"I am 25 and have had severe alopecia areata
since I was about 4 years old. In July, I started
taking Mircette birth control pills. Would my taking
these pills have anything to do with the recent worsening
of the alopecia? "
M.
The term "alopecia" means hair loss. There
is quite a large list of different causes and conditions
regarding hair loss. Alopecia areata is a condition
affecting about 1-2% of women and results in quarter-sized
clumps of hair falling out at once. The cause of alopecia
areata is unknown, although it is suspected that the
autoimmune system plays a role. Affected hair follicles
are thought to be attacked by a person's own immune
system (white blood cells), resulting in the cessation
of hair growth in patchy areas. When all of the hair
in this patch enters this resting phase at once, the
hairs all slough off shortly after, creating a bald
patch.
In your case with taking the birth control pills,
the process is probably somewhat different and I doubt
the immune system is altered at all. Rather, the estrogen
in the pills probably stimulated and prolonged the
growth phase of many hair follicles. This causes more
than the usual 10% of hairs to reach the resting phase
and then the sloughing phase about 3-4 months later.
The net result of this growth stimulation is a more
than normal sloughing of hairs (normally 50-100 each
day) several months down the line. In this case the
hair loss should not be patchy like your basic disease
but rather generalized. It usually only lasts for
a month or two and the hairs resume a random growth
pattern. When you stop the pills, the same process
may take place because the growth phase shortens throwing
more hairs into a resting phase several months later.
Thus the pills can be causing some hair loss now,
but the loss is not part of your disease process and
will go away soon.
How do hormones normally affect hair growth?
A small degree of hair loss is always present. Random
hairs shed or break off so that with every brush of
the hair, some hairs are at the end of their natural
cycle. This natural hair growth cycle (anagen phase)
takes as long as 6-10 years. This is followed by a
resting, nonmetabolic phase (telogen) that lasts for
about 2-3 months (range 6 weeks to 6 months). At the
end of the telogen phase, the hair shafts slough off.
These phases are important because many hormones,
medications or diseases can change phase duration
and thus accelerate hair loss or cause more than a
normal amount of the hair to be in synchronous growth
and then slough. For example, estrogens during pregnancy
prolong the anagen growth phase and when pregnancy
is over, a large number of hairs go into the telogen
resting phase. As expected, 6 weeks to 6 months later
large amounts of hair break or slough. It gives the
impression that one's hair is all falling out. Actually
hairs gradually go back to their random pattern of
growth and rest and the "hair loss" problem
subsides.
In addition to whatever treatment your doctor is
giving you for the alopecia areata, you might also
want to try essential oil therapy to rub on the scalp
to stimulate hair growth in the patchy areas. One
study showed almost a 50% improvement in women with
alopecia areata who used a daily mixture of thyme,
rosemary, lavender, and cedarwood essential oils in
a mixture of carrier oils (jojoba and grapeseed) and
massaged it into their scalps (1).
Can oral contraceptives or hormone replacement
cause hair loss?
Yes. Both oral contraceptives and hormone replacement
contain estrogen which stimulates hair growth and
prolongs the anagen growth phase. Most women will
tell you that hair growth accelerated when first starting
the replacement therapy. Their hair actually got thicker.
Then some women may describe an increased rate of
hair sloughing or loss several months after starting
the hormonal medications. This is not a reason to
stop the hormones; the loss will go away shortly with
no net change in the amount of hair. In fact if you
stop the hormones then, several months later there
may be some more sloughing.
The same is true of younger women starting oral contraceptives.
They may not notice the increased hair growth and
thickness as much as an older, menopausal woman who
has thinner hair to start with, but the gobs of hair
in the hair brush several months after starting oral
contraceptives does not go unnoticed. This loss of
hair following estrogen stimulation by pills, HRT
or even pregnancy is called telogen effluvium. Again,
this is not a reason to stop the birth control pills.
Both the use of Depoprovera® and Norplant®
contraceptive implants have about a 10% incidence
of increased hair loss (1, 1).
What are other common causes of hair loss?
Drugs that can cause temporary hair loss include cancer
treatment chemotherapeutic agents, some anticoagulants
(blood thinners), excessive vitamin A intake, vitamin
A derivitives such as Accutane® or Retin A®
used to treat acne and skin problems, and beta-adrenergic
blockers used to control blood pressure such as Inderal®,
Lopressor®. Some antidepressant and antianxiety
drugs can also cause hair loss (1).
Hair loss can be the result of toxic agents or events
such as burns, x-rays, injuries of skin on the scalp,
and exposure to certain chemicals including those
used to purify swimming pools, and to bleach, dye,
and perm hair. Even products that claim to straighten
hair can be associated with unexpected increase rates
of loss (1). Crash dieting has also been implicated
(1). Again, normal hair growth usually returns several
months after the cause is eliminated. Some autoimmune
diseases, hypothyroid conditions or chronic skin conditions
are also associated with hair loss and if the conditon
is chronically active, so is the hair loss.
What can be done to lessen hair loss caused by birth
control or hormone replacement?
Almost always, it is just best to continue taking
the hormonal medications rather than stopping them.
The new growth, resting and sloughing phases eventually
resume the normal random pattern of hair growth and
loss. Stopping the hormonal medications just prolongs
the hair loss.
The main caution women must look for when alopecia
is due to hormone therapy is to make sure that they
are not receiving hormones that have much testosterone-like
(androgen) activity. Some women who are genetically
sensitive may develop a male pattern hair loss (balding
on the side of the head) if their total androgen hormone
level is too high. If this is the case, there should
also be excess hair growth on the face, chest and
lower abdomen in addition to the balding. The androgen
hormone effect may come from the type of progestin
in the birth control pills or it may come from a combination
of estrogen and testosterone in the menopausal hormone
replacement. If there is any suspicion that the hair
loss follows a male pattern balding, then any androgenic
compounds must be eliminated.
How can hair loss fron excess androgens be
stopped?
Male pattern hair loss or balding is called androgenic
alopecia. Sometimes blood androgen levels (testosterone,
DHEA) are elevated above normal values while at other
times they are normal, but the woman is just much
more genetically sensitive to whatever levels are
present. In either case, attempts to lower how much
testosterone gets to the hair follicle in the skin
is the preferred treatment. The actual compound that
stimulates sexual hair distribution growth as well
as male pattern balding is called dihydrotestosterone.
Dihydrotestosterone formed by a conversion from testosterone
by an enzyme called 5-alpha-reductase. This is important
because it means you can block androgenic hair loss
by not only lowering freely available serum testosterone,
but also by blocking the 5-alpha reductase enzyme.
This is how the compounds minoxidil, flutamide and
finasteride work, that men use to prevent baldness
and regrow hair; they reduce the 5-alpha-reductase
activity (1, 1).
Minoxidil helps stimulate hair growth in women with
androgenic alopeica (1) and can even shorten the duration
of baldness caused from some chemotherapy treatments
(1). Flutamide has also been successful at preventing
hair loss as well as reducing excess male pattern
hair growth (1). Imipramine is another medication
that may have some success at preventing hair loss
(1) but it is not known whether it affects the 5-alpha-reductase
enzyme activity.
The other main method to lower free serum testosterone
is to increase the binding of it to sex hormone binding
globulin (SHBG) and thus less testosterone is free
to affect hair growth in the skin. Estrogens work
by this mechanism in that they increase the amount
of SHBG which in turn binds more of the blood testosterone
making it inactive. Any estrogen will in effect lower
free testosterone and thus improve androgenic alopecia.
In summary, the best strategy for androgenic alopecia
is:
eliminate any androgenic medications
add estrogen treatment such as oral contraceptives
or HRT if possible
trial of flutamide (250 mg/day) for 6 months
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