Menopause Masterclass: Why Your Hair Is Thinning and What Works

25:49Dr. Mary Claire Haver:So if the ferritin results are borderline or confusing, you may want to get a full iron panel, including a serum iron, a TIBC, which is total iron binding capacity, and the iron saturation. This can really help clarify whether iron deficiency is actually present. And in general, an iron saturation above 20 % is considered to be reassuring. So number two, thyroid testing. It doesn't just measure TSH here. Here we're trying to get really, really specific. TSH is thyroid stimulating hormone. TSH is produced in the brain and it talks to the thyroid gland to create this T3 and T4 hormones that go out into the body and do their work and the T3 is converted to T4 in the periphery.

26:37Dr. Mary Claire Haver:I'm getting clinicians will only order a TSH and then it'll do a reflex T3 and T4. But most people who diagnose hair loss and think it's attributed to hypothyroidism want to go ahead and get all the labs up front. So, and then with TSH is best around 0.5 to 2.5, rather simply within range, specifically for the hair follicle. Number three, vitamin D. Vitamin D, vitamin D. You hear me talk about vitamin D all the time. Levels below 40 are common, common, common in midlife. 60 to 80 % of women who are in postmenopause, who are postmenopausal, will expect to have a low vitamin D level. So the cutoff for, you know, deficiency is 30 for vitamin D, but low is considered to be less than 60.

27:24Dr. Mary Claire Haver:And in our clinic, we are shooting for a 60 to 100 vitamin D level. And it has been linked to weight gain, increased cancer risk, like lots of things. And it's such a simple thing. Most women do not know what their vitamin D level is. So the next time you're in your clinician's office, make sure you ask for vitamin D and certainly if you're having hair loss. Okay, number, we're on number four, vitamin B12. B12 deserves attention, particularly for women taking a GLP-1. I know many of you are. Or that acid-reducing medication like omeprazole or PPIs. or if you're following a strict vegetarian diet or a low meat diet, many clinicians like to see a B12 above 500 picograms per milliliter for optimal neurologic and cellular function.

28:11Dr. Mary Claire Haver:Reasonable thing to check. Okay, and then next is the CBC. That is a really common lab. Most of you will have it at your annual exam, at your well-woman exam. It helps to rule out anemia. It helps to rule out low platelets. It looks at your white cells, your red cells, and your platelets and their distribution as well as their size. If you're iron deficient, we tend to see the red cells shrink in size. So it really helps with this workup of looking at low iron levels and anemia. And then the Comprehensive Metabolic Panel or CMP, what we say in medicine. This is just a general baseline. Look at your metabolic function, your liver, your kidney function.

28:50Dr. Mary Claire Haver:It's not really hair specific, but it's still really important in context. And it is usually drawn routinely at your annual visit. If there are signs of androgen excess, meaning higher testosterone levels or DHT or androgen levels than we would expect, things like physical symptoms of acne, of temporal hair loss specifically, of new facial hair growing where you never had it before, chin hair, nose hair, et cetera, growing out of your ear. um anybody had ear hair like i had one and it freaked me out beyond i think that was one of the i just didn't expect it and i was like doing something and i looked in the mirror and i have like a 30x magnifying mirror because my eyesight has dwindled dramatically in menopause and with age and i swear to god it was two and a half feet long by the time i found it and i was like how How have I been walking around with this giant ear hair?

29:52Dr. Mary Claire Haver:And I had no idea. So I just say this story so that you don't feel alone and that these things happen to me as well. I plucked it. It's never come back again. Thank you, Jesus. But I'm always looking for it and feeling for it. Okay. So signs of androgen excess. New hair are where you never had it before. Scalp thinning specifically at the temples or at the crown, irregular cycles, et cetera. That's when we need to start checking your testosterone levels and something called SHBG. SHBG, you'll hear a lot about, and I did a great podcast with Dr. Jim Simon. He really did a deep dive into SHBG. It's steroid hormone binding globulin.

30:33Dr. Mary Claire Haver:Okay, so you know we talked about ferritin is like the protein that hangs on to iron. SHBG is a protein that hangs on to estrogen, progesterone, and testosterone. It is sex hormone binding globulin. It binds those hormones and renders them inactive until the hormone falls off and then it can like be free and go be active in the tissue. So the higher our levels of SHBG are, the lower the activity of our sex hormones like estrogen and testosterone. When we have a low SHBG, we may have higher activity of our testosterone, of our DHT. Our SHBG goes up when our estrogen levels are up. So especially with oral estrogen.

31:12Dr. Mary Claire Haver:So if you are on a birth control pill for treatment of, you know, heavy periods or for contraception, you will have higher SHBG typically than you would have had without it. That is going to bind the activity of your androgen hormones, okay? If you have low SHBG, as we see in menopause, you will have higher activity and more free, more of the testosterone that you have circulating will be free and active. What do you want to bring to this appointment when you go? I would take photos. Show your scalp from above and your part line and the full head. Make sure to take them under the same lighting every four to six weeks.

31:53Dr. Mary Claire Haver:In the intro, I talked about your scrolling through old pictures when you were younger. If you can show what your hair used to look like and now what it looks like now, I mean, that's evidence enough. I wish I could just tell you that you could talk to someone and they would believe you right away. but it is nice to have proof in the pictures to make it more dramatic and how serious you are about wanting to get this fixed and evaluated. If you're still having cycles, if you're in perimenopause, premenopause, you know, be specific about your menstrual cycles. How often, how heavy are your periods?

32:27Dr. Mary Claire Haver:Are they heavier than they used to be? How many hours can you last with a tampon or with a pad? Are you having to leave meetings? You know, you can't get through the night sleeping in your bed, is your mattress a crime scene, you know, on certain days of the month. These are all very, very, very important. Remember, your period should be painless, predictable, and never cause you any drama or trauma in your life. Common does not mean it's okay. Common means it happens to a lot of people. Normal means common in medicine. It doesn't mean, well, you just have to live with it. So, okay. You want to bring your medicines.

33:04Dr. Mary Claire Haver:So write down your medication list, your doses, how often you actually take it, including the purine medicines, as needed medicines, and how often you're actually taking those and any supplements that you're taking. Please bring that all, or at least the information, so that you have that ready to discuss with your clinician. You want to make note of your diet. How much protein are you taking? And so when I say diet, I want you, before you go to this doctor's appointment, to track your nutrition for a week or two. Download a free nutrition tracker. My favorite is Chronometer, C-R-O-N-O-M-E-T-E-R, chronometer.com.

33:39Dr. Mary Claire Haver:We do have a partnership with them, so full disclosure. But my daughter, Catherine, who's now in medical school, her undergrad was in nutrition science. And this was the app they used to track nutrition. It wasn't built for weight loss or calorie counting. You can do all that with it, but it was really developed to track actual nutrition. The database is really, really clean. And so use a nutrition tracker to track protein intake, caloric intake. You know, if you're in a GLP-1, you need to know how many calories you're getting in. And if you're in a very, very restrictive caloric intake, this could be contributing to your hair loss.

34:16Dr. Mary Claire Haver:If you're not getting enough protein, this most likely is contributing to your hair loss. and any recent weight loss that's not related to, you know, medication or doing it on purpose. So family history, do, you know, is there hair loss in your mother and your sisters and your grandmothers? You know, how did their hair age with them? That's all very, very, very important.

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38:13Dr. Mary Claire Haver:So now we're going to talk about treatment and I'll go over, you know, I had female pattern hair loss. I've had post shed recently, actually about three months ago. I don't know, you guys on video, you can see my hair like gets thinner towards the bottom. I had COVID and the flu kind of back to back last fall and was really, really ill. Also launching a book and working my tail off. And four months later, started having tremendous shed. That's all stopped. But I had to reassure myself in the shower, like, don't freak out. Think what was happening three to four months ago. What was happening? I was like, I'm sick.

38:51Dr. Mary Claire Haver:I was sicker than I've been in years and years and years. I was also flying all around the country, incredibly run down. And all of that probably contributed to the telogen effluvium that I was having. But on top of that, I had female pattern hair loss. My part was getting wider. My hair was getting thinner, right? I didn't have any loss of hairline, but I could just tell my ponytail was getting narrower. I used to pop rubber bands as a kid all the time. I couldn't, you know, do more than two twists. And then I was now I was doing like four. I had like half the volume of what I used to have. And so, of course, I got upset about it.

39:27Dr. Mary Claire Haver:So researched hair loss. Even though I was a doctor, I realized I don't know much about it, didn't know how common it was, and went and had my own labs done and figured out this was hormonally related to the changes I was going through in menopause and then got on some treatment therapy. And it's much, much better. So those of you who can see me on video, I still have hair. hair loss in midlife is rarely one lever problem, right? We talked about the five main causes, but really rarely is it ever just one. Combination therapy is the rule, not the exception, right? So I can't tell you, take this big expensive bottle of biotin or, you know, there's topical treatments, there's oral medications, we'll go through them all.

40:10Dr. Mary Claire Haver:And there's procedures that in combination may stop, may stop or reverse your hair loss. But the first step, the first step should be to correct any nutritional deficiencies. Let me say that again. You know, nothing topical, nothing oral, nothing procedural will compensate for an unaddressed iron, thyroid, or nutrient deficiency. Start with those. What is your vitamin D? What is your ferritin? Do you have a normal functioning thyroid? Do you have normal functioning thyroid hormone? levels. You must know those first. Again, I'm not expecting you to pull over and take notes if you're driving. We have all of this in a beautiful guide for you.

40:54Dr. Mary Claire Haver:It'll be in the show notes. You link, put in your email, and we will email you the whole guide. Okay. So let's correct the deficiencies. So how do we do that? All right. So iron, let's talk about iron. Most common thing, 70 % of women have low iron, low ferritin. Okay. How do we, oral iron is the cheapest and easiest way to get it back up. So eating iron-rich foods, but if you can't do that, if you have allergies or don't like iron-rich foods or struggling to get them, you can take oral iron, typically taken with vitamin C, and often the iron has vitamin C in it, and away from calcium coffee and tea, okay, for maximum absorption.

41:34Dr. Mary Claire Haver:325 milligrams of iron sulfate, typically once a day, twice a day. And what I've learned is you can actually have the same benefit by skipping. You go every other day with that iron dose. You don't have to take it every day. So some of the gastrointestinal side effects, some of the constipation, can be lessened by just taking it every other day rather than every single day. So there is also, and I think massively underutilized, but very, very expensive if you don't have insurance, is IV iron. IV iron, I've watched it work miracles in patients. I've seen it work in restless leg syndrome. I've seen it for hair loss.

42:15Dr. Mary Claire Haver:I've seen it for chronic fatigue. I've had IV iron myself when I was in perimenopause and having these crazy heavy periods. In getting ready for this podcast, I looked at the cost of IV iron. Like if you wanted to have it done, it's in the thousands of dollars. It can be. And often you need multiple treatments. So without insurance, it may be cost prohibitive, but is definitely worth, if you have insurance, asking your clinician if you're a good candidate for IV iron, especially if you're on oral iron and you can't get your ferritin level up. This may be kind of critical for you to be as healthy as possible.

42:55Dr. Mary Claire Haver:For thyroid disease, you want to treat to the optimal range, not just the normal range. for vitamin D, at least to get that vitamin D serum level above 40 nanograms per milliliter. And then for protein, it looks like 0.8 to 1 grams for every pound of body weight for women in midlife, especially for those on GLP-1s or in active weight loss. I have a sub stack that we just published about a week before I recorded this video where I talked about, for those of you on GLP-1s, how much protein do you actually need? Now, we're not talking about protein intake as far as hair loss goes in that substack, but we're talking about where we limited the amount of muscle loss and how much protein that would take.

43:43Dr. Mary Claire Haver:So we will link that substack in the show notes so that you can go and read that if you're on a GLP-1. So the second front, so we've talked about the common deficiencies. Now we're going to talk about treatment options, medical treatment options. So minoxidil, all right? Minoxidil extends the antigen phase of the follicle. So remember, back in the very beginning of this podcast, we talked about the three phases of hair growth, antigen, telogen, and catagen. We want 80 to 95 % of our hair follicles to be in the growing phase and stay there. And so it looks like minoxidil, as well as being a blood pressure medicine also will extend that phase for us.

44:26Dr. Mary Claire Haver:Now, minoxidil is the mainstay of treatment for female pattern hair loss. It has decades of data behind it. So for women, there's a women's version and there's a men's version because the studies were done at a lower percentage strength for hair loss in women at 2%. Men are given the 5%. Every dermatologist I've talked to says, tell women to just do the 5%. Don't pay the pink tax. Go with the higher strength and use it topically. Topical minoxidil comes in a spray. It comes in a foam. It comes in several different ways to apply it. You just have to figure out what's best for you. When I was using topical minoxidil, I've switched to oral and we're going to talk about that.

45:08Dr. Mary Claire Haver:I got the liquid version and it came with a dropper. I found the dropper to be messy and I would get drips on my face and hard to kind of put. So a dermatologist friend told me to put it in a cheap spray bottle. So I bought a little half ounce spray bottle from Walgreens, just poured the minoxidil in there, and I would divide my hair into sections and just spray along. I'd divide it five ways. So one, two, three, four, five. And I would spray along the hairline, massage it in, and go to bed. And I would just sleep like that. I was using a lot of minoxidil topically when I was working as a hospitalist.

45:41Dr. Mary Claire Haver:So, and it was super easy for me. My hair was up in a surgical cap almost every single day at work. And so it was easy for me to put the minoxidil on, throw it up in the scrub cap and just forget about it. I didn't have to worry about styling my hair, having it pretty. That topical minoxidil did tend to make my hair a lot harder to style. It tended to make it a little flat and oily. So over time, when I transitioned out of that position to where I was going to clinic every day, the hair math was getting hard on top of that i come from a family with lots of gray hair my brothers are all silver foxes my sister has let her gray come in it's beautiful i haven't obviously have not gotten there yet i'm at least 60 gray so i have to color my hair now every two to three weeks you know to keep up with the gray again that's my choice eventually i will let the gray come in so just the hair math was getting a lot because it has to be squeaky clean to get the color to stick.

46:36Dr. Mary Claire Haver:So I couldn't have minoxidil in it. And my derm friends were like, switch to oral minoxidil. And I was like, oh, I can do that? So yeah. So oral minoxidil is typically you can get it in a 5 milligram or 2.5 milligram dose. I do the 2.5 milligram and I just break it in half. It's scored. It's super easy for me to break open. And I take one of those at night just because it's easy. I put it at my bedside with my progesterone and that's when I take it. So I switch to the oral at night. It works great. Some of the unexpected side effects, and do not laugh, but I was noticing a little more hair growth in areas that I wasn't used to it.

47:15Dr. Mary Claire Haver:I was with my daughter and she was like, Mom, Maddie, you have hair coming out of your nose. And I was like, excuse me, what? And I run into the mirror, into my 30x magnifying mirror and did see, yeah, there was a little more hair growth there. So I've learned how to manage that. That is a unfortunate side effect of my minoxidil use, but one that is easy for me to manage and I understand where it's coming from and it is worth the incredible hair of my head. Those of you on video can see all the baby hairs here. This is from the minoxidil. Minoxidil is a long-term commitment. Whatever hair you gain from using it will go away when you stop using it.

47:56Dr. Mary Claire Haver:So it is not a permanent fix. It's treating a symptom and will only treat it as long as you are using it. And you really have to use it for a consistent six months before you can throw in the towel. Another thing to remember is you will shed when you start using minoxidil, either topical or oral. This is normal. Remember, we're going to shift some hair into different phases. So I always warn patients, If you want to start minoxidil, you're going to shed. You're going to have this telogen effluvium thing in this first month. Don't worry. The hair will come back. But it is a little freaky because you're taking medication to grow hair.

48:35Dr. Mary Claire Haver:And all of a sudden, you're losing hair faster. But the medication does work. And the daily reality of it can be harder than some people anticipate. So I just like to put all the warnings up front. It works. It takes a serious commitment. There may be side effects you're not used to. You're going to shed before it gets better. But if you stick with it, you probably will be fairly happy with the results. So oral minoxidil, some fun facts about the oral minoxidil. A lot of people are worried about potential safety issues. So there are several studies I'm quoting here, and most are since 2021. So in 1 ,400 patients, only 1.2 % discontinued due to systemic side effects.

49:15Dr. Mary Claire Haver:So 99-ish percent of patients continued the course, and were happy with it without side effects. There were no clinically significant blood pressure changes in patients with normal blood pressure. So don't worry about dropping your blood pressure or taking it at this very, very, very low dose. This is, remember, the 1.25. You're cutting the 2.5 in half. There was no association with tachycardia, which is rapid heart rate in a large retrospective cohort study done in 2025. No association with pericardial effusion or any heart issues. and all the cardiovascular data is supported across multiple studies.

49:53Dr. Mary Claire Haver:So the studies consistently show that combining minoxidil with an antiandrogen, something that blocks that DHT, that dihydrodestosterone, that's what actually binds at the hair follicle receptors, with or without procedure outperforms any single treatment for female pattern hair loss. Okay? And we're going to get to those. What are the antiandrogens? Okay, we're going to talk about them. So again, it works great by itself. It works synergistically when you combine it with an antiandrogen if you have female pattern hair loss, which most of you who are listening to this this far, this is the number one cause.

50:37Dr. Mary Claire Haver:All right, so let's talk about the antiandrogens. All right, so two big groups here are finasteride and spironolactone. Oral finasteride improves hair density in many postmenopausal women. It's been studied in female pattern hair loss and better evidence in postmenopausal patients than in premenopausal patients. So it seems to be a sweet spot for postmenopausal patients. You can do oral finasteride and there is actually some topical available as well. Spironolactone has an antiandrogen action. It binds to that DHT receptor. It's really useful in women with signs who also have androgen excess. So acne, they're having unwanted hair growth, they're having irregular cycles or polycystic ovarian syndrome.

51:21Dr. Mary Claire Haver:So if you were in our younger patient cohort, we're going to lean more towards boronalactone for you versus a finasteride product. What is the HRT question here? Does HRT really help? HRT by itself, hormone replacement therapy in the form of estrogen plus or minus a progestogen is not a hair loss treatment. Not. Despite the biological plausibility that estrogen extends antigen, there's really no robust randomized clinical trial or evidence to support that systemic hormone therapy alone reverses female pattern hair loss. So that is a fallacy. Hormone therapy may slow progression by maintaining estrogen's protective effect on the follicle, but the data is really observational and inconsistent, probably because most of us have multiple causes of hair loss all contributing to what's happening on our head.

52:15Dr. Mary Claire Haver:Hormone therapy addresses many of the contributors. It can improve your sleep, reduce cortisol-driven stress on the follicle. It supports iron status by reducing heavy bleeding and perimenopause. All right, hormone therapy cannot be the mainline therapy for hair loss. It can help. It probably helps. We don't have great data to prove it, but that is not, like if you go in and you're like, I'm losing hair. And they're like, you just need hormone therapy. Stop. No. Okay. So let's talk about procedural options. And I had to do, like, these are things that I don't do in clinic. Okay. But there are things I know some about.

52:49Dr. Mary Claire Haver:And Dr. Erica Kelly and I on the podcast discussed these in detail. But in general, we have PRP, which is platelet-rich plasma. So you get a blood draw, they extract blood out, They get a little tube of it, and then they spin it down, and they get the platelets from your own blood to facilitate healing and with a serum to combat hair loss. This is not usually a standalone therapy. And basically, they pull the blood, they pull out the good stuff that they want, and they inject it into where you're losing hair. But this should not be standalone therapy. You need to have someone who knows what they're doing.

53:25Dr. Mary Claire Haver:You often need multiple treatments. And again, eventually, the processes that cause your hair loss, this is not something you're going to do once and then be done with it. Microneedling. So microneedling is when we take tiny, tiny needles and poke holes in your head at the scalp. Some of you may have microneedling done on different parts of your body. It's treating the dermis and epidermis by causing micro damage that makes your body react in a way that makes the skin and hair follicles healthy in the long term. Okay, it kind of drives healing to the area. So microneedling is particularly effective when combined with minoxidil, likely works by enhancing absorption and inducing a growth factor release to make the hair follicle healthier.

54:13Dr. Mary Claire Haver:There is low level laser therapy. Again, you need to go to somebody who knows what they're doing. You want to do an FDA clear treatment that has, and it has modest evidence, it can be really expensive. If you have a laser done in the hands of someone who doesn't know what they're doing, you can end up worse off than before you can end up with scarring. And then of course, there's hair transplantation, less common in women, but it is available. This can be really effective as a last resort and is best for women who have also gotten medical therapy. So let's talk about supplements. There are some supplements that have been shown to target inflammation and enzymes that can contribute to hair growth, such as palmetto.

54:52Dr. Mary Claire Haver:When I was researching for the new menopause, because of the SHBG we talked about earlier, a lot of people struggle with signs of androgen excess. So basically, their testosterone levels aren't higher, just the activity of that testosterone is higher because their SHBG is lower. And salt palmetto is one of the things that can actually help to combat some of those. It's an anti-androgen. So for people who have like phantom smells or have new body odor that they never had before, saw palmetto can be one of the treatment options. And I learned about that when I was researching for the new menopause.

55:30Dr. Mary Claire Haver:Pumpkin seed oil, curcumin, marine collagen. I've seen on TikTok, and you guys may have seen it, people using rosemary oil or making their own rosemary extract by boiling rosemary down and putting that water in a spray bottle. And there's actually decent evidence to support hair growth there. Um, most people know about biotin, but I have to tell you, there's essentially no evidence that it helps women unless you have a biotin deficiency. So if you have a deficiency, we want to correct it. Taking megadoses of said vitamins does not give you a superpower. And like in the case of zinc may also contribute to hair loss.

56:08Dr. Mary Claire Haver:There's a very popular supplement available for, I think,$90 a bottle,$90 a month that That showed like a couple of extra hairs a month. If you want to spend your money on that, that's fine. But outside of a documented biotin deficiency, you might be wasting your money. Action plan. So where do we go from here? So I've given you a ton of information. I want you to go right now to the show notes and go get your guide. Okay. Everything I've said today is in there. Questions to ask your doctor, different treatment options, when to do what treatment and in what order, what labs to ask for to make sure that all stones are being turned for you.

56:46Dr. Mary Claire Haver:We're not leaving anything, no stone left unturned. So I'm going to give you an action plan. Do these five things. Number one, take three photos of your scalp today from above and your part line and the full head and do it under good lighting and repeat that every month. Okay. Go look at old photos that showed that you had more hair and with a photo of today. Just know your baseline so that you can go in with evidence to support your case, okay? Number two, schedule a visit with your primary care doctor or maybe your OBGYN, your family medicine doctor, your internist, and bring in the lab list.

57:18Dr. Mary Claire Haver:Ask. Ask, okay? Number three, review your current medication list, okay, and your supplement list. If you've started anything new in the last six months, look up whether or not hair loss is a known side effect. Number four, know your protein intake. Audit your protein intake. Women in general are not getting enough protein to support bone, muscle, or hair. So again, Chronometer, C-R-O-N-O-M-E-T-E-R, is my favorite app. There is a free version. Just track protein and fiber. I'm always saying to check fiber. Unrelated to hair, but it's a good idea. If you're going to check one, just check both. And see how much protein you're actually getting every day.

58:00Dr. Mary Claire Haver:And you might be surprised, especially if you're undergoing weight loss, especially if you're on a GLP-1 or had a gastric bypass. You should know this. If you're under 0.8 grams for every pound of body weight, you're probably running low. Most women run about 0.5 to 0.6. So you may need to up that protein in your diet. And if you've been told it's just menopause, women go through this, it's just stress, you deserve better than this. You deserve a workup and not a brush off. So hair loss is not a vanity problem. It is a medical condition with real causes and real treatment options. And the failure for us to take this seriously is one of the most reliable ways the medical system dismisses the female experience.

58:44Dr. Mary Claire Haver:Your hair is telling you something about your iron, about your thyroid, about your vitamin D, about your hormones, about inflammation, and the metabolic state of your whole body. You deserve a clinician who treats your hair the way that it would treat any other tissue in your body. You can have your hair back or at least you can have a fair fight for it. Hopefully you learned something today and hopefully you will download our free guide and take it to your clinician and get some answers. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr.

59:19Dr. Mary Claire Haver:Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepauzelife.com. Full episodes of Unpaused are available on YouTube at Dr. Mary Claire. Unpaused is presented by Odyssey in conjunction with Good Roommate Media and Longwave Digital.