Why is My Hair Falling Out? Women’s hair loss causes and treatments.

Losing hair? Don't panic—we’ve got you covered! In this episode of The Savvy Patient, cohosts Erin Stein and endocrinologist Dr. Gillian Goddard break down everything you need to know about the hair on your head—focusing on why hair falls out, how to distinguish normal shedding from true scalp hair loss, and what medical treatments actually work. Dr. Goddard explains the biology of the hair growth cycle (Anagen, Catagen, Telogen, and Exogen) and clarifies that shedding every day is completely normal. Temporary hair shedding caused by telogen effluvium is also normal—and you may be surprised by common stressors that trigger it such as pregnancy or anesthesia. We review more serious, non-reversible forms of alopecia before tackling the common androgenic (female and male pattern) hair loss, genetics, and evidence-based treatments, detailing the pros and cons of minoxidil, injections, and red-light therapy. Get the real facts, cut through the marketing noise, and keep your scalp healthy. 

We take a moment to remind you that while this is a medical discussion, it is not providing a diagnosis or treatment or any medical advice. The only way to get a diagnosis, treatment or medical advice for your particular condition is through a discussion with your doctor.

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Get your copy of The Hormone Loop by Dr. Gillian Goddard wherever books are sold.

This episode was produced and edited by Erin Stein. Music: “All We Live For (instrumental)” by Wolfclub licensed through Audiio.com. Intro and outro edited, and video created, by Ian Mayer. The Savvy Patient logo by Amanda Spielman.

TRANSCRIPT

Erin Stein: Hello everyone. Welcome to the Savvy Patient.

Gillian Goddard: Welcome.

Erin Stein: Today we are talking about hair.

Gillian Goddard: We are.

Erin Stein: Mainly, the hair on your head. 

Gillian Goddard: Pretty much only the hair on your head.

Erin Stein: We're not really discussing other kinds of hair.

Gillian Goddard: No, we're talking about scalp hair today.

Erin Stein: Gillian just asked me if I was ready for this and I don't think that I am, so I don't know if you guys are.

Gillian Goddard: Hahaha. But this is like one of the number one things that people come to me complaining about, believe it or not as an endocrinologist, hair loss.

Erin Stein: Well, it's so critical to our appearance for most of us. Women, in particular.

Gillian Goddard: Women, in particular. I mean I think men too, but it is much more socially acceptable to be bald as a man than it is to be bald as a woman.

Erin Stein: Yes, there's been a nice little pro-bald movement on the men's side of things. And if you're a punk rock woman who has lots of tattoos and piercings, then it's expected that you have a shaved head of some kind, but the standard gendered norm is still women have beautiful, luscious hair.

Gillian Goddard: Correct.

Erin Stein: And when it starts to fall out...

Gillian Goddard: [It’s] very anxiety provoking.

Erin Stein: Yeah, it's not a good time. We're not going to focus necessarily on the color changing aspect of this

Gillian Goddard: Yes, gray hair. Not this time.

Erin Stein: Not this time. This time we're really going to focus on your hair's falling out.

Gillian Goddard: Why and what can you do about it?

Erin Stein: Yeah. Apparently, there are a lot of reasons why it could be falling out.

Gillian Goddard: Yes, but before we get to all the reasons why your hair might be falling out, why don't we talk a little bit about a hair cycle? Because hairs go through cycles.

Erin Stein: Ooh, okay.

Gillian Goddard: This is important because part of the hair cycle is shedding and so I think it's important to know what's normal.

Erin Stein: Yes, I do shed a lot. As my husband likes to remind me constantly.

Gillian Goddard: Of course, of course. your hairs are longer than his; he sheds too.

Erin Stein: He sheds a lot more than he realizes.

Gillian Goddard: Ha ha. Hair goes through three different stages over the course of like the lifetime of a strand of hair. So, the first phase is called anagen. That's the growth phase. It's the longest phase. This is when hair grows. The hair is growing in a follicle.

Erin Stein: Okay, so the hair is growing in a follicle in a little hole in your head.

Gillian Goddard: Okay, sure.

Erin Stein: An inlet, if you prefer.

Gillian Goddard: Sure. I mean hole sounds much larger than the thing that we're talking about.

Erin Stein: I know, a tiny hole.

Gillian Goddard: Tiny, tiny hole. So, most of our hair at any given time, most of our scalp follicles are in anagen, 85 to 95% of them. This phase for any given follicle lasts for two to six years. You get two to six years of growth from a single follicle. Most of our follicles are in anagen. Then we transition to catagen. Catagen is super short, just four to six weeks, and at this point, there are some changes around the cells around the hair bulb, which is the part of the hair that's in the follicle.

Erin Stein: Okay.

Gillian Goddard: And those cells go undergo apoptosis, which is a scientific term that is basically like programmed cell death. Like, the cell is supposed to die. The follicle retracts. There's sort of a change in how the bulb of the hair sits in the follicle. That is super short. And only one to two percent of scalp follicles are in catagen at any given time. And then comes telogen and that lasts two to four months, and that's the resting phase. So, this is when hair it's still attached to your head, but these are hairs that can come out kind of easily. It's not quite as anchored and it's considered like a rest. Your follicles are not doing very much. It's laying the groundwork at the level of the follicle for the next anagen phase. And about five to fifteen percent of scalp follicles are in telogen at any given time. And then there's exogen, which is shedding, so the hair bulb detaches from the follicle and falls out. And this is at the end of telogen. It's normal to shed. Everyone sheds.

Erin Stein: Okay, so you have a hair follicle, it grows a hair, and it keeps growing a hair for two to six years.

Gillian Goddard: Yes.

Erin Stein: Then it's like, okay, that's enough. And it prepares itself to shove that hair out.

Gillian Goddard: Yeah.

Erin Stein: And then your hair does come out, and it grows another hair. 

Gillian Goddard: Yes. That's correct.

Erin Stein: I assume our follicles are not all on the same schedule? Like there must be some staggered…

Gillian Goddard: No, one hundred percent, but there are certain times of year where it is more common to shed. People have more shedding in the spring and summer. This makes sense if you think about it. Even though, unlike other animals, our coat, so to speak, does not thin significantly in the spring and summer, we tend to shed more hairs in the spring and summer. But on an average day, the average human sheds anywhere from a hundred to a hundred and fifty hairs. And when you think about it, like, that's not nothing.

Erin Stein: Whoa. That's a lot.

Gillian Goddard: Yeah. A hundred to a hundred and fifty is normal.

Erin Stein: That is so much more than I would have thought.

Gillian Goddard: Yes. Yes.

Erin Stein: Huh. So, when you do find hair in the shower, it doesn't necessarily mean anything.

Gillian Goddard: No, and so when people come to me and they say they're losing their hair, the first question I ask them is actually not how many hairs are coming out, because the more hair you have, the more hairs you will be shedding at any given time, right?

Erin Stein: Yeah, I have a lot and a lot comes out.

Gillian Goddard: Right. And that makes sense because it's a percentage of your hair follicles that are going to be in exogen at any given time. So that matters to me much less than whether or not, like—I mostly see women and so I ask about the volume of your ponytail. Is your ponytail volume getting smaller? Do you need to wrap the rubber band around more times? Because that is a better indication, assuming you have hair that can get into a ponytail, that is a better estimation of overall hair volume than how many hairs you are losing at any given time. And one of the most unhelpful things people do when they come to see the doctor about hair loss is bring the shed hair from the shower floor with them. You do not need to do that. I believe you that you are shedding hair without needing physical evidence of it or pictures.

Erin Stein: Ha ha ha. Right. if you really feel strongly, take a picture, but don't bring the hair.

Gillian Goddard: You would be amazed. Please don't bring your hair to the doctor's office. I mean the hair that's not attached to your head, of course.

Erin Stein: Listen, I feel somewhat generous toward these individuals that you feel like you need to bring evidence of your medical plight to the doctor.

Gillian Goddard: I do too, but it does not tell me anything that I cannot get from a conversation with you.

Erin Stein: Yeah, we want to educate you that you should be shedding, you will be finding hair in the shower, you will find it on your pillow and in the sink, and your husband may complain about it constantly, even though he's shedding just as much hair. But you should be able to notice if suddenly there's a lot more hair in the shower or in the sink or in your brush or whatever.

Gillian Goddard: Or if your ponytail's getting smaller.

Erin Stein: But you know, a lot of women don't have ponytail length hair, so every time we wash our hair, some hair comes out. And you should have a hair catcher on your drain, so you don't have to snake your drain constantly.

Gillian Goddard: This conversation is going in a very odd direction. I didn't know we were a plumbing podcast.

Erin Stein: I know, I know, sorry. Well listen, must needs. I don't want people to feel gaslit like, you know if suddenly you're losing a lot more hair than normal, but also it is normal to lose a reasonable amount of hair every day.

Gillian Goddard: Yes, yes. And the most common thing that causes hair loss where people will notice an increase in hair loss besides seasonal hair loss, which we already talked about, is something called telogen effluvium. And you basically lose all your resting hairs at once. There's a couple different situations where people will experience telogen effluvium. And the most common one is actually postpartum. So, during pregnancy, you don't lose resting hairs, so you actually shed very little hair during pregnancy. This is because estrogen acts on the hair follicles and causes this to happen. This is why anyone who's ever been pregnant knows that you will never have better hair than when you are pregnant. It is the one appearance related thing that I loved about being pregnant. I've never had better hair than when I was pregnant. But what goes up must come down.

Erin Stein: Ha ha.

Gillian Goddard: All those resting hairs then tend to get shed kind of all at once, usually around four to five months postpartum. I think the best way to think about this is this is also when babies get super bald is around four to five months; they lose their like baby hair and start to grow their real hair. And mom and baby are pretty bald together.

Erin Stein: This is a fun fact that nobody tells you.

Gillian Goddard: That's true. This is correct. This is one of those things about pregnancy nobody tells you. And there is absolutely nothing that you can do about it. There is no vitamin that is going to stop this from happening. There is no shampoo that is going to stop this from happening. It is going to happen. It will be painful and then it will end and then you will have a halo of little baby hairs growing back.

Erin Stein: We mean emotionally painful. It shouldn't actually hurt.

Gillian Goddard: It's not physically painful, but emotionally it's rough.

Erin Stein: Does it literally all happen at once or like over a couple weeks?

Gillian Goddard: I would say it happens over a month or so, in my personal experience, times four.

Erin Stein: In your personal experience.

Gillian Goddard: But there's some other things that cause telogen effluvium too. Stopping birth control pills causes telogen effluvium. Similar to pregnancy, right? Like you've got more estrogen than usual when you're taking a birth control pill and when you stop the pill, a couple months later you will get a shed that's similar to pregnancy. And similar to pregnancy, there's nothing you can do about it. Anesthesia causes telogen effluvium and it doesn't happen at the time that you have the anesthesia. It happens like four or five months later. And so, if you have a surgery, four or five months later you'll notice increased shedding and it's just telogen effluvium, it will grow back. So, I think the message here, of course, is that telogen effluvium is just a loss of the resting hairs, and those follicles will recycle and you will start growing hair again. COVID causes telogen effluvium, again, a few months later. And stress, big stressors can cause telogen effluvium. And this can be physical stress or emotional stress, when you think about stress, this makes sense in a like evolutionary context…

Erin Stein: Does it?

Gillian Goddard: It does. 

Erin Stein: Explain.

Gillian Goddard: When our ancestors were roaming, the stress that they often experienced was needing to find a new place to live. And often that involved shortages of food.

Erin Stein: Sure. 

Gillian Goddard: And when you are trying to conserve resources, full head of luscious locks is not high priority. And so you shed your resting hairs because it takes energy to maintain them.

Erin Stein: Okay, so stress related extra shedding is these resting hairs…

Gillian Goddard: Yes, that's correct.

Erin Stein: And not other hairs? Okay.

Gillian Goddard: Yeah. Yes. Hairs in anagen don't typically fall out.

Erin Stein: Anecdotally we think being stressed out makes your hair fall out, but it doesn't mean you're going to go bald.

Gillian Goddard: Right. Correct.

Erin Stein: I think that's new information. You just walked us through all these phases that your hairs are in and so only one type of hair in a particular kind of phase is shedding. That is not common knowledge, in my opinion.

Gillian Goddard: Right. Yeah. Yes, I hear what you're saying, but it is true.

Erin Stein: Thank you. So you don't have to worry about your entire head of hair falling out because you're stressed.

Gillian Goddard: Or because you're postpartum, or because you stopped your birth control pills, or because you had anesthesia.

Erin Stein: I did not know this anesthesia thing and I had some.

Gillian Goddard: It's real. And the more anesthesia you have, the longer the procedure, the more it happens, because it's a stressful event. And so, the bigger your surgery, the more shedding you're likely to see.

Erin Stein: It might explain the baby hairs that I've been wondering about.

Gillian Goddard: It might, indeed. Yes. But that's all temporary. Then there are these other types of hair loss that can be more permanent. And these are types of hair loss where the follicles themselves are affected. There are several types of alopecia. Alopecia is just the medical word for hair loss, but typically when we talk about alopecia, we are talking about an autoimmune process where the immune system affects the hair follicles. The most common type of alopecia is alopecia areata. You get like, they literally look like someone took a hole punch. You get a perfectly round spot on your scalp, the hairs all fall out and it's all the hairs. So, this is affecting hairs in all phases because obviously you don't have like a little circle of hairs that are all in the same phase. Typically, with alopecia areata it starts out little and then can spread. It can be self-limited, but it is helped with topical immunosuppression or steroids. Sometimes dermatologists will inject a steroid into the scalp in the spot where the hair is missing to kind of calm down the autoimmune process and allow those follicles to start functioning again. There's also a frontal fibrosing alopecia which is an alopecia that sort of starts at the hairline and causes the hairline to move back like almost in a straight line. And fibrosing alopecia is often not reversible. And so, this is something that you want to get diagnosed and get under control as much as you can with a dermatologist sort of quickly. And then there's alopecia totalis. And what's different about alopecia totalis is it doesn't just affect the follicles of the scalp; it affects all the hair follicles. So, when someone develops alopecia totalis, they can lose all of their body hair too, including eyebrows and eyelashes.

Erin Stein: That would not be fun.

Gillian Goddard: And so those can be really devastating types of hair loss because you know, alopecia totalis and frontal fibrosing alopecia are not typically reversible and so they can be quite devastating.

Erin Stein: So, with the first one, is it one bald spot or you get multiple bald spots?

Gillian Goddard: Usually it's a single one, but sometimes people have multiple spots at the same time.

Erin Stein: Okay. And then with the other two, it feels like a catch twenty-two because you want to do something about it as soon as possible, but you also don't know what's happening unless your hair falls out. So, this feels like a horrible situation.

Gillian Goddard: Right. Correct. I mean, particularly with frontal fibrosing alopecia, it tends to progress back. If you think you have one of these two types of alopecia, the person you want to see as quickly as possible is the dermatologist. For most hair loss issues, the dermatologist should actually be your first stop. There are a couple really easily reversible ones. Tinea capitis, which is basically a fungus growing on your scalp that affects the hair follicles. You can treat the fungus and then the hair will grow back.

Erin Stein: Gross.

Gillian Goddard: Traction alopecia, which is you're literally pulling the hairs out of the follicle and the follicles get sort of angry and upset if you're wearing your hair pulled back very, very tight, like in a very, very tight ponytail for example.

Erin Stein: Is this a ballet dancer related issue?

Gillian Goddard: You know, it's interesting. Most ballet dancers don't pull their hair back quite that tight. They pull it more loosely back and then kinda smooth it over. Seriously.

Erin Stein: Gymnast then.

Gillian Goddard: Maybe.

Erin Stein: They're required to pull their hair back. Yes, they appear to be pulling their hair back pretty tightly for competition at least.

Gillian Goddard: I can only speak to what I know. I was a ballet dancer; I was never a gymnast.

Erin Stein: That makes sense as you're literally stressing your follicle.

Gillian Goddard: Yeah, your follicles are like, Ouch.

Erin Stein: And all you do is leave it alone for a while or you treat it?

Gillian Goddard: Yeah, you can get it to stop. It can be somewhat permanent, but you can get it to stop by not wearing your hair pulled back quite so tight. The other thing that can happen in some cases is breakage that seems like hair loss. There are some things that can cause defects in the hair shaft that can cause it to be susceptible to breakage. Hypothyroidism happens to be one of those things. It actually changes it, there's a chunk of hair, like there's a length of the shaft that actually has a disrupted structure and it makes it particularly susceptible to breakage. Certain types of malnutrition can do this too, and certain types of vitamin deficiencies can also do that. But sometimes it's hard to tell depending on where your hair is breaking, is it breaking or is it coming out at the follicle? And that is often something that a dermatologist can help figure out. But by far the most common type of hair loss that is loss, not shedding, is female and male pattern hair loss.

Erin Stein: Mm-hmm. Here we go.

Gillian Goddard: Up to nineteen percent of women experience female pattern hair loss.

Erin Stein: That’s a lot.

Gillian Goddard: One fifth of the population.

Erin Stein: And how many men experience male pattern hair loss?

Gillian Goddard: Among Caucasian men, men of European descent, male pattern hair loss affects about 50% of men by age 50…

Erin Stein: Wow.

Gillian Goddard: 80% by age 80, and about 90% of men of European descent have some degree of hair loss in their lifetime. This is much less common among men of Asian descent. Some studies done in China showed just 21% of men experience male pattern hair loss. So, there is clearly a genetic component. 

Erin Stein: Clearly.

Gillian Goddard: Anytime we talk about race or ethnicity, we are using it as a surrogate for genetics and so clearly male pattern hair loss has a genetic component, so does female pattern hair loss. Men of African descent have less male pattern hair loss than Caucasian men. But there is less data, like there's not a study where they're looking specifically at men of African descent. Tends to be lower: less men have it and fewer men and it's less severe. There are other things that people of African descent are more susceptible to, including breakage because of differences in the natural moisture, and structure of the hair shaft itself. And then some hairstyling practices like braids can cause some traction alopecia as well. So, there are other things that people of African descent are more susceptible to and there are some differences in styling practices that can make it more difficult to kind of sort out.

Erin Stein: Yep. Okay, so back to us white ladies losing our hair. 

Gillian Goddard: Yes. Yes.

Erin Stein: When does this start to happen?

Gillian Goddard: Typically, in perimenopause and this is because estrogen, so male and female pattern hair loss collectively are called androgenic hair loss and that is because androgens, hormones like testosterone and DHEA are acting on the hair follicle and causing the hair follicle not to function anymore. These receptors in the hair follicles are not very specific. And so, both estrogen and testosterone can bind to these receptors in the hair follicles. And so, when women are in their reproductive years, there's so much more estrogen around that the estrogen is sort of beating out the testosterone in most cases. When our estrogen levels fall in perimenopause and menopause, there is more opportunity for the androgens to bind to the receptors in the hair follicle and cause those hair follicles not to function well. The exception to this is women with polycystic ovarian syndrome or PCOS or what we now call PMOS. Those women have higher testosterone levels often in many cases and so they can have female pattern hair loss during their reproductive years due to those higher testosterone levels and higher DHEA levels, so those hormones can bind to those receptors in the follicles more because there's more of it around. Androgenic hair loss has a really classic pattern and when I describe it, you'll be like, of course. and that's because only certain follicles are susceptible to testosterone and other androgens. First, you see hair loss at the temples and the crown and then on the top of the head.

Erin Stein: Mm. I think that's very interesting that different follicles will react differently to the hormones. That's actually wild.

Gillian Goddard: Isn't that interesting? And the genetic piece of it is that not everyone's follicles are particularly susceptible to hormones. The next time you're at a family reunion, look around. People used to think, I'm sure you've heard this, that male pattern hair loss ran in the mother's line. So, like, if your maternal grandfather was bald, you would also be bald. This is not true. You get the genetics for your hair follicles from both sides of the family so look at both sides. Take a gander. That's kind of what you're in for, at least naturally.

Erin Stein: Mm-hmm, mm-hmm. I am somewhat genetically blessed with a great deal of hair.

Gillian Goddard: Hmm. Mm. Not so over here. I was not genetically blessed when it came to the hair department, both from the type of hair that has grown off my head since I was a child to keeping it there during perimenopause. I actually experienced a pretty significant amount of androgenic hair loss beginning in my early forties to the point where I was, starting to panic and envisioning, you know, we've all seen that little old lady and she's got like three hairs pulled up into like a little bun. I was having visions of that in my future and starting to get very concerned.

Erin Stein: We could invest in some hats.

Gillian Goddard: I decided to go a different route.

Erin Stein: Okay, so if you start to notice some hair creep backward or on top. What do you do?

Gillian Goddard: So, there's a couple of different things that have been shown to be effective. The thing that has the best evidence and there's a big Cochrane review of this. So, Cochrane reviews are like when there's so much data that they're doing reviews and meta-analyses of other reviews and meta-analyses, they write a Cochrane review. And so, there is a Cochrane review all about androgenic hair loss. And the thing that has the most data is minoxidil. So minoxidil is the active ingredient in Rogaine, but it was actually originally developed as a blood pressure medicine, and you can get it in pill form also. The benefit of Rogaine in theory is that you're putting it right on the part of your scalp where you want the hair to grow. And so, in theory, it causes fewer side effects.

Erin Stein: Mm-hmm.

Gillian Goddard: In reality, in practice, it's kind of a pain in the butt. It's not always easy to get it on your scalp as opposed to on your hair. There are two main formulations of topical minoxidil. There's a men's solution and a women's foam and the men's solution tends to be gloppy and drippy and changes the texture of your hair so that it kind of is weighed down, which when you're losing your hair and don't have a lot of hair, you maybe don't really want your hair to be weighed down. It also can drip and it will like drip down your face and for a man that's no big deal but for a woman that can mean you're getting more hair growth on your face where you probably don't want it. 

Erin Stein: Probably not.

Gillian Goddard: I mean each to his own, but you know, generally speaking. the women's foam for a long time was only available in the lower percentage. Rogaine comes in a two and a half percent and a five percent formulation and not shockingly, the 5% formulation is more effective. And for a long time, you could only get the foam in the 2%, but now you can actually get the foam in the 5%. The foam feels kind of like a mousse that you might use to give your hair some body. I think it is harder to get it where you want it to be. It doesn't weigh down the hair, but it can make hair feel kind of crunchy. And topical minoxidil, not the minoxidil itself, but the vehicle that they put the minoxidil in so that you can put it on your scalp, tends to be irritating for a lot of people, so it makes their scalp itchy. So, what tends to happen is people don't stick with it. I totally get that because I didn't either. But there is pretty significant and good data looking at oral minoxidil. Oral minoxidil is generic, it's super cheap. You definitely do not need to buy specially compounded minoxidil pills from an online purveyor of prescriptions. You can get it at your regular CVS for pennies—maybe not quite pennies—but for a few bucks for a one-month supply and it tends to have very few side effects occasionally when people first start taking it. They feel a little lightheaded, but they typically get used to it, it doesn't do that anymore. The biggest downside of oral minoxidil is you can't direct it where you want it to go. It will cause all of your hair to grow more. It will not change the texture of your hair. So, if you have peach fuzz on your face, it's not going to mean you're suddenly growing a wiry beard, but you will have more longer peach fuzz.

Erin Stein: Mm-hmm.

Gillian Goddard: Most of the women I know…and me…really don't care about that. It's easy enough to derma plane that extra hair right off and keep the benefits of the scalp hair growing and they're happy to do that because the effects of the minoxidil on scalp hair for many women is pretty significant. The other thing that's been shown to be helpful for androgenic alopecia is platelet-rich plasma injections. Basically, you have your own blood drawn, they spin it down, they pull this specific part of the plasma out, and then they inject it into your scalp. that plasma is full of growth factors that help recruit the follicles and help them to function better. And it has been shown in randomized studies to improve both the number of follicles growing hair in a little square patch per like square centimeter or square inch. It's also been shown to increase the diameter of the individual strands of hair. And you can use minoxidil and PRP together. There's nothing about them that would mean you couldn't do one or the other. You can do both.

Erin Stein: How often would you need to do the PRP?

Gillian Goddard: The problem with the PRP is twofold. One is, yes, you do need to do it, not constantly, but you do have to do it from time to time, and it's not covered by insurance. So minoxidil is definitely the more cost-effective option even if you're doing topical minoxidil which you have to pay for out of pocket. But I really think oral minoxidil is like the best deal going, because it really costs nothing and is quite effective.

Erin Stein: It takes a while for hair to grow, so how long before you see results? And then follow up question, how long do you have to take it?

Gillian Goddard: Both excellent questions. So, this is true. Hair is slow. And so, anything you do to try to affect your hair, you really have to be patient. Whatever treatment you're talking about, you have to give it some time to work because hair just doesn't change that quickly. Typically, what you see with minoxidil, the first thing that happens is the hair loss stops. And that can often happen within a couple of weeks, and then you can start to see new hair growth after about six to eight weeks of taking minoxidil. Interestingly, you can see an increase in the number of hair follicles that are functional, so the number of follicles actually growing hair can increase for the first two years that you take minoxidil. So, you can continue to see more and more follicles getting recruited over the first two years. And I would say I started to really see a noticeable difference in my hair 12 to 16 months after I started taking it. My stylist who I see every three months or so was like, what are you doing to your hair? Because it is so totally different than it's ever been before. 

Erin Stein: In a good way.

Gillian Goddard: Positively, yes. She was like, I'm going to tell everybody! the downside of minoxidil is it only works while you're taking it. So, if you stop using it, both the topical or the pill, if you stop using it, it will stop working. That is true of pretty much every treatment we have for androgenic alopecia.

Erin Stein: So even though it's recruiting more follicles for two years, if you stop taking it, do those newly recruited follicles just I don't want to say die off, but stop functioning again?

Gillian Goddard: It seems like it, yeah.

Erin Stein: Yeah. That's annoying.

Gillian Goddard: It is. I will say though, taking a teeny, teeny white pill every day is really not very burdensome. The time it takes me to take the pill and then the time it takes me even to deal with the prescription and go pick it up every ninety days is way less than the time I save dealing with thin, lifeless hair.

Erin Stein: Fair. So, can I take my red-light face therapy mask and just put it on my scalp? Because it seems like everyone's talking about red light therapy.

Gillian Goddard: There is some data looking at red light therapy for scalp hair loss. It does seem like it can be beneficial. However, you have to get the light to your scalp.

Erin Stein: Right.

Gillian Goddard: And so that's one factor. And you have to make sure you have enough light to be beneficial. So, most of these studies are done with like special lasers. They're not done with the red-light mask that you bought for your face or even they now make red light caps. Those are not what's being used in the clinical trials, so a little bit fire beware, but all right, there's like a little bit of data.

Erin Stein: Mm-hmm. Mm-hmm. Maybe. But again, if you have a lot of hair like me, I don't think that light's getting to my scalp.

Gillian Goddard: Correct. Yeah.

Erin Stein: I bought a topical hair growth serum, and I can go in little rows, but I'm not getting my whole scalp with that stuff, right? 

Gillian Goddard: Right. It is a challenge.

Erin Stein: And everyone at home is like, Erin, you have enough hair, what are you talking about? But I don't want to lose my eyebrows. That's my old lady fear. I don't want to have to draw a thin pencil line in for an eyebrow. I want an eyebrow.

Gillian Goddard: Fair, fair. I think this is the PTSD that we have from growing up in the nineties and overplucking.

Erin Stein: Yes. Give me Brooke Shields and her eyebrows any day.

Gillian Goddard: It's helpful to think about how to approach it if you are noticing hair loss. So, if you feel like you're noticing hair loss, remember you can have some seasonal shedding. Think back four or five months, what was going on in your life? Did you have anesthesia? Did you have a baby? Did you stop your birth control pill? If so, I would say try to take a deep breath, wait a month or two. See what happens. If you notice that your hair loss is particularly dramatic, if you notice that it fits one of these patterns, the dermatologist is the best place to start. Dermatologists can do something called a pull test where they actually try and gently pull out some strands, and they can also do both a hair they can look at the hair follicle under the microscope and they can do a scalp biopsy if they think that it's necessary where they can look at the hair follicles in the skin of your scalp and see if they can see what it is that's causing the problem. And so, they are the most equipped to do some significant work up. They also oftentimes will do blood work. And there's a few reasons for this. One is, you know, we mentioned there's a couple of different endocrine problems that can cause hair loss or hair breakage. So, both overactive and underactive thyroid, and then PCOS or PMOS can cause hair loss. So, a lot of dermatologists will do blood work for those things. There's also a handful of vitamin deficiencies that can significantly exacerbate hair loss. So, vitamin D, vitamin B12, iron and zinc having deficiencies in those vitamins can cause hair loss. And so most dermatologists will also check those levels obviously. If you are deficient in something, supplementing it can be beneficial. So, if you're iron deficient, taking iron can be beneficial. If you're significantly vitamin D deficient, taking vitamin D can be beneficial. But there is zero evidence that taking these vitamins, if you're not deficient, is going to do anything to improve your hair. You do not need a hair, skin, and nail vitamin. You do not need an expensive product that is mostly vitamin D, to the tune of ninety dollars for a month's supply. And you do not need to take biotin. High doses of biotin have not been shown to be beneficial for your hair.

Erin Stein: Yep, we just popped that balloon. There was a moment where it was biotin everything.

Gillian Goddard: It doesn't make a difference. There's no evidence that it's helpful.

Erin Stein: There's definitely hair and nail vitamins at the store right now.

Gillian Goddard: And being marketed all over the internet by the algorithm.

Erin Stein: This is something we've touched on before, but it's this fallacy that is capitalized on with the marketing for these things that if you don't already have a deficiency in these things, taking them is not going to do anything. We have this idea that as long as I take more of it, it'll do something. And that's not how it works. It's the absence of it that does something.

Gillian Goddard: Exactly. That's exactly right. I think that's a great way of putting it.

Erin Stein: We gotta retrain our brains, ladies.

Gillian Goddard: That's right. More is not better. You need enough. You need to be sufficient in it. But being more than sufficient in it will not be beneficial.

Erin Stein: No. And in can in fact be bad for you if you take way too much of it.

Gillian Goddard: Especially certain things. you can overdose on vitamin D. It is a fat-soluble vitamin, so unlike other vitamins, it doesn't just go out in your urine. And you can overdose on iron and taking too much iron is not great for your liver. So, you really don't want to be taking these supplements taking these vitamins unless you're deficient.

Erin Stein: Minoxidil—just to go back to that for a second—it grows more hair on your head, but it is not making your hair thicker or like the individual hairs thicker or healthier necessarily. 

Gillian Goddard: Yes, they are. So, it increases both the number of active follicles per unit of area, and it increases hair thickness.

Erin Stein: It does. Even though it's not affecting your peach fuzz.

Gillian Goddard: Yes, so here's an important point. So, we have different types of hairs. We have vellus hair, which is peach fuzz, or like what women grow on their arms, and then we have terminal hairs. Terminal hairs are like scalp hair, underarm hair, pubic hair, leg hair, and for men, facial hair. 

Erin Stein: Beard. Mm-hmm.

Gillian Goddard: Yeah, beard. Minoxidil isn't going to turn your vellus hair into terminal hair. If that makes sense.

Erin Stein: It does. But I think that's an important clarification. Because not all women just have peach fuzz either on their face. 

Gillian Goddard: Right. Right. That's true. That's a topic for another day.

Erin Stein: A topic for another day. See, we did touch on other kinds of hair. We just didn't go super far in depth. I feel like that was a good start on our hair that we feel so strongly about.

Gillian Goddard: That's right.

Erin Stein: Send us questions more questions about our hair. And don't buy the vitamins. Don't buy the red-light therapy cap.

Gillian Goddard: And don't get sucked in by the online virtual medicine provider who says that they're giving you some super special minoxidil, you just need the stuff from the CVS.

Erin Stein: Or, you know, Walgreens. 

Gillian Goddard: Or your local mom and pop!

Erin Stein: Yes, if you have one of those, you should go. the mom-and-pop pharmacies are the best. That was hair. Thanks for hanging out. No? Yeah, we haven't figured out how to end these episodes yet. The end. Bye.

Gillian Goddard: Bye!