Normal Hair Loss in a 64-Year-Old Woman
Losing 50-100 hairs per day is physiologically normal, and what this patient describes—hair coming off with brushing and noticing hair around the house without clumps or bald spots—falls within the expected range for a postmenopausal woman. 1, 2
What This Patient Is Experiencing
This presentation is consistent with normal daily hair shedding, which becomes more noticeable in postmenopausal women due to age-related changes in hair density and diameter. 3, 2
The absence of large clumps, bald spots, or patchy loss makes pathologic alopecia (such as alopecia areata or severe telogen effluvium) unlikely. 1, 4
Hair loss affects over 50% of postmenopausal women, with up to 40% experiencing some degree of frontal/parietal thinning, so this patient's concern is common for her age group. 3
When Normal Shedding Becomes Pathologic
The key distinguishing features that would indicate a problem requiring workup include:
Diffuse thinning over the central scalp with widening of the part suggests androgenetic alopecia (female pattern hair loss), the most common pathologic cause in this age group. 1, 4, 2
Discrete circular patches with exclamation mark hairs (short broken hairs at margins) would indicate alopecia areata. 1, 5
Scalp inflammation, scaling, or scarring suggests tinea capitis or cicatricial alopecia requiring immediate evaluation. 1, 4
Sudden increase in shedding over weeks to months following a stressor (illness, surgery, medication change) suggests telogen effluvium. 5, 2
Clinical Approach
Reassurance is appropriate when:
- Hair loss is gradual and has been stable
- No visible thinning or bald patches are present on examination
- The patient can still achieve her usual hairstyle
- No systemic symptoms are present 1, 2
Further evaluation is warranted if:
- The patient or clinician observes visible scalp through the hair, particularly at the crown or part
- There is a positive hair pull test (>6 hairs easily extracted from different scalp areas)
- Associated symptoms suggest systemic disease (fatigue, weight changes, irregular periods if perimenopausal) 1, 2
Common Pitfalls to Avoid
Do not order extensive laboratory panels (autoimmune workup, hormone panels) when the clinical examination shows no evidence of pathologic hair loss. 1, 5
Do not dismiss the patient's psychological distress—even normal age-related changes can significantly impact quality of life and may warrant counseling or cosmetic interventions. 6, 4, 2
Recognize that increased hair shedding noticed during brushing often reflects increased awareness rather than increased loss, particularly when no objective thinning is visible. 2
If Pathologic Hair Loss Is Suspected
Laboratory testing should be targeted based on clinical findings:
Serum ferritin (goal ≥60-70 ng/mL for optimal hair growth) if chronic telogen effluvium or diffuse thinning is present 1, 7
TSH and free T4 if thyroid disease is suspected based on systemic symptoms 1, 5
Vitamin D level if deficiency is suspected, as 70% of alopecia areata patients are deficient versus 25% of controls 5
Testosterone, free testosterone, and SHBG only if signs of androgen excess (acne, hirsutism) are present 1