What treatment is appropriate for diffuse scalp hair loss after switching from Ryeqo (medroxyprogesterone) to Mirena (levonorgestrel) and starting levothyroxine, with a Thyroid-Stimulating Hormone (TSH) level of 1.5, mild iron deficiency (ferritin 54.8, transferrin saturation 25%), and vitamin D insufficiency (34 ng/mL)?

Treatment for Diffuse Scalp Hair Loss After Hormonal Transition

Your hair loss is most likely telogen effluvium triggered by the hormonal shift from Ryeqo to Mirena, and you should optimize your iron stores with supplementation while stopping copper, as your ferritin of 54.8 is suboptimal for hair regrowth and copper excess can paradoxically worsen hair loss.

Immediate Actions Required

Stop Copper Supplementation

• Copper supplementation should be discontinued immediately, as excess copper can interfere with zinc absorption and contribute to hair loss, particularly when you're already taking zinc supplementation
• The temporal relationship between starting copper and hair loss onset is highly suggestive of copper-induced telogen effluvium
• Continue zinc supplementation, as it supports hair growth and thyroid function

Optimize Iron Status

• Your ferritin level of 54.8 ng/mL is insufficient for optimal hair regrowth, even though it's technically "normal"
• Target ferritin levels of at least 70-80 ng/mL for hair regrowth, with some experts recommending >100 ng/mL for women with hair loss
• Your transferrin saturation of 25% is at the lower end of normal, confirming functional iron deficiency
• Supplement with oral iron (ferrous sulfate 325 mg daily or every other day) taken with vitamin C for enhanced absorption

Address Vitamin D Insufficiency

• Your vitamin D level of 34 ng/mL is insufficient; optimal levels for thyroid autoimmunity and hair health are >40 ng/mL
• Increase your vitamin D supplementation to 4000-5000 IU daily to achieve levels of 50-60 ng/mL 1
• Vitamin D supplementation may reduce thyroid autoimmunity if you have Hashimoto's thyroiditis, which could be contributing to hair loss 1
• Continue K2 supplementation alongside vitamin D for optimal calcium metabolism

Thyroid Management Assessment

Current Thyroid Status

• Your TSH of 1.5 mIU/L is optimal and within the reference range, indicating adequate levothyroxine dosing 2
• No adjustment to levothyroxine is needed at this time, as your thyroid function is well-controlled 2, 3
• Monitor TSH every 6-12 months or if symptoms change 2

Levothyroxine and Hair Loss Connection

• Levothyroxine itself, when properly dosed, does not cause hair loss 4, 5
• Both hypothyroidism and hyperthyroidism can cause hair loss, but your euthyroid state (TSH 1.5) makes this unlikely 3
• Continue current levothyroxine dose without modification 2

Understanding the Hormonal Trigger

Ryeqo to Mirena Transition

• Ryeqo (relugolix/estradiol/norethindrone) provides systemic hormonal suppression, while Mirena (levonorgestrel IUD) provides primarily local progestin effects
• This represents a significant hormonal shift that commonly triggers telogen effluvium 2-4 months after the change
• Hair loss from hormonal transitions typically peaks at 3-4 months (matching your timeline) and resolves spontaneously over 6-12 months

Expected Timeline

• Telogen effluvium from hormonal changes typically lasts 3-6 months from onset
• Hair regrowth usually begins 3-4 months after the triggering event resolves
• Full recovery may take 12-18 months as hair cycles normalize

Topical Treatment Consideration

Minoxidil 5% Solution

• Consider starting minoxidil 5% topical solution if hair loss persists beyond 6 months or is causing significant distress 6
• Apply 1 mL twice daily directly to the scalp in areas of hair thinning 6
• Results typically appear at 2-4 months of consistent use, with maximum benefit at 12 months 6
• Allow 4 hours before washing hair after application 6
• Important caveat: Initial increased shedding may occur in the first 2-4 weeks as miniaturized hairs are replaced by healthier ones 6

When NOT to Use Minoxidil

• Do not use if scalp is red, inflamed, infected, irritated, or painful 6
• Discontinue if you experience chest pain, rapid heartbeat, faintness, dizziness, or unwanted facial hair growth 6
• Not recommended if pregnant or breastfeeding 6

Supplement Optimization Protocol

Continue These Supplements

• Zinc: Supports hair growth and thyroid function; continue current dose
• Selenium: Important for thyroid hormone conversion; continue current dose
• Vitamin B12: Supports hair follicle health; continue current dose
• Omega-3: Anti-inflammatory properties support scalp health; continue current dose
• Vitamin D + K2: Increase D to 4000-5000 IU daily as noted above; continue K2

Add Iron Supplementation

• Ferrous sulfate 325 mg daily (or every other day to minimize GI side effects)
• Take with vitamin C (orange juice or supplement) on an empty stomach for best absorption
• Separate from levothyroxine by at least 4 hours
• Recheck ferritin in 3 months with goal of >70-80 ng/mL

Monitoring Plan

Short-term (3 months)

• Recheck ferritin, transferrin saturation, and vitamin D levels
• Assess hair shedding pattern (should be decreasing)
• Continue current levothyroxine dose

Medium-term (6 months)

• Recheck TSH and free T4 2
• Evaluate hair regrowth progress
• Consider adding minoxidil if no improvement

Long-term (12 months)

• Most telogen effluvium resolves by this point
• If persistent hair loss continues, consider dermatology referral for scalp biopsy to rule out other causes

Critical Pitfalls to Avoid

• Do not increase levothyroxine dose based on hair loss alone when TSH is normal, as overtreatment causes more harm than benefit 2
• Do not restart copper supplementation without documented deficiency
• Do not expect immediate results - hair regrowth takes months due to the hair growth cycle
• Do not stop levothyroxine thinking it's causing hair loss, as this will worsen thyroid function 4, 3
• Avoid excessive supplementation of any single nutrient, as this can create imbalances