Does PCOS Cause Hair Loss?
Yes, polycystic ovary syndrome (PCOS) directly causes female pattern hair loss (androgenic alopecia) in reproductive-age women through androgen-mediated effects on scalp hair follicles, occurring in addition to—and distinct from—the more commonly recognized hirsutism (excessive body/facial hair growth). 1, 2, 3
Understanding Hair Loss in PCOS
Two Distinct Hair Manifestations
PCOS produces opposite effects on hair depending on anatomic location due to varying androgen receptor sensitivity: 3
Scalp hair (androgenic alopecia): Androgens miniaturize hair follicles, causing progressive thinning and loss in a female pattern distribution (diffuse thinning over the crown and frontal scalp with preservation of the frontal hairline). 1, 3
Body/facial hair (hirsutism): The same androgens stimulate terminal hair growth in androgen-sensitive areas (face, chest, abdomen, back). 2, 3
Pathophysiology
Elevated androgens (testosterone, androstenedione, DHEAS) in PCOS act on genetically susceptible scalp hair follicles, shortening the anagen (growth) phase and prolonging the telogen (resting) phase, resulting in progressive miniaturization and eventual hair loss. 3
Female pattern hair loss can occur even with normal biochemical androgen levels, indicating that local tissue sensitivity and peripheral androgen metabolism play critical roles beyond serum measurements. 1
Clinical Significance
Androgenic alopecia is one of the three cardinal dermatologic manifestations of hyperandrogenism used in PCOS diagnostic criteria (along with hirsutism and acne), and may provide an early clinical clue to the diagnosis. 2, 3, 4
Hair loss significantly impairs quality of life and psychological wellbeing in PCOS patients, warranting specific therapeutic attention. 2, 5
Diagnostic Approach
Clinical Assessment
Evaluate for diffuse thinning over the crown and frontal scalp with preservation of the frontal hairline (Ludwig pattern), distinguishing it from other causes of alopecia. 1, 3
Document the presence of other hyperandrogenic signs: hirsutism (Ferriman-Gallwey score), acne, and acanthosis nigricans. 2, 3, 4
Laboratory Evaluation
Measure androgens even if hair loss is the only presenting symptom: 4
Total testosterone and free testosterone (preferably by LC-MS/MS): Total testosterone shows 74% sensitivity and 86% specificity; free testosterone shows 89% sensitivity and 83% specificity for PCOS. 6
DHEAS to assess adrenal androgen contribution (sensitivity 75%, specificity 67%). 6
Androstenedione if testosterone is normal but clinical suspicion remains high (sensitivity 75%, specificity 71%). 6
Complete the PCOS diagnostic workup: 4
TSH and prolactin to exclude thyroid disease and hyperprolactinemia. 6
Fasting glucose and 2-hour oral glucose tolerance test (75g load). 6, 4
Fasting lipid panel (total cholesterol, LDL, HDL, triglycerides). 6, 4
Pelvic ultrasound for polycystic ovarian morphology (≥20 follicles per ovary or ovarian volume ≥10 mL). 6
Critical Pitfall
Do not dismiss PCOS as the cause of hair loss based solely on normal androgen levels—local tissue sensitivity and peripheral conversion can drive androgenic alopecia despite normal serum values. 1
Treatment Algorithm
Step 1: Mandatory Lifestyle Modification (All Patients)
Target 5–10% weight loss through a 500–750 kcal/day energy deficit, which improves metabolic parameters, reduces circulating androgens, and may slow hair loss progression. 7, 2, 4
Exercise ≥150 minutes/week of moderate-intensity activity plus resistance training twice weekly. 7
Implement behavioral strategies (goal-setting, self-monitoring, relapse prevention). 7
Step 2: First-Line Pharmacotherapy
For women NOT attempting pregnancy: 7, 4
Combined oral contraceptives (COCs) are first-line therapy: 7, 2, 4
- Suppress ovarian androgen production
- Increase sex hormone-binding globulin (SHBG), reducing free testosterone
- Provide endometrial protection
- Require 3–6 months to assess response
Add metformin 850 mg three times daily (titrated as tolerated) to: 7
- Improve insulin sensitivity
- Lower circulating androgens
- Promote modest weight loss
- Enhance metabolic parameters
Step 3: Add Anti-Androgen if Hair Loss Persists
If androgenic alopecia remains bothersome after 3–6 months of optimal COC therapy: 7
Add spironolactone 50–100 mg daily: 7
- Blocks androgen receptors at the hair follicle
- Inhibits peripheral testosterone synthesis
- Requires 6 months to see clinical improvement
- Must be combined with effective contraception (teratogenic risk)
- Baseline serum potassium required; routine monitoring unnecessary in young, healthy women without comorbidities
The COC + spironolactone combination is synergistic and more effective than either agent alone, with the COC mitigating menstrual irregularities caused by spironolactone. 7
Step 4: Adjunctive Hair-Specific Therapies
These address the symptom but not the underlying hormonal cause: 8, 2
Topical minoxidil 2% or 5% applied twice daily to the scalp (may take 4–6 months for visible results). 2
Low-level laser therapy and platelet-rich plasma are emerging second-line options with limited efficacy data. 1
Laser hair removal for concomitant hirsutism requires multiple sessions and should be combined with systemic anti-androgen therapy for optimal results. 8
Critical Treatment Pitfalls
Do not use topical minoxidil alone without addressing the underlying hyperandrogenism—hair loss will progress despite cosmetic improvement. 8, 2
Do not add spironolactone before 3 months of COC therapy unless hair loss is severely impairing quality of life. 7
Never prescribe spironolactone without confirmed effective contraception due to feminization risk in male fetuses. 7
Do not discontinue the COC when adding spironolactone—maintaining both agents yields superior efficacy and tolerability. 7
Long-Term Monitoring
Every 6–12 months, assess: 7
Oral glucose tolerance test to screen for progression to type 2 diabetes. 7
Fasting lipid panel to track cardiovascular risk. 7
Blood pressure measurement. 7
Body weight and BMI. 7
Clinical response of hair loss (photographic documentation helpful). 5
Special Considerations
Pregnancy Planning
Discontinue spironolactone before attempting conception (teratogenic; does not impair fertility). 7
Metformin is safe during pregnancy per ACOG guidelines, though not routinely recommended solely for preventing gestational complications. 7
Achieve 5% pre-pregnancy weight loss if overweight, which improves metabolic and reproductive outcomes. 7