Written by Dr. Sanjana V.B Bhms,dbrm,cdn

Founder & medical director of siahmsr wellness.in

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Reviewed by SIAHMSR medical team.

Climacteric hair loss

   Climacteric is the period of life which begins with the decline in ovarian activity . According to the definition, the period includes peri-menopause, menopause and post-menopause. This is a transition phase  in the life of women, and it is accompanied by various health consequences i.e., menopausal symptoms, osteoporosis, coronary heart disease, or Alzheimer's disease etc.

  Menopausal hormonal fluctuations have deep impact on women’s body and mind. The hair also undergoes some changes. The average age of natural menopause is about 49–51 years.

Hair cycle

Hair cycle includes sequential phases of growth and rest that each hair follicle goes through ,such as

1. anagen (active hair growth)

2. catagen (involution)

3. telogen (resting)

4. exogen [release of telogen hair] .

   In physiological conditions, on the scalp of a person  80% of hair may be in the course of growing (anagen), 1% in the period of involution of hair follicle (catagen) and the rest of percentage is hair in the rest period (telogen).

 It is common in menopausal women to have decreased hair density and alopecia. The hair of women during menopause is affected by fluctuations in circulating levels of sex steroids. Almost 20-60% of women before reaching the age of 60 suffer from hair loss. The most common form of progressive alopecia in elderly women is female pattern alopecia (FPA), which often worsens during the perimenopause, particularly if it begins much earlier in young women.

Female pattern hair loss is a common problem affecting a large number of women globally. The decreased anagen phase duration and regression of scalp hair to finer vellus hair are particularly caused by androgens in FPA.

   Most often FPA is studied in relation to androgens in the field of hair research but now there is increasing scientific and clinical data availability to suggest that non-androgen signals also can affect the folliculo-sebaceous unit in causing FPA.

Certain drugs and hormone replacement therapy has impact on hair loss in climacteric women. Tibolone, as an alternative to hormone replacement therapy (HRT), has been reported to increase the severity of diffuse alopecia and possibly induce facial hypertrichosis.

The decreased anagen phase duration and regression of scalp hair to finer vellus hair are particularly caused by androgens. They commonly lead to climacteric alopecia [3].

However, it must be noted that some women presenting with alopecia do not have an increase in circulating androgen levels. It indicates that probably androgen skin receptors are abundant or  other androgen-independent mechanisms are involved in these women leading to hair loss .

FPA predominantly affects hair follicles from the parietal and fronto sagittal areas of scalp.

This may lead to bitemporal hair thinning but leaving an intact frontal hairline.

In FPA, both the scalp stratum corneum and the hair shafts show a decreased capacitance level indicating an impaired moisturization. Hair capacitance mapping seems to be a promising method in the assessment of the dynamics of hair surface moisture.

  The discovery of estrogen receptor beta has  brought significant change in hair biology and FPA. It has  redefined previous concepts of estrogen activity and signalling in hair biology.

    It is postulated that estrogens modulate hair growth due to their influence on a few other hormones, growth factors, transcription factors and cytokines. The menopause is a period of declining  estrogen levels.

    According to a study conducted in pre- and postmenopausal women without alopecia, it has been reported that menopausal status significantly influenced hair parameters such as hair growth rate, percentage anagen and hair diameter distributions, most notably in the frontal scalp. This elucidates the role of declining estrogen in hair loss in menopausal women.

 Analyses of hair amount using a model of hair density and hair diameters suggest that the impact of changing hair parameters is most notable in the mid-forties for women.

Frontal fibrosing alopecia (FFA)

   It is a particular type of hair loss which is probably worsened by menopausal hormonal fluctuations, although hormone replacement therapy [ HRT] cannot help to control it. Postmenopausal FFA is a distinct cicatricial alopecia .

 It is characterized by the destruction of the upper portion of the hair follicle by a lymphoid cell infiltrate. This process may lead to a symmetrical regression of the frontal and temporal hairline, combined with partial to complete loss of hair from the eye brows.

The hair loss is manifested relatively late in FFA during the disease progression. Therefore FFA is often seemed to be stable initially and this may impact the treatment efficacy later.

Moreover, it is still enigmatic how climacteric changes cause this selective targeting of the frontotemporal scalp. In a small percentage of women some benefit for FFA has been reported with androgen-dependent therapy.

Treatment  

Conventional [modern]medicine

 Oral antiandrogens and topical minoxidil may help to regrow some hair. However, early diagnosis and initiation of treatment is recommended as these treatments are more effective at arresting progression of hair loss than stimulating regrowth.

Adjunctive nonpharmacological treatment modalities include:

·       Counseling

·       Cosmetic camouflage  

·        Hair  transplantation

Complementary &alternative system of medicine

Homeopathy

Internal medications to address or reduce the symptoms of menopause related hormonal imbalances are prescribed. Some medications include Carbo veg, Lachesis, Sepia etc. Medications are prescribed on parameters based on individualization. Some topical medicated applications also are recommended by homeopathic physicians for climacteric hair loss.

Nutritional intervention

The perimenopausal and menopausal women are suggested to take a well-balanced diet rich in essential nutrients listed below. Supplements are recommended  in cases of poor intake  and severe deficiency  resulting from multiple causes.

· Beta-carotene

Beta carotene is important to hair growth as beta-carotene is converted to vitamin A which helps growth of hairs. Preformed vitamin A is found in foods from animal sources, including dairy products, eggs, fish, and meats. Include more leafy green vegetables, orange and yellow vegetables, tomato products, fruits, and some vegetable oils.

· B group vitamins

  B Vitamins are significantly important for healthy hair, particularly vitamins B1, B2, Niacin & Pantothenic acid. Reduced levels of thiamin (vitamin B1), riboflavin (vitamin B2), niacin, and pantothenic acid can contribute to the undernourishment of hair-follicle cells.

Sources of B vitamins are Fortified breakfast cereals, fish, beans, lentils, green peas, enriched or fortified cereals, breads, brown rice, sun flower seeds ,yogurt.

Vitamin B5 (pantothenic acid) gives hair flexibility, strength and shine and helps prevent hair loss and greying.

Pantothenic acid is found in a wide variety of foods like nuts, seeds, dairy milk, yogurt potatoes   eggs, brown rice oats ,broccoli,  fortified cereals ,organ meats (liver, kidney), beef, chicken breast,  mushrooms, avocado.

· Folic acid

This B group vitamin [vitamin B9] is very crucial for hair growth as folic acid deficiency may contribute to decreased hair-follicle cell division and growth. Folic acid is also essential for the maintenance of healthy methionine amino acid levels in the body. The sources include:

Turnip greens, spinach, romaine lettuce, asparagus, Brussels sprouts, broccoli, black-eyed peas, mustard greens, green peas, kidney beans, canned tomato juice, oranges, grapefruit, papaya, and banana, avocado.

· Biotin

 Biotin or Vitamin H, more commonly known as biotin, is part of the B complex group of vitamins. A study conducted at Harvard University suggests that biotin is one of the most important nutrients for preserving hair strength, texture, and function. People who are eating adequate amount of protein should not have a problem with biotin deficiency, though vegans may be at risk.

Good food sources of biotin are eggs, liver and soy.

Biotin from natural sources helps hair growth. However, biotin intake as a supplement for hair loss is not having any scientific evidence.

• Vitamin C

  Vitamin C intake is crucial in patients with hair loss associated with iron deficiency as it plays an essential role in the intestinal absorption of iron. Menopause may be associated with menorrhagia and metrorrhagea and depleted iron stores resulting from it. In case of severe deficiency supplements are recommended.

Vitamin C also helps to build collagen, which is crucial for promoting hair growth &maintaining the strength of hair. Collagen plays a significant role in maintaining the health of scalp and hair follicles. It is the primary component of the dermis that contains hair follicles and plays a key role in repairing the dermis and the skin on the scalp at the base of the hair follicle.  Therefore, declining collagen levels, in menopausal women may contribute to subsequent hair loss. The main sources of vitamin C are strawberries, papaya, potato, broccoli, kiwi fruit, mangoes ,guava ,gooseberries ,bell peppers etc.

• Vitamin E

  Vitamin E helps to maintain the integrity of cell membranes of hair follicles. The vitamin provides physical stability to cell membranes and acts as an antioxidant while promoting healthy skin and hair.

Vitamin E is involved in the oxidant/antioxidant balance and helps to protect against free-radical damage.

Sources of vitamin E include nuts and seeds, wheat germ oil, Sunflower, safflower, and soy bean oil, sunflower seeds, almonds, avocado, peanuts, peanut butter, beet greens, collard greens, spinach & pumpkin.

• Amino acids

Amino acids also play a vital role in hair health. Proteins are the major sources of amino acids.

L-Methionine, one of four sulfur-containing amino acids, supports hair strength by providing adequate amounts of sulfur to hair cells. Hair requires sulfur for normal growth and appearance.

L-Cystein – supports hair strength by the provision of sulphur.

The chief sources of methionine are animal products as they contain all the essential amino acids and include meat, fish, poultry, eggs, and dairy products. The plant sources are sunflower seeds, tofu, edamame, black beans, refried beans, cashews.

• Proteins

Proteins are very important in the growth and maintenance of strength of hair. The daily requirement is 0.83 g/kg BW. Sources of healthy proteins include lean meat, legumes such as beans and peas, nuts &seeds, milk, cheese, and yogurt, whole grains, vegetables ,eggs, soy products.

·     .  Minerals

It has been found that certain minerals including iron, magnesium, sulfur, silica, selenium and zinc are also very important for maintaining healthy hair.

Selenium

It is an essential trace element that plays a role in protection from oxidative damage as well as hair follicle morphogenesis. The mineral is involved in hair formation and is needed by the body for regulating and activating thyroid hormones, imbalances in which can lead to hair fall.

Liver, fish, eggs, whole grains, meat, fish, nuts etc. are excellent sources of selenium.

 Iron

Telogeneffluvium is a type of excessive amount of hair loss related to deficiency of iron. It is essential to ensure the intake of iron, and maintain adequate amounts of serum ferritin [iron storage in the body]. Consume more leafy vegetables, beans such as red kidney beans, dates, chickpeas, seafood etc.

 Iodine

Iodine is a mineral that is important for synthesis or production of thyroid hormones. Any changes in the hormone levels can lead to hair thinning and hair loss. Main sources of iodine are seaweed (nori, kelp, kombu, wakame),fish, shellfish (cod, canned tuna, oysters, shrimp, iodized table salts ,dairy (milk, cheese, yogurt)eggs, beef liver, chicken.

• Healthy fats

Omega 3fatty acids

Omega 3fatty acids also have a significant role in hair growth and maintenance of scalp and hair follicular health. The essential omega-3 fatty acids found in fish sources, prevent a dry scalp and dull hair color.

Vegetarians [pure vegans] are at risk of these nutrient deficiency, if they are not choosing diet carefully or do not take supplements. They help in reducing dryness of scalp skin.

Most popular sources of omega 3 fatty acids are walnuts, chia seeds, flax seeds, fish oil, flaxseed oil etc.

These are vital nutrients that support the health of hair follicles. Whenever the follicle health is compromised, hair loss or thinning occurs.

References for further reading

1.    Mirmirani P. Hormonal changes in menopause: do they contribute to a “midlife hair crisis” in women? British Journal of Dermatology. 2011;165(s3):7–11 https://pubmed.ncbi.nlm.nih.gov/22171679/

2.    Messenger AG. Hair through the female life cycle. British Journal of Dermatology. 2011;165(supplement s3):2–6. https://pubmed.ncbi.nlm.nih.gov/22171678/

3.    Dinh QQ, Sinclair R. Female pattern hair loss: current treatment concepts. Clinical Interventions in Aging. 2007;2(2):189–199. https://pubmed.ncbi.nlm.nih.gov/18044135/

4.    Xhauflaire-Uhoda E, Piérard-Franchimont C, Piérard GE, Quatresooz P. Weathering of the hairless scalp: a study using skin capacitance imaging and ultraviolet light-enhanced visualization. Clinical and Experimental Dermatology. 2010;35(1):83–85

https://pubmed.ncbi.nlm.nih.gov/19583736/

5.    Dawn G, Holmes SC, Moffat D, Munro CS. Post-menopausal frontal fibrosing alopecia. Clinical and Experimental Dermatology.

https://pubmed.ncbi.nlm.nih.gov/12558629/

6.    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6380979/

7.    https://www.hsph.harvard.edu/nutritionsource/iodine/

8.     http://siahmsrwellness.in/nutrition/list/essential-nutrient

9.      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9324272/

10.                       https://www.drugwatch.com/health/collagen/hair-growth/#:~:text=Collagen%20contains%20amino%20acids%20used,layer%20that%20contains%20hair%20follicles

11.                       http://siahmsrwellness.in/vitamin-b-complex

12.                       https://www.medicinenet.com/what_foods_are_high_in_methionine_what_good_for/article.htm

13.                       https://pubmed.ncbi.nlm.nih.gov/12188398/#:~:text=Climacteric%20is%20the%20period%20of,%2C%20menopause%20and%20post%2Dmenopause.

14.                        Shapiro J. Clinical practice: Hair loss in women. N Engl J Med. 2007;357:1620–1630.

15.                       https://pubmed.ncbi.nlm.nih.gov/22938001/