Women expect their hair to turn gray as they age, but they may be far less prepared for another ego-challenging aspect of aging: Their hair falls out.

You can cover gray with dye, but it's harder to disguise the sparsely covered scalps that millions of women start to notice in their 50s and 60s. Some unlucky ones have thinning hair long before that. This kind of hair loss is unrelated to cancer treatment or other serious health problems.

Of course, there are plenty of men who wish desperately to restore their youthful locks, and a few — we can think of one powerful one — who cling to elaborate comb-overs, but many balding men simply clip their hair short and go on with their lives. Dermatologists say hair loss is emotionally harder for women, who are often deeply embarrassed by thinning hair even though it's quite common. By the time they reach 50, about 40 percent of women are experiencing what's known as female-pattern hair loss, said Gopal Patel, a dermatologist with Aesthetic Dermatology Associates in Media. Women of African descent struggle with even more conditions that can damage hair follicles and cause bald spots.

"Hair is such an important part of youth and vitality," said Aradhna Saxena, a Montgomery County dermatologist who is affiliated with Abington Hospital-Jefferson Health. "I don't think people realize that until it's gone."

Aradhna Saxena.
Handout
Aradhna Saxena.

It is normal for women to lose 50 to 100 hairs a day, dermatologists said. It's also normal for a woman to get more hair during pregnancy and return to normal after the baby is born. George Cotsarelis, chair of dermatology at Penn Medicine, studies hair thinning in men and women.

He said women also often shed more hair than usual about three months after an illness or rapid weight loss. Hair lost that way typically comes back. People shed a little more hair in the fall than during other seasons, he said. That's probably a vestige of the coat changing animals do in preparation for winter.

Many other women, though, start noticing thinning hair on top of their heads. Doctors say the defining sign is a widening of the part. The hairline itself is usually intact, but the hair becomes less dense behind it. Doctors will often run a battery of tests to make sure there are no treatable medical conditions, such as anemia, thyroid problems, tumors, or hormonal problems. "Ninety percent of the time, it's normal," Patel said.

The cause of female-pattern hair loss is unknown, but doctors said there is a strong genetic component. The risk can come from male or female relatives. Though it looks as if the hair is falling out, that's not really what's happening. Cotsarelis said hair follicles are becoming smaller and producing hairs that may be so small that you can't see them.  Women tend to retain more normal, thick hairs than balding men do.

George Cotsarelis is chair of dermatology at Penn Medicine.
Courtesy of Penn Medicine
George Cotsarelis is chair of dermatology at Penn Medicine.

Like other doctors, Cotsarelis decried the lack of funding for studying hair loss. Said Patel: "The biggest challenge we face is we don't really have great data."

Because the condition is usually considered cosmetic, insurance companies don't cover treatments.  Doctors warn that the available treatments may thicken hair growth for some women, but that the more realistic goal is to stop or slow the thinning.

While thinning generally worsens after menopause, doctors said hormone treatments typically do not improve hair growth. Minoxidil lotion or foam, which can be purchased over the counter, is the first line of treatment. About half of women who use it have not lost more hair a year later, Cotsarelis said. Spironolactone, a blood-pressure drug, can also help, doctors said. Some may also try finasteride — approved to treat baldness in men — off-label. The evidence that it works in women is weak, Patel said.

Beyond that, things get more controversial, with some doctors saying there's inadequate evidence for other treatments. Saxena thinks there is enough scientific evidence to support some of the alternatives and recommends them to patients. But they are not for women on tight budgets. There's Nutrafol, a "nutraceutical" that costs about $80 a month. Women can also get injections in the scalp of platelet-rich plasma made from their own blood. The first four treatments cost about $2,000 at Saxena's practice in Fort Washington or Lansdale. Maintenance injections, done every three to six months, cost $515 each. Women can also buy Theradome, a light-emitting helmet, for $895 online.  Saxena, who has hair loss herself, said she has had the injections and currently uses minoxidil, spironolactone, and Nutrafol.

Gopal Patel is a dermatologist with Aesthetic Dermatology Associates in Media.
Courtesy of Gopal Patel
Gopal Patel is a dermatologist with Aesthetic Dermatology Associates in Media.

Patel said the problem with those treatments is that they have not been subjected to large or head-to-head research. There's great variation in how doctors give the plasma treatments and in laser-based devices, so it's hard for patients to know whether they're getting a proven regimen. Nutrafol seems promising, he said, but he does not think that company-funded research showing its effectiveness has been replicated. He has not recommended it yet.

If their hair thinning progresses despite treatments, women are left with trying hair transplants, weaves or wigs, or letting the world see their scalps.

Black women often have some extra problems. Tight braids can cause traction alopecia along the hairline. That hair might grow back with a gentler hairstyle.

The more upsetting problem is central centrifugal cicatricial alopecia, a type of baldness that starts at the crown of the head and spreads outward. "It's hugely, hugely difficult," said Susan Taylor, a dermatologist at Penn Medicine who specializes in treating women with CCCA. "It affects quality of life." She said it is seen "almost exclusively" in women of African descent. One study found it in 10 percent to 15 percent of black women, but Taylor thinks it's more common. "I could see women all day, every day, with this problem," she said.

Central centrifugal cicatricial alopecia is a kind of hair loss that occurs almost exclusively in women of African descent.
Susan Taylor
Central centrifugal cicatricial alopecia is a kind of hair loss that occurs almost exclusively in women of African descent.

It used to be called hot-comb alopecia, but Taylor said even women who wear their hair natural can develop CCCA. Though its exact cause is unknown, the damage stems from scalp inflammation. If left untreated, it can "scar" or destroy the hair follicle.

"The treatment is very successful in regard to preventing further hair loss, not necessarily in growing new hair," Taylor said. She tells women, "Run, don't walk" if they see bald patches. Hairdressers can play an important role, she said, because they may be the first to see the bald areas.

Susan Taylor is a dermatologist at Penn Medicine.
Courtesy of Penn Medicine
Susan Taylor is a dermatologist at Penn Medicine.

CCCA is treated with oral antibiotics, which reduce inflammation, and cortisone cream.  Sometimes, Taylor may also inject cortisone into the scalp or use Plaquenil, a drug typically used for malaria, lupus and sarcoidosis.

Doctors said hair products are likely not the cause of female hair loss, so perms and dyes probably won't hurt you. Really harsh chemicals and high heat are not recommended. "Anything that causes pain is a sign of damage," Cotsarelis said.

The treatments are not likely to return hair to its former glory. That means many women need to find hairstyles that make the most of what's left.

Giovanni Mele, a stylist who owns Giovanni and Pileggi in Center City, said many women with thinning hair try to wear their hair long. He thinks they're much better off with short, pixie-like styles with light layering on top. He recommends that lighter-skinned women choose colors that are a little darker than blond or gray. He is a fan of a hair-thickening product made by Nioxin.

Syreeta Scott, a stylist who owns Duafe Holistic Hair Care in North Philadelphia and is a passionate advocate for healthy lifestyles, tells women who notice thinning that they're likely going to have to change their hairstyles.

"Wearing your hair natural, it is imperative," Scott said. A lot of women resist that, but she tells them it's not their hair that makes them successful. "It is not about your hair," she said. "It has everything to do with you showing up and being present."