Just like with men, if they will either color or not color their hair so as to decrease the color contrast between their hair and scalps, they will discover their hair loss is much less noticeable. If they are willing to use the remaining hair in specific styles to help cover the areas of hair loss, then I will recommend increasing the length and curl of the hair to add volume. Women typically have a remarkable ability to style their remaining hair and conceal their hair loss. If women who understand these issues can even get a little extra hair, they are very grateful.

If a woman now has, or potentially will have significant hair loss, the transplant will possibly need to be concentrated in specific areas and combined with specific hair styles. In most cases the transplant is concentrated in the front behind the hairline and the patient will then let the hair in front grow long and use it pulled back over the thinning area.

Another big difference between men and women is in telogen hair loss (loss of preexisting hair due to the shock of surgery) in the transplanted areas. As noted before, in men this loss is unusual, occurring in perhaps 5 to 10% of cases. In women, however, I see it, to some degree, in perhaps 25 to 50% of cases. I stress to the patient that if it is healthy hair that is lost, it will return, albeit in four to eight months. If it was hair that had miniaturized, it might not return at all. I emphasize that if this telogen loss occurs, the scalp will look even more bald for three to five months then before the operation. After that, the transplanted hair begins to grow. The other hair that fell out slowly begins to return soon thereafter. I further explain that there is no way to determine in whom this will occur. I have transplanted some women in whom it occurred one time and not the other. It is a risk that the female patient must assume. If it occurs, and the woman was made aware of this possibility before hand, she will be much more understanding than if she were not warned of it at all.

I will often use 2 and 3 follicular unit grafts in women for this reason. I feel that with the larger multi-unit follicular unit grafts and the reduction in the number of needle sticks necessary to plant them by 50% or more, there is less risk of a telogen phenomenon occurring. I do stress to the patient that there could be some plugginess with this technique if she loses much additional hair in the future. Most women tell me they are willing to assume this risk because if they lose much more hair anyway, they plan on wearing a wig. If they do decide to have me transplant the larger multi-unit follicular unit grafts, I still utilize single follicular units for any hairline work.

One final disadvantage women must accept is the possibility of having a more limited donor area. Men typically have good hair remaining on the sides of their scalps above their ears. Unfortunately, many women will have thin hair in this area making it unsuitable for transplantation.Otherwise, women can be great candidates. Just like with men, it depends on the degree of hair loss, the quality of remaining hair, and their expectations.