Can Polycystic Ovary Syndrome (PCOS) with elevated testosterone levels cause hair loss?

PCOS with Elevated Testosterone Can Cause Hair Loss

Yes, polycystic ovary syndrome (PCOS) with elevated testosterone levels can cause hair loss, specifically androgenic alopecia (female pattern hair loss). 1, 2

Mechanism of Hair Loss in PCOS

Hyperandrogenism, present in approximately 75% of PCOS cases, is both a diagnostic criterion and a well-established contributor to the pathogenesis of PCOS 1. The elevated androgens in PCOS can manifest as:

• Female pattern hair loss (FPHL) - characterized by reduction of hair density in the central area of the scalp, while the frontal hairline is generally preserved 2
• Hirsutism (excessive hair growth in male-pattern distribution)
• Acne

The hair loss occurs because elevated testosterone and other androgens can:

1. Miniaturize hair follicles on the scalp
2. Shorten the growth phase of hair
3. Lead to progressively finer, shorter, and less pigmented hair

Diagnosis of Androgen-Related Hair Loss

When evaluating PCOS patients with hair loss:

• Look for the typical patterns of FPHL: centrifugal expansion in the mid-scalp or a frontal accentuation/Christmas tree pattern 2
• Assess for biochemical hyperandrogenism through laboratory testing
• According to the Androgen Excess and PCOS Society, assessment of androgen excess is mandatory in all patients with FPHL 2

Laboratory Testing

The most accurate androgen measurements include:

• Total testosterone (TT)
• Free testosterone (FT)
• Sex hormone-binding globulin (SHBG)
• Free androgen index (FAI)
• Other androgens that may be elevated: androstenedione, dehydroepiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DHEAS) 1, 3

Treatment Options

For PCOS patients with hair loss due to elevated androgens, treatment should target both the underlying hormonal imbalance and the hair loss directly:

1. First-line therapy: Combined oral contraceptives (COCs) 4

   • COCs increase SHBG, which binds free testosterone, reducing its activity
   • This leads to decreased androgen effects, including improvement in hair loss
   • Studies show COCs can increase SHBG binding capacity five-fold and significantly depress total and free testosterone levels 5

2. Anti-androgen treatments:

   • Spironolactone 100 mg daily can improve androgen-related symptoms, though visible improvement typically takes 6 months 4, 6
   • 5α-reductase inhibitors may be added for severe hair loss 2

3. Topical treatments:

   • Minoxidil 5% is recommended as first-line topical treatment for FPHL 2

4. Lifestyle modifications:

   • Weight loss of 5-10% in overweight/obese PCOS patients can improve hormonal parameters 4
   • Regular physical activity (150 min/week moderate intensity or 75 min/week vigorous) 4
   • Low glycemic index diet rich in fiber and omega-3 fatty acids 4

Important Considerations and Caveats

• Persistence of the problem: Unless the underlying cause of PCOS is addressed, medical therapy for hair loss will need to be continued indefinitely 6
• Timing of improvement: Hair regrowth is slow, and patients should be counseled that visible improvement may take 6 months or longer
• Comprehensive approach: Treatment should address both the cosmetic concern of hair loss and the underlying hormonal imbalance
• Monitoring: Regular follow-up every 6 months with hormone level assessment is crucial for managing PCOS patients 4
• Pregnancy considerations: Many treatments for PCOS-related hair loss (particularly anti-androgens) are contraindicated in pregnancy, so effective contraception is essential if these medications are used in women of reproductive age

Recent research has identified novel androgen pathways that may contribute to hyperandrogenism in PCOS, including the backdoor pathway and C11-oxy pathway, which may provide future therapeutic targets 3.