Is hair loss in women a sign of PCOS?

When we talk about Polycystic Ovarian Syndrome (PCOS), we broadly deal with its unpleasant manifestations such as acne, pigmentation of the skin, the dreaded weight loss, the deadbeat feeling of laziness, etc. No matter what the indications are, the mystery remains in how we manage to tackle them with effective results and minimal side effects. What we miss out on are symptoms that may look common and harmless but not to a trained eye. These are the underlying portrayals that look normal but on a deeper search, prove to uncover something much more. 

Normal testosterone levels in women

The womanly biological system generally secretes lowered amounts of testosterone than males. That is why testosterone is a primary male sex hormone. The natural level ranges from 17-70 nanograms per deciliter (ng/dL), as compared to males where the levels are from 275-1000 ng/dL.

What is the function of testosterone in females?

Testosterone, as mentioned being a manly hormone plays a role in the following processes:- 

• Bone mass and muscle strength, 
• Maintenance of libido, 
• Regulation of other hormones, 
• Stimulates production of new blood cells,
• Maintenance of female reproductive cells and tissues, and so much more.

Do the testosterone and androgen levels increase in some women? Why is that?

Women who have higher levels of testosterone, expose to underlying medical conditions such as polycystic ovary syndrome (PCOS), thyroid imbalance, or insulin resistance. Variations in the chromosomal, physiological, and biochemical levels amongst women in all areas of life, are simply because of the genes they carry. However, in severe cases, increased testosterone in the blood may be present as indications of tumours or cancers on the ovaries or adrenal glands (where the testosterone is released from)

Q.) Tell-says of high testosterone in women

These signs correspond to the typical physique of the male body, such as:-

• Mild to severe acne,
• Excess facial and/or body hair,
• Hair weakening and thinning,
• Irregular menstrual cycles,
• Increased body (muscle) mass,
• Decreased sex drive,
• Obesity and infertility in severe cases. 

Female Pattern Hair Loss

So let us magnify the headlines and talk in focus on hair thinning and hair loss in women who have PCOS. It is scientifically known as Alopecia but is more commonly termed "Female Pattern Hair Loss" (FPHL). Let us understand what it is and why it is important to break down the reasoning for its existence in a woman's life.

Even the healthiest person (if they even exist) may tend to lose or shed hair, it is a natural process that is healthy for the hair. Although most women (and men) shed on average 100-150 strands of hair per day. Despite this, a random and unusual amount of hair sticking out of the comb, or a dried-up tumbleweed of hair rolling around on the ground will surely cast a depressing spell as the effect of hair loss is significantly noticeable. As disheartening as this may seem, hair loss for women is a standard regular, almost all of us have experienced it at some age, but when exactly should you be worried about it? 

According to a 2019 study by the University of Palermo, Italy; a definitive and common type of hair fall is prevalent among women, where the hairline recession happens in 2 ways:-

• Either the thinning will start mid-scalp and gradually spread in a circular pattern.

• Or the thinning will start at the hairline and gradually spread backwards along the centre of the scalp in a triangular pattern (sometimes referred to as a "Christmas tree pattern"). 

This has suggested a relationship between polycystic ovary syndrome(PCOS) and hair fall and is subtly different from the male pattern of hair loss

This type of hair loss in women is referred to as androgenetic alopecia because it is related to the hyperproduction of androgen. Androgen is a predominant male sex hormone. It is seen majorly in men (responsible for male characteristics- deep voice, broad shoulders, body hair) and minorly in women (it is not completely absent in females). When the female body produces androgen (like testosterone) in excess it tends to kick start puberty and pubertal signs early on, which also accelerates the growth of bodily or facial hair in uncommon places. This effectively results in the thinning of the hair on the head, especially in the centre of the scalp. Women with PCOS are clinically known to have a high level of the male hormone androgen. Thus an imbalance of androgen in the woman's hormonal system is responsible for subsequent hair loss. This is branded by the term hyperandrogenism.  

How exactly does PCOS cause hair loss?

Now we get to the good stuff! It all begins with testosterone in the oil gland of the hair follicles, which is broken down into DHT (Dihydrotestosterone) which is an effectual androgen. This reaction makes the hair follicle shrink thus degrading and finally destroying the once healthy hair follicle. This process is called “Follicular Regression”. The degree to which women may lose hair depends on the amount of DHT their bodies produce. Female pattern hair loss involves miniaturization of the hair follicle that occurs gradually with time, followed by long-term damage of the follicles that are rendered inactive. 

FPHL may first be seen during the reproductive years, the post-pubescent or teenage stage, and in the ages surrounding menopause considering these are the times the hormones are most subjected to fluctuations. Due to other factors such as age, and multiple genetic (polygenetic), environmental, and growth factors, hair thinning and hair loss are seen as more prevalent in older women nearing menopause and during the post-menopausal stage. 

Women with an increased count of androgen or excessive response to androgen, also mean that the androgen hormone receptors are found in increased amounts. These conditions tend to clinically manifest as physical symptoms in the form of unwanted hair growth and/or acne and androgenetic alopecia

“In a meta-study conducted in 2003 of patients with excess androgen count, 

• 72.1% were diagnosed with PCOS, and 
• 56.6% of the total number of patients were considered affected by classic PCOS, 
• 15.5% of the total number of patients were affected by mild ovulatory PCOS.”

Difference between alopecia and unwanted hair growth

Essentially alopecia is a recession of the hairline on a woman's head that may be caused by the high levels of androgen hormone in her system. As opposed to unwanted hair growth or hirsutism (HUR-soot-iz-um) which is a condition in women affected by PCOS that results in excessive growth of dark or coarse hair in a male-like pattern primarily seen on the face, chest, and back regions. With hirsutism, extra hair growth often arises from excess male hormones (androgens), majorly testosterone.

Women with Alopecia

Studies show that women affected by PCOS have higher levels of androgen and insulin in their blood.

A Clinical Diagnosis

Patterned hair loss is typically diagnosed clinically through multiple factors such as medical history, a physical examination, and a simple hair-pull test.

History

A complete history report must be done of the patient in question including the age at which hair loss began, the duration, the degree to which hair loss continues, and the progressive pattern of hairline recession. Hair shedding during the menstrual cycle must also be noted along with a gynecologic history. A gynaecological history may reveal cases of PCOS or hyperandrogenism if present

The patient should be asked about any family history of hair loss, metabolic syndromes (eg, high insulin levels, hypertension, obesity), androgen levels, medications, and medical history.

Other miscellaneous causes that worsen hair loss, like iron deficiency, thyroid dysfunction, and nutritional deficiencies, should be considered and managed to improve treatment results.

Physical examination 

A complete dermal or skin evaluation should be conducted, especially covering the face, scalp, and nails.

The hair loss region, its progression, and the health of existing hairs will be noted by your doctor so that a proper diagnosis can be made.

Blood test

If you notice physical signs that you may have high testosterone levels, visit your doctor and explain your situation, they may ask for a blood test. Usually, a blood test is done as it is simple and will give a clear explanation of most problems. Taking your blood, they will test the testosterone, insulin, and cholesterol levels as these chemicals float around in your blood freely, especially in the mornings. A blood test is vital if you have PCOS or if your menstruation is irregular because of other reasons such as vigorous exercise or anaemia, etc.

Hair-Pull test (do not try this at home)

The hair-pull test is a simple yet useful method to assess the health of hair and the hair root by grasping onto a clutch of hair. If more than 6 hairs are observed to come loose, then hair loss activity is present. The Pull test is only a general approach to diagnosing alopecia.

Treatment Options to Manage hair loss:

As simple as it may be, The most likely treatment would be to counterbalance the highly varying levels of androgen in the body which is causing the evident hair loss. 

Diet

Women who experience PCOS tend to have high levels of insulin in their blood, thus stimulating the ovaries to produce abnormal levels of androgen. This is aggravated by the carbohydrates found in their diets. In such a way, insulin levels must be managed to prevent the cycle of events that may follow additionally with hormonal supplements to aid in the internal balance to the right amount. 

Nutritional and iron supplements

Oral supplementation with essential amino acids, biotin, zinc, and other micronutrients may be taken as per your physician's advice. 

An iron deficiency thus does not allow new hair cells to be produced in the hair growth stems. Lack of iron in the blood or an iron deficiency may also be a cause of alopecia for women with a history of PCOS, anaemia, or heavy menstrual bleeding. 

Exercise

Exercise has always been known to improve health, so why not for hair loss too? Regular suitable exercises to get your heart pumping and limbs sore by the end of the day can also improve the regulation of hormone production in the blood.

Anti-androgens 

Since testosterone is a type of androgen hormone, it tends to increase the rate of hair loss in women troubled with PCOS. Thus these women would benefit from anti-androgen drugs for their treatment. Although this may end in side effects such as fatigue, depression, and weight gain.

For women, oral anti-androgens such as are often used as blockers to the androgen receptor, thereby blocking the much more potent DHT and free testosterone from interacting with the androgen receptor, thus physiologically behaving like a direct antagonist. It also inhibits androgen synthesis and enhances the conversion of testosterone to estradiol.

Microneedling

Microneedling is a non-invasive clinical procedure where tiny needles are rolled over the skin of the scalp, this induces a wound healing process to transpire by producing collagen in the affected scalp region. By doing so, the hair roots gain strength and stimulate the follicles by inducing blood circulation. There are minimal side effects and the results seem to show promise. However, the micro-needling treatment is not a universal method of treatment as it may not show positive results in all cases.

Hair transplant

A mildly invasive surgical procedure, Hair Transplantation, has been used popularly to treat androgenetic alopecia since the 1950s. Though it deals with a more medical treatment approach, the results are a generation of new follicles with stronger roots and structure.  

It involves the removal of a region of the back of the scalp (the unaffected region) to fill in the space which is the bald patch or spot and replacing the damaged follicles with healthy ones, thus stimulating growth and rejuvenating the follicles.