Hair replacement surgery, a 40-year-old procedure, is now at a stage where its history can be re-examined, present procedures enumerated, and its future evaluated. The provocative observation that donor site, composite grafts, or occipital hair follicles, when transferred to the frontal area of the scalp, not only survive and grow but continue in a growth pattern throughout the patient's life has spurred a major subspecialty of cosmetic surgery. The innovations, refinements, and new techniques that emerged during the ensuing 40 years truly have made Norman Orentreich's original experiment a definitive subspecialty. This article reviews some of the prior advances during this time, where they stand now, and state-of-the-art techniques.

History of the Procedure

The science of hair transplantation defined the nature of male pattern baldness and predicted treatment programs for each pattern and stage. The work of Norwood, Ayers, and Stough defined candidates for hair transplantation and state-of-the-art methodology for the 1960s and 1970s using hand punches, graft sizes, and patterns of replacement. Objective observations by Dr Walter Unger, with meticulous hair counts, defined the ideal graft size of 4.0-4.5 mm for maximum hair growth. Additionally, particular patterns for best aesthetic results were reviewed. Microphotography by Dr Tom Alt clearly demonstrated which grafts were ideal and defined the techniques necessary to produce these ideal grafts. Innovators such as Uebel developed the approach of micrografts (1-3 follicles) or minigrafts (3-8 follicles) to improve the natural appearance of the grafts.

The very best grafts were produced with a mechanically rotating power punch using a carbon steel trephine designed by Richard Shiell. Saline injected into the donor area to produce the proper tissue turgor for graft harvesting clearly produced superior grafts because the punches cut cleanly through the rigid scalp tissue. Cluster harvesting and closure of the donor site became the normal procedure, producing the least amount of scars in the donor area. These innovations in graft harvesting produced superior quality hair grafts for greater density and coverage of the recipient sites.

Aesthetic concerns for hairline placement, growth and direction of hair grafts, and hair angulation in the recipient sites further refined major grafting techniques.

Problem

Transplantation began as a punch graft technique using skin biopsy punches of convenient sizes. In the early years, the procedure was performed simply as a skin biopsy, with no specific planning. Hairlines were established as a consensus between the patient and physician, and random grafts were placed behind this point according to the desire and wishes of the patient. Typically, 20-30 grafts were placed at a time, donor areas were left open to granulate in by secondary intention, and multiple small treatment sessions occurred over years until both physician and patient were satisfied. Surprisingly, many of the results remained quite good. Patients with the best hair type, skin color, and densities, even after 30-40 years, continue to have adequate cosmetic results.

Those with less than desirable cosmetic results experienced adverse effects including a tufting or corn-stalking appearance of grafts, inappropriate hair lines, cobblestoning, scars, and progression of hair loss beyond transplanted areas. Future advances and refinements were made in response to these problems.

Frequency

Alopecia is a common problem within our population. In the United States, it is estimated that 35,000,000 men and 21,000,000 women experience hair loss. It is so common in men that it is actually accepted as normal.

Androgenic alopecia in females is an increasingly frequent problem based on heredity and hormonal change. There is much speculation concerning the more frequent occurrence of this problem among premenopausal women but the answer remains obscure. Both of these conditions are considered "donor dominant" and thus amenable to hair transplant surgery.

Etiology

Donor versus recipient dominance refers to the ability of hair grafts taken from an occipital donor area to grow and survive after transplantation to the frontal recipient site of alopecia. This phenomenon is explained by the presence of 5-alpha reductase in the cells of the recipient hair follicles. This enzyme, found in skin, is responsible for conversion of testosterone to dihydrotestosterone (DHT). Even normal circulating amounts of testosterone may be excessively converted to DHT or the hair follicle may be abnormally receptive to DHT, creating androgenic alopecia. The donor follicles from occipital regions have less or no enzyme and thus are not influenced by hormonal factors. The mesenchyme-derived dermal papilla at the base of the mainly epithelial hair follicle controls the type of hair produced. This is probably the site through which androgens act on follicle cells by altering the regulatory paracrine factors produced by dermal papilla cells.

Recipient dominant conditions refer to a diseased recipient area, which will destroy the healthy donor follicle when transplanted. These conditions include cicatricial or scarring alopecia, such as discoid lupus erythematosus, lichen planopilaris (lichen planus of skin and hair follicles), and other active scarring skin diseases of hair and scalp that attack the healing donor follicles. This disease can be treated medically and when the condition resolves, healthy hair grafts can be placed into the resultant but quiescent scar.

Pathophysiology

Androgenic alopecia as described above accounts for most of the patients seen for hair restoration. However, there are numerous other causes for hair loss, and the treating physician should recognize that some of these are not amenable to surgical treatment as there is no unaffected donor site.

Alopecia areata is an autoimmune hair cycle shift that can be present in any area of the scalp, including donor areas, so that all scalp hairs may be involved, leaving no healthy donor follicles. It also resolves with medication and topical therapy, with hair regrowth in most instances. Diffuse female alopecia also involves the entire scalp and thus is not amenable to hair transplantation.

By Simeon Bennett and John Lauerman

(Bloomberg) -- Those with slick domes, thinning tops and receding hairlines may one day be helped by the discovery of genes that put people at risk for baldness and a stem cell that may replenish hair follicles.

Two studies released today in the journal Nature Genetics may help explain why some people lose their hair, and how they may eventually be able to grow it back, scientists from London- based GlaxoSmithKline Plc, the U.K. and Sweden said.

Hair loss affects about one in four Caucasian men before age 30. While drugs such as Johnson & Johnson's Rogaine and Merck & Co.'s Propecia can help hair regrow or prevent loss in some patients, they don't work for everyone. Treatments that target the DNA responsible may be more promising, said Tim Spector, who led the gene study.

``Early prediction before hair loss starts may lead to some interesting therapies that are more effective than treating late-stage hair loss,'' said Spector, a researcher in Kings College London's department of twin research and genetic epidemiology, in a statement.

Spector and colleagues analyzed the genes of 578 men in Switzerland with early-onset hair-loss, and compared them against those of 547 others who were retaining their hair. They then confirmed their findings against groups from the U.K., Iceland and the Netherlands, studying about 5,000 people in all.

Those with hair loss commonly shared the same variations of two genes that together made them seven times more likely to suffer baldness, researchers from Kings College London and GlaxoSmithKline Plc wrote in the journal Nature Genetics.

More Study Needed

The research associates the genes with hair loss, though further studies are needed to prove the connection. The genetic variations were also found in women, though the link wasn't statistically significant and more research is needed, the authors said. The study was partly funded by Glaxo.

In the stem cell study, researchers led by Viljar Jaks of Sweden's Karolinska Institute examined mouse hair follicles for signs of rapid growth. They found a protein, called Lgr5, on the surface of long-lived, active stem cells in hair cells; the same protein has been identified on stem cells in the intestine, they said in the study.

Cells bearing the Lgr5 marker were capable of maintaining hair follicles for as long as 14 months, the researchers said. In mouse studies, just a few of these cells were able to build an entire hair follicle, they said in the study.

The search for a cure for baldness began at least 3,000 years ago. Ancient Egyptians treated hair loss with fats from crocodiles, geese, lions, ibex, snake and hippopotamuses, according to the U.S.-based Coalition of Independent Hair Restoration Physicians.

`Balding Pattern'

Two of three men will be bald or have a ``balding pattern'' of hair loss by 60, according to the U.S. National Institutes of Health. The condition may be hereditary in more than 80 percent of cases, and has also been linked to maladies including heart disease and metabolic syndrome, the authors wrote.

Americans spent more than $115 million on hair transplant therapy last year, the authors said, and Merck's Propecia earned the Whitehouse Station, New Jersey-based drugmaker $405.4 million.

Though hair loss can be embarrassing and unpleasant for anyone, society considers hair loss in women a sort of cosmetic disaster. But it's not just social factors that set male and female baldness apart. The actual causes and symptoms of hair loss in women can be different as well. Join our guests as they explain the distinction between the two.

Webcast Transcript

DAVID R. MARKS, MD:  Hi, and welcome to our webcast.  I'm Dr. David Marks.  A lot of people who lose their hair feel embarrassed, especially women.  For them, it can be a cosmetic disaster.  But it's not just social factors that set male and female baldness apart.  Causes and symptoms of hair loss can also be different in men and women.

Here to talk about these differences are two experts.  First is Dr. Neil Sadick.  He's a dermatologist and cosmetic surgeon at the Weill Cornell Medical College.  Welcome.

NEIL SADICK, MD:  Hi, David.

DAVID R. MARKS, MD:  Next to him, Dr. Michael Reed.  He's a dermatologist and hair transplant surgeon at NYU here in New York City.  Thanks for being here.

MICHAEL REED, MD:  Thank you, David.

DAVID R. MARKS, MD:  It really can be a cosmetic disaster for women, but it's something that we don't hear a lot about.  Why is that?

"Women's hair is their crowning glory, and if you don't have beautiful thick hair, then what has happened to you as a woman?" said Joan Denton, who suffered from hair loss.

Most women would love to have locks that were long, thick and lustrous, but some end up with the exact opposite.

Denton would not even walk outside when her hair loss got bad.

"It was scary. It was heart-wrenching," said Denton.

But now, she says enjoys the outdoors. Dr. Alan Bauman says it takes a variety of therapies to help women combat hair loss.

"Just like if you are on a health kick, you want to use diet and exercise to get the result, the same is true in other areas of medicine -- like hair loss. And today, the number of tools are increasing," said Dr. Bauman.

One of the newest tools involves using lasers. The light energy stimulates cells and causes hair to grow. Patients need up to three, 15-minute sessions a week in an office setting.

The cost is $4,000 a year, or patients can try hand-held lasers at home for up to $3,500.

"The FDA has approved a number of devices," Bauman said.

Rogaine is another option. The 2 percent solution of the product is FDA approved for women and costs about $40 per month.

Doctors can also prescribe Propecia, a pill that costs about $60 a month. Also, the tried and true hair transplant offers impressive results for women for about $10,000.

Joan Denton tried lasers, drugs and had a transplant.

"I am a different person. I got my life back. I no longer have to worry about going out and having the wind blow," she said.

Denton says she hopes other women will feel confident about going outside, as well.

Since Propecia is not FDA approved for women, doctors have to prescribe it off-label.

The results vary for each of the hair loss treatments, but Dr. Bauman says hair transplants typically take up to a year to get the full result for women.

The most common reason for performing hair transplantation is for male pattern baldness. However, women can also suffer from thinning of their hair and there can be a wide spectrum of severity. Whilst society accepts a balding male scalp, it is less forgiving when the scalp becomes visible on a woman. Conversely, it is far more acceptable and even fashionable for women to wear wigs or hairpieces and therefore it is rare to see women with balding scalps in public. The most common cause of female hair loss is androgenetic alopecia due to the hormone testosterone. Although found in greater quantities in men, testosterone is also produced in women by the ovaries and adrenal glands. It causes involution and atrophy of the hair follicle bulb and results in thinning of the hair, more often in women over forty.

There are four main patterns of female baldness:

• The geographic pattern is the most common and starts a few centimetres behind the hairline so that a fringe of normal hair growth remains at the normally positioned hairline but balding extends towards the crown. The area at the lower part of the back of the head is usually unaffected as in male pattern baldness and can be used as a donor site.
• The frontal pattern involves receding of the hairline giving a long forehead and the objective of hair restoration is to lower the hairline to a more natural position.
• The temporal pattern has loss of hair at the temples and gives the patient's hairline a masculine appearance. This is easily corrected with a relatively small number of transplanted hairs.
• The diffuse alopecia pattern involves the whole scalp, including the back of the head. In contrast to the other types of balding, although there is decreased density, the remaining hairs are of good quality and rather than becoming fine and wispy. Hiding the donor scar may be difficult in these cases.

Historically, hair restoration procedures gained a bad reputation because the techniques available left an unnatural, 'pluggy' appearance. This meant that it was often immediately obvious that the individual had undergone a surgical procedure. Current methods, however, give a natural hairline and pattern of hair growth, which is unnoticeable to all except the most informed observer. This involves the transplantation of individual hair follicles or groups of hairs, known as follicular units.

If a woman is planning to have a hair transplantation procedure, however, it is important to be realistic. Balding is often a progressive phenomenon as it is in men. If treatment is started early, before the genetically determined extent of balding is reached, then further procedures are likely to be needed and should be planned for. Likewise, if severe balding is present, there may not be enough donor hair to be transplanted to recreate adequate density over a large area and compromises may be necessary. It is these factors, amongst others, which make it important for anyone considering hair transplant surgery to meet with the surgeon who will be performing the operation and following the patient up for many years after.

When well planned and skilfully executed, hair transplantation can yield remarkable results, transforming not only how a woman looks but also how she feels about herself and interacts with society. It is no longer necessary for women who are balding to hide it under wigs. If losing your hair bothers you, a permanent solution is available!

The Procedure

The surgery is performed under a light sedation and administered by an experienced anaesthetist so that discomfort is kept to a minimum. Local anaesthetic is infiltrated, a strip of hair bearing scalp is removed from the back of the head and the wound is sutured. The individual hairs and follicular units are then carefully dissected by the team so that the roots are not damaged. Fluid with adrenaline is injected into the recipient sites to reduce the amount of bleeding and the hairs are then implanted using small stab incisions. Care is taken to create a natural hairline. The duration of the operation varies from one to five hours depending on the extent of the area to be grafted.

Planning your surgery

Following your consultation at LPSA, you will be given pre-operative advice sheets and post-operative instructions for care of the grafts. It is important to follow these. You will also be given guidelines on drinking, smoking and taking or avoiding certain medications. Although the procedure will not take all day, you should keep the day of surgery free of other commitments. Someone will need to pick you up after the surgery and you should rest for the remainder of the day.

Why choose London Hair Transplant at LPSA?

Mr Greg Williams FRCS FRCS (Plast.) is on the General Medical Council Specialist Register as a fully qualified plastic surgeon. He has a specific interest in the field of hair restoration and performs hair transplantation on a regular basis as part of his NHS position as a Consultant Burns Surgeon at the Chelsea and Westminster Hospital in London. The initial consultation and assessment is directly with him, not a cosmetic advisor. More importantly, the surgery is performed by him rather than a technician. Since an anaesthetist rather than the surgeon is responsible for your sedation, you can expect the procedure to be as comfortable as possible without actually having a general anaesthetic. LPSA is a partnership of some of London's top plastic surgeons and insists on the highest standards of care for its patients.

All surgery carries some uncertainty and risk

The procedure is generally extremely safe but the risks and complications that can occur will be discussed at the initial consultation. It is important, however, to recognise that results cannot be guaranteed and that your expectations may not be met. This is why a thorough discussion with Mr Williams is so important. Balding is progressive by definition and it is necessary to plan for future hair loss. Many women have been disappointed by overzealous procedures at an early stage of balding, which can be difficult to correct in later years. Mr Williams will help you set realistic and achievable goals for your hair restoration journey.

"Currently, there is no widely accepted or standard method for assessing the number of hairs shed daily," according to background information in the article. The widely held belief that it is normal to shed 100 hairs per day is based on the assumption that the average scalp contains 100,000 hairs, 10 percent of which are in the telogen (resting) phase. Although this idea is prevalent, it has not been scientifically validated and does not indicate whether shedding remains constant with age or if it is similar between men and women.

Carina A. Wasko, M.D., of Baylor College of Medicine, Houston, and colleagues studied hair loss in 60 healthy men (half age 20 to 40 and half age 41 to 60) without evidence of alopecia (baldness). All participants were given identical combs and instructions to wash hair with the same brand of shampoo for three consecutive mornings. On the fourth day, they were asked to comb hair forward for 60 seconds over a towel or pillowcase of contrasting color before shampooing. The men combed their hair this way and then counted hairs shed for three consecutive days. This procedure was repeated in eligible participants six months later.

Participants age 20 through 40 shed 0 to 78 hairs, with an average loss of 10.2 hairs per 60-second test. Men age 41 to 60 shed 0 to 43 hairs, with an average loss of 10.3 hairs per 60-second test. Results were consistent on consecutive days for all participants. "When repeated six months later in both age groups, the hair counts did not change much. The hair counts were repeated and verified by a trained investigator, with results similar to those of subject hair counts," the authors write.

"In summary, the 60-second hair count is a simple, practical and objective tool for monitoring conditions associated with hair shedding," the authors conclude. "Low intrapatient variability demonstrates that dependable results over an extended period of time are obtainable. The similarity between investigator and subject hair counts indicates that patients can reliably count hairs.

"Studies of the 60-second hair count in normal women and in the setting of hair disease still need to be performed."

Co-author Dr. Miller is a consultant for and has received honoraria from Pfizer Inc. This study was supported by a study grant from Merck.

"We showed that wound healing triggered an embryonic state in the skin which made it receptive to receiving instructions from wnt proteins," says senior author George Cotsarelis, MD, Associate Professor of Dermatology. "The wnts are a network of proteins implicated in hair-follicle development."

Researchers previously believed that adult mammal skin could not regenerate hair follicles. In fact, investigators generally believe that mammals had essentially no true regenerative qualities. (The liver can regenerate large portions, but it is not de novo regeneration; some of the original liver has to remain so that it can regenerate.)

In this study, researchers found that wound healing in a mouse model created an "embryonic window" of opportunity. Dormant embryonic molecular pathways were awakened, sending stem cells to the area of injury. Unexpectedly, the regenerated hair follicles originated from non-hair-follicle stem cells.

"We've found that we can influence wound healing with wnts or other proteins that allow the skin to heal in a way that has less scarring and includes all the normal structures of the skin, such as hair follicles and oil glands, rather than just a scar," explains Cotsarelis.

By introducing more wnt proteins to the wound, the researchers found that they could take advantage of the embryonic genes to promote hair-follicle growth, thus making skin regenerate instead of just repair. Conversely by blocking wnt proteins, they also found that they could stop the production of hair follicles in healed skin.

Increased wnt signaling doubled the number of new hair follicles. This suggests that the embryonic window created by the wound-healing process can be used to manipulate hair-follicle regeneration, leading to novel ways to treat hair loss and hair overgrowth.

These findings go beyond just a possible treatment for male-pattern baldness. If researchers can effectively control hair growth, then they could potentially find cures for people with hair and scalp disorders, such as scarring alopecia where the skin scars, and hair overgrowth.

This research was funded in part by the National Institute of Arthritis, Musculoskelatal and Skin Disease and the Pennsylvania Department of Health. Other co-authors in addition to Cotsarelis are Mayumi Ito, Zaixin Yang, Thomas Andl, Chunhua Cui, Noori Kim, and Sarah E. Millar, all from Penn.

Cotsarelis and Ito are listed as inventors on a patent application related to hair-follicle neogenesis and owned by the University of Pennsylvania. Cotsarelis also serves on the scientific advisory board and has equity in Follica, a start-up company that has licensed the patent from the University of Pennsylvania. Cotsarelis was also a co-founder of Follica.

Barrandon was part of a French research team who reported in the scientific journal Cell that stem cells could be used to generate skin containing hair and sebaceous glands in mice. But at that time it was unclear whether the stem cells in hair follicles were true stem cells, capable of long-term renewal, or multipotent progenitor cells that would not permanently engraft in the follicle.

In the current PNAS study, the Swiss researchers have answered that question, using rat whisker hair follicles to demonstrate that the clonogenic keratinocytes in hair follicles are true stem cells.

Barrandon's group isolated stem cells from rat whisker follicles, labelled them, and grew them in culture for 140 generations. They then implanted progeny cells into the skin of newborn mice whose hair follicles were just being formed. This skin was then grafted onto athymic (nude) mice. Some cells were incorporated into developing follicles, but other follicles were completely made up of labelled cells. Each progeny cell contributed to the formation of eight different types of cell in the follicle, including those of the outer root sheath, inner root sheath, the hair shaft, the sebaceous gland and the epidermis.

After 125 days, a biopsy was taken from the graft, and labelled stem cells were isolated, subcloned, cultivated and then once again transplanted. The rat whisker stem cells participated again in forming all the cell types needed to form the hair follicle and sebaceous glands, resulting in hair bulbs that underwent repeated normal phases of growth, rest and regeneration. The fact that the transplanted cells participate in the hair cycle over long periods of time shows that they are true multipotent stem cells and not progeniture cells.

"With the progeny of a single stem cell, it would be theoretically possible to generate the complete hair bulb of a human being, and one that would last for years," explains Barrandon.

The ability of the stem cells in hair follicles to repeatedly regenerate all the different cell types of the follicle and sebaceous glands has important implications for regenerative medicine. The method could one day be used to regenerate hair on patients with severe burns. This study is a logical complement to other work in Barrandon's Laboratory of Stem Cell Dynamics, recognized for research into the reconstruction of injured tissues and organs.

Wounds, including skin ulcers and other dermatological problems associated with diabetes, circulatory problems, and other diseases, are a growing medical problem in the United States, notes senior author George Cotsarelis, MD, Associate Professor of Dermatology. Previous work by the Penn research team had outlined the hair-growth process to show that stem cells in the hair follicle "bulge" area generate new lower hair follicles, which in turn, generate new hair. Their latest finding-that these same stem cells play a key role in initiating wound healing-will help lay the foundation for designing more effective wound-healing strategies.

Even minor wounding resulted in mobilization of follicle stem cells to generate daughter cells that quickly move into the wound area. “About one-third of the coverage of the wound came from the stem cells in the hair follicle,” says Cotsarelis. “In the future, we think that we will be able to design treatments that enhance the flow of cells from the hair follicle to the epidermis in the hope of enhancing wound healing and treating patients with wounds.”

Follow the Blue Light

Clinicians have known for some time that when the skin is abraded new cells come from the hair follicle. What remained a mystery was the exact nature of the origins of the new cells-specifically, what percentage stems from the deep follicle and what percentage from the epidermis near the wound.

Cotsarelis’ team found that adult stem cells from the lowest portion of the hair follicle, or “bulge,” quickly ascend the follicle in response to wounding and ultimately comprise about 30 percent of the new cells in a wound when it first starts to heal. In addition, the stem cells respond rapidly to surface wounding-within two days-by generating short-lived “transient-amplifying” cells that respond to acute wound-healing needs.

Using a genetically engineered mouse designed in their lab, the researchers were able to visually follow the fate of the stem cells as they migrated from deep within the skin to the surface wound site. The mouse stem cells express a reporter gene that encodes an enzyme, which can be detected with a special blue-color reaction. “We could see blue lines coming from the follicles going toward the center of the wound,” says Cotsarelis. “They formed a striking radial pattern like the spokes of a wheel.”

Hope for Hair Loss?

The research also showed that stem cells might be a therapeutic target in certain types of hair loss. Using a different engineered mouse also designed in the Cotsarelis lab, one in which the hair-follicle stem cells could be destroyed after administration of a drug, the researchers discovered that the animals permanently lost all of their hair. This hair loss mimics types of hair loss seen in humans called scarring alopecias. But, cautions Cotsarelis, more studies are needed to determine if the loss of hair-follicle stem cells plays a role in hair loss in humans.

This research was funded in part by the National Institutes of Health. Other co-authors in addition to Cotsarelis are Mayumi Ito, Yaping Liu, Zaixin Yang, Jennifer Nguyen, and Fan Liang, all from Penn, as well as Rebecca J. Morris from the Columbia University College of Physicians and Surgeons, New York.

Is there a relationship between hair loss and menopause?

The most common cause of hair loss is low thyroid function, which is common among menopausal women. Other causes include, but are not limited to: changes in hormone levels (decrease or increase), increased testosterone, increased stress (physical or emotional), various medications, scalp/dermatological issues and heredity. Any time sudden hair loss is experienced, one must consider events which took place up to three months prior to the hair loss, as factors affecting hair loss can often take up to three months to have an effect, i.e., were you diagnosed with something new in the past few months? Did you start taking medication during the past few months? Did you go through a traumatic experience (death of a loved one/friend, divorce and any other event that can be categorized as 'traumatic'). Subsequently, any treatments for hair loss should be given at least three months to have noticeable effects.

You might look into Soy isoflavones which have estrogenic effects (without the risk of synthetic HRT) and have helped many women's hair thinning problems.

When progesterone levels fall as a result of lack of ovulation, the body responds by increasing its production of the adrenal cortical steroid, androstenedione, an alternative precursor for the production of other adrenal cortical hormones. Androstenedione conveys some androgenic (male-like) properties, in this case, male pattern hair loss. When progesterone levels are raised by natural progesterone supplements, the androstenedione level will gradually fall, and your normal hair growth will eventually resume. Since hair growth is a slow process, it may take four to six months for the effects to become apparent. This can be corrected by using naturally compounded hormones.

Additional Information on hair loss and hair in general.

"Hair Loss in women: It's more common than you may think
Originally published in Mayo Clinic Health Letter

"You wouldn't guess it from the male-oriented ads for hair-growth products, but about two-thirds of women also face hair loss at some point in life. Not surprisingly, many find it as alarming as men do perhaps even more so.

For many, the loss is permanent. But some causes of hair loss in women are treatable. Seeing your physician can help you get to the root of the problem.

How your hair grows

Your hair is made of keratin (KER-uh-tin), the same protein that makes up your nails and the outer layer of your skin. The part you see and style is called the hair shaft. It's actually dead tissue made by your hair follicles tiny bulb-like structures beneath your scalp's surface.

The average head has about 100,000 hairs. Your hair grows and is shed regularly. You usually lose 50 to 100 strands each day. If you have a normal head of hair, you probably don't notice this small loss.

Hair usually grows about half an inch per month, although this slows as you age. Each hair remains on your head for two to six years, and during most of this time is continually growing.

As a hair gets older, it may enter a resting stage in which it remains on your head but doesn't grow. At the end of this stage, the hair usually falls out. Usually, the follicle replaces it in about six months.

But many factors can disrupt this cycle. The result can be that your hair falls out early or isn't replaced.

Age and hormones

Most people naturally experience some hair loss as they get older. But age, changing hormones and heredity cause some to lose more hair than others. The result can be partial or total baldness, known as alopecia (al-o-PEE-she-uh).

Men are far more likely than women to have hair loss and baldness as they age. "Male-pattern baldness" is the receding hairline and hair loss on top of the head. It's typically genetic.

But there's also a "female-pattern baldness" also inherited that can cause modest to significant hair loss in women as they age. The hair loss can first become apparent in women by ages 25 to 30.

Female-pattern baldness starts with the replacement hairs becoming progressively finer and shorter. They can also become almost transparent.

Usually, the hair loss is far less prominent than it is in men. It also occurs in a different pattern. Most women first experience hair thinning and hair loss where they part their hair and on the top of the head, but don't have a receding hairline.

About 50 percent of women who experience hair loss have female-pattern baldness. Unfortunately, it's often permanent just as in men. (Dearest Note: Not all hair thinning and loss must be permanent. There have been cases of perimenopausal women, for example, experiencing thinning and lost hair who, once their hormone levels become balanced, can experience the thickness of previously thinning and the regrowth of lost hair that occurred during the ebbing and flowing hormonal years).

Other causes A variety of other factors may cause hair loss often temporary in women. These may include:

• Medications Some drugs used to treat cancer can cause your hair to fall out. But other prescription drugs, such as blood thinners, antidepressants and high blood pressure medications, can also cause hair loss. So can birth control pills and high doses of certain vitamins.
• Diet: Too little protein in your diet can lead to hair shedding. So can too little iron. Bottom line: Too strenuous dieting can result in hair loss! If you want to lose weight, do it the sensible way, especially if you have a hair thinning/loss problem to begin with.
• Stress or illness You may start losing hair one to three months after a stressful situation, such as major surgery. High fevers, severe infections or chronic illnesses can also result in hair loss. Auto-immune disorders can cause hair loss.
• Childbirth Some women lose large amounts of hair within two to three months after delivery.
• Alopecia areata Alopecia areata (ar-e-AH-tuh) is a condition in which hair loss occurs only in certain areas, resulting in hairless patches the size of a coin or larger.
• Thyroid disease An overactive or underactive thyroid can cause hair loss. (Dearest Note: One may get her thyroid numbers in order after beginning a regimen of thyroid medication. HOWEVER, there have been reported cases of women experiencing hair loss FROM the thyroid medication.)
• Ringworm If this fungal infection occurs on your scalp, it can cause small patches of scaling skin and some hair loss.

How to treat your tresses with care

Treatment options

Hair loss caused by medical conditions, medications or stress is often treatable and reversible. Your hair may even return on its own.

Although hair loss in women caused by aging and heredity is usually permanent, you may wish to ask your physician about these options:

• Wigs If your hair loss is widespread, wigs may be a relatively inexpensive and easy option.
• Minoxidil (Rogaine) Now sold over-the-counter, minoxidil may help stop hair loss in some people. Effectiveness varies and you need to keep using it to maintain benefits.
• Hair transplants An option for some men, these have less satisfactory results in women. However, a new method, called micrograft hair transplantation, uses single hair grafts and has been successful in selected patients.

Personal Tips from Dearest:

If it's any consolation, many women who've experienced thinning hair or hair loss during the perimenopausal years will see an end to the thinning and loss once their homones level off and they're post-menopausal. If all the hair doesn't necessarily return (and often much of it does), there's likely to be no additional loss.

• I know how many women adore their long or blunt cut tresses. However, if you can see your way to it, it's often a good idea to cut your hair short and in layers. Shorter, layered hair adds fullness and body and, as opposed to longer hair, there's no heavy "pull" from the scalp.
• Don't use combs, but soft brushes and try to avoid things like hair spray. Using a "good" mousse (I use Clairol Condition) or soft gel after washing can give your hair additional body without harming the hair.
• I have a trick for fine hair or thinning hair: Blow dry in the opposite direction to how you normally part your hair. When dry, brush it back in the other direction. I learned this from Vidal Sassoon years ago. You can double the "look" of the volume of your hair. I've been doing this for about 20 years.
• Another tip is after washing your hair, dry it in whatever manner you normally do. Then turn your head upside down, give your head a vigorous shake, and once back in a standing position, either "place" your hair using your fingers, rather than a brush or comb. You can also use a hair pick to style your hair. The upside down - shaking - also gives a great deal of fullness to otherwise flat looking thin hair. You'd be amazed at how creative you can be with your fingers without pulling at the root of the hair.
• Avoid using any type of hair comb and anything that "tugs" at your hair.
• I always alternate shampoos -- at least once a month - another thing I learned from Vidal Sassoon many years ago.
• If you've had hair thinning at the temples (which many of us have from wearing hair pulled back in ponytails when we were younger), cutting your hair short and creating whispy bangs can camouflage the areas that have thinned out.
• If you go to a beauty salon for a haircut, tell them you don't want your hair cut in a "feathering" manner. Feathering has a tendency to make hair look even thinner. What you want is to achieve full looking layers, not anything too wispy and thin.

The big question: Is there any connection between what you put in your mouth and keeping a full head of hair?

For men, the answer is a resounding no. (Sorry, guys. Except in cases of extreme malnutrition, no amount of vitamins or minerals will regrow hair.) But for some women who have experienced hair loss related to physical trauma, crash dieting or heavy menstrual flow, the answer is yes.

Actually, when it comes to hair loss, everyone is a loser—all of the time. Even the owner of the world’s most luxurious locks sheds 50 to 150 hairs a day. What separates him from the guy who could double as a billiard ball? In someone with a full head of hair, new hairs constantly grow in, filling all of the empty spaces. Whether you sprout enough new hairs to prevent baldness depends mostly on your parents. Genes are the culprits in what is known as male- or female-pattern baldness.

Researchers have found, however, that certain nutrients often seem to be determining factors in hair regrowth in women.

Iron and the Maiden

When a woman loses iron because of something such as trauma, poor diet or heavy menstruation, several things happen. Among them: Her body literally stops producing hair until she gets more iron.

“I’ve been practicing medicine for more than 30 years now, and it’s my experience that in most females who are menstruating regularly, there is mild to severe iron-deficiency anemia,” says Wilma Bergfeld, M.D., a dermatologist and director of the Section of Dermatopathology (the study of the causes and effects of skin diseases and abnormalities) and Dermatological Research at the Cleveland Clinic.

The Daily Value for iron is 18 milligrams. But getting enough iron is only part of the picture, says Alexander Zemtsov, M.D., associate professor of biochemistry and molecular biology at Indiana University School of Medicine in Indianapolis.

Because iron absorption is boosted by vitamin C, he recommends talking to your doctor about a prescription for Niferex with Vitamin C. Each capsule contains 50 milligrams of iron and 100 milligrams of vitamin C. Or you can get over-the-counter Niferex, which has 50 milligrams of iron, and take it with 100 milligrams of vitamin C. “I recommend taking one of these capsules a day until the hair is back to normal, usually in two to three months,” says Dr. Zemtsov.

High daily intake of iron can cause iron overload in some people. For this reason, doses exceeding the Daily Value (18 milligrams) should be taken only under medical supervision.