Why does PCOS cause hair loss?
PCOS is considered a set of symptoms (this is why it is referred to as a syndrome) that likely reflects a state of excess androgens, or male hormones, in women. Although in younger women we often think about hirsutism, or excess hair growth in “unwanted” areas such as the upper lip, chin, or chest area as one of the symptoms of PCOS, it is true that women may also experience hair loss in the scalp. The pattern of hair loss may be similar to a male pattern of hair loss and tends to focus on the frontal scalp but can include the vertex as well. This can be subtle at first or some women may initially just think they are losing their hair from stress or other factors and not realize that this type of hair loss, especially early in life, can be the symptom of a hormonal imbalance. It can also be subtle as you may still see hair, however the quality of the hair has changed dramatically. The hair becomes fine, wispy, light or white, and unmanageable.
Is this a common occurrence for women dealing with PCOS?
A large published review of the medical literature found that hair loss has been reported in as many as 20 to 30% of women with PCOS (https://academic.oup.com/jcem/article/104/7/2875/5342938?login=true)
However, I suspect that this number may be somewhat low or under reported since the hair loss is not always obvious in the initial stages. The challenge I have found is that I rarely hear women with PCOS complain of a “shedding phase” the way we do with stress induced hair loss or Telogen Effluvium. Many times the hair loss is noted by family members, friends or hair dressers once it has progressed enough to be somewhat more obvious. The clinical diagnosis of hair loss can be considered a subjective finding in that it is based on the patient’s perception. A more scientific approach would be to consider a scalp biopsy to see if there is an alteration in the ratio of hairs in the growth and resting phases.
What is the relation to androgenic alopecia?
PCOS can trigger a pattern of hair loss similar to androgenic alopecia however not all women with androgenic alopecia have PCOS. Although PCOS can result in hair thinning or loss as a manifestation of androgen excess, androgenic alopecia or female pattern hair loss does not necessarily result from excess androgens as this has not been consistently seen. It is possible that female pattern hair loss is more related to the loss of estrogen’s impact on hair growth.
(Note: There is a push to call hair loss in women Female Pattern Hair Loss to avoid assuming its purely androgen related and/or purely genetic. The reason is because women unfortunately seemed to get put into categories that make some physicians less inclined to give them the benefit of the doubt and rule out other treatable causes of hair loss that occur in the same pattern. They are frustratingly told there is not much they can do and it is incredibly upsetting to women and to myself and other dermatologists who know that if the diagnosis is accurate and made early we can often intervene to at least stop progression of hair loss.)
What are the symptoms of PCOS-related hair loss?
The pattern and process of hair loss is notable in PCOS.
The pattern of hair loss is generally one of two patterns :
- Accentuation of the christmas tree distribution of hair loss: This is when women lose hair along their frontal scalp. When they part their hair down the middle, the part is widened and irregular.
- Loss along the vertex or crown that expands outwards.
The process of hair loss starts as a change in the quality of hair. Women will often say they feel like their hair used to be coarser or thicker. Although there is still hair present, it’s of a finer wispier or frizzier quality that makes it difficult to manage. Many women will say that they know their hair and they know it's different!
How is PCOS-related hair loss diagnosed?
PCOS is generally diagnosed by meeting a set of criteria based on symptoms, with at least 2 of the 3 being met.
- Menstrual irregularities : This can be missed, irregular or loss of a menstrual cycle.
- Cysts on the ovaries (hence, polycystic ovaries) : diagnosed by ultrasound
- Signs of androgen excess: This is the category for hair loss - it can be patterned hair loss of the scalp but is more commonly hair growth of the upper lip, chin, chest, and/or abdomen (also known as hirsutism). Acne is included in this category as well.
To meet a diagnosis of PCOS related hair loss, at least one of the first two criteria would need to be met along with hair loss in a patterned distribution to suggest a sign of androgen excess. It would of course be helpful to see other signs of androgen excess in terms of acne or hirsutism to fulfil the 3rd category..
How is it treated?
The hair loss associated with PCOS is generally approached in a similar way to female patterned hair loss. The one caveat is that I generally add oral medications earlier than later for PCOS patients knowing that they are generally younger and can often benefit from early intervention. Minoxidil is the first line mainstay of most therapeutic regimens for hair loss. Spironolactone is an oral medication that can benefit PCOS patients by improving hair growth on the scalp and reducing it on the face while also improving acne. Although finasteride can be used, it seems to have more benefit for post menopausal women than for PCOS related hair loss. PRP injections can supplement a therapeutic regimen as well.
Tips or tricks for recovery?
Early diagnosis and intervention is the key to better outcomes. The most difficult aspect of hair loss is to recover lost hair and to maintain a positive outlook since hair loss is tremendously personal. I have seen far more tears shed in my exam rooms from discussing hair loss than diagnosing skin cancer. This has nothing to do with vanity. This has everything to do with a sense of control. When it comes to a skin cancer diagnosis, most people recognize there is an algorithm of steps to follow and that if we systematically approach the diagnosis and treatment we will likely be in a good position. There is also a sense of prevention with skin cancer since so many people are learning and recognizing the need to skin cancer screenings for early detection and diagnosis.
Hair loss is overwhelming because we do not have the same sense of control or clearly laid out steps to recover. Also, I often say that watching hair grow is like watching water boil or grass grow- it’s a slow process! I think the best thing we can do is to educate ourselves on hair as much as possible from an early age and learn to recognize when something is not right. Many younger women (espcially those with long hair) do not see a hair dresser often enough to have someone actually recognize something isn’t right based on change. I try to encourage patients to understand normal hair growth patterns and cycles to better understand when something changes to be aggressive with early interventions when possible. It is so much easier to maintain growth than it is to recover it!