Androgenic Alopecia in Polycystic Ovary Syndrome (PCOS)

Androgenic alopecia is a common form of hair loss in both males and females. It's particularly common in females with polycystic ovary syndrome (PCOS).

PCOS is a hormonal disorder that causes the enlargement of the ovaries and the development of fluid-filled cysts. In addition to hair loss, females with PCOS often experience weight gain, acne, and hirsutism (excessive facial or body hair) due to increases in male hormones.

Your healthcare provider can help you determine if your hair loss is due to PCOS and if so, how to treat it.

This article describes the symptoms and causes of androgenic alopecia. It also covers some of the medications used to treat hair loss in people with PCOS.

Hands holding a comb full of hair
Sol de Zuasnabar Brebbia / Getty Images

Symptoms of Androgenic Alopecia With PCOS

Androgenic alopecia, also known as androgenetic alopecia, is the patterned loss of hair that can affect males and females. In people with PCOS, the pattern is usually different from what is seen with male pattern hair loss.

With male pattern hair loss, the hair loss will start in the front of the head and gradually recede to the back.

With female pattern hair loss, the pattern will develop in one of two different ways:

  • The thinning will start mid-scalp and gradually spread in a circular pattern.
  • The thinning will start at the hairline and gradually spread backward along the center of the scalp in a triangular pattern (sometimes referred to as a "Christmas tree pattern" where the thinning is wider at the front and narrower at the back).

Rather than complete baldness, female pattern baldness typically causes thinner and shorter hair. Even so, the thinning can be significant enough to expose large areas of the scalp.

In people with PCOS, androgenic alopecia rarely occurs in isolation. In addition to female pattern hair loss, people with PCOS may also experience:

Causes of Androgenic Alopecia With PCOS

The cause of PCOS is unknown. However, it is thought to involve a combination of genetic and environmental factors that trigger an imbalance in female hormones (called estrogens) and male hormones (called androgens).

Under normal circumstances, females and males have specific proportions of estrogens and androgens in their bodies to function normally. When the balance is thrown off, any number of hormonal problems can occur.

This can trigger a condition known as hyperandrogenism in which the body produces excessive amounts of androgens. Chief among these is the androgen testosterone.

In males, testosterone is responsible for male sex characteristics like facial hair, increased stature and muscle growth, and a deeper voice. It also contributes to hair loss due to the conversion of testosterone into an androgen known as dihydrotestosterone (DHT).

DHT is also the cause of hair loss in females with PCOS.

In both males and females, around 10% of testosterone is converted into DHT. Once released into the bloodstream, DHT can link to receptors on hair follicles on the scalp, causing them to shrink. Even if the hair doesn't fall out, it can become visibly thinner.

People with PCOS are vulnerable to androgenic alopecia because they have excessive amounts of testosterone in their bodies and, in turn, excessive amounts of DHT.

How to Treat Androgenic Alopecia With PCOS

Though results can vary, people with androgenic alopecia may benefit from certain over-the-counter drugs, prescription medications, and specialist procedures.

Over-the-Counter Medications

Currently, there is only one product approved for the treatment of female pattern hair loss in the United States: an over-the-counter topical drug known as Rogaine (minoxidil).

Rogaine will not cure PCOS-related hair loss, but it may help manage it. Keep in mind that once you stop using Rogaine, the hair loss may re-occur.

Another over-the-counter option is iron supplements. Some studies have shown that iron deficiency plays a role in female patterned hair loss and that iron supplements may help prevent it. Even so, there is currently no clear evidence that taking iron supplements can reverse the hair loss once it occurs.

Prescriptions

There are other medications that work directly on sex hormones. They may be prescribed if Rogaine falls short or blood tests reveal that you have excessively high androgen levels. With that said, there is only limited evidence supporting their use. Results can vary.

Some of the prescription medications used to treat female pattern hair loss include:

  • Spironolactone: This oral diuretic ("water pill") has anti-androgenic properties. Spironolactone is often used in combination with birth control pills for women with PCOS. It can also be used with Rogaine.
  • Finasteride: Sold under the brand names Proscar, Propecia, and others, this oral drug is typically used to treat enlarged prostate. It can be used off-label to lower testosterone in people with PCOS. With that said, it must be used with birth control due to the risk of birth defects.
  • Flutamide: Formerly sold under the brand name Eulexin, the drug is commonly used to treat prostate cancer but also has anti-androgenic effects. Even so, it is associated with a high risk of liver toxicity and liver damage.

Surgery and Specialist-Driven Procedures

Some people may opt for hair transplantation surgery if the hair loss is severe. This includes follicular unit extraction (FUE) in which individual hair follicles are removed and transplanted. In another procedure, follicular unit transplantation (FUT), a strip of skin is removed from the scalp to harvest hair follicles for transplantation.

Another option is platelet-rich plasma (PRP) injections. This is a process in which blood is spun to separate blood cells from the main liquid component called plasma. Scalp PRP injections have shown some promise in reversing alopecia in people with patchy hair loss.

Are There Tests to Diagnose Androgenic Alopecia?

PCOS is one of the main causes of androgenic alopecia in females—but not the only one. There are other conditions that can alter hormones and trigger female pattern hair loss, including:

Because there are many causes of androgenic alopecia, your healthcare provider will order different tests to help narrow the possibilities.

How PCOS Is Diagnosed

There are no tests that can definitively diagnose PCOS. PCOS ultimately involves a diagnosis of exclusion, meaning that all other causes must be excluded before a diagnosis can be reached.

The investigation typically starts with the following tests and procedures:

  • Pelvic exam: This is the manual examination used to evaluate the uterus, ovaries, and other pelvic organs.
  • Blood tests: These include hormone tests, blood glucose tests (used to check for signs of diabetes common in people with PCOS), and an anti-Mullerian hormone test (used to assess how well your ovaries are working).
  • Transvaginal ultrasound: A handheld device is inserted into the vagina to get images of the ovaries. People with PCOS generally have ovaries that are 1½ to 3 times larger than normal, either with or without cysts.

Based on the initial findings, additional tests and procedures may be ordered to rule out possible causes. This may take time and patience.

When to See a Healthcare Provider

Androgenic alopecia is neither dangerous nor necessarily a cause for alarm. While distressing, the condition can often be treated once the underlying cause is identified.

With that said, early treatment is more likely to render positive results than waiting until the hair loss is severe.

There are certain types of alopecia that warrant immediate attention. This includes cicatricial alopecia, a poorly understood inflammatory condition that destroys the stem cells and oil glands of hair follicles, leading to scarring and permanent hair loss.

See a healthcare provider immediately if any or all of the following occurs:

  • Your hair loss is sudden and profuse.
  • Your hair loss is accompanied by scalp redness, itching, scaling, or changes in pigmentation.
  • Your hair loss is accompanied by pus-filled bumps or draining pimple-like lesions on the scalp.

The treatment of cicatricial alopecia varies by the underlying cause. It may involve oral antibiotics like doxycycline, oral immunosuppressants like Sandimmune (cyclosporine), topical steroids like Vanos (fluocinolone), and injected steroids like triamcinolone acetonide.

Summary

Androgenic alopecia is a patterned loss of hair that's common in females with polycystic ovary syndrome (PCOS). It is caused by the excess production of testosterone that contributes to other PCOS symptoms such as weight gain, diabetes, acne, and abnormal facial or body hair.

Androgenic alopecia may be treated with topical Rogaine (minoxidil) or oral drugs like spironolactone, finasteride, or flutamide that bring down testosterone levels. Platelet-rich plasma (PRP) injections or hair transplant surgery may be pursued if topical or oral medications fail to provide relief.

A Word From Verywell

If female pattern hair loss is seriously bothering you, ask your primary care healthcare provider for a referral to a specialist known as an endocrinologist. These are physicians specially trained in diseases and disorders of the endocrine (hormonal) system.

Endocrinologists have expertise in many hard-to-diagnose hormonal conditions, like PCOS. They can also recommend the latest, most effective treatments for conditions like androgenic alopecia.

Frequently Asked Questions

  • How effective is Rogaine in treating androgenic alopecia?

    Rogaine (minoxidil), a topical drug used to treat androgenic alopecia in people with PCOS, has been shown to significantly increase hair thickness after one year. Even so, results can vary. Oral minoxidil has proven less effective, although it may reduce hair shedding.

  • What are the side effects of Rogaine?

    Rogaine is considered safe but can cause side effects in some, including:

    • Skin irritation
    • Differences in hair color or texture from surrounding hair
    • Hypertrichosis (excessive hair growth in places like the cheeks or forehead)
  • How common is androgenic alopecia?

    Some studies suggest that 67% of males experience some degree of androgenic alopecia compared to 24% of females. Polycystic ovary syndrome (PCOS) is one of the most common causes in females of reproductive age.

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