90 – Hair loss, hormones and menopause: what’s really causing it? Archana Rao

0:02So lots of people ask about their hair and our hair is changing all the time. I look at my teenage children and their hair is very thick, it's very long and my hair will never grow long, it's just one of the ways it is and I know my hair texture is different to how it was several years ago but time and time again in the clinic people tell me that their hair changes in quality, changes in texture, it changes in density, and I know it's related to their hormones. So I'm really grateful that you're here today to just talk about hair. So many people just think it's something on our heads. They don't realise that it's not just what we put on it as well that makes a difference.

0:44So you are a dermatologist, a specialist in skin and hair, actually. And it's important that we think about skin and hair differently, don't you think? Absolutely. Because people will come to a dermatologist, Louise, and they'll say, you know, I have a skin problem. But very often they are at loss as to what to do or who to go to when it's their hair problems that they are worried with. And remember, I agree with you 100%. Hair is a woman's crowning glory, rightly so. You know, it's amazing how much people underestimate it. The fact that you get up in the morning, you see a good head of hair. It doesn't, I don't think it sounds artificial or superficial in any way, but it can actually make or break your day.

1:28I see women who, you know, they shed loads of hair in the morning. It can dampen their self-confidence and it comes at a very vulnerable time in their life. that is what drew me to understanding more about skin and hair especially in perimenopause or menopause because I've had more than one patient come in and say you know things change we put on weight our body is not the same we get more stressed we can see lots of changes happening in our body we see spots coming out like teenage spots but when the hair starts falling it's the last straw. And it really defeats their self-confidence. And when I looked at literature, I realized actually, you know, there's so much in dermatology.

2:12We study the length and breadth of skin and hair problems. But there's pediatric dermatology, there's geriatric dermatology, there's skin cancers, but nobody is actually focused on the skin and hair problems in menopause. and in a world today where we're talking so much about menopause, how it's impacting women today, how understanding it, treating it can empower them in this really good, best, what should be their best phase in their life. I thought, okay, there's very little over here. So I have spent my last 10 years as a consultant and even more trying to understand that and streamline it for my patients.

2:51Yeah. And it's, it is so important because it's something we're not really talked about I wasn't taught about at medical school about hormones and when I did dermatology I wasn't taught about the impact of hormones on hair and we see it a lot and people like you say are very confused who to go to to get advice there's lots of people who market themselves as hair specialists and they might be okay looking at the scalp but they're not they're not trained in medicine you know as a dermatologist you are trained in general medicine as well and that's really important because there are a few conditions that are not related to hormones that can contribute to hair loss.

3:31So as doctors, we're always making sure we're not just blaming the hormones. Yes, absolutely. And that's really important. So firstly, to start off with, it's a really good question. Who should I go to? And we had a survey, actually. So one of my roles is education. I'm very passionate about education. So we have the British Association of Dermatologists, a small subgroup called the British Hair and Nail, which looks at all hair and nail diseases across the country. We give advice. I chaired the meeting, the annual meeting recently, and we had a very interesting paper about who people go to when they first have this problem.

4:11And there was trichologists and there was dermatologists, there was hairdressers, but nobody even mentioned their GP, which was really something that I found slightly shocking. But this is what I would say when you have a hair loss problem. And a lot of my work, Louise, is also on GP education. So I do a lot of GP education. you can discuss it with your GP because like you said very correctly a general practitioner a doctor who's trained in medicine will be able to notice that's pathology that's ball patches I think that needs to go to a dermatologist actually it's a bit of shedding I think this is female pattern alopecia or stress indias which is telogen effluvium so I may do run some blood tests and oh actually it's an underactive thyroid correcting that can be as simple as that so a GP is a good start a trichologist is and I I'm lecturing I lecture for trichologists because I think it's so important they understand pathologies and work within their scopes yes if they see somebody with female pattern alopecia they should be well equipped to tell them actually you can use minoxidil topical minoxidil and they're a huge asset because I honestly, if I'm running a service and I run one on the NHS, it took me many years, Louise, to convince managers to have a hair loss clinic for dedicated medical causes on the NHS.

5:35Well, I don't want to be seeing that. If you can deal with that, if you can recognize female pattern, tell them what the advice is. I'm so happy with that. But when you have different pathologies, so when you have alopecia areata, patchy hair loss, or when you have potential scarring alopecia and we'll talk about in a minute something which I see very commonly in perimenopausal and menopausal women called frontal fibrosing like the name suggests. It's scarring alopecia so it actually permanently damages the hair follicles. These are the patients that I want trichologists, GPs to recognize this is a pathology and this needs to go to dermatologists.

6:15Again I would say you send it to a dermatologist with a special interest in hair because not all my colleagues like or are well trained to see hair patients and it's it you know like I would say I'll see a paediatric eczema but if it goes beyond step three I will refer it to somebody who specializes in paediatrics similarly for me. Yeah and that's really important to see the right doctor so a lot of people trivialize hair and you know a lot of people think well actually if I've got it and something like eczema you can see it you can give people sympathy but all our hair is different so me thinking my hair's thinner it still might be thicker than somebody else and then people trivialize it so it is really important to make sure that medical causes like you say like thyroid imbalance or iron deficiency is excluded before just thinking about hormones but there are some conditions that are more associated with perimenopause menopause hormonal changes because as we've said before on other podcasts all three hormones actually even testosterone which people don't realize beneficial for hair growth and keeping the hair follicles as healthy as possible the skin healthy the blood supply to the scalp all these things are really important for our hair but you've mentioned this condition frontal fibrosing alopecia which is It's almost exclusively happens in women, doesn't it?

7:43And it can be associated with hormones. But the treatment is more than just giving hormones back. And I do want to talk a little bit about it because I haven't spoken about it before, but it is very, very common. And the more I look out for it on people walking down the street, the more I can see it. And I think women don't go and get advice. And if they do, they don't see the right person. So do you mind just explaining what it is, how we can diagnose it? the treatment options? Absolutely. And thank you. So Louise, one thing, it's one of my research options. So I saw my first patient and she was a mother of a GP.

8:23And she had been, as I joined as a new consultant at Kingston, they asked me to, they requested me to see her. They said that the new consultant who's joined has an interest in hair. So why don't you see her? And she was diagnosed as female pattern alopecia as most perimenopause and menopausal women are. When I saw her, her hairline from here was somewhere down there. So it was over here on her crown, her hairline. So she'd lost all that hair. And I spoke to her about it. I said, yeah, this is frontal fibrosing. And she wept, Louise, she just wept in my place. She said, if someone had did it, would I still have my hair?

8:59Do you know how decapacitating is to walk out without hair to walk around looking bald and people staring at you. And that's when it became an area of interest. Now, Louise, it's for whatever reasons, we never knew about this condition two decades ago. It's just sprung up two decades ago in literature. And then the number has increased fast and furious. In fact, some of my recent lectures at the trichology conferences internationally have been the epidemic of frontal fibrosing alopecia because rightly so. I like you. I walked down the street, I'm in Sainsbury's and I'm like, oh, she has frontal fibrosing alopecia.

9:37I don't know if she knows about it. So frontal fibrosing alopecia, you're right. It's almost exclusively seen in postmenopausal, predominantly Caucasian females. However, it's becoming really common now. I've seen it in younger women. I see it in all races, Asians, Afro-Caribbeans. I've even seen a few men with it. But the majority of women are menopausal. So we do believe that the hormonal tilt which happens in perimenopause predisposes towards that. There's a role of genetics. And because there has never been anything documented more than two decades ago. Look, we've known about psoriasis and eczema for decades and decades and centuries.

10:21We've never known about this. So we are, a lot of our research is directed to finding out what in the environment over the last two decades could have possibly triggered it. And under the scanner are creams, facial creams, because a lot of more cosmeceuticals that people use on their face and up and above that sunscreen. So we're looking at it, but we're still in a gray zone. We don't know exactly what can cause, and it's going to be a tricky one. The one thing we can do about is we understand it's hormonal. What is really important for women to understand is its permanent hair loss. So you see with a loss, it starts off with a loss of hair on the eyebrows.

11:00And most women, not wrongly so, presume that this is a part of menopause and say, oh, my hair is thinning. But when the hair margin starts going back, so it starts receding back, and sometimes the scalp can be itchy to a point they can't sleep. Sometimes it can be asymptomatic, but they see the margin receding backwards. Now, if it is treated in time, it's completely stoppable. You can't reverse it. You can't get hair that has already been lost, but you can definitely prevent more damage. And that's why I think it's really important for GPs to recognize, for trichologists to recognize and send them to a specialist like myself, because then we can lay out the treatment options for patients.

11:43And the treatment options are varied. They can start off with topical steroids. If it's very localized, I even inject steroids into the scalp. And sometimes we need more systemic treatments or immunomodulatory treatments like hydroxychloroquine, which have been used for years in things like rheumatoid arthritis and, you know, lupus, things like dutestosteroids. So there's more research coming in, but there's very little in terms of guidelines. I am actually, we are working on the national guidelines with two of my junior doctors. So, but there are treatment options and we assess the patients and we treat them, advise them accordingly.

12:23So is it thought to be more of an autoimmune process where the body is attacking itself? Like we see a lot more autoimmune diseases in perimenopausal and menopausal women. Absolutely, we do see and I see an increasing number of autoimmune problems, skin as well as hair. But this definitely comes under autoimmune. And the way I explain it to my patients is we have immune cells, all of us do. It helps us fight against infection. Now, for reasons we don't completely understand, but usually in a genetically predisposed, hormonally predisposed person, the last thing, the last cascade to kind of set it off is usually stress.

13:05and lots of times you'll have people who will put it connected to a stressful event with loss of a spouse, loss of a parent. I even had one lady and she said I was on the jury for a very soul-destroying case of child abuse and I remember this happened shortly afterwards. So stress is that last trigger that puts that cascade into flow and those immune cells which protect our body, just turn around and start targeting the body. If they target the thyroid glands, we get thyroid problems. If we target the joints, you can get arthritis. Here they target the scalp and it results in alopecia. So yes, it's predominantly, for all practical purposes, genetically predisposed, hormonally influenced autoimmune hair loss.

13:55And it's very interesting because I've got particular interest in autoimmune conditions and the immune function of our hormones. And people don't often realise that all our immune cells, the way that they work optimally, so better, is when they've got hormones present. And a lot of women I see with this condition, and any hair loss actually, are very scared of taking testosterone because they feel that they're going to get this male pattern baldness because of testosterone. Yet when I measure their level of testosterone, it's usually undetectable. It's really low. But they think it's going to make it worse.

14:30but we know that testosterone can be very beneficial for autoimmune conditions because it can help the way the immune cells and also our mitochondria function better in the presence of testosterone. And it might be because women have less testosterone than men. It's one of the reasons that we get more autoimmune conditions because men are protected with their testosterone. So it's not a reason if someone has this condition, it doesn't mean they can't have testosterone. And I think it's really important that people realize that as well. Do you know what, Louisa, and that for me, I've read your work and I know that your research is predominantly on that.

15:09And for that, you know, again, for a lot of dermatologists like myself, this is a huge learning curve. Because when you when we are learning a condition which is evolving in front of your eyes, you're living, you're learning, you're researching and you're trying and putting things together. But you're right, it's very commonly asked to me, should I take HRT? Will it fix the problem if I take HRT, if it's a hormonal problem? Now, the truth, Louise, is it's not going to fix it. Once this sets in, it needs treatment other than HRT. But like you said, I completely and wholly agree. If your hormones are array, and it's not actually fitting in, your body is less receptive to treatment.

15:50So I always explain it to a patient like it's like putting pieces of a puzzle together. You know, if you're diabetic and you've got eczema and sores on your body, unless you treat the diabetes, your skin's ability to heal is impaired. So you can slap on all the amount of creams on your eczema, but it's going to keep coming back. Same with things like HRT. If your estrogen is really low, your testosterone is down to the boots, your hormones are all over the place. your body is less likely to respond to treatment. So I, for one, a lot of my treatment protocols, I will tell them, I say, of course, HRT is not my remit.

16:28It would be a remit of someone like yourself. And I would tell them, you see a specialist, get it done. It will help the overall management. And putting things together as a whole is much more important than choosing bits and pieces. And it's so important because there's so much in medicine, and it's very siloed. And it's very seldom to see a woman who's perimenopausal or menopausal that doesn't have other symptoms. So although for them it might be their hair, but they also might have dry, itchy skin. They might have palpitations. They might have urinary tract symptoms. So it's making sure that as doctors we're asking the right questions and piecing it all together as well.

17:08But certainly hormones have a hugely important role on the skin and the hair. And often I say to women, you know, your skin is a window into our bodies. And what frustrates me, and I know it does you too, is this plethora of menopause branded products, you know, menopause shampoos, menopause face creams. And that's really not fair on women because it's not treating the underlying problem. But it's also trying to say to women, it's very superficial, like your face is more important than the other area of skin in your body. and your hair is all very topical, you know, if you put something on it.

17:46And it's not like that at all. It isn't. And you're absolutely right. You know, lots of things in your career as a doctor, they kind of shape the direction you take and your interest. So one of the things, again, when I would sit in clinic, I would have ladies coming and they would have bags of stuff. I bought this, I bought this. And one old lady, I still remember her, she came and she said, oh Dr. Rao I went I was told to see someone you know with respect to hair loss I went there they told me oh you know apply some minoxidil and they gave me a blow dry and I was with a bill of thousand pounds I don't want a blow dry I didn't want a fancy blow dry I just wanted someone to tell me what's wrong and then when you look at it the amount of money and energy and it also has a negative impact on your mental health when you keep on spending money and time and energy so yes I 100 % agree with you.

18:40I'm very against this marketing gimmick of, you know, this is a menopause related hair loss shampoo. And of course, you have everybody over 45 buying that shampoo. A shampoo cannot fix hair loss. It just cannot. There is never going to be a shampoo that fixes hair loss. I always tell my patients finding a good shampoo is important and I choose it for them. I help them choose it. Let me put it that way. Because it's like soil. You know, your soil will be clean your your plants will grow so obviously your hair will grow if it's dry scaly lots of syboric dermatitis or inflammation scales it's going to struggle to grow but that's the role it has a shampoo is never going to cause you to you know get hair back again whether it has got caffeine in it or anything else you know I'm not buying it and I that's what I want to educate women that if you want to put your money and your time and your resources you put it where it will actually give you some results and then you know you've tried the best and then you make peace with it and more likely than not Louise when they do use the correct advice and they're given the correct explanation they're much happier and much at peace so if for example if you see a woman with frontal fibrosing and you don't explain to her you know the hair has gone back this one you won't get but let's try and stop this from spreading backwards she's going to consider every treatment to failure because my hair is not coming back.

20:05So it's education. It's key. Yeah, absolutely. And I think what's really important is that don't feel ashamed asking for advice and help because so many dermatologists, sadly, are not trained specifically in hair changes and hair loss, especially when it comes to hormonal changes as well. So sometimes people have to see a few doctors before they find the one and some doctors will say well it's only your hair but actually if you are noticing changes it is definitely worth speaking to somebody but also just remind yourselves or know that any hair loss it can be associated with events that happened several weeks even months before so sometimes people say you know I started testosterone and the next day my hair fell out well it's not going to be like one application of testosterone so because of the way the hair cycle is so it's very important you have to be a bit of a detective when it comes to hair loss I've realized and I often ask for advice from colleagues and it's really important that as doctors we we think about it in a very multifactorial way but having having advice from people who understand and also can give treatment options because often in dermatology, like in other areas of medicine, it's not just one treatment that's the game changer, is it?

21:32Yes, is it? And lots of times I explain this to my patients when they come to clinic, you know, they want one answer. They want one treatment that will fix it for good. And I often tell them, especially when they're shedding, I say, look, all of us go through hair loss as we grow older. It's not pathological, It's physiological. That's the way the hair cycle thins out. Like you said, you compare yourself with your teenagers. If I compare myself with my 12-year-old daughter who had exactly the same hair when I was her age, it's much thinner and that is to be given. But when you have female pattern alopecia, your hair shouldn't shed.

22:06It shouldn't be shedding and falling like that. So then that means there's something else added to it. And that could be iron deficiency, a very common cause in this age group. and it can be a host of things, vitamin D differentiator, an underactive thyroid gland, a drug that's not suited in. You're right, it's a bit of detective work. You've got to go back three to six months. Is that a new pill that you've taken? I've had people who've had hair loss post-collagen, you know, when they're taking collagen to get thicker hair. So it is being a bit of a detective. It is trying to find out and it's not always one solution.

22:39It is a combination of things and by perimenopause and menopause you've got to understand sometimes it's a host of things that you've got to put together to make it work. Yeah and it's been patient as well because any any skin condition, hair condition, it can take several weeks or months to see a response and that's going from whether it's acne, whether it's eczema, whether it's hair loss, you know you have to be as a dermatologist incredibly patient don't you? Absolutely and I think that's what I tell them I tell them I'm not there's no follow-up for a hair patient before six months there just isn't unless it's alopecia areata which is the patchy hair loss and I inject those sometimes with steroids so I call them more often for otherwise for things like this I say no it's six months because it is going to take time your hair cycle is anywhere between two or six years we halt the process we assess it we take it yeah so a lot of time goes into that initial consultation, trying to, and that's why, you know what, Louise, I do, I send a questionnaire now because I've read it.

23:43I have a tentative diagnosis by the time they come in. I obviously examine their scalp and see if it all kind of marries in. And most of my time then is spent in counselling because it's breaking so many myths people have in their minds, you know, about what is right and what to expect. Yeah, it's so important. So I'm very grateful for your conversation and I'm sure we'll have more in the future because we can ask the audience, you know, what other topics they want to have because there's, you know, you've got such a wealth of experience and knowledge and you can't see all the women that have hair thinning and hair changes because it's so, there's so many of us.

24:19So we will ask about what other topics and hopefully you can come back for more. So just finally before I finish, I always ask for three take-home tips. So three things that women should do if they think that actually they might have this frontal fibrosing alopecia and they're worried maybe they've lost the eyebrows they're losing some of their hairline what are the three things that you would say to those women? Absolutely so I think the three things these are the warning signs or the little red flags that I want women to think about when they're looking at hair loss and they've heard us and they said not quite sure if I have that or not if you have symptoms on your scalp which is soreness tenderness any odd symptoms on your scalp if you see your hair margin going back receding backwards in a fashion that is not normal for you and or if you see any rashes on your scalp you look and you say why is that red I feel this very red look there's not feeling anything but I'm finding a little bit of redness out here so definitely have it looked at Habit Assist because it can be your key to stopping further hair loss.

25:32Perfect. So great advice and we've got information on the website as well. So thank you so much for your time. It's been a pleasure Louise. Thank you for having me.