Causes of Hair Loss
Are you worried that your hair is falling out? Is your pony tail thinner or your parting wider? You could be suffering from alopecia.
Losing hair is one of women’s worst nightmares and yet it might surprise you to know that hair loss, otherwise known as alopecia, can affect up to 49%1 of women at some stage in their life with 13% of women in their 30s being affected.2
For some, the hair loss may be sudden and obvious. It may also just be temporary and occur just a few months following childbirth or periods of stress. For others however, the loss will be slow and insidious and may not be noticeable until they’ve lost 50% of their hair.
Hair loss has more than just a physical impact, it has a massive effect on emotional well-being. Research shows that 55% of women experiencing female pattern hair loss will suffer depression as a side effect of this condition.3
Causes of Hair Loss
Whilst the impact alopecia can have on your self-confidence is evident, it may also be an external sign that something else is going on inside and the sooner it is investigated and addressed, the better. When investigating the cause, it is important to track back six months at least to identify possible triggers.
Some causes of hair loss include:
Female pattern hair loss is often due to production of excess androgens, which are a group of hormones that play a role in male traits and reproductive activity. This could be excess testosterone in women or a high conversion of testosterone to dihydrotestosterone (a stronger type of testosterone which has a greater effect on hair follicles) in men and women. This type of hair loss is most commonly found in women suffering from polycystic ovarian syndrome and will often be accompanied by other symptoms of high testosterone such as acne, growth of facial or body hair along with changes in menstrual cycle and weight gain. It is characterised by thinning hair over the crown and scalp where the front hairline usually remains complete. The initial stages are usually noticed by a widening of the central part.
So what causes excess androgens? The biggest culprit is elevated insulin.4 High insulin triggers the ovaries to produce androgens instead of estrogen. Insulin also decreases the production of sex hormone binding globulin (SHBG) which binds hormones and makes them inactive.5 Low SHBG means you have more free and circulating testosterone that acts on hair follicles.
There is mixed evidence for the role of estrogen and progesterone in hair loss. Estrogen and progesterone levels drop significantly after menopause (as well as after childbirth), causing the hair to grow more slowly and becomes much thinner. A decrease in these hormones can also trigger an increase in the production of androgens which we have already seen can lead to hair loss.
- Hormonal Contraception
Female hair loss is also often the direct result of hormonal contraception. The worst offenders are the injection, implant, Nuvaring and birth control pills such as Triphasil. These contain progestins (a synthetic progesterone) that are highly androgenic (testosterone-like) and can decrease the size of hair follicles. Hair loss from androgenic progestins may take months (sometimes even years) to become noticeable and even longer to reverse.
- Autoimmune disease
Alopecia areata frequently occurs in association with other autoimmune diseases such as thyroid disorders, anaemias and other skin disorders with an underlying autoimmune component. It affects nearly 2% of the general population at some point during their lifetime.6 It is caused by an abnormality in the immune system where the person’s immune system is attacking their own body, in this case, the actual hair follicles. When this happens, the hair begins to fall out in clumps and often, the hair loss can be quite pronounced. Genetics can play a role in autoimmune conditions including alopecia areata along with other triggers such as an imbalanced microbiome and environmental triggers.7 In some people, the hair grows back but falls out again later and in others, the hair grows back and remains.
- Thyroid disease
Thyroid hormones directly affect hair growth as they are essential for the development and maintenance of the hair follicle.8 Clinical or sub-clinical hypothyroidism is often found in patients suffering from hair loss due to an up-regulation of serum thyroid-stimulating hormone (TSH) and changes of insulin serum level.9
The most common cause of hypothyroidism in developed countries is an autoimmune condition called Hashimoto’s thyroiditis where the thyroid gland is inflamed caused by the body’s own immune cells attacking itself. In such cases, both low thyroid function and the autoimmune antibodies against the thyroid contribute to the hair loss.
- Nutrient deficiencies
When it comes to hair loss, diet is one of the most important factors. Not only can a poor diet lead to leaky gut and trigger autoimmune diseases, it can also result in nutrient deficiencies. Besides inadequate food intake and certain illnesses, increased nutrient loss and poor nutrient absorption can also cause nutrient deficiencies. Low iron, zinc, protein, folate, biotin, vitamin D and vitamin B12 have all been associated with alopecia.
Iron is one of the key nutrients associated with hair loss with women being more susceptible due to menstruation. Research has found that ferritin (the storage form of iron in your body) is the blood test marker that best correlates to hair loss.10 After giving birth, iron is frequently depleted as foetal requirements are significant in the third trimester.11 Absorption of iron can also be compromised by low stomach acid, inflammatory bowel or coeliac disease. Blood loss from excessive menstrual bleeding or stomach ulcers can also deplete iron stores.
Low iron can cause hair loss due to impaired oxygen and nutrient delivery to tissues (iron in the form of haemoglobin transports oxygen in your blood). Iron is also a cofactor in an enzyme required for DNA synthesis and reduced DNA synthesis leads to decreased growth of hair.12
- Vitamin D
Studies show an association between alopecia areata and low vitamin D levels due to its immune-modulatory effects.13 The degree of deficiency also correlates with the severity and duration of the disease. Vitamin D is also important for the normal function of your ovaries. If your ovaries do not work properly, then they aren’t producing normal levels of the hormones that influence hair growth. Vitamin D should be supplemented if levels are low.
Protein is essential as hair itself is made of the protein keratin. Thus protein malnutrition, can result in hair changes that include hair thinning and hair loss.14 In fact, every cell requires protein for life; it is needed for tissue repair and the construction of new tissue. If you do not consume enough protein, your body will compensate and adapt by rationing and cutting off the supply to the hair follicles. One of the first signs of a protein deficiency is dry and brittle hair. Keep in mind however, that protein deficiency is uncommon. In fact, most people get more than their daily recommended allowance from food and even people who don’t eat meat are not likely to lack in protein.
It is well established that alopecia is a sign of zinc deficiency with hair regrowth occurring with zinc supplementation.15 Low levels of zinc can lead to changes in the protein structure of hair follicles and the weakening of their structural integrity. Zinc plays a crucial role in DNA and RNA production which is a requirement for the efficient division of follicle cells leading to better hair growth. Zinc also helps to keep hormone levels regulated. For example, high levels of zinc in the body promotes the production of testosterone16 and high levels of testosterone can lead to male pattern hair loss. Excess zinc can also disrupt the absorption of other essential hair minerals such as iron.
- B complex
The proteins and nutrients are also needed to reach the scalp through your circulation. Your red blood cells and circulatory system require not just iron to do this but also the B complex vitamins.
B12: One particularly important vitamin is B12 which promotes healthy hair growth by assisting in the production of oxygen-rich blood cells which feed the hair follicles. At the base of the bulb which is the bottom part of the follicle, is the papilla, which contains blood vessels. Its main job is to connect your follicles to your body’s blood supply to deliver the oxygen and nutrients necessary for hair growth. As B12 helps produce red blood cells, having enough of this vitamin is essential to the hair growth process.
Biotin: Research shows that 38% of women complaining of hair loss have suboptimal levels of biotin.17 Biotin deficiency can arise due to inborn errors of metabolism and deficiencies in certain enzymes, smoking, intake of drugs interfering with biotin metabolism and inflammatory bowel disease. Pregnancy and lactation is associated with an increase demand for biotin. The research however, does not support treating women complaining of hair loss with oral biotin supplementation unless there is a biotin deficiency.
Folate: Folate deficiency can also cause hair, skin and nail changes. In fact, studies have shown that those with autoimmune-induced hair loss have lower levels of folate.18 Folic acid is also involved in the formation of red blood cells in your body which have the job of carrying oxygen to the hair follicles. It also stimulates the proliferation of the hair follicles and activates the sebum glands on your scalp which keep the moisture intact and prevent hair loss. Folate deficiency doesn’t only lead to hair loss, it can also lead to premature greying.
- Essential fatty acids
Low levels of omega-3 and omega-6 fatty acids can cause loss of scalp hair as well as lightening of the hair.19 Essential fatty acids play a role in modulating androgen action which can cause male pattern hair loss.20 Arachidonic acid, an omega-6 fatty acid may promote hair growth by enhancing follicle proliferation.21 Also, essential fatty acids play an important role in the regulation of oil production in the skin which may promote healthy hair growth.
Stress is a common cause of hair loss. Stress could be in the form of trauma, illness, undereating or some other form of physical stress. It creates inflammation and according to a research, sufferers of androgenic alopecia have higher markers of inflammation. Stress can deplete the adrenal glands that deals with the physiological side of stress as well as push the body into an autoimmune state. It can also deplete you of key vitamins and minerals many of which can cause hair loss. There are three types of hair loss that are associated with high stress levels:
1) Telogen effluvium- this is where significant stress pushes vast amounts of hair follicles into resting phase. Over the course of a few months, affected hairs might fall out suddenly when simply brushing or washing your hair.
2) Trichotillomania- this is an irresistible urge to pull hair from your scalp as a way of dealing with negative emotions such as stress, tension, loneliness or anxiety.
3) Alopecia areata- stress can be one of the triggers of this type of hair loss. Stress can trigger an autoimmune response where the body’s immune system attacks the hair follicles leading to hair loss.
- Toxin Exposure
Exposure to certain toxins including heavy metals such as thallium and mercury, for which industrial and mechanical workers are at most risk, are well-known to cause hair loss. Other toxic metals and compounds that have been associated with hair loss include arsenic, lithium, cadmium, aluminium, lead and boric acid.22 These heavy metals can upset the hormone balance, deplete the body of nutrients and can even damage the hair follicle resulting in excessive shedding and impaired hair growth. Other reported toxic causes of alopecia include selenium, vitamin A, botulinum toxin and chemicals found in the fungal species, Podostroma cornu-damae. The synthetic opioid MT-45 and mould have less evidence and their role in toxic hair loss is still emerging.
- Scalp Infections
Certain infections on the scalp can also cause hair to fall out. For example, several different bacteria can affect the skin, producing lesions and hair loss. Staphylococcus bacteria can produce scarring alopecia (folliculitis decalvans).23 Fungal infections can also cause hair loss. Tinea capitus for example, which is typically caused either by Microsporum canis or Trichophyton tonsurans, can produce scalp eruptions and hair loss in both children and adults.24 Other common infections that can induce hair loss include ringworm, Trichomycosis nodularis and folliculitis (inflammation of the follicles).
- Drug-Induced Hair Loss
Several pharmaceutical drugs have been known to cause hair loss.25 Some of the most common are:
- Anticoagulants (Coumadin, heparin)
- Antidepressants (Prozac, lithium. Fluoxetine)
- Antiepileptics (Valproic acid, Dilantin)
- Antihypertensives (Metropolol, Propanolol, Enalapril)
- Cardiovascular drugs (ACE inhibitors, beta-blockers, statins)
- Chemotherapy drugs
- Endocrine drugs (Clomid, danazol)
- Gout medications (colchicine, allopurinol)
- Cholesterol-lowering drugs
- NSAIDs (Ibuprofen, Naproxen)
- Ulcer medications (Zantac, Tagamet)
Tops Tips to Treating Hair Loss
In the same way as treating any other condition, the best way to resolve this problem is to identify the underlying cause that’s driving the hair loss. Rather than simply buying a hair supplement, it is best to investigate and address any underlying root cause (no pun intended) whether it is hormonal, inflammatory, autoimmune, nutritional, infective or stress-related.
Some things you can do in the meantime include:
- Avoid inflammatory foods such as deep-fried foods and foods with refined sugar and eat anti-inflammatory foods such as fruits and vegetables, nuts and seeds
- Maintain healthy intestinal bacteria through probiotic foods and supplements because they also work to reduce inflammation. Eat plenty of plant foods to feed bacteria, and also avoid antibiotics as much as possible.
- Ensure adequate intake of iron and zinc-rich foods including green leafy vegetables, legumes, nuts and seeds and improve nutrient intake by consuming a variety of coloured fruits and vegetables
- Address food sensitivities in the case of autoimmune hair loss
- Learn to manage your stress effectively and ensure you’re getting plenty of rest and relaxation
- Get out in the sun to increase your vitamin D levels
1 Chan, L. & Cook, D. (2018). Female pattern hair loss. Australian Journal of General Practice, 47(7). doi: 10.31128/AJGP-02-18-4498
2 Dinh, Q. Q., & Sinclair, R. (2007). Female pattern hair loss: current treatment concepts. Clinical interventions in aging, 2(2), 189–199.
3 Camacho, F. M., & García-Hernández, M. (2002). Psychological features of androgenetic alopecia. Journal of the European Academy of Dermatology and Venereology : JEADV, 16(5), 476–480. https://doi.org/10.1046/j.1468-3083.2002.00475.x
4 Navarro, G., Allard, C., Xu, W., & Mauvais-Jarvis, F. (2015). The role of androgens in metabolism, obesity, and diabetes in males and females. Obesity (Silver Spring, Md.), 23(4), 713–719. https://doi.org/10.1002/oby.21033
5 Wallace, I.R., Mckinley, M.C., Hunter, S.J. et al. (2013). Sex hormone binding globulin and insulin resistance. Clin Endocrinol (Oxf), 78:321-329. doi:10.1111/cen.12086.
6 Pratt, C. H., King, L. E., Jr, Messenger, A. G., Christiano, A. M., & Sundberg, J. P. (2017). Alopecia areata. Nature reviews. Disease primers, 3, 17011. https://doi.org/10.1038/nrdp.2017.11
7 Pratt, C. H., King, L. E., Jr, Messenger, A. G., Christiano, A. M., & Sundberg, J. P. (2017). Alopecia areata. Nature reviews. Disease primers, 3, 17011. https://doi.org/10.1038/nrdp.2017.11
8 Vincent, M., & Yogiraj, K. (2013). A Descriptive Study of Alopecia Patterns and their Relation to Thyroid Dysfunction. International journal of trichology, 5(1), 57–60. https://doi.org/10.4103/0974-7753.114701
9 Velija-Asimi, Z., & Karamehic, J. (2007). The effects of treatment of subclinical hypothyroidism on metabolic control and hyperinsulinemia. Medicinski arhiv, 61(1), 20–21.
10 Moeinvaziri, M., Mansoori, P., Holakooee, K., Safaee Naraghi, Z., & Abbasi, A. (2009). Iron status in diffuse telogen hair loss among women. Acta dermatovenerologica Croatica : ADC, 17(4), 279–284.
11 Bothwell T. H. (2000). Iron requirements in pregnancy and strategies to meet them. The American journal of clinical nutrition, 72(1 Suppl), 257S–264S. https://doi.org/10.1093/ajcn/72.1.257S
12 Kantor, J., Kessler, L. J., Brooks, D. G., & Cotsarelis, G. (2003). Decreased serum ferritin is associated with alopecia in women. The Journal of investigative dermatology, 121(5), 985–988. https://doi.org/10.1046/j.1523-1747.2003.12540.x
13 Almohanna, H. M., Ahmed, A. A., Tsatalis, J. P., & Tosti, A. (2019). The Role of Vitamins and Minerals in Hair Loss: A Review. Dermatology and therapy, 9(1), 51–70. https://doi.org/10.1007/s13555-018-0278-6
14 Guo, E. L., & Katta, R. (2017). Diet and hair loss: effects of nutrient deficiency and supplement use. Dermatology practical & conceptual, 7(1), 1–10. https://doi.org/10.5826/dpc.0701a01
15 Alhaj, E., Alhaj, N., & Alhaj, N. E. (2007). Diffuse alopecia in a child due to dietary zinc deficiency. Skinmed, 6(4), 199–200. https://doi.org/10.1111/j.1540-9740.2007.05881.x
16 Fallah, A., Mohammad-Hasani, A., & Colagar, A. H. (2018). Zinc is an Essential Element for Male Fertility: A Review of Zn Roles in Men's Health, Germination, Sperm Quality, and Fertilization. Journal of reproduction & infertility, 19(2), 69–81.
17 Trüeb R. M. (2016). Serum Biotin Levels in Women Complaining of Hair Loss. International journal of trichology, 8(2), 73–77. https://doi.org/10.4103/0974-7753.188040
18 Yousefi, M., Namazi, M. R., Rahimi, H., Younespour, S., Ehsani, A. H., & Shakoei, S. (2014). Evaluation of Serum Homocysteine, High-Sensitivity CRP, and RBC Folate in Patients with Alopecia Areata. Indian journal of dermatology, 59(6), 630. https://doi.org/10.4103/0019-5154.143567
19 Goldberg, L. J., & Lenzy, Y. (2010). Nutrition and hair. Clinics in dermatology, 28(4), 412–419. https://doi.org/10.1016/j.clindermatol.2010.03.038
20 Liang, T., & Liao, S. (1992). Inhibition of steroid 5 alpha-reductase by specific aliphatic unsaturated fatty acids. The Biochemical journal, 285 ( Pt 2)(Pt 2), 557–562. https://doi.org/10.1042/bj2850557
21 Munkhbayar, S., Jang, S., Cho, A. R., Choi, S. J., Shin, C. Y., Eun, H. C., Kim, K. H., & Kwon, O. (2016). Role of Arachidonic Acid in Promoting Hair Growth. Annals of dermatology, 28(1), 55–64. https://doi.org/10.5021/ad.2016.28.1.55
22 Yu, V., Juhász, M., Chiang, A., & Atanaskova Mesinkovska, N. (2018). Alopecia and Associated Toxic Agents: A Systematic Review. Skin Appendage Disorders, 4(4), 245-260. https://doi.org/10.1159/000485749
23 Otberg, N., Kang, H., Alzolibani, A. A., & Shapiro, J. (2008). Folliculitis decalvans. Dermatologic therapy, 21(4), 238–244. https://doi.org/10.1111/j.1529-8019.2008.00204.x
24 Martin, E. S., & Elewski, B. E. (2003). Tinea capitis in adult women masquerading as bacterial pyoderma. Journal of the American Academy of Dermatology, 49(2 Suppl Case Reports), S177–S179. https://doi.org/10.1067/mjd.2003.327
25 Richard L. Lin, Lilit Garibyan, Alexandra B. Kimball & Lynn A. Drake (2016) Systemic causes of hair loss, Annals of Medicine, 48:6, 393-402, DOI: 10.1080/07853890.2016.1180426
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