What is the etiology and treatment of alopecia in a post-menopausal woman?

From the Guidelines

Alopecia in post-menopausal women is primarily caused by endocrine-related alopecia, specifically estrogen-induced alopecia (EIA), which is characterized by grade 1 alopecia on the crown of the scalp and recession of the frontal and bitemporal hairline. This condition is more frequent in post-menopausal women receiving aromatase inhibitors (AIs) and usually develops between 6 and 18 months after therapy initiation 1. The etiology of EIA involves the miniaturization of hair follicles and a decreased anagen-to-telogen ratio, which can be exacerbated by hormonal changes during menopause.

Some key factors to consider in the diagnosis of alopecia in post-menopausal women include:

• Laboratory testing to rule out differential diagnoses, such as thyroid gland function, iron stores, vitamin D, and zinc levels 1
• Examination for female-pattern hair loss, alopecia areata, or inflammatory (scarring) alopecia 1
• Assessment of hair follicle miniaturization and anagen-to-telogen ratio to confirm EIA

Treatment of EIA in post-menopausal women may involve:

• Topical minoxidil 5% solution or foam applied twice daily to the affected areas to prolong the growth phase of hair follicles and increase blood flow to the scalp
• Oral anti-androgens like spironolactone (50-200 mg daily) to block the effects of androgens on hair follicles
• Platelet-rich plasma injections administered every 3-6 months to promote hair growth
• Nutritional support with iron supplementation and daily biotin 2.5-5 mg to promote hair growth and prevent further hair loss.

From the Research

Etiology of Alopecia in Post-Menopausal Women

• The etiology of alopecia in post-menopausal women is complex and multifactorial, with hormonal changes playing a significant role 2, 3.
• The reduction in ovarian hormones and increased androgen levels during menopause can manifest as hair and skin disorders, including alopecia 3.
• Female pattern hair loss (FPHL) or androgenic alopecia is the most common type of hair loss affecting women, with reduced hair density and a serious psychological impact 4.

Treatment of Alopecia in Post-Menopausal Women

• Current therapies aim to rectify underlying hormonal imbalances and improve cosmetic appearance, but there is little evidence to support treatment for these disorders specifically in post-menopausal women 3.
• Anti-hormonal therapy (e.g. cyproterone acetate, spironolactone) is helpful in treating female pattern alopecia in some women who have normal hormone levels 2.
• Minoxidil is approved for treating female androgenetic alopecia, and studies have shown that it can increase hair regrowth compared to placebo 4.
• Other treatments, such as finasteride and dutasteride, have been tried in post-menopausal women with normal hormone levels, but larger controlled studies are needed to fully define their role and place in treatment 2, 5.

Associated Factors

• Vitamin D deficiency has been associated with autoimmune diseases, including alopecia areata, but its role in post-menopausal alopecia is not well established 6.
• Hormonal changes, such as increased androgen levels, are thought to contribute to the development of alopecia in post-menopausal women 2, 3.