Hair Balding and PCOS
Frederick R. Jelovsek MD
Questions About PCOS And Balding
"Could you please give more information on polycystic ovarian syndrome? I want to become pregnant but of course I am starting to bald. Everything I read states I better get treatment before it really goes bad. Neither my parents nor any of my 3 older brothers are balding in the crown area, so may I ask where on what side of genetics does this come from? My primary MD answers that it is probably my (testosterone) level which is 102.
Background: I am 34, irregular menses after off of the BCP after 9 years and never had a problem with periods prior. I started back on BCPs due to balding. I have been off BCPs for 14 months only.
My basic question is... how have I inherited the PCOS and the baldness".
Polycystic ovarian syndrome (PCOS) is often considered a symptom rather than a disease. In other words, many conditions that inhibit ovulation can cause the ovaries to appear polycystic and to secrete more androgens (testosterone) than normal. On the other hand, this condition often seems to run in families so it must represent a specific genetic disease in some instances. Suffice it to say that PCOS may have multiple causes, and at least sometimes there is a genetic inherited cause, but not always.
PCOS, originally described under the name of Stein-Leventhal syndrome, is often associated with excess body hair growth (hirsutism), obesity, non insulin dependent diabetes mellitus and high blood pressure. Current concepts are that the obesity is either a cause or a result of insulin resistance and that the high insulin levels in turn cause excess androgen production in the ovary. This is based on the fact that:
- administration of insulin to women with PCOS increases androgens
- administration of glucose to women with PCOS increases both insulin and androgens
- weight loss decreases the levels of both insulin and androgens
- in test tubes, insulin stimulates ovarian cell androgen production
- if Lupron® is given to women with PCOS to decrease ovarian androgen production, these women still test by glucose tolerance to be insulin resistant.
Thus it is likely that PCOS is often a sign of insulin resistance syndrome and the insultin resistance precedes the androgen excess. Why do some women with PCOS have a problem with too much hair while others seem to go bald?
Both excess body hair growth in women and baldness can be due to too much blood hormone testosterone, an androgen. The blood testosterone is converted to a hormone called dihydrotestosterone which directly stimulates the hair follicle to grow. Body hair grows in response to testosterone much more so than does head (crown) hair. In the case of baldness, the head hairs are actually sensitive to too much testosterone and male-pattern balding is the result. There appears to be a genetic predisposition to premature balding in men (before age 30) . The head hair follicles are just supersensitive to the dihydrotestosterone and the hairs fall out instead of growing.
If women have excess testosterone or other androgens such as dihydroepiandosterone (DHEA), the very fine body hairs will turn into coarse, dark hairs on the abdomen growing toward the navel and on the face in a beard and mustache pattern. If they have a genetic predisposition to baldness and the androgens are high enough, balding results. Therefore in PCOS with elevated androgens, most women have increased body and facial hair growth and some of them also have balding if they are genetically predisposed. If the testosterone blood levels are extremely high such as from an ovarian or adrenal gland tumor, then balding can occur even though there is not a genetic predisposition. In these cases, deepening of the voice and enlargement of the clitoris also occur due to the excessively high testosterone levels.
How is polycystic ovarian syndrome inherited?
We have known about the tendency for polycystic ovarian syndrome to occur in families for many years. Only recently have there been some studies suggesting how this condition may sometimes be inherited. One study from the United Kingdom found evidence that PCOS associated with male pattern baldness was probably inherited as an autosomal dominant trait, i.e., one half of the female offspring of a woman carrying this gene will have PCOS. Male members of these families have about a 20-25% incidence of premature balding. If you have 3 brothers and father without any baldness, you would actually only expect one of the 4 to be affected. Thus this situation is still consistent with a genetic cause in your case.
In some studies as many as 10% of women have anovulation and androgen excess that becomes labelled as PCOS. There is also a high incidence of insulin resistance syndrome that may progress to type 2 diabetes. One study looked at a group of women with PCOS and male pattern baldness and found that a gene for insulin resistance was highly related suggesting a genetic link between type 2 diabetes and PCOS.
What can be done to arrest the progression of baldness due to excess androgens in PCOS?
Since some of the tendency to baldness is genetic in the environment of high testosterone, the only factor that can be altered is to lower the level of testosterone in the blood of women with PCOS. Testosterone is highly bound in the blood to sex hormone binding globulin (SHBG) and only about 1% of it is free and active on the hair follicles. This free testosterone is converted to dihydrotestosterone by an enzyme called 5-alpha reductase. In order to decrease hair growth then, the mechanisms would be to:
- decrease the manufacture of testosterone in the ovary - weight loss
- to lower the amount of free testosterone in the blood by increasing sex hormone binding globulin (SHBG) - spironolactone (a diuretic), estrogens,
- to impair the action of 5-alpha-reductase enzyme - saw palmetto extract, finasteride (Propecia®), and flutamide (Eulexin®)
Birth control pills work because they contain estrogen which increases SHBG thus lowering free testosterone. Saw palmetto, an herbal preparation used in approximately 160 mg twice a day doses in benign prostatic hypertrophy, may be effective for excess hair growth in women since it has been shown to impair 5-alpha-reductase activity. Finasteride and flutamide have been tested in hirsutism and both are effective. Flutamide (Eulexin®) seems to be slightly more effective than finasteride and totally reduces excess hair growth by about 50%. All of the treatments work while they are being given but when discontinued, the excess hair growth returns.
What is the best overall treatment strategy for PCOS to improve chances of getting pregnant?
The main treatment for polycystic ovarian syndrome for infertility is to induce ovulation since anovulation is the primary mechanism by which PCOS causes infertility. In order to induce ovulation, there are two main strategies - weight loss and clomiphene citrate (Clomid®) or other ovulation induction medications. Weight loss restores ovulation and can result in as high as a 33% pregnancy rate. Clomiphene is more effective in inducing ovulation and in general, in a good infertility treatment program, a pregnancy rate of 70% may be attained.
To decrease the tendency toward baldness and improve ovulation in order to get pregnant, weight reduction to a body mass index of less than 27 should be a cornerstone of treatment. Taking saw palmetto or a prescription for flutamide may help the hair growth until weight loss kicks in. Then, a trial of clomiphene under a doctor's direction can help induce ovulation if the other measures have not yet worked.
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