Alopecia and breast diseaseBMJ 1997; 314 doi: http://dx.doi.org/10.1136/bmj.314.7079.481 (Published 15 February 1997) Cite this as: BMJ 1997;314:481
A 26 year old woman with refractory cyclical mastalgia was started on a regimen of 10 mg tamoxifen daily. She was otherwise well and not taking any other drugs. After three months she developed alopecia on her crown. Tamoxifen was stopped and her hair began to grow back. Because of continuing symptoms, she was given goserelin 3.6 mg monthly. After two injections the mastalgia resolved, but a new area of alopecia developed. Three months after discontinuing goserelin there were signs of regrowth.
A 62 year old woman with breast cancer was treated with adjuvant tamoxifen 20 mg daily. She had been taking bezafibrate for five years to treat hyperlipidaemia, and temazepam for three years. After three months she developed hair thinning over her temples and areas of alopecia (fig 1). Tamoxifen was stopped, but there was no regrowth.
Tamoxifen is widely used to treat breast cancer and is under investigation as a chemopreventive agent. Tamoxifen and goserelin are highly effective in refractory mastalgia.1 2 Tamoxifen competes for the oestrogen receptor,1 and goserelin causes a fall in oestradiol to postmenopausal concentrations, with a lesser fall in androgens.3 Male pattern baldness is genetically determined, induced by androgens, and occurs in 15% of postmenopausal women.4 In areas of male pattern baldness oestrogens initiate hair growth and androgens cause the transformation of terminal to vellus hairs. Withdrawal of oestrogenic stimuli causes the hair follicle to shift into a resting phase. Tamoxifen and goserelin produce an environment of hypo-oestrogenism with relative hyperandrogenism, which leads to hair loss in susceptible women. In older women the follicle may not recover.
Alopecia is reported on the data and patient information sheets for proprietary tamoxifen (Nolvadex, Zeneca). However, neither the generic forms of tamoxifen nor proprietary goserelin (Zoladex, Zeneca) report alopecia in the datasheets. With widening indications for tamoxifen and goserelin in young women, the distressing adverse event of hair loss should be highlighted before treatment is started.