Workup for Female Androgenetic Alopecia
Routine endocrinologic testing is NOT recommended for most women with androgenetic alopecia unless they present with clinical signs or symptoms of hyperandrogenism. 1
Clinical Assessment
The diagnosis of female androgenetic alopecia (FPHL) is primarily clinical and can be confirmed through:
- Medical history and physical examination focusing on the pattern of hair loss (diffuse thinning of the crown with preserved frontal hairline, Ludwig pattern) 2, 3
- Dermoscopy to identify characteristic features and aid diagnosis 4
- Assessment for signs of hyperandrogenism including hirsutism, oligomenorrhea, infertility, clitoromegaly, truncal obesity, and acne 1, 3
Laboratory Testing Indications
When Testing IS Indicated
Laboratory evaluation should be performed only when patients present with additional signs or symptoms of androgen excess: 1
- Hirsutism 1
- Oligomenorrhea or irregular menstrual cycles 1, 2
- Infertility 1
- Clitoromegaly 1
- Truncal obesity 1
- Severe or persistent acne 1, 3
Recommended Hormonal Panel (When Indicated)
When hyperandrogenism is suspected, order: 1, 4, 2
- Total and/or free testosterone 1, 4
- Dehydroepiandrosterone sulfate (DHEA-S) 1
- Luteinizing hormone (LH) 1
- Follicle-stimulating hormone (FSH) 1
- Thyroid-stimulating hormone (TSH) to rule out thyroid disease 4
- Prolactin if hyperprolactinemia is suspected 4, 2
Additional Testing for Specific Conditions
- Fasting glucose or 2-hour oral glucose tolerance test if polycystic ovary syndrome (PCOS) or insulin resistance is suspected 4, 2
- Fasting lipid panel to evaluate for dyslipidemia associated with PCOS 4
- Pelvic ultrasonography if PCOS is suspected (diagnosis requires 2 of 3: hyperandrogenism, ovulatory dysfunction, or polycystic ovaries) 1
When Testing is NOT Indicated
Routine endocrinologic testing is not recommended for women presenting with typical female pattern hair loss without signs of hyperandrogenism, as most will have normal hormone levels. 1, 2 The association between acne severity and androgen levels remains unclear, and routine testing does not affect management in uncomplicated cases. 1
Common Pitfalls to Avoid
- Over-testing: Ordering extensive hormonal panels in women with isolated FPHL and no signs of hyperandrogenism wastes resources and does not change management 1
- Missing PCOS: Failing to screen for polycystic ovary syndrome in premenopausal women with FPHL plus irregular menses or other hyperandrogenic features 1, 2, 3
- Ignoring psychological impact: Not addressing the significant psychological distress that hair loss causes, which may warrant referral for psychological support 1, 5
Differential Diagnosis Considerations
While the diagnosis is usually straightforward, consider: 1, 4