Female pattern hair loss (FPHL), also called female androgenic alopecia is a diffuse, non-scarring loss of hair. The hair loss is most apparent in the frontal, central, and parietal scalp regions. This condition is most common in adult females and its incidence increases with age. Unfortunately, this disease shows variable responses to treatment.
Not surprisingly, FPHL can lead to low self-esteem, poor body image, depression, and a lower over-all quality of life.
We know that the hair follicle changes in alopecia are similar for men and women, but the presentation and response to therapy is different.
FPHL normally occurs during the reproductive years. The second peak occurs at menopause (50-60 years of age). A study conducted in 2001 found a 3% incidence of FPHL among 1008 Caucasian women in their 30’s. This prevalence increased slowly with age and was 32% in the ninth decade of life. The combined prevalence was 19%.
The first line of treatment for FPHL is Minoxidil (Rogaine). Many are familiar with Rogaine as it has been approved for use in men’s hair-loss since 2006.
We are not completely sure how minoxidil works but it is thought to promote the growth phase of the hair follicle, shorten the resting phase, and enlarge miniaturized follicles.
In 2014, 5% minoxidil was approved for FPHL. Before this, only 2% minoxidil solution was approved for use in women. Studies have shown that once daily application of a 5% foam is as effective as twice daily application of a 2% solution. This is important because once daily application is more convenient for the patient.
There are side effects associated with the use of minoxidil. During the Rogaine clinical trials conducted by Johnson and Johnson, the following side effects were reported in at least 2% of the study participants.
One of the common concerns among women using hair growth products is the worry of hair growing in the wrong places. Hypertrichosis has been reported with both strengths of minoxidil but is significantly less with the 5% foam.
It is recommended that minoxidil be applied at least 2-4 hours prior to bedtime with hands thoroughly washed after application to limit unwanted hair growth on the face.
Although I do own stock in Johnson and Johnson, I currently am not paid for promoting their products. I have included the link to the Rogaine site below as a convenience to my readers. Both 2% solution and 5% unscented foam are available at:
Other Treatment Options
If Minoxidil is ineffective, other medications may be tried. It is important to note that although these secondary treatments may be tried, no conclusive evidence supporting their effectiveness is available. In fact, a Cochrane Review including 47 trials with 5290 subjects, found only minoxidil to be effective for FPHL.
Although evidence is lacking, these systemic treatments are still utilized in some situations. They will be briefly discussed here.
Spironolactone is an aldosterone antagonist. It works by blocking androgen receptors and has some inhibition of androgen synthesis.
It is usually the initial second-line agent employed for FPHL because it is often used in women for other indications such as acne, hirsutism, and polycystic ovarian syndrome. This gives providers more confidence in regards to side effects and tolerability. Spironolactone has limited positive data available for its use in FPHL. One open-label study treated patients with either spironolactone or cyproterone. The average duration of treatment in this study was 16 months. There was not difference between the groups. Forty-four percent of the patients experienced regrowth of hair, forty-four percent showed no change, and twelve percent had continued hair loss.
Finasteride is often used to treat baldness in men. It works by inhibiting the conversion of testosterone to dihydrotestosterone. This medication is usually well tolerated in females and because of the limited options for women who fail minoxidil, it may be another option.
Flutamide has a few studies supporting its usefulness in FPHL. In one prospective cohort study of 101 premenopausal women, flutamide was associated with an average of 15% improvement of hair thickness at six months and 28% at two years.
Another case study found flutamide reversed hair loss in a patient who had failed treatment with a combination of spironolactone and topical minoxidil.
Flutamide is associated with side effects such as decreased libido, GI distress and rarely liver failure. The threat of liver failure has limited flutamide’s use in FPML.
Low-Level Laser Light Therapy (LLLT)
Photobiomodulation therapy, or low-level laser light therapy has also been used to treat FPHL. A study published in 2014 in The American Journal of Clinical Dermatology found a clinically significant difference in terminal hair density between an FDA approved low-level laser product (Lasercomb) and a sham device. This was a randomized, double-blind sham device controlled study of 128 male and 141 female subjects.
The patients who used the Lasercomb also reported an improvement in hair thickness and an overall improvement of their hair loss condition as compared to the sham treated patients.
There were no serious adverse effects reported with the use of the Lasercomb. This device may be a good alternative for hair-loss patients who either do not respond to medications or have adverse effects or contraindications to available treatments.
More information on the Ultima 9 Classic LaserComb can be found at:
When all other treatments fail, hair transplantation surgery is an option. Unfortunately, this is not always effective as transplant failure is possible. This procedure is also costly and time-consuming for the patient. There may also be an increased amount of hair loss early on and pain and infection is also a risk.
PCOS Alopecia Treatment
Polycystic ovarian syndrome (PCOS) alopecia is caused by an increase in male hormones. Treatments for this are the same as those listed above. In addition, birth control pills may be used to help decrease androgen levels. Oral contraceptives not only help with hair loss but also can be effective for the treatment of other PCOS symptoms such as acne and irregular menstruation.
There is evidence that weight loss in women with PCOS can also decrease androgen levels. Even a loss of five to ten percent of body weight can have a significant effect on PCOS symptoms.14
Female pattern hair loss is an unfortunate ailment that increases in prevalence with age. This condition leads to poor self-esteem, a distorted body image, and may even lead to depression. Unfortunately, the treatments available for this disorder are scarce. The only scientifically proven method is topical minoxidil, or Rogaine. Other treatments have been used with some success but are not well supported by the clinical literature.
Please leave any questions or comments below. Thanks for reading, and have a great day!
Michael J. Brown, RPh, BCPS, BCPP
Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.
Feel free to send Michael a message using this link.