Women expect their hair to turn gray as they age, but they may be far less prepared for another ego-challenging aspect of aging: Their hair falls out.
You can cover gray with dye, but it's harder to disguise the sparsely covered scalps that millions of women start to notice in their 50s and 60s. Some have thinning hair long before that. This kind of hair loss is unrelated to cancer treatment or other serious health problems.
Of course, there are plenty of men who wish desperately to restore their youthful locks, and a few cling to elaborate comb-overs, while many men clip their hair short.
Dermatologists say hair loss is emotionally harder for women, who are often deeply embarrassed by thinning hair. By the time they reach 50, about 40 percent of women are experiencing female-pattern hair loss, said Gopal Patel, a dermatologist with Aesthetic Dermatology Associates in Media, Pennsylvania. Women of African descent struggle with additional conditions that can damage hair follicles and cause bald spots.
"Hair is such an important part of youth and vitality," said Aradhna Saxena, a Montgomery County dermatologist who is affiliated with Abington Hospital-Jefferson Health. "I don't think people realize that until it's gone."
It is normal for women to lose 50 to 100 hairs a day, dermatologists said. It's also normal for a woman to get more hair during pregnancy and return to normal after the baby is born.
George Cotsarelis, chairman of dermatology at Penn Medicine, studies hair thinning in men and women. He said women also often shed more hair about three months after an illness or rapid weight loss. Hair lost that way typically comes back. People shed a little more hair in the fall than during other seasons, he said.
Many other women, though, start noticing thinning hair on top of their heads. Doctors say the defining sign is a widening of the part. The hairline itself is usually intact, but the hair becomes less dense behind it. Doctors will often run a battery of tests to root out treatable medical conditions, such as anemia, thyroid problems, tumors or hormonal problems. "Ninety percent of the time, it's normal," Patel said.
The cause of female-pattern hair loss is unknown, but doctors said there is a strong genetic component that can come from male or female relatives. Though it looks as if hair is falling out, Cotsarelis said, what's really happening is hair follicles are becoming smaller and producing hairs that may be so small they can't be seen. Women tend to retain more normal, thick hairs than do balding men.
Like other doctors, Cotsarelis decried the lack of funding for studying hair loss. Said Patel: "The biggest challenge we face is we don't really have great data."
Because the condition is usually considered cosmetic, insurance companies don't cover treatments. Doctors warn that the available treatments may thicken hair growth for some women, but that the more realistic goal is to stop or slow the thinning.
While thinning generally worsens after menopause, doctors said hormone treatments typically do not improve hair growth. Minoxidil lotion or foam, which can be bought over the counter, is the first line of treatment. About half of women who use it have not lost more hair a year later, Cotsarelis said. Spironolactone, a blood-pressure drug, can help, doctors said. Some may also try finasteride — approved to treat baldness in men — off-label. The evidence that it works in women is weak, Patel said.
Beyond that, things get more controversial; some doctors say there's inadequate evidence for other treatments. Saxena thinks there is enough scientific evidence to support some alternatives, which he recommends to patients. But they are not for women on tight budgets. Nutrafol, a "nutraceutical," costs about $80 a month. Women can get injections in the scalp of platelet-rich plasma made from their own blood; the first four treatments cost about $2,000 at Saxena's practice in Fort Washington or Lansdale. Maintenance injections, every three to six months, cost $515 each. Women can also buy Theradome, a light-emitting helmet, for $895 online. Saxena, who has hair loss herself, said she has had the injections and uses minoxidil, spironolactone and Nutrafol.
Patel said those treatments have not been subjected to large or head-to-head research. There's great variation in how doctors give the plasma treatments and in laser-based devices, so it's hard for patients to know whether they're getting a proven regimen. Nutrafol seems promising, he said, but he does not think that company-funded research showing its effectiveness has been replicated. He has not recommended it yet.
If their hair thinning progresses despite treatments, women may try transplants, weaves or wigs — or let the world see their scalps.
Black women often have extra problems. Tight braids can cause traction alopecia along the hairline. That hair might grow back with a gentler hairstyle.
More upsetting is central centrifugal cicatricial alopecia, baldness that starts at the crown and spreads outward. "It's hugely, hugely difficult," said Susan Taylor, a dermatologist at Penn Medicine who specializes in treating women with CCCA. She said it is seen "almost exclusively" in women of African descent. One study found it in 10 to 15 percent of black women, but Taylor thinks it's more common. "I could see women all day, every day, with this problem," she said.