How do I determine if my nutritional hair loss has an androgenic component?

Determining Androgenic Component in Nutritional Hair Loss

To determine if your nutritional hair loss has an androgenic component, you need to assess for the characteristic pattern of hair loss (frontal/vertex thinning in men, central thinning with preserved frontal hairline in women), obtain specific laboratory testing including total or free testosterone levels, and evaluate for clinical signs of androgen excess such as acne, hirsutism, or menstrual irregularities. 1, 2

Clinical Pattern Recognition

The distribution of hair loss is your first diagnostic clue:

• Androgenetic alopecia (AGA) presents with a reproducible pattern: temples, vertex, and mid-frontal scalp in males (Hamilton-Norwood classification), or central region thinning with preserved frontal hairline in females (Ludwig system) 1, 2
• Nutritional hair loss (telogen effluvium) typically manifests as diffuse, chronic hair shedding without a specific pattern 3, 4
• If you observe both diffuse thinning AND patterned loss, both mechanisms may be contributing 4

Essential Laboratory Workup

Order these tests to differentiate nutritional from androgenic causes:

For Nutritional Assessment:

• Serum ferritin (most important single test for iron stores; levels ≤15 μg/L confirm iron deficiency with 98% specificity in women of childbearing age) 3, 5
• Complete blood count (CBC) to assess for anemia and mean corpuscular volume 5
• Transferrin saturation (less affected by inflammation than ferritin; critical if ferritin appears normal but iron deficiency suspected) 5
• Thyroid-stimulating hormone (TSH) to exclude thyroid disease 1, 5
• Vitamin D, folate, and vitamin B12 levels 1, 5

For Androgenic Assessment:

• Total testosterone or bioavailable/free testosterone levels to detect ovarian hyperandrogenism 1
• Fasting glucose and 2-hour oral glucose tolerance test (women with polycystic ovary syndrome have increased risk of diabetes) 1
• Fasting lipid panel (dyslipidemia frequently accompanies androgenic conditions) 1

Physical Examination Findings

Look for these specific signs of androgen excess:

• Acne, male-pattern balding, or clitoromegaly 1
• Distribution and excess of body hair (hirsutism) 1
• Acanthosis nigricans (velvety, hyperpigmented skin in neck folds, axillae, beneath breasts, or vulva—indicates insulin resistance) 1
• Enlarged ovaries on pelvic examination 1
• Signs suggesting other causes: buffalo hump, moon facies, hypertension, abdominal striae (Cushing's syndrome) 1

Critical History Elements

Document these specific details:

• Onset and duration of hair loss and any signs of androgen excess 1
• Menstrual history (chronic anovulation suggests polycystic ovary syndrome) 1
• Medication use, particularly exogenous androgens 1
• Family history of cardiovascular disease, diabetes, and hair loss patterns 1, 2
• Lifestyle factors: diet quality, recent weight loss, restrictive eating, alcohol use 1, 6

Interpretation Pitfalls

Avoid these common diagnostic errors:

• Ferritin can be falsely elevated during infection, inflammation, or chronic disease, potentially masking true iron deficiency 5
• If ferritin is "normal" (15-60 ng/mL) but you have microcytic anemia or low mean corpuscular volume, iron deficiency may still be present—check transferrin saturation and serum iron/total iron-binding capacity 5
• Women with coexisting signs of polycystic ovary syndrome require screening for ovarian or adrenal disorders (late-onset congenital adrenal hyperplasia) 1, 2

Diagnostic Algorithm

Follow this sequence:

1. Assess hair loss pattern visually and with photography—patterned suggests androgenic, diffuse suggests nutritional 1, 4
2. Obtain baseline labs: CBC, ferritin, transferrin saturation, TSH, total/free testosterone, fasting glucose, lipid panel 1, 5
3. If testosterone elevated or signs of hyperandrogenism present: pursue 2-hour glucose tolerance test and consider pelvic ultrasound for polycystic ovaries 1
4. If ferritin <30 ng/mL: diagnose iron deficiency as contributing factor (even if not anemic) 3
5. Consider tissue transglutaminase antibodies if unexplained iron deficiency found (celiac disease screening) 5

When Both Conditions Coexist

Nutritional deficiencies and androgenetic alopecia frequently overlap:

• Iron deficiency has been associated with lower ferritin levels in patients with androgenetic alopecia, suggesting it may be an initiating or exacerbating factor 1
• Correcting iron deficiency may lead to better treatment responses in androgen-dependent alopecia 1
• Address both conditions simultaneously: treat nutritional deficiencies while initiating androgen-targeted therapy (minoxidil for both sexes, finasteride for men, antiandrogens for women) 2, 4