How to manage a woman in her 40s with hair loss?

Management of Hair Loss in a Woman in Her 40s

Begin with a focused clinical examination to determine the pattern of hair loss—diffuse central thinning with preserved frontal hairline suggests androgenetic alopecia (the most common cause), while discrete patches indicate alopecia areata—and this distinction drives all subsequent management decisions. 1

Initial Clinical Assessment

Key History Elements

• Duration of hair loss: Onset <1 year suggests better prognosis with potential spontaneous remission in 34-50% of alopecia areata cases 1, 2
• Pattern recognition: Diffuse thinning over central scalp with preserved frontal hairline indicates androgenetic alopecia, while discrete patches suggest alopecia areata 1
• Medication history: Specifically ask about chemotherapy or drugs causing anagen effluvium 1
• Associated symptoms: Ask about irregular periods, acne, or hirsutism (suggesting androgen excess), and psychological stress 1, 3

Physical Examination Findings

• Look for exclamation mark hairs (short broken hairs at patch margins)—these are pathognomonic for alopecia areata and can be identified with dermoscopy 1, 4
• Assess for scalp inflammation or scaling: This suggests tinea capitis or scarring alopecia rather than androgenetic alopecia or alopecia areata 1
• Check for signs of androgen excess: Acne, hirsutism, or male-pattern distribution 1

Laboratory Testing Strategy

Investigations are unnecessary in most cases when the diagnosis is clinically evident. 1, 2 However, targeted testing is appropriate when:

• Check serum ferritin in all women with hair loss—iron deficiency accounts for 70% of female alopecia cases, and optimal ferritin ≥60 ng/mL is needed for hair growth 1, 3
• TSH and free T4 should be checked, as thyroid disease commonly causes hair loss 1
• Vitamin D and zinc levels if deficiency is suspected 1
• Total testosterone, free testosterone, and SHBG only if signs of androgen excess are present (acne, hirsutism, irregular periods) 1
• Avoid ordering extensive autoimmune panels in straightforward cases 1, 2

Common Pitfall

The corresponding ferritin level for female anemia (Hb 12.0 g/dL) is only 5.1 ng/mL, which is far below the adequate level for hair growth (40-60 ng/mL). Women can have significant iron deficiency affecting hair growth while still having "normal" hemoglobin levels. 3

Treatment Algorithm Based on Diagnosis

For Androgenetic Alopecia (Most Common in Women in Their 40s)

Topical minoxidil 2% solution twice daily is the first-line treatment—it arrests progression rather than stimulates regrowth. 1, 4

• This is the only FDA-approved topical treatment for female androgenetic alopecia 5, 6
• Set realistic expectations: minoxidil primarily prevents further loss rather than causing dramatic regrowth 1
• If signs of androgen excess are present, consider systemic antiandrogen therapy with cyproterone acetate (always with contraceptives), spironolactone, or finasteride 7
• Platelet-rich plasma (PRP) injections show promise with increased hair density in clinical trials, requiring repeated treatments every 6 months 1, 4

For Limited Patchy Alopecia Areata

Watchful waiting with reassurance is a legitimate first option, as 34-50% recover within one year without treatment. 1, 2, 4

If treatment is desired:

• Intralesional corticosteroids (triamcinolone acetonide 5-10 mg/mL) are the treatment of choice, with 62% achieving full regrowth with monthly injections 2, 4
• Best response occurs in patients with fewer than five patches <3 cm in diameter 2
• Counsel that regrowth cannot be expected within 3 months of any individual patch development 1, 2
• Skin atrophy at injection sites is a consistent side effect 2

For Extensive Alopecia Areata

Contact immunotherapy is the best-documented treatment but has <50% response rate and requires multiple hospital visits over months. 8, 1, 4

• This is the only treatment likely to be effective in alopecia totalis/universalis, though response rates are even lower 8
• Wigs provide immediate cosmetic benefit and are often the most effective solution for extensive alopecia areata 8, 2, 4

For Iron Deficiency-Related Hair Loss

Initiate iron supplementation within 6 months for better prognosis, targeting ferritin ≥60 ng/mL (corresponding Hb ≥13.0 g/dL). 3

• Disease duration is an important prognostic factor—earlier treatment yields better outcomes 3
• Patients with subjective improvement of hair regrowth show greater increases in ferritin levels after supplementation 3

Treatments to Avoid

Do not use potent topical corticosteroids for alopecia areata—there is no convincing evidence of effectiveness. 8, 1, 2

• Avoid systemic corticosteroids or PUVA due to potentially serious side effects and inadequate efficacy evidence 8, 2, 4
• Oral zinc and isoprinosine are ineffective in controlled trials 8, 2
• Avoid excessive biotin supplementation due to potential diagnostic test interferences 5

Essential Counseling Points

• No treatment alters the long-term course of alopecia areata, though some can induce temporary hair regrowth 1, 2
• Alopecia areata has no direct impact on general health, so balance psychological effects against treatment risks 2
• Address psychological impact: Hair loss can cause anxiety, depression, and social difficulties requiring psychological support 2, 4
• Consider referral for psychological support if significant distress is present 4

Follow-Up Recommendations

• Schedule follow-up at 3 months to assess treatment response 4
• Monitor ferritin and hemoglobin levels every 3 months if treating iron deficiency 3
• Provide written instructions for self-monitoring 4