Correspondence

Hair Loss in Women

N Engl J Med 2008; 358:533-534January 31, 2008

Article

To the Editor:

In the Clinical Practice article on hair loss in women by Shapiro (Oct. 18 issue),1 the assertion that “the yield of testing [for hormonal causes of female-pattern hair loss] is expected to be low in the absence of other features suggesting androgen excess” is not supported by the cited series of patients with female-pattern hair loss.2 Although the “majority” of patients in this series had normal serum androgen levels, 42 of 109 subjects had hyperandrogenism, as defined by an increase in testosterone, non–sex hormone–binding globulin-bound testosterone, dehydroepiandrosterone sulfate (DHEAS), androstenedione, or dihydrotestosterone.2 In 2 of 44 patients, cosyntropin stimulation testing revealed 21-hydroxylase deficiency.2 Although the generalizability of the findings in this series is limited, the polycystic ovary syndrome has become even more prevalent since their publication.3 Likewise, nonclassic congenital adrenal hyperplasia is an occasional cause of hyperandrogenism in premenopausal women. A rapid onset of hyperandrogenism marked by hirsutism, acne, female-pattern hair loss, clitorimegaly, voice deepening, or menstrual irregularity warrants evaluation for ovarian and adrenal tumors, with measurement of total testosterone and DHEAS. Finally, hyperthecosis ovarii should be considered in postmenopausal women with slowly developing and often severe hyperandrogenism. These diseases are not just the domain of “interested endocrinologist[s]”4 but the responsibility of all treating physicians.

Amnon Schlegel, M.D., Ph.D.
University of California, San Francisco, San Francisco, CA 94110
amnon.schlegel@ucsf.edu

4 References

1. 1

   Shapiro J. Hair loss in women. N Engl J Med 2007;357:1620-1630
   Full Text | Web of Science | Medline

2. 2

   Futterweit W, Dunaif A, Yeh HC, Kingsley P. The prevalence of hyperandrogenism in 109 consecutive female patients with diffuse alopecia. J Am Acad Dermatol 1988;19:831-836
   CrossRef | Web of Science | Medline

3. 3

   Norman RJ, Dewailly D, Legro RS, Hickey TE. Polycystic ovary syndrome. Lancet 2007;370:685-697
   CrossRef | Web of Science | Medline

4. 4

   Olsen EA, Messenger AG, Shapiro J, et al. Evaluation and treatment of male and female pattern hair loss. J Am Acad Dermatol 2005;52:301-311
   CrossRef | Web of Science | Medline

Author/Editor Response

The general consensus in the dermatologic community is to order measurements of androgen levels for patients with female-pattern hair loss only if indicated.1 For the first 5 years of my practice, I routinely ordered measurements of serum androgen levels in all my patients with female-pattern hair loss. The yield of a positive result was extremely low for women without other clinical signs of androgen excess. Schlegel cites the study by Futterweit et al. However, this study population was not representative of the general population, since many of the patients had been referred to endocrinologists.

Dermatologists and family physicians see the vast majority of women with female-pattern hair loss. It has been estimated that 38% of women in the general population have female-pattern hair loss.2 Most of these millions of women do not have clinical signs of androgen excess. Evidence to support routine testing for hyperandrogenism in such women is lacking. I agree with Schlegel, however, that the possibility of androgen excess should routinely be considered in patients with female-pattern hair loss.

Jerry Shapiro, M.D.
Vancouver Coastal Health Research Institute, Vancouver, BC V5Z 4E8, Canada

2 References

1. 1

   Olsen EA, Messenger AG, Shapiro J, et al. Evaluation and treatment of male and female pattern hair loss. J Am Acad Dermatol 2005;52:301-311
   CrossRef | Web of Science | Medline

2. 2

   Birch MP, Messenger JF, Messenger AG. Hair density, hair diameter and the prevalence of female pattern hair loss. Br J Dermatol 2001;144:297-304
   CrossRef | Web of Science | Medline