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Hair Loss


It is important to realize that some families have more members than others who develop hair loss (baldness or alopecia) of the scalp. To put it differently, baldness is common and the quest for a permanent baldness cure is also common. Notably, there is a baldness pattern in certain families. For one thing, researchers identified the baldness genetics that is responsible for familial hair loss. It must be remembered that in some men and women with baldness hormonal reasons accounts for this. Another key point, when all of the bad genetic factors come together, complete baldness develops on top of the head in an early age (around 30 to 40), particularly with male baldness.

Androgenetic alopecia (=inherited hair loss)

A point often overlooked is that most hair loss cases fall into the category of “androgenetic alopecia” where male hormonal factors and inherited factors come together. By all means, by the age of 50 years about 50% of men and at the time of menopause 40% of women have significant hair loss. 5-alpha-reductase is an enzyme within prostatic tissue and in the hair follicle. In the prostate it metabolizes testosterone into dihydrotestosterone (=DHT). In particular, DHT is the “culprit” that is responsible in stimulating the prostate to grow 2-3 times the normal size after the male menopause, which occurs at about the age of 50.

The same enzyme causes hair loss and prostatic hypertrophy in males

This condition of prostate enlargement is has the name benign prostatic hypertrophy (see link under “Related Topics” below). The same enzyme (5-alpha-reductase) is present in androgen susceptible hair follicles on the scalp and it converts testosterone to DHT. Too much DHT leads to premature hair loss, but fortunately this can now be remedied. Here is an illustration what happens to the hair follicles under the influence of DHT in a sensitive male. Finasteride (Propecia) is a DHT inhibitor and this normalizes the hair growth in a large percentage of males who receive this treatment (see below).


Another key point, in men hair loss presents in the frontotemporal and the top of the head (=vertex) regions. On the other hand, in women hair loss is more diffuse and occurs mainly in the center area of the top of the scalp and the adjacent parts on each side (high temporal areas). To clarify, men’s hair loss is classified according to the Norwood/Hamilton scale, women’s hair loss according to the Ludwig scale. The above links connect you to a site with pictures of these patterns.

Hair Loss

Hair Loss


The good news is that there are newer medications available that can in the case of male baldness be taken orally and in the case of female baldness it can be applied topically. 

Male baldness

For male baldness where the problem is a genetic overabundance of the enzyme 5-alpha-reductase in the hair follicle, as explained above, this can be treated with finasteride, which inhibits this enzyme. 1 mg per day of this (brand name: Propecia) is sufficient and should show a response over a period of 2 years. Only, when this long trial does not work can it be called a “treatment failure”. 60 % of men respond and about 80% stabilize after 2 years. This dosage of finasteride is about 1/5-th of that , which is used for most men with prostate hypertrophy.

Female baldness

Female baldness is treated with topical minoxidil (brand name: Rogaine), which will show a 50% minimal regrowth response rate in women (using 2% minoxidil).

Minoxidil use for women for Ludwig type I and II hair loss

In women systemic androgen modulation using spironolactone (brand name: Aldactone) can be added, which is also marginally active. However, this has been largely replaced in 2007 by topical 2 % or 5% minoxidil for women according to Dr. Jerry Shapiro (Vancouver and New York) who spoke at a conference in Vancouver about this (Ref. 13). Minoxidil is available as a 5% solution without a prescription at Costco in the US. In Canada there is still a prescription needed for 5% and it has to be made up by the pharmacist, while the 2% solution is available without a prescription in drug stores in Canada. Ludwig type I and II has a 63% response rate in women and is safe to use the 5% Minoxidil solution daily once or twice (depending on how severe the hair loss is) for the rest of your life (according to Dr. Shapiro).

Hair transplant procedure

Those who do not respond to any of these therapies have to consider a permanent hair transplant procedure. The physician takes small pieces of hair from high density growth areas (occipital scalp) and transplants them to the scalp, which has no or little hair. Lately mini- and micro grafts, containing only 2 or 3 hair follicles, have revolutionized this area of plastic surgical or dermatological surgical specialties. For Ludwig stage III in women and Norwood/Hamilton stage V to VII (see pictures under these links) these cosmetic surgical methods would be advisable.

Look for Medical Hair Restoration expert

Hair transplantation performed by professionals is the only safe and effective way to regain your hair; fully grown and with a natural appearance. To find qualified practitioners you could use the link above or google Medical Hair Restoration (American Board of Hair Restoration Surgery certified) to find an expert who could explain this procedure in more detail. When all else fails and the costs of surgical methods is not affordable, a simple hair piece wig would be a more economical solution (Ref. 8).

Don’t forget to ask your physician for hormone tests

However, before you consider this, do a battery of hormone tests; see under “Anti-aging medicine for women and men” under “Related Topics” below to see whether bioidentical hormone replacement is what you need.
See also the page “Hair restoration” (=Hair transplant) from under “Related Topics” below.


. Habif: Clinical Dermatology, 3rd ed.,1996, Mosby-Year  Book, Inc.

2. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse  Station, N.J., 1999. Chapter 117.

3. Cotran: Robbins Pathologic Basis of Disease, 6th ed.,1999, W. B.  Saunders Company

4. Noble: Textbook of Primary Care Medicine, 3rd ed., 2001, Mosby,  Inc.

5. Rakel: Conn’s Current Therapy 2001, 53rd ed., 2001, W. B. Saunders  Company

6. Goroll: Primary Care Medicine, 4th ed., 2000, Lippincott Williams &  Wilkins

7. Richard J. Lewis, M.D. at the 42nd Annual St. Paul’s Hosp. CME  Conf., Nov.1996, Vancouver/BC

More references

8. Jerry Shapiro, Prof. Dermatol., UBC, at 45th Annual St. Paul’s Hosp.  CME Conf., Nov.1999, Vancouver/BC

9. D Seager Int J Cosmet Surg Vol 6, No. 1, 1998: 27-31.

10. Townsend: Sabiston Textbook of Surgery, 16th ed.,2000, W. B.  Saunders Company

11. Ferri: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright © 2004 Mosby, Inc.

12. Rakel: Conn’s Current Therapy 2004, 56th ed., Copyright © 2004 Elsevier

13. 2007 St. Paul’s Hospital CME Conference for Family Physicians, Convention Centre, Vancouver, Nov. 20-23, 2007.

Last modified: March 7, 2023

This outline is only a teaching aid to patients and should stimulate you to ask the right questions when seeing your doctor. However, the responsibility of treatment stays in the hands of your doctor and you.