What is the recommended evaluation and management for a female patient with possible androgenic (male hormone-related) hair loss?

Evaluation and Management of Female Androgenic Hair Loss

First-Line Treatment

Topical minoxidil 5% applied twice daily is the cornerstone of treatment for female androgenic alopecia and must be continued indefinitely to maintain benefits. 1

Diagnostic Evaluation

Clinical Assessment

• Look for the characteristic pattern: central scalp thinning with preserved frontal hairline (Ludwig pattern) or frontal accentuation (Christmas tree pattern), distinguishing this from diffuse alopecia areata or telogen effluvium 2, 3
• Examine for miniaturized hairs using dermoscopy—these are the hallmark of androgenic alopecia 2
• The scalp should appear normal without inflammatory scaling; if scaling is present, consider seborrheic dermatitis as a separate condition 2

Laboratory Testing Strategy

Endocrine evaluation is mandatory in all patients with female pattern hair loss to assess for androgen excess: 3

• Free and total testosterone
• DHEA-S (dehydroepiandrosterone sulfate)
• Androstenedione 2

Additional recommended testing (though optional): 3

• TSH and free T4 (thyroid disease associates with hair loss) 2
• Serum ferritin (though routine iron testing is not recommended for alopecia areata, it should be checked in androgenic alopecia) 2
• Vitamin D and zinc levels 2
• Prolactin (if menstrual irregularities present) 4

When to suspect polycystic ovarian syndrome (PCOS):

• If testosterone >2.5 nmol/L, consider PCOS or valproate effect 4
• Add LH and FSH if PCOS suspected 2
• Consider pelvic ultrasound for polycystic ovaries (>10 peripheral cysts, 2-8 mm diameter) 4

Treatment Algorithm

For Women WITHOUT Hyperandrogenism

Start with topical minoxidil 5% twice daily 1, 3

Consider adding platelet-rich plasma (PRP) for optimal results:

• Initial phase: 3-5 treatment sessions spaced exactly 1 month apart
• Maintenance phase: 1 session every 6 months
• Dose: 5-7 mL PRP per session at 0.05-0.1 mL/cm²
• PRP combined with minoxidil produces the highest increase in hair density compared to either treatment alone 1

For Women WITH Hyperandrogenism or Severe Hair Loss

Add antiandrogen therapy to topical minoxidil: 3

• Cyproterone acetate (always with oral contraceptive containing ethinylestradiol) 5, 6
• Spironolactone 5, 6, 3
• 5α-reductase inhibitors (finasteride or dutasteride) 3

For specific conditions:

• PCOS with insulin resistance: Add metformin 5
• Adrenal hyperandrogenism: Glucocorticosteroids for adrenal suppression plus antiandrogens 5
• Hyperprolactinemia: Bromocriptine or cabergoline 5
• Postmenopausal women: Consider finasteride 2.5 mg daily or dutasteride even if androgens are normal 5

Monitoring Treatment Response

Schedule formal evaluation at specific intervals: 1

• 3 months initially for minoxidil alone
• 12 months for PRP combination therapy
• Meaningful changes may take 12-24 months 1

Use objective measures to assess response: 1

• Standardized before-and-after photographs
• Trichoscopy to measure hair density and diameter
• Hair pull tests
• Patient self-assessment questionnaires

Positive response indicators: 1

• Increased hair density per cm²
• Increased hair shaft diameter
• Decreased proportion of telogen hairs
• Improved patient satisfaction scores

Critical Pitfalls to Avoid

• Never stop treatment prematurely—hair loss will return to pretreatment status if therapy is discontinued 1, 7
• Do not use unproven supplements without documented deficiencies 1
• Avoid inadequate follow-up—patients need regular monitoring to assess response 1
• Do not overlook psychological impact—counseling and cosmetic camouflage options are essential 1

Advanced Cases

For severe or treatment-resistant cases: 1, 6

• Hair transplantation should be considered
• Hair systems or prostheses may be appropriate
• Weight loss improves outcomes in hyperandrogenic women 5